Controversial issues in kyphoplasty and vertebroplasty in osteoporotic vertebral fractures.

Kyphoplasty (KP) and vertebroplasty (VP) have been successfully employed for many years for the treatment of osteoporotic vertebral fractures. The purpose of this review is to resolve the controversial issues raised by the two randomized trials that claimed no difference between VP and SHAM procedure. In particular we compare nonsurgical management (NSM) and KP and VP, in terms of clinical parameters (pain, disability, quality of life, and new fractures), cost-effectiveness, radiological variables (kyphosis correction and vertebral height restoration), and VP versus KP for cement extravasation and complications profile. Cement types and optimal filling are analyzed and technological innovations are presented. Finally unipedicular/bipedicular techniques are compared. Conclusion. VP and KP are superior to NSM in clinical and radiological parameters and probably more cost-effective. KP is superior to VP in sagittal balance improvement and cement leaking. Complications are rare but serious adverse events have been described, so caution should be exerted. Unilateral procedures should be pursued whenever feasible. Upcoming randomized trials (CEEP, OSTEO-6, STIC-2, and VERTOS IV) will provide the missing link.

Controversial issues in kyphoplasty and vertebroplasty in malignant vertebral fractures.

BACKGROUND: Kyphoplasty (KP) and vertebroplasty (VP) have been successfully employed in the treatment of pathological vertebral fractures. METHODS: A critical review of the medical literature was performed and controversial issues were analyzed. RESULTS: Evidence supports KP as the treatment of choice to control fracture pain and the possible restoration of sagittal balance, provided that no overt instability or myelopathy is present, the fracture is painful and other pain generators have been excluded, and positive radiological findings are present. Unilateral procedures yield similar results to bilateral ones and should be pursued whenever feasible. Biopsy should be routinely performed and 3 to 4 levels may be augmented in a single operation. Higher cement filling appears to yield better results. Radiotherapy is complementary with KP and VP but must be individualized. CONCLUSIONS: In cases of painful cancer fractures, if overt instability or myelopathy is not present, unilateral KP should be pursued, whenever feasible, followed by radiotherapy. The technological advances in hardware and biomaterials, as well as combining KP with other modalities, will help ensure a safe and more effective procedure. Address.

Adverse prognostic factors and optimal intervention time for kyphoplasty/vertebroplasty in osteoporotic fractures.

INTRODUCTION: While evidence supports the efficacy of vertebral augmentation (kyphoplasty and vertebroplasty) for the treatment of osteoporotic fractures, randomized trials disputed the value of vertebroplasty. The aim of this analysis is to determine the subset of patients that may not benefit from surgical intervention and find the optimal intervention time. METHODS: 27 prospective multiple-arm studies with cohorts of more than 20 patients were included in this meta-analysis. We hereby report the results from the metaregression and subset analysis of those trials reporting on treatment of osteoporotic fractures with kyphoplasty and/or vertebroplasty. RESULTS: Early intervention (first 7 weeks after fracture) yielded more pain relief. However, spontaneous recovery was encountered in hyperacute fractures (less than 2 weeks old). Patients suffering from thoracic fractures or severely deformed vertebrae tended to report inferior results. We also attempted to formulate a treatment algorithm. CONCLUSION: Intervention in the hyperacute period should not be pursued, while augmentation after 7 weeks yields less consistent results. In cases of thoracic fractures and significant vertebral collapse, surgeons or interventional radiologists may resort earlier to operation and be less conservative, although those parameters need to be addressed in future randomized trials.

Double approach operation for large extracompartmental proximal thigh tumors.

Resection of large femoral triangle tumors that invade the bone (or vice versa) still remains a challenge. A lateral-only approach would hinder dissection of the mass, away from the femoral vessels, while an iliofemoral-only type of approach would make bone resection and megaprosthetic reconstruction very arduous. The authors describe a two-stage, one-position operation via a double surgical approach: the first stage is comprised by an iliofemoral approach and dissection of the femoral vessels, followed by proximal femoral resection and reconstruction stage. One illustrative case is presented along with the authors overall experience. We believe that this operation facilitates wide tumor resection in a safe and step-wise manner, as not to add to the morbidity of the procedure.