Special Focus Section

31

Balloon Tibioplasty: Pearls and Pitfalls Cyril Mauffrey, MD, FACS, FRCS1 Gareth Roberts, MBBCh, MRCS1 Benoit Herbert, MD1 David Hak, MD, MBA1

University of Colorado, School of Medicine, Denver, Colorado J Knee Surg 2014;27:31–38.

Abstract

Keywords

► ► ► ►

tibial plateau balloon tibioplasty osteoplasty

Address for correspondence Cyril Mauffrey, MD, FACS, FRCS, Director of Orthopaedic Research, Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204 (e-mail: [email protected]).

Methods of tibial plateau fracture fixation have evolved over the last decades; however the techniques used to reduce these fractures have remained relatively unchanged. Balloon tibioplasty, a minimally invasive novel technique used in the reduction of depressed tibial plateau fractures, has been gaining popularity. This technique offers a slow controlled expansion of the balloon with multidirectional force vectors and a large surface area allowing for more bone to be elevated simultaneously. The technique also creates a well-defined bone void of known volume while theoretically compressing the surrounding bone, potentially limiting the risk of cement extrusion as well as late subsidence of the elevated bone. Although an attractive option, as with all novel techniques there is a learning curve. The purpose of this article is to briefly describe our technique of balloon tibioplasty, potential contraindications, and to illustrate some possible complications, and provide some tips and tricks we have found useful to avoid them.

Tibial plateau fractures account for around 1% of all fractures.1 As with other periarticular fractures they show a bimodal age distribution, being common in young adults (20 to 40 years of age) as well as in the osteoporotic elderly (> 60 years of age). Treatment has evolved over the decades from closed treatment in a plaster cast or cast brace to open reduction and internal fixation with early mobilization. Several methods of fixation have emerged, particularly with the advent of locking plate technology, however the methods of reduction have remained relatively unchanged with either direct open reduction or indirect reduction using a bone tamp. Access to the subchondral bone defect is usually gained through the fracture itself or through a cortical window within the metaphyseal bone, from where the defect can be reached and elevated. Bone graft, cancellous chips, or biological cements are then used to support the elevated articular fragment and fill the metaphyseal void. Several challenges have been identified with this technique due to the hardness and small surface area of the stainless steel tamps, unidirectional vector of reduction, and lack of a controlled elevation. These limitations can lead to fragmentation of the depressed fragment, overreduction, and joint

penetration with the bone tamp, or malreduction of the articular surface. Recently balloon tibioplasty has been introduced as an alternative reduction method, with early positive results. The multidirectional vector of reduction, its minimally invasive technique, controlled elevation/expansion, softness of the material, and large surface area of the balloon make it an attractive option. The surgical technique itself has previously been well-described and is gaining popularity (►Fig. 1).2 However, as with any new technique there is a learning curve and up to 60% of previously reported cases that had some form of intraoperative complication.3 The purpose of this article is to present our technique of balloon tibioplasty for depressed tibial plateau fractures, describe potential contraindications, and include several tips and tricks we found useful for when “things go wrong.”

received October 28, 2013 accepted after revision November 1, 2013 published online December 13, 2013

Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

Balloon Tibioplasty Balloon tibioplasty has been used in spine surgery for several years.4 It involves introducing an inflatable balloon below an area of compression and using the force generated by

DOI http://dx.doi.org/ 10.1055/s-0033-1363516. ISSN 1538-8506.

Downloaded by: National University of Singapore. Copyrighted material.

1 Department of Orthopaedic Surgery, Denver Health Medical Center,

Derly O. Cuellar, MD1

Pearls and Pitfalls of Balloon Tibioplasty

Mauffrey et al.

Fig. 1 Intraoperative fluoroscopic views demonstrating our “standard” percutaneous balloon tibioplasty, as previously described. 6 Bottom right panel, arrow pointing at a small amount of extruded calcium phosphate into the soft tissue, a “no harm” event. (Reprinted with permission from Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8.)

inflating the balloon to restore the native anatomy. The defect left by the balloon is then filled with a bone filler to support the subchondral bone. Outside of the spine it has been used in the distal radius, proximal humerus, acetabulum, proximal tibia, calcaneus, and cuboid with positive results.5–11 The advantages of balloon tibioplasty include: • A minimally invasive percutaneous approach (only requiring an eight gauge, 4 mm hole) (►Fig. 2). • A slow controlled expansion/reduction, with numerous feedbacks both visual (by fluoroscopy) and tactile (syringe plunger firmness) with balloon pressure readings. • A large surface area, which elevates more bone than traditional bone tamps. • A multidirectional vector of elevation. • Creation of a cancellous bone void of known volume, which can be easily filled with bone fillers. The device used for balloon tibioplasty is the KyphX Inflatable Bone Tamp (Kyphon Inc./Medtronic, Sunnyvale, CA), composed of three biocompatible parts: The Journal of Knee Surgery

