TITLE PAGE

Type of Article: Case Report

Total Femoral Replacement with Mega

Prostheses in Patient with Pathological
Fracture due to Multiple Myeloma : A case
report

Ida Bagus Gede Arimbawa 1*, I Gde Eka Wiratnaya 2, I Made

Tusan Sidharta 1
1
Resident of Orthopaedic and Traumatology Department, Sanglah
General Hospital, Udayana University, Bali, Indonesia
2
Staff Of Orthopaedic and Traumatology Department, Sanglah
General Hospital, Udayana University, Bali, Indonesia
1
Resident of Orthopaedic and Traumatology Department, Sanglah
General Hospital, Udayana University, Bali, Indonesia

*Corresponding author:

Dr. Ida Bagus Gede Arimbawa

Orthopaedic and Traumatology Department,
Sanglah General Hospital, Udayana University,
Bali, Indonesia
Phone (or Mobile) No.: +62 813-533-05660
Email: [email protected]
ABSTRACT

Introduction
Multiple myeloma is the most frequent tumor that occurs
primarily in bone. In the case of primary malignant bone tumor,
the orthopedic surgeon often has to deal with the need to
reconstruct a large skeletal defect or replace bone of low quality.
For lesions involving the femur, internal fixation frequently fails;
therefore, prosthetic reconstruction may be the optimal choice for
treatment.

Case
A 52-year-old male patient diagnosed with pathological
fracture of right femoral bone due to multiple myeloma. He was
underwent total femoral replacement with mega prostheses in
Sanglah General Hospital on 26 October 2015.

Discussion
The total femoral replacement system is designed as a
modular system that can be used to replace diseased or deficient
bone in the femur Treatment of pathological fractures in multiple
myeloma with mega prostheses appears to be a feasible option.
They were able to mobilize early with good pain relief and had a
useful functional limb.

Conclusion
Limb salvage surgery with mega prostheses can be
considered as a viable option for treating painful pathological
fractures in multiple myeloma. It provides pain relief, early
mobilization, and good functional outcome with improved quality
of life. Proximal femoral replacement with mega prostheses
provided for long-standing stability fixation. The new generation
of megaprostheses provides better provision for more secure soft
tissue reattachment and ability to reapproximate the retained of
proximal host bone to the prosthesis.

Keywords: Multiple Myeloma, Pathologic Fracture, Total

Femoral Replacement, Mega Prostheses
INTRODUCTION

Multiple myeloma is the most frequent tumor that occurs primarily

in bone. Most patients are in the sixth and seven decades of life.
The median age at diagnosis is 65 years with a slight male
predilection. Lytic bone disease is a hallmark of plasma cell
myeloma, and a substantial percentage of patients develop
pathologic fractures. Bone resorption occurs as the result of
osteoclastic stimulation and activity.1

Typically, a patient presents with an impending or pathologic

fracture with no prior diagnosis of myeloma. In the patient with
bone lesions and unknown primary malignancy, the workup
includes radiographs of the entire bone; bone scan; MRI of
extremity; CT scan of the chest, abdomen, and pelvis; complete
blood count; serum and/or urine electrophoresis; prostate-specific
antigen in men; and, in women , a breast examination or
mammogram.1,2

When the electrophoresis is positive, radiographic bone survey and

bone marrow biopsy are performed for staging. However, no
further biopsy of lesions is required for diagnosis. Biopsy is
required in some cases, such as in the patient with suspected
plasmacytoma when electrophoresis is not obtained. Biopsy must
be done carefully because myeloma lesions can be very vascular,
and there is a risk of substantial blood loss. This should also be
taken into account during preplanning for intramedullary or open
procedures.1,2

In the case of primary malignant bone tumor, the orthopedic

surgeon often has to deal with the need to reconstruct a large
skeletal defect or replace bone of low quality. For lesions
involving the femur, internal fixation frequently fails; therefore,
prosthetic reconstruction may be the optimal choice for treatment.
Mega prostheses reconstruction is thought to be technically less
demanding than other complex reconstructive procedure.3
CASE

A 52-year-old male retired, presented with history of inability to

walk and swelling over middle thigh since one year. The patient
gave a history of an ongoing pain, worsens at night and was not
relieved with simple analgesic. In April 2015, patient was
undergone surgery due to pathological fracture on right proximal
thigh following a trivial trauma.

