OKOJ, Volume 11, No. 10

Femoral Component Revision in Total Hip Arthroplasty

Revision total hip arthroplasty is associated with increased morbidity, mortality, and cost of health care. The number of total hip revisions has been projected to increase 137% by 2030. Determining the best approach to use for femoral revision may be challenging, and requires the surgeon to be comfortable with performing extensile surgical procedures and utilizing modular components. A femoral revision procedure includes identification of the mode of failure of the primary arthroplasty, and selection of the appropriate surgical approach to maximize visualization and facilitate component exchange. Proper visualization is paramount, and the surgeon should be comfortable with performing an extended trochanteric osteotomy. With the projected rise of the number of revision total hip arthroplasties over the next several years, there will be increased need for surgeons to be well-versed in more advanced adult reconstruction techniques and be familiar with newer implant designs. We review the recently published literature and report on modes of failure, surgical techniques, implant choices, and outcomes following difficult femoral revision.

    • Keywords:
    • total hip arthroplasty

    • femoral revision

    • modular femoral component

    • cemented femoral implant

    • noncemented femoral implant

    • extended trochanteric osteotomy

    • Subspecialty:
    • Adult Reconstruction

Biologic Repair of the Intervertebral Disk

The intervertebral disk is a pliant, multi-component tissue that performs a demanding biomechanical role in the spine. Disk degeneration is an inevitable consequence of aging, the rate of which depends on the combined effects of mechanical loading of the spine, impaired metabolite transport, disk-cell dysfunction, and other yet to be clarified inherited factors. Degeneration leads to the accumulation of matrix damage, biomechanical instability, and, in some individuals, pain. Biologically based therapies for intervertebral disk degeneration hold the promise of minimally invasive treatment and long-term symptom relief. The main categories of current approaches include bioactive proteins, genetic manipulation, and cell-based therapies. Injection of proteins, including growth and anti-inflammatory factors, can stimulate desirable responses in disk cells, but may have limited durability due to short protein half-life. Gene therapy can coax host cells to more sustainably secrete extracellular matrix, yet the clinical impact may be limited by the inherently low disk cellularity and potential safety concerns. The most promising therapies include delivery of cells that are primed to survive in the challenging disk environment and participate with host cells to rebuild matrix and down-regulate inflammation. For all approaches, therapy optimization is hampered by lack of ideal preclinical animal models, inadequate diagnostics for identifying patients, and sensitively monitoring outcomes, safety concerns, and, ultimately, development costs.

    • Keywords:
    • intervertebral disk

    • protein therapy

    • gene therapy

    • stem cells

    • degeneration

    • tissue engineering

    • Subspecialty:
    • Spine

    • Basic Science

Balloon Osteoplasty for Depressed Fractures of the Tibial Plateau

Tibial plateau fractures represent a wide range of complex injuries that require technical skills for adequate reduction of the articular surface. Anatomic restoration of the joint line and mechanical alignment of the limb are always highly sought after goals, although the exact amount of acceptable step-off is still debated. Traditional surgical methods of reduction of depressed tibial plateau fractures have centered on the creation of a cortical window and the use of a metallic bone tamp to elevate the depressed fragment. However, advocates for the use of more modern reduction techniques have argued that the hard metallic bone tamp can fracture the depressed articular fragment and penetrate the knee joint. In the past few years, alternative ways of controlled reduction of the depression using an inflatable balloon have been described. In this paper, we aim to describe the surgical technique of inflation osteoplasty for reduction of depressed tibial plateau fractures under direct arthroscopic visualization. We believe that the combination of percutaneous techniques of balloon osteoplasty and knee arthroscopy, to visualize and improve the quality of reduction, allows earlier range of motion following surgery, less swelling, lower pain level, and higher patient satisfaction.

    • Keywords:
    • tibial plateau fracture

    • inflation osteoplasty

    • balloon tamp

    • Subspecialty:
    • Trauma