Vol. 27

No. 1/2014

• A proximal luer fitting. • A central catheter. • A distal inflatable tip with radiopaque markers. Balloon inflation is achieved using an external inflation syringe filled with a radiopaque dye (i.e., Omnipaque [iohexol], GE Healthcare, Chicago, IL). The inflation syringe system measures the volume (mL) and pressure (pounds per square inch, psi) within the balloon. The inflatable bone tamp is U. S. Food and Drug Administration (FDA)-approved for use “as conventional bone tamps for the reduction of fractures and/or creation of a void in cancellous bone in the spine, hand, tibia, radius, and calcaneus.”12

Balloon Tibioplasty: Preoperative Considerations Numerous authors have reported their early experiences using balloon tibioplasty, but only Heiney and O’Connor have followed up sufficient patients to show that a good reduction is achieved and maintained for at least 12 weeks.13

Downloaded by: National University of Singapore. Copyrighted material.

32

Pearls and Pitfalls of Balloon Tibioplasty

Mauffrey et al.

33

the appropriate candidates has been the main cause of problems in one series (►Fig. 3).3

Indications

Fig. 2 Intraoperative photograph illustrating the “true” percutaneous balloon tibioplasty technique, with minimally invasive incisions for the medial-to-lateral cannulas, anterioposterior rafting wires, and lateral cannulated lag screws insertions. (Reprinted with permission from Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8.)

To date there has been no published randomized trial comparing the results of balloon tibioplasty versus traditional bone tamps for the treatment of depressed tibial plateau fractures. In a cadaveric model, balloon tibioplasty has been shown to be superior to a metal tamp, which was “unable to adequately reduce articular comminution and easily penetrated the joint or over reduced the articular surface.”2

Preoperative Planning It is imperative that all tibial plateau fractures being considered for balloon tibioplasty undergo a fine cut CT scan to assess the fracture’s suitability and plan the reduction. Identifying the area of depression and its position in the coronal, sagittal, and axial plans is crucial. Failure to plan and identify

In our opinion, balloon tibioplasty works best for isolated depressed tibial plateau fractures or simple split-depressed tibial plateau fractures, that is, Shatzker types II and III.14 The ideal fracture is one with a large depressed fragment that is centrally located. The presence of a complete cortical ring is important for achieving articular reduction, since the balloon expands in all directions not just upward toward the articular surface. A simple associated split can be easily reduced with a pointed reduction clamp, thereby reconstructing the cortical ring before balloon inflation. However, when a posterior split exists, controlling this split with a clamp becomes more difficult and we would suggest other reduction techniques for these fracture patterns (►Fig. 4).

Hint It is important to close the split to create a cortical ring; however, over tightening of the clamp may create the so-called “trap-door” effect, which will prevent elevation of the depressed fragments.

Time from Injury From our experience we would suggest that balloon tibioplasty be performed within 2 weeks following the injury. Some of our research suggests that cases with longer delays have higher failure rate.3

Balloon Tibioplasty: Surgical Procedure The skin around the knee is marked to denote the joint line, the level of the greatest articular depression, and the tibial tubercle. For lateral depression fractures, a stab incision is made on the medial side corresponding to the level of

Fig. 3 A computed tomography (CT) scan depicting the importance of preoperative planning with a fine cut CT scan, which must be scrutinized for proper patient selection. A breach of the posterior wall and presence of a posterolateral split (arrows) is considered a contraindication for balloon tibioplasty and other techniques should be considered. (Reprinted with permission from Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8.) The Journal of Knee Surgery

Vol. 27

No. 1/2014

Downloaded by: National University of Singapore. Copyrighted material.

Fracture Configuration

Pearls and Pitfalls of Balloon Tibioplasty

Mauffrey et al.

Fig. 4 Intraoperative fluoroscopy depicting a nonreducible lateral plateau fracture due to the balloon’s force acting on the area of least resistance and leading to further displacement of the posterolateral split fragment (arrow, lower right panel). (Reprinted with permission from Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8.)

greatest depression. A sharp introducer is then used to breach the medial cortex and is advanced about 1 cm. A cannula is then inserted parallel to the joint line, aiming 2 to 5 mm below the deepest portion of the depression in both the sagittal and coronal planes, as confirmed by fluoroscopy.13

Rafting Wires It is our preference to insert three rafting wires (2 mm Kirschner wires) beneath the cannula in an anterior-toposterior direction. These create a base on which the balloon can rest during the inflation phase, thereby directing the force of the balloon upward against the depressed fragments rather than downward into the metaphyseal cancellous bone. This is particularly important in older patients with osteoporotic bone since the balloon’s inflation force will act, preferentially, on the area of least resistance. Alternatively, newer instrumentation is available that accomplishes a similar purpose.

