[Infectious complications of surgically treatment pelvic fractures]

Based on case histories, the authors draw attention to important infectious complications in patients surgically treated for pelvic injuries. These complications were recorded in four out of 75 patients (5.3%) undergoing surgery for pelvic fracture in the period from 2001 to 2005. The chief risk factors for the development of infection included the poor state of health of a polytraumatized patient in combination with a long stay in an acute care unit, and severe trauma and bleeding of soft tissue structures in B and C types of pelvic injury. Bacteriological findings showed the presence of several pathogenic species (Enterobacter cloacae, Citrobacter koseri, Pseudomonas aeruginosa and Klebsiella oxytoca) or multi-resistant bacteria (methicillin-resistant Staphylococcus aureus).

Transrectal stent in endoscopic palliative therapy of malignant stenosis of the rectum

BACKGROUND/AIMS

To check the feasibility and safety of endoscopic stent introduction in colorectal cancer therapy.

METHODOLOGY

A total of 62 patients with inoperable tumors of the rectum and rectosigmoid were treated by introducing stents. Stents were also introduced in 3 patients with advanced prostate tumors obturating (narrowing) the rectum. In 3 cases, the stents were introduced under X-ray control. In all other cases, an endoscopic approach to the stent introduction was employed.

RESULTS

Stents could not be introduced in 4 patients. In 1 case, the bowel was perforated above the malignant (tumorous) stenosis. In 4 patients, it was necessary to remove the stents because of dislocation. Growth of the tumor into the stent was not experienced. Experience with acute obstruction treatment was minimal as only two patients were treated for this indication.

CONCLUSIONS

Endoscopic stent introduction is a safe palliative procedure making it possible to improve the quality of life of patients with inoperable tumors of the rectum and rectosigmoid.

Bilateral avulsion of the puborectal muscle: magnetic resonance imaging-based three-dimensional reconstruction and comparison with a model of a healthy nulliparous woman

OBJECTIVES

Obstetric trauma to the puborectal muscle seems to be an important cause of pelvic floor dysfunction in women. Due to the complicated three-dimensional (3D) arrangement of the pelvic structures, two-dimensional images are not sufficient to demonstrate its relationships in a complex fashion. Thus, we aimed to create a 3D computer model to visualize the normal female pelvic floor anatomy and to compare this with the anatomy after bilateral avulsion of the puborectal muscle following delivery.

METHODS

We created two 3D computer models of the female pelvic floor, one of a healthy nulliparous woman and the other of a woman with bilateral puborectal muscle avulsion after vaginal delivery. The data for the models were obtained from magnetic resonance imaging examinations and the following structures were depicted: pelvic bones, puborectal muscle, internal obturator muscle, urethra, urinary bladder, vagina and rectum. The models were compared.

RESULTS

The models allowed us to demonstrate in three dimensions changes in the puborectal muscle after avulsion. Its relations to the bone, internal obturator muscle, perineal membrane and the deep part of the external anal sphincter were modeled and differences from the normal non-injured anatomy were demonstrated. Avulsion altered the support to the whole endopelvic fascia and destabilized both the anterior and the posterior vaginal walls.

CONCLUSIONS

The use of 3D technology including modeling allows for the acquisition of new knowledge and aids in the understanding of both normal and pathological pelvic anatomy.

[Can the new CT-based classification of acetabular fractures be useful for clinical practice?]

Currently, conventional diagnosis of acetabular fractures is often supplemented and even replaced by CT examination, as this can provide a more detailed image of the extent of fracture and its morphology. Supported by developmental anatomy, Harris et al. proposed a new classification for acetabular fractures in which the pubic bone component of the acetabulum is shown to coincide with the anterior column of the acetabulum. There is no need to abandon the generally accepted and much used Letournel-Judet classification, but changes in the algorithm of acetabular fracture examination will certainly require that the CT classification of acetabular fractures is included. The Harris classification, based on evaluation of simple and unambiguous axial CT scans, is readily understood by both radiologists and orthopedic trauma surgeons and thus the use of it will foster greater interdisciplinary cooperation resulting in a better care for patients with acetabular fractures. Key words: acetabular fracture, CT-based classification, CT-based diagnosis.

