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Arch Orthop Trauma Surg (2010) 130:171–176

DOI 10.1007/s00402-009-0945-2

ORTHOPAEDIC SURGERY

Total femur replacement


Adel Refaat Ahmed

Received: 7 January 2009 / Published online: 31 July 2009


© Springer-Verlag 2009

Abstract Conclusion Endoprosthetic femoral replacement is a reli-


Background Total femoral replacement after massive able mean to restore mechanical and functional results after
resection of bone and soft tissue sarcoma of the thigh can extensive resection of the femur.
restore femoral integrity and allow patients to resume
ambulation, albeit at a compromised level. This compro- Keywords Bone tumors · Total femur replacement
mised functional capacity is superior to that achieved after
hip disarticulation. Most reports of total femoral replace-
ments are isolated case studies. Only few reported series Introduction
have been identiWed.
Methods We treated nine consecutive patients by total With improved survival from primary bone malignancies
femur resection and reconstruction with total femur caused by newer chemotherapy regimens, the development
replacement between 1993 and 2007. Four had a primary of limb salvage surgical resections has Xourished. In the
malignant bone tumor, four had a primary malignant soft- lower extremity, where the primary function of the skeleton
tissue tumor, and one had a metastatic disease. is to support body weight for purposeful ambulation, the
Results After a mean follow-up of 51 (8–200) months, success of these massive endoprosthetic bone and joint
four patients were still alive, whereas Wve patients died of replacements has been remarkable. The most extreme use
malignant disease. Mechanical loosening of the tibial com- of this technique has been in replacing the whole femur
ponent was seen in one patient. Infection was encountered [2, 5, 6, 8, 9, 14].
in two patients. Four patients had excellent outcomes. Total femoral replacement can restore femoral integrity
Competence of the extensor mechanism is the major deter- and allow patients to resume ambulation, albeit at a compro-
minant of functional outcome of these patients. The Xexion mised level. In authors’ experience, this compromised func-
range of knee motion ranged from 20 to 120° (mean 60°). tional capacity is superior to that achieved after hip
According to Enneking’s functional evaluation method, the disarticulation. Most reports of total femoral replacements
function ranged from 30 to 93% (mean 72%). Using the are isolated case studies [1, 11, 13]. Only few reported series
International Society of Limb Salvage radiographic evalua- have been identiWed. LaVoie et al. [9] reported 2 excellent, 9
tion method, all the available radiographs show excellent good, 9 fair, and 4 poor results in 24 patients with a mini-
results. Excellent results also were seen for the radiographic mum of 2-year follow-up. Their amputation rate was 28%,
evaluation of the hip. reoperation rate was 87%, and prosthetic complications
occurred in 71% of their patients. Morris et al. [12] reported
on seven patients with total femur replacement, three for pri-
mary bone malignancy and four for salvage procedures after
A. R. Ahmed (&) failed limb-sparing surgery. Their clinical and radiological
Department of Orthopaedic Surgery,
Alexandria University, Smouha Landmark Building 44-D,
results were excellent or good at Wnal follow-up of
14th May St., Smouha, Alexandria, Egypt 23 months. Ward et al. [14] reported 21 patients, the results
e-mail: egyptadel28@hotmail.com; adeljapan@yahoo.com of 19 of them were satisfactory in 16 and poor in 3. Hereby

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172 Arch Orthop Trauma Surg (2010) 130:171–176

we report on nine patients evaluated by well-documented


clinical, radiological, and functional methods of evaluation.

Patients and methods

Nine patients who had malignant bone and soft-tissue


tumor of the femur and thigh that were treated with exci-
sion and reconstruction using total femur prosthesis were
identiWed between January 1993 and April 2007 from our
sarcoma. The mean age of these patients at the time of the
initial reconstruction was 47 years (range 10–74 years).
Four patients were males and Wve were females. The histo-
logical diagnosis was bone sarcoma in four (three osteosar-
coma and one chondrosarcoma), soft-tissue sarcoma in four
(two malignant Wbrous histiocytoma, one malignant
schwannoma, and one solitary Wbrous tumor), and one met-
astatic osteosarcoma involving the femur.
All tumors were staged according to the Musculoskeletal
Tumor Society Staging System [3]. Five patients were
stage IIB, one stage IIIB, and two stage IB. At the time of
the initial evaluation, all patients had a thorough oncologic
examination, which included radiographs of the involved
bone, scintigraphy of the entire skeleton, chest radiographs,
and imaging of the neoplasm with angiography, computed
tomography, and magnetic resonance imaging (Fig. 1). All
patients received adjuvant chemotherapy except the solitary
Wbrous tumor patient. The follow-up periods ranged from 8
to 200 months (mean 50 months) (Tables 1 and 2).

