Osteoplasty: Percutaneous Bone Cement Injection beyond the Spine

Minimally invasive interventional guided imaging therapies of musculoskeletal tumors

Historically, musculoskeletal (MSK) tumors, which include both bone and soft tissue tumors, have been managed as distinct entities. The incidence of metastases, particularly bone metastasis, in patients with MSK tumors can result in the emergence of significant complications such as pain, impairment of vital anatomical structures, or pathological fractures. Given these issues, a diverse team of experts is typically engaged in intricate treatment decision-making concerning the necessity of surgery, radiation, chemotherapy, or a mix of these methodologies. Nevertheless, percutaneous image-guided minimally invasive interventional therapy for MSK tumors represent a promising approach for treating such tumors. Over the past decade, significant progress has been made in this technique, leading to its growing acceptance in ordinary clinical practice. MSK tumors can be effectively treated by the use of ablation techniques, either as standalone procedures or in conjunction with other percutaneous treatments. Various image-guided techniques have been employed to observe the ablation zone and nearby structures, such as fluoroscopy, ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). However, CT is the favored method due to its widespread availability and ability to visualize the tumor and its environs. The procedures employed include ethanol injection, radiofrequency ablation, microwave ablation, cryoablation, and magnetic resonance (MR)-guided high-intensity focused ultrasound (HIFU). The technique can be performed in combination with cementation, with or without additional metallic stabilizing devices, depending on the location of the lesion. Improved local tumor control can be attained by combining ablation with bland embolization or transarterial chemoembolization. This article provides an overview of the fundamental elements of minimally invasive interventional guided imaging therapy for MSK malignancies.

In vitroassessment of a gallium-doped glass polyalkenoate cement: chemotherapeutic potential, cytotoxicity and osteogenic effects

Metastatic bone lesions are often osteolytic, which causes advanced-stage cancer sufferers to experience severe pain and an increased risk of developing a pathological fracture. Gallium (Ga) ion possesses antineoplastic and anti-bone resorption properties, suggesting the potential for its local administration to impede the growth of metastatic bone lesions. This study investigated the chemotherapeutic potential, cytotoxicity, and osteogenic effects of a Ga-doped glass polyalkenoate cement (GPC) (C-TA2) compared to its non-gallium (C-TA0) counterpart. Ion release profiles revealed a biphasic pattern characterized by an initial burst followed by a gradually declining release of ions. C-TA2 continued to release Ga steadily throughout the experimentation period (7 d) and exhibited prolonged zinc (Zn) release compared to C-TA0. Interestingly, the Zn release from both GPCs appeared to cause a chemotherapeutic effect against H1092 lung cancer cellsin vitro, with the prolonged Zn release from C-TA2 extending this effect. Unfortunately, both GPCs enhanced the viability of HCC2218 breast cancer cells, suggesting that the chemotherapeutic effects of Zn could be tied to cellular differences in preferred Zn concentrations. The utilization of SAOS-2 and MC3T3 cell lines as bone cell models yielded conflicting results, with the substantial decline in MC3T3 viability closely associated with silicon (Si) release, indicating cellular variations in Si toxicity. Despite this ambiguity, both GPCs exhibited harmful effects on the osteogenesis of primary rat osteoblasts, raising concerns about excessive burst Zn release. While Ga/Zn-doped GPCs hold promise for treating metastatic bone lesions caused by lung cancers, further optimization is required to mitigate cytotoxicity on healthy bone.

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.

Evaluation of Intramedullary Methods with Polymethylmethacrylate for Fixation of Bone Lesions of the Extremities

Objective  To evaluate the better potential and functional results in pain control in the treatment of pathological fractures and prophylactic fixation with an intramedullary nail associated with polymethylmethacrylate, compared with the utilization of an intramedullary nail in long bone tumor lesions.

Methods  From January 2012 to September 2017, 38 patients with 42 pathological lesions (fractures or impending fractures according to the Mirels criteria) were treated surgically. Sixteen patients allocated to the control group underwent a locked intramedullary nail fixation, and 22 patients with pathological lesions were allocated to treatment with an intramedullary nail associated with polymethylmethacrylate. Postoperatively, the patients were submitted to the Musculoskeletal Tumor Society (MSTS) rating scale, radiographic assessment, and to the assessment of events and complications related to the treatment.

