A Novel Tripod Percutaneous Reconstruction Technique in Periacetabular Lesions Caused by Metastatic Cancer

Assessing Pain and Functional Outcomes of Percutaneous Stabilization of Metastatic Pelvic Lesions via Photodynamic Nails: A Bi-Institutional Investigation of Orthopaedic Outcomes

Background

Minimally invasive surgical interventions for metastatic invasion of the pelvis have become more prevalent and varied. Our group hypothesized that the use of percutaneous photodynamic nails (PDNs) would result in decreased pain, improved functional outcomes and level of ambulation, and decreased use of opioid pain medication.

Methods

We performed a retrospective chart review of patients with metastatic pelvic bone disease undergoing stabilization with PDNs (IlluminOss Medical) at 2 institutions. Functional outcome measures assessed include the Combined Pain and Ambulatory Function (CPAF), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, and PROMIS Global Health-Physical. Pain was assessed using a visual analog scale (VAS). Outcomes were assessed preoperatively and at 6 weeks, 3 months, 6 months, and 1 year following surgery.

Results

A total of 39 patients treated with PDNs were included. No cases of surgical site infection or implant failure were identified. The median pain VAS score decreased from 8 preoperatively to 0 at the 6-week time point (p < 0.0001). The median CPAF score improved from 5.5 points preoperatively to 7 points at the 3-month mark (p = 0.0132). A significant improvement in physical function was seen at 6 months in the PROMIS Physical Function (p = 0.02) and at both 6 months (p = 0.01) and 1 year (p < 0.01) for the PROMIS Global Health-Physical. The rate of patients prescribed opioid analgesia dropped from 100% preoperatively to 20% at 6 months following surgery (p < 0.001). By 6 weeks, all patients were fully weight-bearing and able to walk independently with or without assistive devices.

Conclusions

Percutaneous stabilization of metastatic periacetabular defects using PDNs is a safe and effective palliative procedure that has been shown to improve patient mobility and provide early pain relief.

Level of Evidence

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

Percutaneous Screws for Column Support During Total Hip Reconstruction of Metastatic Disease of the Acetabulum

Reconstruction of the hip joint in the setting of metastatic lesions of the acetabulum is particularly challenging and can carry significant morbidity for patients who are already medically frail. Novel techniques to minimize morbidity and optimize function warrant exploration for these patients. Here, we present a 50-year-old woman was unable to walk secondary to metastatic breast cancer involving the acetabulum with articular disruption. A primary reconstruction technique was used that combined percutaneous stabilization of the acetabulum and cemented total hip arthroplasty using primary components. Existing reconstructive techniques for metastatic lesions of the acetabulum often require extensive open surgical approaches and revision components. Percutaneous acetabular stabilization combined with cemented total hip replacement may be a less-morbid and equally durable option.

Effective Management of Sacral Stress Fractures in Gastric Cancer: Iliosacral Screw Fixation Following a Type 3 Hemipelvectomy

Metastatic pelvic tumors pose a significant challenge in oncologic orthopedics due to their complex management and the high potential for postoperative complications. This case study discusses a 75-year-old male with a sacral stress fracture following a type 3 internal hemipelvectomy for a metastatic lesion from gastric cancer in the left pubic bone. Initial conservative treatments failed to yield satisfactory improvement, leading to surgical intervention. Open reduction and internal fixation with an iliosacral screw, despite complications, significantly alleviated pain and improved mobility. This case underscores the difficulty in diagnosing sacral stress fractures versus metastatic lesions and highlights the effectiveness of iliosacral screw fixation in managing postoperative sacral stress fractures. It emphasizes the procedure's role in providing early pain relief and enhancing daily activity levels. Additionally, it points out the importance of addressing altered bone metabolism in the postoperative care of patients with metastatic pelvic tumors. This contributes to the literature by stressing the incidence of sacral stress fractures as a critical, though often overlooked, complication and demonstrating the benefits of iliosacral screw fixation in such scenarios for better recovery and quality of life.

Management of metastatic bone disease of the pelvis: current concepts

PURPOSE

Metastatic disease of the pelvis is frequently associated with severe pain and impaired ambulatory function. Depending on the patient's characteristics, primary tumor, and metastatic pelvic disease, the treatment choice may be varied. This study aims to report on the current management options of metastatic pelvic disease.

METHODS

We comprehensively researched multiple databases and evaluated essential studies about current concepts of managing a metastatic bone disease of the pelvis, focusing on specific indications as well as on the result of treatment.

