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Jeffrey P. Beckenbaugh, DO

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Abstract:
Peri-operative Dexamethasone for Control of Pain After Total Knee Arthroplasty

Indirect reduction and fixation of a Lateral Plateau depression fracture utilizing balloon tibioplasty in a cachectic, malnourished patient: A Case Report

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Biomet Orthopaedics

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Indirect reduction and fixation of a Lateral Plateau depression fracture utilizing balloon tibioplasty in a cachectic, malnourished patient: A Case Report

By Mike Van Manen DO; Lawrence Pollack, DO

Abstract
Tibial plateau fractures account for approximately 8% of fractures in the elderly (1). Metaphyseal bone becomes weakened with a decrease in bone density.  This in turn increases the risk of comminution and involvement of the articular surface in patients with osteoporosis. The patient in this report is a 61 year-old caucasian female who had a simple fall resulting in a depressed fracture of her left lateral tibial plateau.  The patient was also very malnourished with a recent 40 pound weight loss due to a recent small bowl obstruction and concurrent small bowel resection.  Her primary internal medicine physician advised she would not be a good candidate for surgery due to her medical condition and poor wound healing capacity. However, she was not able to ambulate due to instability about her knee and was bedridden due to the pain caused by the fracture.  Thus, we elected to perform a minimally invasive technique utilizing balloon tibioplasty and calcium phosphate. The percutaneous technique was utilized for an indirect reduction of the depressed fragment using an inflatable balloon bone tamp.  Fixation and support of the elevated fragment was provided with filling the defect with calcium phosphate.  Immediately after the procedure she was ambulatory with minimal pain with no reports of instability about her knee.  Her one small stab incision healed with no complications.  This techique offered a minimally invasive way of treating her depressed  lateral tibial plateau fracture allowing her to get out of bed and regain ambulation with little to no insult to her soft tissues.

Introduction
Fracture care is becoming more challenging with our elderly who have other co-morbidities that affect surgical options.  With increasing osteoporosis, low energy falls are resulting in more fractures especially in the weak metaphyseal location of long bones (1). This includes distal radius fractures, proximal humerus fractures, intertrochanteric hip fractures and tibial plateau fractures.  Tibial Plateau fractures constitute 1% of all fractures and 8% of fractures in the elderly (1).  The mechanism usually involves a varus or valgus load with an axial force (1).  Soft tissue injury is very common especially in high energy open fractures.  Surgical treatment is usually halted until soft tissue swelling subsides and local skin conditions improve. Surgical incisions made through injured and damaged soft tissues about the knee have high complication rates.  Non-operative treatment is indicated for non-displaced or minimally displaced fractures in patients with osteoporosis (1). This constitutes partial weight bearing in either a cast or hinged fracture brace (1).  Operative indications include depressed fragments greater than 10 mm or instability >10 degrees in a fully extended knee (1). Open fractures with an associated compartment syndrome is another indication for surgery.  Surgical treatment entails temporary external fixation and definitive open reduction and internal fixation. Restoration of the joint surface  and tibial alignment are the goals of surgery (1).  This is usually accomplished with buttress plating with subchondral rafting screws. Depressed articular fragments can be elevated using a metal tamp and filling the defect with bone graft filler.  Other authors have also incorporated knee arthroscopy to aid in the reduction of the articular fragment.  Surgery  of tibial plateau fractures are not without complications in patients who are older with multiple co-morbidities.

The treatment history of tibial plateau fractures is rife with complications (2).  Such complications occurred because surgical approaches abused the tenuous soft tissue envelope of a fractured knee (2). Wound dehiscence and infection too frequently developed with large midline incisions with large subcutaneous flaps about the knee (2).  Limitations for surgical treatment  around the knee involve patients with poor wound healing capacity. These patients may either be diabetic, malnourished, chronic smokers or have peripheral vascular disease with poor cutaneous blood supply. Malnourished patients lack the protein synthesis required for the repair phase  of wound healing. Smoking has been shown to cause reduced cutaneous blood flow as well as decreased subcutaneous soft-tissue oxygenation and aerobic metabolism (3). One study demonstrated that collagen production is impeded in persons who smoke (4) The surgeon must be aware of the nutritional indices when assessing healing potential (5).  A total lymphocyte count of 1500 mmm3, a serum albumin level of 3.5 g/dl and a total serum protein count concentration of 6.2 g/dl are all minimal levels necessary to optimize tissue healing. (6) Pre-operative assessment of the skin and the risk of wound complications becomes vital when surgically treating tibial plateau fractures (7). If surgery is to be performed, other alternative minimally invasive techniques should be explored to minimize wound complications to the tenuous skin around the knee.

