Instrumentation failure following pediatric spine deformity growth-sparing surgery using traditional growing rods or vertical expandable prosthetic titanium ribs.

BACKGROUND: Instrumentation failure (IF) is a major complication associated with growth-sparing surgery for pediatric spinal deformities; however, studies focusing on IF following each surgical procedure are lacking. We aimed to evaluate the incidence, timing, and rates of unplanned return to the operating room (UPROR) associated with IF following each surgical procedure in growth-sparing surgeries using traditional growing rods (TGRs) and vertical expandable prosthetic titanium ribs (VEPTRs). METHODS: We reviewed 1,139 surgical procedures documented in a Japanese multicenter database from 2015 to 2017. Of these, 544 TGR and 455 VEPTR procedures were included for evaluation on a per-surgery basis. IF was defined as the occurrence of an implant-related complication requiring revision surgery. RESULTS: The surgery-based incidences of IF requiring revision surgery in the TGR and VEPTR groups were 4.3% and 4.0%, respectively, with no significant intergroup difference. Remarkably, there was a negative correlation between IF incidence per surgical procedure and the number of lengthening surgeries in both groups. In addition, rod breakage in the TGR group and anchor-related complications in the VEPTR group tended to occur relatively early in the treatment course. The surgery-based rates of UPROR due to IF in the TGR and VEPTR groups were 2.0% and 1.5%, respectively, showing no statistically significant difference. CONCLUSIONS: We found that IF, such as anchor related-complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries. This finding may help in patient counseling and highlights the importance of close postoperative follow-up to detect IF and improve outcomes.

Failed back surgery syndrome successfully ameliorated with Chiropractic Biophysics® structural rehabilitation improving pain, disability as well as sagittal and coronal balance: a Chiropractic Biophysics® case report with a 6†year follow-up.

[Purpose] To present the case of the amelioration of chronic pain and disability in a patient suffering from failed back surgery syndrome. [Participant and Methods] A 27-year-old male with chronic low back pain was treated with a Coflex® intra-spinous instrument, however, it was removed shortly after due to poor outcome including worsening pain and disability. Radiographic assessment revealed significant posterior translation of the thorax complicated by significant loss of the normal lumbar lordosis and a left lateral translated thoracic cage posture. Chiropractic Biophysics® technique was applied over a 5.5-month period leading to structural spine improvements as well as improved pain, Oswestry disability index (ODI) and quality of life (QOL). [Results] There was a 21 mm reduction in posterior thoracic translation, a 6.2° improvement in lumbar lordosis and a 16 mm reduction in lateral thoracic translation corresponding with improved ODI and QOL scores. A 6 year follow-up showed successful outcome despite some degenerative changes in the spine at the prior surgical level. [Conclusion] This case adds to the growing literature showing the efficacy of non-surgical spinal rehabilitative methods in improving outcomes in patients with spinal deformity and associated disabilities. This case also demonstrates necessity of the continued criterion standard of spinal radiography for biomechanical assessment.

Reduction of thoraco-lumbar kyphosis results in the alleviation of low back pain in an adolescent basketball player: a Chiropractic Biophysics® (CBP®) case report.

[Purpose] To present the case of a significant reduction in thoraco-lumbar deformity and alleviation of chronic low back pain in an otherwise healthy and active adolescent male basketball player. [Participant and Methods] A 17 year old was assessed with chronic low back pain persisting for 4 years. Radiographic assessment revealed a prominent thoraco-lumbar kyphosis. Chiropractic Biophysics® structural rehabilitation including mirror image® exercise and traction methods as well as spinal manipulative therapy was performed 2-3 times per week. [Results] There was a 12° improvement in the thoraco-lumbar deformity corresponding with the alleviation of chronic low back pains and near complete reduction in disability after 36 treatments over a 4-month period. [Conclusion] This case adds to the growing literature showing the efficacy of the non-surgical spinal rehabilitative methods of Chiropractic Biophysics in improving spine alignment and relieving spinal pain syndromes. This case also demonstrates the importance of the routine screening for spine alignment via radiography in leading to proper biomechanical diagnosis and treatment.

