Osteoporosis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Surgery is not the first-line treatment option for patients with osteoporosis. Vertebroplasty, kyphoplasty, lordoplasty, and vesselplasty are the procedures that are usually reserved for patients with either pathological or osteoporotic vertebral fractures and also in patients refractory to medical therapy. Surgery options for osteoporosis are very limited. In case of hip fracture, open reduction internal fixation or total hip replacement surgery, in rare cases, are the options.

Surgery

Surgery is not the first-line treatment option for patients with osteoporosis. Vertebroplasty, kyphoplasty, lordoplasty, and vesselplasty are the procedures that are usually reserved for patients with either pathological or osteoporotic vertebral fractures and also in patients refractory to medical therapy. Surgery options for osteoporosis are very limited. In case of hip fracture, open reduction internal fixation or total hip replacement surgery, in rare cases, are the options.

Fracture site	Surgery method	Brief description	Indications	Contraindications	Complications
Vertebrae	Vertebroplasty {{#ev:youtube|L_NpAJND_II}}	Minimally invasive surgery Image-guided by fluoroscopy Bone cement (PMMA) injection in fractured vertebra	Osteoporotic patients refractory to medical therapy Encountering vertebral fracture	Asymptomatic vertebral fractures Reasonable response to medical therapy Severe coagulopathies Any ongoing local/systemic infection.	Cement leakage into other spaces (e.g., paraspinal, intradiskal) Compression destruction of nerve roots due to cement leakage Pulmonary embolism Cardiac perforation Adjacent vertebrae fracture
	Kyphoplasty	Adjunctive method for vertebroplasty Initially a balloon inflated in the fractured vertebra Larger amount of bone cement is applied to meet the original vertebral height and lesser amount of cement extravasation	Pain control in osteoporotic patients Vertebral tumors refractory to medical therapy, encountering vertebral fracture	Infection Coagulation disorders Allergy to bone cement Anatomical variations Posterior vertebral cortical bone fusion Retroverted fragments	Cement leakage Pulmonary embolism Rarely balloon rupture
	Lordoplasty	Applying 6 cannulas (2 pedicles each) for any single fracture site in vertebrae Intact cranial and caudal vertebrae are injected with denser cement Other cannulas (4 pedicles each) introduced Kyphotic osteoporotic vertebra pushed toward the lordosis with support of cranial and caudal vertebrae Vertebral positions are allied by cross bolt, while 2 cannulas in fracture site deliver the PMMA cement to the collapsed vertebra When cement becomes hard, cannulas are replaced from the site	Osteoporotic and pathological vertebral fractures	Infection Coagulation disorders Allergy to bone cement Anatomical variations Posterior vertebral cortical bone fusion Retroverted fragments	Cement leakage (from 6 cannulas in vertebrae)
	89o6r8bcs0w}}	Pre-injection of some "porous" polyethylene terephthalate in vertebral bodies Prepare some hollow container in place for cement injection Cement injected in the vertebral bodies The vertebrae will be more stable and have less height loss during the time	Osteoporotic vertebral fracture Pathological vertebral fracture due to soft tumor tissues	Infection Coagulation disorders Allergy to bone cement Anatomical variations Posterior vertebral cortical bone fusion Retroverted fragments	Any allergic reaction to bone cement or other material that used during operation Pneumothorax Pulmonary embolism Epidural hematoma Arterial injury Anterior spinal artery syndrome Death
Hip	Open reduction internal fixation (ORIF)	Open surgery to set fractured bones together Fixation of screws and/or plates to enable or facilitate healing	Osteoporotic hip fracture with segments misalignment	Infection Coagulation disorders Severe osteoporosis	Nonunion Malunion Fat embolism Claudication
	Total hip replacement	Open surgery to exciseosteoporotic hip joint Replacement of the joint with prosthesis	Osteoporotic hip joint Avascular necrosis (AVN) Traumatized and malaligned joint Joint stiffness	Infection Coagulation disorders Severe osteoporosis	Joint instability Feet length difference Fat embolism Claudication

Vertebroplasty

• The procedure was first performed in 1984 by Galibert and Deramond, French neurosurgeons, in order to treat aggressive hemangioma in C2 vertebra. It had a very satisfying outcome. The success of this procedure in a favorable way led to extend its usage to other destructive bone diseases, such as multiple myeloma, metastatic bone tumors, and also osteoporotic vertebral fractures.

