Pudendal nerve in pelvic bone fractures

Experimental assessment of pelvis slipping during postless traction for orthopaedic applications

BACKGROUND

The application of lower limb traction during hip arthroscopy and femur fractures osteosynthesis is commonplace in orthopaedic surgeries. Traditional methods utilize a perineal post on a traction table, leading to soft tissue damage and nerve neuropraxia. A postless technique, using high-friction pads, has been considered as a potential damage-free alternative. However, whether these pads sufficiently prevent patient displacement remains unknown. Thus, this study systematically assesses the efficacy of commercial high-friction pads (PinkPad and CarePad) in restraining subject displacement, for progressively increasing traction loads and different Trendelenburg angles.

METHODS

Three healthy male subjects were recruited and tested in supine and Trendelenburg positions (5° and 10°), using a customized boot-pulley system. Ten load disks (5 kg) were dropped at 15s intervals, increasing gradually the traction load up to 50 kg. Pelvis displacement along the traction direction was measured with a motion capture system. The displacement at 50 kg of traction load was analyzed and compared across various pads and bed inclinations. Response to varying traction loads was statistically assessed with a quadratic function model.

RESULTS

Pelvis displacement at 50 kg traction load was below 60 mm for all conditions. Comparing PinkPad and CarePad, no significant differences in displacement were observed. Finally, similar displacements were observed for the supine and Trendelenburg positions.

CONCLUSIONS

Both PinkPad and CarePad exhibited nearly linear behavior under increasing traction loads, limiting displacement to 60 mm at most for 50 kg loads. Contrary to expectations, placing subjects in the Trendelenburg position did not increase adhesion.

Management of Neglected Pubic Symphysis Diastasis and Sacroiliac Joint Disruption With Erectile Dysfunction in Polytrauma: A Case Report

Pelvic fractures are the most common among patients sustaining high-energy trauma. They are associated with high morbidity and mortality rates, often because of high blood loss and injury to the lumbosacral plexus, genitourinary system, and gastrointestinal system. The age, complexity of the pelvic fracture, and pubic symphysis diastasis would represent risk factors for erectile dysfunction after major and neglected pelvic injuries; the neglected pelvic ring injuries could cause disabilities that manifest with symptoms like pain, lower limb length discrepancy, standing or sitting imbalance and even sexual dysfunction. Herein, we report a case of a young adult who sustained polytrauma and was diagnosed with neglected pubic symphysis diastasis, sacroiliac joint disruption, and erectile dysfunction. The patient regained erectile function after the surgical management of pubic symphysis diastasis and sacroiliac joint disruption.

Deep gluteal space anatomy and its relationship with deep gluteal pain syndromes

INTRODUCTION

Increasing interest has been seen in understanding the anatomy and biomechanics involved in the Deep Gluteal Syndrome, therefore the main objective of our paper was to define the anatomy of the deep gluteal space concerning the important osseous, muscular and neurological structures.

METHODS

12 cadaveric models (24 hemipelvises) were used. We proceeded with classical anatomic dissection and evaluated numerous osseous, musculotendinous and neurologic structures and their relationships. We also determined the femoral anteversion and neck-shaft angles.

RESULTS

We found that 15.4% of lower limbs examined presented variations in the sciatic nerve (SN) emergence, and this was significantly longer in men. The distance from the SN to the trochanteric region was also significantly lower in males.The average ischiofemoral distance (IFD) was 2.5 ± 1.3 cm, at the same time that the structures comprised in that space showed superior areas, such as the quadratus femoris (QF) with 5.0 ± 1.1 cm and the SN with 1.4 ± 0.3 cm widths.Besides that, we also evaluated the distance from the SN to the lesser trochanter (LT) and the ischial tuberosity (IT), in the ischiofemoral space, reaching average values of 1.1 ± 0.7 cm and 1.5 ± 0.6 cm respectively.Regarding the relationship between the proximal hamstring insertion, we verified that the LT was at an average distance of 1.6 ± 1.1 cm, that the SN was only 0.2 ± 0.3 cm lateral to it, and the PN is just 2.6 ± 1.2 cm proximal to it.

