Intracardiac bone cement embolism as a complication of vertebroplasty: management strategy

Injecting a ventricular tachycardia into the heart-Α unique case report

INTRODUCTION

A 52-year-old woman presented with a complex ventricular arrhythmia in an intraoperative context, during kyphoplasty for an osteoporotic fracture of a lumbar vertebra. The subject showed no indications of a previous cardiovascular condition.

METHODS AND RESULTS

Causes of arrhythmias associated with the procedure were excluded. Due to her positive family history for dilated cardiomyopathy, upcoming thoughts were made for unmasking a previous asymptomatic cardiomyopathy. Nevertheless, an intracardiac cement embolism was diagnosed and, finally, the patient underwent an open-heart surgery with successful removal of the cardiac cement. Νo new arrhythmia recorded during follow up.

CONCLUSION

To the best of our knowledge, this is the first reported case of ventricular arrhythmogenic presentation of a cardiac cement embolus after a KP procedure.

Comparison of a directional cement delivery device versus conventional device in unilateral percutaneous kyphoplasty for the therapy of osteoporotic thoracolumbar fracture in the elderly

BACKGROUND

Percutaneous kyphoplasty (PKP) has been demonstrated to be effective in the treatment of osteoporotic vertebral compression fractures (OVCF). However, bilateral puncture techniques take more time to accept more X-ray radiation; some spinal surgeons apply unilateral puncture PKP, but the cement cannot be symmetrically distributed in the vertebral body, so we apply a directional bone cement delivery device that undergoes PKP through the unilateral pedicle puncture. This research aims to compare the clinical and radiological results of PKP via unilateral pedicle approach using a traditional bone cement delivery device and a directional bone cement delivery device and determine the value of a directional delivery device for the therapy of thoracolumbar compression fracture in the elderly.

METHODS

We undertook a retrospective analysis of patients with single-level OVCF treated with unilateral pedicle puncture PKP from Jan 2018 to Jan 2020. Operation time, radiation exposure, bone cement injection volume, and the incidence of bone cement leakage were recorded for presentation, and the cement leakage and bone cement distribution were measured by X-ray and computed tomography scan. The patients were followed up postoperatively and were assessed mainly with regard to clinical and radiological outcomes.

RESULTS

There was no significant difference in the operation time, radiation exposure time, and incidence of bone cement leakage between the two groups. A significant difference was observed in the volume of bone cement injection between the two groups. All patients in both groups had significantly less pain after the procedures, compared with their preoperative period pain. There were no significant differences in Visual Analogue Scale, the relative height of the vertebral body, Cobb angle, and Quality of Life Questionnaire of the European Foundation for Osteoporosis between the two groups at 1 week after PKP, significant difference was observed only 12 months after operation.

CONCLUSION

Application of directional bone cement delivery device is safe and feasible, compared with the application of traditional bone cement delivery device, without prolonging the operative time, radiation exposure time, and the incidence of bone cement leakage. It has the advantages of good short- and medium-term effect, excellent bone cement distribution, and low incidence of kyphosis recurrence.

Current status and challenges of percutaneous vertebroplasty (PVP)

A narrative review regarding percutaneous vertebroplasty (PVP) for osteoporotic vertebral fracture (OVF) is provided herein, addressing the epidemic of OVF in Japan, the latest response to the criticism of PVP for OVFs, the indications and potential risks of PVP for OVFs, and a future perspective for PVP. Each year in Japan, approximately 32,000 patients aged 55 years or older suffer from chronic low back pain for several months to several years due to a compression fracture. PVP is one of the surgical treatments for an OVF, and it is less invasive compared to the traditional open surgery. PVP is suitable for OVF patients who have difficulty walking as assessed by the modified Yokoyama's activities of daily living (ADL) scoring system, and for patients with Kummell's disease diagnosed by CT and MRI examinations. Serious adverse events related to PVP occur in 1.1-3.3% of the cases, but direct deaths from PVP are extremely rare at less than 1%. Recent studies demonstrated that OVF patients treated with PVP are less likely to die after the treatment than non-surgically treated patients, which conflicts with the Cochran reviews' conclusion not supporting PVP for OVFs. Novel robotic systems and procedure-support devices are being developed, providing a next step toward fully automated PVP procedures.

