退变性腰椎侧凸伴骨盆倾斜的影像学特征及矫形术后转归

目的 ：总结退变性腰椎侧凸患者伴骨盆倾斜的影像学特征,并分析脊柱矫形术后相关的影像学参数和骨盆倾斜的转归。方法：回顾性分析2005年1月～2019年12月在我院行后路脊柱侧凸矫形内固定融合手术的181例退变性腰椎侧凸患者的临床资料。术前合并骨盆倾斜20例,年龄46～75岁（62.10±7.56岁）,随访时间12～96个月（47.21±19.13个月）。15例患者C7铅垂线（C7PL）偏移方向与骨盆髂嵴较高侧保持一致,定义为Ⅰ型;5例患者C7PL偏移方向与骨盆髂嵴较低侧一致,定义为Ⅱ型。收集患者术前、术后即刻及末次随访时的Cobb角、冠状位平衡（coronal vertical axis,CVA）、锁骨角（clavicle angle,CA）、顶椎偏距（apical vertebral translation,AVT）、骶骨倾斜角（sacral obliquity angle,SOA）、骨盆倾斜角（pelvic obliquity angle,POA）等影像学参数以及顶椎位置、融合节段、截骨方式、远端固定椎位置等临床指标,并进行组内比较与组间比较。结果：Ⅰ型组术后及末次随访时的Cobb角...     

椎弓根螺钉-棒系统矫治麻痹性脊柱侧凸

目的探讨应用椎弓根螺钉-棒系统矫治麻痹性脊柱侧凸（paralytic scoliosis，PS）的一些手术问题。方法2000年5月～2005年5月，应用钛质椎弓根螺钉-棒系统治疗18例Ps患者，男i0例，女8例；年龄11～26岁。其中脊髓灰质炎后遗症13例；先天性脊髓发育不良（myelodysplasia，MS）5例，2例为2次手术。术前脊柱侧凸Cobb角55～125°，牵引下侧凸Cobb角30～105°。合并骨盆倾斜3～55°。3例术前先施行头-盆环牵伸；2例实施一期后路弧顶椎楔形截骨矫形内固定术；余仅行后路椎弓根螺钉-棒系统矫形内固定。固定节段为6～15个，所用螺钉数6～16枚。结果术后患者均无感染及神经症状加重，伤口均Ⅰ期愈合。16例获随访6个月～3年，平均1年9个月。无断钉、断棒现象。术后Cobb角40．29±15．45°，矫正率44％～81％，平均52．95％，与术前比较差异有统计学意义（P〈0．001）。随访时1例MS患者Cobb角丢失较明显，余患者与术后比较无明显改变（P〉0.05）。骨盆倾斜术后测量为14．77±10．56°，与术前比较差异有统计学意义（P〈0．05）；其中1例随访1年时较术后有加重，余患者均无明显变化（P〉0．05）。结论应用椎弓根螺钉-棒系统，多椎体的固定，短节段的融合，方法可靠，疗效满意。矫治麻痹性脊柱侧凸时，应将骨盆及下肢的功能和畸形程度统筹考虑。     

先天性脊柱侧凸合并骨盆倾斜患者术后转归的影响因素分析

目的探讨先天性脊柱侧凸合并骨盆倾斜患者术后转归的影响因素。方法选取手术治疗的先天性脊柱侧凸合并骨盆倾斜患者20例,均予以脊柱后路矫形内固定手术,其中有9例同时进行全脊椎截骨手术,6例同时进行椎弓根截骨手术。术后进行站立位全脊柱正位X线片以测量躯干偏移(TS)、骨盆倾斜角(POA)、L5倾斜角(L5OA)、腰骶椎间角(LSA),对比手术前后影响数据差值的相关系数,手术6个月后在对患者进行SRS-22评分量表调查和随访并对比分析,找出与骨盆倾斜的相关影响因素。结果 20例患者术后的Cobb角、TS、POA、L5OA、LSA等影响学参数均获得显著矫正,手术前后差异均有统计学意义(P0.05);术后的SRS-22量表评分明显高于术前,差异有统计学意义(P0.05)。术后骨盆倾斜角变化绝对值,与主弯Cobb角、TS、L5OA和LSA等指标变化的绝对值呈正相关。结论先天性脊柱侧凸合并骨盆倾斜患者进行脊柱后路矫形内固定手术后得到转归,其影响因素与L5OA、LSA有关。     

