Total Femoral Arthroplasty Research Articles

TOTAL FEMORAL ARTHROPLASTY FOR NON-ONCOLOGICAL INDICATIONS

There is a paucity of data available for the use of Total Femoral Arthroplasty (TFA) for joint reconstruction in the non-oncological setting. The aim of this study was to evaluate TFA outcomes with minimum 5-year follow-up.This was a retrospective database study of TFAs performed at a UK tertiary referral revision arthroplasty unit. Inclusion criteria were patients undergoing TFA for non-oncological indications. We report demographics, indications for TFA, implant survivorship, clinical outcomes, and indications for re-operation.A total of 39 TFAs were performed in 38 patients between 2015–2018 (median age 68 years, IQR 17, range 46–86), with 5.3 years’ (IQR 1.2, 4.1–18.8) follow-up; 3 patients had died. The most common indication (30/39, 77%) for TFA was periprosthetic joint infection (PJI) or fracture-related infection (FRI); and 23/39 (59%) had a prior periprosthetic fracture (PPF). TFA was performed with dual-mobility or constrained cups in 31/39 (79%) patients. Within the cohort, 12 TFAs (31%) required subsequent revision surgery: infection (7 TFAs, 18%) and instability (5 TFAs, 13%) were the most common indications. 90% of patients were ambulatory post-TFA; 2 patients required disarticulation due to recurrent PJI. While 31/39 (79%) were infection free at last follow-up, the remainder required long-term suppressive antibiotics.This is the largest series of TFA for non-oncological indications. Though TFA has inherent risks of instability and infection, most patients are ambulant after surgery. Patients should be counselled on the risk of life-long antibiotics, or disarticulation when TFA fails.

Total femoral arthroplasty for non-oncological indications.

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit. Data were collected retrospectively from a large tertiary referral revision arthroplasty unit's database. Inclusion criteria included all patients who underwent TFA in our unit. Preoperative demographics, operative factors, and short- and long-term outcomes were collected for analysis. Outcome was defined using the Musculoskeletal Infection Society (MSIS) outcome reporting tool. Overall, 38 TFAs were identified. The mean age was 73 years (42 to 80). All patients underwent TFA for non-oncological indications, most commonly as a consequence of infection (53%) and periprosthetic fracture (26%). The mean follow-up time was ten years (0 to 26); 63% of TFAs were considered a success based upon the MSIS outcome reporting tool. The mean time between TFA and death was 8.5 years (0.2 to 19.2), with two patients dying within one year of surgery. Within the cohort, 66% suffered at least one complication, dislocation being most common (37%); 55% of the total cohort required at least one subsequent operation. In total, 70% of TFAs undertaken for infection were considered infection-free at time of final follow-up. The percentage of mobile patients improved from 52% to 65% between pre- and postoperation, with all patients being able to at least transfer from bed to chair at time of final review. This study is the largest in the UK assessing the use of TFA in patients with bone loss secondary to non-oncological conditions. It demonstrates that TFA has a significant complication profile, however it is favourable in terms of mortality and rehabilitation when compared to amputation and disarticulation.

Two-Stage Exchange Using a Total Femur Spacer in the Management of Periprosthetic Joint Infection – Spacer Complications and Implant Survivorships

BackgroundChronic periprosthetic joint infection after revision hip and knee arthroplasties can lead to subsequent massive femoral bone loss. In these cases, resection of the residual femur and placement of an antibiotic total femoral spacer can be an option to salvage the limb. MethodsThis is a single-center retrospective analysis of 32 patients (median age 67 years; range 15-93; 18 women) who underwent placement of a total femur spacer for chronic periprosthetic joint infection with massive femoral bone loss between 2010 and 2019 as part of a planned two-stage exchange. The median follow-up period amounted to 46 months (range, 1-149). Implant and limb survival were analyzed using Kaplan-Meier survival estimates. Potential risk factors for failure were analyzed. ResultsThere were 34% (11 of 32) of patients having a spacer-associated complication, and 25% underwent revision for this reason. After the first stage, 92% were considered infection-free. There were 84% of patients who underwent second-stage reimplantation of a total femoral arthroplasty using a modular megaprosthetic implant. Infection-free implant survival was 85% after 2 years and 53% after 5 years. There were 44% of patients who underwent amputation after a median time of 40 months (range, 2-110). Most commonly, coagulase-negative staphylococci were cultured at first-stage surgery, while polymicrobial growth was most common at reinfection. ConclusionTotal femur spacers can lead to infection control in over 90% of cases with a reasonable complication rate for the spacer itself. However, the reinfection and subsequent amputation rate after second-stage megaprosthetic total femoral arthroplasty is around 50%.