There was no significant proximal lymphadenopathy or distal

neurovascular deficit. The general examination was unremarkable.
Local examination revealed a scar over lateral and a large swelling
over middle aspect of the thigh, firm in consistency and fixed to
the bone. Active movements of right knee were restricted.
Radiological examination revealed a fracture of proximal femur
with internal fixation and lytic lesion involving a shaft and extends
to distal part (Figure 1). CT angiography of proximal femur
revealed femoral tumor with involvement of deep femoral artery
(Figure 2). All routine hematology investigations and x-ray chest
were normal. A BMP was done with Ki67 positive 80% and
interpreted as plasma cell myeloma.

Patient underwent wide excision of the tumor with clear margins.

The patient was put in a lateral position, and the proximal femur
was dissected through a posterolateral approach. Following tumor
excision, prepare the acetabulum with a fit cup, resects the top of
the tibia and ream the tibial canal. A customized, titanium, bipolar,
total femoral mega prosthesis was then inserted (Figure 3). Local
soft tissue reconstruction was performed and the wound was closed
over a negative suction drain after meticulous haemostasis.

Postoperatively, quadriceps exercises was started on day one with

knee range after day five. The patient was made to stand with
support on the fifteenth day and started partial weight bearing. The
wound was healed without complication.

The excised specimen was sent for histopathological examination.

Microscopic evaluation of the resected specimen confirmed the
diagnosis plasma cell myeloma. The patient received radiotherapy
for treatment or other complications along with biphosphonates.
DISCUSSION

Multiple myeloma represents approximately 10% of all

haematological cancers.4,9 The annual incidence is reported to be
5-10 per 100,000 population.4,10 It occurs as a result of
unregulated, progressive proliferation of neoplastic monoclonal
plasma cells.4,11 Although widespread disease with infiltration of
the bone marrow or multiple destructive bone lesions is seen in the
most cases, a solitary bone lesion may be present in 5-10% of
cases. Bone destruction is due to increased osteoclastic bone
resorption and inhibition osteoblastic bone formation resulting in
osteolytic lesions predisposing to pathological fractures.4,11

Myeloma is common in elderly patients and rare in patients below

40 years of age.4,11,12,13 There is a slight male preponderance and it
commonly occurs in the sixth or seventh decade of life.4,11
Treatment of multiple myeloma may be difficult and challenging.
Though chemotherapy is successful in many patients, it does not
produce skeletal healing, and hence there is a risk of osteopenia
and subsequent pathologic fracture. Also, use of radiation therapy
is often able to relieve pain and diminish local tumor.4

As the disease progression is slow and the long-term survival of

these patients is better when compared to pathological fracture due
to metastasis from other tumors, surgical treatment was aimed at
achieving adequate margins of resection and reconstruction that
can provide long term stability.4 The mainstay of treatment in most
patients with multiple myeloma is chemotherapy and/or
radiotherapy combined with biphosphonates. However surgical
treatment is indicated in the treatment of certain complications like
pathological fractures of extremities and vertebral compression
fractures producing progressive neurological deficit or spinal
instability. As these patient have a relatively long period of
survival compared to patient with other secondary bone tumors,
prosthetic replacement for pathological fractures can provide better
functional outcome and improve their quality of life.1,2,4

Limb salvage surgery, currently an accepted bone tumor treatment

method, has traditionally been a difficult problem in orthopedic
oncology. Currently, the three most popular option are using an
endoprosthesis, allograft-prosthetic composite and biological
reconstruction. Endoprosthesis replacement offers several
advantages, such as early stability, mobilization, and weight
bearing, a shorter operating time and hospital stay in comparison to
biological reconstruction, and it allows the early introduction of
postoperative adjuvant therapy.3,6,7
The kinematic rotating-hinged knee joint prosthesis was designed
to allow modular reconstruction of large femoral deficits after
tumor resection. Incorporated in its design were several features
aimed at minimizing mechanical failure. First, the articulation
between femoral and tibial components allowed axial rotation as
well as distraction. This was intended to reduce the potentially
disruptive forces generated by a hinge. Secondly, a porous coating
was applied to the segmental portion of the prosthesis that was
adjacent to cortical bone to encourage bone ingrowth, biological
fixation and a more graduated transfer of stress across the
prosthetic bone junction, thereby reducing sudden changes in
elastic moduli.5

