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■ tips & techniques Section Editor: Steven F. Harwin, MD Intraoperative Fabrication of Bone Tamps for Indirect Reduction of Depressed Articular Segments MAJ Josef K. Eichinger, MD; Daphne Beingessner, MD, FRCSC Abstract: The use of bone tamps for indirect reduction of de- pressed articular segments is an established method of treat- ment for intra-articular fractures in a variety of joint injuries. Customized bone tamps can be fabricated intraoperatively us- ing commonly available instruments and supplies consisting of Steinmann pins and T-handled chucks. The technique com- bines the use of bone tamps through carefully created metaph- 1A 1B yseal windows, fl uoroscopic guidance, packing with cancel- Figure 1: Radiographs (A) and CT scan (B) of intra-articular distal radius frac- lous bone, and adequate fi xation. This treatment methodology ture with depressed scaphoid fossa. can allow for a minimally invasive or soft tissue preserving approach for the treatment of some intra-articular fractures while achieving anatomic reduction of the joint surface. Several commercially avail- articular joint-depression in- able bone tamps of varying juries of the distal tibia and sizes and confi gurations exist distal radius, respectively. ndirect reduction of de- the ideal choice of bone tamp, and work effectively in most Treatment included the use of Ipressed articular surfaces including the joint of interest, clinical scenarios. However, a novel technique using intra- has been used in the treat- the size of the articular seg- there are occasional scenarios operative fabrication and the ment of articular fractures.1,2 ment, the distance from the in which these instruments are use of customized bone tamps Reduction is usually per- metaphyseal window to the either not available or do not to assist in the reduction of formed through a traumati- articular surface, and the angle possess the ideal geometry depressed articular segments. cally or carefully created or curve of the tamp required needed to achieve reduction. Preoperative plain radio- metaphyseal window through to negotiate the window and This article presents a graphs and computed tomog- which the bone tamp is insert- impact the articular seg- technique that quickly and ef- raphy (CT) were obtained for ed. Several variables dictate ment in the desired direction. fi ciently allows fabrication of both patients. The fi rst patient, bone tamps of varying sizes a 29-year-old man, sustained and geometry from readily a closed intra-articular com- Dr Eichinger is from the Department of Orthopaedics, Womack Army available materials and tools minuted distal radius fracture Medical Center, Fort Bragg, North Carolina; and Dr Beingessner is from Harborview Medical Center, University of Washington, Seattle, Washington. in the operating room. following a fall while snow- Drs Eichinger and Beingessner have no relevant fi nancial relationships boarding. Imaging revealed a to disclose. MATERIALS AND METHODS volar Barton’s pattern with as- Correspondence should be addressed to: MAJ Josef K. Eichinger, MD, Two patients underwent sociated articular depression Department of Orthopaedics, Womack Army Medical Center, 2817 Reilly Rd, Fort Bragg, NC 28307 ([email protected]). open reduction and internal of the scaphoid fossa (Figure doi: 10.3928/01477447-20111021-19 fi xation (ORIF) for traumatic 1). The second patient, a 970 ORTHOPEDICS | ORTHOSuperSite.com Cover Story Cover illustration © Scott Holladay DECEMBER 2011 | Volume 34 • Number 12 971 ■ tips & techniques The next step is determin- ing geometry of the fabricated bone tamp. This is based in large part on the location and size of the metaphyseal win- dow relative to the articular segment requiring reduction. A metaphyseal window farther from the articular surface re- quires less curvature/bending than that of a window closer to the articular surface. The win- dow created should remain in 2A 2B 3 the metaphyseal region within the surgical incision; straying Figure 2: Radiograph (A) and CT scan (B) of B-type pilon fracture with articu- Figure 3: Creation of the metaphy- lar depression. seal window. toward the diaphysis is unde- sirable due to the formation of a diaphyseal stress riser and greater diffi culty in develop- ing a window through cortical bone. However, the creation of the metaphyseal window does not need to be precise because the bone tamps can be adjusted as needed. The diameter of the metaphyseal window should be approximately twice the 4A 4B diameter of the Steinmann Figure 4: Fabrication of the bone tamp (A, B). pin being used. If possible, the window should use open- ings already present in the 30-year-old man, sustained a struments is performed. In fi rst step is deciding what di- metaphysis. The window is closed intra-articular commi- injuries with articular depres- ameter of Steinmann pin to easily formed by using a post- nuted pilon fracture with as- sion, preoperative planning use. In general, the larger the age stamp technique in which sociated articular depression may reveal an opportunity to articular