Prosthetic Joint Infection in Mega-Arthroplasty Following Shoulder, Hip and Knee Malignancy-A Prospective Follow-Up Study.

The risk of prosthetic joint infection (PJI) in mega-prosthesis for malignancy is increased compared with non-tumor cases. While several studies describe PJI in tumor-related arthroplasty, prospective studies comparing infection characteristics among different joints are limited. The present study analyzes mega-arthroplasty for hip, knee, and shoulder malignancy and compares the epidemiology, diagnosis, microbe spectrum, treatments, and outcomes between the different entities. The retrospective inclusion criteria were as follows: (1) mega-arthroplasty (2) in the hip, knee, or shoulder joint and a total femur arthroplasty (3) following a malignant bone tumor or metastasis (4) between 1996 and 2019. All included patients were prospectively followed and invited for a renewed hospital examination, and their PJI characteristics (if identified) were analyzed using both retrospective as well as newly gained prospective data. A PJI was defined according to the Infectious Disease Society of America (IDSA) and re-infection was defined according to the modified Delphi Consensus criteria. In total, 83 cases of tumor mega-arthroplasty at a mean follow-up of 3.9 years could be included (32 knee, 30 hip, and 19 shoulder cases and 2 cases of total femur arthroplasty). In total, 14 PJIs were identified, with chondrosarcoma in 6 and osteosarcoma in 3 being the leading tumor entities. Knee arthroplasty demonstrated a significantly higher rate of PJI (p = 0.027) compared with hips (28.1% vs. 6.7%), while no significant difference could be found between the knee and shoulder (10.5%) (p = 0.134) or among shoulder and hip cases (p = 0.631). The average time of PJI following primary implantation was 141.4 months in knee patients, 64.6 in hip patients, and 8.2 months in shoulder patients. Age at the time of the primary PJI, as well as the time of the first PJI, did not show significant differences among the groups. Thirteen of the fourteen patients with PJI had a primary bone tumor. Statistical analysis showed a significant difference in the disadvantage of primary bone tumors (p = 0.11). While the overall cancer-related mortality in the knee PJI group (10%) was low, it was 50% in the hip and 100% in the shoulder group. The risk of PJI in knee tumor arthroplasty is significantly increased compared with hips, while cancer-related mortality is significantly higher in hip PJI cases. At the same time, mega-prostheses appear to be associated with a higher risk of infection due to a primary bone tumor compared with metastases. The study confirms existing knowledge concerning PJI in tumor arthroplasty, while, being one of the few studies to compare three different joints concerning PJI characteristics.

Non-oncologic Total Femoral Arthroplasty: A Case Report

As patient longevity continues to improve, the rate of lower limb revision arthroplasties will continue to increase as patients outlive the expiration of their implants. With continued bone loss and reduced stability, there is a limit to the number of revision operations that can be performed. Total femoral arthroplasty (TFA) is an increasingly popular limb-salvaging alternative that can restore some degree of daily function to patients. This report presents a 73-year-old male with multiple right lower-limb operations following two extreme motorcycle accidents in the last 22 years. Due to continued pain and poor femoral bone stock following multiple total knee arthroplasty (TKA) revisions, a TFA was performed. The procedure was successful and post-operative expectations were met despite setbacks in immediate rehabilitation. Overall, TFA is an effective alternative to lower limb amputation in the setting of aseptic, non-oncologic bone loss following multiple knee revisions. However, careful management is necessary to reduce the risk of infection and other complications.

Two-stage strategy in end-stage hip periprosthetic joint infection: utility of industrially prefabricated custom-made antibiotic spacers.

