Diagnostic accuracy and safety of percutaneous MRI-guided biopsy of solid renal masses: single-center results after 4.5 years.

OBJECTIVES: To retrospectively evaluate diagnostic accuracy and complications of magnetic resonance imaging (MRI)-guided biopsy of radiologically indeterminate solid renal masses (RM). METHODS: Electronic records of all consecutive patients undergoing MRI-guided biopsy of solid RM (using free-breathing T2-BLADE and BEAT-IRTTT sequences) between April 2014 and October 2018 were reviewed; 101 patients (69 men, 32 women; median age 68 years; range 32-76) were included. Patient and RM characteristics, procedural details/complications, pathologic diagnosis, and clinical management were recorded. Diagnostic accuracy was calculated on an intention-to-diagnose basis. Diagnostic yield was also evaluated. Multi-variable analysis was performed for variables with p < .20, including patient age/sex; RM size/location/contact with vascular pedicle, RENAL score, number and total length of biopsy samples, and biopsy tract embolization, to determine factors associated with diagnostic samples, diagnostic accuracy, and complications. RESULTS: Median RM size was 2.4 cm (range 1-8.4 cm). There were 86 (85%; 95%CI 77-91%) diagnostic and 15 (15%; 95%CI 9-23%) non-diagnostic samples; 6/15 (40%) non-diagnostic biopsies were repeated with 50% malignancy rate. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 96% (95%CI 89-99%), 100% (95%CI 77-100%), 100% (95%CI 95-100%), 82% (95%CI 57-96%), and 97% (95%CI 90-99%), respectively. Primary and secondary diagnostic yields were 85% (95%CI 77-91%) and 91% (95%CI 84-96%), respectively. Seven (7%; 95%CI 1-10%) complications were observed. No tested variables were associated with diagnostic samples, diagnostic accuracy, or complications. CONCLUSIONS: MRI-guided biopsy of solid RM is associated with high diagnostic accuracy and low complication rate. The technique might be helpful for inaccessible tumors. KEY POINTS: • MRI-guided biopsy of radiologically indeterminate solid renal masses (RM) appears safe, with a low rate of minor self-limiting hemorrhagic complications. • Diagnostic accuracy and primary/secondary diagnostic yield are high and appear similar to reported estimates for US- and CT-guided RM biopsy. • MRI guidance may be particularly useful for RM with poor conspicuity on US and CT, for relatively inaccessible tumors (e.g., tumors requiring double-oblique steep-angled approaches), and for young patients or those with renal failure.

Freezing Nodal Disease: Local Control Following Percutaneous Image-Guided Cryoablation of Locoregional and Distant Lymph Node Oligometastases: A 10-Year, Single-Center Experience.

PURPOSE: To retrospectively assess the technical feasibility, safety, and oncologic outcomes of percutaneous image-guided cryoablation (PCA) of locoregional and distant lymph node metastases (LNMs). METHODS: All consecutive patients undergoing PCA of LNMs between February 2009 and December 2019 were identified using a retrospective database search. Every patient was followed up at 1, 3, 6, and 12 months after treatment using contrast-enhanced magnetic resonance imaging and at approximately 3-6-month intervals using computed tomography or positron emission tomography-computed tomography. The Kaplan-Meier method was used to calculate local tumor progression-free survival, disease-free survival, and overall survival. Locoregional and distant groups were compared using the Fisher test. Technical success, technique efficacy, complications, and oncologic outcomes were analyzed. RESULTS: Fifty-six metachronous oligometastatic LNMs (median size, 15 mm [interquartile range, 13-15 mm; range, 9-36 mm]) were treated in 37 sessions in 29 patients and defined as locoregional (26/37 sessions) or distant (11/37 sessions). Seventeen patients had undergone prior surgery or radiotherapy. Six patients underwent 8 retreatments for locoregional progression. An additional visceral oligometastasis was treated in 4 of the 11 distant LNM PCA sessions. The technical success and primary technique efficacy rates were 100%. The complication rate was 5.4% (2 transient nerve palsies). At a median follow-up of 23 months, there were 2 instances of local tumor progression (5.6%); the 1-, 2-, and 3-year local tumor progression-free survival was 100%, 94.3%, and 94.3%, respectively. Thirteen (45%) patients demonstrated no disease progression. The 1-, 2-, and 3-year overall survival was 96.2%, 90.5%, and 70%, respectively. The patients were free from systemic oncologic therapy following 20 (54%) sessions, with a mean treatment break of 19.1 months. CONCLUSIONS: The PCA of lymph node oligometastases is feasible and safe, and offers promising local tumor control at midterm follow-up.

