Notfall-Embolisation bei schwerer Blutung nach traumatischer Symphysensprengung

Bleeding after instable fractures of the pelvic ring results in a mortality-rate of 7-21 percent. A 65-year-old male patient who fell from his horse and sustained an open book injury with disruption of the symphysis and iliosacral joint developed a dangerous haemorrhagic shock situation in the emergency room. A computer tomography with contrast medium was performed immediately. The outflow of contrast medium behind the symphysis indicated an acute arterial bleeding. An angiography revealed a bleeding from both Aa. obturatoriae and the right A. epigastrica inferior. The difficulty to stop the bleeding surgically resulted in the decision to embolize the vessels angiographically. This procedure terminated the acute bleeding and haemorrhagic shock situation immediately. The pelvic ring disruption was stabilized by internal fixation ten days later. The patient had an uncomplicated course.

Instability of the posterior pelvic ring associated with disruption of the pubic symphysis

The patient with instability of the posterior pelvic ring and disruption of the pubic symphysis is a challenging problem for orthopedic surgeons. These represent high-energy injuries and management of these patients requires a multidisciplinary team approach. The orthopedic surgeon's understanding of the injury patterns, their associated injuries, and effective treatment strategies can reduce morbidity and mortality for patients.

The 'iris effect': how two-dimensional and three-dimensional ultrasound can help us understand anti-incontinence procedures

OBJECTIVE

The objective of this prospective, observational study in patients after tension-free vaginal tape (TVT) implantation was to describe the spatial relationship between suburethral sling implants, urethra and bony pelvis with the help of translabial two-dimensional and three-dimensional (3D) ultrasound.

METHODS

A total of 141 women were examined by translabial ultrasound, supine and after voiding. The TVT sling is highly echogenic and easily identified posterior to the urethra. Tape location was described in the mid-sagittal plane relative to bladder neck and inferoposterior symphyseal margin, at rest and on Valsalva maneuver. In a subset of 83 women, 3D volume ultrasound was performed.

RESULTS

The cranial tape margin was situated on average 9.3 mm above and 16.5 mm posterior to the symphyseal margin (Valsalva: 3.9 mm below and 9.6 mm behind the symphysis); the average tape movement on Valsalva was 16 (range, 2-34.2) mm. The distance between tape and inferoposterior symphyseal margin narrowed highly significantly from 20.4 +/- 4.3 mm at rest to 12.9 +/- 3.9 mm on Valsalva (P < 0.001). When a fitted line plot was placed through tape coordinates on an x-y coordinate system, it became evident that tape movement occurs in an arc around the fulcrum of the posterior symphysis pubis. The result is an increasing reduction in the gap between tape and symphysis pubis (termed the 'iris effect'), implying mechanical compression of the urethra.

CONCLUSIONS

The curative effect of the TVT on stress incontinence is likely to be due to mechanical compression of the urethra between implant and symphysis pubis. A large variation in tape location and movement explains its wide margin of clinical safety and efficacy.

Unstable pelvic insufficiency fracture in a patient with rheumatoid arthritis

The occurrence of pelvic insufficiency fractures in patients with rheumatoid arthritis has not previously been well emphasized. These fractures are difficult to detect clinically, and appropriate radiological investigation is necessary for diagnosis. A 72-year-old woman with rheumatoid arthritis presented with severe left groin pain. Pelvic radiographs showed parasymphyseal fractures, and marked instability of these fractures was observed at the follow-up 2 weeks later. Computed tomographic scan of the sacrum showed a widened linear fracture gap in the left sacral ala. Because the patient's pain was so severe that she could not change position, external fixation was performed to achieve rapid pain relief and early mobilization. Although most patients with these fractures respond well to simple conservative treatments, parasymphyseal fractures combined with sacral fractures may cause disruption of the pelvic ring and occasionally need operative management.

Automatic registration of MR and SPECT images for treatment planning in prostate cancer

RATIONALE AND OBJECTIVES

To aid in surgical and radiation therapy planning for prostate adenocarcinoma, a general-purpose automatic registration method that is based on mutual information was used to align magnetic resonance (MR) images and single photon emission computed tomographic (SPECT) images of the pelvis and prostate.

MATERIALS AND METHODS

The authors assessed the effects of various factors on alignment between pairs of MR and SPECT images, including the use of particular pulse sequences in MR imaging, image voxel intensity scaling, the use of different regions on the MR-SPECT histogram, spatial masking of nonoverlapping visual data between images, and multiresolution optimization. A mutual information algorithm was used as the cost function for automatic registration. Automatic registration was deemed acceptable when it resulted in a transformation with less than 2 voxel units (6 mm) difference in translation and less than 2 degree difference in rotation from that obtained with manual registration performed independently by nuclear medicine radiologists.

