Percutaneous stabilization of impending pathological fracture of the proximal femur

Percutaneous-Reinforced Osteoplasty: A Review of Emerging Treatment Strategies for Bone Interventions

Percutaneous-reinforced osteoplasty is currently being investigated as a possible therapeutic procedure for fracture stabilization in high-risk patients, primarily in patients with bone metastases or osteoporosis. For these patients, a percutaneous approach, if structurally sound, can provide a viable method for treating bone fractures without the physiologic stress of anesthesia and open surgery. However, the low strength of fixation is a common limitation that requires further refinement in scaffold design and selection of materials, and may potentially benefit from tissue-engineering-based regenerative approaches. Scaffolds that have tissue regenerative properties and low inflammatory response promote rapid healing at the fracture site and are ideal for percutaneous applications. On the other hand, preclinical mechanical tests of fracture-repaired specimens provide key information on restoration strength and long-term stability and enable further design optimization. This review presents an overview of percutaneous-reinforced osteoplasty, emerging treatment strategies for bone repair, and basic concepts of in vitro mechanical characterization.

Combination of Percutaneous Screw Fixation and Cementoplasty for Lytic Bone Metastases: Feasibility, Safety and Clinical Outcomes

OBJECTIVE

To evaluate feasibility, safety and efficacy of a combination of screw fixation and cementoplasty for pathologic bone fracture.

METHODS

In this single-center prospective study, all consecutive percutaneous screw fixations under assisted CT guidance for palliation and fracture treatment of pathologic bone fracture were reviewed from July 2019 to February 2021. The primary outcome measure was the procedures' technical success, defined as the correct placement of the screw(s), without any complications. Secondary outcome measures were the safety, the procedures' early analgesic effects and impacts on quality of life at 4 weeks.

RESULTS

Technical success was achieved in 11/11 procedures (100%) among 11 patients. No major complications attributable to the procedure were noted. The mean pain scored significantly decreased at the initial follow-up: 8.0 ± 2.7 versus 1.6 ± 2.5 (p < 0.05). Opioid doses were statistically lower after procedure: 70.9 ± 37 versus 48.2 ± 46 mg/day (p < 0.05). The mean EQ5D score had significantly increased by the early post-procedure consultation: 42.5 ± 13.6 vs 63.6 ± 10.3 (p < 0.05).

CONCLUSION

Combination of percutaneous screw fixation and cementoplasty for pathologic bone fracture is feasible and safe. It is efficient to reduce pain, decrease the consumption of opioids and improve the quality of life at 4 weeks after the procedure.

Ablation Techniques in Cancer Pain

Painful bone metastases are a frequently encountered problem in oncology practice. The skeletal system is the third most common site of metastatic disease and up to 85% of patients with breast, prostate, and lung cancer may develop bone metastases during the course of their disease.

Complications of percutaneous image-guided screw fixation: An analysis of 94 consecutive patients

PURPOSE

The purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures.

MATERIALS AND METHODS

From July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (<24hours) and delayed (>24hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

RESULTS

A total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7±12.7 [SD] years; age range: 32-88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and>24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%).

CONCLUSION

The rate of per-procedural and early (within 24hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (>24hours).

Advanced Interventional Pain Management Approach to Neoplastic Disease Outside the Spine

Neoplastic disease of the musculoskeletal system may result in serious morbidity and mortality secondary to cancer related bone pain, pathologic fracture, altered structural mechanics, and involvement of adjacent structures.¹ Recent advances in cancer detection and treatment have allowed more patients to live longer. The prevalence of osseous metastatic disease has increased to 100,000 new patients developing bone metastases each year.² These patients are seeing long-term exposure to chemotherapy and radiation leading to increased skeletal events, morbidity, and a negative impact on quality of life. Bone metastases in conjunction with poor bone quality often prevent surgical therapy. Utilization of thermal ablation in this patient population is supported by contemporary literature and offers a minimally invasive approach to pain palliation, local tumor control, and decreased morbidity with unique advantages compared to surgery or radiation.³ In addition to spine disease, interventional radiologists are able to meaningfully impact pelvic, shoulder girdle, and long bone metastases. Adding to ablation we have in our repertoire the ability to provide structural support utilizing cement and/or screw fixation as an adjunct for both pain palliation and mechanical stabilization.^4-6 These novel therapies have allowed more patients with metastatic disease to be treated. The focus of this chapter is to highlight importance of patient selection, ablative modality selection, integration of cementoplasty (also described as osteoplasty) and osseous fixation, and procedural techniques/strategy in the pelvis and other common sites of bone metastases outside the spine.

Augmented versus non-augmented percutaneous cementoplasty for the treatment of metastatic impending fractures of proximal femur: A systematic review

INTRODUCTION

Percutaneous cementoplasty (PC) has been widely used for the stabilization of impending fractures of the proximal femur due to metastatic lesions. Augmented percataneous cementoplasty (APC) with fixation devices aims to improve mechanical consolidation and stability of the construct. However, the clinical benefit of the combined technique has not been clearly established. The purpose of the current review was to compare the efficacy between APC and PC for impending pathologic proximal femoral fractures from metastatic malignancy, in terms of pain relief, operative time and fracture related complication rates.