Augmented reality and artificial intelligence-based navigation during percutaneous vertebroplasty: a pilot randomised clinical trial.

PURPOSE: To assess technical feasibility, accuracy, safety and patient radiation exposure of a novel navigational tool integrating augmented reality (AR) and artificial intelligence (AI), during percutaneous vertebroplasty of patients with vertebral compression fractures (VCFs). MATERIAL AND METHODS: This prospective parallel randomised open trial compared the trans-pedicular access phase of percutaneous vertebroplasty across two groups of 10 patients, electronically randomised, with symptomatic single-level VCFs. Trocar insertion was performed using AR/AI-guidance with motion compensation in Group A, and standard fluoroscopy in Group B. The primary endpoint was technical feasibility in Group A. Secondary outcomes included the comparison of Groups A and B in terms of accuracy of trocar placement (distance between planned/actual trajectory on sagittal/coronal fluoroscopic images); complications; time for trocar deployment; and radiation dose/fluoroscopy time. RESULTS: Technical feasibility in Group A was 100%. Accuracy in Group A was 1.68 ± 0.25 mm (skin entry point), and 1.02 ± 0.26 mm (trocar tip) in the sagittal plane, and 1.88 ± 0.28 mm (skin entry point) and 0.86 ± 0.17 mm (trocar tip) in the coronal plane, without any significant difference compared to Group B (p > 0.05). No complications were observed in the entire population. Time for trocar deployment was significantly longer in Group A (642 ± 210 s) than in Group B (336 ± 60 s; p = 0.001). Dose-area product and fluoroscopy time were significantly lower in Group A (182.6 ± 106.7 mGy cm2 and 5.2 ± 2.6 s) than in Group B (367.8 ± 184.7 mGy cm2 and 10.4 ± 4.1 s; p = 0.025 and 0.005), respectively. CONCLUSION: AR/AI-guided percutaneous vertebroplasty appears feasible, accurate and safe, and facilitates lower patient radiation exposure compared to standard fluoroscopic guidance. These slides can be retrieved under Electronic Supplementary Material.

Anatomical risk evaluation of iatrogenic injury to the infrapatellar branch of the saphenous nerve during medial meniscus arthroscopic surgery.

PURPOSE: To determine the relationship of the medial meniscus with the infrapatellar branches of the saphenous nerve, the primary goal is to define and characterize different risk areas for these nerves during medial meniscus surgery. METHODS: After dissecting 20 embalmed cadaver knees, we defined 7 readily identifiable anatomical landmarks. For each knee, we recorded 2 morphological criteria and 16 measurements. RESULTS: The most common anatomical course is a main trunk that is 8 mm anterior to the tuberculum adductorium and 60 mm posterior to the midpoint of the medial patellar margin. It has two main infrapatellar branches. The nerve division is 23 mm above the joint line. The path is oblique with an angle of 55.5°. The anterior meniscal landmark is 24 mm from the upper branch and 42.5 mm from the lower branch. The posterior meniscal landmark is 55 mm from the upper branch and 38 mm from the lower branch. CONCLUSIONS: We defined a common anatomical course for the saphenous nerve and its infrapatellar branches. Then, three different areas were defined at risk for iatrogenic nerve injuries during medial meniscus.

Imaging-guided percutaneous cryotherapy of bone and soft-tissue tumors: what is the impact on the muscles around the ablation site?

