Orthopaedics & Traumatology: Surgery & Research (2013) 99, 829—836

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ORIGINAL ARTICLE

Minimally invasive treatment of displacedintra-articular calcaneal fractures using theballoon kyphoplasty technique: Preliminarystudy

J.L. Labbe ∗, O. Peres, O. Leclair, R. Goulon,P. Scemama, F. Jourdel

Service de chirurgie orthopédique, centre hospitalier territorial de Nouméa, BP J5, Noumea, NewCaledonia

Accepted: 6 June 2013

KEYWORDSIntra-articular jointdepression fracture;Calcaneus;Balloon osteoplasty;Cement stabilisation

SummaryBackground: The balloon kyphoplasty approach to the treatment of vertebral fractures canbe adapted to achieve the reduction and cement stabilisation of intra-articular compressionfractures at other sites, such as the calcaneus.Patients and method: We studied six patients with a median follow-up of 12 months (range,6—30 months). Fluoroscopy guidance was used to obtain optimal balloon positioning underthe joint depression site. Reduction was achieved by expanding the balloon and stabilisationby injecting the cavity with resorbable tricalcium-phosphate cement in the younger patientsand polymethyl-metacrylate cement in the two elderly patients with osteoporosis. No internalfixation was used.Results: No intra-operative, postoperative, or delayed complications were recorded. Medianhospital stay length was 4.5 days (range, 3—7 days). All the fractures healed within the usualtimeframe, without loss of reduction. Median time to full weight-bearing ambulation was 52.5days (range, 15—75 days). The functional outcomes correlated with the good anatomic results,with a median American Orthopaedic Foot and Ankle Society score of 87.0 (range, 86—97).Discussion: This preliminary study shows that balloon reduction and cement fixation ofintra-articular calcaneal fractures is easy to perform, reproducible, and devoid of specific

complications. Good-quality reduction and stabilisation until fracture healing were achieved,and time to recovery of self-sufThese results support the use ofLevel of evidence: Level IV, retr© 2013 Elsevier Masson SAS. All

∗ Corresponding author.E-mail address: jl.labbe@cht.nc (J.L. Labbe).

1877-0568/$ – see front matter © 2013 Elsevier Masson SAS. All rights rehttp://dx.doi.org/10.1016/j.otsr.2013.06.008

ficiency was short, even in elderly patients with osteoporosis. this minimally invasive technique.ospective study.rights reserved.

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yphoplasty is a surgical procedure developed in the pastecade by applying the principles of balloon angioplastyo the vertebras [1]. Kyphoplasty consists in reducing1 compression fractures of osteoporotic vertebras byradually inflating two balloons introduced percutaneouslyhrough the pedicles. The cavity left after removal ofhe balloons is filled with polymethyl-metacrylate cementPMMAc). A recent advance is the development of resorbablericalcium-phosphate cement (Ca-Pc) that is well suited tohe mechanical loads through the spine and can be combinedith short-segment percutaneous internal fixation to treatore complex vertebral fractures in young patients.Based on our experience and on reports of good outcomes

fter kyphoplasty [2], we decided to adapt this minimallynvasive technique to the treatment of intra-articular cal-aneal fractures.

We hypothesised that balloon reduction with cemento-lasty is a simple and reproducible technique providingatisfactory anatomic reduction and stabilisation until frac-ure healing with functional outcomes similar to thosebtained using other techniques.

atients and methods

atients

e retrospectively reviewed the medical charts of the sixatients managed at our centre for displaced intra-articularractures of the calcaneus between 2009 and 2011. Thereere five men and one woman with a median age of 46.5

ears (range, 41—67 years) and a median follow-up of 12onths (range, 6—30 months). All six patients had closed

ractures due to falls, of which two occurred at work. Thewo oldest patients had untreated osteoporosis (Table 1).

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Table 1 The series.

