Métastase osseuse du fémur traitée par enclouage centromédullaire : évaluation clinique et radiologique par le score de Tokuhashi

Obert, L.; Jarry, A; Lepage, D.; Jeunet, L.; Tropet, Y.; Vichard, P; Garbuio, P.

doi:10.1016/s0035-1040(05)84485-x

Cited by 10 publications

(1 citation statement)

References 15 publications

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“…This bone pain is usually managed with analgesia, chemotherapy and bisphosphonates; however, the risk of pathological fracture remains high. For those impending pathological fractures of the long bones, surgical intervention via intramedullary nailing provides a solution associated with reduced blood loss and morbidity [ 20 ]. Furthermore, prophylactic nailing was found to result in increased survival and ambulation rates six months post-surgery [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

Chemotherapy May Obviate Prophylactic Femoral Nail Surgery for Multiple Myeloma Patients With High Mirels’ Score Lesions and Impending Pathological Hip Fracture

Divekar¹,

Ajayi²,

Barkham³

et al. 2023

Cureus

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Bone involvement presents in >80% of patients with multiple myeloma. This causes lytic lesions for which prophylactic surgery is indicated to prevent pathological fractures if the lesion is graded ≥9/12 on Mirels' score. Although successful, these surgeries have risks and extended recovery periods. We present a case indicating myeloma chemotherapy may obviate prophylactic femoral nailing for high Mirels' score lesions in the femoral head with impending pathological hip fracture.A 72-year-old woman presented in December 2017 with back pain. A plain X-ray indicated degenerative anterolisthesis in her lumbosacral spine. Serum analysis revealed abnormal protein, globulin, alkaline phosphatase, and albumin levels while protein electrophoresis and serum immunofixation revealed raised immunoglobulin A (IgA) kappa paraprotein and kappa serum free light chains, respectively. Whole-body CT scans showed widespread lytic bone lesions and bone marrow biopsy confirmed infiltration by plasma cells. She was diagnosed with International Staging System (ISS) stage 3 multiple myeloma, which was successfully treated with bortezomib, thalidomide and dexamethasone with regular bisphosphonates that year. She presented again to the hospital in June 2020 with acute back and pelvic pain; Her paraprotein and serum-free light chains had increased significantly from her previous clinic appointment, indicating serological progression. MRI showed a relapse of the myeloma deposits in her right femoral head and spine. The deposit in her femoral head was graded 10/12 on Mirels' score, which indicated prophylactic femoral nailing. Instead, the patient was treated with daratumumab, bortezomib, and dexamethasone with escalation to monthly zoledronic acid infusions, as it was thought surgery would provide limited cytoreductive effect, preventing chemotherapy for six weeks post-surgery, potentiating pathological hip fracture and disease progression at other sites. This resulted in a complete response, thus reducing the deposits such that the femoral lesion was graded <8 on Mirels' score, improved her pain, and restored her ability to traverse stairs. She remains in complete response with ongoing daratumumab and denosumab maintenance treatment as of December 2022.Chemotherapy and bisphosphonates substantially reduced the myeloma deposit in the femoral head such that indications of prophylactic surgery were eliminated according to Mirels' score recommendations. This reduced the risk of pathological hip fracture whilst eliminating surgical complications. Further research should be conducted into the safety and efficacy of this treatment regimen in patients with high Mirels' score lesions. With this knowledge, consideration can be taken as to whether prophylactic femoral nailing is necessary given strong indications.

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Section: Discussionmentioning

confidence: 99%

Chemotherapy May Obviate Prophylactic Femoral Nail Surgery for Multiple Myeloma Patients With High Mirels’ Score Lesions and Impending Pathological Hip Fracture

Divekar¹,

Ajayi²,

Barkham³

et al. 2023

Cureus

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Benefits of early intramedullary nailing in femoral metastases

Arvinius

Parra

Serrano-Mateo

et al. 2013

International Orthopaedics (SICOT)

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Purpose Pathological fractures of the long bones are common complications of metastatic disease; however, the outcome of different surgical techniques for the treatment of these fractures has not been clearly defined. The aim of this study was to evaluate differences in prophylactic and therapeutic intramedullary nailing in femoral metastasic implants. Methods Sixty-five patients with metastasis of the femur were analysed retrospectively (37 females; 28 males) between 1995 and 2011 (follow-up 15 months). Forty-four presented with pathological fractures and 21 impending fractures (Mirel ≥7). The operative treatments used were intramedullary fixation with reamed long Gamma nails. The studied parameters were survival, radiological and analytical findings, and functional outcomes. Results Prophylactic nailing resulted in immediate postoperative deaths in 5 % vs. 11.4 % in therapeutic, and one technical complication was detected in each group. Among the surviving patients 75.9 % of the fractures and 100 % of impending lesions were able to walk after the operation. The mean survival time was 11 months in the therapeutic (range 1-49) and 14 in the prophylactic group (1-34). The prophylactic intramedullary nails required a lower transfusion rate (1.4 concentrates vs. 3.0), mobilised earlier (day 4.0 vs. 9.7) and needed a shorter hospital stay (eight days vs. 16 days) compared to therapeutic nails (p <0.05). Conclusion Femoral intramedullary nailing of metastasic lesions provides satisfactory results both clinically and radiologically. Early treatment of the metastases prevents fractures and gives better results, improving life quality of these patients.

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