RESULTS

Pelvic metastases not in the periacetabular region can be managed with modification of weight-bearing, analgesics, bisphosphonates, chemotherapy and/or radiotherapy. Minimally invasive approaches include radiofrequency ablation, cryoablation, embolization, percutaneous osteoplasty, and percutaneous screw placement. Pathological or impending periacetabular fracture, excessive periacetabular bone defect, radioresistant tumor, and persistent debilitating pain despite non-surgical treatment and/or minimally invasive procedures can be managed with different surgical techniques. Overall, treatment can be divided into nonoperative, minimally invasive, and operative based on specific indications, the expectations of the patient and the lesion.

CONCLUSION

Different treatment modalities exist to manage metastatic pelvic bone disease. Decision-making for the most appropriate treatment should be made with a multidisciplinary approach based on a case-by-case basis.

Clinical efficacy analysis of percutaneous "tripod" combined with radiofrequency ablation and bone cement filling in the treatment of periacetabular metastases

BACKGROUND

To investigate the clinical efficacy of a percutaneous "tripod" combined with radiofrequency ablation and bone cement filling surgery in treating acetabular bone metastases.

METHODS

We retrospectively analyzed 11 patients who underwent percutaneous "tripod" combined with radiofrequency ablation and bone cement filling for acetabular bone metastases at a tertiary care hospital from February 2021 to December 2022.

RESULTS

11 cases with 13 hips underwent this procedure, including two female patients who underwent both sides, and the rest were unilateral. All cases were followed up for 3-24 months, with a mean of 12 months and a median follow-up time of 11 months. Two of the 11 patients died by the final follow-up, and nine survived. One died 7 months after surgery, and one died 8 months after surgery; the survival of the deceased patients was 7.5 months (range: 7-8 months), with a median survival time of 7.5 months. All 11 patients completed the surgery successfully, and the average unilateral operation time was 167.4 min (148-193). The amelioration of postoperative pain, concomitant with improved quality of life, was observed significantly, ultimately resulting in a prolonged and sustained effect.

CONCLUSIONS

The combination of percutaneous "tripod", radiofrequency ablation, and bone cement filling can effectively relieve pain without delaying the patient's systemic anti-tumor therapy and is a minimally invasive, safe, and effective procedure for the treatment of periacetabular metastases.

Minimally invasive management of pathologic fractures of the pelvis and sacrum: Tumor ablation and fracture stabilization

BACKGROUND

Pathologic fractures of the pelvis/sacrum due to metastatic bone disease (MBD) cause pain and dysfunction due to mechanical instability of the pelvic ring. This study presents our multi-institutional experience with percutaneous stabilization of pathologic fractures and osteolytic lesions from MBD throughout the pelvic ring.

METHODS

The records of patients undergoing this procedure from 2018 to 2022 were reviewed retrospectively from two institutions. Surgical data and functional outcomes were recorded.

RESULTS

Fifty-six patients underwent percutaneous stabilization, with a median operative duration of 119 min (interquartile range [IQR]: 92.8, 167) and median estimated blood loss of 50 mL (IQR: 20, 100). The median length of stay was 3 days (IQR: 1, 6), and 69.6% (n = 39) of patients were discharged home. Early complications included one partial lumbosacral plexus injury, three acute kidney injuries, and one case of intra-articular cement extravasation. Late complications included two infections and one revision stabilization procedure for hardware failure. Mean Eastern Cooperative Oncology Group (ECOG) scores improved from 3.02 (SD 0.8) preoperatively to 1.86 (SD 1.1) postoperatively (p < 0.001). Ambulatory status also improved (p < 0.001).

CONCLUSIONS

Percutaneous stabilization of pathologic fractures and osteolytic defects of the pelvis and sacrum is a procedure that improves patient function, ambulatory status and is associated with a limited complication profile.

Comparison of Percutaneous Interventional Ablation-Osteoplasty-Reinforcement-Internal Fixation (AORIF), Long Intramedullary Nailing, and Hemiarthroplasty for the Treatment of Focal Metastatic Osteolytic Lesions in the Femoral Head and Neck

PURPOSE

Osteolytic metastatic lesions in the femoral head and neck are traditionally treated with intramedullary long nailing (IM) or hemiarthroplasty (HA). Recovery, surgical complications, and medical co-morbidities delay oncologic care. This study sought to elucidate the comparative efficacy of percutaneous ablation-osteoplasty-reinforcement-internal fixation (AORIF), IM, and HA in stabilizing osteolytic lesions in the femoral head and neck.