Objective
Several surgeons in the USA have begun using an inflatable bone tamp to reduce depressed tibial plateau and distal radius fractures (8).  Conventional techniques use bone tamps and similar instruments to aid in the reduction of depressed articular fragments, which can  increase the surgical trauma to the fractures site or soft tissue envelope (9).  This concept  ‘balloon tibioplasty” was built upon the success of balloon kyphoplasty that is currently being used by surgeons around the country to treat symptomatic compression fractures of the thoracic and lumbar spine (8)(9) . A literature review was completed, and we were unable to find a specific case report or research article in the literature that has addressed this minimally invasive procedure.  Specifically no report on a patient that had clinical evidence of poor wound healing capacity and a specific Shatzker type III depressed lateral tibial plateau fracture.  The following case report utilizes this technique to treat a specific  lateral depressed tibial plateau fracture in a malnourished elderly patient who otherwise was  a very poor candidate for the conventional operative techniques used to treat tibial plateau fractures.

Case Report
Our case report involves a 61 year-old caucasian female who recently had a low energy fall resulting in an unstable depressed lateral tibial plateau fracture. She also had lost roughly 40 lbs in a  3- 4 month span due to a small bowel obstruction that was treated with a small bowel resection.  At the time of her orthopedic consultation, she weighed approximately 65 lbs. and was very cachectic.  She was severely malnourished with no appreciable appetite.  She also was developing breakdown of her skin over bony prominences around her heals and elbows.  She was not ambulatory after her fall due to significant left knee pain and instability.  Prior to the fall she was a community ambulator with no need for external ambulatory assistance. She was employed as a nurse on medical leave after her small bowel resection.  She was medically admitted to the hospital for generalized weakness and failure to thrive.  She was also having severe gastritis that was confirmed by an EGD. Significant past medical history consisted of  colon cancer with colon resection in 2006, gastritis, hx of breast cancer and coronary artery disease and Raynaud’s disease.  Family history consisted of her father having a myocardial infarction at age 65.  She quit smoking cigarettes in 1979, and only drank alcoholic beverages occasionally.

Exam
The initial examination revealed a cachectic bedridden 61 year-old female that was alert and oriented times three.  Her skin revealed some non-healing ulcerations around her heals and elbows.  Her orthopedic examination was within normal limits except for her left knee.  Her left thigh musculature demonstrated severe muscle wasting with significant  atrophy. Her left knee revealed severe pain with ROM. She had evidence of instability with varus stresses both in extension and with 30 degrees of flexion.  Her lateral joint line would gap to approximately 15 mm with a varus stress with her knee in full extension. Compared to her right leg which only gaped open 5 mm with a stable endpoint.  She had very limited swelling and a very small knee effusion.  Posterior drawer and Lachman’s exam where normal.  There were no open  lacerations or significant bruising around her left knee. Neurovascular exam was within normal limits with 2+ distal pulses of the left leg. 

 

Labs and X-rays

Xrays

Pre-op CT scan and initial x-rays demonstrating a lateral plateau,
depression fracture

Pertinent  labs: related to her malnourishment
Pre-albumin was low at 16.4 mg/dl,
albumin was 1.8 mg/dl,
Total serum protein 3.7 mg/dl, 
hemoglobin was 8.2 and hematocrit was 24.1.

Initial Treatment
Her initial treatment consisted of IV fluids and nutritional support with supplementation of choice and calorie counts.  Originally when admitted she was kept at bed rest as she was not able to ambulate.  She was initially placed in a long leg posterior splint and made non weight bearing.  The next morning during rounds, the orthopedic team decided to change her to a hinged knee brace with continued non weight bearing, and mobilized her with the assistance of physical therapy. A wound care consult was ordered to treat her heal and elbow ulcerations.  After her splint was applied she was only able to get to a chair for a couple hours a day due to  the pain in her knee.  With the NWB restrictions she was unable to ambulate with a walker.  Due to her pain and lack of ability to work with physical therapy she continued to decline. Surgical options were discussed and she elected to undergo surgery due to her lack of mobility and continued pain. However, she was a poor surgical candidate due to her lack of wound healing and very tenuous skin around her knee.  She was also chronically anemic and had a low blood count.