Results  The evaluation using the MSTS questionnaire showed better functional results in the group associated with polymethylmethacrylate, in comparison with the control group, which obtained an average score of 16.375 out of a maximum of 30 points (54.6%). The group studied with association with polymethylmethacrylate obtained a mean of 22.36 points (74.5%). The procedure proved to be safe, with similar complication and severity rates, and with no statistical difference in comparison with the standard treatment.

Conclusion  Stabilization of tumor lesions with an internal fixation associated with the polymethylmethacrylate demonstrated early rehabilitation and improved the quality of life, allowing rapid functional recovery. The use of polymethylmethacrylate has advantages such as reduced bleeding, tumor necrosis and higher mechanical stability.

Bone cement as a local chemotherapeutic drug delivery carrier in orthopedic oncology: A review

Metastatic bone lesions are common among patients with advanced cancers. While chemotherapy and radiotherapy may be prescribed immediately after diagnosis, the majority of severe metastatic bone lesions are treated by reconstructive surgery, which, in some cases, is followed by postoperative radiotherapy or chemotherapy. However, despite recent advancements in orthopedic surgery, patients undergoing reconstruction still have the risk of developing severe complications such as tumor recurrence and reconstruction failure. This has led to the introduction and evaluation of poly (methyl methacrylate) and inorganic bone cements as local carriers for chemotherapeutic drugs (usually, antineoplastic drugs (ANPDs)). The present work is a critical review of the literature on the potential use of these cements in orthopedic oncology. While several studies have demonstrated the benefits of providing high local drug concentrations while minimizing systemic side effects, only six studies have been conducted to assess the local toxic effect of these drug-loaded cements and they all reported negative effects on healthy bone structure. These findings do not close the door on chemotherapeutic bone cements; rather, they should assist in materials selection when designing future materials for the treatment of metastatic bone disease.

Percutaneous cementoplasty of periprosthetic loosening: can interventional radiologists offer an alternative to revision surgery?

OBJECTIVE

To evaluate feasibility and validate both safety and efficiency of radiological percutaneous periprosthetic bone cementoplasty (RPPBC) performed under local anesthesia as an alternative minimally invasive treatment of aseptic implant loosening.

METHODS

In this case series, seven patients (mean age 81 years, range 73 to 89 years, 2 men and 5 women) were enrolled between February 2011 and January 2020 with confirmed aseptic loosening of orthopedic implants. One patient presented with tibial component loosening of an unicompartmental knee arthroplasty, one with glenoid component loosening from a reverse shoulder arthroplasty, one femoral gamma nail, and four presented with pedicle screw loosening after staged posterior lumbar interbody fusion. All patients underwent clinical, biochemical, and imaging assessments to confirm the diagnosis of aseptic loosening. All benefited from RPPBC under dual CT and fluoroscopic guidance. All procedures were performed under local anesthesia by an experienced radiologist. Preprocedural, immediate and 6-month post-cementoplasty pain levels on a visual analogue scale (VAS), and functional outcomes were evaluated. Immediate and 6-month postprocedural CTs were performed to evaluate the treated region.

RESULTS

All RPPBC were well tolerated by patients throughout the procedure. None of the patients suffered from local or systemic infection post-RPPBC, or periprosthetic fractures. No recurrent implant loosening was observed. Six patients were pain free at 6 months. All patients expressed functional improvements during validated outcome score evaluations.

CONCLUSION

RPPBC appears to be an efficient and reliable treatment strategy for aseptic loosening of orthopedic implants in elderly patients deemed unfit for revision surgery.

KEY POINTS

• Radiological percutaneous periprosthetic bone cementoplasty offers immediate and long-lasting pain relief in elderly frail patients, or those deemed unfit for revision surgery despite presenting with symptomatic aseptic loosening of orthopedic implants. • Radiological percutaneous periprosthetic bone cementoplasty brings quick and long-lasting improvements in clinical functional outcomes and offer effective pain reduction, thereby improving the overall quality of life. • Radiological percutaneous periprosthetic bone cementoplasty is a safe, quick, reliable, and well-tolerated minimally invasive procedure which can be easily performed under simple locoregional anesthesia and requires short-term hospital stay.

