Biarticular total femur spacer for massive femoral bone loss: the mobile solution for a big problem

Abstract

Bone cement spacers loaded with antibiotic are the gold standard in septic revision. However, the management of massive bone defects constitutes a surgical challenge, requiring the use of different nails, expensive long stems, or cement-coated tumor prostheses for preparing the spacer. In most cases, the knee joint must be sacrificed. We describe a novel technique for preparing a biarticular total femur spacer with the help of a trochanteric nail coated with antibiotic loaded cement, allowing mobility of the hip and knee joints and assisted partial loading until second step surgery. This technique is helpful to maintain the length of the leg, prevent soft tissue contracture, and help eradicate the infection preserving the patient comfort and autonomy while waiting to receive total femoral replacement.

Preliminary outcomes of proximal femur megaspacers

“… [27] and Saez-Ruiz et al. [28] have reported 2 different techniques for the fabrication of total femur megaspacers in patients with total femur bone stock loss. These 2 surgical strategies have the same objective: to control infection to make a prosthetic reconstruction possible.…”

“…We believe that the invasion of the proximal tibia could pose a risk of infection dissemination in a sterile bone. The distal femur resection described by Canhan [27] and Saez-Ruiz [28] brings about new knee instability, thus making it necessary for patients to use a knee orthosis for light toe-touch weight-bearing ambulation. Our spacer design intends to allow full weight-bearing ambulation after 3 weeks (the time required for soft tissue healing).…”

“…Our spacer design intends to allow full weight-bearing ambulation after 3 weeks (the time required for soft tissue healing). The authors [27] , [28] describe a posterolateral approach because of extensile properties. While they perform large approaches that will potentially damage the soft tissue envelope, we intend to preserve it because we believe that it is of capital importance for fracture healing and effective antibiotic delivery.…”

Progress of antibiotic-loaded bone cement in joint arthroplasty

“…[ 85 ] Multi-antibiotic-loaded cement played an essential role in application of a total femur spacer and filling. [ 86 , 87 ] New bone defect filling and cement fixation techniques are still being designed. [ 88 – 91 ] Some questions have developed in the process and remain unsolved.…”

Creating a dual articulating antibiotic spacer for management of an infected total femur prosthesis hemiarthroplasty

“…While initial techniques described in the literature demonstrated articulating hip joints with a fixed knee joint [17], [18], [19], [20], total knee arthroplasty literature has shown improvements in range of motion (ROM) as well as improved soft-tissue management at the definitive surgery when an articulating spacer is used, which has led toward the favoring of a dual articulating spacer [21], [22]. To our knowledge, 3 techniques describing dual articulating total femur spacers have been described to date, with each involving an acetabular cup at the definitive procedure [23], [24], [25]. Here, we present our surgical technique for manufacturing a dual articulating total femur spacer which allows preservation of the native acetabulum using a hemiarthroplasty head, modular proximal femur body, femoral intramedullary nail, and a commercially available injection-molded articulating distal femur.…”