METHODS

A retrospective study of 67 patients who underwent IM, AORIF, or HA for osteolytic femoral head and neck lesions was performed. Primary outcome was assessed using a combined pain and ambulatory score (Range 1-10: 1 = bedbound, 10 = normal ambulation) at first follow-up (~ 2 weeks). Surgical complications associated with each treatment were compared.

RESULTS

Sixty-seven patients (mean age, 65 ± 13, 36 men and 31 women) underwent IM (40), AORIF (19), and HA (8) with a mean follow-up of 9 ± 11 months. Two patients in the IM group (5%), three in the AORIF group (16%), and none in the HA (0%) group required revision procedures. AORIF demonstrated superior early improvement in combined pain and ambulatory function scores by 3.0 points [IQR = 2.0] (IM p = 0.0008, HA p = 0.0190). Odds of post-operative complications was 10.3 times higher in HA than IM (95% confidence interval 1.8 to 60.3). Future revision procedures were not found to be statistically significant between AORIF and IM (p = 0.234).

CONCLUSIONS

A minimally invasive interventional skeletal procedure for focal femoral head and neck osteolytic lesions may serve as an effective alternative treatment to traditional surgical approaches, conferring a shorter recovery time and fewer medical complications.

Emerging Minimally Invasive Percutaneous Procedures for Periacetabular Osteolytic Metastases

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Periacetabular osteolytic skeletal metastases are frequently associated with pain and impaired ambulatory function. Minimally invasive techniques allow for the restoration of ambulation without interrupting critical systemic cancer therapy.

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The open surgical management of massive periacetabular osteolytic lesions, such as by curettage, internal fixation, or complex total hip reconstruction, is associated with blood loss, hospitalization, rehabilitation, and complications such as infection or delayed wound-healing.

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Minimally invasive percutaneous procedures have become increasingly popular for the management of periacetabular osteolytic metastases by interventional oncologists and orthopaedic surgeons before complex open surgical procedures are considered.

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Minimally invasive procedures may include various methods of cancer ablation and reinforcement techniques. Minimally invasive procedures may entail cancer ablation, polymethylmethacrylate (PMMA) cement reinforcement, balloon osteoplasty, percutaneous screw fixation, or combinations of the aforementioned techniques (e.g., ablation-osteoplasty-reinforcement-internal fixation [AORIF]).

Percutaneous Ablation, Osteoplasty, Reinforcement, and Internal Fixation for Pain and Ambulatory Function in Periacetabular Osteolytic Malignancies

Background Osteolytic neoplasms to periacetabular bone frequently cause pain and fractures. Immediate recovery is integral to lifesaving ambulatory oncologic care and maintaining quality of life. Yet, open acetabular reconstructive surgeries are associated with numerous complications that delay cancer treatments. Purpose To determine the effectiveness for short- and long-term pain and ambulatory function following percutaneous ablation, osteoplasty, reinforcement, and internal fixation (AORIF) for periacetabular osteolytic neoplasm. Materials and Methods This retrospective observational study evaluated clinical data from 50 patients (mean age, 65 years ± 14 [SD]; 25 men, 25 women) with osteolytic periacetabular metastases or myeloma. The primary outcome of combined pain and ambulatory function index score (range, 1 [bedbound] through 10 [normal ambulation]) was assessed before and after AORIF at 2 weeks and then every 3 months up to 40 months (overall median follow-up, 11 months [IQR, 4-14 months]). Secondary outcomes included Eastern Cooperative Oncology Group (ECOG) score, infection, transfusion, 30-day readmission, mortality, and conversion hip arthroplasty. Serial radiographs and CT images were obtained to assess the hip joint integrity. The paired t test or Wilcoxon signed-rank test and Kaplan-Meier analysis were used to analyze data. Results Mean combined pain and ambulatory function index scores improved from 4.5 ± 2.4 to 7.8 ± 2.1 (P < .001) and median ECOG scores from 3 (IQR, 2-4) to 1 (IQR, 1-2) (P < .001) at the first 2 weeks after AORIF. Of 22 nonambulatory patients, 19 became ambulatory on their first post-AORIF visit. Pain and functional improvement were retained beyond 1 year, up to 40 months after AORIF in surviving patients. No hardware failures, surgical site infections, readmissions, or delays in care were identified following AORIF. Of 12 patients with protrusio acetabuli, one patient required a conversion hemiarthroplasty at 24 months. Conclusion The ablation, osteoplasty, reinforcement, and internal fixation, or AORIF, technique was effective for short- and long-term improvement of pain and ambulatory function in patients with periacetabular osteolytic neoplasm. © RSNA, 2023.

