The deficit of femoral bone stock is a frequent finding. This situation is mostly derived from the increased number of hip and knee arthroplasties and the consequent increase of failed implants, periprosthetic fractures and infections. There are other non-tumoral causes that generate this type of deficit, such as hardware failures in pathological bone, osteomielytis, congenital bone defects and metabolic bone diseases, etc.1,2,3.Several solutions have been proposed, which must be analyzed depending on the cause and magnitude of the femoral and acetabular bone loss, the patient’s muscle status (particularly the gluteus medius), the presence of infection, the age and background of the patient, and, of course, the surgeon’s expertise and his surgical facilities. This last aspect is essential, as revision and conversion surgeries are very demanding, for both patient and surgeon.
The most frequent alternatives include the use of cemented or non cemented long femoral stems, with proximal or distal fixation, associated or not to bone graft. Many studies have referred to the advantages and disadvantages of each of these treatment alternatives2,3,4. Nevertheless, in certain cases, the femoral bone deficit is so significant that there is not enough bone to properly fix any of these revision implants. In these patients, an option is the total hip replacement with a megaprosthesis, and among them, the total femur replacement (TFR)4,5,6,7,8,9.
Buchman was the first to report a total femur replacement in a patient with Paget ́s disease10. The first total femur implants were made of hip and knee prosthesis united by a polyethylene shaft, to which these components were adapted5,10. Even if this was a low cost versatile design, in time it was observed that polyethylene alone was not an adequate material to bear the load and torsions at a femoral level, particularly in young patients with high functional demand, since most of the initial patients were operated due to tumours4. In the mid 80s, modularity revolutionized reconstruction prosthesis, allowing the surgeon to estimate the existing bone defect, and therefore select the appropriate components for more accurate reconstructive surgery1,11.
The good outcome of patients treated with TFR for neoplastic causes widened the indication of this treatment to patients with massive femoral bone loss due to several non-neoplastic causes, not being the estimated survivorship of the patient an excluding factor in the decision process12. However, except for the publications from Endo-Klinik in Hamburg, Germany, which exceed 100 cases7, the rest of TFR reports in non-neoplastic pathology analyze around 20 cases at the most. Additionally, in all these series the pre-operative diagnosis are varied, making it difficult to obtain from them a clear conclusion on the evolution of these patients on the medium and long term. In this study we evaluate the indications, surgical technique and post operative care of TFR in non-neoplastic disorders.
Total hip replacement was first used routinely in the 1950’s and evolved rapidly through the 1960’s and 1970’s to become a successful and reliable operation. Further advances over the past 30 years have further improved the outcomes of total hip replacement surgery.
Total Femur Replacement | Dr Ashwani Maichand, …
A retrospective analysis of 6 patients (4 women and 2 men), operated between May 2004 and May 2006, was made (Table 1). The average age was 80 years old (68 to 94 years old). 4 patients were operated of their left limb.
The pre-operative diagnosis includes 5 patients (84 %) with periprosthetic fractures and non unions. Three patients with acute periprosthetic fractures in the short femoral segment lying between a long femoral stem and a total knee prosthesis and 1 case each of periprosthetic non-union, infected periprosthetic non union and a twice operated non-union in a femur with Paget ́s disease and degenerative changes in the hip and knee (Fig. 1).
Before TFR surgery, 2 patients were able to barely walk a few steps with severe pain and assistance of a walking frame and the other 4 patients could not walk. All patients had had several previous surgeries, with an average of 4.3 surgeries (2 to 11).
The patients were evaluated at 20 and 45 days after surgery, and at 3, 6 and 12 months and annually.