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Orthopaedics & Traumatology: Surgery & Research 100 (2014) S169–S179

Available online at

ScienceDirectwww.sciencedirect.com

eview article

yphopasty and vertebroplasty

. Teyssédou , M. Saget , P. Pries ∗

ervice de chirurgie orthopédique et traumatologie, 2, rue de la Milétrie, 86000 Poitiers, France

a r t i c l e i n f o

rticle history:ccepted 15 November 2013

eywords:yphoplastyertebroplastyertebral compression fracturesolymethylmethacrylate

a b s t r a c t

Vertebroplasty and balloon kyphoplasty are percutaneous techniques performed under radioscopic con-trol. They were initially developed for tumoral and osteoporotic lesions; indications were later extendedto traumatology for the treatment of pure compression fracture. They are an interesting alternative toconventional procedures, which are often very demanding. The benefit of these minimally invasive tech-niques has been demonstrated in terms of alleviation of pain, functional improvement and reduction inboth morbidity and costs for society. The principle of kyphoplasty is to restore vertebral body anatomygently and progressively by inflating balloons and then reinforcing the anterior column of the verte-

ercutaneous bra with cement. In vertebroplasty, cement is introduced directly under pressure, without prior ballooninflation. Both techniques can be associated to minimally invasive osteosynthesis in certain indications.In our own practice, we preferably use acrylic cement, for its biomechanical properties and resistanceto compression stress. We use calcium phosphate cement in young patients, but only associated to per-cutaneous osteosynthesis due to the risk of secondary correction loss. The evolution of these techniquesdepends on improving personnel radioprotection and developing new systems of vertebral expansion.

© 2014 Published by Elsevier Masson SAS.

. Introduction

Vertebroplasty and balloon kyphoplasty are increasinglymportant options for radiologists, orthopedic surgeons and neu-osurgeons managing spinal lesions.

They are percutaneous techniques, performed under radio-copic control. The principle of kyphoplasty is to restore vertebralody anatomy gently and progressively by inflating balloons andhen reinforcing the anterior column of the vertebra with cement.he balloons create a cavity within the vertebral body, compressinghe cancellous bone and thus limiting the risk of cement leakagerom the vertebral body. In vertebroplasty, cement is introducedirectly under pressure, without prior balloon inflation.

Vertebroplasty was developed in France by Galibert and Dera-ond in 1984 [1]. Its original indication was for aggressive vertebral

ngioma. Its proven efficacy led to an extension of indications toetastatic and myelomatous osteolytic lesions, and then to osteo-

orotic vertebral compression fractures.Kyphoplasty was developed from the vertebroplasty concept,

nitially by Reiley in 1998, then taken up by Belkoff et al. in 20012]. At first reserved to tumoral and osteoporotic lesions [3], it has

∗ Corresponding author. Tel.: +33 5 49 44 43 95; fax: +33 5 49 44 41 12.E-mail address: p.pries@chu-poitiers.fr (P. Pries).

877-0568/$ – see front matter © 2014 Published by Elsevier Masson SAS.ttp://dx.doi.org/10.1016/j.otsr.2013.11.005

gradually established its role in the treatment of fractures in youngpatients [4].

The benefit of these minimally invasive techniques comparedto conventional attitudes (conservative treatment or open surgery)has been demonstrated in terms of pain and functional improve-ment. Cement injection into the vertebra may have an analgesiceffect by consolidating microfractures and reducing the mechanicalstress associated with weight and activity, and also by destroy-ing bone nerve endings by cytotoxic and exothermal action in thecourse of cement polymerization.

Morbidity, moreover, is minimal, and the techniques bring costsavings over the medium term.

2. Technique

2.1. Instrumentation

Most cementoplasty instrumentation is basically similar (Fig. 1),differing in whether or not balloons or stents are used to expandthe vertebra.

