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Vertebral compression fractures (VCF) are frequent injuries mostly related to bone fragility[1][1] and are successfully treated by cementoplasty, such as vertebroplasty or kyphoplasty.[2 3][2] Vertebroplasty requires the use of two-dimensional (2D) imaging for intraoperative control of cement

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.

Percutaneous osteoplasty (POP) is defined as the injection of bone cement into various painful bony lesions, refractory to conventional therapy, as an extended technique of percutaneous vertebroplasty (PVP). POP can be applied to benign osteochondral lesions and malignant metastatic lesions throughout the whole skeleton, whereas PVP is restricted to the vertebral body. Common spinal metastases occur in the thoracic (70%), lumbosacral (20%), and cervical (10%) vertebrae, in order of frequency. Extraspinal metastases into the ribs, scapulae, sternum, and humeral head commonly originate from lung and breast cancers; extraspinal metastases into the pelvis and femoral head come from prostate, urinary bladder, colon, and uterine cervical cancers. Pain is aggravated in the dependent (or weight bearing) position, or during movement (or respiration). The tenderness and imaging diagnosis should match. The supposed mechanism of pain relief in POP is the augmentation of damaged bones, thermal and chemical ablation of the nociceptive nerves, and local inhibition of tumor invasion. Adjacent (facet) joint injections may be needed prior to POP (PVP). The length and thickness of the applied needle should be chosen according to the targeted bone. Bone cement is also selected by its osteoconduction, osteoinduction, and osteogenesis. Needle route should be chosen as a shortcut to reach the target bony lesions, without damage to the nerves and vessels. POP is a promising minimally invasive procedure for immediate pain relief. This review provides a technical survey for POPs in painful bony lesions.

Background In advanced cancer patients, pelvic bone metastasis often causes pain and gait disturbance. The use of percutaneous bone cement [polymethylmethacrylate (PMMA)] injection for pain management and strengthening in pelvic bone metastasis has rarely been reported. To evaluate this method, we aimed to determine surgical outcomes and complications over a long-term follow-up period using a large patient group. Patients and Methods We retrospectively collected data from 178 patients who underwent percutaneous cementoplasty for pelvic metastatic lesions, 201 in total. Surgical outcomes evaluated included pain reduction and improvement of ambulation. Mortality within 1 month after procedure and pulmonary embolism caused by thrombus, fat, tumor emboli, or bone cement were investigated as surgical complications. For long-term survivors, pain relapse and mechanical failure were analyzed. The mean follow-up period was 12.6 months, and there were 159 fatalities at last follow-up. Results The mean regional pain numerical rating scale scores decreased from 6.1 preoperatively to 2.4 1 month after procedure (p < 0.01). Gait function was maintained, worsened, and uncheckable in 68%, 24%, and 8% of patients, respectively, 1 month after procedure. Of long-term survivors followed up for > 12 months (n = 53), there were no significant changes in serial plain radiographs, and regional pain aggravation was observed in 9%. Pulmonary cement embolism and bone cement implantation syndrome was observed in 11% and 10%, respectively. However, all patients with these complications were asymptomatic. Conclusions Percutaneous cement injection into the pelvis is a feasible and safe palliative surgical option for patients with advanced malignancy in terms of pain reduction and maintenance of ambulatory function under regional anesthesia.

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.

To evaluate the feasibility and safety of percutaneous transpedicular fixation by PEEK polymer implants and cementoplasty for vertebral compression fracture (VCF). From February 2019 to December 2019, 6 consecutive patients (3 men and 3 women; mean age 55 ± 8 years; range 40–64 years) who had percutaneous transpedicular fixation with cementoplasty for the treatment of VCF (5 tumor lesions, 1 traumatic) were included. The procedure duration, length of hospital stay, and complications were reported. Visual analog scale (VAS) and the Oswestry disability index (ODI) for pain and disability were assessed before and 2 months after the procedure. The mean procedure duration was 74 ± 47 min (range 20–140 min). The median length of hospital stay was 3 days (range 2–63) after the procedure. Only minor adverse events were reported (4 asymptomatic cement leakages) but no severe complications. No cases of procedural site fracture during follow-up were noted (median 198 days; range 78–238 days). The mean VAS score decreased from 6.2 ± 1.8 mm (median 6 mm; range 4–9 mm) before the procedure to 1.7 ± 2.1 mm (median 1; range 0–5 mm) after the procedure. The ODI decreased from 36 ± 14% (range 18–54%) before the procedure to 23 ± 10% (range 11–30%) at 2-months follow-up. Percutaneous transpedicular fixation of VCF by PEEK implants with cementoplasty appears feasible and safe.

Periacetabular metastatic lesions cause debilitating weight-bearing pain and pose a risk of pelvic pathologic fracture. Minimally invasive percutaneous stabilization is an alternative palliative therapy over extensive open reconstructive surgeries. This study aimed to investigate the biomechanical behaviors of three distinct techniques of percutaneous periacetabular stabilization. A total of 20 composite hemipelves custom-made to contain Harrington type III periacetabular lesion based on a patient's computed tomograpy scans were assigned to treatment groups of cementoplasty alone using polymethyl methacrylate (Cement), screw fixation alone using ischial and posterior-to-anterior screws (Screws), cement-augmented screws (Screws&Cement), and a control group (Untreated). All hemipelves were loaded in a mechanical test configuration mimicking a single-legged stance, and failure load, failure deformation, and construct stiffness were determined. In the experiments, Screws&Cement demonstrated the highest yield strength (4711 ± 362 N) and was 12% higher than Cement (4005 ± 304 N, p = 0.019), 125% higher than Screws (2097 ± 359 N, p < 0.0001), and 184% higher than Untreated (1658 ± 254 N, p < 0.0001). No significant difference in yield strength was found between Screws and Untreated. Screws&Cement also demonstrated the highest stiffness (1013 ± 92 N/mm), followed by Cement (893 ± 49 N/mm), and both groups were significantly stiffer than Screws (543 ± 114 N/mm, p < 0.0001) and Untreated (580 ± 91 N/mm, p < 0.0001 for Screws&Cement, and p = 0.0003 for Cement). This study demonstrated that a cement-augmented periacetabular reconstruction is an effective option for percutaneous treatment of Harrington III periacetabular metastatic lesion. The addition of pelvic screws over cementoplasty significantly improved the pelvis load-bearing strength. When large periacetabular lesions are present, augmented screw fixation appears to be the superior choice of treatment.