Balloon Insertion The balloon is then inserted through the cannula, and the cannula is then withdrawn to ensure that the radiological markers identifying the proximal and distal end of the balloon are positioned just past the cannula and beneath the depressed fragments. The Journal of Knee Surgery

Vol. 27

No. 1/2014

Balloon Inflation The device is inflated in a stepwise manner and we use the included pressure monitor to check the volume and pressure within the balloon, which we keep below 4 mL and 400 psi, respectively. Fluoroscopy is used to check that the balloon is inflating in the desired direction after every 0.5 mL of inflation. As a general guide a volume of 4 mL is commonly required to elevate a tibial plateau fracture, and in some cases two balloons are required to achieve sufficient force and volume to elevate the depressed fragments.

Hint The pressure reading can give the surgeon additional feedback information. When in a nonfractured area the balloon pressure increases very rapidly and stays high with minimal change in volume, that is, the balloon is not able to move any bone. In contrast, if the pressure continues to fall or there is no increase in pressure then either the void is too big or the balloon is no longer within bone and additional techniques are required (►Fig. 5).

Downloaded by: National University of Singapore. Copyrighted material.

34

Mauffrey et al.

Fig. 5 Intraoperative fluoroscopic views of a nonreducible lateral tibial plateau fracture. Arrows showing the balloon penetration into the knee joint requiring a salvage technique, that is, conversion to a “semiopen” technique using a traditional bone tamp and cancellous bone grafting. (Reprinted with permission from Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8.)

Hint

Hint

Balloon failure can occur and the shape of the balloon on fluoroscopy can be a sign of impending failure. Balloons that fail tend to inflate distally between the rafting wires or laterally, rather than forming a concave shape beneath the depressed fragments. If this is seen, then deflating and repositioning the balloon or the rafting wires can prevent failure. If the balloon bursts then the radiopaque contrast dye will escape, this causes no harm but requires a washout with 100 to 200 mL of saline which can be flushed through the cannula, to allow visualization (►Fig. 6).

Sometimes a second balloon is required if the amount of the depression is greater than the volume of one balloon. If this is the case then a second balloon is inserted, about 1 cm proximal to the site of insertion of the first balloon. The first balloon should be kept inflated, so that the second balloon does not simply expand into the bone void created by the first balloon.

Fig. 6 Intraoperative fluoroscopy showing a bursted balloon with leakage of radiopaque dye within metaphyseal bone and knee joint. This complication is easily corrected by a washout with 100 to 200 mL of sterile saline through the cannula, to allow visualization. (Reprinted with permission from Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8.) The Journal of Knee Surgery

Vol. 27

No. 1/2014

35

Downloaded by: National University of Singapore. Copyrighted material.

Pearls and Pitfalls of Balloon Tibioplasty

Pearls and Pitfalls of Balloon Tibioplasty

Mauffrey et al.

Fig. 7 Arthroscopic images of solidified calcium phosphate crystals within the knee joint after accidental extrusion of the bone graft substitute filler, in a depressed medial tibial plateau fracture. (Reprinted with permission from Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8.)

Maintaining Reduction

Bone Graft Substitute

Once the articular fragments are reduced, the balloon is partially deflated leaving space for two 1.6 mm Kirschner wires, inserted from medial-to-lateral in the subchondral bone to support the restored articular fragments. The balloon is then deflated and removed.

A bone graft substitute, such as rapid-setting calcium phosphate, is injected through the cannula to fill the void left by the balloon to provide mechanical support to the reduced articular surface. Advantages of the balloon system are that the true void volume requiring filling is known from the gauge reading, thereby minimizing wastage of expensive bone fillers and the bone filler is delivered to the correct area.

Hint

Warning

Ahrens et al overcorrected the depression by 1 mm over the anatomical joint surface and reduced the fragment by slow knee motion.15 This technique in their opinion provided self-reduction of the fracture and tended to produce the best results, with a congruent joint line. In our experience this has not been necessary.

Calcium phosphate needs to be backfilled from deep to superficial, that is, toward the cannula. Fluoroscopy plays an important role while filling the defect as the liquid bone substitute can escape into the surrounding soft tissues or the joint itself. Extravasation of bone filler into the joint should be removed through an arthrotomy or arthroscopically (►Fig. 7). This complication occurred in 5% of cases in one series.3

Fig. 8 Intraoperative fluoroscopy of the “back-up plan,” conversion to the use of traditional bone tamps and structured bone grafting, for a nonreducible articular fragment. (Reprinted with permission from Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8.) The Journal of Knee Surgery

Vol. 27

No. 1/2014

Downloaded by: National University of Singapore. Copyrighted material.

36

Pearls and Pitfalls of Balloon Tibioplasty

Cannulated screws or a plate and screw construct are then implanted depending on the fracture configuration and personal preference of the surgeon. Depending on the bone filler used screws may need to be placed before material setting.