强直性脊柱炎胸腰段后凸畸形矫形前后影像学参数分析

【摘要】 目的 通过对强直性脊柱炎（ankylosing spondylitis, AS）僵硬性胸腰段后凸畸形矫形前后影像学参数对比分析及相关性研究,探讨经椎弓根椎体截骨（pedicle subtraction osteotomy,PSO）矫形对矢状面脊柱骨盆序列的影响,进而探究AS后凸患者脊柱骨盆序列的代偿机制。 方法 2004年1月～2010年3月, 38例AS僵硬性胸腰段后凸畸形患者行后路单节段或双节段截骨矫形椎弓根螺钉内固定术。矫形前后拍摄全脊柱侧位X线片,测量AS患者全脊柱后凸角（Cobb T1~S1）、矢状面平衡距离（sagittal vertical axis,SVA）、骨盆入射角（pelvic incidence,PI）、骨盆倾斜角（pelvic tilt,PT）、骶骨倾斜角（sacral slope,SS）及截骨角度（PSO angle）。观察矫形前后影像学参数变化,控制影响患者个体差异的因素,将影像学参数做偏相关分析。 结果 矫形前,Cobb T1~S1=56°±28°,PI=45°±9°,PT=38°±13°,SS=7°±12°,SVA=21 cm±9 cm;矫形后,Cobb T1~S1=11°±22°,PI=46°±9°,PT=21°±10°,SS=24°±9°,SVA=9 cm±5 cm。矫形前,PT、SVA与Cobb T1~S1偏相关系数分别为r=0.81（P＜0.01）、0.64（P＜0.01）;矫形后,PT、SVA与Cobb T1S1偏相关系数分别为r=0.58（P＜0.05）、0.72（P＜0.01）。PSO angle与Cobb T1~S1、PT偏相关系数分别为r=－0.82（P＜0.01）、－0.56（P＜0.05）,PSO angle与SVA无相关性。 结论 矫形前后,AS患者通过后旋骨盆代偿全脊柱后凸所致的矢状面失平衡;骨盆后旋程度、矢状面平衡距离与全脊柱后凸程度呈正相关;人体自身代偿机制优先恢复骨盆的中立状态而非改善矢状面平衡距离。     

远端融合节段选择对退变性脊柱侧后凸患者矫形术后骨盆入射角变化的影响

【摘要】 目的：探讨远端不同融合节段对退变性脊柱侧后凸患者矫形术后骨盆入射角（pelvic incidence,PI）变化的影响。方法：回顾性分析2010年5月~2018年4月因退变性脊柱侧后凸于我院行后路矫形长节段融合内固定手术患者的病历资料,男5例,女37例;年龄50~69岁（60.6±6.9岁）。按远端融合节段不同分为两组：融合至L5纳入A组（14例）,融合至骨盆纳入B组（28例）。测量并记录两组患者术前的侧凸Cobb角、局部后凸角（regional kyphosis,RK）和术前、术后的腰椎前凸角（lumbar lordosis,LL）、脊柱矢状面平衡（sagittal vertical axis, SVA）、骨盆入射角（pelvic incidence,PI）、骨盆倾斜角（pelvic tilt,PT）及骶骨倾斜角（sacral slop,SS）,比较两组患者术后PI改变的差异,分析其与术前矢状面参数的关系。结果：两组患者的术前冠状面Cobb角度、RK、内固定节段数、性别分布、年龄均无统计学差异（P＞0.05）。A组患者术前和术后PI分别为46.4°±16.7°和44.1°±13.6°,无显著性差异（P=0.104）。B组患者术前PI为50.9°±13.6°,术后减少至44.0°±13.7°,差异有显著性（P<0.05）,其中15例（53.6%）患者术后与术前相比PI减少大于5°。术前A组的PI-LL显著小于B组（P=0.015）,而LL显著大于B组（P=0.032）;两组术后PI改变（ΔPI）有统计学差异（P=0.04）。相关性分析结果显示B组ΔPI与术前PI（P=0.009）、术前LL（P=0.020）、术前PI-LL（P=0.0003）和术前PT（P=0.006）有显著相关性,线性回归分析ΔPI=-3.117+0.201×术前PI-0.116×术前LL。结论：后路矫形长节段融合固定治疗退变性脊柱侧后凸患者中,远端融合至骨盆的患者相较于融合至L5的患者术后更有可能出现PI的显著性降低;融合至骨盆的患者术后PI的显著改变可能与术前较大的PI和术前更大程度的矢状位失平衡相关。     

