Pathologic fracture of proximal femur shaft due to metastatic pulmonary adenocarcinoma treated with close intramedullary locking nail - Two case reports

Wei-Cheng Lai ； Shih-Wen Kao ； Chih-Lung Wu ； Tsay-I Chiang ； I-Chang Chang

《Formosan Journal of Musculoskeletal Disorders》 8卷4期 (2017/11) Pp. 182-186

https://doi.org/10.6492/FJMD.20160710

摘要

Introduction: With improvements in oncological treatments, the increased life expectancy results in a higher incidence of pathologic fracture of proximal femoral shaft due to metastatic pulmonary adenocarcinoma. Osteosynthesis cannot prolong life, but can achieve good pain control and early mobilization. This report evaluates the use of close intramedullary locking nailing, without tumor curettage and bone cement augmentation, for the treatment of those patients. Case Report: Two patients with pulmonary adenocarcinoma and metastatic complete pathologic fracture of proximal femoral shaft received close proximal femoral nail fixation. The metastatic tumor fracture site was not open and the fracture cortex contact was well after close osteosythesis application. Through the intramedullary nail entry point, the intramedullary tissue at the pathological fracture site was taken by using curettage, and the histopathological confirmation was made. Both patients received adjuvant radiotherapy and chemotherapy thereafter. Although the metastatic tumor continues to grow, the fracture union was achieved and well preserved throughout patient life. One patient expired at 13 months, and the other at 11 months after osteosynthesis surgery. Both patients' performance status improved from Grade 4 before operation to grade 1 to 2 one month after surgery. Discussion: Intramedullary nail due to load sharing capabilities is generally considered the preferred treatment and may stabilize the entire length of the femur to prevent fractures due to further tumor progression. Reaming with aspiration venting may minimize tumor embolism complications. Methyl methacrylate augmentation means more extensive dissection, and may impair fracture healing due to thermal necrosis, and may cause early fracture crack and interfere future revision surgery. With tumor palliation, fracture union still can be achieved using close antegrade locking nailing. Conclusion: If good bone contact can be achieved after close osteosynthesis, tumor curettage and bone cement augmentation are not always necessary for pathologic fracture of proximal femoral shaft due to metastatic pulmonary adenocarcinoma.

關鍵字

close intramedullary locking nailing ； proximal femoral shaft pathologic fracture ； pulmonary adenocarcinoma