[Our results of surgical management of unstable pelvic ring injuries]

PURPOSE OF THE STUDY

The authors present a group of patients treated for pelvic fractures in a period of 6 years and they evaluate radiographic findings and clinical outcomes following surgical management of type B and type C fractures.

MATERIAL AND METHODS

Between July 1998 and June 2004, a total of 271 patients with pelvic fractures, 162 men and 109 women (average age, 42 years; range, 15 to 93 years) were hospitalized at the authors' departments. Of these, 141 patients were operated on (94 men, 47 women; average age, 37 years; range, 15 to 72 years) and 130 were treated conservatively (average age, 47 years; range, 15 to 93 years). The clinical outcome assessment in patients with type B and type C fractures treated surgically was based on the Majeed scoring system, and the radiographs were evaluated as described by Matta and Tornetta.

RESULTS

In 85 % of the patients, pelvic fractures were due to a high-energy trauma caused by traffic accidents in 63 % (pedestrian injury, 30 %; injury of the driver or passenger, 28 %; motorcycle injury, 5 %), by falls from heights in 20 % (occupational injury, 10 %; suicidal attempt, 10 %) and by other causes in 2 %. Sports accidents, usually due to a low-energy trauma, accounted for 8 % of the injuries (falls from a bicycle, violent kicks) and ordinary falls of elderly persons for 7 %. Type A injury was in 56 patients (21 %), type B in 103 patients (38 %) and type C in 112 patients (41 %). In 27 % of the patients, pelvic ring injury was part of a multiple trauma, in 58 % it was a combined injury and in 15 % it presented as a single trauma. Primary neurological deficit was found in nine patients (9 %) with type B fracture and in 20 patients (18 %) with type C fracture; this difference was statistically significant (p = 0.005). Urogenital injury was co-existent with type B fracture in 12 patients (12 %) and with type C fracture in 15 patients (13 %); the difference was not significant (p = 0.734). In seven patients (3 %), the injury involved an open fracture. Thirty-three patients (12 %) died during hospitalization. The difference in death rate between the patients with type C and those with type B fractures was significant (p = 0.021). Excellent and good clinical outcomes were achieved in 83 % and 70 % of the patients with type B and type C fractures, respectively. The difference was not significant (p = 0.236). Radiographs showed excellent reduction in 83 % of type B fractures and in 61 % of type C fractures; the difference was not significant (p = 0.271). Intra-operative complications were recorded in 22 %, early post-operative ones in 13 % and late complications in 11 % of the patients.

DISCUSSION

The significant difference in primary neurological deficit between the patients with type C fractures and those with type B fractures was attributed to more severe injury and vertical dislocation of the posterior segment in type C fractures. On the other hand, the fact that urogenital involvement was not significantly higher in type C fractures can be explained by an equal presence of anterior segment injury in both type B and type C fractures. The significantly higher number of deaths in patients with type C fractures, as compared with those with type B fractures, was related more to severe injuries of other organ systems in polytraumatized patients than to injuries of the pelvis itself, although severe injury to the posterior segment in type C fractures can result in massive bleeding into the retroperitoneum.

CONCLUSIONS

An active approach to the treatment of patients with unstable pelvic fractures, which is based on the correct diagnosis, comprehensive multi-disciplinary care, urgent primary stabilization and early definitive fixation by internal osteosynthesis, offers a prospect of survival and a good functional outcome for the patient. However, a high proportion of lasting sequelae due to altered biomechanics of the pelvic ring, and irreversible injuries to neural structures and the urogenital system may lessen good results achieved by a demanding surgical procedure on the skeleton.

[Pelvic ring injury]

The authors compare their experience with the treatment of pelvic ring injuries with the literature data concerning the etiology, diagnosis and classification of this trauma, co-existing pathologies, primary therapeutic procedures, timing of the definitive treatment, surgical approaches, osteosynthesis of the posterior and anterior segments, complications and lasting sequelae. The authors regard the issue of surgical treatment as an independent discipline in the field of musculoskeletal system traumatology. They see the reason for it in the variability and complexity of primary therapeutic procedures and the necessity of following up and attending to the patients in whom treatment of complications and lasting sequelae requires multi-disciplinary co-operation.