不同侧凸方向的Lenke 5型脊柱侧凸前路矫形疗效的比较

【摘要】 目的：比较不同侧凸方向的Lenke 5型脊柱侧凸前路矫形内固定的手术疗效。方法：对2005年1月~2009年12月期间在我院手术治疗的Lenke 5型青少年特发性脊柱侧凸（AIS）患者进行回顾分析。按照侧凸方向分为左侧凸组（L组,n=38）和右侧凸组（R组,n=14）,在术前、术后及末次随访时的X线片上测量两组患者的如下参数：冠状面参数包括胸弯、胸腰弯/腰弯Cobb角及冠状面平衡等;矢状面参数有胸椎后凸角、胸腰段交界角、腰椎前凸角和整体矢状面平衡等。对两组病例的上述参数进行独立样本t检验,分析比较两组的矫形疗效。结果：两组术前主弯Cobb角、主弯累及节段及代偿胸弯Cobb角均无显著性差异（P＞0.05）。L组、R组平均随访时间分别为3.1±0.9年（2~4年）、2.7±0.8年（2~3年）。与L组相比,R组手术时间（208.8±41.4min vs. 225.6±39.6min）及出血量（236.5±159.6ml vs. 284.4±164.7ml）较多,但均无统计学差异（P=0.132和P=0.345）。L、R组腰弯平均矫正率分别为66.7%和64.4%（P=0.808）,末次随访平均矫正丢失率分别为4.6%和5.1%（P=0.992）;L、R组胸弯平均矫正率分别为49.8%和47.7%（P=0.886）,末次随访时平均矫正丢失率分别为13.4%和14.3%（P=0.759）。两组均无血管损伤及神经并发症,无1例发生内固定失败。L组术后2例患者发生远端Adding-on,1例患者发生近端交界性后凸;R组1例出现近端Adding-on。结论：前路胸腰弯/腰弯矫形融合术是治疗Lenke 5型脊柱侧凸的有效方法,且不同侧凸方向对矫形疗效无明显影响。     

后路半椎体全切钉棒固定治疗幼儿和青少年先天性脊柱侧凸畸形的对比研究

[目的]评价后路半椎体切除钉棒固定术治疗婴幼儿青少年先天性脊柱侧后凸畸形的临床效果。[方法]回顾性分析施行后路半椎体切除术的先天性脊柱侧后凸16例幼儿和12例青少年患者的临床资料,均行后路一期半椎体切除及钉棒固定融合术。对手术时间、术中出血量及手术前后Cobb角进行了对比研究。[结果]幼儿组患者手术时间平均185 min;术中出血量平均375 ml,平均输血量450 ml;固定节段平均5.1个椎体。青少年组患者手术时间平均275 min;术中出血量平均765 ml,平均输血量850 ml;固定节段平均8个椎体。两组患者术后随访13²6个月,平均18.5个月。站立位全脊柱正侧位X线片示侧凸Cobb角幼儿组平均为12°,平均矫正率68.4%;终末随访时侧凸Cobb角平均17°,丢失5°,平均矫正率55.3%。青少年组侧凸Cobb角平均47°,平均矫正率13.0%;终末随访时侧凸Cobb角平均48°,丢失2°。幼儿组围手术期并发症包括伤口愈合不良1例,无神经系统并发症。青少年组伤口愈合不良2例,神经损害2例。[结论]后路半椎体切除可直接去除致畸因素,后路钉棒固定在幼儿组可获得良好的矫形。青少年组患者由于脊柱侧凸僵硬,矫形不佳,并且术后患者神经损害并发症较高。因此,对于先天性半椎体脊柱侧凸患者,幼儿期即行手术矫形,可以获得较佳的治疗效果。     

