This study aimed to identify factors associated with increased rates of blood transfusion in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF).

A retrospective case-control study was performed for AIS patients treated at a large children's hospital between August 2018 and December 2020. All patients with a diagnosis of AIS were evaluated. Data on patient demographics, AIS, and transfusion parameters were collected. Univariate regression and multivariate logistic modeling were utilized to assess risk factors associated with requiring transfusion. Odds ratios (OR) and 95% confidence interval (CI) were calculated. Surgeries were done by three surgeons and thirty anesthesiologists. To quantify the influence of anesthesia practice preferences a categorical variable was defined as “higher-transfusion practice preference”, for the provider with the highest rate of transfusion.

A total of 157 AIS patients were included, of whom 56 were transfused RBC units (cases), and 101 did not receive any RBC transfusion (controls). On univariate analysis, the following variables were significantly correlated with receiving RBC transfusion: “higher-transfusion practice preference,” “administration of crystalloids,” “receiving fresh frozen plasma (FFP),” “receiving platelets,” “pre-operative hemoglobin,” “cell saver volume,” and “surgical time.” On multiple regression modeling, “pre-operative hemoglobin less than 120 g/L” (OR 14.05, 95% CI: 1.951 to 135.7) and “higher-transfusion practice preference” (OR 11.84, 95% CI: 2.505 to 63.65) were found to be meaningfully and significantly predictive of RBC transfusion.

In this cohort, we identified pre-operative hemoglobin of 120 g/L as a critical threshold for requiring transfusion. In addition, we identified significant contribution from anesthesia transfusion practice preferences. Our multivariate model indicated that these two factors are the major significant contributors to allogenic blood transfusion. Although further studies are required to better understand factors contributing to transfusion in AIS patients, we suggest standardized, peri-operative evidence-based strategies to potentially help reduce variations due to individual provider preferences.

Introduction: Various techniques have been described for cup position in deficient acetabuli. Medialization allows an optimal cup position in the true acetabulum affording cover of the implant in the superolateral area by the bony roof and avoiding the need for a structural graft to cover the protruding lateral edge of the cup.

Materials and Methods: During the last 5 years 51 cases of cup medialization have been done during Resurfacing Replacement or THR with hard-hard bearing surfaces (mean follow up 35.2 month). 15 cases were done with the medial acetabuloplasty technique and 36 cases were done by simple over-reaming the medial wall and morselized bone grafting. The mean followed up was 16 months.

Surgical technique: Medial Acetabuloplasty: After a cartilage removal, we drill perforations in a horizontal line to weaken the central area of the medial wall. Using an impactor the medial wall is fractured and shifted medially for a few millimeters and the cavitation so produced is filled with morselized bone graft. This technique preserves a shell of bone medially which together with the graft brings about medial bony wall preservation. In extreme acetabular deficiency, this technique is also useful by minimizing the extent of morselized bone grafting needed in the superolateral area for lateral roof bone formation.

Results: The medial wall defect was consistently reformed during the first year. In neither the over-reaming with morselized bone graft nor in the group using the medial acetabuloplasty was the stability of the cup compromised.

Conclusion: The lateral structural graft techniques are more cumbersome, take more time and the results are less certain.

In the short term there was no difference in hip scores or in the radiological assessment between medialization with or without acetabuloplasty. We suggest this technique seems to have the potential for very good long term results.

Introduction: Extracorporal Shock Wave Therapy (ESWT) has become a useful adjunct for the treatment of various musculo-skeletal inflammatory conditions.

The aim of the study is prospective assessment of the efficacy of ESWT for the treatment of recalcitrant greater trochanteric bursitis (GTB).

Material and Methods: Prospective evaluation and follow-up of fourteen patients with persistent GTB two of them with bilateral problem. All the patients failed to response to conventional treatment with oral NSAID’s, physiotherapy, US and more than one steroid injection to the grater trochanter region. All patients underwent compete physical examination. A Comprehensive VAS Score (grading from 0–10) which were obtained prior to therapy and at follow-up. ESWT was applied in six consequitive courses each of 1500 impulses of 0.32mj/mm^2 to the lateral side of the grater trochanter region.

