Total femur replacement, indications for the procedure and its complications: a systematic review

Total femur replacement (TFR) is a solution that allows orthopedic surgeons to address the most complicated cases in hip, femur, and knee reconstruction. Complete femur prostheses are used in both oncologic patients with femur tumors that require resection and in cases of complicated prosthetic failure with massive bone defects. TFR is an alternative to hip disarticulation that allows the patient to spare the limb and preserve its function. However, the indications for surgery vary and the procedure has been reported to present a high risk of serious complications.

We follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. An electronic database was searched for articles reporting indications, complications, and primary diagnoses prior to TFR. We reviewed study type, number of patients, and complications reported in the study.

15 articles including 651 patients were analyzed. Primary diagnoses before TFR can be divided into two groups: oncological and non-oncological. In some articles, there is no clear demarcation between the indications for the surgery and the primary diagnosis prior to TFR. The most common primary diagnosis in oncological patients was osteosarcoma (48,3%) and in non-oncological patients it was osteoarthritis (42,2%). The most common indications for the procedure were oncological (50,8%), followed by fracture (17,1%) and loosening (8,9%). The most common categories of postoperative complications were infection (32,4%), soft tissue failure (13,9%), and dislocation (12,9%).

Surgeons must be aware of the high risks of complications related to the procedure and should qualify their patients after careful mutual consideration and with a personal approach to potential risks and an overall prognosis. All percussions should be made to avoid periprosthetic infection as main complication. After the surgery any findings indicating possible infection should be investigated to avoid implant failure. High risk of dislocation indicates that more constrained or dual-mobility cups should be considered.