Patients 1 2

Sex Female Male

Age, years 67 66

Cause: falls Tree, 2 m Stairs

Side Right Right

Utheza class Mixed Horizontal

Sanders class IIA IIC

Approach Posterior Posterior

Cement PMMAc PMMAc

Complications 0 0

Stay length 3 d 5 d

Pre-op. Böhler +3◦ +4◦

Post-op. Böhler +26◦ +12◦

Step-off < 2 mm 0

Time to weight-bearing ambulation 15 d 21 d

Analgesics None None

AOFAS score 95 86

PMMAc, polymethyl-methacrylate cement; Ca-Pc, tricalcium-phosphatankle-hindfoot score.

J.L. Labbe et al.

The radiographs and reconstructed computed tomogra-hy (CT) images showed a horizontal fracture in 1 patientnd combined fractures in 5 patients, according to thetheza classification [3]. In the Sanders classification [4],ll six fractures were type II (2 IIA, 3 IIB, and 1 IIC)ith one or two secondary fracture lines involving thelantar cortex. Median initial Böhler’s angle was −1.5◦

range, −14◦ to +14◦). The CT reconstruction images weresed to determine the optimal balloon position in eachatient.

urgical procedure and postoperative management

et Upll patients were positioned on an orthopaedic traction tableith trans-calcaneal traction and no tourniquet. Fluoro-

copic monitoring in the sagittal plane and the 30◦ Brodenncidence was used [5]. The traction pin was placed in theostero-inferior part of the posterior calcaneal tuberosity tochieve immediate reduction of the hindfoot ascension andarus and to distract the subtalar joint. Two patients weren the supine position with the knee flexed on a poplitealupport and the other four patients were in the prone Tren-elenburg position (10—20◦) with the affected lower limbxtended (Fig. 1).

The kyphoplasty kit (Kyphon, KPT 1502, Medtronic Inc.,inneapolis, MN, USA) included an inflatable bone tamponnected to an inflation syringe with manometric control,ntra-osseous trocars, a guide-pin, and cannulae. The infla-ion syringe was filled with a radio-opaque solution to allowuoroscopic visualisation of balloon inflation during the pro-edure.

alloon introduction cannulated trocar was introduced percutaneously intohe cancellous bone (Fig. 2). For the patients in the prone

3 4 5 6

Male Male Male Male41 41 50 43Dive 2 m (at work) Ladder, 3 m 3 m (at work)Right Right Right LeftMixed Mixed Mixed MixedIIB IIB IIB IIAPosterior Posterior Lateral LateralCa-Pc Ca-Pc Ca-Pc Ca-Pc0 0 0 07 d 5 d 4 d 3 d−14◦ −6◦ −14◦ +4◦

+30◦ +30◦ +16◦ +28◦

0 0 < 2 mm 060 d 75 d 45 d 75 dNone None None None87 87 87 97

e cement; AOFAS, American Orthopaedic Foot and Ankle Society

Minimally invasive treatment of displaced intra-articular calcaneal fractures 831

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Figure 1 Set up of the patient: a: supine position;

position, the trocar was inserted via a posterior approachthrough the postero-superior prominence of the heel, tothe sub-talar joint, in the forward and lateral direction.For the patients in the supine position, trocar insertionwas via the direct lateral approach. A guide wire wasinserted through the trocar and advanced towards the frac-ture site 3 to 4 mm under the apex of the lesion. Then,the trocar was removed and replaced by a cannula, andthe guide wire was removed. The deflated balloon with itstwo metallic markers was introduced through the cannula(Fig. 2b). Care was taken to ensure that the balloon couldbe advanced and removed without resistance to avoid tear-ing, rupture, or extraction difficulties. The kit containeda trephine for use in preparing the introduction canal ifneeded.

ReductionOnce the balloon was positioned at the site identified pre-operatively on CT scan images, it was expanded gradually.Ascension of the osteo-articular fragment(s) up to the jointspace was monitored on the fluoroscopy screen. Ballooninflation resulted in compaction of the cancellous boneunderlying the fracture and maintained adhesion betweenthe fragments (Fig. 2c). A 15-mm/4 mL balloon with a max-

imum pressure of 300 PSI (20 bar; rupture threshold, 400psi) was consistently sufficient to reduce the fracture andoffered sufficient plasticity to allow a small degree of off-centreing.

