CLINICAL ORTHOPAEDICS AND RELATED RESEARCH

Number 400, pp. 225–235

© 2002 Lippincott Williams & Wilkins, Inc.

Distal Femur Resection With

Endoprosthetic Reconstruction
A Long-Term Followup Study

Jacob Bickels, MD*; James C. Wittig, MD*;

Yehuda Kollender, MD**; Robert M. Henshaw, MD*;
Kristen L. Kellar-Graney, BS*; Issac Meller, MD**;
and Martin M. Malawer, MD*

The distal femur is a common site for primary was estimated to be good or excellent in 94 pa-
and metastatic bone tumors and therefore, it is tients (85.4%), moderate in nine patients (8.2%),
a frequent site in which limb-sparing surgery is and poor in seven patients (6.4%). Complica-
done. Between 1980 and 1998, the authors treated tions included six deep wound infections (5.4%),
110 consecutive patients who had distal femur six aseptic loosenings (5.4%), six prosthetic poly-
resection and endoprosthetic reconstruction. ethylene component failures (5.4%), and local
There were 61 males and 49 females who ranged recurrence in five of 93 patients (5.4%) who had
in age from 10 to 80 years. Diagnoses included a primary bone sarcoma. The limb salvage rate
99 malignant tumors of bone, nine benign- was 96%. Distal femur endoprosthetic recon-
aggressive lesions, and two nonneoplastic condi- struction is a safe and reliable technique of func-
tions that had caused massive bone loss and ar- tional limb sparing that provides good function
ticular surface destruction. Reconstruction was and local tumor control in most patients.
done with 73 modular prostheses, 27 custom-
made prostheses, and 10 expandable prostheses.
Twenty-six gastrocnemius flaps were used for The distal femur is a common anatomic loca-
soft tissue reconstruction. All patients were fol- tion for primary and metastatic bone tumors.6,7
lowed up for a minimum of 2 years. Function
These tumors traditionally were treated with re-
section arthrodesis or amputation of the extrem-
From the * Department of Orthopedic Oncology, Wash- ity, with unfavorable functional and psycho-
ington Cancer Institute, Washington Hospital Center, logic outcomes.9,27 Improved survival among
George Washington University, Washington DC; and
**The National Unit of Orthopedic Oncology, Tel-Aviv patients with sarcomas made these drawbacks
Sourasky Medical Center, Sackler Faculty of Medicine, even more pronounced and stimulated the in-
Tel-Aviv University, Tel-Aviv, Israel. vestigation of a less aggressive surgical ap-
Reprint requests to Martin M. Malawer, MD, Department proach. Simon et al26 compared the results of
of Orthopedic Oncology, Washington Cancer Institute,
Washington Hospital Center, 110 Irving Street, NW, limb-sparing resections with those of amputa-
Washington, DC 20010. tion in 227 patients who had an osteosarcoma of
Received: May 7, 2001. the distal femur. They concluded that doing a
Revised: September 18, 2001. limb-sparing procedure in lieu of amputation
Accepted: October 11, 2001. did not shorten the disease-free interval or com-