Instrumentation comprises beveled trocars (or Yamshidi nee-dles) for the entry point and trajectory through the bone, blunt

K-wires to guide the cannulae carrying the balloon or stent, acurette in case of dense cancellous bone, and devices for bonefilling. The technique also requires an iodized contrast agent forfluoroscopic control of balloon inflation, and a dose of cement.

S170 S. Teyssédou et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S169–S179

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.2. Patient positioning

Our attitude is to perform the procedure in theater under generalnesthesia. The patient is positioned in ventral decubitus on thepine-surgery table in hyperlordosis, thus partially reducing theraumatic vertebral kyphosis (Fig. 2).

The procedure requires peroperative radioscopic control usingne or two fluoroscopes to obtain AP and lateral views; wedvise using two fluoroscopes, so as the limit the risk of infectionssociated with manipulating them during surgery. The frontal flu-roscope tank should be placed upwards. Having two surgeons, onen either side of the patient, reduces surgery time and irradiationime by operating on both sides simultaneously.

One technical variant is to operate under CT. This provides bet-er visualization of the vertebra than radioscopy, especially in smallumoral lesions. However, it does not allow injection under flu-roscopy or monitoring the progress of the cement within theertebral body.

In upper thorax procedures, superimposition of the two shoul-ers on lateral views hinders peroperative fluoroscopic control, anday even lead to abandoning cementoplasty. This is especially true

n squat or muscular patients, for whom 3D fluoroscopy or peroper-tive CT seems indispensable. In other cases, it is usually possible to

eliminate” the shoulders, either by positioning the arms along theody and strapping them down or by holding them in antepulsion inhe so-called “Superman posture” (although the latter incurs a risk

Fig. 2. Patient positioning.

Fig. 3. Insertion of Yamshidi needle.

of stretching the brachial plexus and generally requires a relativelynarrow operating table such as the new carbon fiber models).

2.3. Surgery

2.3.1. Spinal approachFor dorsal and lumbar vertebrae, an extrapedicular posterolat-

eral or a transpedicular approach is possible, the latter having thegeneral advantage of avoiding dorsal pleural-parenchymal compli-cations or lumbar psoas hematoma, with much less cement leakagefrom the vertebral body through the puncture hole; however, it isnot feasible in case of pedicular lysis or presence of internal fixa-tion material. The lesion level is determined before draping and theposition of the vertebral pedicles is marked on the skin.

2.3.1.1. Transpedicular approach. As the objective is to injectcement into the center of the vertebral body, the incision shouldbe shifted about 1 cm away from the pedicular skin landmark sothat the cannulae converge horizontally. Vertically, the height ofthe incision depends on how steeply the cannula is to descend: fora very steeply descending orientation, the incision had to be shiftedabout 1 cm upward of the projection of the pedicle (Fig. 3).

The trocar entry point is determined manually, at the base ofthe superior articular process at the junction with the transverseprocess (Fig. 4A, B). The trocar advances to the inner edge of thepedicular ring seen on AP view; the ring is not to be crossed beforethe posterior wall of the vertebral body, seen on lateral view, hasbeen; otherwise the trocar will penetrate the spinal canal (Fig. 5A,B). The trocar is introduced beyond the posterior wall of the verte-bral body (Fig. 6). The major risks of this transpedicular approachare radicular lesion or dural breach through the medial pedicularcortical bone; this risk can easily be corrected by rigorous frontalfluoroscopic control of the pedicle or by adapting the caliber of thetrocar to the size of the pedicle, especially in the superior dorsalregion.

2.3.1.2. Extrapedicular posterolateral approach. We reserve the pos-terolateral approach to cases in which the transpedicular approachis contraindicated: pedicular lysis or internal fixation material.Some authors prefer a posterolateral approach at dorsal level wherepedicle size is reduced. The entry point is about one hand-width

from the spinous processes. At dorsal level, it is essential to makesure that the needle is always behind the line of pleural reflection:otherwise, the risk is a pleural wound and possible hemotho-rax. At lumbar level, the risks are the same as in vertebral body

S. Teyssédou et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S169–S179 S171

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Fig. 4. A. Diagram of frontal entry point. B. Diagram of lateral entry point.

iopsy: renal fossa puncture, psoas hematoma and above all leak-ge through the puncture hole.