• In patients, who are refractory to long term medical therapy and have encountered vertebral compression fracture, vertebroplasty would be a good option. Vertebroplasty is a minimally invasive surgery that needs an image-guided fluoroscopy assistance. In this method, some bone cement (mostly polymethylmethacrylate (PMMA)) is injected into the body of the vertebra that has been fractured. This procedure may lead to improve the stability of fractured vertebra, take it back to the normal shape. PMMA injection is done under precise fluoroscopic observation to prevent any leakage of cement into the spinal canal. The most important advantages of the vertebroplasty procedure are minimal invasion rather than other open surgical methods, and rapid symptomatic relief as compared to other medical treatments. 

• Vertebroplasty may cause a rapid response in patients with osteoporosis. The patients may experience immediate pain and discomfort relief, along with gradual correction of the stooped spine (kyphosis) that occurs because of the compression fracture in the anterior aspect of vertebrae. The main risk for the procedure is that sometimes the cement injection may compromise the foraminal spaces, leading to radicular pains.

• The mechanism of lowering pain in osteoporotic patients following vertebroplasty is not clear completely. Some of the proposed theories include correcting micro-fractures, along with vascular, chemical, and also thermal factors. It is assumed that either temperature properties of injected cement destroy pain receptors, or compression effect of the cement crushed the nerve endings in situ. In 2009, Kallmes found that rapid pain relief and symptomatic cure in osteoporotic patients with vertebral compression fracture was not significantly different from control group.

Indications

• Indications for vertebroplasty for osteoporosis include osteoporotic patients refractory to medical therapy and having vertebral fracture.

Contraindications

• Absolute contraindications for vertebroplasty for osteoporosis include asymptomatic vertebral fractures and patients with reasonable response to medical therapy, as well as severe coagulopathies or any ongoing local/systemic infection. However, any allergy to the cement or any other material that may be used during the operation is included, too.
• Relative contraindications for vertebroplasty for osteoporosis include the fracture or defect in the posterior aspect of the vertebral body, tumor extension into the spinal canal and vertebra plana.

Complications

• Potential complications of vertebroplasty for osteoporotic surgical treatment include cement leakage into other spaces (e.g., paraspinal and intradiskal), compression destruction of nerve roots due to cement leakage, pulmonary embolism, cardiac perforation, and adjacent vertebrae fracture.

Kyphoplasty

• If the osteoporotic patient is referred within 3 months from the vertebral fracture, it would be possible to cure the resulted kyphosis through balloon kyphoplasty, completely. The procedure is, in fact, an adjunctive method for vertebroplasty, in which initially a balloon is used to inflate the fractured vertebra; then, a larger amount of bone cement is applied there to meet the original vertebral height and a lesser amount of cement extravasation. Generally, kyphoplasty results in favorable outcomes and osteoporotic patients can go back to normal life.

• It has found that kyphoplasty is better when comapred to vertebroplasty in the final outcome, spinal height correction, and preventing leakage of cement. Kyphoplasty has an obvious priority to vertebroplasty in middle spinal height correction and also wedge fractures of vertebrae.

• Kyphoplasty procedure last about 1.5 hours. The patient usually needs to be observed for only a few hours, but in some cases, it may be necessary to hospitalize the patient for a day.

Indications

• Indications for kyphoplasty include:
  • Pain
  • Vertebral tumors refractory to medical therapy
  • Vertebral fracture.

Contraindications

Contraindications for kyphoplasty for osteoporosis include:

• Infection
• Coagulation disorders,
• Allergy to bone cement or any other material that may be used during the operation
• Any anatomical variations that would disturb the normal route of surgery, such as posterior vertebral cortical bone fusion and retroverted fragments.

