Percutaneous Augmented Peripheral Osteoplasty in Long Bones of Oncologic Patients for Pain Reduction and Prevention of Impeding Pathologic Fracture: The Rebar Concept

Effectiveness of RF ablation and cementoplasty in enhancing functional capacity in pelvic malignant bone metastases

PURPOSE

Pelvic and sacral bone metastases cause significant morbidity. The primary aim of the study is to thoroughly evaluate the increase in functional capacity resulting from combined RF ablation and cementoplasty surgery applied to malignant bone metastases of the pelvic bones.

METHODS

Twenty patients who underwent RF ablation and cementoplasty for malign pelvic bone and sacrum metastases between January 2014 and December 2021 were retrospectively identified. The inclusion criteria were having a life expectancy of more than 1 month, being > 18 years old, and having at least 1 month of follow-up. The Visual Anlogue Scale (VAS) pain, Karnofsky Performance Status (KP), and Musculoskelatal Tumor Society (MSTS) scores were calculated.

RESULTS

VAS pain values decreased, and KP values increased postoperatively (p = 0.006 and p = 0,013). There was no statistically significant increase in MSTS (p > 0.05). The correlation relationships between lesion filling ratio and VAS pain, KP, and MSTS scores were not statistically significant (p > 0.05). Cement leakage was observed in 5 patients (25.0%), and no symptoms related to this leakage were observed.

CONCLUSION

The pelvic region, given its close proximity to blood vessels, nerves, and joint areas, along with the distinct challenges associated with its surgery, requires separate evaluation. In studies evaluating applications in the isolated pelvic ring region, as in our study, functional gains have been most comprehensively assessed in this study, demonstrating that the procedure results in significant functional improvements.

Combination of Elastic Nail(s) and Cementoplasty to Treat Pathological Fractures in Long Bones of the Upper Limb

OBJECTIVE

To describe and study retrospectively the combination of elastic nails and cementoplasty to stabilize pathological fractures in the upper limb and present the results on pain and mobility.

MATERIALS AND METHODS

Between January 2022 and April 2024, six patients with a median age of 65 were treated with elastic nailing and cement injection. Pathological fractures were located in the clavicle (n = 3), humerus (n = 1) and radius (n = 2). Displacement at the fracture site was noted in two cases.

RESULTS

All nails were inserted successfully. Two nails were used for the humerus (n = 1) and the radius (n = 2), and a single nail was used for the clavicle (n = 3). A median volume of 6.5 cc of PMMA was injected. Median duration of the procedure was 155 min. Median pain score dropped from 8/10 the day before intervention to 3.5/10 at 10 days of follow-up and 3/10 at one-month follow-up. Three patients could move their upper limb without limitation. For the five patients for whom imaging was available, no fracture displacement was recorded at a median last follow-up of 3 months. There was no delayed complication.

CONCLUSION

The combination of elastic nail and cementoplasty is feasible and allows to reduce pain and restore limb function. It may offer an alternative to patients suffering from pathological fractures in the upper limb and who are not candidates for surgery.

Musculoskeletal oncology and thermal ablation: the current and emerging role of interventional radiology

The role of interventional radiology (IR) is expanding. With new techniques being developed and tested, this radiology subspecialty is taking a step forward in different clinical scenarios, especially in oncology. Musculoskeletal tumoral diseases would definitely benefit from a low-invasive approach that could reduce mortality and morbidity in particular. Thermal ablation through IR has already become important in the palliation and consolidation of bone metastases, oligometastatic disease, local recurrences, and treating specific benign tumors, with a more tailored approach, considering the characteristics of every patient. As image-guided ablation techniques lower their invasiveness and increase their efficacy while the collateral effects and complications decrease, they become more relevant and need to be considered in patient care pathways and clinical management, to improve outcomes. We present a literature review of the different percutaneous and non-invasive image-guided thermal ablation methods that are currently available and that could in the future become relevant to manage musculoskeletal oncologic diseases.

Multimodal locoregional procedures for cancer pain management: a literature review

Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.

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.