Prosthesis Fig. 1 a MRI (Saggital, T1-weighted image) showing intramedullary


dissemination of the tumor. b, c Radiographs of the hip and knee dem-
onstrating excellent outcome of the prosthesis
Modular hinged titanium Zimmer prosthesis which utilizes
a bipolar femoral head component and a hinged cemented
constrained total knee system was used for this method. chanter with its attached abductors was osteotomized for
later reattachment to the prosthesis. Distally, the patella was
dislocated medially. The neurovascular bundle was exposed
Surgical technique and separated from the tumor, with ligation of the vessels
passing to the tumor and the femur. Muscles attached to the
The Watson–Jones approach to the hip was used, with a long linea aspera were divided together with the insertion of the
incision on the lateral side of the thigh. The gluteus medius adductor magnus. The femur was then removed after divi-
and minimus, together with the external rotators, were sion of the capsule at the knee. The proximal tibia was osteo-
detached depending on the surgical margin. The gluteus tomized and reamed for the press-Wt insertion of the tibial
maximus tendon was divided and the sciatic nerve was component. The parts were then assembled and a trial reduc-
exposed and protected. Part of the quadriceps was excised en tion carried out to test stability and tension. The glutei and
bloc with the tumor according to standard oncologic surgical the remaining vasti were attached to the holes in endopros-
principles; rectus femoris was preserved to enhance hip Xex- thesis. Meticulous hemostasis is essential and the dead space
ion and knee extension. The capsule of the hip was divided was eliminated as possible. The endoprosthesis was covered
circumferentially near the acetabulum and the femoral head with the remaining muscles and the wound closed in layers
dislocated; the insertion of the psoas was divided. Whenever over large-bore suction drains [2, 12].
the surgical margin allows and to obtain reasonable stability The average operating time was 4.5 h and blood loss
of the prosthesis and adequate hip abduction, the greater tro- during surgery was 1.3 L.

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Arch Orthop Trauma Surg (2010) 130:171–176 173

Evaluation methods

wide resection, VI vastus intermedius, VM vastus medialis, VL vastus lateralis, RF rectus femoris, LR local recurrence, CDF continuous disease free, DOD death of disease, AWD alive with
Add surgery additional surgery, Meta metastasis, CS chondrosarcoma, OS osteosarcoma, MFH malignant Wbrous histiocytoma, Mal.Sch malignant schwannoma, SFT solitary Wbrous tumor, WR
CDF (200)

AWD (23)
DOD (41)

DOD (24)
CDF (79)

CDF (30)
(months)

DOD (8)

DOD (9)
Status
The surgical margin of the resected specimen was evalu-
ated according to the evaluation system of the Japanese
Tibial component
Orthopedic Association [7]. Simply in this system, a sur-
Complications

gical margin is evaluated according to the distance of the


margin from tumor’s reactive zone, and consequently is

Infection
failure

Lung lobectomy (16) Infection


None classiWable into the four categories of curative, wide,

None
Hemipelvectomy(39) None

None

None
marginal, or intralesional margin. A curative margin is
deWned as a margin >5 cm outside the reactive zone; a
wide margin is a margin of 4–1 cm; a marginal margin is

Debridment (2)
a margin passing through the reactive zone; and an int-
Add. surgery

ralesional margin is a margin passing through the tumor


parenchyma. Moreover, a wide margin can be divided
None

None

LR & bilateral lung (2) None

None

LR & bilateral lung (5) None


into two subgroups of adequate and inadequate wide
margins. An adequate wide margin is deWned as a margin
¸2 cm, and an inadequate wide margin is a margin of
1 cm [7].
Iliacus & bilateral
LR & meta site

For the functional evaluation, Enneking’s method was


VL&VM&VI&RF Lt. lung (11)
lung (39)

used [4]. For the radiographic evaluation of the prosthe-


(months)a

sis, The ISOLS method was used [5]. For radiographic


None

None

None
None

evaluation of the hip, the method of Morris et al. [12]


was used.
VL&VM&VI

VL&VM&VI
Proximal femur VL&VM&VI

VM&VI&RF
quadriceps

Results
SacriWced

VM&VI
VL&VI

Surgical margins
VI
distal femur

Curative margin was obtained in four patients, adequate


Middle femur

Middle femur
Distal femur

wide margin in three, marginal margin in one, and the


Middle &

patient with metastatic osteosarcoma of the femur was


Site

VL

VI.

treated by marginal resection of the tumor.


