Case 9

Percutaneous Pelvic Augmentation:

Supra-Acetabular Region
John M. Mathis

Clinical Presentation

A 57-year-old man, with known metastatic carcinoma to bone, pre-

sented with severe pain in the region of the right hip. The patient was
unable to walk and was basically confined to bed, as even transfers to
a wheelchair created severe pain. The patient had an indwelling pain
pump, but this did not manage the acute pain caused by hip motion
and weight bearing.

Imaging Findings

A computed tomography (CT) scan of the pelvis revealed bone destruc-

tion of the pelvis in the region above the right acetabulum by tumor
(Case Figure 9.1A,B). Local radiographs of this area also confirmed the
lytic process (Case Figure 9.1C). The adjacent femur was not involved.

Procedure

Percutaneous bone augmentation with cement was chosen because of

the minimally invasive nature of the procedure with essentially no
postprocedure recovery. The surgical procedure that was an alternative
was discussed with the patient and declined because of the protracted
recovery that would be necessary.
The patient received intravenous Ancef (1 gram) and intraven-
ous procedural sedation with fentanyl and Versed. An 11-gauge
trocar–cannula system was introduced along the pelvic axis into the
supra-acetabular area (Case Figure 9.2A). Fluoroscopy along the tract
of the needle and perpendicular to the needle axis allow needle
positioning.
Simplex P was mixed with 30% sterile barium sulfate and then
injected into the tumor mass above the acetabulum (Case Figure 9.2B).
The needle was withdrawn as local filling was achieved (Case Figure

285
286 J.M. Mathis

A B

Case Figure 9.1. (A,B) Axial CT scans of the pelvis show destruction of the pelvis above the acetabu-
lum on the right (white arrows). A soft tissue mass of tumor is seen adjacent to the affected bone (white
arrowheads). (C) A pelvic radiograph demonstrates the lytic destruction of bone (black arrows) in the
supra-acetabular region on the right.

9.2C,D). After the immediate region above the acetabulum was filled,
a new needle was introduced above the original fill zone (Case Figure
9.3A). This allowed an additional layer of cement to be added to
increase the augmentation of bone in this region (Case Figure 9.3B,C).
This can be done several times as needed to eventually have the cement
bridge areas of normal bone. The procedure was tolerated well by the
patient, and there were no clinical side effects.

Results

The patient had substantial pain relief within 24 hours of the proce-
dure. He was able to transfer from bed to wheelchair with assistance
and with minimal pain. Also, he was able to walk with a walker with
only mild pain. This was a tremendous improvement and allowed him
to resume care at home by his family.
 Case 9 Percutaneous Pelvic Augmentation 287

A B

C D

Case Figure 9.2. (A) Fluoroscopic image showing the cement injection needle in place above the acetab-
ulum. (B,C) Cement (white arrows) is being injected at various locations along the needle track. (D)
The final cement deposition in this first needle location.

Discussion

This case demonstrates the opportunity for percutaneous, image-

guided bone augmentation in areas other than the spine. This patient’s
longevity was not affected by this treatment, but he did achieve an
improved quality of life that allowed him to be at home with his family.
The recovery from minimally invasive procedures is usually markedly
shorter than for comparable open surgical procedures.
288 J.M. Mathis

A B

Case Figure 9.3. (A) Fluoroscopic image showing the second needle position (white arrow) but before
more cement is injected here. (B) Additional cement has been injected through the second needle. (C)
Final image shows the total cement (white arrows) volume placed in the supra-acetabular region, aug-
menting this portion of previously destroyed bone.