Life-threatening intracardiac cement embolisms after percutaneous kyphoplasty: a case report and literature review

BACKGROUND

Percutaneous kyphoplasty is a popular technique in the treatment of osteoporotic vertebral fractures, but intracardiac cement embolism can be a life-threatening complication.Case presentation: The authors present a case involving a patient who developed dyspnea and chest tightness after percutaneous kyphoplasty. Echocardiography and chest computed tomography confirmed several foreign bodies in the right atrium and pulmonary arteries causing cardiac perforation and pericardial tamponade. Conservative treatment was administered, and the patient died of respiratory and heart failure.

CONCLUSIONS

The present case highlights that surgical removal may be the first-choice treatment for symptomatic intracardiac cement embolism.

The combination of radiofrequency ablation and vertebroplasty shows advantages over single vertebroplasty in treating vertebral neoplastic lesions

OBJECTIVE

To investigate the safety and efficacy of the combination of radiofrequency ablation (RFA) and vertebroplasty versus single vertebroplasty in treating spinal metastases.

MATERIALS AND METHODS

The data of 35 patients with vertebral neoplastic lesions who received RFA combined with vertebroplasty (group A, 15 patients with 17 lesions) or single vertebroplasty (group B, 20 patients with 24 lesions) from March 2016 to June 2019 were retrospectively compared. The data of patients' Visual Analogue Scale (VAS) scores prior to the treatments, 1 week, 1 month, 3 months, and 6 months after the treatments, injected cement volume, ratios of cement leakage were compared between the two groups.

RESULTS

All procedures were successfully done without severe complications. The VAS scores in group A were decreased more rapidly 1 week after the treatments and remained more stable at 6 months than that in group B (P < 0.05). The cement injected in group A (5.95 ± 1.45 mL, range 4-9.5 mL) was significantly more than that in group B (4.09 ± 0.55 mL, range 3.1-5.5 mL) (P < 0.05). The ratio of vascular cement leakage in group A was significantly lower than that in group B (P < 0.05), while no statistical difference was found in the non-vascular cement leakage (P > 0.05).

CONCLUSIONS

Our study shows that the combination of RFA and vertebroplasty has a better analgesic effect with more injected cement and lower rates of venous cement leakage than single vertebroplasty.

Cardiac Perforation Caused by Cement Embolism after Percutaneous Vertebroplasty: A Report of Two Cases

Background

Percutaneous vertebroplasty (PVP) is a minimally invasive surgical technique in which polymethyl methacrylate (PMMA) is injected into the weakened vertebral body to strengthen it. However, this procedure is associated with various complications, the most common being cement leakage. Cardiac perforation caused by cement escape into the venous system is another complication, which is rare but potentially life‐threatening even if not treated promptly.

Case Presentation

Here, we report two elderly patients who developed cardiac perforation caused by cement escape into veins following PVP. Both patients had a history of severe osteoporosis. On admission, they presented with lower back pain and limited movement. MRI revealed vertebral bodies compression fracture in both patients. Considering the advanced age of the patients, PVP was performed to avoid the risk of potential complications associated with nonoperative therapy. Unfortunately, the rare and fatal postoperative complication, cardiac perforation caused by cement escape into veins, occurred in both patients. Emergency open‐heart surgery was performed to remove cement material and repair the heart, both patients recovered well and were discharged.

Conclusions

Although PVP is a safe and minimally invasive surgical technique, it is associated with various serious complications as seen in the present cases. We therefore recommend that surgeons should be aware of such complications. Appropriate timing of surgical operation, meticulous surgical procedures, early intraoperative and postoperative monitoring of cement leakage may improve outcomes of patients with such complications.

Risk factors for predicting cement leakage in percutaneous vertebroplasty for spinal metastases

BACKGROUND

The study aimed to identify the risk factors of cement leakage following percutaneous vertebroplasty for spinal metastases.

