Which fractures are best treated with bone cement augmentation rather than open reduction and internal fixation?

Fracture Treatment: Cement Augmentation vs. Open Reduction Internal Fixation

Bone cement augmentation is preferred over open surgery for vertebral compression fractures (both osteoporotic and metastatic), acetabular/pelvic metastatic lesions under compression forces, and in elderly patients with limited life expectancy who have osteoporotic fractures of weight-bearing bones, while open reduction and internal fixation remains the standard for displaced long bone fractures, femoral neck fractures, and metastatic lesions requiring structural support beyond compression.

Vertebral Compression Fractures

Osteoporotic Vertebral Fractures

• Vertebroplasty and kyphoplasty provide immediate pain relief and functional improvement superior to continued medical management when conservative therapy has failed, with patients showing statistically significant improvement in disability scores (mean change of 8.3 points on Roland-Morris questionnaire at 1 month, p<0.0001) 1
• The hallmark of successful vertebral augmentation is sudden improvement in pain and return of function, unlike the gradual 2-12 week improvement seen with natural healing 1
• Both procedures can be applied to all vertebral levels from C0 to coccyx, with major complications occurring in less than 1% of patients 1
• Cement leakage occurs in up to 72% of cases on CT imaging but remains asymptomatic in the vast majority, with no patients showing reactive pulmonary changes despite 26% having cement pulmonary emboli on CT 1

Malignant Vertebral Fractures

• Kyphoplasty demonstrates superior outcomes over conservative management for cancer patients with vertebral compression fractures, with the treatment effect showing 8.4 points improvement on disability scores (95% CI 7.6-9.2, p<0.0001) at 1 month 1
• Vertebral augmentation provides immediate pain relief, avoids delays in chemoradiation therapy, allows outpatient care in most cases, and enables tissue biopsy 1
• Serious complications range from 0-11.5% with mortality between 0-7%, including 0.5% attributable deaths (primarily from cement pulmonary embolus or post-procedure infections) 1

Metastatic Long Bone Disease

When Cement is Appropriate

• Cementoplasty is particularly effective for bones subjected to compression forces, including extensive iliac lesions and acetabular metastases without extensive joint communication or acetabular fossa damage 1
• Cement augmentation combined with percutaneous screw fixation is reserved for patients with limited life expectancy who are unfit for open surgery, particularly useful in anatomically challenging areas like the pelvis or C2 1
• For metastatic humeral disease, cement augmentation during fixation provides improvements in postoperative pain and mobility with no difference in complications compared to fixation alone 1

When Open Surgery is Required

• Intramedullary nailing is the preferred operative approach for metastatic long bone disease, providing good functional results in 80-85% of patients with effective analgesia in the majority 1
• Standard total joint arthroplasty is indicated for pathologic fractures of the femoral head and neck, and for intertrochanteric fractures with metastases in the neck and head 1
• Open surgical approach is recommended when extensive osteolytic destruction exists or lesions are in bones subjected to forces other than compression (femur, humerus, tibia) 1
• Complete radiographic evaluation is essential before surgery to assess bone integrity, as healthy bone is necessary for proper fixation and hardware durability 1

Osteoporotic Fractures in Elderly Patients

Proximal Humerus

• Most proximal humeral fractures can be treated non-operatively with good functional outcomes 2
• When surgical fixation is required in osteoporotic bone, cement augmentation with PHILOS plate fixation provides appropriate reduction with significant mechanical support for displaced unstable fractures with marked bony defect 3

Femoral Neck

• Stable non-displaced femoral neck fractures are addressed with percutaneous cannulated fixation, while displaced fractures require hemiarthroplasty or total hip replacement 2
• Bone cement implantation syndrome (characterized by hypoxia, hypotension, or loss of consciousness around cementation time) can be reduced through proper surgical technique including medullary lavage, cement gun use, and femoral venting 1

Tibial Plateau

• Insufficiency fractures of the tibial plateau in osteoporotic patients can be treated with percutaneous polymethylmethacrylate augmentation ("tibiaplasty"), allowing immediate full weight-bearing with excellent pain reduction 4
• This minimally invasive technique is feasible with no secondary loss of reduction or progression of arthrosis observed in radiological controls 4

Augmentation Principles and Outcomes

Mechanical Benefits

• Cement augmentation increases screw pullout strength by approximately 4-fold in osteoporotic bone models, with tricalcium phosphate cement performing equivalently to PMMA 5
• TCP-augmented locked plate constructions show 5-fold increase in fixation strength compared to standard plates without augmentation (p<0.05) 5
• Augmentation strengthens bone around screws, providing valuable support against cut-out even in angle-stable plate-screw systems 6

Common Pitfalls

• Avoid PMMA cement when removal might become necessary due to great difficulties in extraction 6
• Ensure proper surgical technique to minimize cement leakage risk: use medullary lavage, good hemostasis before insertion, cement gun for retrograde insertion, and femoral venting 1
• Radiotherapy should be performed 2-4 weeks following orthopedic procedures for metastatic disease (30 Gy in 10 fractions or 20 Gy in 5 fractions) 1
• Preoperative embolization is indicated for highly vascularized metastases (kidney, melanoma, thyroid) ideally performed the day before surgery 1