3.5 £ 9.5 £ 6.5 VI
resected tumor

121 £ 7 £ 5.5

Oncologic outcome
7.5 £ 6 £ 25

Mal. Sch/IIIB Marginal 25 £ 5 £ 2.5

25 £ 4.5 £ 3
17 £ 12 £ 7

23 £ 7 £ 7
9£5£6
Size of

The results were as follows: continuous disease free (CDF)


Table 1 Summary of the patients with primary sarcoma

in three patients, alive with disease (AWD) in one patient,


and death of disease (DOD) in Wve patients. Local recur-
Curative

Curative
Curative

Curative
Margin

rence was occurred in one osteosarcoma patient and in


WR-4

WR-2
WR-2

malignant schwannoma patient, both patients developed


bilateral lung metastasis and DOD at 9 and 8 months post-
Calculation from the date of admission

operatively, respectively.
Age Gender Diagnosis/

disease, NED no evidence of disease


MFH/IIB
MFH/IIB

SFT/IB
OS/IIB
OS/IIB
OS/IIB
CS/IB
stage

Complications

In two patients, postoperative superWcial infection occurred


and both of them were successfully treated by surgical
M

M
F

F
F

debridement and the prosthesis could be saved. Failure of


the tibial component in the form of loosening at the cement
45

67

10
62
67

26
62
74

bone interface occurred in one patient, the patient remains


Patient

asymptomatic at 200 months following surgery and


no.

required no additional surgery.


1

3
4
5

6
7
8

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174 Arch Orthop Trauma Surg (2010) 130:171–176

Table 2 Summary of the single patient with metastatic disease


Patient Age/ Diagnosis/site Meta site Margin Size of resected Site of femoral SacriWced Add. Complications Status
no. gender of primary (months)a M. tumor meta quadriceps surgery (months)
disease

1 12/M OS/IIB Bilateral Marginal 3 £ 5.5 £ 5 Proximal VI None None DOD (50)
lung (24) (Rt.) femur
Lt. femur Rt. femur (43) 6.5 £ 6.5 £ 7.5 Distal (Rt.) femur
Add. surgery additional surgery, Meta metastasis, OS osteosarcoma, VI vastus intermedius, DOD death of disease
a
Calculation from the date of admission

Table 3 Functional and radiographic results


Patient no. ROM ROM Extension Gait Enneking’s X-ray R X-ray I X-ray A X-ray
(Xexion)a (extension) power (MMT) evaluation (%) hip

Primary cases
1 7 0 2 T cane NA NA NA NA NA
2 NA NA 2 NA NA NA NA NA NA
3 120 0 2 Without crutches 97 E E E E
4 30 0 2 Single crutch 67 E E E E
5 75 0 3 Without crutches 80 E E E E
6 80 0 2 Lofstrand 87 E E E E
7 30 0 2 T cane 73 E E E E
8 20 5 2 Lofstrand 70 E E E E
Metastatic cases
1 NA NA 2 Could not walk 30 NA NA NA NA
ROM range of motion, X-ray R, remodeling (ISOLS), X-ray I interface (ISOLS), X-ray A anchorage (ISOLS), X-ray hip hip assessment, NA no
data available, E excellent
a
Calculation at the end of follow-up or last visit before death or amputation