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one position; c: fluoroscopic incidence: 30◦ Broden.

tabilisationhe balloon was deflated and removed and the cavity washen filled with radio-opaque cement (Fig. 2d). In the twoatients older than 65 years of age, we used high-viscosityMMAc (Kyphon HV-R, Medtronic). The slow polymerisa-ion rate of this cement translated into a working timef 8—10 min, and the resulting good user control and easef handling allowed complete filling of the cavity, with norawbacks. In the younger patients, we used Ca-Pc (KyphosS, Medtronic), which hardened quickly via an isothermiceaction and was both osteoconductive and resorbable [2].s recommended, we followed the precautions required dur-

ng the crystallisation phase of the Ca-Pc, with a 20-min waiteriod between the last injection and joint mobilisation, asell as a 24-h delay before achieving optimal resistance toompression.

When there was a risk of cement leakage into the joint orutside the bone, or when balloon removal was followed byoss of reduction, we used the ‘‘eggshell’’ procedure. Afternjection of 1 mL of cement, the balloon was re-introducednto the cavity and inflated to induce peripheral displace-ent of the cement around the balloon and against the

avity wall, while perfecting the reduction (Fig. 3a). Oncehe cement hardened, the balloon was removed (Fig. 3b).

he shell stabilized and sealed the cavity, allowing fillingith no risk of leakage (Fig. 3c).

When Broden’s view showed diastasis in the coronallane between the thalamic fragments, compression of the

832 J.L. Labbe et al.

Figure 2 Technique: a1 and a2: sagittal and coronal computed tomography (CT) reconstructions of a Sanders type IIB fracture.Intra-operative sagittal fluoroscopic view: b: introduction of the balloon (patient in the prone position); c: fracture reduction byinflation of the balloon; d: cementoplasty (tricalcium-phosphate cement); e1 and e2: CT 1 year after surgery.

Minimally invasive treatment of displaced intra-articular calcane

Figure 3 Eggshell technique, intra-operative sagittal fluoro-scopic view: a: re-inflation of the balloon after the injection of

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1 mL of bone cement perfects the reduction; b: the balloon isremoved once the cement has hardened; c: cementoplasty.

thalamus between the thumb and forefinger under the lat-eral and medial malleoli, maintained during cementoplasty,was sufficient to ensure reduction.

Joint mobilisation was started immediately after the pro-cedure. Crutches were used to eliminate weight bearing for45 days, after which weight bearing was resumed gradually.

So

al fractures 833

ostoperative assessment methods

he patients underwent clinical re-evaluation after 30, 60,nd 90 days; 6 months; and more than 1 year. We recordedhe complications, median hospital stay length, time toalking resumption, and time to work resumption. At the-month follow-up evaluation, the functional outcome wasssessed by determining the American Orthopaedic Foot andnkle Society (AOFAS) score [6].

The anatomical result was assessed based on the qual-ty of reduction of the fractures and on the radiographsnd CT scans obtained 45 days, 3 months, and 6 monthsfter surgery; in some patients, imaging was also obtainedfter more than 1 year. The Böhler’s angle improvement andhe criteria developed by Rammelt et al. [7] for evaluat-ng joint surface step-offs were recorded. Given the limitedollow-up in our patients, we did not evaluate a score forsteoarthritis.

esults

unctional outcomes

edian time from injury to surgery was 2 days (range,—5 days). There were no intra-operative, postoperative,r delayed complications, particularly involving the skin.edian hospital stay length was 4.5 days (range, 3—7 days).

