Early experience with resuscitative endovascular balloon occlusion of the aorta for unstable pelvic fractures in the Republic of Korea: a multi-institutional study

PURPOSE

Recently, trauma centers in the Republic of Korea introduced resuscitative endovascular balloon occlusion of the aorta (REBOA) for application in severe pelvic fracture cases. This study aimed to determine the efficacy of REBOA and its associated factors in enhancing survival.

METHODS

Data from patients with severe pelvic injuries at two regional trauma centers from 2016 to 2020 were retrospectively reviewed. Patients were dichotomized into REBOA and no-REBOA groups, and patient characteristics and clinical outcomes were compared using 1:1 propensity score matching. Additional survival-based analysis was performed in the REBOA group.

RESULTS

REBOA was performed in 42 of the 174 patients with pelvic fractures. As patients in the REBOA group had more severe injuries than did patients in the no-REBOA group, 1:1 propensity score matching was performed to adjust for severity. After matching, 24 patients were included in each group and mortality was not significantly different (REBOA 62.5% vs. no-REBOA 41.7%, P = 0.149). Kaplan-Meier analysis revealed no significant differences in mortality between the two matched groups (log-rank test, P = 0.408). Among the 42 patients treated with REBOA, 14 survived. Shorter REBOA duration (63 [40-93] vs. 166 [67-193] min, P = 0.015) and higher systolic blood pressure before REBOA (65 [58-76] vs. 54 [49-69] mmHg, P = 0.035) were associated with better survival.

CONCLUSIONS

The effectiveness of REBOA has not been definitively established; however, it was not associated with increased mortality in this study. Additional studies are required to better understand how REBOA can be effectively used for treatment.

Does primary tumor resection improve survival for patients with sarcomas of pelvic bones, sacrum, and coccyx who have metastasis at diagnosis ?

BACKGROUND

Recent studies demonstrated that primary tumor resection (PTR) improves survival of patients with metastatic bone sarcomas. However, it remains quite unclear regarding the role of PTR in the treatment of sarcomas of pelvic bones with synchronous metastasis at diagnosis.

METHODS

Using the Surveillance, Epidemiology, and End Results Program, we enrolled a total of 385 patients with sarcomas of pelvic bones, sacrum, and coccyx who have metastasis at initial diagnosis, including 139 patients with osteosarcoma, 176 with Ewing sarcoma, and 70 with chondrosarcoma. Association between PTR and disease-specific survival (DSS) were investigated using the univariable and multivariable Cox regression models. Hazard ratio (HR) and 95% confidence interval (CI) were reported. Representative institutional PTR strategies and clinical outcomes for patients with metastatic pelvic sarcomas from our cancer center were displayed.

RESULTS

The usage rate of PTR was 28.1% (39/139) in osteosarcoma, 13.6% (24/176) in Ewing sarcoma, and 41.4% (29/70) in chondrosarcoma with synchronous metastatic lesions. PTR was not associated with an improved DSS for metastatic pelvic osteosarcoma (HR = 0.686, 95% CI = 0.430 ~ 1.094, P = 0.113) and Ewing sarcoma (HR = 0.580, 95% CI = 0.291 ~ 1.154, P = 0.121). The use of PTR was associated with an improved DSS for metastatic pelvic chondrosarcoma (HR = 0.464, 95% CI = 0.225 ~ 0.954, P = 0.037).

CONCLUSION

Primary lesion resection may provide a survival benefit for metastatic chondrosarcoma, but not for osteosarcoma and Ewing sarcoma of pelvic bones, sacrum, and coccyx. This population-based study recommends an active surgical intervention for metastatic chondrosarcoma while non-surgical treatment for metastatic osteosarcoma and Ewing sarcoma of the pelvis in terms of survival improvement.

Initial experience, feasibility, and technical development with an electromagnetic navigation assistance in percutaneous pelvic bone cementoplasty: retrospective analysis

OBJECTIVES

To assess the feasibility and technical outcomes of pelvic bone cementoplasty using an electromagnetic navigation system (EMNS) in standard practice.

MATERIALS AND METHODS

Monocentric retrospective study of all consecutive patients treated with cementoplasty or reinforced cementoplasty of the pelvic bone with EMNS-assisted procedures. The endpoints were periprocedural adverse events, needle repositioning rates, procedure duration, and radiation exposure.

RESULTS

A detailed description of the technical steps is provided. Thirty-three patients (68 years ± 10) were treated between February 2016 and February 2020. Needle repositioning was required for 1/33 patients (3%). The main minor technical adverse event was soft tissue PMMA cement leaks. No major adverse event was noted. The median number of CT acquisitions throughout the procedures was 4 (range: 2 to 8). Radiation exposure and mean procedure duration are provided.

CONCLUSION

Electromagnetic navigation system-assisted percutaneous interventions for the pelvic bone are feasible and lead to low rates of minor technical adverse events and needle repositioning. Procedure duration and radiation exposure were low.

KEY POINTS

• Initial experience for 33 patients treated with an electromagnetic navigation assistance for pelvic cementoplasty shows feasibility and safety. • The use of an electromagnetic navigation system does not expose to high procedure duration or radiation exposure. • The system is efficient in assisting the radiologist for extra-axial planes in challenging approaches.

Hematopoietic Stem Cell Identification Postirradiation

Radiation exposure is particularly damaging to cells of the hematopoietic system, inducing pancytopenia and bone marrow failure. The study of these processes, as well as the development of treatments to prevent hematopoietic damage or enhance recovery after radiation exposure, often require analysis of bone marrow cells early after irradiation. While flow cytometry methods are well characterized for identification and analysis of bone marrow populations in the nonirradiated setting, multiple complications arise when dealing with irradiated tissues. Among these complications is a radiation-induced loss of c-Kit, a central marker for conventional gating of primitive hematopoietic populations in mice. These include hematopoietic stem cells (HSCs), which are central to blood reconstitution and life-long bone marrow function, and are important targets of analysis in these studies. This chapter outlines techniques for HSC identification and analysis from mouse bone marrow postirradiation.

