Vol. 20 • Issue 17
• Page 10
With hip and knee replacement surgeries becoming more routine, hospitals across the country have rolled out clinical pathways and treatment programs to cover the continuum of care. Patients are educated on associated pain levels, length of the recovery period and options for both short- and long-term rehabilitation.
But imagine if instead of replacing a knee joint that has deteriorated, the standard was to amputate the leg above the knee. Seems antiquated, doesn't it? Even in this day and age of advanced orthopedic solutions and breakthroughs in prosthetics, patients with a severely compromised femur secondary to cancer, osteoporosis or poor bone stock may be presented with amputation or immobilization as the only options.
But there is another surgical option and it's one that dates back to the 1950s: total femur replacement.
Total femur replacement surgery is a viable option for select patients suffering from a severely compromised femur. To date, there are just 80 surgeries performed annually in the United States. To give a little perspective, about 773,000 Americans have a hip or knee replaced each year.1The problem is that there is limited existing research on long-term patient outcomes for total femur replacement. Hospitals are often not prepared with treatment protocols for this patient population.
According to rehabilitation experts at the Hospital for Joint Diseases at NYU Langone Medical Center in New York, NY, the number of these surgeries performed is set to rise as incidences of cancer increase and aging Baby Boomers require more joint replacements. Total femur replacement will likely never be as common as total hip and knee procedures, but the facility's therapists are adamant about being prepared for the trend.
Total femur replacement may be an option for patients with osteosarcoma or a malignant tumor, deep sepsis, prosthetic loosening, osteolysis or periprosthetic fracture around the total hip or total knee prosthesis.
The alternatives-including revision, open reduction internal fixation, immobilization or amputation-are grim and not guaranteed to work.
"With a growing number of cancer cases and more total joint revisions on the horizon, the procedure will become more common. The patients who receive total joint replacements are younger than in years past and the volume of cases is growing. People need to be aware of the surgery and what it entails," acknowledged Allison Lieberman, PT, MSPT, GCS, senior PT at the Hospital for Joint Diseases.
Three types of surgeries can be performed, depending on patient circumstance: intramedullary total femur replacement, total femur replacement or partial femur replacement.
Total femur replacement involves a total hip replacement proximally, a total knee replacement distally and a rod connecting the two to act as the femur. The prosthetic is made of cobalt chromium with high-density plastic in the artificial hip and knee joints to allow for range of motion.
"In the instance that a patient is presented with the option of a total femur replacement versus amputation, naturally many will choose to salvage the limb," shared Patricia Guastella, PT, MSPT, program manager of inpatient PT.
The salient advantages of having the procedure include salvaging the patient's limb and providing immediate stability that allows for early mobilization. Some of the disadvantages include removal of most-if not all-of the host bone, poor or absent soft-tissue attachment to the new prostheses, potential for hip and knee instability and high perioperative morbidity.2
A First at NYU
Gina Beecher, DPT, a staff PT at the hospital, developed an in-service designed to familiarize staff with the procedure and impart knowledge regarding the rehab component.
"When our first patient arrived, I researched the procedure to answer my questions about muscle reattachments, post-op precautions and patient outcomes," Dr. Beecher shared.
To make the task less daunting, Dr. Beecher simplified her message: she recommends that therapists think of rehab after total femur replacement as similar to total knee or hip procedures, but with a longer recovery period.
According to Lieberman, treating these patients is a challenge for the PTs and one that requires commitment and dedication.
Because the surgery is not currently performed on site, the Hospital for Joint Diseases accepts patient referrals to their inpatient rehab program from local hospitals.
"We offer a high level of aggressive rehabilitation," Lieberman shared. "A five- to eight-day stay is standard for primary joint replacements; however, a patient with a total femur replacement often qualifies for a longer length of stay due to greater functional impairments."
Although there is lacking research to show what patients face long-term, it seems that complications are less common than one would think considering the severity of the procedure. "It is more common for patients to experience complications from cancer post-surgery than to have complications directly from the procedure," shared Dr. Beecher.
Potential complications of the procedure include dislocation of the hip and infection of the wound site. Doctors commonly prescribe prophylactic antibiotics to offset complications of infection.
Rehab is an integral part of the recovery period, with the procedure being invasive and the precautions strict. A patient's PT plan of care includes bilateral lower-extremity strengthening, stretching, range of motion, balance, gait and stair training. The program emphasizes the importance of patient goals, which incorporate community access activities in preparation for discharge home.