2 Broome B, Mauffrey C, Statton J, Voor M, Seligson D. Inflation

3

Arthroscopy We perform the majority of our balloon tibioplasties with concurrent arthroscopy to assess the quality of reduction and address any associated meniscus tears (present in up to 90% of cases according to Gardner et al).16 Arthroscopy may also help with the identification and treatment of complications such as calcium phosphate extrusion in the joint (►Fig. 7).

4

Back-Up Plan

6

Alternative instrumentation, such as bone tamps, should always remain available as balloon failures or failures to elevate the depressed articular fragment commonly occurs (20% of cases) (►Fig. 8).3

Learning Curve As with any relatively new procedure a steep learning curve is associated with balloon tibioplasty.3,13 Surgeons who wish to try this new technique should familiarize themselves with the balloon device, attend a practical course, or visit a center proficient with this novel technique.

5

7

8

9

10

The Future To date, the benefits of balloon tibioplasty have only been shown in case series and laboratory testing, however randomized control trials are currently underway.17 In addition, several questions remain unanswered regarding this minimally invasive technique. Is percutaneous fixation (with screws only) of split depressed fractures adequate or is open plate fixation necessary? What is the ideal postoperative weight bearing and range of motion regimen for these patients? Are our current methods to fill in the void left by the balloons adequate, practical, and cost-effective?

11

12 13

14

15

Acknowledgement We would like to acknowledge Dr. Philip F. Stahel for providing us with the radiographs of surgical cases in this manuscript.

References 1 Court-Brown CM, Caesar B. Epidemiology of adult fractures: A

review. Injury 2006;37(8):691–697

37

16

17

osteoplasty: in vitro evaluation of a new technique for reducing depressed intra-articular fractures of the tibial plateau and distal radius. J Orthop Traumatol 2012;13(2):89–95 Mauffrey C, Fader R, Hammerberg EM, Hak DJ, Stahel PF. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013;7(1):8 Boonen S, Wahl DA, Nauroy L, et al; CSA Fracture Working Group of International Osteoporosis Foundation. Balloon kyphoplasty and vertebroplasty in the management of vertebral compression fractures. Osteoporos Int 2011;22(12):2915–2934 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(2):204–209 Hahnhaussen J, Hak DJ, Weckbach S, Heiney JP, Stahel PF. Percutaneous inflation osteoplasty for indirect reduction of depressed tibial plateau fractures. Orthopedics 2012;35(9): 768–772 Sandmann GH, Ahrens P, Schaeffeler C, et al. Balloon osteoplasty—a new technique for minimally invasive reduction and stabilisation of Hill-Sachs lesions of the humeral head: a cadaver study. Int Orthop 2012;36(11):2287–2291 Mauffrey C, Bailey JR, Hak DJ, Hammerberg ME. Percutaneous reduction and fixation of an intra-articular calcaneal fracture using an inflatable bone tamp: description of a novel and safe technique. Patient Saf Surg 2012;6(1):6 Heim KA, Sullivan C, Parekh SG. Cuboid reduction and fixation using a kyphoplasty balloon: a case report. Foot Ankle Int 2008; 29(11):1154–1157 Gupta AK, Gluck GS, Parekh SG. Balloon reduction of displaced calcaneus fractures: surgical technique and case series. Foot Ankle Int 2011;32(2):205–210 König B, Khodadadyan C, Schäffler A, Pflugmacher R, Stöckle U. [Percutaneously navigated balloon fracture reduction in a displaced acetabular fracture]. Unfallchirurg 2007;110(12): 1072–1075 Melkerson MN. 510(k) Number, K123771. In: Administration TFaD ed; 2012 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 Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968–1975. Clin Orthop Relat Res 1979;(138): 94–104 Ahrens P, Sandmann G, Bauer J, et al. Balloon osteoplasty—a new technique for reduction and stabilisation of impression fractures in the tibial plateau: a cadaver study and first clinical application. Int Orthop 2012;36(9):1937–1940 Gardner MJ, Yacoubian S, Geller D, et al. The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma 2005;19(2): 79–84 Jordan R, Hao J, Fader R, Gibula D, Mauffrey C. Study protocol: trial of inflation osteoplasty in the management of tibial plateau fractures. Eur J Orthop Surg Traumatol 2013; June 26 (e-pub ahead of print)

The Journal of Knee Surgery

Vol. 27

No. 1/2014

Downloaded by: National University of Singapore. Copyrighted material.

Fixation

Mauffrey et al.

Balloon tibioplasty: pearls and pitfalls.

Methods of tibial plateau fracture fixation have evolved over the last decades; however the techniques used to reduce these fractures have remained re...
325KB Sizes 0 Downloads 0 Views