Levine Nicole L, Eward William C, Brigman Brian, Sag Alan Alper, Visgauss Julia D
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.
Department of Interventional Radiology, Duke University Medical Center, Durham, North Carolina.
JBJS Essent Surg Tech. 2024 Sep 13;14(3). doi: 10.2106/JBJS.ST.23.00070. eCollection 2024 Jul-Sep.
Percutaneous tripod fixation of periacetabular lesions is performed at our institution for patients with metastatic bone disease and a need for quick return to systemic therapy. We have begun to use the IlluminOss Photodynamic Bone Stabilization System instead of the metal implants previously described in the literature because of the success of the IlluminOss implant in fixing fragility fractures about the pelvis.
At our institution, the procedure is performed in the interventional radiology suite in order to allow for the use of 3D radiographic imaging and vector guidance systems. The patient is positioned prone for the transcolumnar PSIS-to-AIIS implant and posterior column/ischial tuberosity implant or supine for the anterior column/superior pubic ramus implant. Following a small incision, a Jamshidi needle with a trocar is utilized to enter the bone at the chosen start point. A hand drill is utilized to advance the Jamshidi needle according to the planned vector; alternatively, a curved or straight awl can be utilized. The 1.2-mm guidewire is placed and reamed. We place both the transcolumnar and posterior column wires at the same time to ensure that there is no interference. The balloon catheter for the IlluminOss is assembled on the back table and inserted according to the implant technique guide. The balloon is inflated and observed on radiographs in order to ensure that the cavity is filled. Monomer is then cured, and the patient is flipped for the subsequent implant. Following placement of the 3 IlluminOss devices, adjunct treatments such as cement acetabuloplasty or cryoablation can be performed.
Alternative treatments include traditional open fixation of impending or nondisplaced acetabular fractures in the operating room, or percutaneous implant placement in the operating room. Implant placement may be performed with the patient in the supine, lateral, or prone position, depending on surgeon preference. Alternative implants include standard metal implants such as plates and screws, or cement augmentation either alone or with percutaneous screws. Finally, ablation alone may be an alternative option, depending on tumor histology.
Open treatment of acetabular fractures is a more morbid procedure, given the larger incision, increased blood loss, longer time under anesthesia, and increased length of recovery. Percutaneous fixation may be performed in either the operating room or interventional radiology suite, depending on the specific equipment setup at an individual institution. At our institution, we prefer utilizing the interventional radiology suite as it allows for more precise implant placement through the use of an image-based vector guidance system and 3D fluoroscopy to accurately identify safe corridors. The use of percutaneous fixation allows for faster recovery and earlier return to systemic therapy. Because the IlluminOss implant is radiolucent, it allows for better evaluation of disease progression and can better accommodate nonlinear corridors or fill a lytic lesion to provide stability.
Postoperatively, we expect the patient to be weight-bearing as tolerated with use of an assistive device. We expect the small incisions to fully heal within 2 weeks. Patients should be able to return to systemic therapy as indicated earlier than with an open procedure.
The use of a hand drill with the Jamshidi needle and trocar can help adjust a drilled pathway and allow for close adherence to a planned vector.Vector guidance systems can be useful to fully capture the area at risk for fracture and to provide maximal stability with the expandable implant, but they are not necessary to perform the procedure.Placing both posterior implants at the same time can be helpful to avoid interference. This is accomplished by drilling and placing the guidewire for both implants prior to reaming and placing the balloon implant.
CT = Computed tomographyPSIS = posterior superior iliac spineAIIS = anterior inferior iliac spine.
在我们机构，对于患有转移性骨病且需要快速恢复全身治疗的患者，采用经皮髋臼周围病变三脚架固定术。由于IlluminOss植入物在固定骨盆周围脆性骨折方面取得成功，我们已开始使用IlluminOss光动力骨稳定系统，而非文献中先前描述的金属植入物。
在我们机构，该手术在介入放射科进行，以便使用三维放射成像和矢量引导系统。患者取俯卧位进行经柱状后上棘至前下棘植入物和后柱/坐骨结节植入物手术，或取仰卧位进行前柱/耻骨上支植入物手术。经小切口，使用带套管针的Jamshidi针在选定起点进入骨骼。使用手摇钻按计划矢量推进Jamshidi针；也可使用弯形或直形锥子。放置1.2毫米导丝并进行扩孔。我们同时放置经柱状和后柱导丝，以确保无干扰。IlluminOss的球囊导管在手术台上组装好并根据植入技术指南插入。球囊充气并在X线片上观察，以确保腔隙被填满。然后固化单体，患者翻身进行后续植入。放置3个IlluminOss装置后，可进行诸如骨水泥髋臼成形术或冷冻消融等辅助治疗。
替代治疗包括在手术室对即将发生或无移位髋臼骨折进行传统切开固定，或在手术室进行经皮植入物放置。植入物放置可根据外科医生偏好让患者取仰卧位、侧卧位或俯卧位。替代植入物包括标准金属植入物，如钢板和螺钉，或单独使用骨水泥增强或与经皮螺钉联合使用。最后，根据肿瘤组织学情况，单独消融可能是一种替代选择。
髋臼骨折的切开治疗是一种创伤更大的手术，因为切口更大、失血增加、麻醉时间延长以及恢复时间延长。经皮固定可在手术室或介入放射科进行，这取决于个别机构的具体设备配置。在我们机构，我们更倾向于使用介入放射科，因为通过使用基于图像的矢量引导系统和三维荧光透视来准确识别安全通道，可实现更精确的植入物放置。经皮固定可使恢复更快并更早恢复全身治疗。由于IlluminOss植入物是射线可透过的，它能更好地评估疾病进展，并且能更好地适应非线性通道或填充溶骨性病变以提供稳定性。
术后，我们期望患者在使用辅助装置的情况下能耐受负重。我们期望小切口在2周内完全愈合。患者应能比切开手术更早地按前述情况恢复全身治疗。
将手摇钻与Jamshidi针和套管针一起使用有助于调整钻孔路径，并能紧密遵循计划矢量。矢量引导系统有助于全面捕捉骨折风险区域，并通过可扩张植入物提供最大稳定性，但进行该手术并非必需。同时放置两个后植入物有助于避免干扰。这通过在扩孔和放置球囊植入物之前为两个植入物钻孔并放置导丝来完成。
CT = 计算机断层扫描；PSIS = 后上棘；AIIS = 前下棘