Operative management of metastatic disease of the acetabulum: review of the literature and prevailing concepts

Metastatic disease of the periacetabular region is a common problem in orthopaedic oncology, associated with severe pain, decreased mobility, and substantial decline of the quality of life. Conservative management includes optimisation of pain management, activity modification, and radiation therapy. However, patients with destructive lesions affecting the weight-bearing portion of the acetabulum often require reconstructive surgery to decrease pain and restore mobility. The goal of surgery is to provide an immediately stable and durable construct, allowing immediate postoperative weight-bearing and maintaining functional independence for the remaining lifetime of the patient. A variety of surgical techniques have been reported, most of which are based upon cemented total hip arthroplasty, but also include porous tantalum implants and percutaneous cementoplasty. This review discusses the various reconstructive concepts and options, including their respective indications and outcome. A reconstructive algorithm incorporating different techniques and strategies based upon location and quality of remaining bone is also presented.

Surgical robot-assisted tripod percutaneous reconstruction technique combined with bone cement filling technique for the treatment of acetabular metastasis

Background: Acetabular metastasis is a type of metastatic bone cancer, and it mainly metastasizes from cancers such as lung cancer, breast cancer, and renal carcinoma. Acetabular metastasis often causes severe pain, pathological fractures, and hypercalcemia which may seriously affect the quality of life of acetabular metastasis patients. Due to the characteristics of acetabular metastasis, there is no most suitable treatment to address it. Therefore, our study aimed to investigate a novel treatment technique to relieve these symptoms. Methods: Our study explored a novel technique to reconstruct the stability of the acetabular structure. A surgical robot was used for accurate positioning and larger-bore cannulated screws were accurately inserted under the robot's guidance. Then, the lesion was curetted and bone cement was injected through a screw channel to further strengthen the structure and kill tumor cells. Results: A total of five acetabular metastasis patients received this novel treatment technique. The data relating to surgery were collected and analyzed. The results found that this novel technique can significantly reduce operation time, intraoperative bleeding, visual analogue score scores, Eastern Cooperative Oncology Group scores, and postoperative complications (e.g., infection, implant loosening, hip dislocation) after treatment. Follow-up time ranged from 3 months to 6 months, and the most recent follow-up results showed that all patients survived and no acetabular metastasis progressed in any of the patients after surgery. Conclusion: Surgical robot-assisted tripod percutaneous reconstruction combined with the bone cement filling technique may be a novel and suitable treatment in acetabular metastasis patients. Our study may provide new insights into the treatment of acetabular metastasis.

Augmenting Pathologic Acetabular Bone Loss With Photodynamic Nails to Support Primary Total Hip Arthroplasty

Background

Pathologic acetabular defects can undermine the stability and osseointegration of a primary total hip arthroplasty (THA) acetabular component. Our service has used photodynamic nails (PDNs) in a modified Harrington technique to provide space-filling stability to a primary acetabular implant without impeding local osseointegration. Here we describe our experience with PDN-augmented THAs.

Methods

An institutional review board-approved retrospective analysis of all patients who underwent PDN-augmented THA in the management of severe (Harrington class II or III) acetabular defects from September 1, 2020 to May 1, 2021 with at least 6 months of follow-up was performed. The primary outcome was implant survivorship. Comparisons between preoperative and 6-week postoperative visual analogue pain scores were made using the Mann-Whitney U test.

Results

Six patients were included in this case series, 5 with metastatic cancer and 1 with pelvic discontinuity and avascular necrosis following failed attempted acetabular fixation. The mean follow-up duration was 10.3 ± 4.3 months. The mean age was 75.5 ± 4.7 years, mean body mass index 27.3 ± 5.6, and 5 patients were female. All but 1 patient was American Society of Anesthesiologists (ASA) class III. Two patients required acetabular revisions, one for aseptic loosening and a second for a pathologic fracture secondary to disease progression. One patient passed away 90 days after the procedure. The mean visual analogue pain score significantly improved from 7.8 ± 1.6 to 2.0 ± 1.4 six weeks after surgery (P = .008).