METHODS

230 consecutive patients with 530 vertebrae were retrospectively reviewed. Characteristics including age, primary cancer, location, pathological fracture, the integrity of the posterior wall, and the volume of bone cement were considered as potential risk factors. Cement leakage was evaluated by postoperative imaging examination and classified into three subtypes with different potential sequelae: spinal canal leakage, intravascular leakage around vertebrae, intradiscal and paravertebral leakage. Univariate and multivariate analyses were used to assess the risk factors.

RESULTS

Leakage was detected in 185 vertebrae (34.9%), 18.3% for intradiscal and paravertebral, 13.2% for intravascular around vertebrae, and 7.0% for spinal canal. Multivariate analysis showed that incomplete posterior wall (P = 0.001) and breast cancer (P = 0.015) were strong predictive factors for spinal canal leakage, incomplete posterior wall (P = 0.024) was for intravascular leakage around vertebrae, thoracic (P = 0.010) and pathological fracture (P = 0.000) were for intradiscal and paravertebral leakage.

CONCLUSIONS

Our findings suggest that cement leakage is common following percutaneous vertebroplasty for spinal metastases. The incomplete posterior wall is an unfavourable factor for intravascular leakage around vertebrae. Vertebrae with incomplete posterior wall and breast cancer metastases are more likely to develop spinal canal leakage.

Bedside echocardiography for diagnosis of intracardiac cement embolism after percutaneous vertebroplasty: A case report

This case report is to demonstrate that a female patient had suddenly become unconscious 14 hours after percutaneous vertebroplasty. Bedside echocardiogram showed that the patient had a strong echo in the right heart with a small amount of pericardial effusion. CT showed high density in the distal branches of both pulmonary arteries and a high density in the right heart. With the help of that, the doctor made the diagnosis of intracardiac cement embolism in a very short time. The bone cement in the heart was removed under emergency cardiopulmonary bypass, then the patient was discharged smoothly.

Transcatheter Removal of Bone Cement Embolism in the Right Atrium after Percutaneous Vertebroplasty: The Embolus Broke in Half and Migrated to the Right Pulmonary Artery Intraoperatively

Bone cement embolism often occurs during percutaneous vertebroplasty. Bone cement pulmonary arterial embolism generally requires no treatment because of the small size and asymptomatic manifestation. Intracardiac bone cement embolisms are rare but associated with a risk of severe complications. Intracardiac bone cement embolisms are mainly removed through open heart surgery. To the best of our knowledge, only three cases of intracardiac bone cement embolisms removed with interventions have been reported. Here, we report another case of successful transcatheter retrieval of a 6-cm-long cement embolism in the right atrium after percutaneous vertebroplasty. The embolus broke in half and migrated to the right pulmonary artery intraoperatively. Using two snares and a filter retrieval device, we advanced from opposite directions. Further, we gently grasped and pulled the fragments of the right pulmonary artery and aligned them in a linear fashion directly into the sheath for uneventful removal.

Snare or Scalpel: Challenges of intracardiac cement embolism retrieval

Intracardiac cement embolism (ICE) after percutaneous vertebroplasty is a rare, but dangerous complication, and guiding principles for its management are not well described. The management of this present case of ICE offers insight to facilitate the treatment decision making process in symptomatic patients requiring extraction.

The Correlation Between the Diffusion Coefficient of Bone Cement and Efficacy in Percutaneous Vertebroplasty

This study investigated the effect of bone mineral density (BMD) on the diffusion coefficient (DC) of bone cement in percutaneous vertebroplasty (PVP) and the correlation between the DC and the efficacy after PVP. This was a retrospective study of PVP cases with follow-up longer than 12 months. The cases were assigned to 3 groups according to the BMD: BMD decrease group, osteoporosis group, and severe osteoporosis group. The 3 groups were compared regarding bone cement injection volume (IV), diffusion volume (DV), DC, visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, and vertebral height loss ratio (VHLR). The correlation between DC and BMD, IV, DV, and VHLR was analyzed. The least significant difference test was used for comparison among the 3 groups, and the Pearson correlation coefficient was used for correlation analysis. There were a total of 132 cases, including 34 males and 98 females with a mean age of 76.5±9.6 years. The DV was larger than the IV in each group (P<.05). There was no statistically significant difference in the IV, VAS score, and ODI among the 3 groups (P>.05). However, there were significant differences in the DC and VHLR among the 3 groups (P<.05). Correlation analysis showed that there were significant correlations between BMD and IV (-0.716), BMD and DC (0.754), IV and DV (0.502), and IV and DC (-0.666) (P<.01). Scatter plot showed that the correlation between IV and BMD was r=0.716, R²=0.513, and the correlation between DC and BMD was r=0.754, R²=0.568. The DV was larger than the IV in PVP, and BMD was closely related to the DC. The higher the BMD, the higher the DC. Short-term follow-up revealed that the DC was inversely proportional to the VHLR. [Orthopedics. 2021;44(1):e95-e100.].