Use of prefabricated mobile spacers in end-stage cases of hip periprosthetic joint infection (HPJI) is hindered when large bone defects exist. In such cases, prefabricated custom-made antibiotic spacers (P-CMAS) offer an alternative. Such spacers are individually designed according to the size and anatomical characteristics of the bone defect. The purpose of this study is to describe and evaluate the use of such patient-specific spacers in a two-stage strategy to treat end-stage HPJI cases, and to report on clinical outcomes. A retrospective study identified all patients with end-stage HPJIs from January 2015 through December 2019, treated using a P-CMAS. Primary outcome: infection eradication rate. Secondary outcomes: spacer-related complications and patient satisfaction. Minimum follow-up: 12 months after the second-stage surgery. A total of 7 end-stage cases (mean of 6.7 previous surgical procedures) were included. Mean bone defect size was 191.57 (range 47-304) mm. Polymicrobial infection was detected in 42.86% of these cases. During the spacer stage there were no periprosthetic fractures, spacer dislocations or breakages, nor spacer-drug-related complications. All patients proceeded with the second stage uneventfully, with an average time between stages of 178 (range 119-326) days. In 5 cases a total femur arthroplasty was the reconstructive procedure performed. After a mean follow-up of 27.29 (range 14-49) months the infection was clinically eradicated in all patients, despite their difficult-to-treat scenarios. Industrially custom-made spacers offer an effective and safe option in performing 2-stage exchange arthroplasty in cases of end-stage HPJI with extensive bone defects.

The challenge of antibiotic selection in prosthetic joint infections due to Corynebacterium striatum: a case report

BackgroundCorynebacterium striatum is a gram-positive facultative anaerobe found in the environment and human flora that has historically been considered a contaminant. More recently, Corynebacterium striatum has been implicated in human infections, including respiratory infections, endocarditis, and bone and joint infections, particularly those involving hardware or implanted devices.Case presentationA 65-year-old man presented for washout of his left total knee arthroplasty following a revision 20 days prior. The patient underwent debridement of his left total knee and revision of the left total femur arthroplasty. Daptomycin was initiated empirically due to a previous rash from vancomycin. Operative tissue cultures grew Staphylococcus haemolyticus, Staphylococcus epidermidis and Corynebacterium striatum. Given concern for daptomycin resistance and the reliability of vancomycin susceptibility, daptomycin was discontinued and vancomycin initiated following a graded challenge. Within a few days, the patient developed a diffuse, blanching, erythematous, maculopapular rash and daptomycin was restarted. Over the next 72 h, his rash progressed and he met criteria for drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. Daptomycin was stopped and oral linezolid initiated; rash improved. C. striatum returned with susceptibility to gentamicin, linezolid, vancomycin and daptomycin. Due to concern for adverse effects on long-term linezolid, daptomycin was restarted and was tolerated for 20 days, at which point purulent drainage from incision increased. The patient underwent another arthroplasty revision and washout. Operative cultures from this surgery were again positive for C. striatum. Repeat C. striatum susceptibilities revealed resistance to daptomycin but retained susceptibility to linezolid. Daptomycin was again changed to linezolid. He completed six weeks of linezolid followed by linezolid 600 mg daily for suppression and ultimately opted for disarticulation.ConclusionsC. striatum has historically been regarded as a contaminant, particularly when grown in tissue culture in the setting of prosthetic joint infection. Based on the available literature and susceptibility patterns, the most appropriate first-line therapy is vancomycin or linezolid. Treatment with daptomycin should be avoided, even when isolates appear susceptible, due to the risk of development of high-level resistance (MIC > 256 µg/mL) and clinical failure.

Novel Cemented Technique for Trochanteric Fixation and Reconstruction of the Abductor Mechanism in Proximal and Total Femoral Arthroplasty: An Observational Study.

BackgroundLittle evidence exists regarding the clinical outcomes of cemented trochanteric fixation for abductor mechanism reconstruction in proximal or total femoral replacements. Clinical outcomes were assessed for a novel cemented technique for trochanteric fixation in femoral megaprostheses.MethodsA descriptive series of 13 patients who underwent proximal or total femoral arthroplasty from 2016 to 2019 were reviewed. Radiographic trochanteric displacement >1 cm defined construct failure. A Kaplan-Meier survival analysis was performed to determine survival rates for these cemented constructs. Demographic information was obtained to better characterize the patient population in whom this technique was used.ResultsEleven patients were included (age = 63.6 years; 45.4% females; body mass index = 31.7). Mean time to final radiographic follow-up was 73.8 weeks. Three of 11 (27.2%) patients had construct failure. Overall, survival at 1 year was 81.8%. At 2 years, survival of cemented constructs was 65.5%. More construct failures occurred in patients who sustained a postoperative dislocation than in those who did not (P = .05).ConclusionsThis novel cemented trochanteric fixation technique for reconstruction of the abductor mechanism in femoral megaprostheses had 81.8% survival at 1 year postoperatively. While longitudinal comparative studies with larger samples are needed, the cemented technique may provide a viable alternative to traditional cementless methods of trochanteric fixation. Increased construct failure rates after postoperative dislocation highlight the importance of robust abductor reconstruction in these implants.