Surgical procedure
Due to her inability to heal a large surgical wound we elected to utilize a minimally invasive technique known as balloon tibioplasty.  Her fracture was a contained depressed fracture with no involvement of the lateral cortex.  We felt this was ideal for this technique.  The risk and benefits were explained to the patient  and she agreed to under go the procedure.  The patient was positioned supine on a radiolucent table. She underwent general anesthesia with an laryngeal mask airway (LMA). A small tourniquet was applied to the operative leg but was not utilized during the case. Her leg was prepped to the ankle using chlorhexidine skin prep.  Her knee was sterilely draped up to mid-thigh and a stockinette was used to drape out the foot and lower leg.  Her fracture was identified in both the AP and lateral planes using C-Arm fluoroscopy.  Under fluoroscopic guidance two 0.062 k-wires were placed through the medial tibial cortex and directed just under the depressed fracture fragment on both the AP and Lateral views. This provided a raft support to enable the balloon to direct the force up to the depressed fragment. A key to this procedure is an understanding that the depressed fragment acts as a trap door with a hinge of bone still attached medial in relation to the lateral tibial plateau (see figure below).  The balloon should be directed just medial to the depressed fragment to hinge it back up to the articular surface rotating it through the medial bone hinge still attached to the articular surface.  The osteointroducer with a trocar tip, was inserted through the medial tibial cortex just underneath and medial the depressed fragment and just above the k-wire raft. The depressed balloon was placed through the cannula and inflated slowly to a max of 200 PSI. Using live fluoroscopy, we were able to see a gradual elevation of the fragment until it looked anatomically reduced on a true AP fluoroscopic view.  This was also confirmed on a lateral fluoroscopic view.  The balloon was deflated and 5 cc of calcium phosphate was placed into the defect. This was allowed to cure for 10 minutes before the leg was brought through ROM testing. The knee regained stability to a varus and valgus stress in both full extension and 30 degrees of flexion. The stab incision was sutured and a small sterile dressing was applied.  0.25% Marcaine was also infiltrated into the area of the stab incision.  The total time for the procedure was roughly 35 minutes, not including the 10 minutes used to let the Calcium Phosphate to harden.  The patient was ambulatory the night of surgery with almost complete relief of her left knee pain. She only required Tylenol for her pain control.

Fig 2

Intra-operative fluoroscopy demonstrating the indirect reduction using a balloon bone tamp used
In standard kyphoplasty techniques. The defect was than filled with calcium phosphate keeping the
depressed fragment reduced. Two .062 k-wires were used to provide a buttress for the balloon during the reduction. The k-wires were removed after the calcium phosphate was hard.

Fig 3

Intra-operative photo of the Kyphoplasty balloon and k-wire buttress

Fig 4

Depressed lateral tibial fracture fragment acts like a trap door  rotating around a medial bone hinge. This is an important concept when placing the balloon below the fragment.

Post-op course
The patient was ambulatory with no restrictions the night of surgery.  She was relatively pain free throughout her remaining hospital stay.  She remained in the hospital for two weeks post operatively regaining her strength. She used a walker for ambulatory assistance the first week  following the procedure. Her nutritional status improved with her increase activity and her surgical wounds healed without complications.  Radiographs taken at two and six weeks post-op revealed no change in  the anatomic reduction with no evidence of subsidence. 

