Percutaneous reduction and fixation of an intra-articular calcaneal fracture using an inflatable bone tamp: description of a novel and safe technique

Two thirds of hind foot fractures involve the calcaneus [1]. 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 [4]. 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 [9].The preoperative planning is critical. A computerized tomography is essential to visualize the fragments involved (Figure 1A, B, C). A number of issues need to be assessed during the planning phase. The first aspect is the identification of the fracture lines and the position of the depressed articular fragment. The former will determine screw placement following reduction maneuver, while the latter will determine the path of the cannula as well as the inflatable bone tamp position in order to obtain the optimal force direction for anatomical reduction. We use templating paper to trace the sagittal, axial and coronal images from the CT scan using the cuts where the art