Total Femoral Arthroplasty for the Salvaged Femur

    When a patient has severely compromised bone stock, a total femoral arthroplasty may be the only option for fixation in a revision hip or knee procedure.

    By Adolph V. Lombardi Jr., MD, FACS

    Complicated revision total hip arthroplasty (THA) and total knee arthroplasty (TKA), septic prosthetic failure, and periprosthetic femoral fractures seem to be increasing.

    The expanding applications for arthroplasty in younger patients coupled with their longer lifespan is translating into more revision procedures. In addition, with the increasing population of older patients – and the increasing number of THA and TKA procedures done in this population – prostheses are being used in more osteoporotic bone and the incidence of periprosthetic fractures is increasing.

    When a patient elects to have THA or TKA, he or she trades arthritic disease for prosthetic disease. Prosthetic disease encompasses the life of the patient with his or her prosthesis, and represents all possible failure modes for that prosthesis. With each subsequent revision, there is accompanying bone loss, especially in cases of failed periprosthetic fracture fixation or prosthetic infection treated with radical debridement.

    Once numerous and frequently massive reconstructive efforts have failed secondary to any etiology or any combination of etiologies, sufficient bone stock may not remain to provide meaningful fixation of femoral components for THAs and TKAs. Furthermore, it is not uncommon for a patient with multiply failed THAs or TKAs and severely compromised femoral bone stock to have concomitant ipsilateral hip or knee arthritis.

    In cases such as these, treatment strategies lie beyond published algorithms. Total femoral arthroplasty has been described as a viable salvage option for these difficult cases. My colleagues and I recently studied complications and outcomes in patients in our practice who had total femoral arthroplasty for salvage of a severely compromised femur.

    The clinical scenarios included numerous revision THA and TKA proceures, failed periprosthetic fractures, and recurrent infection treated with multiple radical debridement surgeries. Fifty-nine patients (average age, 73.7 years) were identified.

    At an average follow-up of 4.8 years, adequate pain relief was achieved, with Harris hip pain scores averaging 33.8 of 44 points, and knee pain scores averaging 42.8 of 50 points. Good function was achieved with 98% of patients able to ambulate, with 43% using no assistive device or a cane only.

    There were 18 complications or subsequent surgeries. Infection and dislocation occurred in 8 patients and 7 patients, respectively.

    Total femoral arthroplasty is rarely performed – we identified only 59 patients in our practice from thousands of patients who underwent hip procedures over a 13-year period. When it is needed, total femoral arthroplasty seems to provide good functional outcomes, acceptable complication rates, and good pain relief in patients with end-stage prosthetic disease.

    Author Information

    Adolph V. Lombardi Jr., MD, FACS is from Joint Implant Surgeons, Inc., The Ohio State University Wexner Medical Center, and Mount Carmel Health System, New Albany, Ohio.

    1. References
      Lombardi AV Jr, Berend KR. The shattered femur: radical solution options. J Arthroplasty. 2006 Jun;21(4 Suppl 1):107-111.
    2. Peters CL, Hickman JM, Erickson J, Lombardi AV, Berend KR, Mallory TH. Intramedullary total femoral replacement for salvage of the compromised femur associated with hip and knee arthroplasty. J Arthroplasty. 2006 Jan;21(1):53-58.
    3. Berend KR, Lombardi AV Jr, Mallory TH, Adams JB, Dodds KL. Total femoral arthroplasty for salvage of end-stage prosthetic disease. Clin Orthop Relat Res. 2004 Oct;(427):162-70.