|Year : 2021 | Volume
| Issue : 3 | Page : 111-114
Pathological fracture of humerus with implant failure in multiple myeloma patient: A rare case report
Bharat Dhanjani, Sudhanshu Shekhar, Ankit Pranjal
Department of Orthopedic Surgery, Asian Institute of Medical Sciences, Faridabad, Haryana, India
|Date of Submission||10-Sep-2021|
|Date of Decision||30-Nov-2021|
|Date of Acceptance||06-Dec-2021|
|Date of Web Publication||20-Dec-2021|
Dr. Sudhanshu Shekhar
House No-D/7, Ajanta Colony, Keshri Nagar, Patna - 800 024, Bihar
Source of Support: None, Conflict of Interest: None
A 42-year-old male diagnosed with multiple myeloma had a history of traumatic oblique fracture mid-shaft of right humerus managed by open reduction and internal fixation with plating at another center. After uneventful period of 1 year, he presented with pain and restricted movement of right shoulder and arm for 4 months. Radiograph exhibits osteolytic lesion (moth-eaten) underneath the plate and pathological fracture of mid-shaft humerus with implant failure. After excluding surgical contraindications, wide excision of tumor and reconstruction with tumor prosthesis was done using deltopectoral approach. Proximal humerus (15 cm) was excised along with the tumor mass and plate, leaving 5 cm of the distal humerus. Components of tumor prosthesis wrapped with prolene mesh were inserted using antibiotic cement. Capsule, rotator cuff tendons was sutured around the prosthesis head using nonabsorbable sutures. Postoperatively, the patient was managed in shoulder immobilizer for 3 weeks, assisted mobilization for the next 3 weeks and active mobilization at 6 weeks. The patient responded to chemotherapy postoperatively. At 1-year follow-up, the patient was able to perform activities of daily, achieved shoulder flexion (0°–90°), abduction (0°–50°) with no evidence of recurrence. Development of tumor metastasis with extensive humeral involvement in traumatic fracture of mid-shaft humerus treated with rigid fixation with a plate is a rare entity.
Keywords: Multiple myeloma, pathological fracture, tumor prosthesis
|How to cite this article:|
Dhanjani B, Shekhar S, Pranjal A. Pathological fracture of humerus with implant failure in multiple myeloma patient: A rare case report. J Orthop Dis Traumatol 2021;4:111-4
|How to cite this URL:|
Dhanjani B, Shekhar S, Pranjal A. Pathological fracture of humerus with implant failure in multiple myeloma patient: A rare case report. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Sep 30];4:111-4. Available from: https://jodt.org/text.asp?2021/4/3/111/332944
| Introduction|| |
Multiple myeloma is the most common primary malignant bone tumor, i.e., constituting around 40% of primary bone tumors. It is a low-grade non-Hodgkin lymphoma as a result of proliferation of malignant clone of plasma cells in bone marrow, where they induce osteolytic lesions and produce monoclonal components (paraprotein). It has male predominance (male:female-2:1) and mostly presents in age group between 30 and 80 years with peak incidence in 7th decade. This presents most commonly in spine (34%) followed by femur (18%), humerus (14%), and pelvis (13%).
Myeloma weakens the bone and nearly 80% patients develop pathological fractures. These pathological fractures of humerus are difficult to heal because of the disease process itself or the use of radiotherapy/chemotherapy. In patients with good life expectancy, endoprosthetic replacement of humerus is both functionally and oncologically a sensible option. The advantage of reconstruction with endoprosthesis over internal fixation of the humerus is that it allows complete removal of the cancerous area, thus minimizing the risk of further tumor-related problems such as nonunion and tumor progression.
| Case Report|| |
A 42-year-old male diagnosed with multiple myeloma had a history of oblique fracture mid-shaft of right humerus [Figure 1]a 16 months back due to fall, which was managed by open reduction and internal fixation with plating at another center and they did not find any signs of tumor at the local site intraoperatively. The patient had no complaints for 1 year after the surgery. Now, he presented to us in outpatient department with pain and restricted movement in the right shoulder and arm for the past 4 months. On clinical examination, we found a localized tender swelling with crepitus in the mid-arm area along with wasting of the arm musculature. On plain radiograph of right arm osteolytic lesion (moth eaten appearance) and pathological fracture of midshaft of humerus with implant failure was noticed [Figure 1]b. Magnetic resonance imaging demonstrated osteolytic expansile lesion involving the humeral shaft for craniocaudal length of 10 cm along with soft tissue component in the anterolateral compartment of right upper arm [Figure 2].
