Osteoplasty in skeletal lesions
The essence of osteoplasty is filling lytic defects with polymethylmethacrylate (PMMA)-based bone cement. The procedure is performed under fluoroscopic guidance using 10–13-G bone trocars under local anesthesia and light sedation.
- Vertebroplasty: Interventions on the spine. Destruction of the posterior vertebral wall is not considered an absolute contraindication. The only strict biomechanical limitation is massive involvement of posterior elements. Absolute contraindications include infections, coagulopathies, and allergy to PMMA.
- Percutaneous sacroplasty (Sacroplasty): Treatment of osteoporotic or pathological fractures of the sacral wings. Guidance is extremely crucial to rule out cement leakage into the sacral foramina.
- Peri-acetabular interventions: The main complication here is intra-articular leakage of PMMA. This causes rapid chondrolysis and arthritis, which may ultimately require arthroplasty.
- Long tubular bones: Due to the poor tolerance of cement to bending and torsional loads, the risk of stress fractures reaches 8–9%. The method is strictly used in inoperable patients with small defects in the epiphyses.
Percutaneous osteosynthesis
Percutaneous osteosynthesis (Percutaneous osteosynthesis) is the fixation of non-displaced fractures using screws. The method is mainly used in cancer patients who cannot undergo open surgery with massive plates.
Screws are inserted perpendicularly to the fracture using cannulated instruments over a Kirschner wire (K-wire). Screw diameter is typically 6–7.2 mm. The surgery requires general anesthesia and a combination of CT and fluoroscopic guidance.
To enhance stability, augmentation osteoplasty is used. In this case, special screws with multiple holes at the distal end are used, through which PMMA is injected. This technique is actively used to prevent fractures in areas of lytic metastases (e.g., in the femoral condyle) and in pathological fractures of the ischial or pubic rami.
Bone tumor ablation
Ablation (Ablation of Bone Tumours) is the direct chemical or physical destruction of a tumor leading to cellular necrosis. It includes thermal ablation, cryoablation, and transcatheter embolization.
The procedure is performed on an outpatient ("one-day") basis. The optimal imaging guidance is CT due to its high resolution, but fluoroscopy is added for cement injection.
Indications are divided into:
- Radical: Complete cure of osteoid osteomas (requires deep anesthesia).
- Local: Control of aggressive hemangioma growth.
- Palliative: Pain relief in late-stage metastasis.
Up to 85% of patients with terminal lung, breast, or prostate tumors suffer from bone metastases. Pain arises from osteolysis, nerve compression, and micro-motion of bone fragments. Thermal ablation relieves such pain much faster than external beam radiotherapy, which takes weeks to work and proves ineffective in nearly a third of patients.
Absolute contraindications for bone interventions are easily remembered as "ICA": Infection, Coagulopathy, Allergy to material (cement or alloy).
Class and exam questions
Can vertebroplasty be performed in the presence of neurological syndrome?
If an acute neurological syndrome develops requiring emergency surgical decompression, vertebroplasty must not be performed. This is an exception.
What to do in case of femoral neck involvement if the cortical layer is preserved?
In such cases, without tumor infiltration of the trochanteric area, a triple reverse osteosynthesis serves as the specific method of choice.
How effective is sacroplasty for pain relief?
According to clinical case reports, cement augmentation can reduce pain from an osteoporotic sacral fracture from 8/10 to 1/10 on the VAS as early as the first day post-surgery.
What else to study on this topic
- Physics and biomechanics of polymethylmethacrylate (PMMA) in bone
- Transcatheter embolization technique in bone tumors
- Specifics of treatment and diagnostic imaging of osteoid osteomas
- Mechanisms of pain syndrome development in metastases
- Contrast agents in interventional onco-orthopedics
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