OBJECTIVE: The objectives of our study were to evaluate the incidence of muscular injury after cryoablation of bone and soft-tissue tumors, to relate MRI findings to the size of the intramuscular ice ball, and to determine the clinical significance of postcryotherapy myositis. MATERIALS AND METHODS: Between January 2010 and October 2012, 24 bone and soft-tissue lesions (16 pelvic lesions, three shoulder lesions, and five paravertebral lesions) in 21 patients treated by imaging-guided percutaneous cryoablation and followed up with MRI were retrospectively analyzed. Muscular hyperintensity on T2 STIR images was graded as follows: grade 0, no myositis; grade 1, local myositis; grade 2, myositis in less than half of the volume of the muscle; or grade 3, myositis in half of the volume of the muscle or more. The presence of T2 STIR hyperintensity in the muscles surrounding the cryoablation site was correlated with the volume of the intramuscular ice ball. RESULTS: Muscular T2 STIR hyperintensity was observed in 87.5% of cases (grade 0 in 12.5%, grade 1 in 45.8%, grade 2 in 20.8%, and grade 3 in 20.8%). The volume of the intramuscular ice ball and grade of myositis (mean volume: grade 0, 2.8 cm(3); grade 1, 9.2 cm(3); grade 2, 17.1 cm(3); grade 3, 42.9 cm(3)) were positively correlated in the 24 lesions in the study cohort (r = 0.64, p < 0.001). Only two cases of myositis (grade 3) were symptomatic, and antiinflammatory drugs promoted pain resolution in both cases. CONCLUSION: Muscular injury around the cryoablation site is commonly observed and is correlated with the volume of the ice ball. When muscular injury around the cryoablation site causes pain, the symptoms differ from the initial tumoral pain and can be treated with antiinflammatory drugs.

Out of sight but kept in mind: complications and imitations of dropped gallstones.

OBJECTIVE: The purpose of this article is to describe the diagnostic pitfalls caused by dropped gallstones left in situ after laparoscopic cholecystectomy. CONCLUSION: Dropped gallstones may rarely become symptomatic, causing recurrent abscesses. Diagnosis is challenging due to unusual clinical presentations, myriad locations, and radiologically occult calculi. Even asymptomatic dropped gallstones may cause diagnostic confusion by masquerading as intraperitoneal neoplastic deposits. Radiologists should be aware of techniques for identifying and retrieving dropped gallstones and be wary of their complications and imitations in patients who have undergone laparoscopic cholecystectomy.

Adjunctive hydrodissection of the bare area of liver during percutaneous thermal ablation of sub-cardiac hepatic tumours.

OBJECTIVE: To report the technique of hydrodissection of the sub-diaphragmatic bare area of the liver, in order to protect the diaphragm/heart during percutaneous thermal ablation (PTA) of sub-cardiac hepatic tumours. MATERIALS AND METHODS: Between January 2016 and December 2018, five patients (four female, one male; mean age 56.2 years) with five sub-cardiac liver tumours (two hepatocellular carcinoma, three metastases; mean size 39 mm) abutting the bare area (segments II/IVA) with expected ablation zones ≤ 5 mm from the myocardium were treated with PTA and adjunctive hydrodissection. Time to perform hydrodissection, distance between superior hepatic and diaphragmatic/pericardial surfaces before and after hydrodissection, ablation efficacy, complications, and local tumour progression (LTP) at last imaging follow-up were recorded. RESULTS: Technical feasibility was 100%, with mean hydrodissection-volume of 126 ml (range 80-200 ml) and median hydrodissection-time of 9 min (range 8-45 min). Liver-diaphragmatic and liver-pericardial distance increased, respectively, from 2.4 mm (range 0-8 mm) to 10.8 mm (range 6-19 mm) and from 4 mm (range 1-10 mm) to 12.6 mm (range 8-20 mm) post-hydrodissection. All procedures were performed at full-power with complete tumour ablation and without complications (including peri-procedural haemodynamic/electrocardiographic disturbances, pericardial effusion and diaphragmatic hernia) or evidence of LTP at mean 12.2-month (range 1-26 month) follow-up. CONCLUSION: Hydrodissection of the sub-diaphragmatic bare area of the liver is technically feasible and may potentially optimize safety PTA of sub-cardiac hepatic tumours.