.3.1.3. Other approaches. Open kyphoplasty may be indicated inase of thoracolumbar fracture with neurologic deficit requiringaminectomy associated to stabilization: the fractured vertebralody can be reinforced, avoiding secondary anterior reconstructionr an extensive posterior assembly, especially in fragile patients

5,6].

Cervical kyphoplasty by short anterolateral cervicotomy haseen described for tumoral pathology [7,8].

Fig. 5. A. Frontal progression of Yamshidi needle. B. Lateral progression of Yamshidineedle.

Fig. 6. A. Frontal passage of the curette. B. Lateral passage of the curette.

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.3.2. Continuation of the procedureA guide wire is introduced in each trocar; the trocars are

emoved, leaving the guide wires. The cannulae are introducednto the vertebral body, guided by the wires. Bone biopsy may bessociated at this point, especially in elderly patients, to screen foreoplastic lesions. A tunnel is created in the vertebral body, using aap drill, to facilitate balloon insertion. The anterior wall of the ver-ebral body must not be damaged, as this could lead to large-vesselesions or cement leakage.

If the cancellous bone is too dense, a curette can be used to createn initial cavity to facilitate and guide vertebral expansion (Fig. 6A,). This should be performed under fluoroscopy, to avoid any cor-ical damage. The curette should always be oriented toward thenterior of the vertebral body.

.3.3. Vertebral expansion during kyphoplastyThe two balloons or stents are introduced into the cannulae

nd positioned under the fracture. They are deployed simulta-eously. Frontal and lateral fluoroscopic controls are continued

Fig. 8. A. Acrylic kyphoplasty: final frontal fluoroscopic view

. B. Lateral balloon inflation.

until reduction is satisfactory (Fig. 7A, B). Direct syringe readingof balloon volume enables an approximate assessment of the doseof cement required.

2.3.4. Fracture stabilizationThe cannulae containing the cement are introduced into the

anterior half of the vertebral body, to limit the risk of leakage intothe canal. The cement is injected progressively, under fluoroscopiccontrol. The resulting cavity is filled entirely, while avoiding over-filling the vertebral body and creating a hyper-rigid spinal segment.If any leakage is observed, the procedure must be stopped. Thecannulae are removed immediately after injection (Fig. 8A, B).

2.3.5. Postoperative courseAnalgesia and thromboprophylaxis are initiated immediately.

The patient is seated in a chair and resumes walking the day aftersurgery. Discharge is possible as of day 2, after radiographic control.

At follow-up, residual pain is assessed on a VAS; spinal flexi-bility is assessed, and independence is estimated on the Oswestry

. B. Acrylic kyphoplasty: final lateral fluoroscopic view.

S. Teyssédou et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S169–S179 S173

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Fig. 9. Concave fracture, frontal plane.

cale. Radiologic assessment focuses on fracture union, impact ondjacent levels (vertebral fracture, disc degeneration) and spinalarameters. Physical therapy may be initiated at an early stage,oncentrating on flexibility. Return to work is authorized at month

or 3, but is often postponed to month 6 for patients with jobsnvolving heavy lifting.

.3.6. Technical tipsOur kyphoplasty experience has taught us 2 main criteria guid-

ng balloon positioning:

the characteristics of the deformity;the density of the cancellous bone (related to patient age: osteo-

porotic or not).