Median time to full weight-bearing ambulation was 52.5ays (range, 15—75 days). The 2 older patients with osteo-orosis spontaneously resumed full weight bearing after 2nd 3 weeks, respectively. Hindfoot motion range was nor-al or only slightly limited for inversion-eversion (75—100%

f normal) and flexion-extension (30◦ or more), with a sta-le plantigrade foot. Functional outcomes were consideredood with a median AOFAS score of 87 (range, 86—97). In theatients who were still employed, time to work resumptionas 3 months.

natomic results

t last follow-up, all six patients had healed fractures witho loss of reduction. Median Böhler’s angle increased from1.5◦ (range, −14◦ to +14◦) preoperatively to +27.0◦ (range,12◦ to +30◦) postoperatively; the value on the unaffectedide was +25.5◦ (range, 21◦ to 36◦). None of the patientsad more than 5◦ of residual varus or a joint surface step-offreater than 2 mm (0 in 4 patients and 1—2 mm in 2 patients).n patients with residual diastasis between the thalamicragments, the joint remodelling induced by immediateobilisation promoted compression of the separation dur-

ng the first 2 months followed by secondary filling (Fig. 4b).ealing was achieved within the expected timeframe in allix patients. After 1 year, none of the patients exhibitedomplete Ca-Pc resorption or lysis at the cancellous boneement interface.

urgery has superseded non-operative orthopaedic meth-ds for intra-articular calcaneal fractures as it decreased

834 J.L. Labbe et al.

Figure 4 Course of the inter-fragment diastasis: a1: joint remodelling seen on the coronal computed tomography (CT) recon-struction on the 2nd postoperative day; a2: 2 months after surgery; b1: filling with restoration of subchondral bone continuity seeno (step

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he rates of osteoarthritis and secondary arthrodesis, pro-uced better outcomes in several comparative studies, andncreased the ease of arthrodesis if osteoarthritis develops8—10]. However, even after perfect reduction and heal-ng, no means are available for predicting the course ofrreversible damage to the cartilage involved by the fracture11].

Open surgery is associated with high rates ofomplications, most notably involving the skin, of nearly5% in some case-series, with a 21% rate of iterative surgery12]. Consequently, surgeons have developed minimallynvasive techniques, which however produce poorer out-omes in terms of fracture reduction and joint stabilisation7,13]. The use of arthroscopy improves overall short-nd medium-term outcomes [7,14]. However, the use of

metal bone tamp carries a risk of trajectory error, jointavity penetration, and dispersion of the fragments duringlevation, particularly when the fracture is comminuted,hich may require conversion to open surgery to achieve

eduction [7]. Percutaneous screw-plate fixation is difficulto perform and the use of K-wires, Steinman pins, orxternal fixation is unreliable and increases the risk ofnfection [15]. Filling the underlying cavity to support the

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educed fragments seems indispensable. Bone grafting inhis situation was first described by Palmer [16]. Contro-ersy ensued, with opponents arguing that well-performedxation was sufficient [4]. Although minimally invasiveethods are gaining in popularity, caution is required to

nsure that they perform at least as well as open surgery.his is not the case at present, due to the use of technicaleans that are unreliable or even unusable in certain

omminuted fractures.Appropriate adaptations of the balloon reduction and

ement stabilisation procedures used in vertebral bal-oon kyphoplasty may constitute a valid option for similarntra-articular compression fractures, most notably at thealcaneus. The single tiny stab incision avoids the occur-ence of skin complications. Gradual balloon expansioneverses the effects of fracture impaction while maintain-ng fragment adhesion and eliminates the complicationsssociated with the use of metal tamps. Fluoroscopy withhe sagittal and Broden’s views provides sufficient intra-

perative monitoring, as confirmed by the postoperativeeconstructed CT images. We did not use arthroscopy, as thisrocedure increases the operating time, risk of iatrogenicomplications, and treatment costs. However, arthroscopy

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Minimally invasive treatment of displaced intra-articular cal

may help to assess the reduction while decreasing radiationexposure to the surgeon, other healthcare personnel, andpatient.