225
 Clinical Orthopaedics
226 Bickels et al and Related Research

promise the long-term survival of these pa- noma to the distal femur. Nine patients had benign-
tients.26 Cosmesis and function, however, were aggressive lesions, and two patients had massive
much better, with preservation of knee motion bone loss and destruction of the articular surface at-
and ability to ambulate. tributable to nonneoplastic diagnoses. Table 1 shows
the histopathologic diagnoses and surgical classifi-
The use of induction chemotherapy, coupled
cation of the patients in this series.10
with advances in imaging and surgical tech- Complete staging studies were done before
niques, now make it possible to do distal femur surgery for all patients with primary bone sarcoma.
endoprosthetic reconstruction in 90% to 95% of Imaging studies included plain radiography, com-
patients with primary bone sarcoma of this puted tomography (CT), and magnetic resonance
site.12,13,19,20,23,25,28 Grimer et al11 showed that a imaging (MRI) of the entire thigh, knee, and leg.
limb-sparing resection with endoprosthetic re- Particular attention was given to tumor extent
construction clearly is more cost-effective than through the distal femur, the anatomic location and
amputation. The reason for this finding is that extent of cortical breakthrough, and magnitude of
most patients with primary bone sarcoma are soft tissue extension and its relation to the popliteal
young and active. If treated by amputation, they vessels. When posterior cortical breakthrough was
present, angiography also was done to evaluate
probably will require a sophisticated artificial
more accurately the patency of the popliteal vessels
limb that has to be replaced at regular intervals, and their relation to the tumor.
and may include the use of an artificial sport
limb, swimming limb, and spare limb. In addi- Surgical Technique
tion, most patients will have stump problems Distal femur resection with endoprosthetic recon-
develop that will necessitate recasting of the struction has three steps: tumor resection, endopros-
socket.11 Successful experience with distal fe- thetic reconstruction, and soft tissue reconstruc-
mur endoprosthetic reconstruction led to its use tion.3,12,19 Each step is summarized.
in the treatment of metastatic bone tumors and
nononcologic diagnoses.1,18,29 Between 1980 Tumor Resection
and 1998, the authors did distal femur resection The patient is placed in the supine position on the
with endoprosthetic reconstructions in 110 con- operating table, and a long medial incision is made.
secutive patients. The current study was done at The incision begins in the midthigh, crosses the
two oncology centers, using the same technique knee along the medial parapatellar area and distal
of resection and reconstruction. On the basis of to the tibial tubercle, and then slightly curves pos-
terior to the pes muscles. The biopsy site is in-
this long-term experience, principles of distal
cluded, with a 2-cm margin in all directions. This
femur resection with endoprosthetic recon- incision enables wide exposure of the distal 1⁄2 of the
struction with emphasis on surgical anatomy, femur, sartorial canal, knee, popliteal fossa, and
surgical technique, and functional and onco- proximal 1⁄2 of the tibia. Distal extension of the in-
logic outcomes are presented. cision allows the use of a gastrocnemius flap, if
necessary. The popliteal space is approached by de-
MATERIALS AND METHODS taching and retracting the medial hamstrings. This
exposes the popliteal vessels and sciatic nerve.
Between 1980 and 1998, 110 consecutive patients The interval between the popliteal vessels and
had distal femur resection with endoprosthetic re- the posterior femur then is developed by ligation
construction. Patients were treated at two institu- and transection of the geniculate vessels. The dis-
tions; all participating surgeons were trained to- tal femur is approached via the interval between the
gether and used the same techniques of resection and rectus femoris and vastus medialis, leaving the in-
reconstruction. There were 61 males and 49 females tact vastus intermedius over the distal femur. A
who ranged in age from 10 to 80 years (median, 21.5 portion of the vastus medialis is left over the me-
years). Nineteen patients were younger than 12 dial soft tissue extension of the tumor. Alterna-
years. Ninety-three patients had primary bone sarco- tively, a portion of the vastus lateralis is left over a
mas, five patients had other primary malignant tu- lateral soft tissue extension. The joint capsule then
mors of bone, and one patient had metastatic carci- is opened longitudinally along its anteromedial
Number 400
July, 2002 Distal Femur Resection With Endoprosthetic Reconstruction 227

TABLE 1. Histopathologic Diagnoses and Surgical Staging of 110 Patients Treated

With Distal Femur Endoprosthetic Reconstruction
Enneking’s Surgical
Classification10
Number of
Histologic Diagnoses Patients IA IB IIA IIB IIB

Primary bone sarcomas Osteosarcoma 74 — 5 1 67 1

Chondrosarcoma 5 — 1 — 4 —
Malignant fibrous histiocytoma 5 — — 2 3 —
Ewing’s sarcoma 4 — — — 4 —
Pleomorphic sarcoma 2 — — — 2 —
Primitive neuroectodermal tumor 1 — — — 1 —
Synovial cell sarcoma 1 — — — 1 —
Leiomyosarcoma of bone 1 — — — 1 —
Other primary malignant Lymphoma of bone 4 NA NA NA NA NA
tumors of bone Multiple myeloma 1 NA NA NA NA NA
Metastatic lesions Malignant melanoma 1 NA NA NA NA NA
Benign-aggressive tumors Giant-cell tumor 8 NA NA NA NA NA
Synovial chondromatosis 1 NA NA NA NA NA
Nonneoplastic diagnoses Osteoarthritis 1 NA NA NA NA NA
Osteoporosis 1 NA NA NA NA NA
Total 110 — 6 3 83 —