Zwart et all. Reported 21 reconstruction, using the uncemented

Kotz medular femur tibia reconstruction prosthesis. There were 2
steam breakages requiring reoperation and 2 amputations because
of infection. The problem of bushing failure in the Kotz prosthesis,
with may also be associated with debris synovitis, has been
reported to be as high as 42% and may occur as early as 2 years
after surgery. Although some have recommended elective
exchange of this component after 2-3 years to preempt bushing
fracture, Capanna et al. have advised caution, because of the risk of
infection. The rotating-hinge design may help to reduce the
stresses to which the bushing is normally subjected.5

The total femoral replacement system is designed as a modular

system that can be used to replace diseased or deficient bone in the
femur. The system also allows the conversion of the proximal and
distal femoral system into total femur using a link shaft. The
system consist s of variety of different trochanter sections,
anatomical in shape, with provisions for trochanteric attachment, a
range of shaft in 15 mm increments to suit differing lengths of
resection, a link shaft available in two lengths of 165mm and
225mm, and a SMILE Knee.8

To complement the system, a range of modular metal and ceramic

head are also available, Individual components of the femoral shaft
are connected using interlocking taper junction allowing quick and
easy assembly. The SMILE Knee has three tibial options in two
sizes; rotating hinge polyethylene tibia suitable for routine cases
rotating hinge metal casing tibia with short and long stems suitable
for extra-articular resections or difficult revisions and a fixed hinge
tibia with short and long stems suitable for knees with marked
instability or gross deformity.8
CONCLUSION

Limb salvage surgery with mega prostheses can be considered as a

viable option for treating painful pathological fractures in multiple
myeloma. It provides pain relief, early mobilization, and good
functional outcome with improved quality of life. Our first
experience with the use of megaprostheses after tumor resection
was encouraging. Total femoral replacement with mega prostheses
provided for long-standing stability fixation.
REFERRENCES

1. Scharschmidt, T.J.Multiple Myeloma: Diagnosis and

Orthopaedic Implications.J Am Acad Orthop Surg,
2011;19:410-419
2. Martinez, F.J et al.2002.Plasma cell myeloma. In
Pathologic and Genetic of Tumors of Soft Tissues and
Bones.IARCpress, Lyon, France.p:302-305
3. Orlic, D et al.Lower limb salvage surgery: modular
endoprostheses in bone tumor treatment. 2006.
International Orthopaedics (SICOT)
4. Natarajan, M.V et al.The role of limb salvage surgery and
custom mega prosthesis in multiple myeloma.Acta Orthop,
Belg.,2007, 73:462-467
5. Choong, F.M et al.Megaprostheses after resection of distal
femoral tumors: A rotating hinge design in 30 patients
followed for 2-7 years. 2008. Acta Orthop Scand.67(4):
345-351
6. Parvizi, J. Proximal femoral replacement with
megaprostheses. Clin Orthop 2004; 420:169-175
7. Gkavardina, A et al.The use of megaprostheses for
reconstruction of large skeletal defects in the extremities: A
critical review. The open orthopaedics journal, 2014, 8,
384-389
8. Anonim.2010. METT Modular Total Femur. Stanmore
Implants Worldwide Ltd.United Kingdom
9. Alexanian R, Dimopoulos M. The treatment of multiple
myeloma. N Engl J Med 1994;330: 484-489.
10. Mundy GR. Myeloma bone disease. Eur J Cancer 1998;34:
246-251.
11. Singer CR. ABC of clinical haematology:Multiple
myeloma and related conditions. B Med J 1997;314: 960-
963.
12. Dürr HR, Wegener B, Krodel A et al. Multiple myeloma:
surgery of the spine : retrospective analysis of 27 patients.
Spine 2002 ; 27 : 320-324.
13. Ishida T, Dorfman HD. Plasma cell myeloma in unusually
young patients : a report of two cases and review of the
literature. Skeletal Radiol 1995 ; 24 : 47-51.
Figure 1. Plain radiograph of right femur shows fracture of
proximal femur with internal fixation. We can see lytic
lesion involving the shaft and extend to distal part.

Figure 2. CT angiography of right thigh. The femoral tumor

involving the deep femoral artery
Figure 3. Total femoral replacement with mega prosthesis
following wide excision of the tumor.