[On the reasons for ankyloglossia relapse. Part 2. Laser technique pitfalls]. / O prichinakh povtornoi plastiki uzdechki yazyka. Chast' 2. Narushenie tekhniki primeneniya lazera.

The paper presents typical complications after laser lingual frenectomy. Laser and scalpel frenectomy are comparable in terms of functional results. Laser technique has some advantages (less pain and discomfort during the procedure and in the early postoperative period, less need for local anesthesia, lower average surgery time) but the exact knowledge of laser technical features is mandatory for optimal surgery results. Laser technique methodology is described allowing to avoid the complications.

The treatment and rationale for the correction of a cervical kyphosis spinal deformity in a cervical asymptomatic young female: a Chiropractic BioPhysics® case report with follow-up.

[Purpose] To present a case demonstrating dramatic restoration of the cervical lordosis and reduction of forward head posture by use of Chiropractic BioPhysics® (CBP®) technique. [Participant and Methods] A 24-year-old cervical asymptomatic female presented with poor craniocervical posture. Radiography revealed forward head posture and an exaggerated cervical kyphosis. [Results] The patient received CBP care including mirror image® cervical extension exercises, cervical extension traction and spinal manipulative therapy. After 36 treatments over 17-weeks, repeat radiography demonstrated a dramatic improvement of an alteration of the cervical kyphosis to a lordosis and a reduction of forward head posture. Subsequent treatment increased the lordosis further. Long-term follow-up at 3.5 years showed some loss of original correction, however, a maintenance of the global lordosis. [Conclusion] This case demonstrates that non-surgical reversal of a cervical kyphosis to a lordosis is possible in a short time using CBP cervical extension protocols. It is logical if the kyphosis had not been corrected, over time, osteoarthritis and various craniovertebral symptoms would have evolved as the literature indicates. The diagnosis of gross spinal deformity, we argue, requires its correction prior to the onset of symptoms and permanent degenerative changes.

Effects of inspiratory muscle training on respiratory muscle strength, respiratory function and functional capacity in adolescents with idiopathic scoliosis : A randomized, controlled trial.

BACKGROUND: Adolescent Idiopathic Scoliosis (AIS) may impair respiratory dynamics and affect the performance of inspiratory and expiratory muscles. The benefit of inspiratory muscle training (IMT) is not well investigated in AIS. We aimed to investigate the effects of IMT on respiratory muscle strength, respiratory function and functional capacity in adolescents with mild to moderate AIS. METHODS: Thirty-six adolescents were randomized into control or IMT groups. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF) were measured by spirometry; respiratory muscle strength by maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP); and functional capacity by 6-min walk test (6MWT) before and after the 8-week-long home-based exercise program. Both groups received conventional exercise program including diaphragmatic breathing exercises, resistive local expansion exercise on the collapsed areas in concave sides of scoliosis, spinal stabilization, strengthening of interscapular muscles and stretching exercises. IMT group also trained with Threshold IMT device for 15 minutes, twice a day for 8 weeks at the intensity of 30% of initial MIP value in addition to conventional exercise program. RESULTS: FEV1, PEF, MIP, MEP and 6MWT distance significantly improved in both groups. IMT group also showed significant improvement in FVC. The increases in FVC, MIP, MEP and 6MWT distance of IMT group were significantly higher compared to control group. CONCLUSION: IMT is found to be beneficial for patients with AIS for achieving further improvements in respiratory function, respiratory muscle strength and functional capacity compared to conventional exercise program alone.

Investigating the "scapula sign" as an indicator of rickets.