近端固定椎的选择对Lenke 5型脊柱侧凸前路矫形疗效的影响

  目的 探讨近端固定椎的选择对Lenke 5型脊柱侧凸前路融合术矫形疗效的影响。方法 2002年1月至2006年12月接受前路选择性单棒矫形手术治疗 且获得2年以上随访的女性Lenke 5型青少年特发性脊柱侧凸患者36例,近端固定至上端椎21例、近端固定至上端椎下方椎体15例。两组患者平均年龄为（15.3± 1.8）岁和（15.5±1.9）岁,平均胸腰或腰主弯Cobb角为46.2°和46.7°,近端胸弯为26.3°和29.6°。平均融合节段为5.3和4.8个椎体。结果 两组平均随访 31和33个月。冠状面胸腰或腰主弯矫正率为79%和70%（P=0.062）,近端胸弯自发矫正率为46%和29%（P=0.044）。矢状面上,术前和术后两组患者腰椎前凸角、 骶骨倾斜角差异均无统计学意义。矢状面平衡维持于较小的负平衡。胸椎后凸角分别有4.0°和2.3°的轻度增加,末次随访时近端固定至上端椎组大于近端固定 至上端椎下方椎体组（P=0.029）。胸腰段交界性成角均表现为轻度后凸增加,并最终保持2°~4°后凸角。近端交界性后凸均有轻度增加,融合节段成角均呈前 凸减小甚至出现后凸趋势。结论 Lenke 5型脊柱侧凸行前路选择性融合术中,近端融合至上端椎较固定至端椎下方椎体可获得更好的冠状面主弯矫正和近端胸弯 自发性矫正,矢状面矫形效果相似。     

锥束CT拼接成像联合工形测量仪在青少年特发性脊柱侧凸矫形术中冠状位平衡评估的应用

【摘要】 目的：探讨锥束CT拼接成像联合工形测量仪在青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）患者矫形术中冠状位平衡评估的应用价值。方法：收集2019年1月~2021年1月在北部战区总医院接受脊柱后路矫形手术且术中均应用锥束CT拼接成像技术联合工形测量仪评估冠状位平衡情况的48例AIS患者的相关资料,患者年龄12~18岁（14.9±1.8岁）,随访时间1~2年（1.8±0.2年）。根据冠状位平衡情况进行分型：A型为冠状位平衡距离（coronal balance distance,CBD）＜20mm,B型为CBD≥20mm且C7铅垂线位于主弯的凹侧,C型为CBD≥20mm且C7铅垂线在主弯的凸侧,将CBD≥20mm定义为冠状位失平衡。记录所有患者术前、术中、术后1周、末次随访时的主弯Cobb角、CBD、骨盆冠状倾角（pelvic coronal obliquity angle,PCOA）以及术前、末次随访时疼痛视觉模拟评分（visual analogue scale,VAS）及Oswestry功能障碍指数（Oswestry disability index,ODI）,比较不同时间点的冠状位平衡情况及临床矫形效果。结果：48例患者术前、术中、术后1周及末次随访时主弯Cobb角分别为58.45°±12.81°、14.13°±5.86°、14.48°±5.98°、14.39°±5.74°,术中及术后1周较术前均有明显改善（P＜0.05）,末次随访与术后1周差异无统计学意义（P＞0.05）;术前、术中、术后1周及末次随访时PCOA分别为3.72°±2.75°、1.25°±0.97°、1.25°±0.96°、1.28°±0.96°,其中术中及术后1周较术前均有明显差异（P＜0.05）,末次随访与术后1周差异无统计学意义（P＞0.05）。所有患者术前冠状位失平衡率为47.91%（23/48）,末次随访时冠状位失衡率为10.42%（5/48）。A型组25例患者术前、术中、术后1周及末次随访时的CBD分别为12.53±4.46mm、8.06±3.15mm、8.37±3.13mm、8.66±3.77mm,术中与术后1周较术前均有明显改善（P＜0.05）,末次随访与术后1周差异均无统计学意义（P＞0.05）;B型组15例及C型组8例患者术前、术中、术后1周及末次随访时的CBD分别为24.57±4.60mm、14.91±4.62mm、14.95±4.49mm、15.06±3.98mm及26.46±6.78mm、16.58±4.00mm、16.94±4.12mm、16.58±3.97mm,两组患者术中与术后1周较同组术前均有明显改善（P＜0.05）,末次随访与同组术后1周差异均无统计学意义（P＞0.05）。所有患者末次随访时VAS评分（3.98±0.57分）及ODI[（21.82±3.12）%]较术前[（7.68±0.64）分、（46.51±4.79）%]均有明显改善（P＜0.05）。结论：锥束CT拼接成像联合工形测量仪是一种有效且整体平衡评估能力强的术中冠状位平衡评估方法,能够更好地辅助脊柱外科医生在AIS患者脊柱侧凸矫形术中进行冠状位平衡的评估,及时调整矫形程度,有效减少术后冠状位失衡发生。     