MATERIAL AND METHODS

Medline, Scopus, and the Cochrane central register of controlled trials were searched for clinical studies up to July 2019. Studies relevant to cementoplasty of the proximal femur were included. The primary outcome of the study was pain relief as assessed using the Visual Analogue Scale (VAS) change. Secondary outcomes included incidence of post-intervention fracture, operative time and complication rate.

RESULTS

Twelve studies with a total of 343 patients were included. No difference was found for all outcomes. For pain relief, pooled results showed a mean difference in VAS score -4.6 ± 1.7 for PC, and -4.3 ± 2.5 for APC (p = 0.41). Post-intervention fractures of the proximal femur occurred in 7% of patients with PC and in 5% of patients with APC (p = 0.4), and the mean duration of interventions was 57.9 ± 8.4 and 56.5 ± 27.5 min, respectively (p = 0.58). Cement leakage into the hip joint or the soft tissues occurred in 5% of cases in PC group and in 8% of cases in APC group (p = 0.16). Six patients in the APC group (4%) experienced major systemic complications, which were treated successfully.

CONCLUSIONS

APC does not seem to improve pain relief, fracture incidence, and operative time when compared with PC. Both techniques appeared effective in terms of resolution of symptoms, prevention of pathologic fractures, and early facilitation of weight-bearing. PC showed more clinical safety, as no major systemic complications occurred. However, due to the relative paucity of large clinical trials, the decision of augmentation of cementoplasty should be individualized according to the size and location of metastatic lesions and the overall medical condition of patients.

Trends in Musculoskeletal Ablation: Emerging Indications and Techniques

Image-guided percutaneous thermal ablation plays an increasingly important role in the multidisciplinary management of musculoskeletal lesions. Established indications for ablation in this setting include the treatment of osteoid osteomas, palliation of painful skeletal metastases, local control of oligometastatic disease, and consolidation of bone tumors at risk for fracture. Emerging indications include the treatment of symptomatic soft tissue masses such as extra-abdominal desmoid tumors and abdominal wall endometriosis. This review will discuss considerations in patient selection and preprocedural workup, ablation technology and techniques, strategies to avoid complications, and expected outcomes of ablation in the musculoskeletal system.

Interventional oncology at the time of COVID-19 pandemic: Problems and solutions

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COVID-19 pandemic modifies in-depth interventional oncology practice.

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Identification of aerosol-generating procedures is crucial for safety.

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Curative treatment of cancers should not be delayed during the COVID-19 pandemic.

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Solutions to overcome shortage in anesthesiology resources are described.

The COVID-19 pandemic has deeply impacted the activity of interventional oncology in hospitals and cancer centers. In this review based on official recommendations of different international societies, but also on local solutions found in different expert large-volume centers, we discuss the changes that need to be done for the organization, safety, and patient management in interventional oncology. A literature review of potential solutions in a context of scarce anesthesiologic resources, limited staff and limited access to hospital beds are proposed and discussed based on the literature data.

Stent screw-assisted internal fixation (SAIF): clinical report of a novel approach to stabilizing and internally fixating vertebrae destroyed by malignancy

OBJECTIVE

Severe lytic cancerous lesions of the spine are associated with significant morbidity and treatment challenges. Stabilization and restoration of the axial load capability of the vertebral body (VB) are important to prevent or arrest vertebral collapse. Percutaneous stent screw-assisted internal fixation (SAIF), which anchors a VB stent/cement complex with pedicular screws to the posterior vertebral elements, is a minimally invasive, image-guided, 360° internal fixation technique that can be utilized in this patient cohort. The purpose of this study was to assess the feasibility, safety, and stabilization efficacy of VB reconstruction via the SAIF technique in a cohort of patients with extensive lytic vertebral lesions, who were considered to have an unstable or potentially unstable spine according to the Spinal Instability Neoplastic Score (SINS).

METHODS

This study was a retrospective assessment of a prospectively maintained database of a consecutive series of patients with neoplastic extensive extracompartmental osteolysis (Tomita type 4-6) of the VB treated with the SAIF technique. VB reconstruction was assessed on postprocedure plain radiographs and CT by two independent raters. Technical and clinical complications were recorded. Clinical and imaging follow-ups were assessed.

RESULTS

Thirty-five patients with extensive osteolytic metastatic lesions of the VB underwent 36 SAIF procedures. SAIF was performed as a stand-alone procedure in 31/36 cases and was associated with posterior surgical fixation in 5/36 (4/5 with decompressive laminectomy). In 1 case an epidural cement leak required surgical decompression. VB reconstruction was categorized as satisfactory (excellent or good rating) by the two raters in 34/36 cases (94.5%) with an interrater reliability of 94.4% (Cohen's kappa of 0.8). Follow-up, ranging from 1 to 30 months, was available for 30/36 levels. Long-term follow-up (6-30 months, mean 11.5 months) was available for 16/36 levels. Stability during follow-up was noted in 29/30 cases.