OBJECTIVE: In 1971, Weiss identified a "scapula sign" comprising a defect at the inferior angle of the scapula in juveniles with vitamin D deficiency rickets, but this has been little studied since. This study aimed to explore pathological variation of this defect in juveniles with other skeletal manifestations of vitamin D deficiency rickets. MATERIALS AND METHODS: 527 juveniles, aged from birth to 12 years, from two post-medieval British assemblages were macroscopically evaluated to document the range of pathological changes at the inferior angle. Scapula maximum lengths were recorded and supplementary radiographs were assessed. RESULTS: Blunting, flattening or squaring of the inferior angle occurred in 34 of 155 (22%) juveniles with other indicators of rickets and occurred frequently in cases of severe active rickets. Coarsening of the border and cupping deformities were identified radiographically, as well as residual defects in healed cases. Scapula lengths in juveniles with active rickets did not consistently deviate from those expected in any age group. CONCLUSIONS: The scapula sign is identifiable in some children with rickets. Differential diagnoses of scapula defects are important but the socio-cultural and environmental context of this sample suggests a link to vitamin D deficiency. SIGNIFICANCE: This finding expands the range of pathological changes known to occur in rickets, helping to improve recognition of this condition in past groups. LIMITATIONS: Small sample sizes prevented observation of the defect in adolescents with rickets. Defects can affect the positioning of standardised scapula length measures, complicating assessments of growth impacts. SUGGESTIONS FOR FUTURE RESEARCH: Continued research into the range of skeletal changes that can develop in vitamin D deficiency to improve the identification of this deficiency in past groups.

Addressing varus and valgus deformity of the ankle: Algorithmic approach to total ankle arthroplasty.

Total ankle replacements have become increasingly popular, providing a viable alternative to ankle arthrodesis in patients with end stage ankle arthritis. Continued advancements in implant design have substantially improved long term survival outcomes as well as patient pain relief, range of motion, and quality of life. Surgeons continue to advance the indications for implantation of total ankle replacements in patients with more severe varus and valgus coronal plane deformity. This report of twelve cases demonstrates our algorithmic approach to total ankle arthroplasty in patients with deformity of the foot and ankle. By proposing a clinical algorithm with case examples, we aim to aid clinicians in successfully approaching coronal plane deformities of the foot and ankle when using total ankle replacement to ultimately improve clinical outcomes.

A Central Slip Injury in a Professional Basketball Player.

Hand injuries are extremely prevalent in sports such as ball sports. Delayed diagnosis or improperly managed injuries have the potential to prolong the athlete's return to the competition and permanently damage their abilities. We report the case of a 35-year-old male professional basketball player who presented to a chiropractor with pain and swelling of the right fifth finger two days after a basketball game. The injury occurred when a player passed the basketball and the ball hit his fifth finger "head-on". Examination revealed enlargement of the middle joint of the right fifth finger and a boutonniere deformity. He was diagnosed with a central slip injury using magnetic resonance imaging (MRI). Since there are no standard treatment guidelines for central slip injuries, multi-model chiropractic therapy was applied to the injury and adjacent sites. The patient returned to the game by the end of the third week and fully recovered within six weeks. Chiropractors must understand how to best guide athletes' clinical management of these injuries, given the inherent need for immediate and complete recovery.

[Clinical characteristics analysis of 22 062 patients of foot and ankle deformity from QIN Sihe Orthopaedic Surgery Database between May 25, 1978 and December 31, 2020].