改良Halo-骨盆架分期牵引治疗重度僵硬性脊柱侧凸的疗效分析

目的：探讨改良Halo-骨盆架分期牵引联合手术治疗重度僵硬性脊柱侧凸的临床疗效。方法：自2004年1月至2010年5月治疗50例重度僵硬性脊柱侧凸患者,男23例,女27例;年龄4～16岁,平均10.8岁;先天性脊柱侧凸24例（分节不良11例,形成障碍7例,混合型6例）,特发性脊柱侧凸26例。采用改良Halo-骨盆架分期牵引联合手术治疗：Ⅰ期术前牵引,Ⅱ期松解牵引,Ⅲ期牵引矫形内固定。对治疗前后患者身高、侧凸Cobb角、后凸Cobb角及矫正率进行观察。结果：患者身高由治疗前平均（152.1±11.1）cm矫正至（158.5±10.5）cm,侧凸Cobb角由平均（91.8±14.5）°矫正至（30.8±7.9）°,后凸Cobb角由平均（69.5±14.0）°矫正至（31.6±10.1）°。Ⅰ期术前牵引后侧凸、后凸Cobb角平均矫正率分别为（30.4±6.6）%、（22.3±5.2）%;Ⅱ期松解牵引后侧凸、后凸Cobb角平均矫正率分别为（26.7±5.1）%、（21.2±6.0）%;Ⅲ期牵引矫形内固定后侧凸、后凸Cobb角平均矫正率分别为（33.7±7.2）%、（27.1±5.3）%（矫正率参照的基准Cobb角是上一期治疗的Cobb角）;分期牵引联合手术治疗的侧凸、后凸Cobb角平均矫正率分别为（66.5±7.2）%、（55.1±6.4）%。各期治疗前后患者身高、侧凸Cobb角、后凸Cobb角及矫正率差异均有统计学意义（P〈0.05）。结论：采用改良Halo-骨盆架分期牵引联合手术治疗重度僵硬性脊柱侧凸,可获得良好的畸形矫正和躯干平衡,并能减少术中、术后并发症,具有临床可操作性。     

Evaluation of pelvic morphology in the sagittal plane

Background contextIt is generally accepted that for normal subjects the angle of pelvic incidence (PI) increases during childhood and then remains unchanged throughout adolescence and adulthood. However, recent findings show that PI increases linearly throughout the lifespan due to morphological changes of the pelvis.PurposeA retrospective study aiming to determine the extent of morphological changes of the pelvis related to the age of the subjects.Study designPelvic morphology was evaluated in a normal adult population by measuring the anatomical parameters of sagittal pelvic alignment.Patient sampleThe final study cohort consisted of 330 subjects (mean age, 45.3 years; standard deviation, 18.1 years; range, 18–87 years; 164 male and 166 female subjects).Outcome measuresPhysiologic measures, obtained as measurements of PI, sacral end plate width (S1W), and pelvic thickness (PTH).MethodsParameters of PI, S1W, and PTH were evaluated from computed tomography images of the subjects. The measured PTH was normalized according to S1W and age of the subjects, allowing the comparison among anatomies of different sizes. The normalized components of PTH in anteroposterior and cephalocaudal directions were computed to determine the configuration and extent of changes in pelvic morphology related to subject age.ResultsStatistically significant correlation with both age and PI was obtained for all normalized parameters (except for the anteroposterior component of PTH for male subjects), and no statistically significant differences were observed between the sexes. With increasing PI that occurs due to the aging process, a decrease of PTH can be observed that is manifested not only as an increase of the distance between the sacrum and the hip axis in the anterior direction but considerably more as a decrease of the distance between the sacrum and the hip axis in the cephalic direction. By considering these morphological changes in the pelvis simultaneously, the hip axis can move only within a narrow area.ConclusionsThe changes in pelvic morphology due to the aging process occur in the anterior direction, which may be due to the remodeling process affecting the coxal bone that results in an anterior drift of the acetabulum relative to the sacrum. More importantly, the changes are considerably more evident in the cephalic direction, which may be the result of the weight-bearing loads and consequent wear of acetabular cartilage.     

