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

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

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

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Arch Orthop Trauma Surg (2010) 130:171–176
Fig. 2 a Pre-operative digital radiograph of case 6 with osteosarcoma
of the mid femur with pathologic fracture Wxed with external Wxator.
b MRI (Coronal, T2-weighted image) showing intramedullary dissem-
ination of the tumor with possible contamination by the external Wxator
sarcomas, and one metastatic tumor. The indications for
such a procedure seems to be very rare since those nine
patients were collected from the whole bone and soft-tissue
sarcoma series treated at the same period at authors’ institute.
Occasionally, total femur replacement will be required
as a revision surgery after the failure of previous attempt at
limb salvage surgery, in metabolic bone diseases, or for
revision of failed arthroplasties [12].
Recently, Mankin et al. [10] described 15 patients with
total femur replacement, their patients were heterogeneous
group of patients not only in the pathology underlying
removal of the whole femur which included neoplastic and
non-neoplastic conditions, but also the type of reconstruc-
tion was heterogeneous which included ten patients with
allografts implanted with total hip replacement and total
knee replacement implants, and Wve patients only had
metallic implants. Our group patients although they are
small in number only nine but they all suVer from sarcoma
and all treated by a single method of reconstruction using a
metallic total femur with bipolar femoral head and con-
strained total knee. Although the diVerence between our
group of patients and that of Mankin et al. is evident, we
share with them the diYculty of the technique and the com-
plexity of the reconstruction [10].
Although our series is small, the functional results for
the hip and knee were excellent or good. It is imperative to
select those patients in which at least either the hip abduc-
tors or the knee extensors could be saved. This was also
reported by Morris et al. Lack of these muscles produced a
poor functional result as the patients cannot control their
limbs. Lack of the quadriceps will place an undue strain on
175
pins done at another hospital. c Pre-operative radiograph showing
healed fracture. d, e Radiographs of the hip and knee demonstrating
excellent stability and Wxation of the prosthesis
the hinge mechanism since the patient walks with a passive
extension gait which may lead to early failure. If complete
excision of the quadriceps is indicated as a part of the surgi-
cal margin, then arthrodesis of the knee joint might be the
appropriate choice for those patients.
The advantages of the modular endoprosthesis used in
this study manifested by its easy to assemble during sur-
gery, so the problems using custom-made prostheses are
avoided. The bipolar hip is easier to insert than a conven-
tional acetabular socket; it is inherently more stable, and
better than uni-polar type of prothesis with regard to long-
term wear. These Wndings are in line with those reported
previously.
We have had no postoperative dislocation with this sys-
tem. One tibial component failed but revision surgery was
not done as the function was still good.
Osteotomising the greater trochanter and its re-attach-
ment with its abductors to the prosthesis is a good
method for maintaining the hip abduction and to provide
soft-tissue stability to the reconstructed hip, provided
that it will not compromise the surgical margin. How-
ever, if resection of the trochanter or the abductors is
indicated then re-attachment of the remaining abductors
to the prosthesis and moreover to the tensor fascia lata is
another alternative, to maintain hip stability and to
improve the gait.
Previous reports have showed variable results and most
show high complication rate, so this procedure should only
be considered when the alternative is hip disarticulation and
the patient should be informed of the potential risk of this
massive reconstruction.
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176
Maintaining abductors of the hip and extensors of the
knee are the main stay for succession of this procedure.
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