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n tips & techniquesSection Editor: Steven F. Harwin, MDPercutaneous Inflation Osteoplasty forIndirect Reduction of Depress...
Cover Story                                  Cover illustration © Scott HolladaySEPTEMBER 2012 | Volume 35 • Number 9	769
n tips & techniques                                                                                                       ...
n tips & techniques                                                3A                                                    3...
n tips & techniques                                                                                                       ...
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Inflation osteoplasty


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  1. 1. n tips & techniquesSection Editor: Steven F. Harwin, MDPercutaneous Inflation Osteoplasty forIndirect Reduction of Depressed TibialPlateau FracturesJens Hahnhaussen, MD; David J. Hak, MD, MBA; Sebastian Weckbach, MD; Jake P. Heiney, MD;Philip F. Stahel, MD, FACS ing the indirect joint reduc- allowed to use crutches withAbstract: Anatomic reduction of articular depression tibial tion of distal radius, calcaneus, touch-down weight bearing toplateau fractures is challenging. The authors describe a new cuboid, tibial pilon, and tibial the left lower extremity. Shetechnique using percutaneous balloon-guided inflation os- plateau fractures.6-10 However, was scheduled for elective sur-teoplasty for a depressed lateral tibial plateau fracture. The until now, no long-term out- gical fracture fixation within 10fluoroscopy-guided inflation osteoplasty restores the joint come has been described for days after injury.surface anatomically in a minimally invasive fashion. The tibial plateau fractures treatedmetaphyseal void is filled with a fast-setting fluid-phase bonesubstitute, and a lateral buttress plate is applied with less inva- by inflation osteoplasty. Surgical Technique Standard precautions aresive incisions. This technique is a valid alternative for indirectreduction of depressed articular tibial plateau fractures. Case Report applied regarding identification A 51-year-old woman sus- and marking of the correct sur- tained a lateral tibial plateau gical site and ensuring a stan-D epressed tibial plateau fractures remain chal-lenging with regard to resto- comes.1-3 The concept of in- direct fracture reduction by balloon-guided inflation ky- depression fracture after a low- energy trauma when falling and twisting her left knee. The dardized preverification pro- cess according to the Universal Protocol, prior to bringing theration of anatomic joint con- phoplasty has been established patient was otherwise healthy patient to the operating room.11gruency, adequate grafting of for many years in the manage- and had no preexisting medi- The surgical procedure is per-the metaphyseal bone defect, ment of osteoporotic verte- cal conditions. On clinical ex- formed while the patient isstable fracture fixation, and bral compression fractures.4,5 amination, she had a left knee under general anesthesia andallowing early knee range of Recently, this technique was joint effusion and tenderness placed on a radiolucent operat-motion to achieve excellent extrapolated to its application on palpation on the lateral side. ing table in the supine position.long-term functional out- for other indications, includ- The knee was stable to varus/ A thigh tourniquet is applied valgus stress examination and but not inflated during the bal- Lachman testing, and she had a loon osteoplasty part of the Drs Hahnhaussen, Hak, Weckbach, and Stahel are from the Department normal neurovascular status to procedure.of Orthopaedics, Denver Health Medical Center, University of Colorado,School of Medicine, Denver, Colorado; and Dr Heiney is from the Depart- the left lower extremity. Plain Under fluoroscopic guid-ment of Orthopaedics, University of Toledo Medical Center, Toledo, Ohio. radiographs and a computed ance, the trocar for the inflatable Drs Hahnhaussen, Hak, and Weckbach have no relevant financial rela- tomography scan of the left bone tamp is placed in a medial-tionships to disclose. Dr Heiney is a consultant for Kyphon, Inc. Dr Stahel’s knee demonstrated a Schatzker to-lateral fashion, using a smallspouse was a salaried employee with Medtronic, Inc, which is the parentcompany of Kyphon, Inc, during this study. type III (AO/OTA 41-B2.2)– percutaneous skin incision on Correspondence should be addressed to: Philip F. Stahel, MD, FACS, equivalent lateral tibial plateau the medial side. The tip of theDepartment of Orthopaedics, Denver Health Medical Center, University of depression fracture (Figure trocar is placed center-centerColorado, School of Medicine, 777 Bannock St, Denver, CO 80204 (philip. 