.3.6.1. Characteristics of the deformity. In the frontal plane, the ver-ebral body may be concave (Fig. 9). Cannula orientation should

Fig. 11. A. Cuneiform fracture, sagittal plane. B. Ballo

then be convergent, so as to create a central cement cavity. The skinincision is lateralized by about 1 or 2 cm with respect to the pro-jection of the pedicles on AP views, enabling oblique introductionof the cannulae. The slope may be steepened when the guide wireis passed through the cannula after crossing the posterior wall ofthe vertebral body, controlled on lateral views; this ensures againstcrossing he vertebral canal. This is the “kissing balloon” as describedby Maestretti (Fig. 10).

In the frontal plane, vertebral body compression may be later-alized, in which case the cannula on the affected side is orientedalong the pedicle axis without convergence, so as to position theballoon at the site of maximal deformity. The skin incision is thenmade along the projection of the pedicle on AP view. In general, theother balloon is convergent, so as to create a single cement cavity.

In the sagittal plane, compression may be cuneiform, in whichcase the balloon is inflated in the anterior part of the vertebral

on inflation in anterior part of vertebral body.

S174 S. Teyssédou et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S169–S179

. B. Balloon inflation in center of vertebral body.

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ody, while remaining remote from the cortical bone so as to avoidnterior leakage (Fig. 11A, B).

In the sagittal plane, the vertebral body may be concave, inhich case the balloon is positioned in the center of the vertebrander the site of maximal deformity (Fig. 12A, B).

.3.6.2. Cancellous bone density. Patient age and the related cancel-ous bone density are determining factors for balloon orientation.racture reduction differs depending on whether the bone is osteo-orotic or not.

In young patients with dense cancellous bone, the balloonhould be positioned close to the collapsed vertebral plateau: if its too remote, expansion is limited by bone resistance and fractureeduction will be insufficient; if on the other hand it is too close,here is a risk of cortical damage and of cement leakage toward theisc. In that case, the cannulae should be oriented almost horizon-ally (Fig. 13A, B), and the skin incision should be at the level of therojection of the pedicle on AP view.

In osteoporotic patients, the balloons should be more remoterom the collapsed plateau. Vertebral expansion is possible only ifnough cancellous bone is compressed, in which case we tend toim at the antero-inferior corner of the vertebra, with a descendingrientation on lateral view (Fig. 14A, B). The skin incision is madebout 1 cm above the projection of the pedicle on AP view.

. Choice of cement

The cement fills the bone defect left by the fracture and by thenflation of the balloons in kyphoplasty. This enables lasting correc-ion of the vertebral deformity, whether traumatic or not, and alsoxerts an analgesic effect, mainly by lesion stabilization. There areresently two types of cement available for kyphoplasty: calciumhosphate (TriCa++) and acrylic (PMMA).

.1. Calcium phosphate cement

Calcium phosphate cement has been available for some 20 years.t is produced by hydrolysis or crystallization of an acid salt and anlkaline salt. The objective is to associate the mechanical proper-ies of acrylic cement to the osteoconductive properties of calcium

hosphate cement. It is resorbable. Although expensive, this kind ofement seemed to be the solution of choice when vertebral cemen-oplasty techniques were first developed, as there was at the timeonsiderable doubt as to the long-term evolution of inert acrylic

Fig. 13. A. Dense cancellous bone, horizontal balloon orientation. B. Difficult balloonexpansion.

S. Teyssédou et al. / Orthopaedics & Traumatology:

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ement injected into the vertebra. Several studies [9,10], includ-ng that of Maestretti in 2007 [4], converged with encouragingesults. Experience, however, has shown that calcium phosphateement is difficult to use by reason of its low radio-opacity andery rapid crystallization. Moreover, resorption is unpredictablend the biomechanical properties are far from optimal, leadingo secondary correction loss [11–13]. These findings prompt us todvise against calcium phosphate cement as a stand-alone solutionn vertebral expansion; association to percutaneous osteosynthesis14], however, avoids secondary correction loss. We use calciumhosphate cement only in association to posterior percutaneoussteosynthesis in traumatic fracture in young patients.

