Percutaneous Fixation by Internal Cemented Screw for the Treatment of Unstable Osseous Disease in Cancer Patients

Abstract

Interventional radiology expertise in image guidance has expanded the treatment options for cancer patients with unstable osseous disease. Percutaneous fixation by internal cemented screw (FICS) describes the technique by which the interventional radiologist stabilizes a fracture or impending fracture with the percutaneous placement of a cannulated screw that is locked in position by polymethyl methacrylate cement. The durable metallic screws provide added resistance to torque and tension stresses that complement the axial compression resistance of cement. Compared with cementoplasty alone, the procedure has been advanced as a more durable and precise technique for stabilization of osseous disease for certain disease presentations in cancer patients. The application of advanced image guidance techniques improves upon existing percutaneous surgical techniques to facilitate approaches that would otherwise prove quite challenging, particularly with stabilization of the pelvic flat bones. This article examines the applications of percutaneous FICS procedures for the treatment of unstable osseous disease in cancer patients. Indications, techniques, and follow-up care are reviewed. Case examples in which FICS can be performed in unstable pathology are detailed.

Keywords: bone fracture; cement consolidation; cementoplasty; interventional radiology; pain palliation; screw fixation.

Fig. 1

Cementoplasty for better screw anchorage : The lytic metastasis is crossed with the 8-gauge needle ( a ), through which cement is injected ( b ). The 8-gauge needle is coaxially exchanged using a 3.2-mm Kirschner wire ( c and d ) for the 8-mm screw that is advanced into the liquid cement ( e ). The Kirschner wire is removed before cement consolidation ( f ). Cementoplasty for improved consolidation : A second 8- to 11-gauge needle is advanced within the lytic lesion ( g ). Cement is injected around the screw ( h and i ).

Fig. 2

The screw insertion track is chosen based on the location of the fracture or lytic osseous metastasis: lateral sacroiliac track and anterior iliopubic track ( a ), posterior transiliac track and caudal to cranial transischial track ( b ), lateral to medial ischiopubic track and femoral inverted triangulation track ( c ), posterior iliopubic track and anterior transiliac track ( d ).

Fig. 3

( a, b ) Lytic prostate metastasis to the left sacral ala and iliac bone that caused 10/10 mechanical pain during weight bearing. Pelvic FICS with CT-guided advancement of two cannulated, fully threaded, 6.5-mm diameter stainless steel screws ( c – e ) with tips anchored into the S1 and S2 vertebral bodies followed by consolidation cementoplasty ( f ). Final oblique coronal view demonstrates screw bridging lytic mass ( g ).

Fig. 4

Lytic prostate metastasis resulted in extensive nonunion sacral fracture ( a : axial view, b : oblique coronal view) that caused 7/10 mechanical pain with some radicular pain from sacral neuroforaminal involvement (arrows). Pelvic FICS with CT-guided advancement of single cannulated, fully-threaded, 8-mm diameter stainless steel screw spanning the entire sacrum and bilateral sacroiliac joints through the S1 vertebral body followed by cement consolidation ( c : axial view, d : oblique coronal view).

Fig. 5

Lytic renal cell metastasis to the iliac pelvic brim (Blue arrow) resulted in severe pain limiting weight bearing ( a : oblique coronal view, b : oblique sagittal view). Locoregional treatment provided with embolization ( c ) and cryoablation ( d ) before pelvic FICS with fluoroscopy-guided advancement of two parallel cannulated, partially threaded, 6.5-mm diameter titanium screws from a posterior transiliac approach ( e ) and consolidative cementoplasty ( f and g ).

Fig. 6

Lytic renal cell metastasis to the iliac pelvic brim, posterior acetabulum, and superior acetabulum (Blue arrows) resulted in severe hip pain limiting weight bearing ( a : oblique sagittal view, b : oblique coronal view, c : axial view). Pelvic FICS with fluoroscopy-guided advancement of single cannulated, fully-threaded, 8-mm diameter stainless steel screw from a posterior transiliac approach ( d : intraprocedural advancement; e and f : screw placement confirmation on CBCT). Liberal consolidative cementoplasty performed to fill lytic tumor and provide added structural support ( g and h ).

Fig. 7

Lytic breast cancer metastasis to the iliopubic branch (white arrow) resulted in severe pain and high risk of fracture ( a : oblique coronal view, b : oblique sagittal view). Pelvic FICS with CBCT advancement of one cannulated, 8-mm diameter stainless steel screws ( c – e ) with tips anchored into the acetabulum ( f – g ).

Fig. 8

Percutaneous FICS of osteolytic metastasis located in the proximal femur. Three screws are inserted through the long axis of the femoral neck in an inverted triangle configuration. Kirschner's wires ( white arrow-head ) are coaxially advanced through 8-gauge needle ( white arrow ) and screws ( black arrow ) are advanced over the Kirschner wires ( a ). The metallic screws provide a resistance to torque and tension stresses that complement the compression resistance of cement ( b ).