CONCLUSIONS

SAIF provides 360° nonfusion internal fixation that stabilizes the VB in patients with extensive lytic lesions that would otherwise be challenging to treat.

Prevention of Pathological Fracture of the Proximal Femur: A Systematic Review of Surgical and Percutaneous Image-Guided Techniques Used in Interventional Oncology

Background and objectives: Patients suffering from bone metastasis are at high risk for pathological fractures and especially hip fractures. Osteolytic metastases can induce a high morbidity rate (i.e., pain, facture risk, mobility impairment), and operation on them can be difficult in this frail population having a reduced life expectancy. Several medical devices have been investigated for the prevention of these pathological hip fractures. Materials and Methods: To investigate these solutions, a literature review and a meta-analysis of primary studies was performed. Data sources included electronic databases (PubMed, CENTRAL and ClinicalTrials.gov) from 1990 until 1 January 2019. Titles, abstracts and full-text articles were reviewed in order to select only studies evaluating the performance of the studied solution to prevent osteoporotic and/or pathological hip fracture. The main outcomes were the occurrence of hip fracture, pain evaluation (VAS score) and adverse events occurrence (including severe adverse events and deaths). All randomised controlled trials (RCTs) and cohort studies were considered. A Bayesian cumulative meta-analysis was undertaken on the primary studies conducted in patients with bone metastasis. Results: A total of 12 primary studies were identified, all were cohort studies without a control group, and one compared two devices, and were thereafter considered separately. In those 12 samples, 255 patients were included, mean age 61.7 years. After implantation, the cumulative risk of fracture was 5.5% (95% confidence interval, 3.0% to 8.6%), and adverse event occurrence was 17.4% (95%CI, 12.6 to 22.8%), with a median follow-up of 10 months. The posterior probability of a fracture rate below 5% was 40.3%. Conclusions: The literature about medical devices evaluation for preventing hip fractures in metastatic patients is poor and mostly based on studies with a limited level of evidence. However, this systematic review shows promising results in terms of efficacy and tolerance of these devices in patients with bone metastases. This treatment strategy requires further investigations.

Interventional Techniques for the Ablation and Augmentation of Extraspinal Lytic Bone Metastases

In addition to being a major source of cancer-related pain, metastatic osseous lesions are frequently at risk for pathologic fracture and its accompanying morbidity. While bony metastases are commonly thought of as occurring within the vertebral column, over 80% are found outside the spine. Percutaneous interventional treatment options for nonspinal metastases offer a broad array of minimally invasive, image-guided procedures that are rapidly effective, reduce the need for opioids, and often work in complementary fashion with adjunct treatments in radiation oncology, orthopaedic surgery, and/or medical oncology. This article presents an approach to assess extraspinal metastases, reviews available interventional techniques in use today, and offers example cases as an introductory primer to the thought process used for selecting the appropriate interventional treatment.

Percutaneous extra-spinal cementoplasty in patients with cancer: A systematic review of procedural details and clinical outcomes

PURPOSE

To perform a systematic review of technical details and clinical outcomes of percutaneous extra-spinal cementoplasty in patients with malignant lesions.

MATERIALS AND METHODS

PUBMED, MEDLINE, MEDLINE in-process, EMBASE and the Cochrane databases were searched between January 1990 and February 2019 using the keywords «percutaneous cementoplasty», «percutaneous osteoplasty» and «extra-spinal cementoplasty». Inclusion criteria were: retrospective/prospective cohort with more than 4 patients, published in English language, reporting the use of percutaneous injection of cement inside an extra-spinal bone malignant tumour using a dedicated bone trocar, as a stand-alone procedure or in combination with another percutaneous intervention, in order to provide pain palliation and/or bone consolidation.

RESULTS

Thirty articles involving 652 patients with a total of 761 lesions were reviewed. Mean size of lesion was 45mm (range of mean size among publications: 29-73mm); 489 lesions were located in the pelvis, 262 in the long bones of the limbs and 10 in other locations. Cementoplasty was reported as a stand-alone procedure for 60.1% of lesions, and combined with thermal ablation for 26.2% of lesions, implant devices for 12.3% of lesions, and balloon kyphoplasty for 1.4% of lesions. The mean volume of injected cement was 8.8mL (range of mean volume among publications: 2.7-32.2mL). The preoperative visual analogic scores ranged between 3.2 and 9.5. Postoperative scores at last available follow-up ranged from 0.4 to 5.6. Thirteen papers reported a reduction of the visual analogic scores of 5 points or more. Nerve injury was the most frequent symptomatic leakage (0.6%).

CONCLUSION

Percutaneous extra-spinal cementopasty is predominantly performed as a stand-alone procedure and for lesions in the bony pelvis. It appears to be an effective tool to manage pain associated with malignant bone tumours. There is however a lack of standardization of the technique among the different publications.

Safety and efficacy of microwave ablation for breast cancer thoracic metastases

Background

The objective of the study was to assess the safety and efficacy of microwave ablation (MWA) for breast cancer thoracic metastasis.