RESULTS

Paired sets of MR and SPECT image volumes from four of five patients were successfully registered. For successful registration, MR images must be optimal and registration must be performed at full spatial resolution and at the full intensity range. Masking, cropping, and the normalization of mutual information, used to register partially overlapping MR-SPECT volumes, were not successful. Multiresolution optimization had little effect on the accuracy and speed of the registration.

CONCLUSION

Automatic registration between MR and SPECT images of the pelvis can be achieved when data acquisition and image processing are performed properly. It should prove useful for prostate cancer diagnosis, staging, and treatment planning.

Osteomyelitis of the pelvis caused by Rhodococcus equi in a two-year-old horse

A 2-year-old female Quarter Horse was evaluated for hind limb lameness, fever (40 degrees C [104 degrees F]), and lethargy of 2 weeks' duration. Hypoproteinemia characterized by hypoalbuminemia and hyperfibrinogenemia was detected. Abdominal ultrasonography revealed thickening of the right dorsal colon wall. Treatment was instituted for putative right dorsal coliis. Lameness evaluation localized signs of pain to the lumbar vertebrae or pelvis. Radiography performed with the horse standing and nuclear scintigraphy revealed no abnormalities. Ventrodorsal pelvic radiography revealed a focal area of bony lysis and proliferation involving the cranial portion of the pubic symphysis. Aspiration yielded purulent exudate containing Rhodococcus equi, which was susceptible to erythromycin. Treatment included surgical debridement of the abscess and oral administration of erythromycin and rifampin. The horse's hind limb lameness completely resolved within 20 days. Infections of the pubic symphysis should be considered when lameness localized to the pelvis is associated with fever and an inflammatory leukogram.

Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers

Pelvic inclination is difficult to control on a standard radiograph of the pelvis and has a direct influence on the appearance of acetabular version. By defining the normal range of the distance between the symphysis and the sacrococcygeal joint on 86 standard anteroposterior radiographs of pelves a technique was developed to evaluate pelvic inclination. A statistically significant correlation between this distance and pelvic inclination was shown in four cadaver pelves. Acetabular retroversion signs (cross-over, posterior wall signs) were evaluated on normal pelves from cadavers (two females, two males) after mounting on a holding device and wire marking of the acetabular rims. Radiographs were taken 3 degrees stepwise through the range of 9 degrees inclination to 12 degrees reclination. At the neutral position, two acetabula appeared with both positive retroversion signs compared with none at 6 degrees reclination. At 9 degrees pelvic inclination all acetabula had both signs. Retroversion signs were significantly more pronounced and found at lower pelvic tilt angles in the pelves from males than from females. Evaluation of pelvic inclination will help to decrease measurement errors in assessment of acetabular orientation and femoral head coverage. This will be valuable in preoperative planning of reorientation procedures.

Osteomyelitis of the pubis: a complication of a chronic indwelling catheter

Pubic osteomyelitis typically occurs after pelvic surgery or trauma. We present a case of pubic osteomyelitis ensuing from a chronic indwelling (for 8 years) urethral catheter in a 40-year-old woman. She presented initially with fever of unknown origin, and broad-spectrum antimicrobial therapy was initiated. Computed tomography of the abdomen and pelvis ultimately revealed cortical destruction of the pubic symphysis, and open biopsy confirmed osteomyelitis. Osteomyelitis of the pubis is a rare entity that typically results from bacteremia, trauma, or the spread of an adjacent focus of infection from previous pelvic surgery. To our knowledge, this is the first report of pubic osteomyelitis resulting from a chronic indwelling urethral catheter.

Osteitis pubis after Marshall-Marchetti-Krantz urethropexy

We report a case of osteitis pubis after Marshall-Marchetti-Krantz urethropexy. There are several theories on the pathogenesis of the postoperative osteitis pubis and inconsistent results with a wide variety of treatments. Also, osteomyelitis and osteitis pubis can have identical symptoms. In our case, the use of a Mitek anchor system and its migration within the joint cavity might have induced a foreign-body reaction as the responsible mechanism of the joint destruction.

Grading scale of radiographic findings in the pubic bone and symphysis in athletes

PURPOSE

Radiographic abnormalities in the pubic bone and symphysis are often seen in athletes with groin pain. The aim was to create a grading scale of such radiologic changes.

MATERIAL AND METHODS

Plain radiography of the pelvic ring including the pubic bone and the symphysis was performed in 20 male athletes, age 19-35, with long-standing uni- or bilateral groin pain. We used two control groups: Control group 1: 20 healthy age-matched men who had undergone radiologic examination of the pelvis due to trauma. Control group 2: 120 adults (66 men and 54 women) in 9 age groups between 15 and 90 years of age. These examinations were also evaluated for interobserver variance.