Interlocking reconstruction-mode stem-sideplates preserve at-risk hips with short residual proximal femora.

We have evaluated the survivorship, outcomes, and failures of an interlocking, reconstruction-mode stem-sideplate implant used to preserve the native hip joint and achieve proximal fixation when there is little residual femur during large endoprosthetic reconstruction of the distal femur. A total of 14 patients underwent primary or revision reconstruction of a large femoral defect with a short remaining proximal femur using an interlocking, reconstruction-mode stem-sideplate for fixation after oncological distal femoral and diaphyseal resections. The implant was attached to a standard endoprosthetic reconstruction system. The implant was attached to a standard endoprosthetic reconstruction system. None of the femoral revisions were amenable to standard cemented or uncemented stem fixation. Patient and disease characteristics, surgical history, final ambulatory status, and Musculoskeletal Tumor Society (MSTS) score were recorded. The percentage of proximal femur remaining was calculated from follow-up radiographs. All 14 at-risk native hip joints were preserved at a mean final follow-up of 6.0 years (SD 3.7), despite a short residual femur, often after proximal osteotomies through the lesser trochanter. Overall, 13 of 14 stems had long-term successful fixation. Eight patients required no reoperation. Three patients required reoperation due to implant-related issues, and three patients required reoperation for wound healing problems or infection. There were no dislocations or fractures. At final follow-up the mean MSTS score was 24.9 (SD 4.1). Nine patients required no ambulation aids, and only one had a Trendelenburg gait. This interlocking, reconstruction-mode stem-sideplate reliably preserves native hip joint anatomy and function after large femoral resection with a short remaining proximal femur, both in the primary and revision setting. This is particularly important for preventing or delaying total femoral arthroplasty in young patients after oncological reconstruction. Hip abductor strength and function could be maintained by this method, and the risk of dislocation eliminated. The success of this technique in this modest series should be verified in a larger collaborative study and will be of interest to revision surgeons and oncologists. Cite this article: Bone Joint J 2021;103-B(2):398-404.

Interprosthetic Femoral Sleeves in Revision Arthroplasty: A 20-Year Experience

BackgroundInterprosthetic femoral fractures in patients with ipsilateral stemmed total hip arthroplasty (THA) and total knee arthroplasty (TKA) can be technically demanding to treat surgically. Nonunion and implant failure are among the main complications following fixation of interprosthetic femoral (IF) fractures. Total femoral arthroplasty (TFA) is associated with a high incidence of infection and instability. IF sleeves have been designed to avoid the disadvantages of these techniques and to provide a stable construct. The aim of this study was to present the results with this device from a single center. MethodsWe reviewed 26 patients who underwent revision arthroplasty procedures, using custom-made cemented IF sleeves between 1997 and December 2017 in our institution. Two-part sleeves were used in 18 patients and one-part sleeves in 8 patients. The most common indication was an IF fracture (18 patients). Patients were monitored for postoperative complications, implant failure, and re-revision. The minimum follow-up of the survivors with nonrevised sleeves was 12 months. ResultsTwenty-three patients were included for the final analysis. The mean survivorship of the IF sleeve was 4.6 years at latest follow-up (mean 48.5 months; range 12 to 156). The overall rate of complications was 47.8%. The rate of mechanical failure was 21.7%. Late infections occurred in 3 patients (13%). At the latest follow-up, the mean Harris Hip Score was 69.9 points (range 39 to 94), and the mean functional Knee Society Score was 42.5 points (range 0 to 90), with average knee flexion of 95° (range 90° to 100°). ConclusionThe IF sleeve is a valid technique for the management of selected patients with IF fractures, particularly when a stable fracture fixation is not possible. Hip instability is not a concern, and functional improvement is achievable. Careful planning is required preoperatively to avoid mechanical failure.