[The role of plain radiography in pelvic trauma in the era of advanced computed tomography]

PURPOSE OF THE STUDY

The aim was to evaluate the diagnostic value of plain X-ray images in the diagnosis of pelvic ring injury in comparison with CT findings.

MATERIAL AND METHODS

The group evaluated consisted of 30 patients, 11 women and 19 men, at an average age of 46 years (range, 20-81 years; women, 20-68 years, men, 20-81 years; average age, 49 and 44 years in women and men, respectively) in whom plain radiography and CT scans were done as part of the initial examination. A retrospective assessment of plain X-ray images was carried out by two independent specialists (radiologist and trauma surgeon). The authors together evaluated CT scans and carried out the final assessment of all medical records. Pelvic radiography was taken with a mobile X-ray unit; CT scans were done according to the standard trauma scanning protocol, using a CT scanner with either one row (CT) or 16 rows (multidetector/MDCT) of detectors.

RESULTS

Based on the evaluation of X-ray and CT findings, a total of 133 fractures or displacements in the sacroiliac joint or pubic symphysis were detected. The radiologist identified 99 (74 %) injured structures and the trauma surgeon 111 (83 %) ones. This difference was not significant on the whole (p = 0.536), nor when individual structures were assessed. False negative findings were made by the radiologist on 10 occasions and by the trauma surgeon on seven occasions; the evaluation of image data sets by both observers was associated with only one false positive finding. The overall sensitivity of plain X-ray images, when compared to CT scans, was 83 %, but it was considerably lower on evaluation by one observer only (radiologist, 67 %; trauma surgeon, 78 %).

DISCUSSION

The biggest difference between the findings of two independent specialists existed in the assessment of injuries to the posterior ring of the pelvis (SI joint, sacrum) on plain X-ray images. However, trauma in this region was identified without any doubt on CT scans. To diagnose the type of pelvic injury from CT scans without a possibility to evaluate standard anteroposterior (AP) radiographs or good-quality 2D or 3D reconstructions was found difficult in over one third of the patients. A validity comparison of standard AP radiography and high-quality 2D or 3D CT reconstructions showed that both had an equal value for the exact detection of pelvic injury type. For correct evaluation of the type of injury, scans from the MDCT were easier to read than those from the CT scanner.

CONCLUSIONS

There is no doubt about the role of standard AP X-ray in the identification of pelvic injury type in polytraumatized, hemodynamically unstable patients. The validity of CT examination for identification of injury to the posterior ring of the pelvis in particular is so high that, in the primary diagnostic procedure, inlet and outlet radiography of the pelvis has lost its importance. The information on the stability and type of injury provided by 2D and 3D CT reconstructions is so exact that, at present, CT examination can reliably replace AP radiography, particularly if, for various reasons, good-quality X-ray images cannot be guaranteed.

[Birth injury of the puborectalis muscle--3D ultrasound evaluation]

OBJECTIVE

Evaluation of the influence of vaginal childbirth on the integrity of the puborectalis muscle with the help of real-time 3D ultrasound.

DESIGN

Prospective pilot study.

SETTING

Institute for Care for Mother and Child, Prague, Czech Republic.

MATERIAL AND METHODS

We examined 20 primigravid women in the third trimester and on the third day after vaginal delivery. The transperineal 3D ultrasound examination was performed and the data were evaluated afterwards in the 4D view software. The VCI (Volume Contrast Imaging) mode with slice thickness 3 millimeters was used for analysis. We evaluated the integrity of the puborectalis muscle on both sides, the quality of the images and the presence of hematomas.