CONCLUSIONS

Our study confirmed the extreme variation in the SN origin that can contribute to the Piriformis syndrome. The IFD obtained in our study showed that this distance was small for the structures contained in this space.The proximal hamstring insertion showed a significantly more extended footprint in males, which puts the pudendal nerve (PN) at higher risk of iatrogenic injury.

Erectile dysfunction and penile rehabilitation after pelvic fracture: a systematic review and meta-analysis

OBJECTIVE

To investigate the rate of erectile dysfunction (ED) after pelvic ring fracture (PRF).

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic literature search of the Cochrane, EMBASE, MEDLINE, Scopus and Web of Science Library databases was conducted in January 2020. Included were original studies performed on humans assessing ED after PRF according to the 5-item International Index of Erectile Function (IIEF-5) questionnaire and fracture classification following Young and Burgess, Tile or Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association. Furthermore, interventional cohort studies assessing the effect of penile rehabilitation therapy with phosphodiesterase-5-inhibitors (PDE-5-I) on IIEF-5 scores compared before and after treatment were included. Results were presented as forest plots of proportions of patients with ED after PRF or mean changes on IIEF-5 questionnaires before and after penile rehabilitation. Studies not included in the quantitative analysis were narratively summarised. Risk of bias assessment was conducted using the revised tool for the Quality Assessment on Diagnostic Accuracy Studies.

RESULTS

The systematic literature search retrieved 617 articles. Seven articles were included in the qualitative analysis and the meta-analysis. Pooled proportions revealed 37% of patients with ED after suffering any form of PRF (result on probability scale pr=0.37, 95% CI: 0.26 to 0.50). Patients after 3 months of penile rehabilitation therapy reported a higher IIEF-5 score than before (change score=6.5 points, 95% CI: 2.54 to 10.46, p value=0.0013).

CONCLUSION

Despite some heterogeneity and limited high-quality research, this study concludes that patients suffering from any type of PRF have an increased risk of developing ED. Oral intake of PDE-5-I for the purpose of penile rehabilitation therapy increases IIEF-5 scores and may relevantly influence quality-of-life in these patients.

PROSPERO REGISTRATION NUMBER

CRD42020169699.

Incidence of erectile dysfunction in pelvic ring injuries: Study of 48 patients at the Antananarivo hospital, Madagascar

INTRODUCTION

Pelvic fractures are responsible for genito-urinary injuries in 25% of cases. The objective of this study was to assess the severity and psychological impact of erectile dysfunction in patients with pelvic ring fractures.

HYPOTHESIS

Unstable pelvic fractures are associated with erectile dysfunction and depression.

PATIENTS AND METHOD

We retrospectively reviewed consecutive patients older than 18 years who were admitted to the orthopaedic and trauma surgery department of the Antananarivo university hospital, Madagascar, over a 3-year period (2014-2016) for pelvic ring fractures. Erectile function was assessed using the 5-item International Index of Erectile Function questionnaire (IIEF-5) and mood using the Major Depression Inventory (MDI). All patients were invited to attend a visit to complete both questionnaires.

RESULTS

The study included 48 patients with a mean age of 39 years (range, 18-82 years) and a mean follow-up of 12 months. The fracture was due to a traffic accident in 81.2% of patients and occurred as one of multiple injuries in 22.9% of patients. The fracture was stable in 34 (70.8%) patients (type A1, 16 patients; type A2, 18 patients) and unstable in 14 (29.5%) patients (type B, 9 patients; type C, 5 patients). Erectile dysfunction was found in 16 (33.3%) patients and was severe in 6, moderate in 4, and mild in 6. Erectile dysfunction was more common in the patients who had type C fractures. Depression was associated with severe erectile dysfunction.