1). The patient was placed in approximately 2 to 3 mm doi: 10.3928/01477447-20120822-04 a knee immobilizer and was the depression, in the anteropos-768 ORTHOPEDICS |
  2. 2. Cover Story Cover illustration © Scott HolladaySEPTEMBER 2012 | Volume 35 • Number 9 769
  3. 3. n tips & techniques 2A 2B Figure 2: Anteroposterior (A) and later (B) fluoroscopic images showing per- cutaneous placement of the trocar for the inflatable bone tamp. The ideal posi- tion of the trocar tip is located centrally, approximately 2 to 3 mm below the 1A 1B peak of depression. fashion to avoid displacement ensuring anatomic reduction, 2 of the lateral split fracture frag- subchondral 1.6-mm K-wires ment during inflation of the bal- are placed to hold the articular loons (Figure 4). Attention must reduction and avoid a second- be paid not to overcompress ary subsidence as the balloons the lateral condyle because this are deflated and withdrawn 1C may lead to entrapment of the (Figure 5). depressed fragment and the in- After applying a lateral ability to achieve an anatomic buttress plate of choice, the articular congruence (so-called metaphyseal void is filled trap door effect). with a fluid-phase hydroxy- 1D In the current case, 2 bal- apatite (eg, Hydroset; Stryker, loons with a volume of 15 Mahwah, New Jersey) injected and 20 cc, respectively, were through the trocars. Three deemed appropriate, using to 4 rafting screws should be the KyphX Xpander Inflatable placed as a subchondral raft Bone Tamp system (Kyphon, to hold the articular reduction Inc, Sunnyvale, California). (Figure 5). The authors recom- As a trial, the balloons are in- mend filling the residual canal flated to approximately 50 psi. of the removed trocar with the 1E 1F The stepwise inflation is then bone substitute as the trocarsFigure 1: Anteroposterior (A) and lateral (B) radiographs of the left knee show-ing a depressed lateral tibial plateau fracture. The extent of central depression performed under fluoroscopic are withdrawn, although nois emphasized on coronal (C), sagittal (D), sagittal (E), and axial (F) sections guidance (Figure 3), until the data suggest that this minorcomputed tomography scans. depressed fragment is ana- void could be a potential stress tomically reduced, without ex- riser (Figure 6A, arrows).terior and lateral planes (Figure thors have recommended plac- ceeding a maximal pressure of2). To avoid subsidence of the ing 2 or 3 rafting K-wires just 250 to 300 psi. Resultsinflatable tamp away from the below the balloon to achieve the Fluoroscopic images should Postoperatively, the patientdepressed fragment into the same effect and avoid subsid- be taken every 0.5 to 1.0 cc was mobilized with touch-cancellous metahpyseal bone, a ence of the bone tamp pressure (or 30 to 50 psi) of progres- down weight bearing on thesecond trocar can be placed with into the weaker metaphyseal sive inflation to ensure proper affected lower extremity andthe tip just adjacent to the other bone, particularly in young pa- positioning of the balloon, and allowed knee range of motiontrocar (Figure 3), which allows tients (C Mauffrey, oral com- adequate metaphyseal void as tolerated. She was followedfor the lower balloon to support munication, January 2012). A formation and to avoid over- up at 2 weeks for a woundthe reduction pressure from the large, pointed reduction clamp correction of the articular frag- check and staple removal. Atmore cranial balloon. Other au- is applied in a percutaneous ment into the joint space. After 6 weeks, radiographs demon-770 ORTHOPEDICS |
