Presenting a follow up of 18 months of a 40 years male after multiple myeloma, where we could achieve union after intramedullary nailing and chemotherapy.
In 123 cancer patients with metastatic disease, 129 pathologic fractures of long bones were assessed to determine the rate of osseous union. Bony healing was observed in 67% of malignant fractures from multiple myeloma, in 44% of fractures secondary to metastatic hypernephroma, and in 37% of neoplastic fractures from breast carcinoma. No patient with a pathologic fracture secondary to lung carcinoma demonstrated bony repair, and none of these patients lived for more than six months after fracture. The overall fracture healing rate for the entire study population was 35%. In the group that survived longer than six months, 74% of fractures united. A life expectancy of longer than six months was the primary factor determining osseous healing in all patients. A total radiotherapy dose of 3000 rad or less did not inhibit callus formation. Internal fixation improved the rate of fracture union by 23% as compared with cast immobilization.
Clin Orthop Relat Res. 1983 Sep;(178):297-302.
Two days back,I saw a case of pathological intertrochanteric fracture of left femur,which had united in ?2 months time,without any intervention.Patient(50+/f) had a history of carcinoma breast,which was treated by mastectomy(left side) along with chemo,back in 2010. Pt had a history of fall in bathroom 2 months back and another history of fall 15 days back.She had back pain,weakness in both lower limbs and was unable to ambulate,but was able to flex both hips voluntarily..There was angular kyphosis around L2 lavel with tenderness. Hard tender mass was palpable in left trochanteric region.Radiographs revealed multiple sclerotic secondaries(osteoblastic) in thoracolumbar spine,pelvis and both proximal femora.There was angular kyphosis around L2 lavel with tenderness.L2 body had collapsed,in addition to uniting fracture of left proximal femur.
Great question Raju:
Non-union of long bones are due to several reasons:
1. Metastatic bone disease with enhance osteoclastic activities, includingnmyeloma; ant osteoclastic agents such a an intravenous bisphosphonates or denosumab have a potent effects in controlling such.
2. Mal-alignment (a mechanical issues and may need surgical intervention
3. True non-union (e.g., atrumatic sub-trochanteric fractures (ASTFs) after prolonged use of bisphosphonates or denosumb. These patents likely to benefit with a short course (e.g., 3- 6 month) treatment with teriparatide injections (daily or EoD). I refer to the following review article it the ResearchGate website (free to download) regarding this:
https://www.researchgate.net/publication/304029549_Optimum_duration_and_safety_of_long-term_use_of_potent_anti-resorptive_medications_in_osteoporosis?ev=prf_pub
Best wishes,
Prof Sunil Wimalawansa
Article Optimum duration and safety of long-term use of potent anti-...
Very interesting question. Anti-resorptive medication should be presribed in patients with pathologic fractures of the long bones. Especially in myeloma patients who have a better tendency to unite. But I think the most important step is to perform a stable internal or external fixation.
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