NA ⫽ nonapplicable

border and ligaments and menisci are removed. metastatic carcinomas. A tibial osteotomy then is
Distal femur osteotomy is done at the appropriate done to allow the introduction of the prosthetic tib-
location as determined by the preoperative imaging ial component. It is done in the same manner as a
studies (Fig 1). In general, 3 to 4 cm beyond the standard knee arthroplasty; approximately 1 cm of
point of proximal tumor extension is appropriate bone is removed. The osteotomy is perpendicular
for primary sarcomas; 1 to 2 cm is sufficient for to the long axis of the tibia.

Fig 1. A distal femur osteotomy is

shown. An intact layer of the vastus in-
termedius muscle is left over the
specimen. Reprinted from Malawer M.
Chapter 30 “Distal Femoral Resection
with Endoprosthetic Reconstruction”
In Malawer MM, Sugarbaker PH Mus-
culoskeletal Cancer Surgery: Treat-
ment of Sarcomas and Allied Diseases.
Kluwer Academic Publishers Dordrecht
2001. Page 475
 Clinical Orthopaedics
228 Bickels et al and Related Research

Endoprosthetic Reconstruction sential. Based on the linea aspera and tibial tuberos-
Since their introduction in the mid1980s, modular ity as the remaining anatomic guidelines, the femo-
prostheses were used preferably for reconstruction ral and tibial components are placed in line with
(Fig 2). Custom-made prostheses were used only in both. The cementing technique involved pulsatile
cases requiring unusual stem length or diameter. Ex- lavage, use of an intramedullary cement restrictor,
pandable prostheses were used in patients younger reduction of the cement by centrifugation, use of ce-
than 12 years. The largest possible stem diameter ment gun, and pressurization of the cement. Patellar
was used. The canal was reamed 2 mm larger than resurfacing is not done routinely because most pa-
the chosen stem diameter. Trial articulation initially tients who have this procedure are young and with-
was done; the device used for this step in the proce- out significant degenerative changes in the patella.
dure includes a femoral stem, body, condyle compo-
nents, axle and polyethylene bushings, and tibial Soft Tissue Reconstruction
bearing and plug components. Special attention is given to covering the prosthesis
The definitive modular prosthesis then is assem- completely with muscle tissue. The remaining vastus
bled (Fig 3). Exact orientation of the prosthesis is es- medialis is sutured to the rectus femoris. The sarto-

A B

Fig 2. (A) Schematics (Reprinted from Malawer M. Chapter 30 “Distal Femoral Resection with Endopros-
thetic Reconstruction” In Malawer MM, Sugarbaker PH Musculoskeletal Cancer Surgery: Treatment of Sar-
comas and Allied Diseases. Kluwer Academic Publishers Dordrecht 2001. Page 479) and (B) an assem-
bled modular, kinematic rotating-hinge distal femur prosthesis are shown (Howmedica, Rutherford, NJ).
Number 400
July, 2002 Distal Femur Resection With Endoprosthetic Reconstruction 229

B C

Fig 3A–C. (A) Installation of the definitive modular prosthesis is shown. Reprinted from Malawer M.
Chapter 30 “Distal Femoral Resection with Endoprosthetic Reconstruction” In Malawer MM, Sugar-
baker PH Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Kluwer Aca-
demic Publishers Dordrecht 2001. Page 480 (B) Anteroposterior Reprinted from Malawer M. Chapter
30 “Distal Femoral Resection with Endoprosthetic Reconstruction” In Malawer MM, Sugarbaker PH
Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Kluwer Academic Pub-
lishers Dordrecht 2001. Page 467 and (C) lateral plain radiographs obtained at the 9-year followup
show a modular endoprosthetic reconstruction of the distal femur after resection of an osteosarcoma
(Howmedica, Rutherford, NJ).
 Clinical Orthopaedics
230 Bickels et al and Related Research