We relay a case of unstable lytic secondary fracture of odontoid process (C2) treated by screw fixation and cementoplasty, using a percutaneous approach. A 62-year-old female patient followed for a breast neoplasia with bone concurrent metastases suffered from diffuse cervical pain. A CT scan showed a lytic fracture of C2. The procedure was performed using CT scan guidance under general anesthesia. After a biphasic enhanced CT scan of the neck and cervical spine, a needle was slowly inserted to hydrodissect the jugulocarotid and prevertebral spaces up to the anterior cortex of C2 using an iodinated contrast agent solution diluted 5% with saline water. Under fluoroscopy guidance and intermittent CT monitoring, a bone pin was navigated though the anterior cortex of C2 and then advanced inside the vertebral body of C2. After checking for optimal positioning of the bone pin, a 34-mm-long titanium screw was inserted into C2 until reaching the posterior cortex. The approach to the transverse fracture line of the body of the odontoid was tangential with no displacement of the bony parts. Cement injection was then performed. One month after the procedure, a CT scan showed no material displacement, and the patient had no visible skin scarring. The patient regained full mobility of the cervical spine, and the pain decreased from 7/10 before the procedure to 0/10 after the procedure according to the patient. Percutaneous screw fixation and cementoplasty to stabilize unstable osteolytic fracture of odontoid process are safe and feasible.

To report the rate of fragmentation of the cement plug following percutaneous cementoplasty with polymethylmethacrylate (PMMA) in the bony pelvis (i.e., pelvic bones or sacrum). Post-interventional and follow-up CT scans of 56 patients (36 men; mean age of 68.4 ± 15.4) with a total of 98 percutaneous cementoplasty procedures were analyzed. Indications for treatment included painful malignant tumors (42.9%; 42/98) and insufficiency fractures (57,1%; 56/98). Fragmentation of PMMA was recorded for each cement plug. Mean interval between the procedure and the last available CT scan was 29.3 ± 18.8 months. There was no significant difference between the length of follow-up of malignant lesions (27.6 ± 15.1 months) and insufficiency fractures (29 ± 20.5 months) (p = 0.69). Fragmentation was diagnosed following 2/98 (2%) procedures, both in the malignant lesions group. The time intervals between the procedure and the first visualization of cement fragmentation were 6 for the first and 24 months for the second patient. Fragmentation of the PMMA plug following percutaneous cementoplasty in the bony pelvis is a rare finding at midterm follow-up. It was only observed in cementoplasty performed in malignant lesions and seems to be more a consequence of local mechanical stresses than as a result of porosity.

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

A systematic review and meta-analysis of pain response after radiofrequency (RF) ablation over time for osseous metastases was conducted in 2019. Analysis used a random-effects model with GOSH plots and meta-regression. Fourteen studies comprising 426 patients, most with recalcitrant pain, were identified. Median pain reduction after RF ablation was 67% over median follow-up of 24 weeks (R2 = −.66, 95% confidence interval −0.76 to −0.55, I2 = 71.24%, fail-safe N = 875) with 44% pain reduction within 1 week. A low-heterogeneity subgroup was identified with median pain reduction after RF ablation of 70% over 12 weeks (R2 = −.75, 95% confidence interval −0.80 to −0.70, I2 = 2.66%, fail-safe N = 910). Addition of cementoplasty after RF ablation did not significantly affect pain scores. Primary tumor type and tumor size did not significantly affect pain scores. A particular, positive association between pain after RF ablation and axial tumors was identified, implying possible increased palliative effects for RF ablation on axial over appendicular lesions. RF ablation is a useful palliative therapy for osseous metastases, particularly in patients with recalcitrant pain.

To compare the clinical efficacies of percutaneous osteoplasty (POP) and combination therapy with percutaneous osteoplasty and transcatheter arterial chemoembolization (POPTACE) for the treatment of pelvic bone metastases. A retrospective study of 100 patients with pelvic bone metastases who had been treated by POP (n = 50) and POPTACE (n = 50) was conducted in this work. The clinical efficacies of these two treatments were evaluated by comparing their pain and functional abilities and bone metastases ability at the pre- and post-operative time points. POPTACE and POP treatments had no significant differences (P > 0.05) in VAS scores and KPS scores. Concerning tumor response, a partial response in 37 of 50 (74%) patients at 1 month for the POPTACE group and a partial response in 26 of 50 (52%) patients at 1 month for the POPC group were observed (P = 0.04). Although POPTACE and POP treatments had significant and similar ability in pain relief and functional recovery ability for the treatment of pelvic bone metastases, POPTACE treatment had a significantly better tumor response ability (partial response and stable response) compared with POP treatment. Both POP and POPTACE were effective methods for the treatment of pelvic bone metastases. Moreover, these initial outcomes suggest POPTACE treatment may be better than POP treatment. POPTACE treatment has great value and is worth promoting vigorously in orthopedics clinics.

Background: Vertebral pathological compression fracture involving extra-nodal lymphoma impacts negatively on the quality of life of HIV-positive patients. The choice of a safe and effective approach to palliative care in this condition remains a challenge. Objective: The purpose of this study was to investigate the safety and efficacy of percutaneous kyphoplasty (PKP) in the treatment of vertebral pathological compression fracture of extra-nodal lymphoma in HIV-positive patients. Methods: A retrospective analysis, from January 2016 to August 2019, was performed on 7 HIV-positive patients, 3 males and 4 females, with extra-nodal lymphoma with vertebral pathological compression fracture. The patients were treated using percutaneous kyphoplasty in our hospital. Preoperative assessment of the patients was conducted regarding their hematological profile, biochemical indicators, liver and kidney function, blood coagulation function, CD4+T lymphocyte count and viral load. Subsequently, the patients were placed on highly active antiretroviral therapy (HAART) and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) regimen. Besides, antibiotics, nutritional support and immune-modulating drugs were also administered, rationally. Postoperative, the height of the anterior edge of the injured vertebrae, Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) values were evaluated. Patients were also monitored for any complications relating to the operation. Results: The average CD4+T cell count for the patients was 164 (range 114 ~247 / ul) while the viral load was 26,269 (range 5,765 ~82,321 copies/ul). All patients received nutritional and immune support and registered significant improvements in the levels of ALB and Hb (P Conclusion: Supported with appropriate perioperative treatment measures, PKP is safe and effective in the treatment of pathological vertebral compression fracture due to extra-nodal lymphoma in HIV-positive patients.

