Gissane described percutaneous elevation of depressed intra-articular fractures and this formed the basis of Essex-Lopresti’s classic 1951 paper. He elevated his tongue-type fractures with a percutaneous Gissane spike. Joint-depression fractures were reduced by a limited open approach before being fixed with a spike. Unfortunately he did not separate the fracture types in his results.
There has been increased interest in percutaneous or limited open reduction techniques recently, often with arthroscopic assistance (Tornetta 2000, Gavlik et al 2002). Essex-Lopresti's technique is used to reduce tongue-type fractures. Joint depression fractures are reduced with an elevator introduced through thesinus tarsi or a punch passed through the inferior surface of the bone. Post-reduction stabilisation has been achieved with K-wires (Stulik et al 2006), a unilateral fixator (Magnan et al 2006) or a ring fixator (Paley and Fischgrund, Talarico 2004, McGarvey et al 2006). Results appear similar to those of open reduction and internal fixation, possibly with lower rates of serious infection. The technique is demanding, particularly in joint depression or comminuted fractures which seem to do slightly less well. The joint fragments are not always fully reduced, but this may not adversely affect the results.
The soft tissue problems have led to other closed or limited open reduction techniques being tried. Baumgaertel and Goetzen (1993) reduced fractures initally with medial percutaneous pins followed by lateral internal fixation when swelling had resolved. Results are difficult to disentangle, but appear to be no worse than those with standard internal fixation, with fewer serious complications.
As yet there are no RCTs comparing open and minimally invasive techniques, so it is difficult to reach a conclusion as to the place of each in management. Perhaps future trials of treatment should include percutaneous techniques as one comparator arm.