Hydrodissection of the Gallbladder Bed: A Technique for Ablations Located Close to the Gallbladder.

OBJECTIVE: To report the technique of hydrodissection of the gallbladder bed, in order to separate the gallbladder wall from the liver surface during microwave ablation of liver malignancies located in segment V. MATERIALS AND METHODS: Between January 2018 and March 2018, percutaneous hydrodissection of the gallbladder fossa was performed during four microwave ablation procedures in three patients (One patient was treated twice for the same lesion, making a total of four procedures for three lesions.) All treated lesions were located in segment V and abutting the gallbladder. Number of hydrodissection needles, volume of hydrodissection, repartition of hydrodissection, separation of tumour from the gallbladder post-hydrodissection, technical success of hydrodissection/ablation, and complications were recorded and evaluated. RESULTS: Hydrodissection of the gallbladder fossa was technically feasible in all four procedures, and microwave ablation was performed at maximum power without any early interruption. Time to perform hydrodissection was 11.3 min on average (range 7-18 min). Minimal distance between the ablation area and the GB increased from virtual to 10 mm on average (range 6-13), with a mean volume of dissection of 65 ml (range 40-100). Technical success was 75%. There was no complication related to the hydrodissection itself, and no acute or delayed gallbladder complication. CONCLUSION: Hydrodissection of the gallbladder bed is a feasible technique to separate the gallbladder from the liver surface. This could potentially decrease the risk of thermal injuries to the gallbladder wall when ablating tumours located in segment V.

Percutaneous MR-guided whole-gland prostate cancer cryoablation: safety considerations and oncologic results in 30 consecutive patients.

OBJECTIVE: To assess the safety and oncological efficacy of percutaneous MR-guided whole-gland prostate cancer (PCa) cryoablation (CA). METHODS AND MATERIALS: Between July 2009 and January 2018, 30 patients (mean age 72.9 ± 5.13 years) with histologically proven, organ-confined (≤ T2cN0M0), predominantly low/intermediate-risk PCa (median Gleason score 7; mean prostate specific antigen 6.05 ± 3.74 ng ml-1 ) underwent MR-guided whole-gland CA. Patients were selected on the basis of prior pelvic radiotherapy (n = 16; 12 for previous PCa), or contra indication/refusal of surgery or radiotherapy. Complications, local progression-free survival (LPFS) and overall survival (OS) were retrospectively investigated. RESULTS: Eighteen [60%] patients reported procedure-related complications: 5/18 [28%] needed surgical/interventional treatments and 13 [72%] conservative or pharmacological treatment. Eleven [73%] complications were noted in the first 15 patients and 7 [47%] in the last 15 patients (p = 0.26). Mean nadir prostate specific antigen was 0.24 ± 1.5 ng ml-1 (mean follow-up 3.8 years; range: 2 - 2915 days). Seven [23%] patients developed histologically proven local progression (mean time to recurrence 775 days, range: 172 - 2014). Mean clinical follow-up was 3.8 years (range 1-2915 days). LPFS was 92.0, 75.7 and 69.4 % at 1-, 3- and 5 year follow-up, respectively. For patients in salvage treatment, LPFS was 100%, 75%, and 75% at 1-, 3- and 5 year follow-up. OS was 100%, 94.4 and 88.5 % at 1-, 3- and 5 year follow-up respectively, with no patients dying from PCa. CONCLUSION: Whole-gland PCa CA offers good oncological efficacy, particularly in post-radiotherapy cases. Although the complication rate is significant, the majority is minor and is managed with conservative or pharmacologic management. ADVANCES IN KNOWLEDGE: MRI-guided whole-gland prostate cancer cryoablation offers good oncological efficacy, particularly in post-radiotherapy cases with a contained complication rate.

Hydrodissection of the Retrohepatic Space: A Technique to Physically Separate a Liver Tumour from the Inferior Vena Cava and the Ostia of the Hepatic Veins.

