Treatment of a patient with multiple myeloma of the femur

Introduction. Multiple myeloma (MM) is a malignant tumor that causes widespread bone damage. The bone is involved in 90 % of MM patients, and 60% of patients develop pathologic fractures.

Material and methods. We report a case of combined surgical treatment and chemotherapy of a multiple myeloma patient who sustained a pathological diaphyseal fracture of the left femur and later presented with a lytic myeloma lesion in the right femur. Closed reduction and interlocking intramedullary (IM) nailing of the left femur was performed for the patient who was diagnosed with bone destruction in the shaft of the right femur a few months later. The right femur was fixed with interlocking IM nail for prophylaxis.

Results. The left femur consolidated at 6 months. The patient had no pain in the right femur, and enlargement in the bone destruction was not seen in the femur. The patient could ambulate with a cane with signs of deforming arthritis in the adjacent joints of the lower limbs.

Discussion. Three common surgical approaches used for bone tumors being complicated or not complicated by a pathologic fracture include nailing/plating, bone replacement and joint arthroplasty. Bone tumor replacement with oncological endoprostheses can be produced in specialized oncological orthopaedic units and is not available with regular trauma and orthopaedic services for different reasons. The operating orthopedic surgeon is to choose the appropriate implant to address the tumor involvement.

Conclusion. Interlocking IM nailing can be the method of choice for a pathologic fracture or for prophylactic bone fixation with appropriate indications identified with the Mirels's scoring system. Intramedullary nailing offers the advantage of minimally invasive stability for the operated limb and early weight-bearing in contrast to plate fixation treatment for fractures and prophylactic plating.

1. Bessmeltsev S.S., Abdulkadyrov K.M. Mnozhestvennaia mieloma. sovremennyi vzgliad naproblem [Multiple myeloma. A modern view of the problem]. Almaty, KOSTA, 2007, 480 p. (in Russian)

2. Harousseau J.L., Dreyling M.; ESMO Guidelines Working Group. Multiple myeloma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol., 2010, vol. 21, no. Suppl. 5, pp. v155-157. DOI: 10.1093/annonc/mdq178

3. Chng W.J., Dispenzieri A., Chim C.S., Fonseca R., Goldschmidt H., Lentzsch S., Munshi N., Palumbo A., Miguel J.S., Sonneveld P., Cavo M., Usmani S., Durie B.G., Avet-Loiseau H.; International Myeloma Working Group. IMWG consensus on risk stratification in multiple myeloma. Leukemia, 2014, vol. 28, no. 2, pp. 269-277. DOI: 10.1038/leu.2013.247

4. Roodman G.D. Skeletal imaging and management of bone disease. Hematology. Am. Soc. Hematol. Educ. Program, 2008, pp. 313- 319. DOI: 10.1182/asheducation-2008.1.313

5. Vaishya R., Vijay V., Agarwal A.K. Healing of pathological fracture in a case of multiple myeloma. BMJ Case Rep., 2017, vol. 2017, pp. bcr2016218672. DOI: 10.1136/bcr-2016-218672

6. Vaishya R., Agarwal A.K., Vijay V. Lessons learnt from a case of multiple myeloma. BMJ Case Rep., 2015, vol. 2015, pp. bcr2015211358. DOI: 10.1136/bcr-2015-211358

7. Harrington K.D. Impending pathologic fractures from metastatic malignancy: evaluation and management. Instr. Course Lect., 1986, vol. 35, pp. 357-381.

8. Mirels H. Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin. Orthop. Relat. Res., 1989, no. 249, pp. 256-264.

9. Jawad M.U., Scully S.P. Classifications in brief: Mirels’ Classification: Metastatic Disease in Long Bones and Impending Pathologic Fracture. Clin. Orthop. Relat. Res., 2010, vol. 468, no. 10, pp. 2825-2827. DOI: 10.1007/s11999-010-1326-4

10. Terpos E., Kleber M., Engelhardt M., Zweegman S., Gay F., Kastritis E., Van de Donk N.W., Bruno B., Sezer O., Broijl A., Bringhen S., Beksac M., Larocca A., Hajek R., Musto P., Johnsen H.E., Morabito F., Ludwig H., Cavo M., Einsele H., Sonneveld P., Dimopoulos M.A., Palumbo A.; European Myeloma Network. European Myeloma Network Guidelines for the Management of Multiple Myeloma-related Complications. Haematologica, 2015, vol. 100, no. 10, pp. 1254-1266. DOI: 10.3324/haematol.2014.117176

11. Zoria V.I., Zlobina Iu.S. Patologicheskie perelomy konechnostei metastaticheskogo proiskhozhdeniia (diagnostika i lechenie) [Pathological limb fractures of metastatic origin]. Travmatologiia i Ortopediia Rossii, 2008, no. 1 (47), pp. 27-34. (in Russian)

12. Skriabin V.L., Denisov A.S., Ladeishchikov V.M., Bulatov S.B. Khirurgicheskaia taktika lecheniia bolnykh s patologicheskimi perelomami pri metastazakh i pervichnykh zlokachestvennykh opukholiakh oporno-dvigatelnoi sistemy [Surgical tactics of treating patients with pathological fractures for metastases and primary malignant tumors of the locomotor system]. Kreativnaia Khirurgiia i Onkologiia, 2012, no. 2, pp. 69-73. (in Russian)

13. Tarasov A.N. Lechebnaia taktika pri patologicheskikh perelomakh (obzor literatury) [Treatment tactics for pathological fractures]. Travmatologiia i Ortopediia Rossii, 2009, no. 2 (52), pp. 150-156. (in Russian)

14. Tepliakov V.V., Karpenko V.Iu., Aliev M.D. Khirurgicheskoe lechenie bolnykh s metastaticheskimi porazheniiami dlinnykh kostei [Surgical treatment of patients with metastatic involvements of long bones]. Vestnik Travmatologii i Ortopedii im. N.N. Priorova, 2007, no. 4, pp. 73-77. (in Russian)

15. Philipp T.C., Mikula J.D., Doung Y.C., Gundle K.R. Is There an Association Between Prophylactic Femur Stabilization and Survival in Patients with Metastatic Bone Disease? Clin. Orthop. Relat. Res., 2020, vol. 478, no. 3, pp. 540-546. DOI: 10.1097/CORR.0000000000000803

16. Angelini A., Trovarelli G., Berizzi A., Pala E., Breda A., Maraldi M., Ruggieri P. Treatment of pathologic fractures of the proximal femur. Injury, 2018, vol. 49, no. Suppl. 3, pp. S77-S83. DOI: 10.1016/j.injury.2018.09.044

17. McLynn R.P., Ondeck N.T., Grauer J.N., Lindskog D.M. What is the adverse event profile after prophylactic treatment of femoral shaft or distal femur metastases? Clin. Orthop. Relat. Res., 2018, vol. 476, no. 12, pp. 2381-2388. DOI: 10.1097/CORR.0000000000000489

18. Tanaka T., Imanishi J., Charoenlap C., Choong P.F. Intramedullary nailing has sufficient durability for metastatic femoral fractures. World J. Surg. Oncol., 2016, vol. 14, pp. 80. DOI: 10.1186/s12957-016-0836-2

19. Ormsby N.M., Leong W.Y., Wong W., Hughes H.E., Swaminathan V. The current status of prophylactic femoral intramedullary nailing for metastatic cancer. Ecancermedicalscience, 2016, vol. 10, pp. 698. DOI: 10.3332/ecancer.2016.698