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n tips & techniquesSection Editor: Steven F. Harwin, MD

Depressed tibial plateau fractures remain chal-

lenging with regard to resto-ration of anatomic joint con-gruency, adequate grafting of the metaphyseal bone defect, stable fracture fixation, and allowing early knee range of motion to achieve excellent long-term functional out-

comes.1-3 The concept of in-direct fracture reduction by balloon-guided inflation ky-phoplasty has been established for many years in the manage-ment of osteoporotic verte-bral compression fractures.4,5 Recently, this technique was extrapolated to its application for other indications, includ-

ing the indirect joint reduc-tion of distal radius, calcaneus, cuboid, tibial pilon, and tibial plateau fractures.6-10 However, until now, no long-term out-come has been described for tibial plateau fractures treated by inflation osteoplasty.

Case RepoRtA 51-year-old woman sus-

tained a lateral tibial plateau depression fracture after a low-energy trauma when falling and twisting her left knee. The patient was otherwise healthy and had no preexisting medi-cal conditions. On clinical ex-amination, she had a left knee joint effusion and tenderness on palpation on the lateral side. The knee was stable to varus/valgus stress examination and Lachman testing, and she had a normal neurovascular status to the left lower extremity. Plain radiographs and a computed tomography scan of the left knee demonstrated a Schatzker type III (AO/OTA 41-B2.2)–equivalent lateral tibial plateau depression fracture (Figure 1). The patient was placed in a knee immobilizer and was

allowed to use crutches with touch-down weight bearing to the left lower extremity. She was scheduled for elective sur-gical fracture fixation within 10 days after injury.

suRgiCal teChniqueStandard precautions are

applied regarding identification and marking of the correct sur-gical site and ensuring a stan-dardized preverification pro-cess according to the Universal Protocol, prior to bringing the patient to the operating room.11 The surgical procedure is per-formed while the patient is under general anesthesia and placed on a radiolucent operat-ing table in the supine position. A thigh tourniquet is applied but not inflated during the bal-loon osteoplasty part of the procedure.

Under fluoroscopic guid-ance, the trocar for the inflatable bone tamp is placed in a medial-to-lateral fashion, using a small percutaneous skin incision on the medial side. The tip of the trocar is placed center-center approximately 2 to 3 mm below the depression, in the anteropos-

Abstract: Anatomic reduction of articular depression tibial plateau fractures is challenging. The authors describe a new technique using percutaneous balloon-guided inflation os-teoplasty for a depressed lateral tibial plateau fracture. The fluoroscopy-guided inflation osteoplasty restores the joint surface anatomically in a minimally invasive fashion. The metaphyseal void is filled with a fast-setting fluid-phase bone substitute, and a lateral buttress plate is applied with less inva-sive incisions. This technique is a valid alternative for indirect reduction of depressed articular tibial plateau fractures.

Drs Hahnhaussen, Hak, Weckbach, and Stahel are from the Department of Orthopaedics, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado; and Dr Heiney is from the Depart-ment of Orthopaedics, University of Toledo Medical Center, Toledo, Ohio.

Drs Hahnhaussen, Hak, and Weckbach have no relevant financial rela-tionships to disclose. Dr Heiney is a consultant for Kyphon, Inc. Dr Stahel’s spouse was a salaried employee with Medtronic, Inc, which is the parent company of Kyphon, Inc, during this study.

Correspondence should be addressed to: Philip F. Stahel, MD, FACS, Department of Orthopaedics, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock St, Denver, CO 80204 (philip.stahel@dhha.org).

doi: 10.3928/01477447-20120822-04

Percutaneous Inflation Osteoplasty for Indirect Reduction of Depressed Tibial Plateau FracturesJens Hahnhaussen, MD; David J. Hak, MD, MBA; Sebastian Weckbach, MD; Jake P. Heiney, MD; Philip F. Stahel, MD, FACS

SEPTEMBER 2012 | Volume 35 • Number 9 769

Cover Story

Cover illustration © Scott Holladay

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terior and lateral planes (Figure 2). To avoid subsidence of the inflatable tamp away from the depressed fragment into the cancellous metahpyseal bone, a second trocar can be placed with the tip just adjacent to the other trocar (Figure 3), which allows for the lower balloon to support the reduction pressure from the more cranial balloon. Other au-

thors have recommended plac-ing 2 or 3 rafting K-wires just below the balloon to achieve the same effect and avoid subsid-ence of the bone tamp pressure into the weaker metaphyseal bone, particularly in young pa-tients (C Mauffrey, oral com-munication, January 2012). A large, pointed reduction clamp is applied in a percutaneous

fashion to avoid displacement of the lateral split fracture frag-ment during inflation of the bal-loons (Figure 4). Attention must be paid not to overcompress the lateral condyle because this may lead to entrapment of the depressed fragment and the in-ability to achieve an anatomic articular congruence (so-called trap door effect).