A novel computer navigation model guided unilateral percutaneous vertebroplasty for vertebral compression fracture: A case report

RATIONAL

Vertebral compression fracture (VCF) is one of the most common diseases in spinal surgery. Traditional percutaneous vertebroplasty (PVP) under fluoroscopy is an effective method to treat vertebral compression fracture. However, there is still a risk of vascular nerve injury and infection caused by inaccurate or repeated puncture. Therefore, the purpose of this paper was to assess the accuracy of unilateral PVP guided by screw view model of navigation (SVMN) for VCF.

PATIENT CONCERNS

A 59-year-old female patient suffered high falling injury, and with back pain as its main clinical symptom.

DIAGNOSES

The patient was diagnosed with a L1 VCF.

INTERVENTIONS

We placed the puncture needle under the guidance of SVMN to reach the ideal position designed before operation, and then injected the bone cement to complete the percutaneous kyphoplasty (PKP).

OUTCOMES

The operative time was 29.5 minutes, the puncture time was 1 time, the fluoroscopy time was 2.9 minutes, and the bone cement distribution was satisfactory. VAS and ODI scores were significant improved postoperatively. No surgical complications, including neurovascular injury and infection, were observed during 28-month follow up.

LESSONS

The SVMN guided percutaneous puncture needle insertion in PKP operation for VCF is an effective and safety technique. Besides, the SVMN has also been a contributor to reduce radiation doses and replace conventional fluoroscopy.

Comparison of a flexible versus rigid bone cement injection system in unilateral percutaneous vertebroplasty

Background

Percutaneous vertebroplasty (PVP) has been demonstrated to be effective in the treatment of acute osteoporotic vertebral fracture (AOVF). However, bilateral puncture takes more time to accept more X-ray irradiation; some scholars apply unilateral puncture PVP, but the cement cannot be symmetrically distributed in the vertebral body, so we use a flexible cement injector that undergoes PVP through the unilateral pedicle puncture. This research aims to compare the clinical results of PVP for AOVF with unilateral pedicle puncture using a straight bone cement injector and a bendable cement injector, determine the value of a bendable cement injector.

Methods

We undertook a retrospective analysis of patients with thoracic and lumbar compression fracture treated with unilateral pedicle puncture percutaneous vertebroplasty from our institution from June 2013 to July 2015. Operation time, radiation exposure, bone cement injection amount, and the incidence of bone cement leakage were recorded on presentation, the cement leakage was measured by X-ray and computed tomography scan. The patients were followed up postoperatively and were assessed mainly with regard to clinical and radiological outcomes.

Results

There was no significant difference in the operation time, radiation exposure time and incidence of bone cement leakage between the two groups. There was significant difference in the amount of bone cement injection and the difference between the two groups. There were no significant differences in VAS and the relative height of the vertebral body and local Cobb angle and QUALEFFO between the two groups at 1 week after PVP, significant difference was observed only 12 months after operation.

Conclusions

Application of flexible cement injector is safe and feasible, compared with the application of straight bone cement injector, without prolonging the operative time, radiation exposure time and the incidence of bone cement leakage; it has the advantages of good long-term effect and low incidence of vertebral fracture recurrence.

Percutaneous vertebroplasty with high- versus low-viscosity bone cement for osteoporotic vertebral compression fractures

Objective

There is no consensus on the best choice between high- and low-viscosity bone cement for percutaneous vertebroplasty (PVP). This study aimed to compare the clinical and radiological outcomes and leakage between three cements with different viscosities in treating osteoporotic vertebral compression fractures.