Materials and methods

Twelve patients in our institution with a single lesion of breast cancer thoracic metastases received MWA and invasive spine surgery from August 2014 to November 2016. MWA was executed using the MWA system (2,450 MHz) at 40 W or 50 W with thermometers to control the ablation end points. The pathology of thoracic metastases was confirmed through intraoperative biopsy before ablation. The postoperative complications were recorded. The patients were followed up at 1, 3 and 6 months with contrast-enhanced computed tomography and magnetic resonance imaging to monitor for tumor recurrence.

Results

The average duration of follow-up for breast cancer thoracic metastases patients (mean age 52.7±8.4 years) was 10.2 months. The rate of postoperative main complications was 8.3% (1/12). The recurrence rate was 16.6% (2/12) as confirmed by persistent enhancement.

Conclusion

MWA may be used as the adjuvant treatment for thoracic metastases of breast cancer. Results showed that few significant complications and less local recurrence occurred during the follow-up stage. Future research should aim at discovering more about the time controls for microwave-tissue interaction and treatment parameters before widespread use.

Fluoroscopy and Cone-Beam CT-guided Fixation by Internal Cemented Screw for Pathologic Pelvic Fractures

Purpose To evaluate the safety and efficacy of palliative treatment of patients with pathologic pelvic by using fluoroscopy and cone-beam CT needle guidance software to perform percutaneous fixation by internal cemented screw (FICS). Materials and Methods This single-center study involved retrospective analysis of 100 consecutive patients with cancer with pathologic pelvic fractures managed with percutaneous FICS. Image guidance was performed with fluoroscopy and cone-beam CT needle guidance software. Pain palliative outcomes and opioid use after FICS were compared by means of paired-sample t test. Results A total of 107 percutaneous FICS procedures were performed from 2010 to 2017 to palliate 141 pathologic fractures in 100 patients (mean age, 65.0 years ± 17.6 [standard deviation; female age, 66.3 years ± 18.0; mean, 63.7 years ± 17.2]). Of 107 procedures, 104 (97.2%) were technically successful, with mean postprocedure hospitalization of 2 days ± 3. Complications occurred in 14 patients: focal pain at procedure site for longer than 48 hours (n = 5), hematoma (n = 3), progressive fracture despite fixation (n = 2), infection (n = 1), tumor track seeding (n = 1), and screw displacement (n = 2). In the 88 patients who completed early follow-up, mean numeric rating scale pain score was significantly improved at 6 weeks from 6.1 ± 2.5 to 2.1 ± 3.0 (P < .001). Opioid use was reduced at 6 weeks (preprocedure vs postprocedure, 91.3 g ± 121 vs 64.6 g ± 124, respectively; P = .04). Conclusion Fluoroscopy and cone-beam CT-guided percutaneous fixation of pathologic pelvis fractures by internal cemented screw is a safe and effective approach that can reduce pain and opioid use. © RSNA, 2018.

Percutaneous Fixation by Internal Cemented Screw for the Treatment of Unstable Osseous Disease in Cancer Patients

Interventional radiology expertise in image guidance has expanded the treatment options for cancer patients with unstable osseous disease. Percutaneous fixation by internal cemented screw (FICS) describes the technique by which the interventional radiologist stabilizes a fracture or impending fracture with the percutaneous placement of a cannulated screw that is locked in position by polymethyl methacrylate cement. The durable metallic screws provide added resistance to torque and tension stresses that complement the axial compression resistance of cement. Compared with cementoplasty alone, the procedure has been advanced as a more durable and precise technique for stabilization of osseous disease for certain disease presentations in cancer patients. The application of advanced image guidance techniques improves upon existing percutaneous surgical techniques to facilitate approaches that would otherwise prove quite challenging, particularly with stabilization of the pelvic flat bones. This article examines the applications of percutaneous FICS procedures for the treatment of unstable osseous disease in cancer patients. Indications, techniques, and follow-up care are reviewed. Case examples in which FICS can be performed in unstable pathology are detailed.

Thermal Ablation of Bone Metastases

Image-guided, minimally invasive, percutaneous thermal ablation of bone metastases has unique advantages compared with surgery or radiation therapy. Thermal ablation of osseous metastases may result in significant pain palliation, prevention of skeletal-related events, and durable local tumor control. This article will describe current thermal ablation techniques utilized to treat bone metastases, summarize contemporary evidence supporting such thermal ablation treatments, and outline an approach to percutaneous ablative treatment.

Integrated CT-Fluoroscopy Equipment: Improving the Interventional Radiology Approach and Patient Experience for Treatment of Musculoskeletal Malignancies

Integrated CT-fluoroscopy equipment augments the comprehensive approach to the treatment of musculoskeletal (MSK) malignancy by interventional radiology techniques. As the role of minimally invasive treatment expands to meet the highly variable presentation of MSK malignancy, creative solutions to treatment challenges are required to improve locoregional tumor control and durability of pain palliation. Challenges to effective treatment can often be attributed to a combination of aggressive tumor biology, large size, forbidding location, and adverse vascularity. In these cases, a tailored treatment approach may necessitate the application of multiple interventional radiology (IR) techniques that require different image guidance capabilities. Integrated CT-fluoroscopy equipment provides the means to leverage both imaging modalities within the same procedural setting to facilitate the simultaneous application of multiple synergistic treatments and protective measures. This article examines the potential role of hybrid units in the IR treatment of challenging MSK malignancies as a means to empower a paradigm transition for a more comprehensive and patient-tailored approach.