Finite element models for fracture prevention in patients with metastatic bone disease. A literature review

Patients with bone metastases have an increased risk to sustain a pathological fracture as lytic metastatic lesions damage and weaken the bone. In order to prevent fractures, prophylactic treatment is advised for patients with a high fracture risk. Mechanical stabilization of the femur can be provided through femoroplasty, a minimally invasive procedure where bone cement is injected into the lesion, or through internal fixation with intra- or extramedullary implants. Clinicians face the task of determining whether or not prophylactic treatment is required and which treatment would be the most optimal. Finite element (FE) models are promising tools that could support this decision process. The aim of this paper is to provide an overview of the state-of-the-art in FE modeling for the treatment decision of metastatic bone lesions in the femur. First, we will summarize the clinical and mechanical results of femoroplasty as a prophylactic treatment method. Secondly, current FE models for fracture risk assessment of metastatic femurs will be reviewed and the remaining challenges for clinical implementation will be discussed. Thirdly, we will elaborate on the simulation of femoroplasty in FE models and discuss future opportunities. Femoroplasty has already proven to effectively relieve pain and improve functionality, but there remains uncertainty whether it provides sufficient mechanical strengthening to prevent pathological fractures. FE models could help to select appropriate candidates for whom femoroplasty provides sufficient increase in strength and to further improve the mechanical benefit by optimizing the locations for cement augmentation.

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.

Combination of Microwave Ablation and Percutaneous Osteoplasty for Treatment of Painful Extraspinal Bone Metastasis

PURPOSE

To evaluate the efficacy and safety of microwave (MW) ablation combined with percutaneous osteoplasty (POP) on painful extraspinal bone metastases.

MATERIALS AND METHODS

In this retrospective study, 50 adult patients with 56 extraspinal bone metastasis lesions, who suffered from refractory moderate to severe pain, were treated with MW ablation and POP. Changes in quality of life were evaluated based on the Visual Analog Scale (VAS), daily morphine consumption, and the Oswestry Disability Index (ODI) before and immediately after the procedure and during follow-up times.

RESULTS

Technical success was achieved in all patients. Mean preoperative VAS score and morphine dose were 7.0 ± 2.6 (range, 3-10) and 66.7 ± 33.2 mg (range, 10-120 mg), respectively. Mean postoperative VAS scores and daily morphine doses were as follows: 1 day, 3.5 ± 2.1 and 36.1 ± 25.8 mg (P < .05); 1 week, 1.5 ± 1.7 and 12.2 ± 14.8 mg (P < .001); 1 month, 0.9 ± 1.4 and 5.7 ± 10.0 mg (P < .001); and 3 months, 0.6 ± 1.2 and 4.7 ± 8.4 mg (P < .001). A significant decrease in the ODI score was also observed (P < .05). Periprocedural death was not observed. A pathologic fracture occurred in 1 (2%) patient with femoral metastasis, and local infection was observed in 2 (4%) patients. Minor cement leakage occurred in 4 (8%) patients with no symptomatic or intra-articular extravasation. No local tumor progression occurred in patients with imaging follow-up.

CONCLUSIONS

MW ablation combined with POP is an effective and safe treatment for painful extraspinal bone metastases, which can significantly relieve pain and improve quality of life.

Sequential Interventional Management of Osseous Neoplasms via Embolization, Cryoablation, and Osteoplasty

The purpose of this study is to determine if sequential interventional therapy can become a mainstay option in providing palliation from fastidious osseous neoplasms in patients with pain refractory to oral analgesia and radiotherapy. This retrospective monocentric study was approved by our institutional review board. Between July 2012 and August 2014, we reviewed 15 patients (6 women, 9 men; age range of 36-81 years) who underwent embolization followed by cryoablation, with or without osteoplasty. Patient demographics and tumor characteristics, including primary histology and the location of metastasis, were included in our review. Pain intensity at baseline, after radiotherapy, and after sequential interventional therapy was reviewed using the hospital electronic medical record. The use of oral analgesia and procedural complications was also noted. Data was then assessed for normality and a two-tailed Student's t-test was performed on mean pain scores for difference phases of treatment. While radiotherapy offers pain relief with a mean pain score of 7.25 ±1.5 (p =<.0001), sequential interventional therapy results in better comfort as demonstrated by a mean pain score of 3.9 ± 2.6 (p=.0015). Moreover, all patients who reported oral analgesic use at presentation reported a decrease in their requirement after sequential interventional therapy. Embolization and cryoablation were performed in all patients, while osteoplasty was indicated in 6 cases. There was no difference in postprocedural pain intensity between patients who required osteoplasty and patients who did not (p = 0.7514). There were no complications observed during treatment. This retrospective study shows that sequential intervention with transarterial embolization, cryoablation, and osteoplasty is both safe and efficacious for bone pain refractory to the current standard of care. We demonstrated that this combination therapy has the potential to become an effective mainstay treatment paradigm in the palliative care of osseous neoplasm to improve quality of life.