RESULTS

The examination before delivery did not show any abnormal anatomy of the examined region. We found four (20%) unilateral defects and one (5%) bilateral puborectalis avulsion after the delivery. The bilateral defect was after the forceps delivery, the other defects occurred after normal uncomplicated vaginal deliveries, where only left mediolateral episiotomy was performed and the birth weight did not exceed 3700 g. In our series, 25% of women suffered an injury of a major muscle of pelvic floor. No defect was diagnosed during the delivery and did not show any connection with the episiotomy.

CONCLUSIONS

3D ultrasound can detect major birth trauma to the puborectalis muscle. The puborectalis muscle avulsion is usually not recognized during the delivery and does not cause immediate problem to the patient.

Surface morphology of kidney, ureters and urinary bladder models based on data from the visible human male

The aim of the present work was to create a simplified high-resolution three-dimensional model of kidneys, ureters and urinary bladder in a data form suitable for finite element/volume based numerical simulations. The exterior morphology of the organs was based on images from the Visible Human Male data set. In both the right and left kidney, there were defined their topographic relations to the neighbouring anatomical structures. This model of kidneys, ureters and urinary bladder will be incorporated into the model of The Visible Human Male abdomen and pelvis and it is ready to be used for numerical simulations in urinary system biomechanics.

Pediatric third, fourth, and sixth nerve palsies: a population-based study

PURPOSE

To determine the population-based incidence and cause of cranial nerve palsies affecting ocular motility in children in the circumscribed population of Olmsted County, Minnesota.

METHODS

The Rochester Epidemiology Project medical records linkage system captures virtually all medical care provided to Olmsted County residents. By means of this database, all cases of third, fourth, and sixth cranial nerve palsy were identified among county residents less than 18 years of age from 1978 through 1992. Medical records were reviewed to confirm the diagnosis, determine the cause, and document county residency. Incidence rates were adjusted to the age and sex distribution of the 1990 white population in the United States.

RESULTS

Over this 15-year period, 36 incidence cases of cranial nerve palsy were identified in 35 children in this defined population. The age-adjusted and sex-adjusted annual incidence of third, fourth, and sixth nerve palsies combined was 7.6 per 100,000 (95% confidence interval, 5.1 to 10.1). The most commonly affected nerve was the fourth (36%), followed by the sixth (33%), the third (22%), and multiple nerve palsies (9%). The most common cause was congenital for third and fourth nerve palsy, undetermined for sixth, and trauma for multiple nerve palsies. Although three cases were associated with neoplasia, a cranial nerve palsy was not present at the time of diagnosis in any case.

CONCLUSIONS

Unlike many institutionally based referral series, our population-based study provides data on the incidence and cause of third, fourth, and sixth nerve palsies in a geographically defined population. In contrast to previous institutionally based series, nearly half the cases were congenital in origin, and in no case did intracranial neoplasia present as an isolated nerve palsy.

Cellular delivery of neurotrophin-3 promotes corticospinal axonal growth and partial functional recovery after spinal cord injury

The injured adult mammalian spinal cord shows little spontaneous recovery after injury. In the present study, the contribution of projections in the dorsal half of the spinal cord to functional loss after adult spinal cord injury was examined, together with the effects of transgenic cellular delivery of neurotrophin-3 (NT-3) on morphological and functional disturbances. Adult rats underwent bilateral dorsal column spinal cord lesions that remove the dorsal corticospinal projections or underwent more extensive resections of the entire dorsal spinal cord bilaterally that remove corticospinal, rubrospinal, and cerulospinal projections. Long-lasting functional deficits were observed on a motor grid task requiring detailed integration of sensorimotor skills, but only in animals with dorsal hemisection lesions as opposed to dorsal column lesions. Syngenic primary rat fibroblasts genetically modified to produce NT-3 were then grafted to acute spinal cord dorsal hemisection lesion cavities. Up to 3 months later, significant partial functional recovery occurred in NT-3-grafted animals together with a significant increase in corticospinal axon growth at and distal to the injury site. These findings indicate that (1) several spinal pathways contribute to loss of motor function after spinal cord injury, (2) NT-3 is a neurotrophic factor for the injured corticospinal projection, and (3) functional deficits are partially ameliorated by local cellular delivery of NT-3. Lesions of the corticospinal projection may be necessary, but insufficient in isolation, to cause sensorimotor dysfunction after spinal cord injury in the rat.

