FIRST EXPERIENCE OF TOTAL FEMORAL REPLACEMENT

WITH MEGA PROSTHESES

IN PATIENT WITH PATHOLOGICAL FRACTURE
DUE TO MULTIPLE MYELOMA
A CASE REPORT

Oleh :

dr. Ida Bagus Gede Arimbawa

Pembimbing :

dr. I Gede Eka Wiratnaya, SpOT (K)

PROGRAM PENDIDIKAN DOKTER SPESIALIS I

BAGIAN/SMF ORTHOPAEDI DAN TRAUMATOLOGY

UNIVERSITAS UDAYANA

2016
 First Experience of Total Femoral Replacement with Mega Prostheses
in Patient with Pathological Fracture due to Multiple Myeloma
A Case Report
Ida Bagus Gede Arimbawa*, I Gde Eka Wiratnaya**
*Resident of Orthopedic and Traumatology Department, Sanglah General Hospital,
UdayanaUniversity, Bali
** Staff of Orthopedic and Traumatology Department, Sanglah General Hospital, Udayana
University Bali

Abstract

Introduction
Multiple myeloma is the most frequent tumor that occurs primarily in bone. Lytic bone
disease is a hallmark multiple myeloma, and a substantial percentage of patients develop
pathologic fractures. 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. Our first experience
with the use of megaprostheses after tumor resection was encouraging. 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 activity1.
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 mammogram1,2.
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 procedures1,2.
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 procedure3.

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.

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
 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.

Figure 3. Total femoral replacement with mega prosthesis following wide excision of the
tumor.
 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. The annual
incidence is reported to be 5-10 per 100,000 population. It occurs as a result of unregulated,
progressive proliferation of neoplastic monoclonal plasma cells. 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 fractures4.
Myeloma is common in elderly patients and rare in patients below 40 years of age. There
is a slight male preponderance and it commonly occurs in the sixth or seventh decade of life.
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 tumor4.
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 stability4. 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 life1,2,4.
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 therapy3,6,7
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 moduli5.
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 subjected5.
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 Knee8.
 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
deformity8.

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