Haemorrhage control in pelvic fractures--a survey of surgical capabilities

Background

In the emergency management of patients with pelvic fractures, there is ongoing debate about the roles of angiography and open pelvic packing. It is agreed that some form of haemorrhage control is required for patients who are haemo-dynamically unstable despite resuscitation. We set out to determine whether on-call general and orthopaedic surgeons would feel able to perform emergency surgical procedures for these patients and whether vascular radiology was available to them.

Methods

Surveys were sent to all 221 general and orthopaedic surgeons in Wales. Questions included: sub-speciality interest, geographical region, whether there is a pelvic binder in their hospital, availability of interventional radiology, and whether surgeons would perform a range of procedures to control haemorrhage in the emergency setting.

Results

There were 141 responses to the survey, giving a 64% response rate. Only 18% reported that their unit had a formal rota for interventional radiology out of hours. 16% did not know. 96% of orthopaedic surgeons would perform external fixation, although only 49% would use a C-clamp. 90% of general surgeons would be able to pack the pelvis from within the abdominal compartment and 84% would be prepared to cross-clamp the aorta if the situation required. Despite being widely recommended in the literature as a method of haemorrhage control, our survey revealed only 45% would perform extra(pre)-peritoneal packing of the pelvis (58% of general surgeons; 34% of orthopaedic surgeons) and only 12% had received formal training in this procedure.

Conclusions

With appropriately targeted training it is likely that the care of patients with pelvic fractures can be significantly improved.     

Control of severe hemorrhage using C-clamp and arterial embolization in hemodynamically unstable patients with pelvic ring disruption

Introduction

Hemorrhage is the leading cause of death in patients with a pelvic fracture. The majority of blood loss derives from injured retroperitoneal veins and broad cancellous bone surfaces. The emergency management of multiply injured patients with pelvic ring disruption and severe hemorrhage remains controversial. Although it is well accepted that the displaced pelvic ring injury must be rapidly reduced and stabilized, the methods by which control of hemorrhagic shock is achieved remain under discussion. It has been proposed to exclusively use external pelvic ring stabilization for control of hemorrhage by producing a ‘tamponade effect’ of the pelvis. However, the frequency of clinically important arterial bleeding after external fixation of the pelvic ring remains unclear. We therefore undertook this retrospective review to attempt to answer this one important question: How frequently is arterial embolization necessary to control hemorrhage and restore hemodynamic stability after external pelvic ring fixation?

Materials and methods

We performed a retrospective review of 55 consecutive patients who presented with unstable types B and C pelvic ring fractures. Those patients designated as being in hemorrhagic shock (defined as a systolic blood pressure less than 90 mmHg after receiving 2 L of intravenous crystalloid) were treated by application of the pelvic C-clamp. Patients who remained in hemorrhagic shock, or were determined to be in severe shock (defined as mandatory catecholamines or more than 12 blood transfusions over 2 h), underwent therapeutic angiography within 24 h in order to control bleeding.

Results

Fourteen patients were identified as being hemodynamically unstable (ISS 30.1±11.3 points) and were treated with a C-clamp. In those patients with persistent hemodynamic instability, arterial embolization was performed. After C-clamp application, 5 of 14 patients required therapeutic angiography to control bleeding. Two patients died, one from multiple sources of bleeding and the other from an open pelvic fracture (total mortality 2/14, 14%).

Conclusions

Although the C-clamp is effective in controlling hemorrhage, one must be aware of the need for arterial embolization to restore hemodynamic stability in a select subgroup of patients.

     

Current management of severe pelvic and perineal trauma

Mortality associated with pelvic and perineal trauma (PPT) has fallen from 25% to 10% in the last decade thanks to progress accomplished in medical, surgical and interventional radiology domains (Dyer and Vrahas, 2006) [1]. The management strategy depends on the hemodynamic status of the patient (stable, unstable or extremely unstable). Open trauma requires specific treatment in addition to control of bleeding. All surgical centers can be confronted some day with patients with hemorrhagic PPT and for this reason, all surgeons should be familiar with the initial management. In expert centers, management of patients with severe PPT is complex, multidisciplinary and often requires several re-interventions. Obstetrical and sexual trauma, also requiring specific management, will not be dealt with herein.     