Digital pair-matching of iliac bones: pilot study on a three-dimensional approach with models acquired through stereophotogrammetry

Three-dimensional (3D) pair-matching has brought about an innovative approach for the analysis of commingled skeletal remains, and it has been tested on bone models acquired through CT and laser scans. Here, 3D models of 40 innominate bones (20 left and 20 right) of 20 documented male individuals from a cemeterial skeletal collection were acquired through a stereophotogrammetric device (VECTRA M3, Canfield Scientific, Inc.). The ventral iliac surface was chosen as the anatomical region of interest (ROI) for the analysis. Each left ROI was mirrored and superimposed on the matching right ROI (contralateral element from the same individual) and mismatching ROIs (contralateral elements from different individuals). The point-to-point distance between models was calculated through the Vectra Analysis Module (VAM) software and the root mean square (RMS) point-to-point distance value was used to evaluate the sorting performance of the method, in terms of sensitivity and specificity rates. Differences in RMS between matches and mismatches were investigated through a Student's t test (p < 0.05). The state of preservation of the remains was assessed following an index of anatomical completeness and differences in RMS distances of true matches according to different anatomical completeness were assessed through the Mann-Whitney test (p < 0.05). RMS point-to-point distances of matches and mismatches were significantly different (p < 0.01), being the matches lower than mismatches. The RMS threshold of 2.9 mm identified all the true pairs; the test was 100% sensitive and 51% specific. The RMS of matches with a better state of preservation are significantly lower than the less preserved matches (p < 0.05). In general, a low RMS distance value may indicate a true match, being it to be further verified. The 3D approach for sorting innominate bones provides a valid screening test that could complete subjective and osteometric methods with numerical evidence of the match. Preliminary data suggest a possible relation between RMS distance values and taphonomic condition, which would benefit from further research.

Restoring femoral medial offset could reduce pelvic obliquity following primary total hip arthroplasty, an observational study

BACKGROUND

Since femoral and horizontal offsets may be contributing factors to hip and pelvic balance, this study seeks to determine whether there is a correlation between pelvic obliquity (PO) after unilateral total hip arthroplasty (THA) and horizontal/vertical offset differences of the replaced and contralateral natural joints.

METHODS

A cross-sectional study was performed on adult patients who underwent unilateral THA between 2017 and 2020. An expert orthopaedic resident measured PO angles and offset parameters. "Delta medial offset" is considered medial offset of the replaced hip minus the medial offset of the contralateral side. "Absolute delta medial offset" is considered the absolute value of the "Delta medial offset."

RESULTS

Finally, 133 patients were included in the study with a mean (SD) age of 45.3 ± 14.8 years and 57.9% female. The PO values (median, IQR) changed from 3.2 (1.7-5.7) before THA to 3.0 (1.50-5.6) after THA, not significantly decreased (P = 0.31). The PO after THA is significantly correlated with PO before THA (correlation coefficient of 0.457, P < 0.001), the delta medial offset after THA (correlation coefficient of - 0.24, P = 0.006), and the absolute delta medial offset after THA (correlation coefficient of 0.284, P = 0.001). The amount of changes of delta medial offset, before and after surgery, was not significantly correlated to PO or PO changes after surgery.

CONCLUSION

PO before the THA and medial offset discrepancy after THA are two important contributing factors for post-operative PO. Restoring the medial offset of the affected side and lowering the delta medial offset between the two sides can significantly decrease post-operative PO.

Reinforced cementoplasty for pelvic tumour lesions and pelvic traumatic fractures: preliminary experience

OBJECTIVES

Pelvic bone pathological lesions and traumatic fractures are a considerable source of pain and disability. In this study, we sought to evaluate the effectiveness of reinforced cementoplasty (RC) in painful and unstable lesions involving the pelvic bone in terms of pain relief and functional recovery.

METHODS

All patients with neoplastic lesion or pelvic fracture for whom a pelvic bone RC was carried out between November 2013 and October 2017 were included in our study. All patients who failed the medical management, patients unsuitable for surgery, and patients with unstable osteolytic lesions were eligible to RC. Clinical outcome was evaluated with a 1-month and 6-month post-procedure follow-up. The primary endpoint was local pain relief measured by the visual analogue scale (VAS).

RESULTS

Twenty-two patients (18 females, 4 males; mean age of 65.4 ± 13.3 years [range 38-80]) presenting with painful and unstable pelvic lesions were treated by RC during the study period. Among the 22 patients, 8 patients presented with unstable pelvic fractures (3 patients with iliac crest fracture, 3 with sacral fractures, and the remaining 2 with peri-acetabular fractures). No procedure-related complications were recorded. All patients had significant pain relief and functional improvement at 1 month. One patient (4.5%) had suffered a secondary fracture due to local tumour progression.

CONCLUSIONS

Reinforced cementoplasty is an original minimally invasive technique that may help in providing pain relief and effective bone stability for neoplastic and traumatic lesions involving the pelvic bone.

KEY POINTS

• Reinforced cementoplasty is feasible in both traumatic fractures and tumoural bone lesions of the pelvis. • Reinforced cementoplasty for pelvic bone lesions provides pain relief and functional recovery. • Recurrence of pelvic bone fracture was observed in 4.5% of the cases in our series.