  4. 4. n tips & techniques 3A 3B 3CFigure 3: Fluoroscopy-guided indirect reduction of the depressed fragment in the lateral tibial plateau by stepwise balloon inflation (A, B), until achieving ananatomic articular reduction (C).strated a maintained anatomic ther advantage, as described forarticular reduction (Figures balloon-guided kyphoplasty6A, B). The patient was then al- for vertebral fractures,5,12 islowed to progressively increase the creation of a cancellousher weight-bearing status to bone void, which allows anweight bearing as tolerated by improved fluid-phase bone ce-10 weeks. She had an excellent ment distribution.long-term outcome and was To the current authors’free of symptoms with full ac- knowledge, this report is thetive range of motion of her left first of a patient with a 1-yearknee (0°-140°) at 3 months. follow-up after successfulThe patient was last seen for management of a depresseda scheduled 1-year follow-up tibial plateau fracture using(14 months postoperatively), at this novel technique. As out-which point final radiographs lined in this case report, the 4demonstrated a maintained technique is minimally inva- Figure 4: Photograph of the medial portals for the balloon trocars and place-long-term reduction and fixa- sive, safe, accurate, and as- ment of a percutaneous pointed reduction clamp to avoid a breach of the lat- eral wall or displacement of a lateral split fragment.tion (Figures 6C, D). sociated with excellent radio- logical and clinical long-termDiscussion results. The percutaneous re- accuracy of inflation osteo- may warrant an unplanned Recently, balloon-guided duction technique spares the plasty-guided articular reduc- return to the operating roomreduction techniques for can- soft tissue envelope, which is tion, as outlined in the current for revision surgery, may off-cellous bone fractures have usually compromised by the report (Figure 3), may facilitate set the overall cost factor. Theemerged in various indica- trauma and associated inflam- the ease and quality of reduc- latter notion is of particulartions, including vertebral frac- matory response. Also, the tion and may contribute to im- importance in the current agetures, foot and wrist injuries, open operative time is short- proved long-term outcomes. of nonreimbursable neverand tibial plafond and plateau ened, which decreases the risk Some potential limitations events, such as postoperativefractures.4-10,12,13 For articu- of a postoperative infection. of this new technique must be infections.18 Finally, as forlar depression fractures of the Posttraumatic osteoarthritis addressed. Incontestably, the any newly introduced tech-proximal tibia, the technique is a common sequelae of de- costs related to the single-use nique, an individual learningof fluoroscopy-guided percu- pressed tibial plateau fractures, instruments for the balloon in- curve will be associated withtaneous inflation osteoplasty leading to long-term morbidity flation technique, as opposed an increased complication rateappears to have several advan- and the potential need for revi- to using a conventional bone in the early phase until a pro-tages over conventional open sion surgery and joint replace- tamp, are drastically increased. vider’s proficiency is achieved.reduction techniques. These in- ment.14,15 A residual articular However, a lack of data existsclude minimal soft tissue com- step-off in the tibial plateau has that analyze whether indirect Conclusionpromise, improved accuracy of been recognized as a major risk costs related to decreased op- The new technique ofarticular reduction, and a lower factor for developing posttrau- erative time and reduced inci- balloon-guided inflation osteo-risk of joint penetration. A fur- matic knee arthritis.16,17 The dence of complications, which plasty represents an improved,SEPTEMBER 2012 | Volume 35 • Number 9 771