Musculoskeletal Oncologic Interventions: Proceedings from the Society of Interventional Radiology and Society of Interventional Oncology Research Consensus Panel

Musculoskeletal interventions are increasingly used with palliative and curative intent in the multidisciplinary treatment of oncology patients with bone and soft-tissue tumors. There is an unmet need for high-quality evidence to guide broader application and adoption of minimally invasive interventional technologies to treat these patients. Therefore, the Society of Interventional Radiology Foundation and the Society of Interventional Oncology collaborated to convene a research consensus panel to prioritize a research agenda addressing the gaps in the current evidence. This article summarizes the panel's proceedings and recommendations for future basic science and clinical investigation to chart the course for interventional oncology within the musculoskeletal system. Key questions that emerged addressed the effectiveness of ablation within specific patient populations, the effect of combination of ablation with radiotherapy and/or immunotherapy, and the potential of standardization of techniques, including modeling and monitoring, to improve the consistency and predictability of treatment outcomes.

Percutaneous image-guided thermal ablation of bone metastases: a retrospective propensity study comparing the safety profile of radio-frequency ablation and cryo-ablation

OBJECTIVES

To retrospectively compare the safety profile of percutaneous image-guided radiofrequency ablation (RFA) and cryoablation (CA) of bone metastases (BM) with and without a propensity score analysis.

METHODS

Between January 2008 and April 2018, 274 consecutive patients (mean age 61.6 ± 12.1 years) with BM were treated at our Institution with RFA (53 patients; 66 BM) or CA (221 patients; 301 BM) and included in this study. Complications were assessed according to the type of ablation modality before and after applying a 1:1 propensity score method taking into account patient's demographics, BM features, procedural details and follow-up findings.

RESULTS

In the whole 9 BM (2.5%) reported major complications without significant difference between RFA (1/66; 1.5%) and CA (8/301; 2.7%; p = 1); 40 BM (10.9%) showed minor complications, which were more common with RFA (22/66; 33.3%) than with CA (18/301; 6.0%, p<.001) mainly due to post-procedural pain occurring more frequently with RFA than CA (20/66; 30.3% vs. 7/301; 2.3%, p<.001). Following 1:1 matching, similar results were obtained, since there were similar rates of major complications with RFA and CA (1/66 [1.5%] and 0/66 [0.0%], respectively; p = 1); and higher rates of minor complications with RFA compared to CA [33.3% (22/66) vs. 2/66 (3%); p<.001] due to preponderant postprocedural pain (90.9% [20/22] minor complications with RFA).

CONCLUSIONS

Similar low rates of major complications are expected with RFA and CA of BM. In the post-operative period, RFA appears more painful than CA, thus warranting for adoption of dedicated analgesic protocols for patients undergoing RFA.

Musculoskeletal interventional oncology: current and future practices

Management of musculoskeletal (MSK) tumours has traditionally been delivered by surgeons and medical oncologists. However, in recent years, image-guided interventional oncology (IO) has significantly impacted the clinical management of MSK tumours. With the rapid evolution of relevant technologies and the expanding range of clinical indications, it is likely that the impact of IO will significantly grow and further evolve in the near future.

In this narrative review, we describe well-established and new interventional technologies that are currently integrating into the IO armamentarium available to radiologists to treat MSK tumours and illustrate new emerging IO indications for treatment.

Hip Fracture Prevention in Osteoporotic Elderly and Cancer Patients: An On-Line French Survey Evaluating Current Needs

Background and objectives: Hip fracture is a major public health issue. Those fractures lead to high costs and a decrease in quality of life. A national French survey was conducted, with the objectives to firstly assess the current management of hip fracture and its prevention, both in the osteoporotic and cancer settings, and secondly to evaluate the opinions of physicians on the potential use of minimally invasive implantable devices to prevent hip fracture in alternative of surgery. Materials and methods: This national survey was conducted in France between April and July 2017. Questionnaires were sent to orthopedic surgeons, interventional radiologists, oncologists, and rheumatologists. Completed questionnaires were analyzed and compared according to two indications: orthopedics-traumatology and oncology. Factors associated with these responses were assessed using univariable analyses, based on chi-square tests or an exact Fisher test, as appropriate. Results: A total of 182 questionnaires were completed and further analyzed. Physicians have highlighted the need for a low re-fracture rate and to improve life expectancy for more than 1 year (50% for responders of the orthopedics-traumatology questionnaire and 80% for the responders interested in both indications), as well as quality of life (12.5% and 31%, respectively), but with no significant differences in the oncologic indication. Most of the experts were willing to use or prescribe implantable devices for prevention (63% in orthopedics-traumatology and 93% in oncology), although limited clinical experience (54 and 58%) and surgical risk (around 30% in each indication) were considered as limits. Conclusions: Prevention of hip fracture remains a concern for physicians. More clinical experience with implantable devices, in particular in cancer patients, is needed, but implemented in a strategy to maximize patient recovery while reducing costs.

