Distal femoral replacement - Cemented or cementless? Current concepts and review of the literature

Abstract

Distal femoral endoprosthetic replacement has been successfully used to reconstruct distal femoral defects after tumor resection for over four decades. Despite continued advances, aseptic loosening continues to be the most common failure mode after infection. Debate still exists about a variety of design features and the optimal fixation method remains controversial. To date, no large-scale study or meta-analysis has demonstrated the superiority of one fixation technique over another. While the classic dichotomy of cemented versus cementless stems is well-known, the contemporary surgeon needs to fully understand the optimal clinical setting for each type of fixation technique and additional strategies to maximize implant stability. In clinical practice, the choice of fixation must be tailored to the individual patient. The surgeon must consider whether the operation is being performed for primary sarcoma or metastatic carcinoma, the presence of distant metastases, age, comorbidities, and whether radiotherapy has been previously given or will be required at the site of fixation. The best strategy for each patient optimizes tumor control and appropriately weighs risks of fixation failure versus the expected patient survival. This review will explore cemented and uncemented distal femoral replacement and highlight modern concepts to optimize each technique.

Keywords: Cement; Cementless; Distal femoral replacement; Endoprosthesis; Sarcoma.

Fig. 1

Cemented distal femoral replacement performed with line-to-line cementing proximally, as well as a porous body segment adjacent to the femoral bone.

Fig. 2

Conventional cementless femoral fixation used with a growing prosthesis in a skeletally immature patient after resection of a distal femur osteosarcoma.

Fig. 3

Compression-compliant cementless fixation performed after resection of a distal femur osteosarcoma in a skeletally mature patient.

Fig. 4

Cemented distal femoral replacement with the addition of a hydroxyapatite-coated collar and side plate for rotational control and the potential for bone ongrowth.