Background Although the majority of available evidence suggests that vertebroplasty and kyphoplasty (KP) can relieve pain associated with vertebral compression fractures (VCFs) and improve function, evidence of clinical and radiographic outcome in highly viscous cement vertebroplasty (HVC) or KP for the treatment of VCFs is limited. The purpose of this study was to compare the clinical effects between HVC and KP in the treatment of single-level osteoporotic VCFs including radiographic and clinical outcomes. Methods From January 2017 to October 2018, 96 patients with single-level osteoporotic vertebral compression fracture who had undergone either KP or HVC surgery at our hospital were reviewed retrospectively, with at least 1 year follow-up. All patients were divided into the HVC group (n = 50) or the KP group (n = 46). Clinical data including clinical and radiologic evaluation results were performed pre- and postoperatively. Results The operation time of the HVC group (32.24 ± 10.08 minutes) was less than that of the KP group (40.76 ± 9.49 minutes), with significant differences. Compared with preoperative data, the visual analog scale scores, Oswestry disability index scores, vertebral body height, and local kyphotic angle were improved after surgery. There were no significant differences between the 2 groups in local kyphotic angle, vertebral body height, leakage rate of bone cement, and incidence of adjacent-level vertebra fracture. Conclusions Restoring the vertebral height and local kyphotic angle corrections of HVC are similar with those of KP. Additionally, KP is not superior in the leakage rate of bone cement and incidence of adjacent-level vertebra fracture compared to HVC.

Therapeutic advances in oncology have led to longer survival in many forms of cancer, including those complicated by bone metastases. When a bone metastasis is painful or when there is a risk of fracture, interventional radiology procedures can be carried out for pain control and/or stabilisation. All of these techniques can be performed under local anaesthesia. Cementoplasty and vertebroplasty are stabilisation procedures consisting in the percutaneous injection of acrylic cement into a lytic bone lesion. The effect on pain can be explained by the consolidation of weakened, fractured or pre-fractured bone, but also to a lesser extent by the toxic, chemical and thermal effect of the cement. Tumour ablation techniques include alcoholisation or thermal ablation (by heat with radiofrequency and microwave or cold by cryoablation). Percutaneous thermal ablation of bone tumours is most often performed as a palliative measure resulting in a significant and lasting reduction in symptoms. Radiofrequency ablation consists in placing needles through which an electrical current passes. Microwave ablation acts by causing very high frequency vibrations of water molecules. Cryoablation releases argon gas at the tip of the needle, forming an "ice ball" effectively destroying tumour cells. Any of these techniques can be combined to radiation therapy, performed before or after radiation. Finally, tumour embolisation can have a goal of pain control, or preparation of surgery to reduce the risk of peroperative haemorrhage.

Purpose To study the interobserver agreement for the analysis of lesion filling following cementoplasty of an acetabular osteolytic lesion, and investigate how subjective analysis compares to volumetric analysis. Materials and methods A total of 21 acetabular osteolysis were retrospectively analysed on pre- and immediate post-cementoplasty CT-scans by two senior interventional radiologists and one resident using a 4 grade scale to quantify lesion filling (Fsubjective): F ≤ 25%, 25% 75%. Volumetric analysis (Fvolumetric) was performed with the delineation of the osteolysis and the cement using regions of interest. The interobserver agreement for Fsubjective was evaluated using the Fleiss’ Kappa test for the 4 grade scale and for a simplified 2 grades scale (F ≤ 50% and F > 50%). The performance of Fsubjective versus Fvolumetric (considered as the gold standard) was then evaluated for each reader using the calculation of accuracy and error to reference for the 4 grades scale and accuracy, sensitivity, specificity, positive predictive value and negative predictive value for the 2 grade scale. Results Interobserver agreement was considered as very low ( 0.2 and

Yue Yang, Qinghua Tian, Dan Wang, Fei Yi, Hongmei Song, Wenbin Li, Chungen Wu Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of ChinaCorrespondence: Chungen Wu; Wenbin LiDepartment of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yi Shan Road, Shanghai, People’s Republic of ChinaTel/Fax +86 18930177559; +86 18930177524Email wucgsh@163.com; liwenbin@sjtu.edu.cnObjective: To report our experience of treating painful C1 osteolytic lesions with cement augmentation via a lateral approach under fluoroscopic guidance.Materials and Methods: Nine consecutive patients (eight men and one woman; mean age: 56.7± 13.2 years) with osteolytic lesions of the atlas who underwent cementoplasty via a lateral approach were enrolled in this study. The technical success rate, operation time, and complications were recorded. Visual analogue scale (VAS) and Neck disability index (NDI) were used to evaluate the pain relief and neck function status pre-procedure (baseline) and post-procedure (at 3 days; after 1, 3, 6, 12, 18, and 24 months; and at the last follow-up).Results: The procedure was technically successful without any complications in all patients. The mean procedure time was 44.3± 7.8 min. There were three cases of bone cement leakage, but no clinical symptoms. The mean VAS score decreased from 6.7± 1.0 before the procedure to 3.7 three days after the procedure. The mean NDI score decreased from 67.3± 11.2 before the procedure to 39.3± 13.7 three days after the procedure. The VAS and NDI scores decreased at each follow-up time point, and the difference was statistically significant compared with the scores before the procedure (P< 0.01).Conclusion: Fluoroscopy-guided lateral approach is a feasible, safe, and effective method for treatment of osteolytic lesions of the atlas and can relieve pain and stabilize the bone.Keywords: atlas, C1, lateral, vertebroplasty, fluoroscopy

To report clinical results after percutaneous cement discoplasty (PCD) in a multicentric case series with a minimum of 2 years of follow-up.Between December 2014 and January 2019, 180 patients with low back pain and advanced degeneration were treated with percutaneous discoplasty in 2 centers. The inclusion criteria were as follows: patients 65 years or older, with mechanical low back pain with or without spinal stenosis, who did not respond to conservative management. Patients were divided into 3 groups: group 1: patients without previous spine surgeries who underwent PCD, group 2: patients with previous spine surgeries who underwent PCD, and group 3: patients with/without previous surgery who underwent PCD plus decompression surgery. Clinical and radiological analyses were performed as well as complication and readmission rates.A total of 156 patients (74% female; mean age, 75.8 ± 5.7 years; mean body mass index, 29.9 ± 5.2) were included in our study. Overall preoperative visual analog score (VAS) and Oswestry Disability Index (ODI) were 7.8 ± 0.9 and 68.1 ± 9.6, respectively. At 2 years of follow-up, mean VAS improvement was 3.56 (95% confidence interval: 3.92-3.20; P0.0001) and mean ODI improvement was 17.18 (95% confidence interval: 19.52-14.85; P0.0001), showing a significant and sustained improvement in both scores. In addition, 84% of patients reached both VAS and ODI minimum important clinical difference at the final follow-up. Finally, 5.7% of patients suffered major complications 30 days postoperatively.PCD showed significant improvement of VAS and ODI scores at 2 years of follow-up with relatively low rate of complications.