CONCLUSION

Erectile function should be assessed in the medium and long term in patients with pelvic ring fractures. If left untreated, erectile dysfunction may lead to depression in these often young patients.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Clinical effect and safety of pulsed radiofrequency treatment for pudendal neuralgia: a prospective, randomized controlled clinical trial

Background

Pudendal neuralgia is an intractable pain related to the pudendal nerve. The clinical effect and safety evaluation of pudendal neuralgia were investigated by pulse radiofrequency (PRF) treatment of pudendal nerve.

Patients and methods

Eighty patients who were diagnosed with pudendal neuralgia were randomly divided into PRF group (PRF and pudendal nerve block [NB]) and NB group. After surgery, the patients were followed up to evaluate the visual analog scale (VAS) score and the Patient Health Questionnaire score on the postoperative day and at 2 weeks, 1 and 3 months. Meanwhile, the patients' efficacy assessment and the usage of pain medication were also recorded for 3 months during follow-up. All the surgical complications were recorded.

Results

A total of 77 patients were followed up, 38 in the PRF group and 39 in the NB group. On the postoperative day, the VAS scores was significantly decreased in both groups than before (P<0.01), whereas there was no statistical difference within the two groups (P>0.05). However, the VAS score of PRF group was significantly lower than that of NB group in 2 weeks, 1 and 3 months after surgery, respectively (P<0.01). In the meanwhile, the Patient Health Questionnaire score of PRF group was also significantly lower than that of NB group (P<0.01) in 3 months after the operation. The clinical effective rate of PRF group was 92.1% in 3 months after surgery, while this rate was only 35.9% in the NB group. The postoperative analgesic usage of PRF group was superior to that of NB group (P<0.01). No severe adverse events were observed in either group.

Conclusion

Compared with the single NB treatment, pudendal nerve PRF combined with NB therapy could provide more long-lasting relief from pain symptoms of pudendal neuralgia and improve the depression symptoms in patients.

Axotomy of tributaries of the pelvic and pudendal nerves induces changes in the neurochemistry of mouse dorsal root ganglion neurons and the spinal cord

Using immunohistochemical techniques, we characterized changes in the expression of several neurochemical markers in lumbar 4-sacral 2 (L4-S2) dorsal root ganglion (DRG) neuron profiles (NPs) and the spinal cord of BALB/c mice after axotomy of the L6 and S1 spinal nerves, major tributaries of the pelvic (targeting pelvic visceral organs) and pudendal (targeting perineum and genitalia) nerves. Sham animals were included. Expression of cyclic AMP-dependent transcription factor 3 (ATF3), calcitonin gene-related peptide (CGRP), transient receptor potential cation channel subfamily V, member 1 (TRPV1), tyrosine hydroxylase (TH) and vesicular glutamate transporters (VGLUT) types 1 and -2 was analysed seven days after injury. L6-S1 axotomy induced dramatic de novo expression of ATF3 in many L6-S1 DRG NPs, and parallel significant downregulations in the percentage of CGRP-, TRPV1-, TH- and VGLUT2-immunoreactive (IR) DRG NPs, as compared to their expression in uninjured DRGs (contralateral L6-S1-AXO; sham mice); VGLUT1 expression remained unaltered. Sham L6-S1 DRGs only showed a small ipsilateral increase in ATF3-IR NPs (other markers were unchanged). L6-S1-AXO induced de novo expression of ATF3 in several lumbosacral spinal cord motoneurons and parasympathetic preganglionic neurons; in sham mice the effect was limited to a few motoneurons. Finally, a moderate decrease in CGRP- and TRPV1-like-immunoreactivities was observed in the ipsilateral superficial dorsal horn neuropil. In conclusion, injury of a mixed visceral/non-visceral nerve leads to considerable neurochemical alterations in DRGs matched, to some extent, in the spinal cord. Changes in these and potentially other nociception-related molecules could contribute to pain due to injury of nerves in the abdominopelvic cavity.