Extensive Inferior Vena Cava Thrombosis Related to COVID-19 Infection in a Patient with Retrievable Filter Due to Multiple Pelvic Bone Fractures

Inferior vena cava (IVC) thrombosis is often attributed to IVC filters. Here, we describe the first case of IVC filter thrombosis associated with severe acute respiratory syndrome coronavirus-2 infection in a 34-year-old male with multiple pelvic fractures. The IVC filter was initially placed prophylactically prior to major orthopedic trauma reconstruction complicated by silent pulmonary embolism, precluding the safe transition to therapeutic anticoagulation due to the high hemorrhagic risk from pelvic fracture fixation. This case highlights the potentially increased risk of severe complications in patients receiving vascular care if they were to contract coronavirus disease-2019 (COVID-19) in the hospital. IVC filter placement in the patient resulted in complete IVC thrombosis after he acquired COVID-19 infection. Prophylactic doses of low molecular weight heparin could not prevent this complication. However, prompt initiation of therapeutic anticoagulation with rivaroxaban led to the complete resolution of IVC thrombosis over weeks after viral negativization and discharge.

MR Imaging of the Pelvic Bones: The Current and Cutting-Edge Techniques

This review presents an overview of the spectrum of the current and cutting-edge MRI techniques for pelvic bone imaging in clinical practice. The current MRI sequences and their advantages, disadvantages and usefullness in the imaging of this complex anatomical region are addressed. Finally, cutting-edge techniques are discussed, including susceptibility weighted MRI, ultrashort echo time MRI, zero echo time MRI and a deep learning-based multiparametric MRI technique named 'synthetic CT,' creating CT-like images without ionizing radiaton.

MAIN POINTS

GRE, SWI, UTE, ZTE MRI and synthetic CT sequences depict the cortical outline of the bones better in comparison to conventional MR images.MRI-based synthetic CT can create HU maps and allows for automated segmentation of pelvic bones.The current and cutting-edge MR techniques for bone imaging are complementary in the characterization of a variety of musculoskeletal disorders.

Fully automated pelvic bone segmentation in multiparameteric MRI using a 3D convolutional neural network

BACKGROUND

Accurate segmentation of pelvic bones is an initial step to achieve accurate detection and localisation of pelvic bone metastases. This study presents a deep learning-based approach for automated segmentation of normal pelvic bony structures in multiparametric magnetic resonance imaging (mpMRI) using a 3D convolutional neural network (CNN).

METHODS

This retrospective study included 264 pelvic mpMRI data obtained between 2018 and 2019. The manual annotations of pelvic bony structures (which included lumbar vertebra, sacrococcyx, ilium, acetabulum, femoral head, femoral neck, ischium, and pubis) on diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) images were used to create reference standards. A 3D U-Net CNN was employed for automatic pelvic bone segmentation. Additionally, 60 mpMRI data from 2020 were included and used to evaluate the model externally.

RESULTS

The CNN achieved a high Dice similarity coefficient (DSC) average in both testing (0.80 [DWI images] and 0.85 [ADC images]) and external (0.79 [DWI images] and 0.84 [ADC images]) validation sets. Pelvic bone volumes measured with manual and CNN-predicted segmentations were highly correlated (R² value of 0.84-0.97) and in close agreement (mean bias of 2.6-4.5 cm³). A SCORE system was designed to qualitatively evaluate the model for which both testing and external validation sets achieved high scores in terms of both qualitative evaluation and concordance between two readers (ICC = 0.904; 95% confidence interval: 0.871-0.929).

CONCLUSIONS

A deep learning-based method can achieve automated pelvic bone segmentation on DWI and ADC images with suitable quantitative and qualitative performance.

Pelvic bone CT: can tin-filtered ultra-low-dose CT and virtual radiographs be used as alternative for standard CT and digital radiographs?

Objectives

To compare ultra-low-dose CT (ULD-CT) of the osseous pelvis with tin filtration to standard clinical CT (CT), and to assess the quality of computed virtual pelvic radiographs (VRs).

Methods

CT protocols were optimized in a phantom and three pelvic cadavers. Thirty prospectively included patients received both standard CT (automated tube voltage selection and current modulation) and tin-filtered ULD-CT of the pelvis (Sn140kV/50mAs). VRs of ULD-CT data were computed using an adapted cone beam–based projection algorithm and were compared to digital radiographs (DRs) of the pelvis. CT and DR dose parameters and quantitative and qualitative measures (1 = worst, 4 = best) were compared. CT and ULD-CT were assessed for osseous pathologies.

Results

Dose reduction of ULD-CT was 84% compared to CT, with a median effective dose of 0.38 mSv (quartile 1–3: 0.37–0.4 mSv) versus 2.31 mSv (1.82–3.58 mSv; p < .001), respectively. Mean dose of DR was 0.37 mSv (± 0.14 mSv). The median signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of bone were significantly higher for CT (64.3 and 21.5, respectively) compared to ULD-CT (50.4 and 18.8; p ≤ .01), while ULD-CT was significantly more dose efficient (figure of merit (FOM) 927.6) than CT (FOM 167.6; p < .001). Both CT and ULD-CT were of good image quality with excellent depiction of anatomy, with a median score of 4 (4–4) for both methods (p = .1). Agreement was perfect between both methods regarding the prevalence of assessed osseous pathologies (p > .99). VRs were successfully calculated and were equivalent to DRs.

Conclusion

Tin-filtered ULD-CT of the pelvis at a dose equivalent to standard radiographs is adequate for assessing bone anatomy and osseous pathologies and had a markedly superior dose efficiency than standard CT.

Key Points

• Ultra-low-dose pelvic CT with tin filtration (0.38 mSv) can be performed at a dose of digital radiographs (0.37 mSv), with a dose reduction of 84% compared to standard CT (2.31 mSv).

• Tin-filtered ultra-low-dose CT had lower SNR and CNR and higher image noise than standard CT, but showed clear depiction of anatomy and accurate detection of osseous pathologies.