Introduction: We relay a case of unstable lytic secondary fracture of odontoid process (C2) treated by screw fixation and cementoplasty, using a percutaneous approach. Case Presentation: A 62-year-old female patient followed for a breast neoplasia with bone concurrent metastases, suffered from diffuse cervical pain. A CT-scan showed a lytic fracture of C2. The procedure was performed using CT-scan guidance under general anesthesia. After a biphasic enhanced CT scan of the neck and cervical spine, a needle was slowly inserted to hydrodissect the jugulocarotid and prevertebral spaces up to the anterior cortex of C2 using an iodinated contrast agent solution diluted 5% with saline water. Under fluoroscopy guidance and intermittent CT monitoring, a bone pin was navigated though the anterior cortex of C2, and then advanced inside the vertebral body of C2. After checking for optimal positioning of the bone pin, a 34mm-long titanium screw was inserted into C2 until reaching the posterior cortex. The approach to the transverse fracture line of the body of the odontoid was tangential with no displacement of the bony parts. Cement injection was then performed. One month after the procedure, a CT scan showed no material displacement, and the patient had no visible skin scarring. The patient regained full mobility of the cervical spine, and the pain decreased from 7/10 before the procedure to 0/10 after the procedure according to the patient.Conclusion: Percutaneous screw fixation and cementoplasty to stabilize unstable osteolytic fracture of odontoid process is safe and feasible

Introduction Biomechanical studies demonstrated the superiority of retrograde supracondylar intramedullary nails (RIN) against locking plates (LP) for the treatment of periprosthetic supracondylar femoral fractures (PSFs); however, clinical results are still conflicting. This study aimed to compare LP and RIN, as well as, cemented and uncemented nails in the treatment of PSFs regarding fracture healing, complications and functional results. Materials and methods A retrospective multicenter analysis of 60 PSFs classified as Rorabeck type I or II was performed. Thirty-one cases were treated with LP while in 29 cases RIN were used. Out of the latter, 14 had nailed cementoplasty, while 15 an uncemented nail. Results The two groups were comparable concerning gender, ASA score, operated side, follow-up time, fracture type and mechanism of injury. The LP was significantly younger than the RIN group. Forty-six cases had fracture union at an average of six months, 11 were healed between seven and twelve months (delayed unions), and three developed non-unions. There was no significant difference in the median union time between RIN and LP groups (six vs five months, p = 0.707) or cemented and uncemented nailing groups (5.5 vs six months, p = 0.354). The RIN group had fewer delayed unions or non-unions than LP group; however, not reaching significance (4 vs 10, p = 0.190). Complications were fewer but non-significantly different between cemented and uncemented nails (one vs five, p = 0.481). The mean postoperative flexion was comparable between RIN and LP groups (99.1° vs 94.9°, p = 0.547) or cemented and uncemented nails (102° vs 96.3°, p = 0.4). The mean Oxford Knee Score did not differ between LP and RIN groups (30.8 vs 31.3, p = 0.93) as well as between cemented and uncemented nails (31.5 vs 30.6, p = 0.801). Discussion PSFs with good bone stock can be treated equally with LP or RIN. Nails demonstrated advantages concerning the fracture healing potential. Orthopaedic surgeons need to be trained in both treatment options to manage PSFs. Cemented nails may increase stability and healing capacity in elderly osteoporotic patients; however, further studies are needed.

BACKGROUND Established tibial nonunions rarely heal without secondary intervention; revision surgery is the most common intervention. Herein, we evaluated the clinical outcomes of patients with tibial nonunion treated with a new technique - minimally invasive percutaneous plate osteosynthesis (MIPPO) - combined with a new onionskin-like autologous bone grafting method. MATERIAL AND METHODS From 2010 to 2013, 18 patients with tibial nonunions (average bone defect: 9.5 mm) were treated with MIPPO technology combined with onionskin-like autologous bone grafting. Indices for clinical evaluation included operative time, fluoroscopy time, blood loss, hospital stay, healing time, postoperative complaints, radiographic performances, the Short Musculoskeletal Function Assessment (SMFA) questionnaire, and the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. RESULTS The average operation and fluoroscopy times for tibial nonunion were 65 min and 15.5 s, respectively, with a total blood loss of 107.7 mL. The mean duration of hospital stay was 12.8 days. The mean follow-up time was 11.9 months, and all patients achieved radiologically confirmed bony healing in an average time of 13.1 weeks. No lower-leg deformity, fixation failure, infection, and vascular, or nerve injuries were recorded in any patient, and only 4 patients complained of slight limb pain upon total weight-bearing at the end of follow-up. The SMFA and AOFAS ankle-hindfoot scores of patients were graded excellent in 14 (77.8%) and good in 4 (22.2%), indicating high functional recovery. CONCLUSIONS MIPPO technology combined with onionskin bone grafting is an efficient method to treat patients with tibial nonunion, especially for patients with poor soft tissue condition.

The purpose of this study was to review the efficacy and durability of pain control and local tumor control using microwave ablation and cementoplasty in treating extraspinal osseous tumors. Painful osseous metastases are a common cause of cancer-related morbidity. Percutaneous thermal ablation presents an attractive minimally invasive option in this vulnerable patient group.A retrospective review included 65 patients (35 men, 30 women) with 77 tumors who underwent image-guided microwave ablation and cementoplasty at a tertiary referral academic center over 18 months. Procedural efficacy was determined with a visual analog scale before the procedure and 24 hours, 2-4 weeks, and 20-24 weeks after the procedure. Locoregional control was assessed at follow-up cross-sectional imaging.The 77 tumors were in the following locations: ilium, 38; acetabulum on supraacetabular region, 23; femur, five; humerus, four; shoulder, four; sternum, three. The tumors were 15 multiple myelomas and metastases from cancers of the following organs: colon, nine; lung, 15; breast, 12; thyroid, seven; prostate, three; and kidney, four. Complete, successful ablation of all 77 tumors was achieved. Mean ablation time was six minutes 15 seconds (SD, 12 seconds), and mean energy used was 5.49 (SD, 2.97) kJ. The mean visual analog scale scores were 6.32 (SD, 1.94) before the procedure, 1.01 (SD, 1.24) at 24 hours, 1.71 (SD, 1.31) at 2-4 weeks, and 2.01 (SD, 1.42) at 20-24 weeks. Follow-up imaging at 20-24 weeks showed no local progression in 42 of 65 patients (64.6%). Six patients died 24-52 weeks after the procedure. No procedure-related complications were reported.Microwave ablation is efficacious in alleviating pain due to osseous metastases. The modality has promise for locoregional control of metastases, particularly in the context of oligometastatic (limited disseminated) disease.