.2. Acrylic cement

Unlike calcium phosphate cement, acrylic cement is inert,roviding immediate mechanical stability in cementoplasty andyphoplasty. Long-term tolerance is excellent, as half a century’sxperience in orthopedic surgery testifies. It is produced by mix-ng a powder of polymethacrylate plus initiator plus opacifier andiquid monomer methyl methacrylate. Polymerization induces atrong exothermal reaction (> 70 ◦C), causing necrosis in the tis-ue in contact with the cement. Acrylic cements show excellentechanical resistance to compression stress, and good longevityhen prepared under vacuum [15]. We prefer acrylic cement as a

tand-alone solution in cementoplasty and kyphoplasty. Moreover,t is much less expensive than calcium phosphate cement.

. Indications

.1. Tumors

The first indications for vertebral cementoplasty were for symp-omatic vertebral angioma [1]. They were then extended to benign

Surgery & Research 100 (2014) S169–S179 S175

(vertebral hemangioma) and malignant (metastases, myeloma)tumors.

Only 3% of vertebral fractures have a malignant origin. Theseare a source of considerable morbidity in case of solid metastaticvertebral tumor or malignant myeloma of poor prognosis. Theyare frequently associated with metastatic tumor, and are usuallypainful. Treatment is often palliative (analgesia, radiation therapy,corset) and sometimes etiological (chemotherapy, etc.).

Cementoplasty may be indicated in painful vertebral tumorwithout signs of compression. Contraindications are major oste-olysis with cortical bone loss, entailing a risk of cement leakage,and osteocondensing lesions preventing vertebral expansion andcement injection. Vertebroplasty may also be indicated for cysticlesions.

The recent Cancer Patient Fracture Evaluation (CAFE) projectincluded 134 patients with metastatic or myelomatous vertebralfracture [16] in a 22-center study spread over the US, Europe, Aus-tralia and Canada. It produced clinical proof of the superiority ofballoon kyphoplasty over non-surgical management in terms ofpain relief and improved quality of life.

4.2. Osteoporosis

Eighty-five percent of vertebral fractures are thought to be ofosteoporotic origin. Annual incidence is estimated at more than700,000 in the US and 450,000 in Europe, although only one-thirdare diagnosed. Incidence doubles in women with the menopause.Onset may be spontaneous or secondary to minimal trauma.

Conventional management of osteoporotic vertebral compres-sion fracture is based on analgesia, with or without corset. Bed-restmay be necessary during the acute phase, followed by earlymobilization and physical therapy. Global management of theosteoporosis by a rheumatologist or family physician should be sys-tematically associated (osteodensitometry, biphosphonates, etc.).

In osteoporotic pathology, cementoplasty is never an emer-gency attitude, although there is at present no consensus on thispoint. Our policy is to propose cementoplasty in case of failure of atleast 1 month’s well-conducted medical treatment after correlatingradiological and clinical data to bone-scan or MRI.

In a series of 254 patients with osteoporotic vertebral fracturemanaged by kyphoplasty, Majd reported immediate postoperativereduction in pain in 89% of cases [17], with ≥ 20% recovery of ver-tebral height in 63%.

4.3. Fractures in young subjects

Stand-alone kyphoplasty is an interesting alternative to tradi-tional attitudes toward compression fracture (Magerl type A) of thethoracolumbar junction without neurological signs. Unlike corsetimmobilization [18], it provides significant reduction of the trau-matic vertebral kyphosis [4,19,20]. Lasting restoration of vertebralbody anatomy correlates directly with good functional results,according to the French Société d’Orthopédie de l’Ouest round-tableof 2008 [21].

Many comparative studies between conservative managementand kyphoplasty reported shorter bed-rest, hospital stay and timeoff work with the latter [22]. The rate of complications is low[23,24], and the difficulties inherent to wearing a corset for 3months are avoided.

After suitable information, we propose kyphoplasty to youngpatients, as it corrects the traumatic vertebral deformity whileavoiding the complications associated with corset immobilizationor open surgery.