Complications

The main complication is cement leakage following the procedure. Other possible complications include pulmonary embolism and rarely balloon rupture.

Lordoplasty

• The most cost effective procedure to alleviate the vertebral compression fracture is lordoplasty.
• It is commonly done following kyphoplasty, when the balloon is deflated and the vertebrae is ready to be injected with cement. It is often used as an alternative to vertebroplasty as it is more cost effective. This procedure may correct the kyphotic angle of the spinal column by 11 to 13 degrees, leading to significant pain relief in 90% of patients. Lordoplasty has a much better 3 months outcome than kyphoplasty, especially in postural and anatomical deviations.

• The procedure consists of applying 6 cannulas, each of them has 2 pedicles, for any single fracture site in vertebrae. On the other hand, the intact cranial and caudal vertebrae are injected with dense cement and strengthened with cannulas that have 4 pedicles. Then, with the support of cranial and caudal vertebrae, the kyphotic osteoporotic vertebra could be pushed toward the lordosis and rearranged in a normal position. All vertebral positions are allied by use of a cross bolt, while 2 cannulas in fracture site deliver the polymethylmethacrylate (PMMA)) (PMMA) cement to the collapsed vertebra; been left to cement become hard. Finally, cannulas are replaced from the site.

Indications

Indications for lordoplasty for osteoporosis include

• osteoporotic
• pathological vertebral fractures.

Contraindications

Contraindications for surgery for osteoporosis include:

• infection
• coagulation disorders
• allergy to bone cement or any other material that may used during the operation
• any anatomical variations that would disturb the normal rout of surgery, such as posterior vertebral cortical bone fusion and retroverted fragments.

Complications

Regarding that 6 cannulas are introduced in vertebrae, the most important complication of lordoplasty may be cement leakage. The cement high viscosity and wide cannulas used to inject the cement are the solutions for the problems.

Vesselplasty

The instrument used in vesselplasty - By Aspine, Via: Wikimedia.org

This procedure is based on pre-injection of a "porous" material, polyethylene terephthalate, in the site of osteoporotic vertebral fracture. The main purpose is to prepare a hollow container in a place where the cement is about to injected; therefore, the cement goes through the vertebral bodies much deeper and leak back from there so much lesser than kyphoplasty or lordoplasty. The concluded vertebrae will be more stable and have less height loss during the time.

Mainly, kyphoplasty procedure is to inject the cement materials in fractured vertebrae in place of the removed deflated balloon, that is the main fact of correction in vertebral osteoporotic fractures. Whereas, in some cases, the main tissue in place is not as hard as main vertebral bone tissue and may collapse after removing or deflating the balloon, such as soft tumor tissue that has led to pathological fracture, indeed. The best way to solve this problem is a modified kyphoplasty, also named vesselplasty, used to treat osteoporotic fractures. The non-stretchable balloon that is used in vesselplasty to inject the cement through, prevent the re-collapse of soft tissue around the fracture.

Vesselplasty, like kyphoplasty, has safer cement delivery to the fractured bone and also less cement leakage, postoperatively.

Indications

Indications for vesselplasty for osteoporosis include patients with osteoporotic vertebral fracture and also pathological vertebral fracture due to soft tumor tissues.

Contraindications

Contraindications for surgery for osteoporosis include infection, coagulation disorders, allergy to bone cement or any other material that may be used during the operation, and also any anatomical variations that would disturb the normal route of surgery, such as posterior vertebral cortical bone fusion and retroverted fragments.

Complications

The complications of vesselplasty procedure include any allergic reaction to bone cement or other material that used during the operation, pneumothorax, pulmonary embolism, epidural hematoma, arterial injury, anterior spinal artery syndrome, and death.

Hip fracture surgery

Hip fractures are treated by open reduction internal fixation (ORIF).

Some patients with a hip fracture who are at high risk for another fracture may benefit from a total hip replacement surgery.

References

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