segment needing el- multiple holes are drilled in following a fall from a bicycle perform a less invasive or in- evation and the larger the joint a circular fashion and com- (Figure 2). direct approach to achieving involved (ie, proximal tibia pleted with a quarter-inch os- At fi nal follow-up, both reduction of depressed articu- vs distal radius), the larger teotome (Figure 3). The cortex patients were evaluated for lar segments. This reduction the Steinmann pin required. removed is later replaced fol- fracture healing, accuracy of technique is achieved through Caution is emphasized with lowing bone grafting and prior reduction, range of motion the use of bone tamps. In addi- this step because selection of a to plate fi xation. (ROM), pain, and return to tion to standard, commercially Steinmann pin with a relative- Once a particular diameter preoperative function. available equipment, bone ly smaller diameter may result of Steinmann pin and a me- tamps can be fabricated intra- in perforation rather than ele- taphyseal window is chosen, 2 SURGICAL TECHNIQUE operatively for specifi c joints vation/reduction of the articu- T-handled chucks are attached Standard preoperative and injury patterns. lar segment. A rule of thumb is to both ends of the Steinmann planning to include fracture The materials required are to use a Steinmann pin with a pin, and the pin is manipulat- templating, intended surgi- Steinmann pins of various di- diameter that is approximately ed into the desired geometry cal approach, and selection ameters, wire or bolt cutters, one-third to one-half the width (Figure 4). Finally, the tips of of required implant and in- and 2 T-handled chucks. The of the articular segment. the pointed Steinmann pin are 972 ORTHOPEDICS | ORTHOSuperSite.com ■ tips & techniques cut off with the wire cutters 2.5-mm Steinmann pin (Figure anteromedial articular surface face (Figure 7). Postoperative or bolt cutters (bolt cutters re- 6A). Allograft cancellous bone was performed under direct radiographs show anatomic quired for diameters of у3.5 chips were also used to back- visualization. However, the reduction of the articular sur- mm). The fabricated bone fi ll and assist with elevation of posteromedial articular surface face with fi nal fi xation applied tamp is now ready for use and the articular segment. Finally, remained impacted and unre- (Figure 8). is inserted into the window to a volar locking plate was ap- duced. Rather than addressing access the depressed articular plied (Figure 6B). the unreduced segment through RESULTS segment (Figure 5). Further additional incisions, a 3.5-mm The technique was used adjustments to the bone tamp Distal Tibia Steinmann pin was fashioned successfully in both patients can be made by simply reat- Treatment occurred in a into a curved bone tamp and and allowed for anatomic re- taching the T-handled chucks staged fashion, with initial inserted through a metaphyseal duction of the articular sur- and bending the Steinmann pin placement of spanning exter- window to achieve anatomic faces of the distal radius and into the desired confi guration. nal fi xation the night of injury reduction of the articular sur- distal tibia fractures. Both Two specifi c clinical ex- followed by ORIF after reso- amples, including fractures of lution of soft tissue envelope the distal radius and proximal swelling. Intraoperatively, an tibia with depressed articular anteromedial incision was used segments, highlight the use of and reduction of the impacted this technique. Distal Radius A fl exor carpi radialis ap- proach was chosen to address the fracture. Manual reduction of the volar Barton’s segment was performed under direct vi- sualization and provisionally secured using Kirschner wire 6A 6B fi xation. Elevation of the de- Figure 6: Indirect reduction of distal radius articular surface using a 2.5-mm pressed articular surface of the Steinmann pin (A). Distal radius fracture following open reduction and internal fi xation (B). scaphoid fossa was performed 5 through a 4.0-mm diameter Figure 5: Insertion of the contoured metaphyseal window using a Steinmann pin through the metaphy- bone tamp fabricated from a seal window. 8 7 Figure 8: AP (left) and lateral (right) radiographs of Indirect reduction of a Figure 7: Pilon fracture following open reduction and internal fi xation. posteromedial articular depression using a 3.5-mm Steinmann pin. DECEMBER 2011 | Volume 34 • Number 12 973 ■ tips & techniques patients went on to unevent- arthrotomy and visual evalu- ful healing of the fractures by ation of the articular surface. 3 months with no complica- Arthroscopic visualization is also tions. The distal radius fracture a form of direct means. Indirect patient obtained full ROM and methods generally include ma- resolution of pain and returned nipulation via ligamentotaxis or to his previous level of activity. percutaneous or limited open ap- The pilon fracture patient ob- proaches in which devices or in- tained full ROM with minimal struments such as tamps, eleva- pain and returned to work.

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