Percutaneous reinforced osteoplasty for long bone metastases: a feasibility study

OBJECTIVE

While percutaneous osteoplasty is common for the treatment of vertebral fractures, low strength of fixation remains a major challenge for use in metastatic weight-bearing bones. With stent, wire, and cement augmentation, this study explores the feasibility of percutaneous reinforced osteoplasty for use in correcting long bone fractures.

MATERIALS AND METHODS

Fifteen explanted swine femora were randomly assigned into three groups. Group 1 (n = 5) was native (intact) bones without any intervention (control), group 2 (n = 5) received cementoplasty, and group 3 (n = 5) received stent and wire scaffolding ("rebar") in addition to cementoplasty. All treatment procedures were performed under fluoroscopic guidance. Mechanical strength of fracture fixation was quantified by peak load to failure, stiffness, work done to fracture, and fatigue testing with four-point bend test.

RESULTS

Percutaneous osteoplasty with or without reinforcement was successfully achieved in all specimens. The respective peak load at failure, flexural stiffness, and work done to fracture (mean ± SEM) for group 1 was 2245 ± 168 N, 14.77 ± 1.3 Nm/degree, and 4854 ± 541 Nmm; group 2 was 468 ± 81 N, 3.9 ± 0.5 Nm/degree, and 401 ± 56 Nmm; and group 3 was 594 ± 90 N, 4.42 ± 0.4 Nm/degree, and 522 ± 54 Nmm. The mean cyclic displacement for groups 1, 2, and 3 were 0.15, 0.58, and 0.48 mm, respectively, at 220-240 N loading.

CONCLUSIONS

While percutaneous reinforced osteoplasty with stent, wire, and cement augmentation resulted in improved mechanical strength in restored bones, it did not differ significantly from specimens that underwent exclusive cementoplasty. With the improvement of fracture strength, the concept may be applicable for prevention or treatment of pathological fractures.

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.

Minimally Invasive Stabilization Using Screws and Cement for Pelvic Metastases: Technical Considerations for the Pelvic "Screw and Glue" Technique

Metastatic disease involving the pelvis is common, often resulting in significant pain and disability. Several percutaneous interventions for unstable pelvic metastatic disease have been described, including osteoplasty, ablation, and screw fixation, that when used alone or in combination can significantly reduce pain and disability from metastatic bone disease. While it is possible to make a significant impact in patient care with basic principles and techniques, certain advanced techniques can extend the application of percutaneous interventions while minimizing morbidity.

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.

Percutaneous screw-reinforced cement osteoplasty for palliation of postremission pain in larger lytic sacro-acetabular iliac cavities

We present 2 cases of palliative percutaneous screw fixation for refractory pain from periacetabular residual cavities, after clinical remission, from osteolytic iliac masses involving the cortices of the sacroiliac joint (SIJ). Two patients-1 with a treated 8 cm breast metastasis and another with a treated 14 cm plasmacytoma-were selected for osseous stabilization based on imaging criteria and physical signs of iliac deformability and SIJ dysfunction. Neither lesion exhibited active malignancy following systemic therapy or discrete fracture. Following computed tomography-guided screw fixation across the mass and SIJ, with surrounding cement osteoplasty, to reduce mechanical stress on abnormal bone, both patients reported pain resolution beyond 1-year. This technique may be a suitable palliation even for large treated pelvic metastastic cavities and in the absence of fracture.

Biomechanical effects of osteoplasty with or without Kirschner wire augmentation on long bone diaphyses undergoing bending stress: implications for percutaneous imaging-guided consolidation in cancer patients

Background

Osteoplasty has been discouraged in long bones. However, despite a substantial lack of pre-clinical biomechanical tests, multiple clinical studies have implemented a wide range of techniques to optimise long bone osteoplasty. The aim of the present study is to evaluate the biomechanical properties of osteoplasty alone and in combination with Kirschner wires (K-wires) in a cadaveric human diaphyseal model undergoing 3-point bending stress.

Methods

Thirty unpaired human cadaveric hemi-tibia specimens were randomly assigned to receive no consolidation (group 1, n = 10), osteoplasty alone (group 2, n = 10), or K-wires augmented osteoplasty (group 3, n = 10). Specimens were tested on a dedicated servo-hydraulic machine using a 3-point bending test. Fracture load was calculated for each specimen; two-sample Wilcoxon rank-sum tests were used to assess differences between groups.