Results: Mean age of 60.6 ± 11.6 (mean ± SD) years (range 81 to 38 years). Mean duration of symptoms 14.2 ± 8.1 months, up to 37 months. Mean VAS dropped from 7.9 ± 0.9 to 1.6 ± 0.8 (p< 0.0001). There were no side effects except minimal local discomfort during the session time.

Conclusion: ESWT is an effective treatment for recalcitrant GTB, with minimal side effect.

Introduction: In avascular necrosis [AVN] of the femoral head the dead bone undergoes osteoclastic osteolysis and is replaced by newly synthesized, immature, weak bone, which cannot withstand the daily loads. The articular surface might caves in because of these changes, and osteoarthritic joint changes can develop. Alendronate interferes with the osteoclastic activities, it can slow-down the bone turnover of the necrotic bone and can differ these changes.

The aim of this study is to delay the speedy renewal of living epiphyses by alendronate medication in order to describe the effects of it on the fate of the necrotic femoral heads in rats.

Methods: Sixty female sprague-dawley rats, 6-month old weighing about 400–500 grams, underwent surgical AVN of the right femoral heads. Forty-four rats, the treated group, were treated with alendronate 200 μgm/kg/day. Sixteen rats, the control group, were treated with saline. Both groups were daily injected subcutaneously for six weeks and sacrificed. Both femoral heads were harvested and were evaluated microscopically and stained by H& E.

Results: The necrotic femoral heads of the control group, which were not treated by alendronate, were severely distorted with osteoarthrosis features as; collapse of the epiphysis, pannus formation, filling of spaces by chronically and mildly inflamed densely textured fibrous tissue which was polluted by numerous tiny particles of necrotic bone. Additionally, large chunks of necrotic articular cartilage were haphazardly scattered in the fibrous tissue. All hematopoietic and fat cells of the intertrabecular spaces of the epiphysis were replaced by fibrous tissue. More often than not, the cartilage of the physis was focally or entirely absent such that osseous trabeculae of the epiphysis and metaphysis linked with each other, forming so-called epiphyseal-metaphyseal bridges. The above described alterations were encountered in all animals, yet their severity varied.

The decisive difference between the necrotic femoral heads of otherwise untreated in opposition to the alendronate-medicated rats was the preservation of a hemispherical configuration of the femoral heads. There was no distortion of the femoral heads in the alendronate-treated animals and the femoral heads preserved their roundness.

All femoral heads of the non-operated left hips were microscopically normal.

Discussion: It has become clear that the degree of architectural distortion of the femoral epiphyses depends on the extent of bone turnover leading to resorption of all debris and its replacement by living osseous and soft tissues. The more rapidly and more extensively the reconstruction of living epiphyses progresses, the smaller is the prospect of reshaping a hemispherical or near-hemispherical femoral head. The recently rebuilt epiphyses cannot carry daily transarticular loads without caving in. The revascularization-related reconstitution of weak bony trabeculae is blamed for the collapse of the femoral heads. If this indeed is the case, the remodeling of the necrotic femoral heads should be delayed, rather than sped-up. Alendronate interferes with the osteoclastic activities and hence, slowing-down the bone turnover.

The osteoclastic activity is detrimental for the conservation of a hemispherical femoral head because of the rapidly occurring replacement of the necrotic bone by living tissues. Halting the activities of the osteoclasts by a biphosphonate would stop the hasty osteoneogenesis, which is responsible for the early femoral capital disfigurement and might delay the regeneration of osteo-arthiritic changes of the joint later on.

A vascular necrosis (AVN) of the head of the femur is a potentially crippling disease which mainly affects young adults. Although treatment by exposure to hyperbaric oxygen (HBO) is reported as being beneficial, there has been no study of its use in treated compared with untreated patients. We selected 12 patients who suffered from Steinberg stage-I AVN of the head of the femur (four bilateral) whose lesions were 4 mm or more thick and/or 12.5 mm or more long on MRI. Daily HBO therapy was given for 100 days to each patient. All smaller stage-I lesions and more advanced stages of AVN were excluded. These size criteria were chosen in order to compare outcomes with an identical size of lesion in an untreated group described earlier. Overall, 81% of patients who received HBO therapy showed a return to normal on MRI as compared with 17% in the untreated group. We therefore conclude that hyperbaric oxygen is effective in the treatment of stage-I AVN of the head of the femur.