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

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

CT fluoroscopy-guided percutaneous osteoplasty with or without radiofrequency ablation in the treatment of painful extraspinal and spinal bone metastases: technical outcome and complications in 29 patients

PURPOSE

We aimed to assess the safety and technical outcome of computed tomography (CT) fluoroscopy-guided osteoplasty with or without prior percutaneous radiofrequency ablation (RFA) in patients with painful osteolyses.

METHODS

We performed a retrospective analysis of 29 patients with painful extraspinal and spinal osteolyses (16 women, 13 men; 63.1±14.4 years) who underwent CT fluoroscopy-guided osteoplasty (10-20 mAs tube current) with or without RFA (26 and 14 lesions, respectively), in 33 consecutive procedures from 2002 to 2016. Technical success was defined as at least one complete RFA cycle and subsequent polymethyl metacrylate (PMMA) bone cement injection covering ≥75% of longest diameter of extraspinal osteolysis on axial plane or of distance between vertebral endplates. Procedure-related complications within 30 days and dose-length-product (DLP) were also evaluated.

RESULTS

Osteolyses were located in the pelvis (acetabulum, n=10; iliac bone, n=4), spine (thoracic, n=6; lumbar, n=5; sacral, n=8), long bones (femur, n=3; tibia, n=1), sternum (n=2) and glenoid (n=1). Mean size of the treated osteolysis was 4.0±1.2 cm (range, 1.9-6.9 cm). Of 40 osteolyses, 31 (77.5%) abutted neighboring risk structures (spinal canal or neuroforamen, n=18; neighboring joint, n=11; other, n=8). Mean number of RFA electrode positions and complete ablation cycles was 1.5±0.9 and 2.1±1.7, respectively. Mean PMMA filling volume was 7.7±5.7 mL (range, 2-30 mL). Small asymptomatic PMMA leakages were observed in 15 lesions (37.5%). Mean total DLP was 850±653 mGy*cm. Six minor complications were observed, without any major complications.

CONCLUSION

CT fluoroscopy-guided percutaneous osteoplasty with or without concomitant RFA for the treatment of painful extraspinal and spinal osteolyses can be performed with a low complication rate and high technical success.

Is Use of Bone Cement for Treatment of Second Metatarsal Stress Fractures Safe? A Case Report

Metatarsal stress fractures are common injuries of the foot and can be a source of chronic pain without appropriate management. Conservative management is first line, but surgery may be indicated in athletes, cases of nonunion, and fractures of the fifth metatarsal. We report a case of a 34-year-old female who presented to clinic for intractable pain of the left foot secondary to a stress fracture of the left second metatarsal, which had been previously treated with injectable acrylic bone cement. Calcium sulfate hydroxyapatite cement has a multitude of applications in orthopedic surgery, but to our knowledge no studies have documented its use in the treatment of metatarsal stress fractures. Our findings suggest that injectable calcium sulfate hydroxyapatite cement is not a suitable stand-alone treatment in fractures of the second metatarsal.

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

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

Interventional radiology in breast cancer

Molecular profiling of metastatic disease may greatly influence the systemic therapy recommended by oncologists and chosen by patients, allowing treatment to be more targeted. Comprehensive care of patients with advanced breast cancer now includes percutaneous image-guided biopsy if this has the potential to influence systemic treatment [1]. Interventional radiologists can contribute significantly to the care of patients affected by breast cancer, in diagnostic and supportive procedures and importantly also in treatment. Interventional radiologists carry out image guided percutaneous biopsies not only of the primary tumour but also of metastases. They insert percutaneous ports and tunnelled central venous catheters. They ablate painful bone metastases, and can treat or prevent pathological fractures. Most importantly they can ablate liver metastases in patients with limited or oligometastatic disease. The inhomogeneity and variety of cell populations in metastatic tumours from breast cancer, which is an important consideration in systemic therapy, is not an important consideration in the treatment of metastatic tumours using percutaneous ablative techniques, which are the major focus of this article. The treatment of primary tumours in the breast is also being explored, but is considered in its infancy at this stage.

Closed intramedullary nailing with percutaneous cement augmentation for long bone metastases

Aims

The purpose of the study was to investigate whether closed intramedullary (IM) nailing with percutaneous cement augmentation is better than conventional closed nailing at relieving pain and suppressing tumours in patients with metastases of the femur and humerus.