• Virtual pelvic radiographs were successfully calculated from ultra-low-dose CT data and were equivalent to digital radiographs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07824-x.

How is quality of life after total hip replacement related to the reconstructed anatomy? A study with low-dose stereoradiography

PURPOSE

The purpose of this study was to evaluate the relationships between the three-dimensional anatomy of operated hip in standing position using low-dose stereo-radiography imaging system and postoperative hip disability and osteoarthritis outcome score (HOOS) after total hip arthroplasty (THA).

MATERIAL AND METHODS

A total of 123 patients who underwent THA during a one-year period were included. There were 50 men and 73 women with a mean age of 67.3±13.6 (SD) years (range: 19-89 years). All patients underwent pre- and postoperative low-dose stereo-radiography examination and completed a HOOS form (score from 0 to 100, 100 for full satisfaction). We recorded 16 anatomical parameters before THA, and 15 after THA. After binary transformation of HOOS score using 70 as threshold value, outcome was assessed using logistic or generalised linear models.

RESULTS

A total of 103 patients (103/123; 83.7%) had a HOOS score≥70 and were considered as the satisfied group. A significant difference in pelvic incidence (the angle between a line perpendicular to the sacral plate at its midpoint and a line connecting the same point to the centre of the bicoxofemoral axis) was found between the satisfied 56.4±10.4 (SD)° (range: 31-85°) and the unsatisfied group 48.7±8.9 (SD)° (range: 40-65) (P=0.006). The relative variation of offset (distance from the centre of rotation of the femoral head to a line bisecting the long axis of the femur) compared to the contralateral hip was -7% in the satisfied group and 7.2% in the unsatisfied group (P=0.01).

CONCLUSION

Pelvic incidence, a parameter independent of the reconstructed anatomy, probably influences the quality of life of patients with THA, via pelvic compensatory capabilities. A loss of femoral offset negatively influences the satisfaction of patients.

Congenital pelvic skeletal anomalies: Clinical and radiographic evaluation of newborns with gastrointestinal malformation

BACKGROUND

Congenital pelvic skeletal anomalies (CPSA) may appear as isolated defects or in association with other anomalies like congenital malformations of the digestive system (CMDS). Minor CPSA in non-syndromic patients are often overlooked. We aimed to assess the frequency of CPSA in newborns with CMDS to review the diagnostic approaches.

STUDY DESIGN

A retrospective review of medical records of 201 newborns who underwent X-rays for different neonatal indications was conducted. In 122 patients CMDS were diagnosed and classified according to the ICD-10 classification; 79 non-CMDS patients acted as controls. Pelvic skeletal segments were examined by X-rays.

RESULTS

Patients with CMDS, showed a higher risk of CPSA (Odds ratio 2.89; 95% CI 1.34 6.23) and other associated malformations in comparison to non-CMDS patients. Newborns with malformations of the large intestine have the highest risk of adjacent CPSA (48%), as it is a developmental defect originating from the same somite. In addition to skeletal agenesis/hypoplasia, we reported dysmorphic and bifid vertebras, trident ileum, and elongated neural arches.

CONCLUSIONS

The high incidence of CPSA in CMDS suggests performing a routine radiographic pelvic evaluation in cases of CMDS in order to identify complex phenotypes that could originate from the same developmental field.

Determination of Any Correlation between Sagittal Spinopelvic Configuration and Progressive Collapse of Acute Osteoporotic Compression Spine Fractures: A Retrospective Radiological Analysis

Study Design

A retrospective cohort study.

Purpose

The aim of this study was to determine any correlations between spinopelvic configuration and progressive collapse following acute osteoporotic compression spine fractures.

Overview of Literature

Few studies have investigated the risk factors for progressive osteoporotic compression spine fractures. However, the correlation between the spinopelvic configuration, which is a crucial to optimize the management of lumbar degenerative diseases, and progressive collapse following acute osteoporotic compression spine fractures was not analyzed.

Methods

We retrospectively identified all patients treated for thoracolumbar fractures in Assaf Harofe Medical Center between January 2008 and July 2013. Pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were measured for the pelvic parameters. For each patient, we classified the fracture according to the AOSpine Thoracolumbar Spine Injury Classification System. Height loss was measured initially and at a minimum of 3-month follow-up. The difference between initial and final height loss was documented as height loss difference.

Results

The study included 124 patients comprised 86 women and 38 men. The mean patient age was 69±9.6 years. The mean length of follow-up was 14±15 months. No significant effect of the PI, PT, and SS angles on the vertebral fracture level (p>0.05) was found. Similarly, no significant relationship between the PI, PT, and SS angle and the fracture type according to the AO classification (p>0.05) was found. There was no correlation between PI, PT, and SS angles and initial height loss, final height loss and height loss difference (p>0.05)

Conclusions

The spinopelvic configuration represented by the PI, PT, and SS angle does not influence progressive collapse following acute osteoporotic compression spine fractures.

Medial iliac stress fractures in athletes: report of two rare cases: review of literature and clinical recommendations

Stress fractures are a common diagnosis in sports medicine and can result in significant loss of function, athlete playing time, and potentially lead to chronic symptoms. However, unusual locations of stress fractures may present with vague symptoms and a relatively benign physical exam, leading to difficulty in arriving at the correct diagnosis. Pelvic stress fractures are less common than lower-extremity stress fractures in athletes, occurring in only 1-5% of all stress fractures and typically occur in pubic rami. Furthermore, iliac bone stress fractures are even rarer, with only a few case reports in the literature. Their presentation can easily be missed on routine workup and imaging. We present two cases of the very rare superomedial iliac bone stress fracture in athletes, an unusual location for this uncommon stress fracture. We review the available literature on this condition and provide clinical commentary on workup and treatment recommendations.