Objective: Based on the clinical data of patients with foot and ankle deformities in the QIN Sihe Orthopaedic Surgery Database, to analyze the characteristics and treatment strategies of foot and ankle deformities, and provide a basis for clinical decision-making. Methods: A total of 22 062 patients with foot and ankle deformities who received orthopedic surgery between May 25, 1978 and December 31, 2020 were searched in the QIN Sihe Orthopedic Surgery Database. The gender, age at operation, regional distribution, etiology, type of deformity, operation method, postoperative fixation method, and other information were collected. Results: Among the 22 062 patients, there were 13 046 males (59.13%) and 9 016 females (40.87%); the age at operation ranged from 1 to 77 years, with a median of 17 years, and 20 026 cases (90.77%) were aged 5 to 40 years. The patients came from 32 provinces, municipalities, and autonomous regions across the China and 5 countries including India and the United States, et al. The etiology and diseases type covered 154 kinds (of which sequelae of poliomyelitis, cerebral palsy, spina bifida and tethered spinal cord, congenital equinovarus foot, post-traumatic foot and ankle deformity, and Charcot-Marie-Tooth disease accounted for the highest proportion). The types of deformities included varus foot, equinus foot, valgus foot, talipes calcaneus, equinocavus, high arched foot, claw toe, and flail foot. Surgical methods included tendon lengthening, soft tissue release, tendon transposition, osteotomy orthopedics, and ankle arthrodesis. The 36 620 operations were performed, including 11 561 cases of hip, knee, and lower leg operations to correct the foot and ankle deformities. Postoperative fixation methods included Ilizarov external fixator in 2 709 cases (12.28%), combined external fixator in 3 966 cases (17.98%), and plaster or brace fixation in 15 387 cases (69.74%). Conclusion: Male patients with foot and ankle deformities account for a large proportion, and the population distribution is mainly adolescents, with a wide distribution of regions, causes and diseases, and talipes equinovarus and varus foot are the main types of deformities. Foot and ankle deformities are often combined with deformities of other parts of the lower limb, which requires a holistic treatment concept. The application of foot soft tissue and bone surgery combined with Ilizarov external fixator and combined external fixators provides a guarantee for the correction of complex foot and ankle deformities.

AO Spine Adult Spinal Deformity Patient Profile: A Paradigm Shift in Comprehensive Patient Evaluation in Order to Optimize Treatment and Improve Patient Care.

STUDY DESIGN: Modified Delphi study. OBJECTIVE: Adult spinal deformity (ASD) is an increasingly recognized condition, comprising a spectrum of pathologies considerably impacting patients' health and functional status. Patients present with a combination of pain, disability, comorbidities and radiological deformity. The study aims to propose a systematic approach of gathering information on the factors that drive decision-making by developing a patient profile. METHODS: The present study comprises of 3 parts. Part 1: Development of prototype of patient profile: The data from the Core Outcome Study on SCOlisis (COSSCO) by Scoliosis Research Society (SRS) was categorized into a conceptual framework. Part 2: Modified Delphi study: Items reaching >70% agreement were included in a 4 round iterative process with 51 panellists across the globe. Part 3: Pilot testing-feasibility: Content validity and usability were evaluated quantitatively. RESULTS: The profile consisted of 4 domains. 1. General health with demographics and comorbidities, 2.Spine-specific health with spine related health and neurological status, 3. Imaging with radiographic and MRI parameters and 4. Deformity type. Each domain consisted of 1 or 2 components with various factors and their measuring instruments. Profile was found to have an excellent content validity (I-CVIr 0.78-1.00; Ave-CVI 0.92) appropriateness, relevance and usefulness. CONCLUSIONS: The present study, is first to provide a universally applicable multimodal ASD patient profile to methodically describe patients. Physicians are encouraged to assess ASD patients holistically using this profile and not just based on radiographic findings.

Physical therapy interventions for the correction of equinus foot deformity in post-stroke patients with triceps spasticity: A scoping review.