OBJECTIVE: To report a technique of percutaneous retrohepatic hydrodissection, highlighting its potential to physically separate liver tumours from the inferior vena cava (IVC) and the ostia of the hepatic veins (HV). MATERIALS AND METHODS: Between December 2017 and April 2018, hydrodissection of the retrohepatic IVC was performed in 5 patients (5 females; mean age 64.5 years) undergoing percutaneous ablation of 5 liver metastases (mean size: 3.6 cm) located adjacent to the IVC. Number of hydrodissection needles, volume of hydrodissection, separation of tumour/liver parenchyma from IVC/HV post-hydrodissection; technical success of ablation; and complications were tabulated. RESULTS: Two to three 22G spinal needles were required per case for adequate dissection. Mean volume to obtain sufficient hydrodissection was 410 ml on average. Physical separation of the IVC and tumour/hepatic parenchyma was successful in all cases, by 9 mm on average (range 5-12 mm). It also leaded to physical separation of the ostia of the right and middle HV in all cases. There was no early or delayed complication, notably no venous thrombosis in the post-operative period. All lesions but one were completely ablated after one session at 3-month follow-up. The patient with residual tumour was successfully retreated. CONCLUSION: Retrohepatic hydrodissection is a feasible technique to separate a tumour from the IVC and/or ostia of the HV. This could potentially limit the heat-sink effect/reduce the risk of thrombosis. Larger follow-up studies are required to assess efficacy on a long-term basis.

Biomechanical effects of osteoplasty with or without Kirschner wire augmentation on long bone diaphyses undergoing bending stress: implications for percutaneous imaging-guided consolidation in cancer patients.

BACKGROUND: Osteoplasty has been discouraged in long bones. However, despite a substantial lack of pre-clinical biomechanical tests, multiple clinical studies have implemented a wide range of techniques to optimise long bone osteoplasty. The aim of the present study is to evaluate the biomechanical properties of osteoplasty alone and in combination with Kirschner wires (K-wires) in a cadaveric human diaphyseal model undergoing 3-point bending stress. METHODS: Thirty unpaired human cadaveric hemi-tibia specimens were randomly assigned to receive no consolidation (group 1, n = 10), osteoplasty alone (group 2, n = 10), or K-wires augmented osteoplasty (group 3, n = 10). Specimens were tested on a dedicated servo-hydraulic machine using a 3-point bending test. Fracture load was calculated for each specimen; two-sample Wilcoxon rank-sum tests were used to assess differences between groups. RESULTS: Median volume of polymethyl methacrylate injected was 18 mL for group 2 (25th-50th percentile 15-21 mL) and 19 mL for group 3 (25th-50th percentile 17-21). There were no significant differences in fracture load between groups 1 and 2 (z = - 0.793; p = 0.430), between groups 1 and 3 (z = - 0.944; p = 0.347), and between groups 2 and 3 (z = - 0.454; p = 0.650). Fractures through the cement occurred in 4 of 30 cases (13.3%); there were no K-wires fractures. CONCLUSIONS: Osteoplasty with or without K-wires augmentation does not improve the resistance of diaphyseal bone to bending stresses.

Adjunctive Thermoprotection During Percutaneous Thermal Ablation Procedures: Review of Current Techniques.

Although rare, unintended thermal injury to organs surrounding the ablation zone can lead to severe complications. Over the past 15 years, different protective methods have been developed to limit risk of complications, and expand indications to include more challenging lesions in various locations including liver, kidney, lung and bone. The most frequently used techniques include hydrodissection, carbodissection, balloon interposition and probe torqueing. In most cases, tumours can be physically separated from sensitive structures, reducing risk of thermal injury. Endoluminal cooling/warming is an alternative option for complex ablations close to the ureter or major bile ducts. Different techniques may be combined to achieve successful protection in locations with complex anatomy. The purpose of this review is to provide an overview of available protective measures and discuss respective advantages/drawbacks.

Efficacy of the Vertebral Body Stenting System for the Restoration of Vertebral Height in Acute Traumatic Compression Fractures in a Non-osteoporotic Population.