Pelvic fracture in the patient with multiple injuries: factors and lesions associated with mortality

OBJECTIVES

The main objective of this study was to identify demographic, clinical, analytical factors or injuries associated with 30-day mortality in patients with pelvic fractures.

MATERIAL AND METHODS

Prospective observational study of patients with multiple injuries including pelvic fractures between January 2009 and January 2017. We recorded demographic, clinical, and laboratory data on arrival at the emergency department; type of pelvic fracture; treatments; associated lesions; and 30-day mortality. Univariable and multivariable models were used to analyze the data.

RESULTS

A total of 2061 multiple-injury patients were attended; 118 had pelvic fractures. Fifteen of the patients with pelvic fractures (12.7%) died within 30 days. Arterial blood pressure on admission was less than 90 mm Hg in 23.7%, heart rate was over 100 beats per minute in 41.52%, lactic acid level was 20 mg/dL or higher in 67.6%, and base excess of -6 or less was recorded for 26.3%. The mean Injury Severity Score was 20 points. Angiographic embolization was required in 80.6% and preperitoneal packing in 3.4%. The main associated lesions were rib fractures (35.6%), hemo-pneumothorax (31.3%), spinal injuries (35.6%), and head injuries (30%).

CONCLUSION

The 6 independent variables associated with risk of death in multiple-injury patients with pelvic fractures are age, female sex, complex fractures (Tile type C), lactic acid level of 20 mg/dL or more, base excess of -6 or less, and bowel perforation.

Experience and Availability of Pelvic Binders at Swedish Trauma Units; A Nationwide Survey

Objective:

To assess availability, experience, and knowledge about the Pelvic Circumferential Compression Device (PCCD) in Sweden.

Methods:

A telephone interview with the current on-call trauma doctors at all trauma units in Sweden was conducted. After a short presentation and oral consent, the doctors were asked to answer four short questions. We asked the doctors to answer whether they knew if they had PCCDs available in their emergency room, how many times had they applied a PCCD, which is the correct level of application for a PCCD, and if a PCCD can stop arterial bleeding.

Results:

The on-call trauma doctors at the nine University hospitals, twenty-two General hospitals and twenty-one District General hospitals, with response rate of 100%, were interviewed. Availability of PCCD was 85 % and there was no difference between hospital types (p=0.546). In all hospitals 29/52 (56%) of those interviewed had used a PCCD at least once. There were significantly more doctors that had used a PCCD at least once in the University hospitals (8/9), compared to General hospitals (13/22) and District General hospitals (8/21) (p=0.034). A total of 43/52 (83 %) doctors defined the greater trochanters as the correct level of application for a PCCD. No difference was found when comparing hospitals (p=0.208). Only 22/52 (42 %) of doctors answered that a PCCD could not stop an arterial bleeding. No difference was found between hospitals (p=0.665)

Conclusion:

Less than half of the doctors knew that a PCCD cannot stop arterial bleeding, while the majority knew the correct level of application of a PCCD.

CT-guided percutaneous sacroiliac stabilization in unstable pelvic fractures: a safe and accurate technique

OBJECTIVE

The use of open reduction and internal fixation (ORIF) for unstable pelvic injuries is associated with extensive blood loss, iatrogenic neurovascular injury, and infection. Moreover, the placement of sacroiliac (SI) screws is a blinded procedure, guided primarily by palpation and two-dimensional radiological screening, which demands expertise. The complex three-dimensional anatomy of SI joint and its proximity to neurovascular structure require a safe and precise technique. Computed tomography (CT)-guided SI joint stabilization allows an accurate intra-operative assessment of screw placement. This study demonstrated a technique of CT-guided closed reduction and screw fixation of the SI joint in unstable pelvic fractures.

METHODS

This was a retrospective non-randomized cohort study conducted at a tertiary care hospital. Six patients with unstable pelvic fractures were operated; the anterior rim was stabilized first by ORIF with plate on the superior and anterior aspects of the pubic symphysis. Subsequently, the posterior stabilization was made percutaneously under CT guidance with a 7-mm cannulated cancellous screw.

RESULTS

The mean operative time was 48 min (35-90 min), the mean effective radiation dose was 9.32 (4.97-13.27), and the mean follow-up was 26 months (6-72 months). All patients had satisfactory healing, with near-anatomic reduction and no complications, except in one case where the plate broke at 61 months post surgery, but no intervention was required. The mean VAS score at the final follow-up was 1.8, and all patients returned to their original occupation without any limitations.

CONCLUSION

CT-guided SI joint stabilization offers many advantages, including safe and accurate screw placement, reduced operating time, decreased blood loss, early definitive fixation, immediate mobilization, and fewer infections and wound complications.

Quantitative MDCT assessment of binder effects after pelvic ring disruptions using segmented pelvic haematoma volumes and multiplanar caliper measurements

OBJECTIVE

To assess effects of pelvic binders for different instability grades using quantitative multidetector computed tomography (MDCT) parameters including segmented pelvic haematoma volumes and multiplanar caliper measurements.

METHODS

CT examinations of 49 patients with binders and 49 controls performed from January 2008-June 2016, and matched 1:1 for Tile instability grade and Pennal/Young-Burgess force vector, were compared for differences in pubic symphysis and sacroiliac displacement using caliper measurements in three orthogonal planes. Pelvic haematoma volumes (ml) were derived using semi-automated seeded region-growing segmentation. Median caliper measurements and volumes were compared using the Mann-Whitney U test, and correlations assessed with Pearson's correlation coefficient. Relevant caliper measurement cutoffs were established using ROC analysis.