Fig 4. Soft tissue reconstruction with the remaining vastus medialis muscle and mobilization of the sar-
torius muscle is shown. Reprinted from Malawer M. Chapter 30 “Distal Femoral Resection with Endo-
prosthetic Reconstruction” In Malawer MM, Sugarbaker PH Musculoskeletal Cancer Surgery: Treat-
ment of Sarcomas and Allied Diseases. Kluwer Academic Publishers Dordrecht 2001. Page 480

rius muscle can be mobilized and rotated anteriorly edema. Continuous suction is required for 3 to 5
for additional closure of the remaining medial soft days, and prophylactic intravenous antibiotic ther-
tissue defect (Fig 4). A large defect requires a medial apy is continued until the drainage tubes are re-
gastrocnemius transfer (Fig 5).21 Similarly, a lateral moved. Knee motion is restricted in an immobiliz-
defect is closed with a lateral gastrocnemius transfer. ing brace for 2 to 3 weeks to allow healing of the
surgical flaps and until the extensor mechanism is
Postoperative Treatment functional. During that time, isometric exercises
The lower extremity is elevated for 3 days, until the are done and weightbearing is allowed.
first postoperative wound check, to prevent wound All patients were followed up for a minimum of

Fig 5. A medial gastrocnemius flap is used to close the remaining medial defect. Reprinted from
Malawer M. Chapter 30 “Distal Femoral Resection with Endoprosthetic Reconstruction” In Malawer
MM, Sugarbaker PH Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases.
Kluwer Academic Publishers Dordrecht 2001. Page 481
Number 400
July, 2002 Distal Femur Resection With Endoprosthetic Reconstruction 231

TABLE 2. Prosthesis Type and Followup of 110 Patients Treated With Distal Femur
Endoprosthetic Reconstruction
Followup
Prosthesis Type 2 to 5 Years 5 to 10 Years More than 10 Years

Custom 5 6 16
Modular 25 36 12
Expandable 2 6 2
Total (percent) 32 (29.1%) 48 (43.6%) 30 (27.3%)

2 years (range, 2–16.5 years; median, 7.8 years). strained knee mechanism; the remaining pa-
Twelve patients were lost for followup after an av- tients had reconstruction with a rotating-hinge
erage of 5.2 years (range, 3.5–8 years). Table 2 knee mechanism. Twenty-one medial, three lat-
shows the followup of the patients in this series ac- eral, and one bilateral gastrocnemius flaps were
cording to the prosthesis type. For the first 2 years af-
used for soft tissue reconstruction. Ten patients
ter surgery, patients were evaluated every 3 months.
On each visit, physical examination, plain radio-
with expandable prostheses had 14 expansions.
graphs, and chest CT scans were done. Patients The time to the first expansion ranged from 9 to
were evaluated semiannually for an additional 3 31 months and the average length of each ex-
years and annually thereafter. An orthopaedic on- pansion was 1.8 cm (range, 1–2 cm).
cologist analyzed the clinical records, imaging stud- Function was estimated to be good or ex-
ies, and operative reports. The histopathologic diag- cellent in 94 patients (85.4%), moderate in
noses, techniques of endoprosthetic and soft tissue nine patients (8.2%), and poor in seven patients
reconstruction, complications, and rates of local (6.4%). Patients who had reconstruction with a
tumor recurrence and revisions were determined. rotating-hinge knee mechanism were more
Functional evaluation was based on direct patient likely to have a good-to-excellent functional
examination by one of the authors and done accord-
outcome (91%) than those who had reconstruc-
ing to the American Musculoskeletal Tumor Society
System.8 This system assigns numerical values of
tion with a constrained knee mechanism (50%).
each of six categories: pain, function, emotional ac- Complications included six deep wound in-
ceptance, supports, walking, and gait.8 Prosthetic fections (5.4%), which resulted in three ampu-
survival analysis was based on the Kaplan-Meier tations, two prosthetic revisions, and one wound
survival estimates and log rank and Breslow tests debridement. Overall, there were 15 revision
were used to evaluate statistical significances.16 Re- surgeries; these included replacement of a
sults presented here are based on each patient’s most failed polyethylene component in six patients
recent followup. and prosthetic revision in nine patients (asep-
tic loosening, six; deep infection, two; radia-
RESULTS tion bone necrosis, one). Two of the polyeth-
ylene component failures occurred in the same
One-hundred ten patients with lesions of the patient; the first occurred 2.5 years after the
distal femur had distal femur resection and en- initial surgery and the second occurred 3.8
doprosthetic reconstruction. Extraarticular re- years later. Polyethylene failures occurred af-
section of the knee was done in only two of ter an average of 3.7 years (range, 1.25–7.25
these patients, both of whom had a primary years) and aseptic loosenings occurred after an
bone sarcoma with tumor extension into the average of 5.5 years (range, 3.2–10.3 years).
knee along the cruciate ligaments. Reconstruc- During revision of their prostheses, all pa-
tion devices included 73 modular prostheses, tients who were operated on because of a loos-
27 custom-made prostheses, and 10 expand- ened prosthesis were found to have a con-
able prostheses. Only eight patients had a con- comitant failure of a polyethylene component.
 Clinical Orthopaedics
232 Bickels et al and Related Research