Musculoskeletal Metastases Management: The Interventional Radiologist's Toolbox

The prevalence of patients with painful bone metastases is constantly increasing. This is related to the rising incidence of cancer and increasing life expectancy of patients with metastatic stage. Advances in imaging and development of percutaneous techniques have gradually allowed offering minimally invasive acts on these metastases: cementing, vertebral augmentation, osteosynthesis, percutaneous thermal ablation, neurolysis, embolization. The purpose of this article is to present the main tools available to date for the interventional radiologist so that each participant can understand their functioning, indications, and limits.

Percutaneous Cement Injection for the Palliative Treatment of Osseous Metastases: A Technical Review

The technical art to percutaneous injection of polymethyl methacrylate (PMMA) cement for the palliative treatment of osseous metastases is not without pitfalls. Pathologic fracture, cortical bone erosion, large lytic tumor, aggressive tumor biology, and tumor vascularity may increase the risk of cement leakage or limit complete consolidation. A calculated and determined approach is often necessary to achieve satisfactory patient-tailored results. This article reviews the challenges and potential complications during the consolidation of osseous metastases. Case examples are presented to facilitate early detection of impending cement leakage, minimize procedural risks, and provide management suggestions for complications. Technical pearls are provided to refine consolidative techniques and improve the comprehensive treatment of painful osseous metastases.

Percutaneous osteoplasty for extraspinal metastases

As an extension of percutaneous vertebroplasty (PVP), percutaneous osteoplasty (POP) refers broadly to percutaneous bone cement injected into various parts of the body and narrowly to cement injected into extraspinal bone lesions. POP mainly includes such surgeries as percutaneous sacroplasty, percutaneous acetabuloplasty, percutaneous femoral osteoplasty, and percutaneous iliac osteoplasty (Figure 1). Currently, POP is a positive and an effective treatment for extraspinal bone lesions in that it can rapidly relieve pain, effectively prevent pathological fractures, and partially inactivate tumors, with few complications. The aim of this review is to detail the POP techniques and report their safety and efficacy in the treatment of extraspinal metastases.

Metastatic Osseous Pain Control: Bone Ablation and Cementoplasty

Nociceptive and/or neuropathic pain can be present in all phases of cancer (early and metastatic) and are not adequately treated in 56 to 82.3% of patients. In these patients, radiotherapy achieves overall pain responses (complete and partial responses combined) up to 60 and 61%. On the other hand, nowadays, ablation is included in clinical guidelines for bone metastases and the technique is governed by level I evidence. Depending on the location of the lesion in the peripheral skeleton, either the Mirels scoring or the Harrington (alternatively the Levy) grading system can be used for prophylactic fixation recommendation. As minimally invasive treatment options may be considered in patients with poor clinical status or limited life expectancy, the aim of this review is to detail the techniques proposed so far in the literature and to report the results in terms of safety and efficacy of ablation and cementoplasty (with or without fixation) for bone metastases. Percutaneous image-guided treatments appear as an interesting alternative for localized metastatic lesions of the peripheral skeleton.

Augmented osteoplasty for proximal femur consolidation in cancer patients: Biomechanical considerations and techniques

According to the literature, prophylactic consolidation of lytic metastasis located in the proximal femur is recommended when the Mirels' score is above 8. Osteoplasty alone provides inadequate consolidation but various devices have been used in association for better consolidation. The aim of this review is to detail the augmented osteoplasty techniques published in the literature and to report their safeties and their efficacies to prevent pathological fracture of the proximal femur. A Pubmed research found 5 studies that evaluated augmented osteoplasty of the proximal femur in cancer patients. All devices demonstrate adequate safety and low rate of secondary pathological fractures.

Increasing Role of Image-Guided Ablation in the Treatment of Musculoskeletal Tumors

In the last decade, percutaneous treatment of musculoskeletal (MSK) tumors has become more established in routine clinical care while also undergoing a number of advancements. Ablative techniques to palliate painful skeletal metastases have gained wide acceptance, while goals for ablation have evolved to include local control of oligometastases and desmoid tumors. Bone consolidation or augmentation is now frequently used in conjunction with or instead of ablation of skeletal tumors to stabilize pathologic fractures or prevent further morbidity that could result from fractures caused by tumor progression. These procedures have traditionally been performed with cement injection, although additional percutaneous consolidation or stabilization devices have been developed. Techniques to monitor the ablation zone and adjacent structures intraprocedurally are now applied to increase the number of tumors amenable to treatment. These include methods to depict, displace, or monitor critical structures adjacent to targeted MSK tumors. Finally, the role of ablation in the comprehensive care of patients with MSK tumors continues to change with the evolving triage of patients between radiation therapy, surgical resection and stabilization, and percutaneous ablative and consolidative management.