RESULTS

Rotationally unstable (Tile B) patients with binders showed significant decreases in sacroiliac diastasis (2.7 mm vs. 4.5 mm; p=0.003) and haematoma volumes (135 ml vs. 295 ml; p=0.008). Globally unstable (Tile C) binder patients showed decreased sacroiliac diastasis (4.7 mm vs. 6.4 mm, p=0.04), without significant difference in haematoma volumes (284 ml vs. 234 ml, p=0.34). Four Tile C patients with binders demonstrated over-reduction resulting in pubic body over-ride.

CONCLUSION

Rotationally unstable patients with binders have significantly less sacroiliac diastasis versus controls, corresponding with significantly lower haematoma volumes.

KEY POINTS

• Haematoma segmentation and multiplanar caliper measurements provide new insights into binder effects. • Binder reduction corresponds with decreased pelvic haematoma volume in rotationally unstable injuries. • Discrimination between rotational and global instability is important for management. • Several caliper measurement cut-offs discriminate between rotationally and globally unstable injuries. • Pubic symphysis over-ride is suggestive of binder over-reduction in globally unstable injuries.

Straight leg elevation to rule out pelvic injury

OBJECTIVE

Pelvic x-ray is frequently used as a screening tool during initial assessment of injured patients. However routine use in the awake and alert blunt trauma patient may be questioned due to low yield. We propose a clinical tool that may avoid unnecessary imaging by examining whether the ability to straight leg raise, without pain, can rule out pelvic injury.

METHODS

We conducted a prospective cohort study with the exposure variables of ability to straight leg raise and presence of pain on doing so, and presence of pelvic fracture on x-ray as the primary outcome variable.

RESULTS

Of the 328 participants, 35 had pelvic fractures, and of these 32 were either unable to straight leg raise, or had pain on doing so, with a sensitivity of 91.43% (95% CI: 76.94-98.2%) and a negative predictive value of 98.57% (95% CI: 95.88-99.70%). The 3 participants with a pelvic fracture who could straight leg raise with no pain, all had a GCS of less than 15, and therefore, among the sub-group of patients with GCS15, a 100% sensitivity and 100% negative predictive value for straight leg raise with no pain to rule out pelvic fracture was demonstrated.

CONCLUSION

Among awake, alert patients, painless straight leg raise can exclude pelvic fractures and be incorporated into initial examination during reception and resuscitation of injured patients.

Update on open reduction and internal fixation of unstable pelvic fractures during pregnancy: case reports

This article aims to report four cases of unstable pelvic fractures in pregnant women treated by open reduction and internal fixation.

Cases report

The study included four cases of pregnant women with unstable pelvic fractures; their outcomes were analyzed and discussed. Data were obtained from two University Hospitals. The mean age of women was 23 years; most (3/4) were primiparous, with a mean pregnancy age of 23 weeks. Two women had Malgaigne-type fractures and the other two had symphyseal disjunction associated with acetabular fractures. All fractures were treated surgically. One foetus was dead on admission to hospital. The other three developed well, along with their mothers. Good evolution was only possible with careful pre-, peri-, and postoperative care for the mother, as well as foetal assessment by a multidisciplinary team. In complex cases such as those presented in the present study, pre-, peri-, and postoperative care are mandatory, as well as the presence of a multidisciplinary team. The mother's life always takes priority in acute clinical pictures, as it offers the best chance of survival to both mother and child.

ASSOCIATED POSTERIOR PELVIC INJURY PATTERNS IN TRANSVERSE-ORIENTED ACETABULAR FRACTURE

Objective:

Our study analyzed the incidence of posterior pelvic injury patterns and their influence on the surgical treatment of transverse-oriented acetabular fractures .

Methods:

Fifty-one transverse-oriented acetabular fracture cases admitted between 1999 and 2013 were evaluated retrospectively. Comparative studies were performed for groups organized by acetabular fracture type, degree of sacroiliac separation, and postoperative reduction quality .

Results:

Associated posterior pelvic injuries were found in 34 (66.7%) of the 51 patients. There were 32 sacroiliac separations in the 34 patients with associated posterior pelvic injury, and ipsilateral sacroiliac separations were more frequent in this subgroup. Measurements guided by computerized tomography showed that 16 sacroiliac separations were ≤0.5 cm (mean=0.43±0.14 cm), 10 were 0.5-1 cm (mean=0.73±0.17 cm), and the remaining 6 were >1 cm (mean=1.55±0.15 cm). In the group of 34 patients with associated posterior pelvic injury, acetabular reduction was anatomic in 19 (55.9%) patients, imperfect in 10 (29.4%) patients, and poor in 5 (14.7%) patients. For isolated acetabular fractures, reduction rates were as follows: 12 (70.6%) anatomic, 3 (17.6%) imperfect, and 2 (11.8%) poor. The rate of anatomic reduction was significantly higher when sacroiliac separation was ≤0.5 cm (p=0.027) .

Conclusion:

Associated posterior pelvic injuries, especially ipsilateral sacroiliac joint separation, accompany most transverse-oriented acetabular fractures and may influence the quality of acetabular reduction. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

Outcome after Surgery for Metastases to the Pelvic Bone: A Single Institutional Experience

BACKGROUND

The pelvic bone is the most common site of bone metastases following the axial skeleton. Surgery on the pelvic bone is a demanding procedure. Few studies have been published on the surgical outcomes of metastasis to the pelvic bone with only small numbers of patients involved. This study sought to analyze the complications, local progression and survival after surgery for metastasis to the pelvic bone on a larger cohort of patients.

METHODS

We analyzed 83 patients who underwent surgery for metastases to the pelvic bone between the years 2000 and 2015. There were 41 men and 42 women with a mean age of 55 years. Possible factors that might be associated with complications, local progression and survival were investigated with regard to patient demographics and disease-related and treatment-related variables.