Methods

This is a prospective study comparing patients who were treated with PVP under local anesthesia: group A (n = 99, 107 vertebrae) with high-viscosity OSTEOPAL V cement, group B (n = 79, 100 vertebrae) with low-viscosity OSTEOPAL V cement, and group C (n = 88, 102 vertebrae) with low-viscosity Eurofix VTP cement. Postoperative pain severity was evaluated using the visual analog scale. Cement leakage was evaluated using radiography and computed tomography.

Results

There was no significant difference in the incidence of cement leakage between the three groups (group A 20.6%, group B 24.2%, group C 20.6%, P = 0.767). All three groups showed significant reduction in postoperative pain scores but did not differ significantly in pain scores at postoperative 2 days (group A 2.01 ± 0.62, group B 2.15 ± 0.33, group C 1.92 ± 0.71, P = 0.646). During the 6 months after cement implantation, significantly less reduction in the fractured vertebral body height was noticed in group B and group C than in group A (group A 19.0%, group B 8.1%, group C 7.3%, P = 0.009).

Conclusions

Low-viscosity cement has comparable incidence of leakage compared to high-viscosity cement in PVP for osteoporotic vertebral compression fractures. It also can better prevent postoperative loss of fractured vertebral body’s height.

Effect and potential risks of using multilevel cement-augmented pedicle screw fixation in osteoporotic spine with lumbar degenerative disease

Background

The increase of augmented level and bone cement dose are accompanied by the rising incidence of cement leakage (CL) of cement-augmented pedicle screw instrumentation (CAPSI). But the effect and potential risks of the application of CAPSI to osteoporotic lumbar degenerative disease (LDD) have not been studied in the case of multilevel fixation. This study aimed to investigate the effectiveness and potential complications of using multilevel CAPSI for patients with osteoporotic LDD.

Methods

A total of 93 patients with multilevel LDD were divided into the CAPSI group (46 subjects) and the conventional pedicle screw (CPS) group (47 subjects), including 75 cases for three levels and 18 cases for four levels. Relevant data were compared between two groups, including baseline data, clinical results, and complications.

Results

In the CAPSI group, a total of 336 augmented screws was placed bilaterally. The CL was observed in 116 screws (34.52%). Three cemented screws (0.89%) were found loosened during the follow-up and the overall fusion rate was 93.47%. For perioperative complications, two patients (4.35%) experienced pulmonary cement embolism (PCE), one patient augmented vertebral fracture, and three patients (6.52%) wound infection. And in the CPS group, thirty-three screws (8.46%) suffered loosening in cranial and caudal vertebra with a fusion rate of 91.49%. The operation time and hospital stay of CAPSI group were longer than the CPS group, but CAPSI group has a lower screw loosening percentage (P<0. 05). And in terms of blood loss, perioperative complications, fusion rate, and VAS and ODI scores at the follow-up times, there were no significant differences between the two groups.

Conclusions

Patients with osteoporotic LDD underwent multilevel CPS fixation have a higher rate of screw loosening in the cranial and caudal vertebra. The application of cemented pedicle screws for multilevel LDD can achieve better stability and less screw loosening, but it also accompanied by longer operating time, higher incidence of CL, PCE and wound infections. Selective cement augmentation of cranial and caudal pedicle screws may be a worthy strategy to decrease the complications.

Removal of intracardiac bone cement embolism after percutaneous kyphoplasty: A case report

RATIONALE

Leakage of bone cement is a common complication after percutaneous kyphoplasty. In rare cases, bone cement can leak into the venous system, which can be life threatening, especially when it causes an embolism in the heart.

PATIENT CONCERNS

A 79-year-old female patient developed chest pain with chest tightness 3 weeks after the percutaneous kyphoplasty.

DIAGNOSES

Initially, negative fluoroscopy results and elevated myocardial enzymes suggested that the patient's chest pain and chest tightness symptoms were manifestations of coronary heart disease. However, in the subsequent computed tomography (CT) examination, foreign bodies in the heart and pulmonary vessels were found.

INTERVENTIONS

The patient underwent emergency surgery to remove the bone cement and repair the tricuspid valve.