PURPOSE To determine the safety and efficacy of percutaneous lumbar discectomy (PLD) and percutaneous disc cementoplasty (PDCP) for painful lumbar disc herniation (LDH) in patients >60 years of age. MATERIALS AND METHODS Sixteen older patients (mean age, 71.00 ± 6.24 years) with painful LDH were treated with PLD and PDCP. The outcome data (the Macnab criteria, visual analog scale score, and Oswestry disability index) were collected preoperatively; at 1 week postoperatively; at posttreatment months 1, 3, and 6; and every 6 months thereafter. In addition, treatment duration, injection volume of bone cement, length of hospital stay, and complications were assessed. RESULTS Treatment was successful in all patients. The pain relief rate at the last follow-up was 87.5%. Six, 8, and 2 patients showed excellent, good, and fair results, respectively; no patient showed a poor result. The average visual analog scale for back and leg pain decreased from 6.75 ± 1.06 and 7.00 ± 0.89 before the procedure to 2.81 ± 1.60 and 2.87 ± 1.75 at 1 month, 2.79 ± 1.58 and 2.71 ± 1.64 at 6 months, and 2.90 ± 1.73 and 3.00 ± 1.76 at 1 year, respectively. The scores were 2.44 ± 1.63 and 2.44 ± 1.71, respectively, at the last follow-up. The Oswestry disability index also changed after the procedure, with significant differences between baseline scores and those at each follow-up (P < .001). The mean procedure duration, injection volume of bone cement, and length of hospital stay were 55.69 ± 5.86 minutes, 2.50 ± 0.63 mL, and 7.06 ± 2.41 days, respectively. There were no complications. CONCLUSIONS The combination of PLD and PDCP is feasible, safe, and effective for older patients with painful LDH.

BACKGROUND Long-term hypocalcemia can result in osteoporotic vertebral compression fracture (OVCF). Transient paralysis and tetraplegia due to hypocalcemia is a rare but severe complication after kyphoplasty. The aims of this prospective clinical study were to investigate the clinical factors associated with serum calcium levels in patients undergoing percutaneous kyphoplasty (PKP). MATERIAL AND METHODS Sixty-eight patients with OVCF were clinically evaluated before and after PKP. Serum calcium was measured before surgery and 24 hours after surgery. Clinical information included the time between vertebral fracture and surgery, the number of involved vertebral bodies, the dose of bone cement required during surgery, and bone mineral density. Correlation coefficient and simple linear regression analysis were performed to identify the clinical factors associated with serum calcium levels. RESULTS Peri-operative serum calcium levels were significantly and positively associated with the dose of bone cement required during PKP and the number of affected vertebral bodies. There was a significant and negative correlation between the time from vertebral fracture to surgery and bone mineral density, which were shown by linear regression analysis to have a predictive value of 5.8% and 47.3%, respectively. CONCLUSIONS For patients undergoing PKP, the amount of bone cement required and the number of affected vertebral bodies were associated with low serum calcium levels. Surgeons should be aware of the importance of measuring and monitoring serum calcium levels in this patient group.

Percutaneous osteoplasty (POP) has been proven to relieve pain due to osteolytic metastases by injecting bone cement to stabilize the pathological fracture. Nevertheless, there have been few reports about POP of metastases in the pubis. This article presents a case involving the use of POP to manage a metastasis in the pubis. After POP the patient experienced significant pain relief and improvement in the quality of life.

Background: To evaluate the benefit of open surgical cementoplasty on the intra osseous nidus in the treatment of arteriovenous malformations (AVMs) on hand and forefoot. Methods: Over the period 2014 - 2017, 9 consecutive patients underwent open cementoplasty of bone f or AVMs of hand and foot. Investigations included digital radiography, Doppler ultrasound, and CT scan with bone and vascular reconstructions. The main outcome end points of this study were: pain, residual AVMs identified by CT scan, and quality of life. R esults: Over a period of 4 years, 65 patients with AVM on hand (38 pts.) or foot (27 pts.) were observed in our institution, 10 pts. (15%) of the cohort had bone involvement. Nine patients (4 F, 5 M) with a mean age of 30 years (range 10 - 50) were included in this study. On their hand (n=5), skeletal changes were at first metacarpal (2pts), in the proximal and middle phalanx (3 pts.). On their foot (n=4), changes were in the metatarsal (3 pts.), in proximal and distal phalanx (3 pts.). Nine patients had a ta rgeted cementoplasty of the involved bone. On control CT scan, 9 patients had no residual intraosseous AV shunts, 4 had minor shunt around bone. Mean follow - up was 29 months (range 10 - 55 m). No morbidity, no delays of healing were observed. Disappearance o f pain was the dominant impact in all the patients. Conclusion: Open surgical cementoplasty is a new option for AVMs bone lesions located in the digits and forefoot. The conclusions are restricted by the short period of follow - up.

The large bone defect treatment is a challenge issue in modern orthopaedic trauma surgery. One of the most used technique is the Masquelet's technique. In this case report we used a modified Masquelet technique to fill a six centimeters bone gap in the proximal femur. A 18-year-old boy with a septic pseudoarthrosis was treated with a two stages procedure: in the first step we used a hollow antibiotic spacer and an intramedullary nail. In the second step, we used both omologous (6 cm of bone allograft) and autologous bone graft with a new intramedullary nail. Immediate partial weight bearing was allowed and after 3 months the patient started walking with complete weight bearing. A year later the fracture had healed uneventfully. The modification of the Masquelet Technique that we have made allows the patient to immediately weight bearing safely, speeding up the functional recovery. Further studies are needed to standardize this type of combined technique.

International audience; Purpose To describe the technique of percutaneous image-guided anterior screw fixation of the odontoid process in five patients using hydrodissection of the jugulo-carotid and pre-vertebral spaces. Methods and Materials Between 03/2018 and 03/2020, five patients from two university hospitals underwent a percutaneous image-guided anterior screw fixation of the odontoid process for one pathological fracture, two impending fractures and two traumatic fractures of the dens. Technical success was defined as a satisfactory positioning of the screw in the odontoid. Detailed data with the number and type of needles required, the time to perform hydrodissection, the volume of fluid used, the time for bone access, the size and lengths of the screws used, technical success, complications, clinical outcomes and follow-up were retrospectively assessed. Results Technical success was achieved in 100% (5/5 cases), with a mean volume of hydrodissection of 218 ± 8.4 mL (range 210–230). Mean total procedure time was 112 ± 34 min (range 70–160). The lengths of the screws ranged from 30 mm to 55 mm. Additional cementoplasty was performed in the three malignant cases. VAS scores dropped on a 10-point scale from mean 5.8 ± 2.2 pre-procedure to 0.8 ± 0.4 after the procedure. No major complication occurred. Conclusion Percutaneous image-guided anterior screw fixation of the odontoid process using hydrodissection of the jugulo-carotid and pre-vertebral spaces is technically feasible and seems safe.