|Figure 1: (a) Plain radiograph showing oblique fracture of mid-shaft of right humerus in a 42-year-old diagnosed case of multiple myeloma (b) Plain radiograph showing mouth eaten appearance of proximal 2/3rd of humerus with pathological fracture along with implant failure 1|
Click here to view
|Figure 2: Magnetic resonance imaging showing osteolytic expansile lesion of humeral shaft along with soft tissue component in the anterolateral compartment of right upper arm|
Click here to view
After excluding any surgical contraindications and taking informed consent from the patient, wide excision of tumor and reconstruction with tumor prosthesis was planned using deltopectoral approach. Soft tissues were retracted, neurovascular structures including axillary, radial, median, and ulnar nerve along with brachial artery were identified, isolated, and preserved. The proximal 15 cm of the humerus was excised (wide excision) along with the tumor mass and plate [Figure 3] leaving 5 cm of the distal humerus. The intramedullary canal of the distal humerus was carefully reamed, thoroughly washed with pulsatile water lavage to remove blood and debris. The components of tumor prosthesis [Figure 4]a were inserted using antibiotic impregnated cement under relative hypotensive anesthesia. Prolene mesh was wrapped around the prosthesis [Figure 4]b. Capsule, rotator cuff tendon was sutured around the prosthesis head using nonabsorbable sutures. Suction drains were placed in the periprosthetic space and closure was performed in layers. Cephalosporin antibiotics were administered intravenously, with the first dose administered 20 min before the surgical incision and continued until the drains were removed, i.e., till 48 h after the surgery. Postoperative radiograph [Figure 5] was satisfactory and the patient was managed in shoulder immobilizer for 3 weeks followed by gradual assisted mobilization of shoulder for further 3 weeks. Active mobilization of shoulder was started at 6 weeks. Postoperatively, after wound healing, the patient received chemotherapy as per protocol (injection bortezomib 2.5 mg and injection zolendronate 4 mg), to which patient is responding. At 1-year follow-up, the patient was able to perform activities of daily living without any discomfort. The shoulder flexion was 0°–90° and abduction was 0°–50° [Figure 6]. Elbow, wrist, and hand functions were normal. Radiograph at 1 year appears reasonably good [Figure 7]. The patient is still under regular follow-up with no evidence of recurrence.
|Figure 4: (a) Assembled components of tumor prosthesis. (b) Intraoperative picture showing implantation of the tumor prosthesis wrapped with prolene mesh|
Click here to view
| Discussion|| |
Humerus is the second most common site of tumor metastases accounting for 16%–39%, with actual or impending pathological fractures., Pathological fractures of the humeral shaft occur late in the course of malignant disease and are reported to occur in only 8%–10% of metastases to this bone. The primary tumors of the breast, prostate, kidney, thyroid, and lung are most frequent to metastasize to the bone. Few series of multiple myeloma metastasizing to bone have also been reported in the literature.
The goals of surgical treatment are immediate pain reduction by stabilizing the fracture, reducing morbidity, and restoring function of the affected extremity., The conservative treatment, i.e., immobilization of the pathological fractures, has resulted in insufficient pain reduction, higher nonunion rate, and little functional improvement. It may be mainly due to the reduced consolidation potential of these lesions because of the biological and mechanical effects of the tumor. Hence, the main treatment remains rigid surgical stabilization of the fracture. Although the upper extremities are not primarily weight-bearing, proximal humerus is subject to rotational and bending forces by the action of the rotator cuff, deltoid, pectoralis major, and latissimus dorsi muscles. This demands great torsional strength of any kind of implant.
As recent advancement of radiation therapy and chemotherapy, limb salvage procedures have been the main method of surgical treatment for humeral malignancies. Nowadays, >80% of the patients are treated with limb salvage surgery without critically compromising oncological principles. Wide resection of tumor should be done in cases where there is extensive involvement of the humeral shaft. In our case, we have observed that even after rigid fixation of traumatic fracture using plate, there can be a possibility of developing metastasis at the same site most likely due to increased blood circulation at the time of healing. There is paucity in the literature regarding metastasis to the fracture site after rigid fixation.
| Conclusion|| |
Metastasis of tumors including multiple myeloma to bones leading to pathological fracture is well-known fact but the development of tumor metastasis with extensive involvement of humerus in a case of traumatic fracture of mid-shaft humerus treated with rigid fixation with a plate is a rare entity. During fracture fixation in a known case of tumor patient even if there are no signs of tumor involvement locally, biopsy should be sent always. Furthermore, tumor metastasis can occur at the fracture site even after fixation with plate or nail.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Azar FM, Canale ST, Beaty JH. Campbell's Operative Orthopaedics, E-Book. Elsevier Health Sciences; 2020.13th
Albagoush SA, Azevedo AM. Multiple Myeloma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021-.PMID: 30521185.
Chandrasekar CR, Grimer RJ, Carter SR, Tillman RM, Abudu A, Buckley L. Modular endoprosthetic replacement for tumours of the proximal femur. J Bone Joint Surg Br 2009;91:108-12.
Dutka J, Sosin P. Time of survival and quality of life of the patients operatively treated due to pathological fractures due to bone metastases. Ortop Traumatol Rehabil 2003;5:276-83.
Ofluoglu O, Erol B, Ozgen Z, Yildiz M. Minimally invasive treatment of pathological fractures of the humeral shaft. Int Orthop 2009;33:707-12.
Gebhart M, Dequanter D, Vandeweyer E. Metastatic involvement of the humerus: A retrospective study of 51 cases. Acta Orthop Belg 2001;67:456-63.
Pretell J, Rodriguez J, Blanco D, Zafra A, Resines C. Treatment of pathological humeral shaft fractures with intramedullary nailing. A retrospective study. Int Orthop 2010;34:559-63.
Frassica FJ, Frassica DA. Metastatic bone disease of the humerus. J Am Acad Orthop Surg 2003;11:282-8.
Hunt KJ, Gollogly S, Randall RL. Surgical fixation of pathologic fractures: An evaluation of evolving treatment methods. Bull Hosp Jt Dis 2006;63:77-82.
Moura DL, Alves F, Fonseca R, Freitas J, Casanova J. Treatment of pathological humerus-shaft tumoral fractures with rigid static interlocking intramedullary nail-22 years of experience. Rev Bras Ortop (Sao Paulo) 2019;54:149-55.
Willeumier JJ, van der Linden YM, van de Sande MA, Dijkstra PD. Treatment of pathological fractures of the long bones. EFORT Open Rev 2016;1:136-45.
Zhao J, Xu M, Zheng K, Yu X. Limb salvage surgery with joint preservation for malignant humeral bone tumors: Operative procedures and clinical application. BMC Surg 2019;19:57.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]