In the current case, 2 bal-loons with a volume of 15 and 20 cc, respectively, were deemed appropriate, using the KyphX Xpander Inflatable Bone Tamp system (Kyphon, Inc, Sunnyvale, California). As a trial, the balloons are in-flated to approximately 50 psi. The stepwise inflation is then performed under fluoroscopic guidance (Figure 3), until the depressed fragment is ana-tomically reduced, without ex-ceeding a maximal pressure of 250 to 300 psi.

Fluoroscopic images should be taken every 0.5 to 1.0 cc (or 30 to 50 psi) of progres-sive inflation to ensure proper positioning of the balloon, and adequate metaphyseal void formation and to avoid over-correction of the articular frag-ment into the joint space. After

ensuring anatomic reduction, 2 subchondral 1.6-mm K-wires are placed to hold the articular reduction and avoid a second-ary subsidence as the balloons are deflated and withdrawn (Figure 5).

After applying a lateral buttress plate of choice, the metaphyseal void is filled with a fluid-phase hydroxy-apatite (eg, Hydroset; Stryker, Mahwah, New Jersey) injected through the trocars. Three to 4 rafting screws should be placed as a subchondral raft to hold the articular reduction (Figure 5). The authors recom-mend filling the residual canal of the removed trocar with the bone substitute as the trocars are withdrawn, although no data suggest that this minor void could be a potential stress riser (Figure 6A, arrows).

ResultsPostoperatively, the patient

was mobilized with touch-down weight bearing on the affected lower extremity and allowed knee range of motion as tolerated. She was followed up at 2 weeks for a wound check and staple removal. At 6 weeks, radiographs demon-

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 is emphasized on coronal (C), sagittal (D), sagittal (E), and axial (F) sections computed tomography scans.

1A 1B

1C

1D

1E 1F

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 peak of depression.

2A 2B

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strated a maintained anatomic articular reduction (Figures 6A, B). The patient was then al-lowed to progressively increase her weight-bearing status to weight bearing as tolerated by 10 weeks. She had an excellent long-term outcome and was free of symptoms with full ac-tive range of motion of her left knee (0°-140°) at 3 months. The patient was last seen for a scheduled 1-year follow-up (14 months postoperatively), at which point final radiographs demonstrated a maintained long-term reduction and fixa-tion (Figures 6C, D).

DisCussionRecently, balloon-guided

reduction techniques for can-cellous bone fractures have emerged in various indica-tions, including vertebral frac-tures, foot and wrist injuries, and tibial plafond and plateau fractures.4-10,12,13 For articu-lar depression fractures of the proximal tibia, the technique of fluoroscopy-guided percu-taneous inflation osteoplasty appears to have several advan-tages over conventional open reduction techniques. These in-clude minimal soft tissue com-promise, improved accuracy of articular reduction, and a lower risk of joint penetration. A fur-

ther advantage, as described for balloon-guided kyphoplasty for vertebral fractures,5,12 is the creation of a cancellous bone void, which allows an improved fluid-phase bone ce-ment distribution.

To the current authors’ knowledge, this report is the first of a patient with a 1-year follow-up after successful management of a depressed tibial plateau fracture using this novel technique. As out-lined in this case report, the technique is minimally inva-sive, safe, accurate, and as-sociated with excellent radio-logical and clinical long-term results. The percutaneous re-duction technique spares the soft tissue envelope, which is usually compromised by the trauma and associated inflam-matory response. Also, the open operative time is short-ened, which decreases the risk of a postoperative infection.

Posttraumatic osteoarthritis is a common sequelae of de-pressed tibial plateau fractures, leading to long-term morbidity and the potential need for revi-sion surgery and joint replace-ment.14,15 A residual articular step-off in the tibial plateau has been recognized as a major risk factor for developing posttrau-matic knee arthritis.16,17 The

accuracy of inflation osteo-plasty-guided articular reduc-tion, as outlined in the current report (Figure 3), may facilitate the ease and quality of reduc-tion and may contribute to im-proved long-term outcomes.

Some potential limitations of this new technique must be addressed. Incontestably, the costs related to the single-use instruments for the balloon in-flation technique, as opposed to using a conventional bone tamp, are drastically increased. However, a lack of data exists that analyze whether indirect costs related to decreased op-erative time and reduced inci-dence of complications, which

may warrant an unplanned return to the operating room for revision surgery, may off-set the overall cost factor. The latter notion is of particular importance in the current age of nonreimbursable never events, such as postoperative infections.18 Finally, as for any newly introduced tech-nique, an individual learning curve will be associated with an increased complication rate in the early phase until a pro-vider’s proficiency is achieved.

