Skeletal Radiology

, Volume 39, Issue 2, pp 117–130

Percutaneous treatment of insufficiency fractures

Principles, technique and review of literature
  • Douglas P. Beall
  • Abhijit Datir
  • Sharon L. D’Souza
  • Logan S. D’Souza
  • Divya Gunda
  • John Morelli
  • Michael Brandon Johnson
  • Nima Nabavizadeh
Review Article

Abstract

Insufficiency fractures of the pelvis, sacrum, spine, and long bones are painful, debilitating, and are common consequences of osteoporosis. Conventional treatment for these fractures varies from conservative therapy to surgery with plate and screw fixation. The former fails to address the underlying problem of fracture and frequently does not alleviate symptoms, while the latter is invasive and not always possible in older populations with low bone density and numerous co-morbidities. Osseous augmentation with polymethylmethacrylate (PMMA) has been used for over two decades to treat fractures related to osteoporosis, but has not been commonly used to treat fractures outside of the vertebral bodies. Osseous augmentation with PMMA is an image-guided procedure and various techniques have been utilized to treat fracture in different locations. We describe various techniques for image-guided osseous augmentation and treatment of insufficiency fractures with bothPMMA and allograft bone for fractures of the pelvis including sacrum, acetabulum, pubic symphysis, pubic rami ilium; appendicular skeleton including distal radius, proximal femur, and vertebral body. We also describe the potential risks and complications associated with percutaneous treatment of insufficiency fractures and techniques to avoid the pitfalls of the various procedures. We will present the process for patient follow-up and data regarding the pre- and postprocedure pain response in patients undergoing treatment for pelvic insufficiency fractures.