RESULTS AND CONCLUSION

The grading scale was based on the type and the amount of the different changes, which were classified as follows: No bone changes (grade 0), slight bone changes (grade 1), intermediate changes (grade 2), and advanced changes (grade 3). The grading scale is easy to interpret and an otherwise troublesome communication between the radiologist and the physician was avoided. There was a high interobserver agreement with a high kappa value (0.8707). Male athletes with long-standing groin pain had abnormal bone changes in the symphysis significantly more frequently and more severely (p>0.001) than their age-matched references. In asymptomatic individuals such abnormalities increased in frequency with age both in men and women.

Computed tomography wire localisation-assisted operative retrieval of a migrated symphysis pubis plate from the ischiorectal fossa

We report an unusual case of migration of a metal plate from the symphysis pubis to the left ischiorectal fossa, and a technique of using pre-operative CT guided wire localisation of the plate as a successful method of assisting plate retrieval.

Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes

OBJECTIVE

The purpose of this study was to describe the application, technique, and results of symphyseal cleft injection in athletes with osteitis pubis.

CONCLUSION

Symphyseal cleft injection is a useful technique for the diagnosis and treatment of osteitis pubis in athletes. The procedure is well tolerated and may facilitate early resumption of competitive duties.

[Computed tomography for the assessment of posterior pelvic injuries in patients with isolated fractures of the pubic rami in conventional radiography]

To investigate the incidence of occult posterior injuries of the pelvic ring in patients with isolated fractures of the pubic rami, additional computed tomography (CT) was performed. Data from 70 patients were collected within a prolective study. Solitary fractures of the anterior pelvic ring based on conventional radiographic diagnosis were included. Spiral CT, slice thickness 5 mm, was carried out in all patients. In only 47% of cases was the diagnosis of isolated fractures of the pubic rami confirmed. A further 35 fractures of the sacrum and two partial disruptions of the sacroiliac joint were diagnosed using CT. All sacral fractures were incomplete, most were found at the anterior part of the bone. Furthermore, CT revealed three acetabular fractures. Dorsal injuries were significantly more frequent after high energy accidents. Clinical examination did not assist in the prediction of posterior injuries of the pelvic ring. There was no correlation between the extent of the anterior injuries in conventional x-ray and incidence of the posterior injuries in CT. None of the patients with dorsal injuries underwent operative treatment. In conclusion, CT is not required for the routine diagnosis of supposed isolated fractures of the pubic rami.

Puerperal diastasis of the pubic symphysis. A case report

BACKGROUND

Puerperal diastasis of the symphysis pubis is an uncommon intrapartum complication. Patients often respond to conservative measures. A small percentage of patients will develop chronic pain and require surgical treatment, which involves debridement or fusion of the symphysis pubis.

CASE

A 33-year-old woman, gravida 1, para 0, with an uncomplicated prenatal course developed acute-onset anterior pubic pain during an otherwise normal delivery. This anterior pubic pain radiated to the left buttock and thigh. The pain persisted postpartum and was exacerbated by any movement. Radiographs confirmed pubic symphysis diastasis. The patient responded to conservative management and was essentially pain free by 10 weeks postpartum.

CONCLUSION

The diagnosis should be considered in a patient with an acute onset of pain during delivery that does not improve postpartum.

Diastasis of the pubic symphysis peculiar to horse riders: modern aspects of pelvic pommel injuries

Diastasis of the pubic symphysis is a well documented injury typically associated with high energy trauma. Three cases in horse riders are here described, emphasising the appropriate modern investigation, including computed tomography, and orthopaedic and urological management.

Early MR changes in vertebral bone marrow for patients following radiotherapy

Our study aimed to evaluate the vertebral marrow changes in patients following radiotherapy (RT) by measuring the T2 relaxation times before and during RT. We were mostly interested in evaluating early MR marrow changes during RT. Fifteen patients treated by RT for cervical cancer were submitted to MR examination before and during RT (5-23 days of RT). T2 values were calculated for irradiated and non-irradiated tissues (lumbar and sacral vertebral bone marrow, symphysis pubis marrow, and regional muscle). Fourteen patients presented increased T2 values for irradiated vertebral bone marrow (VBM), and 3 patients showed increased T2 values even for non-irradiated VBM. We found T2 variations for VBM as early as in the fifth day of RT for an absorbed dose as small as 9 Gy. Calculated T2 values in irradiated and also in non-irradiated tissues prove very early tissue alterations.