Objective: Equinus foot deformity (EFD) is the most common deformity following a stroke. Several approaches have been suggested for its correction, including pharmacological, surgical, and physical therapy (PT) interventions. This scoping review aims to map and synthesize the available evidence focusing on physical therapy treatments for EFD caused by triceps surae (TS) spasticity. Methods: Scoping review methodological frameworks have been used. Pubmed, Cinahl, and Cochrane databases were searched for primary literature. Studies focusing on the treatment of EFD in adult stroke patients were included only when the intervention involved PT treatments and presented at least one outcome measure for the functional and/or structural condition of the TS. Data were systematically collected and reported in tables inclusive of type of intervention, sample characteristics, dosage, comparators, outcomes, follow-up timeline, and treatment efficacy. A narrative synthesis was also added. Results: Of the 642 experimental or observational screened studies, 53 were included, focusing on stretching exercises, shock waves, electrical stimulation, dry needling, TENS, vibration therapy, ultrasounds, cryotherapy, and active physiotherapy. Patients with EFD benefited from specific physical therapy treatments. These usually resulted in Modified Ashworth Scale reduction, typically by 1 point, and an increase in ROM. Interventions consisting of shock waves, dry needling, and electrostimulation showed the best results in reducing EFD. Heterogeneous dosage and delivery mode generally limited conclusions. Conclusions: This scoping review summarized available primary literature based on PT treatments for the correction of EFD. By highlighting the remaining gaps in knowledge, it provides a reference for future studies on this pathology. Further investigations are necessary to pinpoint the best dosage and delivery methods. Future studies should investigate whether early rehabilitation programs started during the acute phase might help prevent or limit the development of secondary deformities.

Hyaluronic Acid Filler Injection for Localized Scleroderma - Case Report and Review of Literature on Filler Injections for Localized Scleroderma.

Introduction: Localized scleroderma, also known as Morphea, is a chronic inflammatory condition of connective tissue, the etiology of which is unknown. There is skin thickening with increased quantities of collagen in the indurative lesion. Skin hyperemia is seen in the early inflammatory stage. This is followed by fibrosis, sclerosis, and atrophy with hypopigmentation or hyperpigmentation. Therapeutic options include corticosteroids, oral or subcutaneous methotrexate, calcipotriol, imiquimod, tacrolimus, mycophenolate mofetil, medium-dose UVA1 phototherapy, and CO2 fractional laser treatment. There is disfigurement in approximately 50% of patients. Surgical excision, autologous bone grafting, and autologous fat grafting have been performed with varying degrees of success in linear morphea. Hyaluronic acid, Calcium hydroxylapatite, Poly L lactic acid, and permanent fillers such as Silicone have been used to correct deformities that occur as a result of morphea. The aim of this case report was to establish hyaluronic acid fillers as an efficacious modality of treating stable localized morphea with facial disfigurement. Case Report: A 35-year-old lady with stable localized scleroderma had an atrophic scar on the right side of her face extending from the labio-mental crease to the midline of the chin. The contour of the chin was lost leading to facial disfigurement. The atrophic scar was treated with 2 fillers with the same cross-linking polymer but two different G primes with excellent cosmetic outcome. A brief review of literature involving fillers for localized scleroderma is also discussed. Conclusion: Hyaluronic acid filler can be used safely in cases of stable localized scleroderma with facial atrophies. It is an effective, minimally invasive treatment with minimal downtime. It is extremely important to inject fillers only in stable cases of localized morphea. This modality of treatment should be considered for a larger trial in patients with similar disfigurements.

CT based bone mineral density as a predictor of proximal junctional fractures.