  5. 5. n tips & techniques fractures: description of a new technique. Eur J Orthop Surg Traumatol. 2010; doi: 10.1007/ s00590-010-0692-7 9. Heiney JP, O’Connor JA. Bal- loon reduction and minimally invasive fixation (BRAMIF) for extremity fractures with the ap- plication of fast-setting calcium phosphate. J Orthopaedics. 2010; 7:e8. 5A 5B 1 0. Heim KA, Sullivan C, ParekhFigure 5: Intraoperative fluoroscopy images. After ensuring anatomic reduction, 2 SG. Cuboid reduction and fixa-temporary K-wires are placed to avoid a secondary subsidence once the balloons are tion using a kyphoplasty bal-deflated (A, B). The metaphyseal void is filled with a fast-setting fluid-phase bone sub- loon: a case report. Foot Anklestitute injected through the trocars (B). A lateral buttress plate is applied and subchon- Int. 2008; 29:1154-1157.dral rafting screws are placed to support the articular reduction (B, C). 5C 1 1. Stahel PF, Mehler PS, Clarke TJ, Varnell J. The 5th anniversary of the “Universal Protocol”: pit- falls and pearls revisited. Patient Saf Surg. 2009; 3:14. 1 2. Anselmetti GC, Muto M, Gug- lielmi G, Masala S. Percutane- ous vertebroplasty or kypho- plasty. Radiol Clin North Am. 2010; 48:641-649. 1 3. Ishiguro S, Oota Y, Sudo A, Uchida A. Calcium phosphate cement-assisted balloon osteo- plasty for a Colles’ fracture on arteriovenous fistula forearm of a maintenance hemodialysis patient. J Hand Surg Am. 2007; 32:821-826. 14. Papagelopoulos PJ, Part- 6A 6B 6C 6D sinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS,Figure 6: Follow-up anteroposterior (A) and lateral (B) radiographs showing a maintained anatomic articular reduction at Soucacos PN. Complications af-6 weeks. The previous trocar path was filled with fluid-phase bone substitute to avoid a potential stress riser (arrows). ter tibia plateau fracture surgery.Follow-up anteroposterior (C) and lateral (D) radiographs showing a maintained anatomic articular reduction at 14 months. Injury. 2006; 37:475-484. 15. Marti RK, Kerkhoffs GM, plateau. J Bone Joint Surg Br. Complications and safety as- Rademakers MV. Correctionsafe, and accurate modality for 2009; 91:426-433. pects of kyphoplasty for osteo- of lateral tibial plateau depres-anatomic restoration of articu- 2. Newman JT, Smith WR, Ziran porotic vertebral fractures: a sion and valgus malunion of the prospective follow-up study in proximal tibia. Oper Orthoplar congruence in depressed BH, Hasenboehler EA, Stahel 102 consecutive patients. Pa- Traumatol. 2007; 19:101-113.tibial plateau fractures, which PF, Morgan SJ. Efficacy of tient Saf Surg. 2008; 2:2. 1 6. Barei DP, Nork SE, Mills WJ, composite allograft and demin-is likely associated with im- eralized bone matrix graft in Iida K, Sudo A, Ishiguro S. 6. Coles CP, Henley MB, Be-proved radiological and clinical treating tibial plateau fracture Clinical and radiological results nirschke SK. Functional out- with bone loss. Orthopedics. of calcium phosphate cement- comes of severe bicondylaroutcomes. Future prospective 2008; 31:649. assisted balloon osteoplasty for tibial plateau fractures treatedcontrolled studies are needed to Colles’ fractures in osteoporotic with dual incisions and medial 3. Stahel PF, Smith WR, Morgancompare the safety and effi- senile female patients. J Orthop and lateral plates. J Bone Joint SJ. Posteromedial fracture frag- Sci. 2010; 15:204-209. Surg Am. 2006; 88:1713-1721.ciency of this new modality ments of the tibial plateau: an unsolved problem? J Orthop 7. Mauffrey C, Bailey JR, Hak DJ, 17. Giannoudis PV, Tzioupis C, with established conventional Trauma. 2008; 22:504. Hammerberg ME. Percutane- Papathanassopoulos A, Obak-reduction techniques. 4. Boonen S, Wahl DA, Nauroy L, ous reduction and fixation of an ponovwe O, Roberts C. Ar- intra-articular calcaneal frac- ticular step-off and risk of et al. Balloon kyphoplasty and ture using an inflatable bone post-traumatic osteoarthritis:References vertebroplasty in the manage- tamp: description of a novel Evidence today. Injury. 2010; ment of vertebral compression 1. Musahl V, Tarkin I, Kobbe P, and safe technique. Patient Saf 41:986-995. fractures. Osteoporos Int. 2011; Tzioupis C, Siska PA, Pape Surg. 2012; 6(1):6. 1 8. Lembitz A, Clarke TJ. Clarify- 22:2915-2934. HC. New trends and techniques 8. Broome B, Seligson D. Infla- ing “never events” and intro- in open reduction and internal 5. Robinson Y, Tschoke SK, Sta- tion osteoplasty for the reduc- ducing “always events.” Patient fixation of fractures of the tibial hel PF, Kayser R, Heyde CE. tion of depressed tibial plateau Saf Surg. 2009; 3:26.772 ORTHOPEDICS |