Functional results tom-made vitallium endoprosthesis, with a good functional


result at 6 months. To our knowledge, during the last
Competence of the extensor mechanism is the major deter- 20 years, nine reports have been published describing the
minant of functional outcome of these patients. The Xexion technique, complications, and results of total replacement
range of knee motion ranged from 20 to 120° (mean 60°). of the femur and herby a new report of this rare surgery.
Two patients can walk without crutches, other patients A high-grade malignant sarcoma (stage IIB), with a pro-
needed some sort of support to walk (Table 3). The manual posed 30% incidence of skip lesions, has been the indica-
test for the extension muscle power ranged from two to tion for this procedure [11]. Now since imaging by CT and
three grades (mean 2.1). According to Enneking’s func- MRI has made it possible to clarify the anatomic location of
tional evaluation method [4], the function of the recon- the lesion, involvement of a large segment of the femur by
structed limbs ranged from 30 to 93% (mean 72%). Using a nearby malignant soft-tissue tumor became another indi-
the International Society of Limb Salvage radiographic cation for total femur replacement. Also total femur
evaluation method [5], all the available radiographs show replacement is indicated in the presence of a metastatic
excellent results (Fig. 2). Excellent results also were seen lesion involving a large segment of the femur to provide
for the radiographic evaluation of the reconstructed hip those patients with a functional limb and remain pain free
according to the method of Morris et al. [12]. in their short-life expectancy. Hence, the indication for
complete excision of the femur in the treatment of primary
tumors is rare, but this radical procedure will usually neces-
Discussion sary when skip lesions are demonstrated or when there is a
massive intramedullary extension of a diaphyseal sarcoma.
Buchanan [1] carried out the Wrst total femur replacement Surgery was performed using total femur replacement
in 1952, and reported a second case in 1965, using a cus- for four primary bone sarcomas, four primary soft-tissue

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Arch Orthop Trauma Surg (2010) 130:171–176 175

Fig. 2 a Pre-operative digital radiograph of case 6 with osteosarcoma pins done at another hospital. c Pre-operative radiograph showing
of the mid femur with pathologic fracture Wxed with external Wxator. healed fracture. d, e Radiographs of the hip and knee demonstrating
b MRI (Coronal, T2-weighted image) showing intramedullary dissem- excellent stability and Wxation of the prosthesis
ination of the tumor with possible contamination by the external Wxator

sarcomas, and one metastatic tumor. The indications for the hinge mechanism since the patient walks with a passive
such a procedure seems to be very rare since those nine extension gait which may lead to early failure. If complete
patients were collected from the whole bone and soft-tissue excision of the quadriceps is indicated as a part of the surgi-
sarcoma series treated at the same period at authors’ institute. cal margin, then arthrodesis of the knee joint might be the
Occasionally, total femur replacement will be required appropriate choice for those patients.
as a revision surgery after the failure of previous attempt at The advantages of the modular endoprosthesis used in
limb salvage surgery, in metabolic bone diseases, or for this study manifested by its easy to assemble during sur-
revision of failed arthroplasties [12]. gery, so the problems using custom-made prostheses are
Recently, Mankin et al. [10] described 15 patients with avoided. The bipolar hip is easier to insert than a conven-
total femur replacement, their patients were heterogeneous tional acetabular socket; it is inherently more stable, and
group of patients not only in the pathology underlying better than uni-polar type of prothesis with regard to long-
removal of the whole femur which included neoplastic and term wear. These Wndings are in line with those reported
non-neoplastic conditions, but also the type of reconstruc- previously.
tion was heterogeneous which included ten patients with We have had no postoperative dislocation with this sys-
allografts implanted with total hip replacement and total tem. One tibial component failed but revision surgery was
knee replacement implants, and Wve patients only had not done as the function was still good.
metallic implants. Our group patients although they are Osteotomising the greater trochanter and its re-attach-
small in number only nine but they all suVer from sarcoma ment with its abductors to the prosthesis is a good
and all treated by a single method of reconstruction using a method for maintaining the hip abduction and to provide
metallic total femur with bipolar femoral head and con- soft-tissue stability to the reconstructed hip, provided
strained total knee. Although the diVerence between our that it will not compromise the surgical margin. How-
group of patients and that of Mankin et al. is evident, we ever, if resection of the trochanter or the abductors is
share with them the diYculty of the technique and the com- indicated then re-attachment of the remaining abductors
plexity of the reconstruction [10]. to the prosthesis and moreover to the tensor fascia lata is
Although our series is small, the functional results for another alternative, to maintain hip stability and to
the hip and knee were excellent or good. It is imperative to improve the gait.
select those patients in which at least either the hip abduc- Previous reports have showed variable results and most
tors or the knee extensors could be saved. This was also show high complication rate, so this procedure should only
reported by Morris et al. Lack of these muscles produced a be considered when the alternative is hip disarticulation and
poor functional result as the patients cannot control their the patient should be informed of the potential risk of this
limbs. Lack of the quadriceps will place an undue strain on massive reconstruction.

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Maintaining abductors of the hip and extensors of the Yamamuro T et al (eds) New developments for limb salvage in
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(2004) The concept of curative margin in surgery for bone and soft
tissue sarcoma. Clin Orthop Relat Res 419:165–172. doi:10.1097/
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