Conclusions

PDN augmentation of the periacetabular bone of patients with large pelvic defects yields durable pain relief and function in vulnerable hosts. PDN should be considered a part of the reconstructive surgeon’s armamentarium.

Percutaneous Screw Stabilization of Non-Periacetabular Pelvic Lesions Caused by Metastatic Cancer and Multiple Myeloma

BACKGROUND

The pelvis is one of the most common locations for metastatic bone disease. While many of the publications that describe surgical treatments focus on periacetabular lesions (Enneking zone II), there is a lack of investigation into lesions in the non-periacetabular areas (zones I, III, and IV). We recently described a minimally invasive percutaneous screw application for metastatic zone-II lesions with excellent results. In the present study, we aimed to extend this approach to the other pelvic areas.

METHODS

Twenty-two consecutive patients with painful non-periacetabular pelvic metastatic cancer were included based on retrospective chart review. There were 16 women and 6 men with an average age of 60 years (range, 36 to 81 years). The most common primary cancers were multiple myeloma (7 cases) and breast (5 cases). The most common locations were the sacrum and the ilium. A pathologic fracture was identified in 15 patients. Most of the lesions were treated with multiple large-diameter screws, except for the isolated zone-III lesions. All of the procedures were completed in a standard operating room without the need for special instruments. Radiation therapy was given to 19 patients; the average dose was 15 Gy. The studied outcomes were pain and functionality as assessed by a visual analog scale (VAS) score and the Eastern Cooperative Oncology Group score (ECOG), respectively.

RESULTS

There were no surgical complications and no need for blood transfusion. The average follow-up time was 7 months (range, 0.3 to 34.0 months). Two patients died within 4 weeks of surgery due to COVID-19 infection. There was significant improvement in the postoperative VAS pain score (p < 0.0001) and the ECOG score (p < 0.05) when compared with the preoperative scores. There was no implant failure or revision surgery. Local bone-healing was observed in 12 of 14 patients (86%) who survived for >3 months after surgery.

CONCLUSIONS

Percutaneous screw application is safe and effective in the treatment of metastatic non-periacetabular pelvic lesions. Given the simplicity of the technique and the instrumentation and the tolerance for concomitant treatments, this approach is worthy of broader consideration.

LEVEL OF EVIDENCE

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

Biomechanical restoration of metastatic cancer-induced peri-acetabular bone defects by ablation-osteoplasty-reinforcement-internal fixation technique (AORIF): To screw or not to screw?

BACKGROUND

Minimally invasive percutaneous polymethyl methacrylate cement augmentation procedures offer numerous clinical advantages for patients with periacetabular osteolytic metastatic bone defects in contrast to open reconstructive procedures that are associated with many complications. Several techniques, such as Ablation-Osteoplasty-Reinforcement-Internal Fixation (AORIF), cementoplasty alone, and screw fixation alone are currently used. There is no consensus on optimal skeletal reinforcement of diseased bones. The purpose of this study was to determine the most effective technique of percutaneous acetabular augmentation for joint preservation, with respect to resilience on cyclic loading and fracture pattern at maximal load to failure.

METHODS

Five cohorts of hemipelvis composite bones with uniform periacetabular defects and various types of reinforcement techniques were utilized to simulate osteolytic metastasis in the weight bearing dome of the acetabulum. Five groups of hemipelves underwent finite element analysis and biomechanical testing for load to failure, energy absorption to failure, stress relaxation on cyclic loading, and fracture locations.

RESULTS

The combination of screws and bone cement augmentation demonstrated significant higher energy absorption than the cement or screw only groups (p < 0.05), and better protection of acetabulum from displaced intraarticular fractures than the screws alone oror cement only groups (p < 0.05). Resilience to cyclic loading was higheest in the screw with cement fixation group than the screw only repair (p < 0.01), though not the cement fixation only group.

INTERPRETATION

These data support the hypothesis that cementoplasty combined with screw augmentation such as the AORIF technique provides the best protection of acetabulum from massive metastatic cancer-induced acetabular fractures compared to augmentation with screws or cement alone.

