BackTable Bone & Sports

From anesthesia decisions to ablation strategy, what really separates a good outcome from a great one in bone tumor ablation? This BackTable MSK Brief features an enlightening conversation between host Kavi Krishnasamy and bone ablation pioneer Dr. Damian Dupuy. They cover anesthesia choices for different patient scenarios, optimal procedural techniques and agent selection for bone ablations, and the combination of local and systemic therapies for oligometastatic and oligo-progressive diseases. The doctors also tackle myths and realities around thermal and cryoablation, examining both clinical trial data and real-world experiences. 

Episode Outline

00:00 - Introduction

00:40 - Selecting General Anesthesia vs. MAC

03:30 - Approach to Multiple Bony Lesions in Metastatic Disease

07:27 - Ablation Confirmation and Techniques Utilized in Bone Ablation 

09:00 - Research Insights Surrounding RFA in Bone

12:16 - Sclerotic vs. Lytic Lesions: Techniques and Considerations

14:47 - Skin Protection During Superficial Lesion Treatments

16:38 - Analyzing Clinical Trials: Motion and OPuS One

20:51 - Conclusion

Resources

Dr. Damian E. Dupuy, MD, FACR

https://www.linkedin.com/in/damian-e-dupuy-md-facr-6b080b1b/ 

Radiofrequency Ablation Provides Rapid and Durable Pain Relief for the Palliative Treatment of Lytic Bone Metastases Independent of Radiation Therapy: Final Results from the OsteoCool Tumor Ablation Post-Market Study

https://pmc.ncbi.nlm.nih.gov/articles/PMC10156864/ 

Cryoablation for Palliation of Painful Bone Metastases: The MOTION Multicenter Study

https://pmc.ncbi.nlm.nih.gov/articles/PMC8011449/

Bone tumor treatment: when do you burn it and when do you freeze it? In this BackTable MSK Brief, Dr. Damian Dupuy joins Host Dr. Kavi Krishnasamy to discuss the technical nuances of radiofrequency ablation (RFA) and cryoablation, patient selection criteria, procedural strategies, and the importance of setting appropriate patient expectations. Dr. Dupuy also shares insights on preventing complications like cryomyositis and myoglobinuria, underscoring the balance between aggressive treatment and patient safety.

Episode Outline

00:00 - Introduction

00:40 - Bone Tumor Interface and Time Under Treatment

05:10 - Patient Selection and Treatment Considerations

07:57 - Approach to Large Bony Lesions

12:37 - Best Treatment Modality: Cryoablation vs. RFA

13:38 - Managing Collateral Damage

15:58 - Navigating Patient Expectations

Resources

Dr. Damian E. Dupuy, MD, FACR

https://www.linkedin.com/in/damian-e-dupuy-md-facr-6b080b1b/ 

Solitary painful osseous metastases: correlation of imaging features with pain palliation after radiofrequency ablation--a multicenter american college of radiology imaging network study

https://pubmed.ncbi.nlm.nih.gov/23657892/

Can genicular artery embolization (GAE) relieve chronic knee pain after total knee arthroplasty (TKA)? In this episode of BackTable MSK, Argentinian interventional radiologist Dr. Rene Viso joins host Dr. Kavi Krishnasamy to discuss the status of GAE in South America, patient selection criteria, procedural techniques, and the challenges of treating post-TKA patients with GAE.

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SYNPOSIS

Dr. Viso also highlights the importance of multidisciplinary collaboration and adjunctive therapies like genicular nerve blocks to improve patient outcomes. The episode concludes with a discussion on Dr. Viso's recent research and case studies, emphasizing the potential and complexities of GAE in managing chronic knee pain.

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TIMESTAMPS

00:00 - Introduction
02:02 - GAE in South America
03:57 - Patient Selection for GAE
13:18 - Procedure Techniques and Device Choices
23:54 - Challenges and Tips for TKA Patients Undergoing GAE
27:17 - Patient Follow-Up After Intervention
29:41 - Handling Treatment Failures
32:57 - Adjunctive Therapies for Post-TKA Patients with GAE
34:46 - Research Update: Dr. Viso’s Recent Publication on GAE in Post-TKA Patients
39:44 - Case Studies and Discussion
50:19 - Future Directions and Final Thoughts

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RESOURCES

Dr. Rene Viso
https://www.linkedin.com/in/rene-viso-11a245132/

Genicular Artery Embolization for Persistent Pain after Total Knee Arthroplasty: Initial Clinical Experience
https://pubmed.ncbi.nlm.nih.gov/41320119/

How is genicular artery embolization reshaping our clinical approach to patients with chronic knee pain? Dr. Rachel Piechowiak and Dr. Faraz Khan, interventional radiologists at IR Centers join Dr. Don Garbett in a deep dive into the current state of Genicular Artery Embolization (GAE).