"Living in New York City presents inherent challenges with busy streets, uneven pavement and inclement weather," Guastella explained. "We attempt to quell patients' concerns with our community re-entry program, wherein the patient together with the therapist can go out into the community and navigate through real-life situations."
The therapists typically venture to the city park across the street from the facility that has been outfitted with modified benches. The benches-which are significantly higher than average-were acquired through a collaboration between the OT department and the NYC Department of Parks and Recreation to accommodate patients with total hip precautions and other impairments that would limit sitting on lower surfaces.
As the patients progress, the therapists help them tackle activities that require multiple skills. In the case of a patient who has a routine of buying a newspaper at the corner market every morning, the PTs address negotiating money and items purchased, crossing the street and walking with an assistive device while holding a bag.
"OT for total femurs is similar to that of joint replacements," explained Angela Cirami, OTR/L, program manager of inpatient OT. "We work on activities of daily living, which are important because of the restrictions noted in strength and range of motion secondary to the nature of the procedure."
The therapists assess the patient first and then introduce adaptive devices. The OTs review total femur precautions that are similar to those of a hip replacement. The patients need a hip kit that aids with ADLs of the lower extremities-including a long-handled reacher, long-handled shoe horn, sock aides and elastic laces-to prevent bending forward from the hip.
"Stair negotiating at home, getting in and out of bed and going to the bathroom on one's own are the most common patient goals," observed Cirami. "Our goal is to restore our patients to their highest functional level in order to achieve a smooth transition home."
As part of the discharge plan, OT orders bath equipment such as shower chairs while PT orders ambulatory devices. Most patients are discharged with recommendations for nursing and PT services at home in order to promote independence with functional activities and help patients continue to work toward long-term goals.
The facility has an outpatient PT network to serve patients once home care services end. A follow-up appointment is made with a physiatrist one month post-discharge from the hospital to assess progress and functional status.
1. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).
2. Peters, C., Hickman, J., Erickson, J., et al. (2006). Intramedullary total femur replacement for salvage of the compromised femur associated with hip and knee arthroplasty. Journal of Arthroplasty, 21(1), 53-58.
Rebecca Mayer is senior regional editor of ADVANCE and can be reached at firstname.lastname@example.org
The first patient with a diagnosis of a total femur replacement at the Hospital for Joint Diseases at NYU Langone Medical Center in New York, NY, had suffered through numerous surgeries for juvenile rheumatoid arthritis, developed poor bone stock and endured multiple revisions.
At 23, Elizabeth Faust (*name changed for privacy) had her first of five total hip replacement surgeries. Because prostheses were predicted to last just five to 10 years at the time, she had to endure several joint revisions. Now in her mid-60s, Faust had her first knee replaced in the 1990s.
Faust went to the Hospital for Special Surgery in New York, NY, for a total femur procedure. She was advised to participate in weight-bearing activities as tolerated and was given standard hip precautions after surgery.
"Elizabeth had functional impairments and additional comorbidities that needed to be addressed with PT. She was compliant with her restrictions and very motivated. She was an excellent candidate for the surgery," shared Allison Lieberman, PT, MSPT, GCS, Hospital for Joint Diseases.
Angela Cirami, OTR/L, worked with Faust on safely executing activities of daily living such as taking clothes out of a low drawer, negotiating obstacles in a household setting and reaching into cabinets. Her severe RA resulted in decreased range of motion at her shoulders, wrists and hands which made these tasks difficult.
Faust worked with the PTs on increasing range of motion of the hip and knees, strengthening quadriceps and managing the significant swelling. The incision that ran from her hip to knee resulted in decreased sensation around the knee. PTs worked on weight shifting and standing balance as well.
Faust was discharged as modified independent for bed mobility and transfers, walking 300 feet with a platform walker and 80 feet with platform crutches. She climbed eight steps with a handrail and a platform crutch with minimal assistance.
Faust was given a home exercise program during her evaluation and received 10 additional exercises to do in bed, sitting on a chair and standing at a counter upon discharge.
"Elizabeth qualified for a home care attendant to assist with her ADLs. Home care PT helped her progress and ensured that she was performing the exercises properly and safely," Lieberman shared.
Presently attending outpatient PT, Faust has been working on standing balance, ROM and strengthening of the lower extremities. To date, she has achieved 120 degrees of knee flexion. She likely will continue PT for several months post-surgery.
Because research is limited on patient outcomes, there is no formal prediction of what Faust can expect moving forward, but the therapists feel she has regained her former quality of life and is progressing well.