What's new in the management of metastatic bone disease

Metastatic bone disease is a common complication of malignant tumours. As cancer treatment improves the overall survival of patients, the number of patients with bone metastases is expected to increase. The treatments for bone metastases include surgery, radiotherapy, and bone-modifying agents, with patients with a short expected prognosis requiring less invasive treatment. Patients with metastatic bone disease show greatly varying primary tumour histology, metastases sites and numbers, and comorbidities. Therefore, randomised clinical trials are indispensable to compare treatments for these patients. This editorial reviews recent findings on the diagnosis and prognosis prediction and discusses the current treatment of patients with metastatic bone disease.

Computer-Assisted Surgical Navigation for Primary and Metastatic Bone Malignancy of the Pelvis: Current Evidence and Future Directions

Computer-assisted navigation and robotic surgery have gained popularity in the treatment of pelvic bone malignancies, given the complexity of the bony pelvis, the proximity of numerous vital structures, and the historical challenges of pelvic bone tumor surgery. Initial interest was on enhancing the accuracy in sarcoma resection by improving the quality of surgical margins and decreasing the incidence of local recurrences. Several studies have shown an association between intraoperative navigation and increased incidence of negative margin bone resection, but long-term outcomes of navigation in pelvic bone tumor resection have yet to be established. Historically, mechanical stabilization of pelvic bone metastases has been limited to Harrington-type total hip arthroplasty for disabling periacetabular disease, but more recently, computer-assisted surgery has been employed for minimally invasive percutaneous fixation and stabilization; although still in its incipient stages, this procedure is potentially appealing for treating patients with bone metastases to the pelvis. The authors review the literature on navigation for the treatment of primary and metastatic tumors of the pelvic bone and discuss the best practices and limitations of these techniques.

Reinforced reconstruction: A technique for the treatment of periacetabular metastases

Purpose

To describe a single-stage reconstruction of intraarticular periacetabular metastases that utilizes a cemented acetabular liner reinforced with percutaneous screws oriented along various osseous fixation pathways.

Methods

A retrospective evaluation of all patients with intraarticular periacetabular metastases who underwent the procedure outlined.

Results

16 procedures (1 bilateral) were included. There were no intraoperative complications or postoperative mechanical failures to date despite allowing the patients to immediately weight bear in the postoperative setting.

Discussion

Utilizing osseous fixation pathways to reinforce a cemented acetabular cup represents a safe and effective strategy to allow for immediate weightbearing in patients with periacetabular metastases.

Emerging Concepts in the Surgical Management of Peri-Acetabular Metastatic Bone Disease

The pelvis is a common site of metastatic bone disease. Peri-acetabular lesions are particularly challenging and can cause severe pain, disability and pathologic fractures. Surgical management of these lesions has historically consisted of cementoplasty for contained lesions and Harrington reconstructions for larger, more destructive lesions. Due to the limitations of these procedures, a number of novel procedures have been developed to manage this challenging problem. Percutaneous techniques—including acetabular screw fixation and cementoplasty augmented with screws—have been developed to minimize surgical morbidity. Recent literature has demonstrated a reliable reduction in pain and improvement in function in appropriately selected patients. Several adjuncts to the Harrington procedure have been utilized in recent years to reduce complication rates. The use of constrained liners and dual mobility bearings have reduced the historically high dislocation rates. Cage constructs and porous tantalum implants are becoming increasingly common in the management of large bony defects and destructive lesions. With novel and evolving surgical techniques, surgeons are presented with a variety of surgical options to manage this challenging condition. Physicians must take into account the patients’ overall health status, oncologic prognosis and anatomic location and extent of disease when developing an appropriate surgical plan.

A graphic guide to the percutaneous tripod acetabular reconstruction for metastatic cancer

Symptomatic peri-acetabular metastatic lesions are often treated with open surgery such as modified Harrington procedures. In an effort to avoid surgical complications inherently associated with open surgical approaches, we developed and recently reported a novel Tripod percutaneous screw technique. The tripod technique is minimally invasive and was found to yield excellent outcomes regarding both pain control and functionality. The procedure is performed in a standard operative theater using fluoroscopic guided percutaneous screws. Despite the simplicity of intraoperative set-up and instrumentation, it is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging for even an experienced orthopedic surgeon. The technique and bony conduits were previously described in the trauma literature, however, there are key points of difference in the setting of metastatic disease. Here we provide a compilation of a stepwise graphic guide for the tripod model in the setting of metastatic peri-acetabular lesions, as well as the tips and tricks based on our own experience. These encompass preoperative preparation, operating room settings, intraoperative fluoroscopic guidance, postoperative care, and subsequent conversion to a cemented total hip arthroplasty, if needed.