INTRODUCTION: To evaluate the effectiveness of percutaneous image-guided vertebral body stenting (VBS) at restoring vertebral height in acute, stable, traumatic thoracolumbar fractures in a young, non-osteoporotic population. MATERIALS AND METHODS: A single-centre retrospective review of all traumatic non-osteoporotic fractures treated with VBS between 2010 and 2017 was performed. Inclusion criteria included patients with recent (< 10 days), symptomatic and stable thoracolumbar compression fractures. Patients with low-energy fractures, osteoporosis and age > 60/50 years (male/female) were excluded. Primary outcomes included: correction of vertebral height, correction of kyphosis angle and Beck Index on reconstructed pre- and post-procedural CBCT images. Secondary outcomes included intra-procedural stent recoil, complications, cement leakage and factors predicting height restoration. RESULTS: Thirty-nine patients (26 men, 13 women; mean age 33.6 years, range 15-57 years) underwent VBS 5 days post-trauma on average (range 1-10), for stable compression fractures located between T5 and L5. Mean vertebral height gain, vertebral kyphosis angle correction and Beck index improvement were 3.8 mm (95% CI 3.36-4.50; P(> 3 mm) = 99.9%), 4.3° (95% CI 3.50-5.20; P(> 3°) = 99.9%) and 0.07 [95% CI 0.053-0.11], respectively (all statistically significant). Technical success was 92%, with 3 "major" stent recoils resulting in loss of vertebral height correction. No symptomatic complications were observed. No predictive factors for procedural success were identified. CONCLUSION: VBS can significantly restore vertebral height in young patients with traumatic vertebral compression fractures.

Embolisation of pulmonary arteriovenous malformations using high-frequency jet ventilation: benefits of minimising respiratory motion.

BACKGROUND: To evaluate patient radiation dose and procedural duration recorded during pulmonary arteriovenous malformation (PAVM) embolisation performed using high-frequency jet ventilation (HFJV) as compared with conventional intermittent positive pressure ventilation (IPPV) METHODS: Patients undergoing PAVM embolisation with HFJV assistance after April 2017 were retrospectively identified as group A, and those treated with IPPV before April 2017 as group B. Primary outcomes were patient radiation dose and procedural duration between groups A and B. Secondary outcomes were difference in diaphragmatic excursion between groups A and B, in group A with/without HFJ assistance, technical/clinical success, and complications. RESULTS: Twelve PAVMs were embolised in 5 patients from group A, and 15 PAVMs in 10 patients from group B. Mean patient radiation was significantly lower in group A than in group B (54,307 ± 33,823 mGy cm2 [mean ± standard deviation] versus 100,704 ± 43,930 mGy cm2; p = 0.022). Procedural duration was 33.4 ± 16.1 min in group A versus 57.4 ± 14.9 min in group B (p = 0.062). Diaphragmatic excursion was significantly lower in group A (1.3 ± 0.4 mm) than in group B (19.7 ± 5.2 mm; p < 0.001) and lower with near statistical significance in group A with HFJV than without HFJV (1.3 ± 0.4 mm versus 10.9 ± 3.1 mm; p = 0.062). Technical and clinical success was 100% in both groups, without relevant complications. CONCLUSION: HFJV-assisted PAVM embolisation is a safe, feasible technique resulting in reduced patient radiation doses and procedural time.

Pulmonary Arteriovenous Malformations Embolized Using a Micro Vascular Plug System: Technical Note on a Preliminary Experience.