Percutaneous Palliative Surgery for Femoral Neck Metastasis Using Hollow Perforated Screw Fixation and Bone Cement

Background:

We introduced a new surgical method of percutaneous hollow perforated screw (HPS) fixation with concomitant bone-cement injection for the treatment of femoral neck metastasis and evaluated its efficacy for the palliative treatment of patients with advanced cancer.

Methods:

The study included 87 patients (39 men and 48 women; mean age [and standard deviation], 64.2 ± 10.2 years; mean body mass index, 24.3 ± 3.2 kg/m²) who underwent percutaneous HPS fixation and cementoplasty (mean cement amount, 19.8 ± 8.3 mL) for the treatment of unilateral or bilateral femoral neck metastasis (total, 95 sites). Anesthesia type, operative time, operative blood loss, pain score changes (according to a visual analog scale [VAS]), walking status, and complications were assessed. The mean duration of follow-up was 10.1 ± 10.8 months (range, 2 to 43 months).

Results:

The majority of procedures were performed with local (3 patients) or spinal (72 patients) anesthesia (total, 75 patients; 86.2%). The mean operative time was 35.9 minutes, and the mean operative blood loss was 97.0 mL. The VAS score for pain improved significantly, from 6.8 ± 2.8 preoperatively to 2.8 ± 2.3 and 2.9 ± 2.8 at 1 and 6 weeks postoperatively (p < 0.001). At 6 weeks postoperatively, 63 (80.8%) of 78 patients were able to walk (with either normal or limping gait, a cane or crutch, or a walker). The prevalence of major local complications (cement leakage into the hip joint, fixation failure) was 10.5% (10 of 95), but major systemic complications (distant cement embolism) were not found.

Conclusions:

Percutaneous HPS fixation and cementoplasty for the treatment of femoral neck metastasis is a minimally invasive technique that provides effective pain relief and early stabilization. This technique seems to be useful for patients with advanced cancer for whom open surgery would be hazardous.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Metastatic bone disease from breast cancer: a review of minimally invasive techniques for diagnosis and treatment

Skeletal-related events in patients with metastatic bone disease include intractable severe pain, pathologic fracture, spinal cord and nerve compression, hypercalcemia and bone marrow aplasia. In patients with breast cancer, the skeleton is the most frequent site for metastases. Treatment options for metastatic bone disease in these patients include bisphosphonates, chemotherapeutic agents, opioids, hormonal therapy, minimally invasive/interventional and surgical techniques. Interventional oncology techniques for breast cancer patients with bone metastases include diagnostic (biopsy) and therapeutic (palliative and curative) approaches. In the latter, percutaneous ablation, augmentation and stabilization are included. The purpose of this article is to describe the basic concepts of biopsy, ablation, embolization and peripheral skeleton augmentation techniques in patients with metastatic bone disease from breast carcinoma. The necessity for a tailored approach applying different techniques for different cases and locations will be addressed.

CT-guided percutaneous screw fixation plus cementoplasty in the treatment of painful bone metastases with fractures or a high risk of pathological fracture

OBJECTIVE

To evaluate the feasibility and effectiveness of computed tomography (CT)-guided percutaneous screw fixation plus cementoplasty (PSFPC), for either treatment of painful metastatic fractures or prevention of pathological fractures, in patients who are not candidates for surgical stabilization.

MATERIALS AND METHODS

Twenty-seven patients with 34 metastatic bone lesions underwent CT-guided PSFPC. Bone metastases were located in the vertebral column, femur, and pelvis. The primary end point was the evaluation of feasibility and complications of the procedure, in addition to the length of hospital stay. Pain severity was estimated before treatment and 1 and 6 months after the procedure using the visual analog scale (VAS). Functional outcome was assessed by improved patient walking ability.

RESULTS

All sessions were completed and well tolerated. There were no complications related to either incorrect positioning of the screws during bone fixation or leakage of cement. All patients were able to walk within 6 h after the procedure and the average length of hospital stay was 2 days. The mean VAS score decreased from 7.1 (range, 4-9) before treatment to 1.6 (range, 0-6), 1 month after treatment, and to 1.4 (range 0-6) 6 months after treatment. Neither loosening of the screws nor additional bone fractures occurred during a median follow-up of 6 months.

CONCLUSIONS

Our results suggest that PSFPC might be a safe and effective procedure that allows the stabilization of the fracture and the prevention of pathological fractures with significant pain relief and good recovery of walking ability, although further studies are required to confirm this preliminary experience.

