Percutaneous Spindle Osteosynthesis Reinforced by Cementoplasty on a Pathological Fracture of the Distal Clavicle

A 77-year-old woman was hospitalized in a palliative care unit for a metastatic hepatocellular carcinoma, which was complicated by a pathological fracture of the distal right clavicle. The patient had complete functional disability of the right upper limb. She experienced severe pain (visual analog scale score = 8/10) triggered by the slightest movement of the right upper limb, and clinical examination revealed a clavicular anteroposterior drawer sign. Computed tomography scan confirmed a fractured lytic lesion of the right distal clavicle (Fig 1). In this case, surgical options were limited (1Singh A. Schultzel M. Fleming J.F. Navarro R.A. Complications after surgical treatment of distal clavicle fractures.Orthop Traumatol Surg Res. 2019; 105: 853-859Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar). The management of these fractures as reported in the literature lacks consensus, because the bone’s friable nature does not allow sufficient anchoring of screws (2Moverley R. Little N. Gulihar A. Singh B. Current concepts in the management of clavicle fractures.J Clin Orthop Trauma. 2020; 11: S25-S30Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). This patient had a poor short-term prognosis, with multiple symptomatic bone metastases requiring narcotic therapy. Radiotherapy (8 Gy in 1 session) was first performed for analgesic purposes. After 1 month, the patient still experienced severe mechanical pain. She had lost all functional independence and could no longer use her walker. Anesthesiologists deemed her unsuitable for general anesthesia, and surgery was refused by the orthopedic surgeons who recommended simple immobilization of the extremity because they thought that the surgical material would not hold. Furthermore, surgery would have required extensive rehabilitation because of the muscle debridement, and the patient had a poor short-term prognosis. A minimally invasive percutaneous approach was proposed. This study obtained approval from the Terre d'Ethique local research committee. Because a distal clavicular fracture is subjected mainly to tensile forces, a simple cementoplasty would not allow sufficient stabilization. Spindles (Stylo Kit; Thiebaud, Thonon-les-Bains, France) were used to reinforce cementoplasty and resist tensile and bending forces, similar to the procedure used to strengthen the femoral neck (3Premat K. Clarençon F. Bonaccorsi R. Degos V. Cormier É. Chiras J. Reinforced cementoplasty using dedicated spindles in the management of unstable malignant lesions of the cervicotrochanteric region.Eur Radiol. 2017; 27: 3973-3982Crossref PubMed Scopus (13) Google Scholar), comparable to Kirschner wire or spindle osteosynthesis performed by orthopedic surgeons. The required length of the spindle was measured preprocedurally. To maintain the possibility of raising the arm >45° for the patient to use her walker, the planned spindle repair would spare the acromioclavicular joint. The procedure was performed under computed tomographic and fluoroscopic guidance with moderate sedation without intubation (ketamine 25 mg, midazolam 2 mg, and remifentanyl 681 μg) and local anesthesia (xylocaine 10 mL and naropeine 10 mL). The patient was placed in the supine position. A percutaneous approach was made posterior to the acromion in the long axis of the clavicular bone. An 11-gauge trocar (t’am; Thiebaud) was placed through the pathological fracture site (Fig 2). A biopsy was performed and confirmed the involvement with hepatocellular carcinoma. The first spindle was introduced within the trocar and anchored in the clavicle’s anterior cortex 3 cm from the medial edge of the lytic lesion. The distal end of the spindle was placed within the pathological bone next to the distal cortical bone. The second spindle was introduced anteriorly to the first one in the distal cortical bone, passed through the lesion, and fixed into the posterior cortex next to the first spindle to strengthen the osteosynthesis (Fig 3). Eventually, the trocar was pulled a few centimeters into the pathological bone to fill the lytic lesion. Three milliliters of cement (poly methyl methacrylate, Be Ever; Thiebaud) were injected under fluoroscopic control, with the final filling considered to be satisfactory. The medial cortical bone, the distal cement, and the cortical attachments of the spindle limited migration risk. The poly methyl methacrylate partially replaced the pathological tissue. The scar was less than one centimeter long.Figure 3Computed tomography scan showed the 2 wires (arrowhead) in place within the clavicle with end within the lesion to create a bridge with healthy bone and respecting the acromioclavicular joint (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) No postoperative immobilization was required. There was no longer an anteroposterior drawer sign clinically. The patient experienced an immediate favorable outcome (visual analog scale score = 2). The patient could perform daily tasks, such as washing, independently, and the recovery of function of her right upper limb allowed her to use her walker to ambulate and to avoid complications of being bedridden. After 1 month, the patient showed a marked decrease in opioid consumption, with a decrease in oral morphine equivalent of 75 mg/d, from 125 to 50 mg/d, primarily to manage pain caused by her other metastases. In addition, she could elevate her arm higher than her shoulder because the acromioclavicular joint was preserved. The American Shoulder and Elbow Surgeons score increased after surgery at 1 month from 12 to 67 points out of 100. Radiography at the 3-month follow-up showed spindles and cement in place (Fig 4). The patient was followed by telephone consultation at 8 months, during which she was determined to have a stable functional outcome. Stabilization of the distal clavicle’s pathological fracture resulted in immediate pain relief, restored upper limb function, and allowed rapid resumption of activities of daily living. The reinforcing percutaneous cementoplasty adjunctive to the spindle placement allowed 3-dimensional stabilization of the fracture site while allowing solid anchoring of the spindles. The authors thank Susannah Carroll for her help in manuscript preparation.