Percutaneous reduction and fixation of an intra-articular calcaneal fracture using an inflatable bone tamp: description of a novel and safe technique
© Mauffrey et al; licensee BioMed Central Ltd. 2012
Received: 22 February 2012
Accepted: 15 March 2012
Published: 15 March 2012
Calcaneal fractures are common injuries involving the hind foot and often a source of significant long-term morbidity. Treatment options have changed throughout the ages from periods of preferred nonoperative management to closed reduction with a mallet, and more recently, open reduction and anatomic internal fixation. The current treatment of choice; however, is often debated, as open management of these fractures carries many risks to include wound breakdown and infection. A less invasive form of surgical management through small incisions, while maintaining the ability to obtain joint congruency, anatomic alignment, and restore calcaneal height and width would be ideal. We propose a novel form of fracture reduction using an inflatable bone tamp and percutaneous fracture fixation. Preoperative planning and experienced fluoroscopy is crucial to successful management using this method. Although we achieved successful radiographic outcome in this case, long-term functional outcome of this technique are yet to be published.
Two thirds of hind foot fractures involve the calcaneus . The treatment of choice for intra-articular fractures is still debated and a number of trials have flourished in recent years to address this particular issue [2, 3]. Possible treatments options for a depressed intra articular fracture include limb elevation with application of a bulky jones dressing, open reduction internal fixation with plate and screws or percutaneous reduction and fixation using screws. Other techniques using fine wire external fixation have also been described . The goal of the treatment of intra-articular displaced fractures is to focus on the anatomical reduction of the articular surface, avoid complications, and correct the length, width and angulation of the tuberosity. The open reduction and internal fixation technique allows the operator to view the articular surface directly during the reduction and fixation process but the high rate of wound breakdown and infection (15-40%) is a concern [5, 6]. Percutaneous techniques use, by definition, a smaller incision but the reduction is often challenging and inadequate. We propose a novel form of reduction using an inflatable bone tamp. This technique has been described in the tibial plateau [7, 8] but very few papers are available for its application in the calcaneus .
We use a radiolucent table. The optimal positioning of the patient is prone with foam padding placed under both knees and a bump under the affected leg to achieve lateral fluoroscopy images without having to move the unaffected leg. Intravenous antibiotics are given at induction before the tourniquet is inflated. The leg is prepared up to the mid-thigh with Chlorhexidine solution and draped in sterile manner. With a sterile marker pen we highlight the Achilles tendon insertion on the calcaneus.
A clear adhesive dressing is applied around the foot and ankle and infiltration of 2 ml of 0.25% Marcaine with 1/200,000 of adrenaline is infiltrated into the area of incision down to the periosteum to reduce postoperative pain and intraoperative bleeding.
We do not check our wounds until removal of sutures on the 14th day post op. We leave the wounds dry and covered. When the sutures are removed, the leg is placed in a protective postoperative boot and the patient remains non-weight bearing for a total of 10 weeks, or until the fracture is radiologically and clinically healed. Physical therapy is important in the early phases to allow active and passive knee, ankle and forefoot range of motion and prevent stiffness.
Pitfalls and difficulties
The operator should be aware of pitfalls and difficulties when performing this technique. During the reduction maneuver, the balloon can burst, leaving the radio-opaque dye in the sub articular region. This can occur if the balloon encounters a very sharp bone fragment. Should this occur, the surgeon should irrigate the bone void via the cannula using normal saline and reinsert a balloon. Another possible difficulty is that the balloon does not inflate evenly and the articular fragment does not elevate. This has been described as the trapdoor phenomenon in tibial plateau fractures . This phenomenon occurs when the compression in the medial to lateral plane prevents the reduction of the articular fragment. It is therefore important not to apply a clamp to reduce the lateral wall or the sustentaculum tali fragments until the articular fragment has been elevated to its anatomical position. Finally, the operator should understand the risk of having a liquid form of calcium phosphate injected into a bone void with potential extravasation into the subtalar joint or through the lateral wall. This risk can be limited by the correct timing of injection of the calcium phosphate so that it is not too runny but also by regular fluoroscopy so as to stop the injection if there is extravasation.
We present one of the first in vivo descriptions of the use of an inflatable bone tamp for intra-articular calcaneal fractures. It is crucial to select the right patients with a fracture that is both amenable to reduction by inflation plasty and with comminution not to severe as to have extravasation of a liquid bone substitute in the joint. The ideal fracture is one with a large depressed articular fragment. The preoperative planning is also critical to determine the ideal angle of the cannula insertion and plan for the vector of push during the balloon inflation phase. This will define the location of insertion of the wires to provide support during the inflation phase. Preoperative planning also serves to identify the angle and direction of the screw that will support the articular fragment and fix the sustentaculum tali fragment. The long-term advantages of this technique are yet to be published and we have no data on long-term functional outcome.
The patient fully agreed with publication of this case report, including the publication of medical data, radiological imaging, and intraoperative pictures. Written informed consent is available to the Editor-in-Chief upon request.
- Sangeorzan BJ, Benirschke SK, Car JB: Surgical management of the os calcis. Instr Course Lect. 1995, 44: 359-370.PubMedGoogle Scholar
- Thordarson DB, Krieger LE: Operative vs.non-operative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot Ankle Int. 1996, 17: 2-9.View ArticlePubMedGoogle Scholar
- Buckley R, Tough S, McCormack R: Operative compared with nonoperative treatment of displaced intra-articular fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002, 84: 1733-1744.PubMedGoogle Scholar
- Mauffrey C, Klutts P, Seligson D: The use of circular fine wire frames for the treatment of displaced intra-articular calcaneal fractures. J Orthopaed Traumatol. 2009, 10: 9-15. 10.1007/s10195-008-0037-z.View ArticleGoogle Scholar
- Maskill JD, Bohay DR, Anderson JG: Calcaneus fractures: a review article. Foot Ankle Clin. 2005, 10: 463-489. 10.1016/j.fcl.2005.03.002.View ArticlePubMedGoogle Scholar
- McBride DJ, Rammamurthy C, Laing P: The hindfoot: calcaneal and talar fractures and dislocations--Part I: Fractures of the calcaneum. Current Orthopaedics. 2005, 19: 94-100. 10.1016/j.cuor.2005.03.004.View ArticleGoogle Scholar
- Broome B, Seligson D: Inflation osteoplasty for the reduction of depressed tibial plateau fractures: description of a new technique. European Journal of Orthopaedic Surgery & Traumatology. 2010, doi:10.1007/s00590-010-0692-7Google Scholar
- Broome B, Mauffrey C, Statton J, Voor M, Seligson D: Inflation osteoplasty: in vitro evaluation of a new technique for reducing depressed intra-articular fractures of the tibial plateau and distal radius. J Orthopaed Traumatol. doi:10.1007/s10195-012-0185-zGoogle Scholar
- Heiney JP, O'Connor JA: Balloon Reduction And Minimally Invasive Fixation (BRAMIF) for Extremity Fractures with the Application of Fast-Setting Calcium Phosphate. J Orthopaedics. 2010, 7 (2): e8-Google Scholar
- Broome B, Mauffrey C, Statton J, Seligson D: How to avoid the 'trap door' effect in reducing tibial plateau fractures. Orthopaedics. 2011, http://www.orthosupersite.com/view.aspx?rid=90262Google Scholar
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