Our results confirm that additional fixation is unnec-essary. The bone cements used ensured excellent osteo-articular stability until fracture healing, with no loss ofreduction and with sufficient resistance to pressure to allowrapid resumption of weight bearing. However, one year afterkyphoplasty, Maestretti et al. observed Ca-Pc cracks andlacunas around the cement on all follow-up CT scans, in theabsence of further trauma and without corresponding clin-ical manifestations [2] The cracks tend to develop withinthe first postoperative week and may be due to incorrectcement application responsible for disturbances in the crys-tallisation process that change the intrinsic properties ofthe cement. Scrupulous adherence to post-cementoplastyrecommendations is clearly indispensable. An animal exper-iment by Verlaan et al. confirmed that neither PMMA norCa-Pc carried a risk of subchondral bone degeneration, evenwhen the bone was fractured [17]. Years of research inspine, trauma, and tumour surgery have established thatboth types of cement can be used safely in these fields.

As the intervertebral discs act as shock-absorbers, allow-ing resumption of the erect position after 24 h, we felt thatweight-bearing elimination until fracture healing was a sen-sible precaution. Nevertheless, earlier weight bearing maybe safe: several patients resumed weight bearing early aftersurgery of their own accord, with no adverse consequences.We used PMMAc in the 2 patients older than 65 years, asadherence to immediate postoperative recommendationsmay be more challenging in the elderly.

Two recent studies performed at the same time as oursevaluated the same method in 4 and 3 patients, respectively[18,19]. In one, PMMAc was used in all four patients, K-wireswere inserted above the fractured inferior cortex to supportthe balloon, and a clamp was used to compress the thalamusand avoid its widening during balloon inflation [18]. In theother study, the three patients were selected based on lessthan 5◦ of varus, and Ca-Pc was used [19]. We believe thattrans-calcaneal traction is crucial to achieve reduction andexpands the range of indications of the technique. Althoughall our patients had one or two secondary fracture linesinto the inferior cortex, destabilisation did not occur dur-ing balloon inflation. A clamp for lateral compression shouldnot be used routinely, as intra-thalamic diastasis is inconsis-tently present and clamp application carries a risk of skincomplications. Intra-operative compression between thethumb and forefinger followed by joint remodelling inducedby mobilisation is sufficient. In neither of the two earlierstudies were any complications recorded, and the postop-erative outcomes were excellent after 3 years and 1 year offollow-up, respectively. Similarly, good anatomic reductionin our patients was consistently associated with good func-tional outcomes. This correlation between anatomic andfunctional outcomes was previously demonstrated by Ram-melt et al. [7].

The treatment of intra-articular calcaneal fractures inelderly patients with osteoporosis remains highly contro-

versial. Non-operative management is widely used but isassociated with numerous complications. The paucity ofpublished data is in striking contrast to the many fixationtechniques designed to expedite rehabilitation after other

al fractures 835

ractures of the limbs or spine. Surgery may be consideredut requires careful patient selection [20]. Our results in twoatients with osteoporosis are extremely encouraging, withn uneventful postoperative course and rapid resumption ofelf-sufficiency.

The cost of the material has decreased since we firstsked Medtronic to produce ‘‘extremity kits’’ (ETL153A,edtronic) containing a single manometric syringe and mod-

fied ballons. However, the kit still costs three times morehan a screw-plate. Nevertheless, the cost/benefit ratio maye favourable: the median hospital stay length and needor local care were diminished, no complications occurred,o secondary surgery to remove material was needed,nd times to weight-bearing and to work resumption werehorter. A medico-economic study to assess this point woulde of interest.

onclusion

ur preliminary results support the continued use of mini-ally invasive balloon reduction and cementoplasty to treat

ntra-articular calcaneal fractures. They confirm our hypoth-sis: the quality of the reduction is excellent, the fractureite remains stable until full healing is achieved, and theood functional outcomes allow the patients to rapidlyecover their self-sufficiency. This technique seems to holdonsiderable promise, particularly for patients with osteo-orosis.

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.

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