ConClusionThe new technique of

balloon-guided inflation osteo-plasty represents an improved,

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).

3B3A 3C

Figure 4: Photograph of the medial portals for the balloon trocars and place-ment of a percutaneous pointed reduction clamp to avoid a breach of the lat-eral wall or displacement of a lateral split fragment.

4

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safe, and accurate modality for anatomic restoration of articu-lar congruence in depressed tibial plateau fractures, which is likely associated with im-proved radiological and clinical outcomes. Future prospective controlled studies are needed to compare the safety and effi-ciency of this new modality with established conventional reduction techniques.

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Tzioupis C, Siska PA, Pape HC. New trends and techniques in open reduction and internal fixation of fractures of the tibial

plateau. J Bone Joint Surg Br. 2009; 91:426-433.

2. Newman JT, Smith WR, Ziran BH, Hasenboehler EA, Stahel PF, Morgan SJ. Efficacy of composite allograft and demin-eralized bone matrix graft in treating tibial plateau fracture with bone loss. Orthopedics. 2008; 31:649.

3. Stahel PF, Smith WR, Morgan SJ. Posteromedial fracture frag-ments of the tibial plateau: an unsolved problem? J Orthop Trauma. 2008; 22:504.

4. Boonen S, Wahl DA, Nauroy L, et al. Balloon kyphoplasty and vertebroplasty in the manage-ment of vertebral compression fractures. Osteoporos Int. 2011; 22:2915-2934.

5. Robinson Y, Tschoke SK, Sta-hel PF, Kayser R, Heyde CE.

Complications and safety as-pects of kyphoplasty for osteo-porotic vertebral fractures: a prospective follow-up study in 102 consecutive patients. Pa-tient Saf Surg. 2008; 2:2.

6. Iida K, Sudo A, Ishiguro S. Clinical and radiological results of calcium phosphate cement-assisted balloon osteoplasty for Colles’ fractures in osteoporotic senile female patients. J Orthop Sci. 2010; 15:204-209.

7. Mauffrey C, Bailey JR, Hak DJ, Hammerberg ME. Percutane-ous reduction and fixation of an intra-articular calcaneal frac-ture using an inflatable bone tamp: description of a novel and safe technique. Patient Saf Surg. 2012; 6(1):6.

8. Broome B, Seligson D. Infla-tion osteoplasty for the reduc-tion of depressed tibial plateau

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.

10. Heim KA, Sullivan C, Parekh SG. Cuboid reduction and fixa-tion using a kyphoplasty bal-loon: a case report. Foot Ankle Int. 2008; 29:1154-1157.

11. 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.

12. Anselmetti GC, Muto M, Gug-lielmi G, Masala S. Percutane-ous vertebroplasty or kypho-plasty. Radiol Clin North Am. 2010; 48:641-649.

13. 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-sinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN. Complications af-ter tibia plateau fracture surgery. Injury. 2006; 37:475-484.

15. Marti RK, Kerkhoffs GM, Rademakers MV. Correction of lateral tibial plateau depres-sion and valgus malunion of the proximal tibia. Oper Orthop Traumatol. 2007; 19:101-113.

16. Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, Be-nirschke SK. Functional out-comes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am. 2006; 88:1713-1721.

17. Giannoudis PV, Tzioupis C, Papathanassopoulos A, Obak-ponovwe O, Roberts C. Ar-ticular step-off and risk of post-traumatic osteoarthritis: Evidence today. Injury. 2010; 41:986-995.

18. Lembitz A, Clarke TJ. Clarify-ing “never events” and intro-ducing “always events.” Patient Saf Surg. 2009; 3:26.

Figure 6: Follow-up anteroposterior (A) and lateral (B) radiographs showing a maintained anatomic articular reduction at 6 weeks. The previous trocar path was filled with fluid-phase bone substitute to avoid a potential stress riser (arrows). Follow-up anteroposterior (C) and lateral (D) radiographs showing a maintained anatomic articular reduction at 14 months.

6A 6B 6C 6D

Figure 5: Intraoperative fluoroscopy images. After ensuring anatomic reduction, 2 temporary K-wires are placed to avoid a secondary subsidence once the balloons are deflated (A, B). The metaphyseal void is filled with a fast-setting fluid-phase bone sub-stitute injected through the trocars (B). A lateral buttress plate is applied and subchon-dral rafting screws are placed to support the articular reduction (B, C).

5B5A

5C