Functional characterization of NGF-secreting cell grafts to the acutely injured spinal cord

Previously we reported that grafts of cells genetically modified to produce human nerve growth factor (hNGF) promoted specific and robust sprouting of spinal sensory, motor, and noradrenergic axons. In the present study we extend these investigations to assess NGF effects on corticospinal motor axons and on functional outcomes after spinal cord injury. Fibroblasts from adult rats were transduced to express human NGF; control cells were not genetically modified. Fibroblasts were then grafted to sites of midthoracic spinal cord dorsal hemisection lesions. Three months later, recipients of NGF-secreting grafts showed deficits on conditioned locomotion over a wire mesh that did not differ in extent from control-lesioned animals. On histological examination, NGF-secreting grafts elicited specific sprouting from spinal primary sensory afferent axons, local motor axons, and putative cerulospinal axons as previously reported, but no specific responses from corticospinal axons. Axons responding to NGF robustly penetrated the grafts but did not exit the grafts to extend to normal innervation territories distal to grafts. Grafted cells continued to express NGF protein through the experimental period of the study. These findings indicate that 1) spinal cord axons show directionally sensitive growth responses to neurotrophic factors, 2) growth of axons responding to a neurotrophic factor beyond an injury site and back to their natural target regions will likely require delivery of concentration gradients of neurotrophic factors toward the target, 3) corticospinal axons do not grow toward a cellular source of NGF, and 4) functional impairments are not improved by strictly local sprouting response of nonmotor systems.

Incidence of nonarteritic anterior ischemic optic neuropathy

PURPOSE

Nonarteritic anterior ischemic optic neuropathy is the most common acute optic nerve disease of adults over age 50 years. This study determined the incidence of acute nonarteritic anterior ischemic optic neuropathy in the circumscribed population of Olmsted County, Minnesota.

METHODS

This was a retrospective study of the incidence of acute nonarteritic anterior ischemic optic neuropathy between 1981 and 1990. The Rochester Epidemiology Project medical records linkage system facilitates identification of the medical records of virtually all Olmsted County residents with a given diagnosis. All cases of acute nonarteritic anterior ischemic optic neuropathy that fulfilled certain inclusion and exclusion criteria were identified.

RESULTS

Twenty-two cases in 21 patients (11 men and 10 women) were recorded. The crude annual incidence rate was 10.3 per 100,000 individuals (95% confidence interval [CI] = 5.1 to 18.4). When adjusted to the age and sex distribution of the 1990 United States white population, the incidence rate was 10.2 per 100,000 (95% CI = 6.5 to 15.6). At diagnosis, the median age was 72 years, mean visual acuity was 20/200 in the affected eye, and the most common visual field defect was an altitudinal deficit (10 cases).

CONCLUSIONS

Although results of this small study should be interpreted cautiously, extrapolation of our findings to the United States white population indicates that nearly 5,700 new cases of acute nonarteritic anterior ischemic optic neuropathy may be expected to occur each year in this group.

FMS hemizygosity in myeloid dysplasia and acute myeloid leukemia with chromosomal aberration del(5)(q) demonstrated by polymerase chain reaction

Interstitial deletions of the long arm of chromosome 5 del(5)(q), are recurring aberrations in the myelodysplastic syndrome and acute myeloid leukemia. Several genes located in region (5)(q23-34) have been implicated as being of pathogenic importance. In this study seven samples of six patients with myelodysplastic syndrome and acute myeloid leukemia who have the del(5)(q) aberration were analyzed by polymerase chain reaction (PCR) and Southern blot technique. FMS hemizygosity was demonstrated in all patients. PCR analysis from peripheral blood samples confirmed the observations of this aberration found by semiquantitative Southern blot. PCR-based analysis can be used for primary diagnosis in addition to cytogenetic evaluation and for follow-up in patients with del(5)(q) aberration.