Structural bone instability from osteoporosis or tumor destruction can result in debilitating pain, fractures, and erosion of muscle attachments. Cementoplasty describes the percutaneous minimally invasive injection of a bone filler to consolidate the weakened bone in order to provide palliative effect and reduce the risk of an impending fracture or progression of an existing fracture. When applied to the spine, the technique is commonly known as vertebral augmentation, a term that encompasses both vertebroplasty and kyphoplasty. Outside of the spine, the procedure is commonly referred to as cementoplasty or osteoplasty, and sometimes with specific anatomical descriptors such as sarcoplasty and acetabuloplasty. This chapter reviews the indications, general techniques, and pitfalls for percutaneous cement stabilization both within and outside of the spine.

Purpose The purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures. Materials and methods From July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (< 24 hours) and delayed (> 24 hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Results A total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7 ± 12.7 [SD] years; age range: 32–88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and > 24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%). Conclusion The rate of per-procedural and early (within 24 hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (> 24 hours).

Purpose To evaluate the outcome of percutaneous vertebral cementoplasty (PVC) as the first-line treatment for traumatic thoracolumbar fractures within an ankylosed spinal segment. Materials and methods Thirty-one patients (15 men, 16 women; mean age: 79.2 ± 11 [SD] years; age range: 66–95 years) with thoracolumbar fractures within an ankylosed spine segment without neurological impairment treated with PVC were retrospectively evaluated. All patients were controlled at six weeks and one year after PVC. Ankylosing conditions, fractures sites and types, radiological consolidation, spinal complications were assessed. Anterior/posterior vertebral height ratios were measured before and after PVC. Postoperative pain relief and treatment success (radiological fracture consolidation) rates were considered. Results The 31 patients had a total of 39 fractures (19 stable [49%], 20 unstable [51%]) treated with PVC. Primary success rate of PVC (initial fracture consolidation without complication) was 61% (19/31). Seven patients (7/31; 23%) exhibited new fractures, and the secondary success rate of PVC (global fracture consolidation one year after repeat PVC) was 87% (34/39). Global consolidation rates of unstable fractures were 85% (17/20) of treated levels. Pain score was null in 84% patients (26/31) one year after PVC. There were no significant differences between pre-PVC (0.62 ± 0.18 [SD]; range: 0.22–0.88) and post-PVC (0.60 ± 0.18 [SD]; range: 0.35–0.88) vertebral height ratios (P = 0.94). Conclusion PVC conveys a high overall success rate and effectively controls pain in patients with vertebral fractures within ankylosed spine segments.

To evaluate the clinical benefit of simultaneous percutaneous microwave ablation (PMA) and percutaneous cementoplasty (PC) for patients with painful osteolytic bone metastases under flat-detector C-arm computed tomography (CACT).Thirty patients (17 men and 13 women) with 42 osteolytic metastatic tumors were prospectively treated with PMA and PC simultaneously under CACT guidance. Technical success, major complications, local tumor control status, and daily morphine consumption were recorded. Visual analog scale, Oswestry disability index, and the short-form 36 questionnaire (SF-36, 8 domains) were used to evaluate pain, functional status, and quality of life (QoL), respectively.The technical success rate was 100% without major complications, and local tumor control rates were 100% and 75% for lesion diameter ≤3 cm and3 cm, respectively. Daily morphine consumption, visual analog scale, and Oswestry disability index improved significantly from the respective pretreatment values of 75 mg, 7.4, and 59.2 to 17.3 mg, 1.7, and 22.9 at 1 week; 8.5 mg, 1.4, and 6.7 at 4 weeks; and 5.3 mg, 1.3, and 9.2 at 12 weeks, respectively (p0.01). The QoL assessments at 4 weeks showed significant improvements in physical function, role physical, bodily pain, general health and vitality (p0.05).Simultaneous PMA and PC under CACT guidance is effective to control pain and improve QoL in selective patients with painful osteolytic bone metastases.

This paper describes a minimally invasive technique of percutaneous intervertebral bridging cementoplasty (PIBC) to augment the fractured vertebrae and immobilize the intervertebral space with endplate-disc complex injury simultaneously. Thirty-two patients with adjacent multilevel osteoporotic thoracolumbar fractures (AMOTLFs) and vertebral endplate-disc complex injury (EDCI) treated by PIBC were retrospectively reviewed. The PIBC technique was a combination of puncture, balloon expansion and bridging cementoplasty. The clinical and radiological assessments were reviewed. The operation time was 82.8 ± 32.5 min, and blood loss was 76.9 ± 31.7 mL. A cement bridge was connected between the two fractured vertebrae across the injured intervertebral space. VAS at three time points including pre-operation, post-operation 1 day and final follow-up was 6.9 ± 0.9, 2.9 ± 0.8 and 1.7 ± 0.8, respectively; ODI at three time points was (71.1 ± 7.8)%, (18.4 ± 5.7)%, and (10.3 ± 5.7)%, respectively; Cobb angle at three time points was 46.0° ± 10.4°, 25.9° ± 8.5°, and 27.5° ± 7.1°, respectively. Compared with pre-operation, VAS, ODI and Cobb angle were significantly improved at post-operation 1 day and final follow-up (P

International audience; The osseous pelvis is a frequent site of metastases. Alteration of bone integrity may lead to pain but also to functional disability and pathological fractures. Percutaneous image-guided minimally invasive procedures, such as cementoplasty and screw fixation, have emerged as a viable option to provide bone reinforcement and fracture fixation, as stand-alone or combined techniques. Understanding the biomechanics of the osseous pelvis is paramount to tailor the treatment to the clinical situation. The purpose of the present review is to present the biomechanics of the osseous pelvis and discuss its implication for the choice of the optimal consolidative treatment.