RESULTS

The overall complication rate was 16% (13/83). Advanced age (> 55 years, p = 0.034) and low preoperative serum albumin levels (≤ 39 g/L, p = 0.001) were associated with increased complication rates. In patients with periacetabular disease, the complication rate was higher in those who underwent total hip replacement arthroplasty (THR) than those who did not (p = 0.030). Local progression rate was 46% (37/83). The overall median time to local progression was 26 ± 14.3 months. The median time from local progression to death was 13 months (range, 0 to 81 months). The local progression-free survival was 52.6% ± 6.4% at 2 years and 36.4%± 7.6% at 5 years, respectively. Presence of skip lesions (p = 0.017) and presence of visceral metastasis (p = 0.027) were found to be significantly associated with local progression. The median survival of all patients was 24 months. The 2-year and 3-year survival rates were 52.5% ± 5.9% and 35.6% ± 6%, respectively. Metastasis from the kidney, breast, or thyroid or of hematolymphoid origin (p = 0.014), absence of visceral metastasis (p = 0.017) and higher preoperative serum albumin levels (p = 0.009) were associated with a prolonged survival.

CONCLUSIONS

Advanced age and low serum albumin levels were associated with high complication rates. Local progression after surgery for metastases to the pelvic bone was affected by the presence of skip lesions, not by surgical margins. Primary cancer type, serum albumin level and visceral metastasis influenced survival.

Improved MDCT monitoring of pelvic myeloma bone disease through the use of a novel longitudinal bone subtraction post-processing algorithm

PURPOSE

To evaluate the diagnostic performance of a novel CT post-processing software that generates subtraction maps of baseline and follow-up CT examinations in the course of myeloma bone lesions.

MATERIALS AND METHODS

This study included 61 consecutive myeloma patients who underwent repeated whole-body reduced-dose MDCT at our institution between November 2013 and June 2015. CT subtraction maps classified a progressive disease (PD) vs. stable disease (SD)/remission. Bone subtraction maps (BSMs) only and in combination with 1-mm (BSM+) source images were compared with 5-mm axial/MPR scans.

RESULTS

Haematological response categories at follow-up were: complete remission (n = 9), very good partial remission (n = 2), partial remission (n = 17) and SDh (n = 19) vs. PDh (n = 14). Five-millimetre CT scan yielded PD (n = 14) and SD/remission (n = 47) whereas bone subtraction + 1-mm axial scans (BSM+) reading resulted in PD (n = 18) and SD/remission (n = 43). Sensitivity/ specificity/accuracy for 5-mm/1-mm/BSM(alone)/BSM + in "lesion-by-lesion" reading was 89.4 %/98.9 %/98.3 %/ 99.5 %; 69.1 %/96.9 %/72 %/92.1 % and 83.8 %/98.4 %/92.1 %/98.3 %, respectively. The use of BSM+ resulted in a change of response classification in 9.8 % patients (n = 6) from SD to PD.

CONCLUSION

BSM reading is more accurate for monitoring myeloma compared to axial scans whereas BSM+ yields similar results with 1-mm reading (gold standard) but by significantly reduced reading time.

KEY POINTS

• CT evaluation of myeloma bone disease using a longitudinal bone subtraction post-processing algorithm. • Bone subtraction post-processing algorithm is more accurate for assessment of therapy. • Bone subtraction allowed improved and more efficient detection of myeloma bone lesions. • Post-processing tool demonstrating a change in response classification in 9.8 % patients (all showing PD). • Reading time could be substantially shortened as compared to regular CT assessment.

Underestimated Sacroiliac Joint Lesion on Computed Tomography in Pelvic Open-book Injury: A Case Report

The classification of anteroposterior compression (APC) injury type is based on using static radiographs, stress radiographs are known as a useful adjunct in classifying type of APC pelvic injuries. According to a recent article, the intraoperative stress examination has led to a change in the treatment plan in more than 25% of patients on 22 patients presumed APC type I (symphyseal diastasis <2.5 cm) injuries. Here authors present a case demonstrating a necessity of intraoperative stress test for excluding concealed posterior ring disruption.

Biomechanical study of the sacroiliac fracture fixation with titanium rods and pedicle screws

OBJECTIVES

To assess biomechanically different fixations means of the sacroiliac joint with pedicle screws and to compare the traditional head height with reduced ones.

METHODS

We used a polyethylene model representing the pelvic ring and simulated a unilateral sacroiliac dislocation. We set up three different constructions: 1) two screws attached to a rod; 2) two rods connected to two small head screws each; and 3) two rods connected to two average headed screws each. We conducted tests in a biomechanical testing and a mechanized processing laboratory.

RESULTS

Group 1 supported an average maximum load of 99.70 N. Group 2 supported an average maximum load of 362.46 N. Group 3 endured an average maximum load of 404.15 N. In the assembly with one rod, the resistance decreased as compared with the one with two bars: 72.5 % compared to small-headed screws and 75.3 % to the traditional screw.

CONCLUSION

The assembly with a single bar presented inferior results when compared to the double bar assembly. There was no statistical difference in the results between the screws used. Experimental Study.

Vertical pelvic ring displacement in pelvic ring injury: Measurements in pelvic outlet radiograph and in cadavers

BACKGROUND

Vertical pelvic ring displacement (VPRD) is a serious injury and needs assessment. Pelvic outlet radiographs are routinely taken. However, relationship of radiographic and actual VPRD is still in question. Thus, measurement of VPRD from pelvic radiographs was studied.

MATERIALS AND METHODS

2 dry pelvic bones and 1 sacrum from same cadaver was reconstructed to be the pelvic ring. Five specimens were enrolled. 10, 20 and 30 mm vertical displacement of right pelvic bone was performed at levels of sacroiliac joint and pubic symphysis for representing right VPRD. Then, the pelvis was set sacral inclination at 60° from X-ray table for outlet and anteroposterior pelvic radiographs. Right VPRD was measured by referring to superior most pelvic articular surface of both sacroiliac joints and sacral long axis. Radiographic VPRD and actual displacement were analyzed by Pearson correlation coefficient at more than 0.90 for the strong correlation and strongly significant simple regression analysis was set at P < 0.01.