OUTCOMES

The postoperative course was uneventful and the patient was discharged on the 13th day after surgery.

LESSONS

If a patient develops chest pain with chest tightness after percutaneous kyphoplasty, the clinicians must be vigilant and take into account the limited sensitivity of fluoroscopy and use chest computer tomography and echocardiogram as the first choice and thereby prevent serious consequences.

Clinical characteristics and management of cardiac and/or pulmonary cement embolus after percutaneous vertebroplasty: a single center experience

Background

Cardiac and/or pulmonary cement embolus (CPCE) caused by the leakage of bone cement after percutaneous vertebroplasty (PVP) are rare but are lethal complications in patients with vertebral compression fracture (VCF). Literature in this field is limited, and guidelines for the management of such complications are unclear. This study aimed to review our center's experience.

Methods

Medical records (clinical characteristics and management) and imaging data (X-ray findings, CT findings, and fluoroscopic findings) of 12 patients with CPCE after PVP between October 2015 and July 2018 at our hospital were collected and examined retrospectively. Their health conditions were also evaluated through a telephone follow-up survey.

Results

Twelve patients with an average age of 76.8±8.5 years were included in our study. One patient who had a cardiac cement embolus and one patient who suffered from an inferior vena cava (IVC) cement embolus were successfully treated via percutaneous retrieval. Ten asymptomatic patients with pulmonary cement embolus (PCE) were managed with conservative observation. All of the patients were alive and remained asymptomatic during the follow-up period (median time, 6.5 months; range, 1-50 months).

Conclusions

More attention should be paid to the possibility of development of CPCE. For patients with cardiac cement embolus, open heart surgery should be considered as a preferred treatment, and percutaneous procedure could be used as an alternative treatment for patients with surgical contraindication or other surgical high-risk factors. For patients with an IVC cement spike, percutaneous retrieval could be recommended. Careful observation and clinical follow-up could be recommended for patients with asymptomatic peripheral or central PCEs.

Percutaneous vertebroplasty with granulated allogeneic bone grafting using screw-view model of navigation for thoracolumbar compressive fracture: A case report

RATIONALE

The aim of this study was to assess the accuracy of percutaneous puncture needle with screw view model of navigation (SVMN) and the effect of periacetabular vertebroplasty (PVP) with granulated allogeneic bone grafting in thoracolumbar compressive fracture (TCF).

PATIENT CONCERNS

A 46-year-old female patient associated with high fall injury showed symptoms characterized by back pain and restricted movement of the right lower extremity.

DIAGNOSES

The patient was diagnosed with a TCF, right femoral neck fracture, and lumbar vertebrae hyperosteogeny.

INTERVENTIONS

A SVMN was used to guide our puncture needle insertion; and PVP was performed with granulated allogeneic bone grafting in this patient.

OUTCOMES

The follow-up lasted for 29 months. It took 2.4 minutes to design the trajectory of puncture needle, 2.1 minutes to implant the puncture needle, and 6.3 minutes to undergone fluoroscopy. Postoperative visual analog scale and Oswestry disability index scores were improved obviously compared with those before the operation. The Cobb angle of fractured vertebrae improved from 9.3° to 7.3° after treatment. The height ratio of fractured vertebrae increased from 79.5% to 90.6% postoperatively. Intraoperative blood loss amounted to 11 ml. No clinical complications were observed, including neurovascular injury and new fracture of adjacent vertebra.

LESSONS

Puncture needle placement under the guidance of SVMN is verified as a convenient, safe and reliable method, and PVP with granulated allogeneic bone grafting can effectively restore the height of anterior fractured vertebra, filling the gaps in the fractured vertebrae, and reconstructing the completeness of the fractured vertebrae.

Cement augmentation of glenoid baseplate screws does not improve primary stability in reversed shoulder arthroplasty: A cadaveric study

INTRODUCTION

Cuff tear arthritis and complex proximal humeral fractures are common pathologies that are frequently addressed by the implantation of a reversed shoulder prosthesis. The present cadaveric study aimed to analyze the effect of cement augmentation of the glenoid component on the primary stability in geriatric patients.

HYPOTHESIS

Cement augmentation of glenoid baseplate screws has an influence on primary stability in reversed shoulder arthroplasty (RSA).