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SYNPOSIS

Dr. Piechowiak and Dr. Khan provide a deep dive on the technical nuances of GAE, covering patient selection, access strategies, and key procedural techniques. The conversation also details complex case scenarios and how to tailor catheters and embolics to navigate challenging anatomy. The doctors then share their structured approach to post-procedure follow-up, underscoring the importance of setting realistic treatment expectations with patients. The episode closes with their perspective on the future of genicular artery embolization, emphasizing the need for robust long-term outcomes data to better define the role of GAE in chronic knee pain management.

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TIMESTAMPS

00:00 - Introduction
05:54 - Patient Workup for GAE
10:42 - Setting Patient Expectations for GAE
16:24 - Procedure Approaches and Techniques
30:41 - Understanding Artery Targeting Strategies
34:56 - Approaches to Microcatheter Selection
38:18 - Choosing the Right Embolic Agents
47:43 - Managing Complications and Follow-Ups
51:23 - Challenges with Post-TKA Patients
54:16 - Future Directions

Frozen shoulder is characterized by progressive motion loss, distinct disease stages, and new treatment opportunities; raising important questions about timing, patient selection, and new interventional strategies. In this episode of the BackTable MSK Podcast, guest host Osman Ahmed welcomes orthopedic surgeon and upper extremity specialist Dr. Sameer Nagda to discuss the intricacies of adhesive capsulitis of the shoulder (“frozen shoulder”).

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SYNPOSIS

Dr. Nagda shares his expertise on diagnosing and treating frozen shoulder, including the evaluation process, treatment options, and the role of early intervention. He emphasizes the importance of recognizing the stages of frozen shoulder and the potential benefits of embolization, particularly in the inflammatory stage. Dr. Nagda also shares his journey into shoulder specialization and his collaborative efforts with IR specialists to improve patient outcomes.

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TIMESTAMPS

00:00 - Introduction
04:29 - The Run Down: What is Frozen Shoulder?
08:37 - Approaching the Diagnosis of Frozen Shoulder
13:51 - Treatment Paradigms
22:48 - Comparing Traditional Treatments vs. Embolization
26:39 - An Orthopedic Surgeon’s Perspective on Embolization for Frozen Shoulder
35:36 - Surgical Options and When to Consider Them
37:55 - Final Thoughts

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RESOURCES

Dr. Sameer Nagda, MD
https://www.sameernagdamd.com/sameer-nagda-md-sports-medicine-specialist-arlington-va.html

Adhesive Capsulitis of the Shoulder
https://journals.lww.com/jaaos/abstract/2011/09000/adhesive_capsulitis_of_the_shoulder.4.aspx

Treatment of Adhesive Capsulitis of the Shoulder
https://journals.lww.com/jaaos/abstract/2019/06150/treatment_of_adhesive_capsulitis_of_the_shoulder.3.aspx

Your bony fixation technique can make (or break) a complex fracture case. In this episode of the BackTable MSK Podcast, host Kavi Krishnasamy welcomes Dr. Brandon Key, interventional radiologist at Medical College of Wisconsin (MCW) in Milwaukee, to discuss bone stabilization techniques in treating pathologic and non-pathologic fractures.

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SYNPOSIS

Dr. Key shares insights into his practice, highlighting the importance of multidisciplinary collaboration with orthopedic surgery, the challenges of training in bony fixation, and the evolving technology that aids in these procedures, including the use of IlluminOss Photodynamic nails in complex bone interventions. Several detailed case studies illustrate the practical application and benefits of these advanced techniques, emphasizing their impact on patient outcomes and functionality.

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TIMESTAMPS

00:00 - Introduction
02:06 - A Run Down of Bone Stabilization in the IR Space
12:54 - What’s in the Toolbox?
17:51 - Patient Preparation and Procedure Setup
29:47 - Combining Fixation with Thermal Ablation
34:12 - Introducing the Photodynamic Nail by IlluminOss
40:22 - “The Learning Curve” of the Photodynamic Nail
47:48 - Dr. Key’s Guidance for Practice Building
52:01 - Literature Highlights on IlluminOss
55:01 - Case 1: Anterior Column Disease
01:01:27 - Case 2: Isolated Posterior Column Disease
01:05:37 - Case 3: Non-healing Pathologic Fracture of Pubic Ramus
01:09:37 - Case 4: Iliac Wing Fixation with Orthopedic Surgery
01:15:40 - Case 5: Sacral Defects
01:19:45 - Case 6: Reconstruction of Posterior Iliac Wing
01:23:50 - Post-Procedure Outcomes and Reflections
01:29:02 - Final Thoughts: Encouragement for Collaboration and Innovation

