1. n tips & techniques
Section Editor: Steven F. Harwin, MD
Percutaneous Inflation Osteoplasty for
Indirect Reduction of Depressed Tibial
Plateau Fractures
Jens 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 with
Abstract: Anatomic reduction of articular depression tibial tion of distal radius, calcaneus, touch-down weight bearing to
plateau fractures is challenging. The authors describe a new cuboid, tibial pilon, and tibial the left lower extremity. She
technique 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 10
fluoroscopy-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 treated
metaphyseal void is filled with a fast-setting fluid-phase bone
substitute, and a lateral buttress plate is applied with less inva-
by inflation osteoplasty. Surgical Technique
Standard precautions are
sive incisions. This technique is a valid alternative for indirect
reduction 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 the
ration of anatomic joint con- phoplasty has been established patient was otherwise healthy patient to the operating room.11
gruency, 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 is
stable fracture fixation, and bral compression fractures.4,5 amination, she had a left knee under general anesthesia and
allowing 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 small
spouse was a salaried employee with Medtronic, Inc, which is the parent
company 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 the
Department of Orthopaedics, Denver Health Medical Center, University of depression fracture (Figure trocar is placed center-center
Colorado, School of Medicine, 777 Bannock St, Denver, CO 80204 (philip.
1). The patient was placed in approximately 2 to 3 mm below
stahel@dhha.org).
doi: 10.3928/01477447-20120822-04 a knee immobilizer and was the depression, in the anteropos-
768 ORTHOPEDICS | Healio.com/Orthopedics
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 trocars
Figure 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 no
is emphasized on coronal (C), sagittal (D), sagittal (E), and axial (F) sections guidance (Figure 3), until the data suggest that this minor
computed 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 of
2). To avoid subsidence of the ing 2 or 3 rafting K-wires just 250 to 300 psi. Results
inflatable tamp away from the below the balloon to achieve the Fluoroscopic images should Postoperatively, the patient
depressed 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 the
second trocar can be placed with into the weaker metaphyseal sive inflation to ensure proper affected lower extremity and
the tip just adjacent to the other bone, particularly in young pa- positioning of the balloon, and allowed knee range of motion
trocar (Figure 3), which allows tients (C Mauffrey, oral com- adequate metaphyseal void as tolerated. She was followed
for the lower balloon to support munication, January 2012). A formation and to avoid over- up at 2 weeks for a wound
the reduction pressure from the large, pointed reduction clamp correction of the articular frag- check and staple removal. At
more cranial balloon. Other au- is applied in a percutaneous ment into the joint space. After 6 weeks, radiographs demon-
770 ORTHOPEDICS | Healio.com/Orthopedics
4. n tips & techniques
3A 3B 3C
Figure 3: Fluoroscopy-guided indirect reduction of the depressed fragment in the lateral tibial plateau by stepwise balloon inflation (A, B), until achieving an
anatomic articular reduction (C).
strated a maintained anatomic ther advantage, as described for
articular reduction (Figures balloon-guided kyphoplasty
6A, B). The patient was then al- for vertebral fractures,5,12 is
lowed to progressively increase the creation of a cancellous
her weight-bearing status to bone void, which allows an
weight 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 the
tive range of motion of her left first of a patient with a 1-year
knee (0°-140°) at 3 months. follow-up after successful
The patient was last seen for management of a depressed
a 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 4
demonstrated 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-term
Discussion 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 room
reduction 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. The
emerged in various indica- trauma and associated inflam- the ease and quality of reduc- latter notion is of particular
tions, including vertebral frac- matory response. Also, the tion and may contribute to im- importance in the current age
tures, foot and wrist injuries, open operative time is short- proved long-term outcomes. of nonreimbursable never
and tibial plafond and plateau ened, which decreases the risk Some potential limitations events, such as postoperative
fractures.4-10,12,13 For articu- of a postoperative infection. of this new technique must be infections.18 Finally, as for
lar 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 learning
of fluoroscopy-guided percu- pressed tibial plateau fractures, instruments for the balloon in- curve will be associated with
taneous inflation osteoplasty leading to long-term morbidity flation technique, as opposed an increased complication rate
appears 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 exists
clude minimal soft tissue com- step-off in the tibial plateau has that analyze whether indirect Conclusion
promise, improved accuracy of been recognized as a major risk costs related to decreased op- The new technique of
articular 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. 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, Parekh
Figure 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 Ankle
stitute 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. Correction
safe, 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 Orthop
lar 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 bicondylar
outcomes. Future prospective 2008; 31:649. assisted balloon osteoplasty for tibial plateau fractures treated
controlled studies are needed to Colles’ fractures in osteoporotic with dual incisions and medial
3. Stahel PF, Smith WR, Morgan
compare 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 | Healio.com/Orthopedics