Background: Proximal junctional fractures (PJFr) can be a catastrophic complication associated with adult spinal deformity surgery. Osteoporosis can be a major risk factor for the cause of PJFr. Recent studies suggest using surrogate computed tomography (CT) scans in place of spinal dual-energy x-ray absorptiometry (DEXA) scores for bone mineral density (BMD). Investigate the feasibility of using preoperative CT based bone mineral density at upper instrumented vertebrae (UIV) and one level proximally (UIV+1) and distally (UIV-1) to predict the possibility of PJFr risk. Methods: Retrospective two-academic center case-controlled study, reviewed consecutive adult spinal deformity surgeries; included constructs encompassing at least five fusion levels and fusions to pelvis. Examined demographic, surgical, and radiographic data preoperatively, postoperatively, and final follow-up. Formed groups based on type of proximal junctional deformity (PJD): Control (no PJD), proximal junctional kyphosis (PJK) and PJFr. Preoperative CT BMD values measured in Hounsfield units (HU) for sagittal and axial planes at UIV, UIV+1, and UIV-1 and compared between groups. Results: N=92 patients. Preoperative CT scan BMD values were significantly lower in PJFr vs. control at: UIV+1 in sagittal (p=0.007), axial (p=0.02) planes; UIV sagittal (p=0.04) and axial (p=0.03) planes; and UIV-1 sagittal (p=0.05) plane. Similarly, lower CT scan BMD values noted in PJFr vs. PJK at: UIV+1 in sagittal (p=0.04) and axial (p=0.03) planes. Trend seen with lower CT scan BMD values at UIV+1 level in PJFr vs. PJK in sagittal (p=0.12) and axial (p=0.10) planes. Preoperative global sagittal imbalance measurements significantly lower in control, but comparable between PJK and PJFr. Conclusions: Higher preoperative global sagittal imbalance with lower preoperative CT BMD values at UIV and UIV+1 vertebral body may increase the risk of proximal junctional fractures after adult spine deformity surgery. Proximal junctional hooks may supplement the pathogenesis. Readers should note the small sample size.Level of Evidence: 3.

Chiropractic care of Parkinson's disease and deformity.

Parkinson's disease (PD) is a progressive neurological disease characterized by muscle stiffness, tremor, slowness of movement, and difficulties with posture and walking. Muscle and joint pain are frequent non-motor symptoms of PD. Pain associated with PD is mainly caused by a combination of truncal dystonia, stooped posture, and muscle rigidity. However, PD deformities were rarely discussed in the literature. A 68-year-old Asian female with PD treated with Levodopa for six years complained of progressive neck pain, contractures, and subluxation of both hands in the last two years. A positron emission tomography (PET) scan revealed decreased rostrocaudal gradient uptake in both posterior putamen. After 9 months of multimodal chiropractic rehabilitation, the patient had significant improvement in symptoms, including pain resolution as per the numeric rating scale and physical and mental improvement as per the PD questionnaire. Radiographic measurement showed significantly improved postural alignment and stability. Measurement of joint motion and angles showed an improvement in hand deformity. Although PD is a neurodegenerative disease that is not curable, multimodal rehabilitation may improve neurological and musculoskeletal functions by inducing proprioceptive balance, motor strength, and joint movement. The current study may illustrate multimodal rehabilitation addressing orthopedic deformity associated with symptoms in a PD patient.

Development of Atypical Ulnar Fracture is Associated with Bisphosphonate Therapy and Severe Spinal Deformity: A Case Report.

Atypical ulna fracture (AUF) is relatively rare and is known to be associated with prolonged bisphosphonate (BP) use. The developmental mechanism remains unclear. We report a patient with an AUF associated with BP and severe spinal deformity. The patient was an 85-year-old woman receiving oral alendronate for 8 years without vitamin D supplementation. During regular kitchen work, she needed left upper limb support. She presented with atraumatic pain over the ulna. Radiographs revealed a transverse fracture in the proximal ulna and ulna bowing deformity. Whole-spine standing radiographs showed severe degenerative kyphoscoliosis. The skin induration with pigmentation on her left elbow that suggested prolonged overload and during standing work, coincided exactly with fracture location. This report suggests that 'direct stress', with persistent local overload on the proximal ulna, is one of the developmental mechanisms of AUF, in addition to persistent suppression of bone remodelling by prolonged BP use and vitamin D deficiency. Level of Evidence: Level V (Therapeutic).

Transgenerational effects of parental crude oil exposure on the morphology of adult Fundulus grandis.