Expanding role of percutaneous ablative and consolidative treatments for musculoskeletal tumours

Interventional approaches to musculoskeletal tumours have significantly changed over the last several years, and new treatments continue to be developed. All ablative modalities are currently applied to the treatment of bone tumours, including radiofrequency, cryo-, microwave, and laser ablation devices. Indications for ablation of bone and soft-tissue tumours have expanded beyond palliation of painful bone metastases and eradication of osteoid osteomas to the local control of oligometastatic disease from a number of primary tumours and ablation of desmoid tumours. In addition, tools for consolidation of bone tumours at risk of pathological fracture have also expanded. With these developments, ablation has become the primary treatment for osteoid osteomas and, at some institutions, desmoid tumours. It may be the primary or secondary treatment for palliation of painful bone tumours, frequently used in patients with pain refractory to or recurrent after radiation therapy. It is used as a treatment for limited metastatic disease or for metastases that grow disproportionately in patients with multifocal metastases, either in combination with systemic therapy or to reserve systemic therapy and its toxicity for more widespread disease progression. Moreover, percutaneous methods to consolidate bone at risk of fracture have become more commonplace, aided by techniques using materials beyond typical bone cement.

Reinforced cementoplasty using dedicated spindles in the management of unstable malignant lesions of the cervicotrochanteric region

OBJECTIVES

In long bones, cementoplasty alone does not provide sufficient stability, which may cause secondary fractures. This study reviewed the safety and efficacy of reinforced cementoplasty (RC) (percutaneous internal fixation using dedicated spindles combined with cementoplasty) for unstable malignant lesions of the cervicotrochanteric region (CTR) of the proximal femur.

METHODS

Eighteen consecutive patients (nine women [50%] and nine men [50%]; mean age 55.1 ± 16.2 years; range 22-85) underwent RC for 19 unstable lesions of the CTR (16/19 [84.2%] bone metastases, 3/19 [15.8%] multiple myeloma lesions). All the patients were considered unsuitable for surgery. Clinical outcome was judged with a mean follow-up of 8.8 ± 7.2 months (range 1-27). The primary endpoints were occurrence of secondary fractures during the follow-up period and local pain relief measured by a visual analogue scale (VAS).

RESULTS

No secondary fracture occurred. Mean VAS improved from 5.9 ± 3.1 (range 0-10) to 2.3 ± 2.4 (range 0-7) at 1 month (p = 0.001) to 1.6 ± 1.7 (range 0-5) at final follow-up (p = 0.0002). One symptomatic cement pulmonary embolism was recorded.

CONCLUSION

RC is an original minimally invasive technique providing pain relief and effective bone stability for unstable malignant lesions of the cervicotrochanteric region in patients unsuitable for open surgery.

KEY POINTS

• Reinforced cementoplasty (RC) combines intralesional spindling with cementoplasty. • RC provides effective bone stability and pain relief. • RC is a suitable minimally invasive option for patients in poor general condition.

Percutaneous image-guided screws meditated osteosynthesis of impeding and pathological/insufficiency fractures of the femoral neck in non-surgical cancer patients

AIM

To present percutaneous image-guided screw-mediated osteosynthesis (PIGSMO) for fixation of impending fractures (ImF) and non-displaced/mildly displaced pathological/insufficient fractures (PF/InF) of the femoral neck in non-surgical cancer patients.

MATERIALS AND METHODS

This is a double-centre single-arm observational study. Retrospective review of electronic records identified all oncologic patients who had undergone femoral neck PIGSMO. Inclusion criteria were: non-displaced or mildly displaced PF/InF, and ImF (Mirels' score ≥8); life expectancy ≥1 month; unsuitability for surgical treatment due to sub-optimal clinical fitness, refusal of consent, or unacceptable delay to systemic therapy.

RESULTS

Eleven patients were treated (mean age 63.7±13.5 years) due to ImF (63.6%, mean Mirels' score 10.1), PF (27.3%) or post-radiation InF (9.1%) under CT/fluoroscopy- (36.4%) or CBCT- (63.6%) guidance. Thirty-two screws were implanted and cement injection was added in 36.4% cases. Technical success was 90.9%. No procedure related complications were noted. At 1-month clinical follow-up (pain/walking impairment), 63.6% and 27.3% patients reported significant and mild improvement, respectively. Imaging follow-up (available in 63.6% cases) showed no signs of secondary fractures, neither of screws loosening at mean 2.8 months. Five patients (45.5%) died after PIGSMO (mean time interval 3.6 months).

CONCLUSIONS

PIGSMO is technically feasible and safe in cancer patients with limited life expectancy; it offers good short-term results. Further prospective studies are required to corroborate mid- and to prove long-term efficacy of the technique.

Percutaneous internal fixation with Y-STRUT® device to prevent both osteoporotic and pathological hip fractures: a prospective pilot study

Background

We studied Y-STRUT® (Hyprevention, France), a new percutaneous internal fixation device, in combination with bone cementoplasty to prevent hip fracture.

Methods

Between February 2013 and February 2015, a total of 16 femoral necks in 4 osteoporotic and 12 oncologic patients have been considered for prophylactic consolidation in this prospective multicentre pilot study involving 4 different hospitals. These consolidations were performed percutaneously under fluoroscopic guidance using Y-STRUT®, a dedicated internal fixation device. For osteoporotic patients, orthopaedic surgeons performed the prophylactic consolidations immediately after surgical treatment of a hip fracture (same anaesthesia) in the opposite side. For oncologic patients, without current hip fracture but considered at risk (Mirels score ≥8), interventional radiologists performed the procedures. We report the preliminary results of feasibility, safety and tolerance of these preventive consolidations using Y-STRUT®.