S176 S. Teyssédou et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S169–S179

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for degenerative pathologies [29], but authors such as Pelegri [30]and Rampersaud [31] have demonstrated its application in trauma-tology. As the multiaxial screws do not allow effective reductionmaneuvers, the aim is to stabilize the fracture with an internal

Fig. 15. Mag

.3.1. Fracture classificationThoracolumbar junction fracture classification seeks to assess

nstability and guide treatment strategy. Classification systems areasically founded on imaging: plain AP and lateral X-ray and CT. Inase of associated distraction or translation, MRI assesses the inter-ertebral disc and posterior ligamentous complex; it is, however,ot readily available in emergency.

We use the Magerl classification [25]. Based on purely mor-hological criteria, it is the most widely used system (Fig. 15).

t distinguishes 3 types of fracture (A = pure compression, = distraction, C = translation or rotation), 3 groups and 3 sub-roups, using the AO codes. Its interest lies in its good predictivealue, with vertebral instability increasing from type A to type C.n the other hand, it distinguishes 27 types of fracture and requires

igorous interpretation of imaging to limit inter-observer variation.In comminutive type A33 fracture, we associate McCormack’s

oad Sharing classification [26] (Table 1), originally intended tossess risk of failure of conservative treatment of burst fracture, butlso useful to guide indications between stand-alone kyphoplastynd associated percutaneous osteosynthesis. Scores are from 3 to 9,ccording to percentage vertebral height loss in the sagittal plane,omminution and vertebral kyphosis reducibility in hyperexten-ion on the operative table.

.3.2. IndicationsKyphoplasty reinforces the vertebral body and restores its

natomy. Indications for stand-alone kyphoplasty are thereforeimited to fractures in which the posterior vertebral arc is con-erved: Magerl type A.

.3.2.1. Type A1 fracture (compression fracture). In type A11 frac-ure, in which body lesions are minimal and there is no vertebralyphosis, functional treatment is indicated. In types A12 and A13,yphoplasty can be considered as an alternative to corset immobi-ization, on a case-by-case basis.

.3.2.2. Type A2 fracture (separation fracture). It is generally agreedhat type A22 (or “diabolo”) fracture requires anterior reconstruc-ion due to the risk of discal incarceration. Kyphoplasty offersn attractive alternative if the inter-fragment gap is moderate

able 1cCormack classification.

Score 1 point 2 points 3 points

Sagittal collapse 30% > 30% 60%Shift 1 mm 2 mm > 2 mmCorrection 3 degrees 9 degrees 10 degrees

Total 3 points 6 points 9 points

assification.

(< 2 mm). In case of failure of kyphoplasty (non-union or insufficientcement injection), anterior revision by corporectomy with removalof cement and reconstruction remains possible.

4.3.2.3. Type A3 fracture (burst fracture). In our experience, typeA31 fracture is the best indication for kyphoplasty as an alternativeto corset immobilization and especially to conventional surgery.Canal stenosis due to posterior displacement of the posterior wallis not an absolute contraindication, if the balloons are correctlypositioned away from the vertebral plateau.

Type A33 burst fracture is also a good indication for kyphoplastyif properly analyzed on pre-operative CT. A load sharing score ≥ 6,on the other hand, is a contraindication: the risk of cement leakageout of the vertebral body and the likely failure of body reinforce-ment indicate corporectomy and implantation of an expandablecage [27,28] (Fig. 16).

4.3.3. Indications for associated posterior percutaneousosteosynthesis

Posterior percutaneous osteosynthesis was originally developed

Fig. 16. Corporectomy with intersomatic cage reconstruction.