AIM: To report our preliminary experience using a Micro Vascular Plug (MVP) deployed through a 2.8Fr micro-catheter for the treatment of pulmonary arteriovenous malformations (PAVMs) in a cohort of patients affected by Hereditary Haemorrhagic Telangiectasia (HHT). MATERIALS AND METHODS: Four consecutive female patients (mean age 38.0 years; range 25-55 years) with PAVMs diagnosed on echocardiogram/bubble test and contrast-enhanced CT (CECT) underwent MVP embolization. One patient was symptomatic with recent transient ischaemic attack. Follow-up was undertaken at 1-month post-procedure with CECT to assess PAVMs permeability and MVP positioning and at 1-, 6-, and 12-month post-procedure, with echocardiography/bubble test and standard neurological history, to confirm absence of right-to-left shunts and recurrent symptoms. RESULTS: Eight PAVMs were treated in 4 patients over 5 interventional sessions (mean 1.6 PAVMs per session). All PAVMs were simple, with mean feeding artery diameter of 4.25 mm. Eight 6.5 mm MVPs were deployed in total (one per lesion). Technical success was 100%. Mean procedural time and patient dose per session were 70 min (range 40-70 min) and 53418 mGy.cm2 (range 6113-101628 mGy.cm2), respectively. No signs of reperfusion neither of MPV migration were noted at 1-month CECT follow-up. At early follow-up (mean 3.75 months; range 1-12 months), clinical success was 100% with no evidence of recurrent right-to-left shunt, and no neurological symptoms. No immediate or late complications were observed. CONCLUSIONS: MVP embolization of PAVMs appears technically feasible, safe, and effective at early follow-up. Further prospective studies are required to confirm long-term safety and efficacy of this promising technique.

Percutaneous Imaging-Guided Screw Fixation of Osteoporotic Transverse Fractures of the Lower Sacrum with Cement Augmentation: Report of 2 Cases.

Osteoporotic fractures of the sacrum usually involve the sacral ala and can be managed with percutaneous cementoplasty if conservative therapy failed to achieve bone consolidation. On the other hand, isolated transverse fractures of the lowest sacrum are more rare, with little literature focusing on their management in the osteoporotic population. If pseudoarthrosis occurs in this location, sacroplasty is not an optimal therapeutic option because of the poor biomechanical resistance of cement to multi-directional stresses. Hence, we report two cases of chronic unhealed transverse fractures of the lowest sacrum successfully managed with percutaneous image-guided screw fixation augmented with cement injection. At last follow-up available, both patients experienced complete pain relief, without evidences of failure of the osteosynthesis on CT-scan controls.

Minimally invasive treatments of painful bone lesions: state of the art.

The role of the interventional radiology (IR) in the musculoskeletal system, and in particular in the bone, is a field of knowledge that is growing significantly in the last years with indications for treatment of both benign and malign lesions. In this paper, we review the state of the art of this application of the IR in the bone (bone metastasis and benign bone lesions) with discussion about all the techniques today used.

Percutaneous CT and Fluoroscopy-Guided Screw Fixation of Pathological Fractures in the Shoulder Girdle: Technical Report of 3 Cases.

OBJECTIVE: To review our initial experience with percutaneous CT and fluoroscopy-guided screw fixation of pathological shoulder-girdle fractures. MATERIALS AND METHODS: Between May 2014 and June 2015, three consecutive oncologic patients (mean age 65 years; range 57-75 years) with symptomatic pathological shoulder-girdle fractures unsuitable for surgery and radiotherapy underwent percutaneous image-guided screw fixation. Fractures occurred through metastases (n = 2) or a post-ablation cavity (n = 1). Mechanical properties of osteosynthesis were adjudged superior to stand-alone cementoplasty in each case. Cannulated screws were placed under combined CT and fluoroscopic guidance with complementary radiofrequency ablation or cementoplasty to optimise local palliation and secure screw fixation, respectively, in two cases. Follow-up was undertaken every few weeks until mortality or most recent appointment. RESULTS: Four pathological fractures were treated in three patients (2 acromion, 1 clavicular, 1 coracoid). Mean size of associated lesion was 2.6 cm (range 1-4.5 cm). Technical success was achieved in all cases (100 %), without complications. Good palliation and restoration of mobility were observed in two cases at 2-3 months; one case could not be followed due to early post-procedural oncologic mortality. CONCLUSION: Percutaneous image-guided shoulder-girdle osteosynthesis appears technically feasible with good short-term efficacy in this complex patient subset. Further studies are warranted to confirm these promising initial results.