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RESOURCES

Dr. Brandon Key, MD
https://www.linkedin.com/in/brandon-key-md-367a01310/

A Prospective Study of the IlluminOss Photodynamic Nail System for Pelvic Stabilization: Treatment of Impending and Actual Fractures from Metastatic Bone Disease, Multiple Myeloma, and Primary Bone Lymphoma
https://pubmed.ncbi.nlm.nih.gov/39281295/

Minimally Invasive Stabilization Using Screws and Cement for Pelvic Metastases: Technical Considerations for the Pelvic "Screw and Glue" Technique
https://pubmed.ncbi.nlm.nih.gov/31435131/

IlluminOss
https://illuminoss.com/us

Flow-FX
https://flow-fx.net/products/

How to stay cool when a thermal ablation case gets complicated? Your toolbox can make all the difference. In this episode of the BackTable MSK Podcast, Dr. Alan Sag returns with host Dr. Jacob Fleming to continue the discussion on thermal protection in musculoskeletal ablation procedures. Part 2 focuses on real-world cases to provide practical insights and illustrate decision-making in complex thermal ablation cases.

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SYNPOSIS

Dr. Sag and Dr. Fleming discuss thermoprotection strategies in real-world cases, such as radiofrequency ablation (RFA) of inoperable rectal cancer and sacral metastases near nerve roots. They also discuss the importance of interdisciplinary collaboration, emerging technologies in the field, and the role of intraoperative neuromonitoring.

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TIMESTAMPS

00:00 - Introduction
00:55 - Ganglion Impar and Pelvic Pain Strategies
09:08 - The Active Thaw Phenomenon
18:20 - Nerve Protection During Ablations
23:16 - Motor and Sensory Neuromonitoring
34:06 - Temperature Management in Ablative Procedures
40:28 - Dosing Strategies for Gabapentin and Lyrica in Nerve Injuries
42:33 - Future Directions

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RESOURCES

Dr. Alan Alper Sag, M.D., FSIR
https://med.miami.edu/faculty/alan-alper-sag-md-fsir

Thermal Protection: Heightened Safety for Minimally Invasive Percutaneous Ablation of Musculoskeletal Tumors
https://pubs.rsna.org/doi/10.1148/rg.240238

Intraoperative Neuromonitoring for Peripheral Nerve Surgery
https://mayoclinic.elsevierpure.com/en/publications/intraoperative-neuromonitoring-for-peripheral-nerve-surgery/

Burns = big consequences. Let’s talk thermoprotection. In this episode of the BackTable MSK Podcast, host Jacob Fleming welcomes longtime friend and colleague Dr. Alan Sag to discuss thermoprotection in musculoskeletal ablation procedures over this two-part episode series. Part 1 focuses on established strategies and new techniques for protecting critical structures during ablation.

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SYNPOSIS

Dr. Sag shares how he approaches thermoprotection in complex MSK ablation cases. The discussion covers hydro-dissection techniques, hydro convection needle strategies, pump and tubing set up, troubleshooting, and visualization of the protective layer.

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TIMESTAMPS

00:00 - Introduction
02:49 - Thermoprotection 101
12:37 - Skin Injury and Mitigation Strategies
18:57 - Avoiding Bottlenecks with Hydrodissection
23:49 - Practical Recommendations for Cold Skin Protection
29:36 - Managing Complications and Wound Care
38:12 - Heating up with RFA and Microwave Ablations

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RESOURCES

Dr. Alan Alper Sag, M.D., FSIR
https://med.miami.edu/faculty/alan-alper-sag-md-fsir

Thermal Protection: Heightened Safety for Minimally Invasive Percutaneous Ablation of Musculoskeletal Tumors
https://pubs.rsna.org/doi/10.1148/rg.240238

Intraoperative Neuromonitoring for Peripheral Nerve Surgery
https://mayoclinic.elsevierpure.com/en/publications/intraoperative-neuromonitoring-for-peripheral-nerve-surgery/

Ablate before you radiate. Success with bone tumor ablation may have as much to do with your procedure technique as it does with your ability to collaborate. In this episode of BackTable MSK, interventional oncologist Dr. Damian Dupuy shares his approach to bone tumor ablation with host Dr. Kavi Krishnasamy, and offers practical advice on how to partner with your cancer care team to make ablation a viable treatment option.