Keywords

Vertebroplasty Kyphoplasty Spineoplasty Augmentation Polymethylmethacrylate 

References

  1. 1.
    Melton LJ III. Epidemiology of spinal osteoporosis. Spine. 1997;15(22):2S–11S.CrossRefGoogle Scholar
  2. 2.
    Evans AJ, Jensen ME, Kip KE, et al. Vertebral compression fractures: pain reduction and improvement in functional mobility after percutaneous polymethylmethacrylate vertebroplasty-retrospective report of 245 cases. Radiology. 2003;226:366–72.CrossRefPubMedGoogle Scholar
  3. 3.
    Harrington KD, Sim FH, Enis JE, Johnston JO, Diok HM, Gristina AG. Methylmethacrylate as an adjunct in internal fixation of pathological fractures. Experience with three hundred and seventy-five cases. J Bone Joint Surg Am. 1976;58:1047–55.PubMedGoogle Scholar
  4. 4.
    Hulme PA, Krebs J, Ferguson SJ, Berlemann U. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine. 2006;31:1983–2001.CrossRefPubMedGoogle Scholar
  5. 5.
    Layton KF, Thielen KR, Wald JT. Percutaneous sacroplasty using CT fluoroscopy. AJNR Am J Neuroradiol. 2006;27:356–8.PubMedGoogle Scholar
  6. 6.
    Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie. 1987;33:166–8.PubMedGoogle Scholar
  7. 7.
    Wilson DR, Myers ER, Mathis JM, et al. Effect of augmentation on the mechanics of vertebral wedge fractures. Spine. 2000;25:158–165.CrossRefPubMedGoogle Scholar
  8. 8.
    Belkoff SM, Mathis JM, Fenton DC, Scribner RM, Reiley ME, Talmadge K. An ex vivo biomechanical evaluation of an inflatable bone tamp used in the treatment of compression fracture. Spine. 2001;26:151–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Mathis JM, Ortiz AO, Zoarski GH. Vertebroplasty versus kyphoplasty: a comparison and contrast. AJNR Am J Neuroradiol. 2004;25:840–5.PubMedGoogle Scholar
  10. 10.
    Gangi A, Guth S, Imbert JP, Marin H, Dietemann JL. Percutaneous vertebroplasty: indications, technique, and results. Radiographics. 2003;23:e10.CrossRefPubMedGoogle Scholar
  11. 11.
    Brown DB, Gilula LA, Sehgal M, Shimony JS. Treatment of chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty. AJR Am J Roentgenol. 2004;182:319–22.PubMedGoogle Scholar
  12. 12.
    Kaufmann TJ, Jensen ME, Schweickert PA, Marx WF, Kallmes DF. Age of fracture and clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol. 2001;22:1860–3.PubMedGoogle Scholar
  13. 13.
    Peh WC, Gilula LA, Peck D. Percutaneous vertebroplasty for severe osteoporotic vertebral body compression fractures. Radiology. 2002;223:121–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Appel NB, Gilula LA. Percutaneous vertebroplasty in patient with spinal canal compromise. AJR Am J Roentgenol. 2004;182:947–51.PubMedGoogle Scholar
  15. 15.
    Shimony JS, Gilula LA, Zeller AJ, Brown DB. Percutaneous vertebroplasty for malignant compression fractures with epidural involvement. Radiology. 2004;232:846–53.CrossRefPubMedGoogle Scholar
  16. 16.
    Mathis JM, Barr JD, Belkoff SM, Barr MS, Jensen ME, Deramond H. Percutaneous vertebroplasty: a developing standard of care for vertebral compression fractures. AJNR Am J Neuroradiol. 2001;22:373–81.PubMedGoogle Scholar
  17. 17.
    Beall DP, Braswell JJ, Martin HD, Stapp AM, Puckett TA, Stechison MT. Technical strategies and anatomic considerations for parapedicular access to thoracic and lumbar vertebral bodies. Skeletal Radiol. 2007;36:47–52.CrossRefPubMedGoogle Scholar
  18. 18.
    Amar AP, Larsen DW, Esnaashari NP, Albuquerque FC, Lavine SD, Teitelbaum GP. Percutaneous transpedicular polymethylmethacrylate vertebroplasty for the treatment of spinal compression fractures. Neurosurgery. 2001;49:1105–15.CrossRefPubMedGoogle Scholar
  19. 19.
    Kim AK, Jensen ME, Dion JE, Schweickert PA, Kaufmann TJ, Kallmes DF. Unilateral transpedicular percutaneous vertebroplasty: initial experience. Radiology. 2002;222:737–41.CrossRefPubMedGoogle Scholar
  20. 20.
    Peh WC, Munk PL, Rashid F, Gilula LA. Percutaneous vertebral augmentation: vertebroplasty, kyphoplasty and skyphoplasty. Radiol Clin North Am. 2008;46:611–35.CrossRefPubMedGoogle Scholar
  21. 21.
    Beall DP, Stanfield M, Martin HD, Stapp AM. Transoral vertebral augmentation with polymethylmethacrylate in the treatment of a patient with a dens fracture nonunion and subarticular vertebral body fracture of C2. Skeletal Radiol. 2007;36:453–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Kallmes DF, Jensen ME. Percutaneous vertebroplasty. Radiology. 2003;229:27–36.CrossRefPubMedGoogle Scholar
  23. 23.
    Cotten A, Boutry N, Cortet B, et al. Percutaneous vertebroplasty: state of the art. Radiographics. 1998;18:311–20.PubMedGoogle Scholar
  24. 24.
    Deramond H, Depriester C, Galibert P, Le Gars D. Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results. Radiol Clin North Am. 1998;36:433–46.CrossRefGoogle Scholar
  25. 25.
    Jacofsky DJ, Papagelopoulos PJ, Sim FH. Advances and challenges in the surgical treatment of metastatic bone disease. Clin Orthop Relat Res. 2003;415S:14–8.CrossRefGoogle Scholar
  26. 26.
    Belkoff SM, Mathis JM, Jasper LE, et al. The biomechanics of vertebroplasty: the effect of cement volume on mechanical behavior. Spine. 2001;26:1537–41.CrossRefPubMedGoogle Scholar
  27. 27.
    Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine. 2000;25:923–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Berlemann U, Ferguson SJ, Nolte LP, Heini PF. Adjacent vertebral failure after vertebroplasty. A biomechanical investigation. J Bone Joint Surg Br. 2002;84:748–52.CrossRefPubMedGoogle Scholar
  29. 29.
