Image-guided Percutaneous Osteosynthesis: Beyond the Limits

In interventional radiology, percutaneous osteosynthesis has experienced major growth, pushing boundaries that were unimaginable 20 years ago. Driven by advanced imaging (computed tomography, cone-beam computed tomography, electromagnetic navigation, computed tomography-fluoroscopy fusion, and emerging robotics), by a refined understanding of bone biomechanics, and by improved knowledge of implant behavior (fully or partially threaded screws, washers, cement augmentation), its indications now extend from trauma to osteoporosis/insufficiency fractures and oncology.This article provides a practical framework for safely going "further": rational selection of devices according to cortical or cancellous bone, planning of long or oblique trajectories (iliosacral, trans-sacro-bi-iliac, acetabular roof, odontoid, sternum), use of adjunct techniques (hydrodissection, thermal ablation, embolization), and, when necessary, external reduction maneuvers under image guidance. We highlight decision-making principles, indications, anatomical limitations, and pitfalls to avoid (sacral foramina, shear forces, narrow corridors), as well as adapted pain management and anesthesia strategies.By mastering indications, guidance systems, and a detailed understanding of underlying pathologies, interventional radiology offers minimally invasive, stable, and durable solutions. This approach accelerates patient remobilization and transforms situations once deemed inoperable into safe, personalized, and reproducible trajectories. These advances firmly establish interventional radiology as a central multidisciplinary actor in musculoskeletal care.