Scientific Session 04 — SS04: Vascular/Interventional - Vascular Interventions and BiopsyMonday, May 6, 2019
2143. Set in Concrete: Stabilization of Impending Pathologic Fractures With Modified Percutaneous Cementoplasty and Screw Fixation
Danda D*, Latich I. Yale New Haven Hospital, New Haven, CT
Address correspondence to D. Danda (firstname.lastname@example.org)
Objective: Despite the multidisciplinary approach to pain in patients with osseous metastatic disease, over 50% of patients remain inadequately treated. Although effective, the standard approach of oral analgesia and radiotherapy leaves approximately 40% of patients with continued debilitating pain. Many of these patients may also have disease adjacent to weight-bearing articular surface rendering, resulting in an increased risk for pathologic fracture. Because these patients are generally poor surgical candidates, open repair is often not feasible or safe. Percutaneous procedures such as cementoplasty have been shown to be effective adjunct therapies in reducing the risk of fracture and improving pain in such patients. When concomitant internal fixation with percutaneous screws is preformed, the efficacy of the procedure has been shown to increase. The purpose of the current study is to detail our institutional experience with a modified cementoplasty and internal screw fixation technique, which uses radiofrequency ablation (RFA) and balloon osteoplasty as part of the procedure.
Materials and Methods: A retrospective chart review of 11 patients who underwent image-guided percutaneous cementoplasty and screw fixation in 12 sites was preformed to determine postprocedural outcomes in terms of improvement in pain and mobility. All the patients had advanced osseous metastatic disease with impending pathologic fractures as determined by Mirels scores = 8 and persistent pain refractory to radiotherapy.
Results: All the procedures were technically successful without postprocedural complications. All the patients who received the modified percutaneous cementoplasty and screw fixation were found to have improved pain and mobility after the procedure. Importantly, all but one patient was treated on an outpatient basis, and none required conversion to open repair.
Conclusion: The cementoplasty and screw fixation technique used was universally successful in the study population, who also demonstrated improved pain and mobility on postprocedural follow-up. We propose that the combination of RFA and balloon osteoplasty may reduce complications involving intra- and extravascular extravasation of polymethylmethacrylate (PPMA). Although ideal for the axial loading forces experienced by the spine, it is known that PPMA has a reduced resistance to shearing and rotational forces experienced within the appendicular skeleton. Concomitant internal screw fixation provides added stability across critical weight-bearing surfaces and minimized the risk of acetabular fracture and protrusio acetabuli. Our technique may increase the penetration of PPMA within the diseased bone allowing increased tolerance to shearing and rotational forces. Given the limitations of a small patient population, limited longitudinal follow-up, and insufficient comparison to other techniques, further inquiry is needed, but our results suggest that this cementoplasty and screw fixation technique may be an effective adjunct strategy in improving pain and reducing the pathologic fracture risk in patients with advanced osseous metastatic disease.