MATERIALS AND METHODS

Glenoid base plates (Delta Xtend, DePuy Synthes, Westchester, USA) were implanted in 6 pairs of formalin-fixated scapulae of 4 female and 2 male donors (average age 83 years). Two angle stable screws were placed at the superior and inferior position. Cement augmentation was performed with 2ml bone cement (Kyphon, Medtronic, Minneapolis, USA) per screw in right specimens. Afterwards, biomechanical testing with 600 to 1000N (100 cycles) at a 65° abduction angle was performed. Finally, a load-to-failure analysis was conducted.

RESULTS

No implant loosening was observed during cyclic tests from 600N to 1000N. In addition no difference in the plastic deformation was detected at 600N (p=0.301), 700N (p=0.522), 800N (p=0.480), 900N (p=0.521) and 1000N (p=0.748). Load-to-failure analyses revealed implant loosening at 3314N (SD 823N) in the cement-augmented implants and at 3059N (SD 974N) in scapulae with non-cemented screws (p=0.522).

DISCUSSION

Cement-augmented fixation of the glenoid component did not result in an increased primary stability in this study. Thus, the application of cement should be critically assessed considering associated risks and increased costs.

LEVEL OF PROOF

Basic science study, controlled laboratory study.

Fatal cardiac perforation and pulmonary embolism of leaked cement after percutaneous vertebroplasty

Percutaneous vertebroplasty consists of percutaneous injection of polymethylmethacrylate (PMMA) via a transpedicular approach for the treatment of collapsed osteoporotic or metastatic vertebrae. Even if percutaneous vertebroplasty is considered to be minimally invasive, threatening complications can occur. Cement leakage is the most common complication of percutaneous vertebroplasty. Rigorous patient selection and individual therapeutic strategy may reduce the occurrence of leakage, in particular the risk of cement entry into the venous system and the spinal canal is the potent major hazard of this technique. Cement pulmonary and cardiac embolism are reported in literature as a cause of unexpected death after percutaneous vertebroplasty. Authors report a fatal case of pulmonary cement embolization occurred after vertebroplasty with haemopericardium, due to the perforation of the right atrium wall from a cement solidified fragment. A complete post mortem examination documented the presence of multiple cement fragments in the pulmonary arteries and transmural perforation of the wall of the right atrium by a whitish needle-like foreign body. Pulmonary microembolization was observed under polarized light.

Cement cardiac embolism following kyphoplasty noted on thoracic imaging

Asymptomatic polymethyl methacrylate cardiac embolism is an uncommon complication of kyphoplasty. We report a case of a 56-year-old female with an incidentally noted radiopaque foreign body in the right ventricular cavity on chest x-ray following kyphoplasty. In this report, we discuss how to differentiate between the potential intracardiac foreign bodies and how to establish the diagnosis of polymethyl methacrylate embolism. Once diagnosed, the management of these patients remains controversial.

Cement pulmonary embolism after percutaneous vertebroplasty in a patient with cushing's syndrome: A case report

BACKGROUND

Vertebroplasty is a procedure most commonly used for vertebral compression fractures. Although it is a relatively safe procedure, complications have been reported. Cement embolism is seen in 2.1%-26% of patients after percutaneous vertebroplasty.

CASE PRESENTATION

a 38-year-old male who was diagnosed with cushing's syndrome, underwent percutaneous vertebroplasty for his thoracic osteoporotic compression fractures. 24-hours following vertebroplasty, he presented to emergency department with acute-onset dyspnea and chest pain. Chest radiography showed an opaque linear lesion in left pulmonary artery which was suggestive of cement embolism. Pulmonary spiral CT-scan further confirmed the diagnosis. The patient's symptoms improved over time, and warfarin was started with close cardiopulmonary assessments for indicators of cement embolus removal.

CONCLUSION

in patients with pulmonary cement embolism, conservative treatment may be recommended rather than a surgical removal except when the obstruction is extensive enough to cause hemodynamic changes. Given that all the related studies have suggested that pulmonary thromboembolism can occur as a complication due to bone cement leakage, discovering new cement alternatives and/or injection devices, seems beneficial.