Results

Four patients (mean 83 years old) had prophylactic consolidation because of a severe osteoporosis (mean T-score −3.30) resulting in first hip fractures. Ten patients (mean 61 years old) were treated because of impending pathological fractures (mean Mirels score 9) related to femoral neck osteolytic metastases. All the procedures were performed with success. Wound healing was achieved in all cases with no access site complication. Radiographic exams performed at 3 months follow-up revealed that Y-STRUT® was well integrated in the bone. For the osteoporotic cohort, mean pain was 0.9 ± 0.7 at 3 weeks. For the oncologic cohort, it decreases from 3.6 ± 2.9 at baseline to 2.4 ± 0.9 at 2 months.

Conclusions

Preliminary results demonstrate the feasibility and safety of Y-STRUT® implantation as well as the tolerance of the device.

Percutaneous low-pressure bone stenting to control cement deposition in extensive lytic lesions

OBJECTIVE

To evaluate low-pressure bone stenting combined with cementoplasty in extensive lytic lesions.

METHODS

A single-centre study involving four consecutive patients (four women) with extensive lytic tumours was performed. The average age was 65 years. Surgical treatment was not indicated or not wished for by the patients. Institutional review board approval and informed consent were obtained. Percutaneous consolidation was performed by an interventional radiologist under fluoroscopy guidance. Follow-up was assessed using the visual analogue scale (VAS).

RESULTS

Under general (n = 2) or local (n = 2) anaesthesia, five 11-gauge bone biopsy needles were advanced in four lesions. Five auto-expandable uncovered stents (10-14 mm diameter and 40-60 mm long) were inserted. In all cases, bone cement was successfully placed into the tumours. The volume of cement that was injected through the cannulas into the stents was 5-10 mL. Using VAS, pain decreased from more than 9/10 preoperatively to less than 2/10 after the procedure for all patients (p < 0.05). No complications occurred during the follow-up (8-19 months).

CONCLUSION

This study suggests that cementoplasty combined with low-pressure bone stenting could allow effective bone stabilization resulting in pain relief.

KEY POINTS

• Low-pressure bone stenting is possible. • This technique improves cement injection control. • The procedure allows effective bone stabilization resulting in pain relief.

Percutaneous osteosynthesis and cementoplasty for stabilization of malignant pathologic fractures of the proximal femur

PURPOSE

To retrospectively evaluate the outcome of patients who underwent radiological percutaneous osteosynthesis and cementoplasty (RPOC) for stabilization of malignant pathological fracture of the proximal femur.

MATERIALS AND METHODS

The clinical files of 12 patients who underwent RPOC for stabilization of malignant pathological fracture of the proximal femur were reviewed. There were 9 men and 3 women with a mean age of 56 years±13 (SD) (range: 35-82 years). All patients had metastases of proximal femur and a high fracture risk (Mirels score≥8) and were not eligible for surgical stabilization. The primary endpoint was the occurrence of a fracture after RPOC. Secondary endpoints were the procedure time, early complications of RPOC, pain reduction as assessed using a visual analog scale (VAS) and duration of hospital stay.

RESULTS

No patients treated with RPOC had a fracture during a mean follow-up time of 382 days±274 (SD) (range: 11-815 days). RPOC was performed under general (n=10) or locoregional (n=2) anesthesia. The average duration of the procedure was 95min±17 (SD) (range: 73-121min). The technical success rate was 100%. All patients were able to walk on the day following RPOC. The average duration of hospital stay was 4days ±3 (SD) (range: 2-10 days). No major complication occurred. One patient complained of hypoesthesia in the lateral thigh. For symptomatic patients (n=7), VAS score decreased from 6.8±1.2 (SD) (range: 5-9) before treatment, to 2.3±1.1 (SD) (range: 1-4) one month later.

CONCLUSION

Preventive RPOC for pathological fracture of the proximal femur is a reliable alternative for cancer patients who are not candidates for surgical stabilization. Studies involving more patients are needed to confirm our preliminary experience.

Percutaneous cementoplasty for painful osteolytic distal femur metastases: a case report

Percutaneous cementoplasty has been shown to immediately restore the mechanical stability of affected bones, prevent further risk of bone fractures, and allow immediate weight bearing. It is emerging as one of the most promising procedures for patients with painful bone metastasis who are unsuitable for surgery or who show resistance to radiotherapy and/or analgesic therapies. This study aimed at describing the procedure, indications, and benefits of percutaneous cementoplasty for painful osteolytic distal femur metastases. We report the case of a painful metastatic lesion in the left distal femur secondary to non-small-cell lung cancer in a 58-year-old woman. The patient underwent percutaneous cementoplasty and experienced effective pain relief and recovery of knee function postoperatively. In addition, no perioperative complication was observed. Percutaneous cementoplasty for osteolytic distal femur metastases offers effective pain relief and restores impaired knee function. Although this method may be a safe option, larger samples of retrospective or prospective confirmation are warranted.