The current study involved exposing adult F0 Gulf killifish (Fundulus grandis) to Macondo-252 oil for 36 to 44 days and assessing the effects of this oiling on the swimming performance and morphology in two generations of progeny reared in clean water. Following exposure to oil, the F0 fish were used as broodstock to generate four lineages of F1 fish using a full-matrix mating design derived from the gametes of clean and oil-exposed parents. Later, the four lineages of F1 fish were used as broodstock to create an F2 generation of the same four lineages. We found few differences in embryonic outcome (% dead,% hatched, and% unhatched) in any of the four lineages of F1 and F2 fish. However, as adults, F1 and F2 fish derived from oil-exposed males from the F0 generation had significantly lower critical swimming speeds (Ucrit) than both the control and maternally oil-exposed lineages. Additionally, progeny of oil-exposed fish had altered body shape based on the statistical analysis of two-dimensional landmark-based geometric morphometrics. Fish from oil-exposed lineages showed increased body depth, altered spinal curvature, and changes in the upward angle of projection of the head. Both generations had a significant main effect of maternal and paternal oil exposure on shape; however, F0 paternal oil exposure explained more of the variance in shape across both generations relative to F0 maternal exposure. Our findings demonstrate that parental exposure to oil can impact the shape and aerobic swimming capacity of offspring for at least two generations after the original paternal oiling.

Relationship between distal radius fracture severity and 25-hydroxyvitamin-D level among perimenopausal and postmenopausal women.

AIMS: Low-energy distal radius fractures (DRFs) are the most common upper arm fractures correlated with bone fragility. Vitamin D deficiency is an important risk factor associated with DRFs. However, the relationship between DRF severity and vitamin D deficiency is not elucidated. Therefore, this study aimed to identify the correlation between DRF severity and serum 25-hydroxyvitamin-D level, which is an indicator of vitamin D deficiency. METHODS: This multicentre retrospective observational study enrolled 122 female patients aged over 45 years with DRFs with extension deformity. DRF severity was assessed by three independent examiners using 3D CT. Moreover, it was categorized based on the AO classification, and the degree of articular and volar cortex comminution was evaluated. Articular comminution was defined as an articular fragment involving three or more fragments, and volar cortex comminution as a fracture in the volar cortex of the distal fragment. Serum 25-hydroxyvitamin-D level, bone metabolic markers, and bone mineral density (BMD) at the lumbar spine, hip, and wrist were evaluated six months after injury. According to DRF severity, serum 25-hydroxyvitamin-D level, parameters correlated with bone metabolism, and BMD was compared. RESULTS: The articular comminuted group (n = 28) had a significantly lower median serum 25-hydroxyvitamin-D level than the non-comminuted group (n = 94; 13.4 ng/ml (interquartile range (IQR) 9.8 to 17.3) vs 16.2 ng/ml (IQR 12.5 to 20.4); p = 0.005). The AO classification and volar cortex comminution were not correlated with the serum 25-hydroxyvitamin-D level. Bone metabolic markers and BMD did not significantly differ in terms of DRF severities. CONCLUSION: Articular comminuted DRF, referred to as AO C3 fracture, is significantly associated with low serum 25-hydroxyvitamin-D levels. Therefore, vitamin D3 supplementation for vitamin D deficiency might prevent articular comminuted DRFs. Nevertheless, further studies must be conducted to validate the results of the current study. Cite this article: Bone Jt Open 2022;3(3):261-267.

Blood preservation techniques in complex spine surgery: Illustrative case and review of therapeutic options.

BACKGROUND: Complex spine surgery predisposes patients to substantial levels of blood loss, which can increase the risk of surgical morbidity and mortality. CASE DESCRIPTION: A 29-year-old achondroplastic male required thoracolumbar deformity correction. However, he refused potential allogeneic blood transfusions for religious reasons. He, therefore, underwent pre-operative autologous blood donation and consented to the use of the intraoperative cell salvage device. Immediately prior to the incision, he underwent acute normovolemic hemodilution. Throughout the case, we additionally utilized meticulous hemostasis. Postoperatively, he was supplemented with iron and erythropoietin and recovered well. When he required a revision procedure 3 months later, similar strategies were successfully employed. CONCLUSION: Numerous strategies exist pre-operatively, intraoperatively, and post-operatively to optimize blood loss management for patients who refuse blood transfusions but warrant major spinal deformity surgery.