B lymphocytes with latent EBV infection appearing in long-term bone marrow cultures (HLTBMCs) from haematological patients induce lysis of stromal microenvironment

Human long-term bone marrow cultures (HLTBMCs) are a valuable in vitro model for studying the role of the haemopoietic microenvironment. Here we report the spontaneous appearance of EBV-positive B cells in 6/40 HLTBMCs from patients with various haematological diseases after 3-5 months of culture. After subcultivation of these cells, a novel type of cell line could be characterized, which displayed surface markers and morphological features typical for EBV transformed B-cell lines. As the deproteinized and ultrafiltrated culture supernatants of these cell lines were found to contain an agent with stroma toxic properties, they were termed SSB lines (stroma-toxic-agent-secreting B-cell lines). This agent also exhibited a colony-inhibitory activity on in vitro myelopoiesis and erythropoiesis. These properties are typical for the two polyamines spermine and spermidine which were detected at elevated levels in the culture supernatants of SSB lines. The hypothesis that latent presence of EBV in bone marrow may induce an increased synthesis of spermine and spermidine, which are known to be associated with malignant haematological diseases and bone marrow aplasia, is discussed.

Minor BCR (m-bcr) rearrangements may appear in major BCR (M-bcr)-positive CML cases

The chromosome 22 derivative, the Philadelphia (Ph) chromosome, results from the reciprocal translocation t(9;22) (q34;q11). On DNA level a BCR/ABL rearrangement involving the so-called major BCR (Mbcr) from chromosome 22 has been associated with chronic myeloid leukemia (CML). For Ph+ ALL a site of rearrangements in the 5' part of the BCR (breakpoint cluster region) gene on chromosome 22, the so-called minor bcr region (mbcr) has been described within the first intron in a 10.8 kb region (=bcr2 or m-BCR1). The BB1 probe detects two Eco fragments of 8.5 and/or 11 kb, which may appear as monomorphic or heteromorphic alleles, both covering bcr2. We have analyzed EcoRI restriction polymorphisms within bcr2 in 42 patients with a rearrangement in M-bcr (including 39 Philadelphia chromosome-positive (Ph+) CML patients and 3 ALLs) and in 18 healthy unrelated volunteers. Of the 42 patients tested, 52.4% (22) had the 8.5 kb bcr2 allele, 21.4% (9) had the 11 kb bcr2 allele, and 26.2% (11) had both the 8.5 and the 11 kb allele. In addition to normal allelic polymorphisms in bcr2, rRFs (rearranged bcr2 restriction fragments) were found in bcr2 as shown in 33% (14 of 42) of our patients. By contrast, no rRFs were found in 18 healthy volunteers. Our results indicate, that heterogeneous rearrangements in bcr2 may appear in addition to BCR/ABL rearrangements involving M-bcr in Ph+CML.

Lid protractor force generation in Graves' eye disease

The posterior vector of the lid protractor force was measured in 29 patients with Graves' eye disease (GED) and 70 normal subjects. Patients with GED had significantly lower mean lid protractor force generation than normal subjects, although GED patients with compressive optic neuropathy did not show this difference. There was a negative correlation between the posterior force vectors and the exophthalmometer reading in GED patients only. It is conjectured that these two factors are linked by orbital and lid inflammation. The inflammation that increases orbital bulk, and thus increases the exophthalmometer reading, may well cause atrophy in the orbicularis oculi muscles, decreasing its force generation.

Positional effects on exophthalmometer readings in Graves' eye disease

Forty-eight patients with Graves' eye disease, half of whom had extraocular muscle restriction, and 45 normal adult subjects underwent exophthalmometry while in the upright and the supine positions to determine whether the difference in measurement due to position would serve to differentiate the groups. A previous report claimed that the upright reading would be greater than the supine reading for normal subjects and patients with Graves' eye disease without clinical extraocular muscle involvement, whereas those with extraocular muscle restriction would show little change in their exophthalmometer readings. Our study showed an increase in exophthalmometer readings in going from the upright to the supine position for normal subjects and both groups of patients with Graves' eye disease. Furthermore, this test did not serve to differentiate these three groups.