Total femur replacement: Primary procedure for treatment of malignant tumours of the femur

https://doi.org/10.1016/j.ejso.2009.11.002Get rights and content

Abstract

We present our experience of treating patients with tumours involving the whole femur with excision and total femur endoprostheses over the last 30 years (1975–2005). There were 26 consecutive patients (14 men and 12 women). Average age was 40 years (14–82 years) at the time of surgery and 21 of the patients had primary malignant bone tumours with five having the procedure for metastases. 11 patients were still alive of which nine were free of disease at the time of review at a mean follow-up of 57 months (3–348). The overall patient survival at 10 years was 37%. The survival of patients with a primary localised tumour was 50% at 10 years.

Revision of the prostheses was necessary in two patients (at 110 and 274 months) because of recurrent dislocation and aseptic loosening. Amputation was necessary in two patients but long term limb survival was 92% at 10 years. Nine patients alive with no evidence of disease had a mean MSTS functional score of 72%.

Introduction

Tumours involving the whole femur present a challenge when limb preservation is considered. These tumours are often large and resection involves removal of the whole femur with disruption of the hip abductor mechanism. Extensive soft tissue dissection and reconstruction of the joint above and below are required.

The options for treating such patients include amputation by hip disarticulation or limb preserving surgery. Limb preserving surgery is better accepted by patients, is more cost effective in the long term, and is associated with significantly lower oxygen consumption and energy requirements per meter walked compared to amputation.1, 2 Moreover, patients' survival is not improved by amputation.3 The choices available for reconstruction in such patients include the use of endoprostheses, allograft or rotationplasty.4, 5, 6, 7, 8, 9, 10, 11, 12, 18

We carried out a retrospective review of patients treated with Total Femur Endoprosthetic Replacement (TFEPR) at our centre over the past 30 years to identify the factors which affect survival, complications and function following TFEPR.

Section snippets

Data collection and ethics

This was a retrospective analysis of data which had been collected prospectively onto our oncology database with further reference to patient charts and radiographs where necessary. Institutional review board ethical approval was granted prior to the study being undertaken.

Tumour diagnosis, staging of tumour,13 treatment and outcome data was obtained from the database. Functional outcomes were collected on surviving patients using the revised Musculo-skeletal Tumour Society (MSTS) system15 and

Patient survival

Kaplan Meier survival curves are shown in Fig. 2. Survival of the patients was related to their oncologic diagnosis. None of the eight patients with metastases at diagnosis undergoing palliative resection were alive at long followup. However, survival of patients with a primary malignant bone tumour without metastases was 50% at 5 years. Eleven patients were alive with an overall mean followup of 105 months (range 9–348), nine patients being free of disease.

Local recurrence

Local recurrence was seen in patients

Discussion

The last few decades have witnessed increased popularity and wider acceptance of endoprosthetic replacement in treating patients with malignant conditions of the bone due to the availability of effective chemotherapy, improved prosthetic design, availability of modular endoprosthesis and increasing experience in the use of these implants.

Total Femur Endoprosthetic Replacement is a major surgical reconstructive procedure for patients with a bone tumour involving the entire femur. The procedure

Conclusion

We believe that our series presents the results of what can be expected in the long term for patients with malignant bone tumours who require total femur endoprosthetic replacement. This form of reconstruction provides predictable results after excisions of the femur for malignant tumours. The complications are comparable to those for similar procedure performed for non-tumour cases even though those with a tumour have more muscle resection and are immunologically challenged from adjuvant

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