Fig 5

Two week post op x-rays obtained after the patient was ambulatory

Discussion
Reduction of the articular surface in displaced tibial plateau fractures is still challenging and may result in joint incongruence, leading to post traumatic arthritis (9). Anatomic reduction of impacted articular fractures should be the goal of any treating surgeon (8).  In this case study the patient was also experiencing instability about the knee due to her lateral depressed tibial plateau fracture that was hindering her ability to ambulate.  Her continued pain and bed rest was contributing to her medical decline and her failure to thrive. Conventional techniques were felt to be to invasive for this patient with the possibility of wound complications due to her malnourishment and poor wound healing capacity. In reviewing this case, it may have been beneficial for us to have ordered further studies to investigate her wound healing capacity such as ABI and TCPO2 saturation. However, with continued communication with her primary care physician, he advised very poor wound healing capacity due to her very poor nutritional status and multiple areas of skin breakdown located around her heals and elbows.  We also contemplated using a minimally invasive plate osteosynthesis (MIPO) technique with placement of a small low profile plate to supplement the balloon tibioplasty. This was available in the room as well as cannulated screws, in the event additional subchondral support to augment the balloon tibioplasty was deemed to be necessary. However, after the procedure she was very stable and we felt the added hardware and fixation would not have added a benefit.  The nature of this lateral depressed tibial plateau fracture, which was contained within an intact lateral wall, allowed for the chance to use a new technique known as balloon tibioplasty without any additional hardware.  The balloon offers the advantage of being minimally invasive and creating a symmetric, contained defect to hold a bone filler for subchondral support (8).  Because we wanted the patient to be able to ambulate immediately post op, we elected to fill the contained defect after reduction with calcium phosphate cement.  A study looking at tibial plateau fractures in goats showed augmentation with calcium phosphate cement prevented subsidence of the fracture fragment and maintained articular congruency as the fracture healed (10). This was in comparison with cancellous autograft which did not maintain an anatomical reduction of the tibial plateau fractures in this model (10). This case study provides an example of this new minimally invasive technique for tibial plateau fractures. Specific elements can be extrapolated from this case study. Specifically the Schatzker III depressed fracture with an intact lateral wall,  that could be fixed with this unique indirect method regardless of the patients specific co-morbidities. This could minimize the complications associated with doing a large incision with prominent hardware. The intact lateral wall could prevent extravasation of cement into the lateral soft tissues and allow a lateral buttress to the balloon during the indirect reduction. This case also gives an example of utilizing calcium phosphate in treating osteoporotic metaphyseal defects to help support the subchondral surface of articular fractures. Not only can the concept of minimally invasive kyphoplasty be used to treat compression fractures of the spine, but also can be applied to the extremities to fix metaphyseal fractures in osteoporotic patients. This case also provides some biomechanical concepts related to the lateral depressed articular fragment of the tibial plateau. Specifically the medial bone hinge of the articular fragment that remains attached to tibial eminence. Much like a trap door, this has implications on proper balloon placement for a successful indirect reduction. The surgical procedure is also outlined that gives an example of utilizing k-wires to support the indirect reduction by the balloon. This allows the force of the balloon to be directed towards the depressed fragment. This is very important in osteoporotic bone due to the lose of metaphyseal bone to support the balloon. This patient’s fracture was roughly two weeks old and was reduced when the balloon was at 200 PSI. Lower PSI may be utilized with more acute fractures.

Conclusion
Utilizing this indirect technique to reduce this patients tibial plateau fracture,  the goals of surgical fixation for tibial plateau fractures were met. The risks of wound complications were minimized do to the small stab incision used to place the trocar.  She regained ambulatory status immediately after surgical fixation with an increase in her strength and spirits after 1 week of physical therapy. With proper patient selection with specific fractures patterns, balloon tibioplasty could be another technique added to the trauma surgeons armamentarium for tibial plateau fractures. More research with higher level evidence will be needed to verify its clinical significance compared to classical techniques. Retrospective and prospective studies will need to be developed to identify more specific indications and contraindications for this technique. In the meantime, this case shows a successful outcome in this specific patient utilizing balloon tibioplasty.

References

  1. Watson T. Shatzker J.  Tibial Plateau Fractures. Skeletal Trauma. Ch 56. Volume 2. Copyright 2003, Elsevier.  PP-2074-2130.
  2. Barei  DP. Nork SE. Mills WJ. Henley MB. Benirschke SK. Complications associated with internal fixation of high energy tibial plateau fractures utilizing a two incision technique. J Orthop Trauma. 2004. Nov-Dec;18(10): 649-57
  3. Sorensen LT, Jorgensen S, Petersen LJ, et al.  Acute effects of nicotine and smoking on blood flow, tissue oxygenation, and aerobe metabolism of the skin and subcutis. J Surg Res 2009;152 (2):224-230
  4. Argintar E, Kostas T, Delahay J, Wiesel B. The Musculoskeletal Effects of Perioperative Smoking.  J Am Acad Orthop Surg 2012;20:359-363
  5. Arnold M,Barboul A.  Nutrition and Wound Healing. Plastic and Reconstruction Surgery: June 2006, Volume 117. Issue 75;pp 42s-58s
  6. Greene K, Wilde A, Stulberg B, Preoperative nutritional status of total joint patients. The Journal fo Arthoplasty. Volume 6. Issue 4; pp 321-325. Dec 1991
  7. Eric M, Water V. High Energy Tibial Plateau Fractures. J Am Acad Orthop Surg 2006; 14: pp20-31
  8. 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 Orthop Traumaol. 2012 Jun; 13 (2);89-95
  9. Pizanis A, Garcia P, Pohlemann T, Burkhardt M. Ballon Tibioplasty: A Useful Tool for Reduction of Tibial Plateau Depression Fractures. J Orthop Trauma, 2012 Mar 16.
  10. Welch RD, Zhang H, Bronson DG. Experimental tibial plateau fractures augmented with calcium phospate cement or autologous bone graft.  J Bone Joint Surg Am. 2003 Feb; 85-A(2):222-31

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