PURPOSE To evaluate the efficacy and safety of combined microwave ablation (MWA) and osteoplasty as a palliative therapy for painful bone metastases. MATERIALS AND METHODS As an extension of a previous limited single-center study, a retrospective review was conducted for 147 patients (77 male, 70 female) with painful bone metastases who underwent MWA combined with osteoplasty. In total, 102 (69.4%), 41 (27.9%), and 4 (2.7%) patients had spinal metastases, extraspinal metastases, and both, respectively. Treatment efficacy was determined by comparing visual analog scale (VAS) scores, daily morphine equivalent opioid consumption, and Oswestry disability index (ODI) scores before treatment and during the follow-up period (mean follow-up, 9.8 months; range 3-16). RESULTS The mean VAS score significantly declined from 6.4 ± 2.3 before treatment to 3.2 ± 2.1, 1.9 ± 1.6, 1.8 ± 1.6, 1.8 ± 1.6, and 1.9 ± 1.6 at 24 hours, 1 week, 4 weeks, 12 weeks, and 24 weeks after treatment, respectively (P < .01). Furthermore, the mean daily morphine equivalent opioid consumption was significantly reduced from 81.5 ± 32.8 mg before treatment to 40.0 ± 20.6, 32.4 ± 10.2, 26.4 ± 10.0, 21.5 ± 8.3, and 19.3 ± 7.4 mg. The mean ODI score also declined after treatment (P < .0001). Major complications occurred in 4 of 147 patients, with 1 pathologic fracture, 1 nerve injury, and 2 mild skin infections. Minor cement leakages were observed at 69 sites (32.8%). CONCLUSIONS MWA combined with osteoplasty is an effective and safe treatment for painful bone metastases.

Summary Skin defects of the elbow follow severe trauma or bone exposure after skin necrosis, osteitis, or management of infected pseudarthrosis. The orthopedic and plastic management of these lesions is fundamental. The authors describe the different clinical frameworks that can lead to bone and/or joint exposure. Before, during or at a distance from bone management (external fixation, internal fixation, temporary cementoplasty, bone graft…), they detail the surgical techniques aimed at covering skin defects of the elbow. The authors review simple skin replacement techniques such as Z-plasties, emphasizing the interest of pedicled flaps of the arm and forearm, as well as muscle or fascio-cutaneous flaps, which are able to cover almost all the elbow skin defects.

To describe several effective imaging-guided, minimally invasive treatments to relieve cancer-associated pain in oncologic patients. Clinical applications, technical considerations, and current controversies are addressed. The great variability in tumor subtype, location, and growth rates dictate the necessity for a tailored treatment approach. While opioids and radiotherapy may provide adequate relief for some patients, alternative minimally invasive procedures may augment theses more traditional treatments or even provide superior palliative relief. Recent image-guided percutaneous techniques applied to reduce cancer-associated pain and minimize opioid dependence include neurolysis, ablation, high intensity focused ultrasound, and bone consolidation. Each technique treats cancer pain in a unique method. Minimally invasive interventional radiology techniques can provide effective and lasting pain palliation for cancer patients through both indirect and direct effects. Selection among treatments techniques should be based upon an individually tailored approach, to include consideration of all treatment modalities.

International audience; Purpose To evaluate the effectiveness of radiofrequency (RF) ablation as measured by change in worst pain score from baseline to 3 mo after RF ablation for the palliative treatment of painful bone metastases. Materials and Methods One hundred patients (mean age, 64.6 y) underwent RF ablation for metastatic bone disease and were followed up to 6 mo. Subjects’ pain and quality of life were measured before RF ablation and postoperatively by using the Brief Pain Index and European Quality of Life questionnaires. Opioid agent use and device-, procedure-, and/or therapy-related adverse events (AEs) were collected. Results Eighty-seven patients were treated for tumors involving the thoracolumbar spine and 13 for tumors located in the pelvis and/or sacrum. All ablations were technically successful, and 97% were followed by cementoplasty. Mean worst pain score decreased from 8.2 ± 1.7 at baseline to 3.5 ± 3.2 at 6 mo (n = 22; P < 0.0001 for all visits). Subjects experienced significant improvement for all visits in average pain (P < .0001), pain interference (P < .0001), and quality of life (P < .003). Four AEs were reported, of which 2 resulted in hospitalization for pneumonia and respiratory failure. All 30 deaths reported during the study were attributed to the underlying malignancy and not related to the study procedure. Conclusions Results from this study show rapid (within 3 d) and statistically significant pain improvement with sustained long-term relief through 6 mo in patients treated with RF ablation for metastatic bone disease.

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.

International audience; Aim: To report the technique of percutaneous double oblique anterior access to the acetabulum and evaluate its feasibility and safety.Materials and methods: Pelvic computed tomography (CT) examinations of 60 patients (30 men and 30 women; mean age 62.6±13.2 years) were retrieved randomly from the picture archiving and communication system (PACS). A virtual intraosseous trajectory was defined on both sides on the axial CT images with the entry point marked 1 cm above the anterosuperior iliac spine and the endpoint defined just above the level of the ischial spine at the midpoint of the posterior acetabulum. Patient age, sagittal oblique angulation, axial oblique angulation, length of intraosseous trajectory, distance from the hip joint, thickness of the iliac bone cortex, and intervening structure(s) between the skin and the bone entry points were recorded.Results: The mean sagittal and axial oblique angulations were 34.2±4.5° and 31.5±6.7°, respectively, and mean length of the intraosseous trajectory was 11.8±0.9 cm. The axial oblique angle and length of the intraosseous trajectory were significantly lower in the female than the male population (p

Introduction Percutaneous cementoplasty (PC) has been widely used for the stabilization of impending fractures of the proximal femur due to metastatic lesions. Augmented percataneous cementoplasty (APC) with fixation devices aims to improve mechanical consolidation and stability of the construct. However, the clinical benefit of the combined technique has not been clearly established. The purpose of the current review was to compare the efficacy between APC and PC for impending pathologic proximal femoral fractures from metastatic malignancy, in terms of pain relief, operative time and fracture related complication rates. Material and methods Medline, Scopus, and the Cochrane central register of controlled trials were searched for clinical studies up to July 2019. Studies relevant to cementoplasty of the proximal femur were included. The primary outcome of the study was pain relief as assessed using the Visual Analogue Scale (VAS) change. Secondary outcomes included incidence of post-intervention fracture, operative time and complication rate. Results Twelve studies with a total of 343 patients were included. No difference was found for all outcomes. For pain relief, pooled results showed a mean difference in VAS score -4.6 ± 1.7 for PC, and -4.3 ± 2.5 for APC (p = 0.41). Post-intervention fractures of the proximal femur occurred in 7% of patients with PC and in 5% of patients with APC (p = 0.4), and the mean duration of interventions was 57.9 ± 8.4 and 56.5 ± 27.5 min, respectively (p = 0.58). Cement leakage into the hip joint or the soft tissues occurred in 5% of cases in PC group and in 8% of cases in APC group (p = 0.16). Six patients in the APC group (4%) experienced major systemic complications, which were treated successfully. Conclusions APC does not seem to improve pain relief, fracture incidence, and operative time when compared with PC. Both techniques appeared effective in terms of resolution of symptoms, prevention of pathologic fractures, and early facilitation of weight-bearing. PC showed more clinical safety, as no major systemic complications occurred. However, due to the relative paucity of large clinical trials, the decision of augmentation of cementoplasty should be individualized according to the size and location of metastatic lesions and the overall medical condition of patients.