Total Femur Arthroplasty for Complex Periprosthetic Fracture – Honorable Mention

Total Femur Arthroplasty for Complex Periprosthetic Fracture – Honorable Mention

Non-Oncologic Total Femoral Arthroplasty: Retrospective Review

Total femoral arthroplasty (TFA) is an option to amputation in the setting of excessive bones loss during revision total hip and knee arthroplasty. Twenty non-oncologic TFAs with a minimum of 2years follow-up were retrospectively reviewed. The average clinical follow-up was 73±49months. The incidence of new infection was 25% (5/20), while the overall infection rate was 35% (7/20). The incidence of primary hip instability was 10% (2/20), while the overall instability rate was 25% (5/20). Six patients (30%) required revision. The average pre-operative HHS was 30.2±13.1. The average post-operative HHS was 65.3±16.9. TFA is a viable alternative to amputation in non-oncologic patients with massive femoral bone deficiency. However, TFA performed poorly in the setting of infection and instability.

Management of a Chronically Infected and Unstable Revision Hip Prosthesis with Total Femur Arthroplasty and Antibiotic Cement – Case Report and Review of the Literature

Background: Infection, instability, periprosthetic fracture, and severe bone loss are troublesome issues in revision hip arthroplasty. The occurrence of all four together represents a unique therapeutic challenge. Literature Review : Total femoral arthroplasty is described following tumor resection and in revision arthroplasty with severe bone loss. In these complex cases infection remains a significant concern with rates between 0 and 47% reported. For cases with infection, 2-stage revision procedures have been developed using antibiotic beads or custom total femur antibiotic spacers. However, these techniques involve long periods of non-weight-bearing that may be poorly tolerated in an older population. Case Presentation : A patient with a chronically infected and dislocating long-stemmed revision hip arthroplasty presented with a severely comminuted distal femur fracture. A 1-stage revision was successfully performed using a modular total femur prosthesis coated with antibiotic cement. Conclusion : This is the first reported instance of a successful 1-stage revision for infection and severe bone loss using total femur prosthesis. This technique may allow for early mobilization and the avoidance of multiple surgical procedures.

Revision Total Hip and Total Knee Arthroplasty for Massive Bone Loss and Periprosthetic Fracture Using a Total Femur Prosthesis: A Case Report

The number of complex total joint arthroplasties being performed each year is continually rising. Patients are undergoing primary and revision total joint arthroplasties at a relatively younger age and face a greater possibility of multiple revision procedures during their lifetime. Surgeons are often faced with significant osteolysis and bone loss and must find ways novel ways to deal with this difficult problem. Total femur arthroplasty using a megaprosthesis is a rare procedure and has been mainly described in the orthopaedic oncological literature, however it has not been described in aseptic, non-tumour related, revision procedures addressing massive bone loss, component loosening and periprosthetic fracture involving ipsilateral hip and knee joints. We present the case of a simultaneous revision total hip and total knee arthroplasty for massive femoral bone loss, aseptic loosening, periprosthetic fracture and functional leg length discrepancy using total femur megaprosthesis. We will briefly review the relevant literature, present the clinical presentation, imaging and surgical procedure as well as the early post-operative course. To our knowledge, total femur replacement for this indication has not been previously described.

Custom-Made Cement-Linked Mega Prostheses: A Salvage Solution For Complex Periprosthetic Femoral Fractures

Periprosthetic femoral fractures with long stem implants, poor bone stock and loosening pose a considerable surgical challenge. We describe a reconstruction technique using a custom-made mega-prosthesis, cement-linked to the femoral stem of a well-fixed existing implant. Clinical and radiological outcomes were assessed at our tertiary referral centre. There were 15 patients with a periprosthetic femoral fracture: 5 proximal and 10 distal femoral arthroplasties linked to existing femoral stems. The survival rate was 93.3% at a mean follow-up of 5.3 years (0.5-19.3) with 1 revision. We present a salvage technique with good intermediate-term outcomes for highly selected patients with complex periprosthetic femoral fractures, as another option to conventional fixation methods. Specifically, it allows immediate weight bearing and avoids some of the morbidity of total femoral arthroplasty or amputation.