    Heini PF, Wälchli B, Berlemann U. Percutaneous transpedicular vertebroplasty with PMMA: operative technique and early results. A perspective study for the treatment of osteoporotic compression fractures. Eur Spine J. 2000;9:445–50.CrossRefPubMedGoogle Scholar
  30. 30.
    Dean JR, Ison KT, Gishen P. The strengthening effect of percutaneous vertebroplasty. Clin Radiol. 2000;55:471–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Tohmeh AG, Mathis JM, Fenton DC, Levine AM, Belkoff SM. Biomechanical efficacy of unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression fractures. Spine. 1999;24:1772–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Mathis JM. Procedural techniques and material: tumors and osteoporotic fractures. In: John M, Mathis JM, Hervé Deramond, Stephan M, editors. Percutaneous vertebroplasty. New York: Springer; 2002. p. 81–107.Google Scholar
  33. 33.
    Lam S, Khoo LT. A novel percutaneous system for bone graft delivery and containment for elevation and stabilization of vertebral compression fractures—technical note. Neurosurg Focus. 2005;18:e10.CrossRefPubMedGoogle Scholar
  34. 34.
    Chiu JC, Stechison MT. Percutaneous vertebral augmentation and reconstruction with an intravertebral mesh and morcelized bone graft. Surg Technol Int. 2005;14:287–96.PubMedGoogle Scholar
  35. 35.
    Frey ME, DePalma MJ, Cifu DX, Bhagia SM, Daitch JS. Efficacy and safety of percutaneous sacroplasty for painful osteoporotic sacral insufficiency fractures: a prospective, multicenter trial. Spine. 2007;32:1635–40.CrossRefPubMedGoogle Scholar
  36. 36.
    Babayev M, Lachmann E, Nagler W. The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate? Am J Phys Med Rehabil. 2000;79:404–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Pommersheim W, Huang-Hellinger F, Baker M, Morris P. Sacroplasty: a treatment for sacral insufficiency fractures. AJNR Am J Neuroradiol. 2003;24:1003–7.PubMedGoogle Scholar
  38. 38.
    Taillandier J, Langue F, Alemanni M, Taillandier-Heriche E. Mortality and functional outcomes of pelvic insufficiency fractures in older patients. Joint Bone Spine. 2003;70:287–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Beall DP, D’Souza SL, Costello RF, et al. Percutaneous augmentation of the superior pubic ramus with polymethyl methacrylate: treatment of acute traumatic and chronic insufficiency fractures. Skeletal Radiol. 2007;36:979–83.CrossRefPubMedGoogle Scholar
  40. 40.
    Garant M. Sacroplasty: a new treatment for sacral insufficiency fracture. J Vasc Interv Radiol. 2002;13:1265–7.CrossRefPubMedGoogle Scholar
  41. 41.
    Heron J, Connell DA, James SL. CT-guided sacroplasty for the treatment of sacral insufficiency fractures. Clin Radiol. 2007;62:1094–100.CrossRefPubMedGoogle Scholar
  42. 42.
    Deen HG, Nottmeier EW. Balloon kyphoplasty for treatment of sacral insufficiency fractures. Report of three cases. Neurosurg Focus. 2005;18:e7.PubMedGoogle Scholar
  43. 43.
    Carrino JA, Blanco R. Magnetic resonance-guided musculoskeletal interventional radiology. Semin Musculoskelet Radiol. 2006;10:159–74.CrossRefPubMedGoogle Scholar
  44. 44.
    Butler CL, Given CA II, Michel SJ, Tibbs PA. Percutaneous sacroplasty for the treatment of sacral insufficiency fractures. AJR Am J Roentgenol. 2005;184:1956–9.PubMedGoogle Scholar
  45. 45.
    Cassidy C, Jupiter JB, Cohen M, et al. Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study. J Bone Joint Surg Am. 2003;85:2127–37.PubMedGoogle Scholar
  46. 46.
    Schmalholz A. External skeletal fixation versus cement fixation in the treatment of redislocated Colles’ fracture. Clin Orthop Relat Res. 1990;254:236–41.PubMedGoogle Scholar
  47. 47.
    Schmalholz A. Bone cement for redislocated Colles’ fracture. A prospective comparison with closed treatment. Acta Orthop Scand. 1989;60:212–7.PubMedCrossRefGoogle Scholar
  48. 48.
    Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE. Pulmonary embolism of polymethylmethacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol. 2004;183:1097–102.PubMedGoogle Scholar
  49. 49.
    Hodler J, Peck D, Gilula LA. Midterm outcome after vertebroplasty: predictive value of technical and patient-related factors. Radiology. 2003;227:662–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Francois K, Taeymans Y, Poffyn B, Van Nooten G. Successful management of a large pulmonary cement embolus after percutaneous vertebroplasty: a case report. Spine. 2003;28:424–5.CrossRefGoogle Scholar
  51. 51.
    Frankel BM, Monroe T, Wang C. Percutaneous vertebral augmentation: an elevation in adjacent-level fracture risk in kyphoplasty as compared with vertebroplasty. Spine J. 2007;7:575–82.CrossRefPubMedGoogle Scholar
  52. 52.
    Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001;285:320–3.CrossRefPubMedGoogle Scholar
  53. 53.
    Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous polymethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol. 1997;18:1897–904.PubMedGoogle Scholar
  54. 54.
    Kirby BS, Doyle A, Gilula LA. Acute bronchospasm due to exposure to polymethylmethacrylate vapors during percutaneous vertebroplasty. AJR Am J Roentgenol. 2003;180:543–4.PubMedGoogle Scholar

Copyright information

© ISS 2009

Authors and Affiliations

  • Douglas P. Beall
    • 1
    • 2
    • 4
  • Abhijit Datir
    • 3
  • Sharon L. D’Souza
    • 1
  • Logan S. D’Souza
    • 1
  • Divya Gunda
    • 1
  • John Morelli
    • 1
  • Michael Brandon Johnson
    • 1
  • Nima Nabavizadeh
    • 1
  1. 1.University of Oklahoma Health Science CenterOklahoma CityUSA
  2. 2.Clinical Radiology of OklahomaEdmondUSA
  3. 3.Department of RadiologyRoyal National Orthopaedic HospitalMiddlesexUK
  4. 4.Oklahoma CityUSA

Personalised recommendations