S. Teyssédou et al. / Orthopaedics & Traumatology:

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Fig. 17. Kyphoplasty associated with a mini-invasive osteosynthesis.

orset effect. Instrumentation is available with pre-curved rodse.g., SextantTM, Medtronic) or with curvable rods (e.g., ViperTM,epuy); the latter allow indications to be extended to the lowernd middle thoracic spine. These various means of posterior percu-aneous osteosynthesis are the perfect complement to kyphoplastyn certain indications:

use of calcium phosphate cement (Fig. 17): the aim is to preventthe secondary correction loss found with this kind of cement, byproviding a supplementary posterior fixation [14];insufficient injection of acrylic cement (e.g., when injection isstopped because of leakage): the aim is as in the previous case;posterior bone lesion: whether in compression (isolated sagi-ttal fracture line on the posterior lamina) or distraction fracture(Chance fracture), percutaneous osteosynthesis provides stabi-lization awaiting bone fusion;disc protection following vertebral plateau impaction: althoughseveral studies demonstrated that kyphoplasty, by restoring ver-tebral body anatomy, partly conserves adjacent discs [32,33], incase of severe damage to the plateaux (in practice, type A22 orA33 fracture) temporary supplementary posterior fixation mayfacilitate fusion;posterior ligamentous complex (PLC) protection: according toVaccaro and the Spine Trauma Study Group, PLC lesions arecentral to the therapeutic algorithm for thoracolumbar junctionfractures [34,35]. The TLICS classification [36] includes an “unde-termined” PLC status: distraction fracture without posterior arcbone involvement (Magerl type B1) and/or without radiologiccriteria of PLC tear. In such fractures, posterior percutaneousosteosynthesis associated to kyphoplasty promotes PLC healingby the protection afforded by the osteosynthesis after vertebralbody anatomy has been restored. The internal fixation materialcan be ablated via short incisions centered on the screws, asdescribed by De Peretti’s team [37].

The advent of new percutaneous pedicular osteosynthe-is instrumentation, with uniaxial screws, allows reductionaneuvers by distraction between the screw-holders ahead of

yphoplasty. In theory, this should provide supplementary correc-ion by ligamentotaxis, although the recent report by Blondel [38]ailed to demonstrate this.

Surgery & Research 100 (2014) S169–S179 S177

5. Contraindications

5.1. Absolute contraindications

The first absolute contraindication to these vertebral cemento-plasty procedures is, obviously, the lack of a spinal surgeon on site.The others are:

• anesthesiological;• infection (septicemia);• > 30% posterior displacement or lytic lesion of the posterior ver-

tebral wall (risk of neurologic compression);• complete vertebral collapse or A.33 fracture with load sharing

score ≥ 6 (see Indications section).

5.2. Relative contraindications

Relative contraindications and precautions concern:

• iodine allergy (in case of balloon rupture), although non-iodizedradio-opaque solutions exist;

• coagulation disorder;• osteocondensing tumor (risk of failure of balloon deployment and

cement injection).

Finally, as described in the Approaches sections, fracture withassociated neurologic deficit is not a contraindication if cemento-plasty is associated to open decompression and stabilization.

6. Complications

The international literature is unanimous as to the low rateof complications associated with vertebral cementoplasty. Recentmeta-analyses found fewer complications in kyphoplasty than invertebroplasty [39–41]. This is partly due to low-pressure cementinjection into a preformed cavity in kyphoplasty, reducing leakagerisk. Balloon correction of part of the traumatic vertebral deformityalso helps avoid mechanical complications.

6.1. Complications related to cement leakage

Taylor [42] demonstrated that, despite high rates of cementleakage, the incidence of associated complications is low (2%).

The most severe leakage-related complication is pulmonaryembolism. It is, however, exceptional: Krueger et al. [43], in a lit-erature review, found 86 cases in 20,000 procedures, only half ofwhich were symptomatic.

Disc degeneration due to cement leaking into the nucleus pulpo-sus is also reported to be exceptional [14], although this is probablybiased by the small number of reports on disc behavior after cemen-toplasty [32].

Finally, the risk of neurologic compression by foraminal or intra-canal leakage is also low [42,44]. In case of heavy peroperativeleakage, we recommend immediate decompression, with associ-ated fixation if neurolysis induces instability.