Objective: To study the effect on pain of per-cutaneous cementoplasty for painful extraspinal bone metastasis. Method: 43 patients with extraspinal bone metastasis were included between April 2006 and October 2014 in this retrospective monocenter study. The primary endpoint was pain level measured on a 0–10 numeric rating scale at week 1 after cementoplasty as compared with pre-cementoplasty. Secondary endpoints were long-term pain level and impact on quality of life and disability. Results: Mean pain score was 4.2 (SD ±3.6) before cementoplasty and 1.09 (SD ±2.4) at week 1 (p = 0.005) (n = 31 patients). At 22 months after cementoplasty, quality of life and disability improved (according to the patient global assessment) for 47.6% and 52.2% of patients (n = 21patients). We did not find a predictor of good response. Cement leakage was the most common adverse event. Conclusion: Percutaneous cementoplasty of extraspinal bone metastasis is a rapidly efficient treatment with few adverse events. Its efficacy persists over time, with a benefit for disability and quality of life. Although this technique is only palliative, it should be considered in this situation. Keywords: Percutaneous cementoplasty, Bone metastasis, Pain management

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.

Background: Vertebral disease is a major cause of morbidity in 70% of patients diagnosed with multiple myeloma (MM). Associated osteolytic lesions and vertebral fractures are well documented in causing debilitating pain, functional restrictions, spinal deformity, and cord compression. Currently, treatment modalities for refractory MM spinal pain include systemic therapy, radiotherapy, cementoplasty (vertebroplasty/kyphoplasty), and radio frequency ablation. Our objectives were to report on the efficacy of existing treatments for MM patients with refractory spinal pain, to determine if a standardized treatment algorithm has been described, and to set the foundation upon which future prospective studies can be designed. Methods: A systematic search of the PubMed database was performed for studies relevant to the treatment of vertebral disease in MM patients. A multitude of search terms in various combinations were used, including but not limited to: “vertebroplasty,” “kyphoplasty,” “radiation,” “multiple myeloma,” “radiotherapy,” and “radiosurgery.” Results: Our preliminary search resulted in 219 articles, which subsequently resulted in 19 papers following abstract, title, full-text, and bibliography review. These papers were then grouped by treatment modality: radiotherapy, cementoplasty, or combination therapy. Significant pain and functional score improvement across all treatment modalities was found in the majority of the literature. While complications of treatment occurred, few were noted to be clinically significant. Conclusions: Treatment options—radiotherapy and/or cementoplasty—for vertebral lesions and pathologic fractures in MM patients demonstrate significant radiographic and clinical improvement. However, there is no consensus in the literature as to the optimal treatment modality as a result of a limited number of studies reporting head-to-head comparisons. One study did find significantly improved pain and functional scores with preserved vertebral height in favor of kyphoplasty over radiotherapy. When not contraindicated, we advocate for some form of cementoplasty. Further prospective studies are required before implementation of a standardized treatment protocol. Level of Evidence: 5.

BACKGROUND Vertebral hemangioma is usually a benign and asymptomatic tumor of blood vessels, but can be aggressive (symptomatic) with expansion, pain, and spinal cord compression. The aim of this study was to review the effects of radiotherapy, surgery, and other treatment approaches in patients with aggressive vertebral hemangioma. MATERIAL AND METHODS Retrospective clinical review included 20 patients who underwent radiotherapy as their first-line treatment for aggressive vertebral hemangioma with mild or slowly developing neurological deficit. External radiation was divided into 20-25 fractions with a total dose of 40-50 Gy. Minimum clinical follow-up after treatment was 20 months. RESULTS The 20 patients included eight men and 12 women (mean age, 46.6 years), with aggressive vertebral hemangioma located in the cervical, thoracic, and lumbar vertebrae in four, 14, and two patients, respectively. Following radiotherapy treatment, 65.0% of patients (13/20) were symptom-free, without recurrence or malignant transformation at the time of last clinical follow-up (average, 75.2 months). Due to minor post-radiation vertebral re-ossification, two of the 13 patients who were initially symptom-free after radiotherapy requested percutaneous vertebroplasty. A further seven patients required surgery after radiotherapy, due to increasing neurological deficit in three patients, and persistent neurological deficit in four patients. At the last follow-up (average, 63.6 months), six patients were symptom-free, and one patient still had slight residual symptoms. CONCLUSIONS Radiotherapy was a safe and effective treatment choice for aggressive vertebral hemangioma, but in case with severe spinal cord compression and neurological deficit, surgical intervention was required.

Introduction: About 50% of patients with cancer develop bone metastasis mainly presenting with distressing, drug-resistant pain. Aim of the work: The study evaluated efficacy and safety of combined cementoplasty and bony radiofrequency ablation in palliation of intractable pain and disability in cancer patients with bony metastases. Patients and methods: The study included 30 adult patients suffering from localized bony metastases causing refractory moderate to severe pain. Radiofrequency bony ablation performed followed by cementoplasty were done under computed tomography (CT) guidance with conscious sedation and local anesthesia. Final CT check was done to ensure adequate lesion filling and to exclude any cement leakage. Pain, hemodynamic variables, and neurological status were checked for a minimum of 2 h before discharge. The patients were followed up weekly in the pain clinic. The primary outcome measures pain severity and daily opioid consumption. The secondary outcome measures were quality of life and the degree of disability, and procedure-related adverse outcomes. Results: Pain score, daily morphine consumption, and Oswestry Disability Index score decreased significantly after 1 day, and 1, 4 and 12 weeks. None of the patients had serious complications during the postoperative follow up visits. Only 4 patients (13.3%) experienced discomfort during, and few days after the procedure, 3 patients (10%) suffered from local infection, and 2 patients (6.7%) reported cement leakage. Conclusion: Combined radiofrequency ablation and cementoplasty is a safe and effective pain relief modality in patients suffering from extraspinal painful bone metastases with improvement of the quality of life. Keywords: Radiofrequency ablation, Cementoplasty, Localized bony metastases, Intractable pain