Patients and Methods

A total of 43 patients (27 men, 16 women, mean age 63.7 years, standard deviation (sd) 12.2; 21 to 84) underwent closed IM nailing with cement augmentation for long bone metastases. A further 27 patients, who underwent conventional closed IM nailing, served as controls. Pain was assessed using a visual analogue scale (VAS) score pre-operatively (pre-operative VAS), one week post-operatively (immediate post-operative VAS), and at six weeks post-operatively (follow-up post-operative VAS). Progression of the tumour was evaluated in subgroups of patients using F-18-fludeoxyglucose (F-18-FDG) positron emission tomography (PET)/computed tomography (CT) and/or bone scintigraphy (BS), at a mean of 8.8 and 7.2 months post-operatively, respectively.

Results

The mean pain scores of patients who underwent closed nailing with cement augmentation were significantly lower than those of the control patients post-operatively (immediate post-operative VAS: 3.8, sd 0.9 versus 6.0, sd 0.9; follow-up post-operative VAS: 3.3, sd 2.5 versus 6.6, sd 2.2; all p < 0.001). The progression of the metastasis was suppressed in 50% (10/20) of patients who underwent closed nailing with augmentation, but in only 8% (1/13) of those in the control group.

Conclusion

Percutaneous cement augmentation of closed IM nailing improves the relief of pain and limits the progression of the tumour in patients with metastases to the long bones. Take home message: Percutaneous cement augmentation while performing closed IM nailing has some advantages for long bone metastases. Cite this article: Bone Joint J 2016;98-B:703–9.

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

PURPOSE

To evaluate clinical efficacy/safety of augmented peripheral osteoplasty in oncologic patients with long-term follow-up.

MATERIALS AND METHODS

Percutaneous augmented peripheral osteoplasty was performed in 12 patients suffering from symptomatic lesions of long bones. Under extensive local sterility measures, anesthesiology care, and fluoroscopic guidance, direct access to lesion was obtained and coaxially a metallic mesh consisting of 25-50 medical grade stainless steel micro-needles (22 G, 2-6 cm length) was inserted. PMMA for vertebroplasty was finally injected under fluoroscopic control. CT assessed implant position 24-h post-treatment.

RESULTS

Clinical evaluation included immediate and delayed follow-up studies of patient's general condition, NVS pain score, and neurological status. Imaging assessed implant's long-term stability. Mean follow-up was 16.17 ± 10.93 months (range 2-36 months). Comparing patients' scores prior (8.33 ± 1.67 NVS units) and post (1.42 ± 1.62 NVS units) augmented peripheral osteoplasty, there was a mean decrease of 6.92 ± 1.51 NVS units. Overall mobility improved in 12/12 patients. No complication was observed.

CONCLUSION

Percutaneous augmented peripheral osteoplasty (rebar concept) for symptomatic malignant lesions in long bones seems to be a possible new technique for bone stabilization. This combination seems to provide necessary stability against shearing forces applied in long bones during weight bearing.

Comparison of Percutaneous Cementoplasty with and Without Interventional Internal Fixation for Impending Malignant Pathological Fracture of the Proximal Femur

PURPOSE

To compare the efficacy of percutaneous cementoplasty (PCP) with and without interventional internal fixation (IIF) on malignant impending pathological fracture of proximal femur.

METHODS

A total of 40 patients with malignant impending pathological fracture of proximal femur were selected for PCP and IIF (n = 19, group A) or PCP alone (n = 21, group B) in this non-randomized prospective study. Bone puncture needles were inserted into the proximal femur, followed by sequential installation of the modified trocar inner needles through the puncture needle sheath. Then, 15-45 ml cement was injected into the femur lesion.

RESULTS

The overall excellent and good pain relief rate during follow-ups were significantly higher in group A than that in group B (89 vs. 57 %, P = 0.034). The average change of VAS, ODI, KPS, and EFES in group A were significantly higher than those in group B at 1-, 3-, 6-month, 1-year (P < 0.05). Meanwhile, The stability of the treated femur was significantly higher in group A than that in group B (P < 0.05).

CONCLUSION

PCP and IIF were not only a safe and effective procedure, but resulted in greater pain relief, bone consolidation, and also reduced the risk of fracture than the currently recommended approach of PCP done on malignant proximal femoral tumor.

Cementoplasty of bone metastases

Cementoplasty is a palliative treatment for bone metastases. It can be performed alone or in addition to other treatments, such as radiotherapy, radiofrequency ablation or cryotherapy. It is usually performed to reduce pain where the metastases involve the spine and pelvis. It can also be used to stabilise bones in the event of lytic metastases with a risk of fracture. Unlike ablation techniques, it should not be considered a cancer treatment.