RESULTS

Radiographic VPRD from outlet and anteroposterior pelvic views at 10 mm actual displacement were 20.12 ± 1.98 and 4.08 ± 3.76 mm, at 20 mm were 40.31 ± 1.97 and 9.94 ± 7.27 mm and at 30 mm were 58.56 ± 2.53 and 11.29 ± 2.89 mm. Statistical analyses showed that radiographic VPRD from pelvic outlet view is 1.95 times of actual displacement with strong correlation at 0.992 coefficient and strongly significant regression analysis (P < 0.001) with 0.984 of R (2) value. Whereas, the measurement from anteroposterior pelvic radiograph was not strongly significant.

CONCLUSION

Pelvic outlet radiograph provides efficient measurement of VPRD with 2 times of actual displacement.

Atypical Pelvic Crescent Fracture Caused by Vertical Shear Force

The crescent fracture consists of a posterior iliac wing fracture with extension into the sacroiliac joint and a dislocation of the sacroiliac joint. This fracture represents a subset of lateral compression injury. The strong posterior ligaments of sacroiliac joint remain intact and a fracture fragment (crescent shape) involving the posterior superior iliac spines remains firmly attached to the sacrum. We report a patient with atypical pelvic crescent fracture that is mainly influenced by vertical shear injury and is characterized by posterior fracture-dislocations of the sacroiliac joint. In this case report, we review the literature on classification and treatment of atypical type of crescent fracture.

Treatment of Unstable Pelvic Ring Injuries

Pelvic fractures are classified according to the stability of the pelvic ring. Unlike stable pelvic fractures, which heal without complications, unstable fractures may lead to pelvic ring deformities, which cause severe complications. An orthopedic surgeon must determine the stability of the pelvic ring by radiography and physical examination of the patient in order to ensure early, prompt treatment. This article includes anatomy of the pelvic ring, classification of pelvic ring injuries, its treatment algorithm, and corresponding cases involving unstable pelvic ring injury.

There have been changes in the incidence and epidemiology of pelvic ring fractures in recent decades?

The pelvic ring fractures comprise 2-8% of all skeletal injuries. As the incidence rises to 25% in polytrauma and represents a negative prognostic factor with regard to morbidity and mortality of patients, we sought with this work to establish the profile of these, compared to an alteration in the profile of patients with pelvic ring fractures in recent decades. To this end, we evaluated the epidemiological profile, mechanism of injury and types of fractures. By reviewing the literature indexed in the databases related to the theme, 20 papers were selected that contained the requirements for the study. For the period between January 1987 and December 1999 (first decade), and another period in January 2000 and December 2010 (second decade), data were analyzed by Mann-Whitney test. The ratings Tile, Young and Burgess AO were adequate to permit their categorization. The research in each decade was homogeneous. At first the lesions were more prevalent in men with 62.5% with a tendency to reverse this pattern given the increase of women in the second decade (p = 0.286). The average age in the first decade was 39.3 years, an increase in the second (p = 0.068). The most prevalent mechanisms of trauma were related to traffic in both periods as well as fractures classified as type A (p = 0.203 and p = 0.457, respectively), having mortality rates decreased (p = 0.396). We conclude that there was a tendency to increase in the average age of patients (p = 0.068); however the increasing involvement of women (p = 0.286) and decreased mortality (p = 0.396) were not significant.

Delayed presentation of intravesical bone penetration after pelvic ring fracture

Retrograde cystography and computed tomography (CT) are considered the gold standard for investigating bladder and pelvic bone injury. However, these methods can miss extraperitoneal bladder rupture caused by a penetrating bone fragment from a pelvic bone fracture. We experienced a routine conventional cystography and CT scan that failed to identify penetration of the bladder by a bone fragment, which thus delayed optimal treatment. Therefore, different diagnostic methods such as CT cystography or cystoscopy should be considered to rule out penetrating injury by a bony fragment in patients with extraperitoneal bladder rupture.

Factors affecting the outcome of extraperitoneal laparoscopic radical prostatectomy: pelvic arch interference and depth of the pelvic cavity

Purpose

To determine the effect of pelvic arch interference and the depth of the pelvic cavity, as shown on preoperative magnetic resonance imaging (MRI), on the performance of extraperitoneal laparoscopic radical prostatectomy (ELRP).

Materials and Methods

In 115 patients, pelvic bone images were obtained at the time of prostate MRI before ELRP. In the reconstructed sagittal plane, we measured the true conjugate diameter, the obstetric conjugate diameter, the difference between the true and obstetric diameters, and the distance between the true conjugate and the prostate apex (pelvic depth). We analyzed which factors were associated with operative time (OT), estimated blood loss (EBL), and positive surgical margins (PSMs).

Results

The difference between the true and obstetric conjugate diameters was 12.7±3.7 mm, and the pelvic depth was 59.9±6.0 mm. The OT, EBL, and the rate of PSMs were 260.1±91.1 minutes, 633.3±524.7 ml, and 19% (22/115), respectively. According to multiple linear regression analysis, predictors of a higher EBL included pelvic depth (3.0% higher per 1 mm increase in diameter difference, p=0.01) and prostate volume (1.5% higher per 1 cc increase in prostate volume, p=0.002). Factors associated with a longer OT were pelvic depth (p=0.04), serum prostate-specific antigen (p=0.04), prostate volume (p=0.02), and Gleason score (p=0.001). For PSMs, only pT2 was an independent factor.

Conclusions

Our results suggest that the depth of the pelvic cavity and prostate volume may increase surgical difficulty in patients undergoing ELRP.