A B

Fig 6. (A) Kaplan-Meier analysis was done of survivorship of custom, modular, and expandable distal
femur prostheses, and (B) the survivorship of overall distal femur prostheses. The overall survivorship
of prostheses was 93% at 5 years and 88% at 10 years; survivorships of custom, modular, and ex-
pendable prostheses were not significantly different.

The overall prosthetic survivorship was 93% at the authors’ experience with 110 consecutive pa-
5 years and 88% at 10 years; custom, modular, tients who had this procedure and had a long-
and expendable prosthetic survivorships were term followup. Used in reconstructive surgery,
not significantly different (log rank, 0.83; Bres- cemented endoprosthetic reconstruction pro-
low, 0.94). Figure 6 shows the Kaplan-Meier vides immediate stability and allows early mobi-
prosthetic survivorship analysis and Table 3 lization and weightbearing.19 Initially, custom-
shows the prosthesis type, functional outcome, made prostheses were used. The preoperative
and indications for prosthetic revisions. design and manufacturing processes required 8
Local recurrence developed in five of 93 pa- to 10 weeks; this caused a significant delay in the
tients with primary bone sarcomas (5.4%). Four timing of resections. A second drawback of
patients were treated with wide local excision custom-made prostheses was the difficulty in
with preservation of the prosthesis and adjuvant determining the actual length and width of the
radiation therapy. Amputation was done in the resected bone on the basis of imaging modalities
fifth patient. A fifth recurrence occurred in a pa- alone.12,28 Introduced in mid1980s, modular
tient with a giant cell tumor of bone. It occurred prostheses revolutionized endoprosthetic recon-
in the soft tissues and was treated with a wide struction. This system enables the surgeon to
local excision. Overall, there were four ampu- measure the actual bone defect at the time of
tations. The limb salvage rate was 96%. surgery and select the most appropriate compo-
nents to use in reconstruction. Components of
DISCUSSION these interchangeable systems include articulat-
ing segments, bodies, and stems of varying
The purpose of this paper was to describe the lengths and diameters. A key design feature in-
functional and oncologic outcomes of distal fe- cludes extensive porous coating on the extracor-
mur endoprosthetic reconstruction. It is based on tical portion of the prostheses for bone and soft
Number 400
July, 2002 Distal Femur Resection With Endoprosthetic Reconstruction 233

tissue fixation.12 Custom-made prostheses cur-

Radiation Bone
rently are used by the authors in cases requiring

Necrosis
TABLE 3. Prosthesis Type, Functional Outcome, and Prosthetic Revision of 110 Patients Treated With Distal Femur an unusual stem length or diameter.