Results

Median volume of polymethyl methacrylate injected was 18 mL for group 2 (25th–50th percentile 15–21 mL) and 19 mL for group 3 (25th–50th percentile 17–21). There were no significant differences in fracture load between groups 1 and 2 (z = − 0.793; p = 0.430), between groups 1 and 3 (z = − 0.944; p = 0.347), and between groups 2 and 3 (z = − 0.454; p = 0.650). Fractures through the cement occurred in 4 of 30 cases (13.3%); there were no K-wires fractures.

Conclusions

Osteoplasty with or without K-wires augmentation does not improve the resistance of diaphyseal bone to bending stresses.

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.

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.

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.

[Image-guided bone consolidation in oncology: Cementoplasty and percutaneous screw fixation]

Bone metastases are a common finding in oncology. They often induce pain but also fractures which impair quality of life, especially when involving weight-bearing bones. Percutaneous image-guided consolidation techniques play a major role for the management of bone metastases. Cementoplasty aims to stabilize bone and control pain by injecting acrylic cement into a weakened bone. This minimally invasive technique has proven its efficacy for bones submitted to compression forces: vertebra, acetabular roof, and condyles. However, long bone diaphysis should be treated with caution due to lower resistance of the cement subject to torsional forces. The recent improvements of navigation systems allow percutaneous image-guided screw fixation without requiring open surgery. This fast-track procedure avoids postponing introduction of systemic therapies. If needed, cementoplasty can be combined with screw insertion to ensure better anchoring in major osteolysis. Interventional radiology bone consolidation techniques increase the therapeutic field in oncology. A multidisciplinary approach remains mandatory to select the best indications.

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.

[Vertebroplasty--state of the art]

BACKGROUND

Percutaneous vertebroplasty (PVP) using PMMA (polymethyl methacrylate) was first described in 1987 by Gallibert and Deramond for the treatment of vertebral body instability in patients with aggressive forms of vertebral hemangioma. Other types of painful osteolytic bone lesions, such as osteoporotic vertebral fractures and vertebral metastasis are in the meantime more commonly treated using this method.

METHODICAL INNOVATIONS

Within the last few years, this technique has become widely accepted and it is proposed for osteolytic bone lesions in areas that are more difficult to approach surgically, e.g., the pelvis and sacrum.

EFFICACY

Rapid pain relief and resulting stability have conferred an important role upon osteoplasty especially in palliative tumor-treatment for patients with shortened expected life spans. In addition, combined treatment of painful osteolytic metastases with image-guided thermoablation and percutaneous cement injection has been shown to be a safe palliative modality in the therapy of nonresectable tumors.

Percutaneous CT and Fluoroscopy-Guided Screw Fixation of Pathological Fractures in the Shoulder Girdle: Technical Report of 3 Cases

OBJECTIVE

To review our initial experience with percutaneous CT and fluoroscopy-guided screw fixation of pathological shoulder-girdle fractures.

MATERIALS AND METHODS

Between May 2014 and June 2015, three consecutive oncologic patients (mean age 65 years; range 57-75 years) with symptomatic pathological shoulder-girdle fractures unsuitable for surgery and radiotherapy underwent percutaneous image-guided screw fixation. Fractures occurred through metastases (n = 2) or a post-ablation cavity (n = 1). Mechanical properties of osteosynthesis were adjudged superior to stand-alone cementoplasty in each case. Cannulated screws were placed under combined CT and fluoroscopic guidance with complementary radiofrequency ablation or cementoplasty to optimise local palliation and secure screw fixation, respectively, in two cases. Follow-up was undertaken every few weeks until mortality or most recent appointment.

RESULTS

Four pathological fractures were treated in three patients (2 acromion, 1 clavicular, 1 coracoid). Mean size of associated lesion was 2.6 cm (range 1-4.5 cm). Technical success was achieved in all cases (100 %), without complications. Good palliation and restoration of mobility were observed in two cases at 2-3 months; one case could not be followed due to early post-procedural oncologic mortality.

CONCLUSION

Percutaneous image-guided shoulder-girdle osteosynthesis appears technically feasible with good short-term efficacy in this complex patient subset. Further studies are warranted to confirm these promising initial results.