Custom Total Femur Spacer and Second-Stage Total Femur Arthroplasty as a Novel Approach to Infection and Periprosthetic Fracture

Total femur arthroplasty procedures have previously been used after tumor excision and as a last resort for failed revision arthroplasty. The patient in this case presented with massive loss of femoral bone stock, a periprosthetic fracture, and recurrent Staphylococcus epidermidis infection. A specially designed total femoral spacer impregnated with antibiotics was created for a 2-stage revision procedure that successfully restored functional ability and eradicated the infection. Although 2-stage protocols with spacers have been used to treat persistent infections after hip and knee arthroplasty, this is the first reported instance of the creation of a total femur antibiotic-impregnated cement spacer and subsequent total femoral arthroplasty as a 2-stage protocol at our institution.

The Use of Total Femoral Arthroplasty as a Limb Salvage Procedure: The Sheffield Experience

Over the last 25 years, 14 patients have undergone total femoral arthroplasty (TFA) after complications of revision arthroplasty surgery. These patients had previously undergone extensive surgery, which had failed, and required salvage surgery. The alternatives would have been amputation or hip disarticulation. A retrospective review of medical records and radiographs was undertaken, and clinical outcome was evaluated using the Musculoskeletal Tumour Society criteria. Before TFA, all patients had previously undergone multiple operations (range, 2-10). In 88% of cases, reconstructive options were not only limited by the availability of minimal host bone but also by deep sepsis. Results were encouraging, with most of the patients having greater mobility and less pain after surgery. A third of the patients achieved a 75% improvement in function. We believe that TFA has a definite role in the management of complex problems after extensive hip and knee revision arthroplasty surgery.

The Shattered Femur: Radical Solution Options

The field of total joint arthroplasty has undergone a tremendous evolution over the past 5 decades. With increased arthroplasty use, indications expanding to younger patients, and increased life span, coupled with the limited longevity demonstrated by all arthroplasty devices to date, many patients have undergone at least one revision procedure. Therefore, reconstructive orthopedic surgeons may sometimes face the so-called shattered femur, defined as a femur that is not reconstructible with conventional methods. The clinical scenarios for which total femoral arthroplasty is indicated and a recommended surgical technique are reviewed.

Total Femoral Arthroplasty for Salvage of End-stage Prosthetic Disease

The complications and outcomes in patients who had total femoral arthroplasty for salvage of a severely compromised femur were studied. The clinical scenarios included numerous revision total hip or knee arthroplasties, failed periprosthetic fractures, or recurrent infection treated with multiple radical debridement surgeries. Fifty-nine patients (average age, 73.7 years) were identified. At an average 4.8 years followup, adequate pain relief was achieved and Harris hip pain scores averaged 33.8 of 44 points, and knee pain scores averaged 42.8 of 50 points. Good function was achieved with 98% of patients able to ambulate and 43% using no assistive device or a cane only. There were 18 complications or subsequent surgeries. Infection and dislocation occurred in eight patients and seven patients, respectively. Total femoral arthroplasty for salvage of a severely compromised femur provides acceptable results even in the most difficult of cases.

Expandable Endoprosthetic Reconstruction of the Skeletally Immature After Malignant Bone Tumor Resection

The mainstay of local control of primary bone malignancies in the skeletally immature has been amputation or, in selected cases, rotationplasty. The development of expandable endoprostheses has permitted an alternative approach for local control in the growing child. Between January 1985 and December 1987, 12 skeletally immature patients with primary malignant bone tumors were treated with extremity reconstruction with cemented custom-expandable endoprostheses after wide resection of their lesions. All patients were observed until death (four) or revision (two) with a minimum two-year follow-up period for the survivors (average, 3.1 years). Seven patients have undergone a total of 11 expansions and one patient was lengthened with a revision-expandable prosthesis. Four patients have not needed expansion. Eight patients have had a total of ten complications. Seven of the ten complications (70%) were prosthesis related and associated with failure of the expansion mechanism. The Musculoskeletal Tumor Society (MSTS) overall rating was good to excellent in seven patients (58%), fair in three (25%), and poor in two (17%). In five distal femoral arthroplasties and one total femoral arthroplasty where the tibial bearing component was cemented through the physis, tibial and epiphyseal growth was observed to be normal and equal to the nonoperative side. This suggests that partial central epiphyseal and physeal ablation does not cause physeal arrest. Although the high rate of expansion mechanism failure necessitates redesign, preliminary results suggest that expandable endoprostheses do offer an alternative to amputation and rotationplasty as a means of local control and extremity reconstruction in children with primary malignant bone tumors.