—
1

1
A wide resection of a high-grade sarcoma of
the distal femur necessitates en bloc removal of
the surrounding cuff of muscles, joint capsule,
Indications for Prosthetic Revision

and ligaments.13,19 After this resection, joint

stability is determined primarily by the me-
Infection
chanical properties of the prosthesis. The early
Deep

—
devices entailed a constrained, hinged-knee
1
1

2
mechanism that allowed only flexion and ex-
tension with no rotation capability. The con-
strained hinge mechanism was associated with
high rates of mechanical failures because forces
Polyethylene

were not distributed appropriately around the

Failure

knee; Inglis and Walker reported fracture

4
2

around the prosthetic femoral stem as being the

most common failure mechanism of constrained
prostheses, occurring in 38% of their patients.15
This was followed by infection (20%) and frac-
ture around the prosthetic tibial stem (5%).15
Loosening
Aseptic

Capanna et al3 reported 95 patients who had

2
3
1
6

distal femur endoprosthetic reconstruction with

a constrained hinge mechanism. They also re-
ported an exceedingly high rate of prosthetic
failure; 28 patients (29.5%) had failure of the
Poor

polyethylene bushing and six patients (6.3%)

3
3
1
7

had fracture of the prosthetic stem. Kawai et

al17 reported a similar experience. In their se-
ries of 40 patients, aseptic loosening occurred
Moderate
Functional Outcome8

and required revision surgery in 11 patients

(27.5%).17 As a result, Roberts et al23 who re-
—
5
4

ported a 64% survival rate of hinged distal fe-

mur prostheses after 7 years, recommended that
hinged mechanisms should not be used for re-
vision of a failed knee prosthesis.
Endoprosthetic Reconstruction

Good-to-Excellent

The use of the kinematic rotating-hinge knee

mechanism (Howmedica, Rutherford, NJ) al-
lowed external and internal rotations of the
19
66

94
9

knee, in addition to flexion and extension. Be-

cause of its improved biomechanical proper-
ties, this design was associated with better func-
tion and was expected to achieve lower rates of
loosening.4,29 In 1993, Shih et al24 compared
Prosthesis

the functional outcome of 45 patients who had

Expandable

a constrained distal femur endoprosthetic re-

Modular
Custom
Type

construction with that of 16 patients who had

Total

reconstruction with a rotating-hinge prosthesis.

 Clinical Orthopaedics
234 Bickels et al and Related Research

Good-to-excellent functional outcomes were greater than 2 years, as that period is the min-
achieved in 33% and 69%, respectively.24 A imum time required in reporting functional
modular, rotating-hinge, endoprosthetic recon- outcome in patients who have had a recon-
structive device was used in the majority of the structive surgical procedure.
patients in the current study and was associated The oncologic objective of distal femur re-
with a better functional outcome than that of the sections is to achieve local tumor control. Pa-
constrained hinged-knee mechanism. tient survival will be determined by the pres-
The presence of polyethylene components ence of metastatic disease and its response to
within the metal prosthetic knee mechanism adjuvant treatment modalities. The rate of local
allows a staged mechanical failure pattern, ac- recurrence is the most appropriate criterion
cording to which polyethylene components fail with which to evaluate the oncologic adequacy
first and doing so, may prevent additional loos- of distal femur resection. Only five of the 93
ening of the prosthesis. This assumption was (5.4%) patients in the current series who were
supported by the findings of the current study, treated for primary bone sarcomas had local re-
which showed that all patients who had a loose currence of their disease. That rate is within the
prosthesis had concomitant failure of a poly- range expected after limb-sparing procedures.22
ethylene component, and patients who had fail- Distal femur endoprosthetic reconstruction was
ure of a polyethylene component presented ear- shown to be a safe and reliable technique of
lier than patients who had prosthetic loosening. reconstructing a large bony defect, providing
This safety mechanism allows less extensive good functional and oncologic outcomes in
revision surgeries because, compared with re- most patients. Although primarily used in the
vision of a loosened prosthesis, replacing a treatment of primary bone sarcomas, distal fe-
failed polyethylene component requires lim- mur endoprosthetic reconstruction also can be
ited surgical exposure and is associated with a used in the treatment of metastatic bone disease
shorter rehabilitation period. Overall, six pa- and nononcologic diagnoses.
tients (5.4%) had their prosthesis revised be-
cause of aseptic loosening. This rate compares References
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