This article is more than 5 years old. Information may no longer be current.
Femoral arthroplasty yields good results in patients with prosthetic disease
Procedure offers surgeons an option for patients with severely compromised femurs.
Click Here to Manage Email Alerts
ORLANDO, Fla. – In a recent study, total femoral arthroplasty produced good functional outcomes, low complication rates and pain relief in patients with end-stage prosthetic disease.
Fifty-nine patients (average age 73.7 years) with various revision total hip or knee arthroplasties (THA, TKA), failed periprosthetic fractures or multiple debridements for recurrent infection were treated with total femoral arthroplasty to salvage a severely compromised femur.
Courtesy of Adolph Lombardi Jr. |
At an average 4.8-year follow-up, Harris Hip Pain scores averaged 33.8 points out of 44. Knee pain scores averaged 42.8 points out of 50. At follow-up 98% of patients could walk – 43% without an assistive device or with a cane only. Researchers found 18 complications or subsequent surgeries. Eight patients experienced infection and seven had dislocations.
“When you don’t have that bone to work with, such as in a comminuted periprosthetic fracture between an ipsilateral total hip and a total knee with failed fixation, your choices are quite limited,” Adolph Lombardi Jr., MD, FRCS, of the New Albany Surgical Hospital in Columbus, Ohio, said at the 22nd Annual Current Concepts in Joint Replacement Winter 2005 meeting.
Lombardi and his colleagues performed 75 total femoral arthroplasties in 75 patients from 1987 to 2005. However, he notes, “You are occasionally going to get a significant problem, such as three that had a disarticulation for recurrent infection.”
Preparation
Lombardi presented the total femoral arthroplasty technique, using the example of a 64-year-old man with severe rheumatoid arthritis, a loosened hip, failed knee and diagnosed infection. With lysis and a failing distal femoral allograft construct, the surgeons used a homegrown PROSTALAC (prosthesis with antibiotic-loaded acrylic cement) Hip System that contained 4 g of vancomycin and 4.8 g of tobramycin per polymethylmethacrylate unit.
Surgeons placed the patient in a semilateral dicubitous position, first approaching the hip to reduce bleeding and making a separate incision in the knee. They used a multi-hold cup for good fixation, multiple screws and a constrained liner that allowed 114º of motion.
After situating the liner, the surgeons completed the acetabulum and opened the knee using the previous standard medial incision and removed the PROSTALAC through the knee incision.
The procedure
Lombardi used a custom stem for the reconstruction process in this particular case. He slid the guide into the tibia and reamed over the IM guide to size the tibia and set the tibial plateau. “We reamed up and sized to make sure that we can fit the device in appropriately,” Lombardi said. “These are big exposures and you have to proceed carefully.”
The surgeons then introduced the total femur from the knee, reducing the small amount of remaining tissue and ensuring the length was adequately restored. “Frequently, these individuals are contracted and short and have a difficult time actually restoring their entire leg length,” Lombardi said. “Or if you try to do that, you have difficulty then in getting appropriate patellar femoral tracking.”
Lombardi and his colleagues found a cone-shaped deficit in the proximal tibia and so used a modular cone on the tibial component. “Certainly we’re going to use a rotating hinge-style knee here … because of the lack of ligamentous support,” he said.
They introduced the final component through the knee, into the wound and then articulated at the knee and hip. “We’re going to again just make a cursory judgment on length and get it reduced and you have to then assemble your knee segment,” Lombardi explained.
For the knee segment, Lombardi said they used an antiluxation rotating hinge to make up for the lack of ligamentous support. After assembling the device, he then closed the incision.
This procedure is appropriate for patients with several failed massive reconstructive efforts for THA and TKA who may not have sufficient bone stock for meaningful femoral component fixation, he said.
For more information:
- Lombardi A. Dealing with severe femoral bone loss: a total solution. #57. Presented at 22nd Annual Current Concepts in Joint Replacement Winter 2005. Dec. 14-17, 2005. Orlando, Fla.