Citing the paucity of evidence to guide decision making when it comes to total femoral replacement, researchers from multiple centers banded together in an attempt to examine outcomes. Their work, “Nonmechanical Revision Indications Portend Repeat Limb-Salvage Failure Following Total Femoral Replacement,” appears in the September 2, 2020 edition of The Journal of Bone and Joint Surgery.
Updated Femoral Replacement Failure Statistics
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Eric Henderson, M.D., assistant professor of Orthopaedics at the Geisel School of Medicine, Dartmouth College in Hanover, New Hampshire, and co-author on the study explained the difficulties with total femoral replacement to OTW, “Total femoral replacement is a very uncommon operation that is technically challenging and has a high failure rate. By combining the outcomes at eight different sites we hoped to shed some light on patient outcomes and be able to provide more meaningful data to guide surgeons and counsel patients.”
In this retrospective cohort study, the researchers looked at 166 patients who received femoral endoprostheses for oncological and revision arthroplasty indications. They looked at patient variables (age, sex, diagnosis group, indication), treatment variables, as well as implant variables (model, decade, length, materials). Failures were analyzed in terms of patient variables, operative technique and time to failure.
Treatment failed for 44 patients (27%), with failure occurring in 24 (23%) of 105 primary total femoral replacements and in 20 (33%) of 61 revision total femoral replacements (the difference was not significant in bivariate analysis but was significant in the multivariate analysis.
Of those experiencing mechanical failure, none had a reoccurrence of their original failure mode; however, all 8 patients from the nonmechanical cohort experienced a reoccurrence of the original failure mode (this difference was statistically significant).
Dr. Henderson: “The most compelling finding we encountered was that patients who had total femoral replacement as a revision procedure for infection or cancer recurrence, and who subsequently went on to have a repeat failure, all had failure by the same mechanism as before.”
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Discussion
This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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