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This podcast is supported by:

Medtronic Osteocool

https://www.medtronic.com/en-us/healthcare-professionals/products/surgical-energy/ablation/radiofrequency-ablation/systems/osteocool-2-0-bone-tumor-ablation-system.html

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SYNPOSIS

The doctors review the history of bone ablation techniques, including radiofrequency and cryoablation modalities. They discuss the significance of targeting the bone-tumor interface for pain palliation and highlight several case studies to illustrate various techniques and successful outcomes. The conversation also touches upon the synergistic benefits of combining ablation with radiation therapy and emphasizes the importance of multidisciplinary collaboration in treating cancer patients.

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TIMESTAMPS

00:00 - Introduction
02:07 - Dr. Dupuy’s Start in Bone Ablation
06:29 - Cryo vs. Microwave Therapies
08:25 - Dr. Dupuy’s Clinical Trial and Research Involvement
12:49 - Patient Selection and Treatment Strategies
25:54 - Sedation and Anesthesia Practices in Bone Ablation
28:46 - Treatment Approach: Oligometastases vs. Progressive Disease
36:22 - Microwave Ablation in Bone: Future Prospects
37:30 - Techniques for Treating Sclerotic and Lytic Lesions
40:01 - Skin Protection Methods in Superficial Lesion Treatments
41:49 - Reviewing Recent Clinical Trials: MOTION, OPuS One, and More
52:35 - Case Studies: Achieving Effective Ablation Techniques
01:08:08 - Final Thoughts and Recommendations

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RESOURCES

Dr. Damian E. Dupuy, MD, FACR
https://www.linkedin.com/in/damian-e-dupuy-md-facr-6b080b1b/

Solitary painful osseous metastases: correlation of imaging features with pain palliation after radiofrequency ablation--a multicenter american college of radiology imaging network study
https://pubmed.ncbi.nlm.nih.gov/23657892/

Radiofrequency Ablation Provides Rapid and Durable Pain Relief for the Palliative Treatment of Lytic Bone Metastases Independent of Radiation Therapy: Final Results from the OsteoCool Tumor Ablation Post-Market Study
https://pmc.ncbi.nlm.nih.gov/articles/PMC10156864/

Cryoablation for Palliation of Painful Bone Metastases: The MOTION Multicenter Study
https://pmc.ncbi.nlm.nih.gov/articles/PMC8011449/

A Multi-Center Observational Trial of Symptomatic, High-Risk Bone Metastases Treated with Percutaneous Ablation and Palliative Radiation Therapy (TRIBUTE)
https://clinicaltrials.gov/study/NCT06859801

“We learn traditionally that bone metastasis is terminal.” 一 Or is it? In this episode of the BackTable MSK podcast, host Dr. Jacob Fleming welcomes Dr. Francis Lee, a leading figure in orthopedic oncology, to discuss advancements in treating skeletal metastasis. Dr. Lee, the Wayne O. Southwick Professor from Yale and President-elect of the Musculoskeletal Tumor Society, shares his innovative AORIF (Ablation, Osteoplasty, Reinforcement and Internal Fixation) technique, which emphasizes collaboration between orthopedic oncologists and interventional radiologists.

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This podcast is supported by an educational grant from Medtronic.

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SYNPOSIS

The conversation covers the complexities of bone metastasis, the biomechanics of skeletal ablation, and the importance of understanding bone-cancer interactions. Dr. Lee also shares insights from his translational research on cancer and bone dynamics, and emphasizes the need for continued interdisciplinary collaboration to drive forward minimally invasive treatments.

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TIMESTAMPS

00:00 - Introduction
01:39 - Crash Course: Orthopedic Oncology 101
13:24 - The Important Role of Biomechanics
20:10 - Dr Lee’s Training and Interdisciplinary Collaboration
28:13 - Intraoperative Imaging and Techniques in AORIF
40:15 - Cannulated Screws for Access and Fixation
42:24 - Case Study: Sacral Insufficiency Fracture and Cement Injection
44:17 - Understanding Cement Properties and Application
46:45 - Case Study Series: Approach to Reconstruction
57:58 - Decision Making in Complex Procedures
01:08:40 - The Power of Bone Regeneration
01:12:31 - Final Thoughts

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RESOURCES

Dr. Francis Lee, MD, PhD, FAAOS, MBA
https://medicine.yale.edu/profile/francis-lee/

Minimally Invasive Image-Guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) for Osteolytic Lesions in the Pelvis and Periarticular Regions of Weight-Bearing Bones
https://pubmed.ncbi.nlm.nih.gov/32139256/