To reduce the rate of complications related to cement leak-age, Greene et al. [45] described the “eggshell” trick: beginning byinjecting a small amount of acrylic cement into the kyphoplastycavity and compacting it by redeploying the balloons before com-pleting injection.

The most frequently reported mechanical complication is frac-ture in adjacent levels, found in osteoporotic patients. It is caused

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178 S. Teyssédou et al. / Orthopaedics & Traumat

y the production of a hyper-rigid segment within the spine [46].he risk is 1.5-fold higher than in medical treatment, and predom-nates at the thoracolumbar junction [47]. There is, however, a biasntroduced by the significantly earlier resumption of activity byyphoplasty patients [48].

The other mechanical complication, and a matter of controversyn vertebral expansion, is loss of correction over time. As men-ioned above in the Cements section, this mainly concerns calciumhosphate substitutes [49].

Infection (spondylodiscitis, subcutaneous abscess) is excep-ional [50], arguing in favor of this percutaneous attitude.

. Alternatives and perspectives

Our experience with kyphoplasty suggests certain improve-ents and perspectives for evolution.

.1. Reducing radiation dose

Fluoronavigation enables reliable kyphoplasty [51] while con-iderably reducing the radiation dose received by the surgeon andheater team during repeated percutaneous procedures [52].

Simple measures, easy to implement, such as simultaneous usef two fluoroscopes, use of an obturator and moving the team backuring surgery also serve to reduce exposure.

.2. Other vertebral expansion devices

Various vertebral expansion systems have recently beenescribed.

The VBSTM system (Synthes) is one of the most widely usedertebral expansion systems in the world. It associates a kypho-lasty balloon and a stent similar to those used in vascular surgery.he principle is that the stent remains in the cavity, preventing theorrection loss classically observed after balloon withdrawal [44].

OsseoFixTM (Scient’x-Alphatec) and Spine JackTM (Vexim) usetents (or jacks) alone. The declared objective is to reduce the dosef cement. However, they show poorer correction of the verte-ral deformity than with balloons, which raise the plateau moreradually and physiologically.

The AscendXTM system (AscendX Spine) introduces the balloonia a unipedicular route, theoretically reducing operative time andadiation. It also enables cement injection to be initiated with thealloon still in place. It is, however, technically difficult to centerhe balloon, which is deployed asymmetrically.

The KivaTM system (Zimmer) deploys a spiral PEEK cage via anipedicular route. The drawbacks are the same as above: poor cor-ection and difficult technique. This system does, however, reducehe risk of cement leakage, and could be a good solution for lyticertebral lesions.

. Conclusion

Vertebral balloon kyphoplasty is a reliable technique, the clini-al benefit of which has been well established. Initially developedor tumoral lesions and osteoporotic compression, it has provedts usefulness in traumatic fracture in young patients, where it is aegitimate alternative to very demanding conventional treatments.he possibility of associating posterior percutaneous osteosynthe-is extends indications to fractures with an element of distraction.enefit in terms of quality of life is a major argument in favor of

eveloping this technique, especially in young patients.

The main issue concerns the cement. As well as the theoreticisk of shock associated with injection, the long-term evolu-ion of acrylic cement within the vertebral body remains to be

[

Surgery & Research 100 (2014) S169–S179

seen. Developing novel “physiological” cements with the samebiomechanical properties as acrylic cements is a hopeful prospect.

Irradiation of patient and theater team by the indispensableperoperative fluoroscopy is a drawback. Experience and rigoroustraining allow the team to reduce exposure significantly.

These percutaneous techniques require surgeons well experi-enced in standard open surgery and able to deal with possibleperoperative complications. Ideally, they should be performed inspecialized spine-surgery centers.

Finally, costs remain high (around D 4000), while reimburse-ment by the French national health insurance scheme is still undernegotiation.

Disclosure of interest

The authors declare that they have no conflicts of interest con-cerning this article.

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