Dynamic assessment of pelvic floor function in women using the intravaginal device test

The aim of the study was to assess pelvic floor function and dysfunction using intravaginal devices (IVD test). One hundred and eighty-five patients were evaluated, 65 (35.1%) in the control group without genital prolapse and 120 (64.9%) in the study group, with prolapse. Anatomic changes were evaluated on a scale described by Halban, and functional classification based on palpation of the muscles of the pelvic floor during contraction. Additionally, weighted vaginal devices were used to assess pelvic floor function. Statistic analysis was performed with the Spearman-Pearson correlation coefficient, the ² test and the response/ operator characteristic curve. There was an acceptable correlation between the IVD test and the functional classification of 0.75. Using this classification, the IVD test showed 86.58% sensitivity, 75.72% specificity, and had a positive predictive value 73.95% and a negative predictive value of 87.64%. Significant differences between pelvic floor muscle activity in those patients with and without genital prolapse were observed (X²=58.28, P=<0.005). It was concluded that pelvic floor assessment can be done through the evaluation of active muscle strength or pelvic floor integrity using the functional classification and the IVD test.EDITORIAL COMMENT: In 1988, Peattie and Plevnick introduced the use of weighted vaginal cones to exercise the pelvic floor muscles and treat stress urinary incontinence [1]. Contreras-Ortiz and Nuñez build on this earlier work, using a similar technique to assess pelvic floor muscle function and integrity. Specifically, pelvic floor function is assessed by a combination of digital palpation of the pubococcygeus muscle at rest and during contraction; pelvic floor integrity is assessed by the patient's ability to retain a weighted cone vaginally for 1 minute. Scoring of these two parameters can then be objectively followed for therapeutic response to treatment for urinary incontinence or pelvic relaxation. Many of us forget to palpate the pubococcygeus muscle at rest and during an elicited contraction during baseline or follow-up examination. As this study indicates, simple assessment of pelvic floor function and integrity is possible, and should be used both clinically and in research.     

Skip and save: utility of pelvic x-rays in the initial evaluation of blunt trauma patients

Background

The cost of medical care is an area of major emphasis in the current healthcare environment. Medical providers have a significant role in reducing costs. One way to achieve this goal is to eliminate practices that add little value to patient care. The pelvic x-ray (PXR) obtained during the initial evaluation of blunt trauma may be an example. The objective of this study was to explore the utility of the pelvic x-ray in the initial evaluation of blunt trauma patients.

Methods

Blunt trauma patients with pelvic fractures of any type admitted to our urban trauma center from January 2012 to December 2013 were reviewed. Demographics including age, sex, race, mechanism of injury, and outcomes were collected. Findings on PXR and computed tomography (CT) were compared for correlation. Patients requiring surgery for their pelvic fractures were identified.

Results

Of the 3,217 trauma admissions over the 2-year period, 153 patients sustained a pelvic fracture. Mean age was 50 years (15 to 97), male 54%, and Caucasian 46%, Hispanic 31%, African American 22%, and Asian 1%. The average injury severity score was 12.9. The main mechanism of injury was motor vehicle collisions 45%, followed by fall from standing 22% and auto and/or pedestrian accidents 12%. There were 22 patients that did not have both CT and pelvic imaging for comparison. Of the 131 patients with both CT and pelvic films, findings were the same in 43 (33%). CT identified one or more additional pelvic fractures in 88 (67%) patients compared with the PXR. In 29 patients (22%), pelvic fractures were not evident on PXR with fractures only identified by CT. The most common missed fractures on PXR were sacral and iliac injuries. Of the 153 patients with pelvic fractures, 24% required surgery for their pelvic injuries. Mortality was 4% for nonpelvic fracture-related causes. The PXR findings did not change management provided by trauma team in the emergency department.

Conclusions

As expected, CT is more sensitive in identifying pelvic fractures compared with PXR. Most blunt trauma patients are undergoing further evaluation with CT. We therefore propose that in patients that are normotensive with no pelvic instability or hip dislocation on physical examination who are to undergo further imaging with CT, the pelvic film should be avoided as it adds little value to patient management. The Advanced Trauma Life Support (ATLS) guidelines should be revised to reflect a diminishing role of the PXR in blunt trauma patients.     

The influence of pyeloureteral peristalsis on pelvic pressure during increase in flow rate

Summary Thirty-nine normal pig pyeloureters were perfused with 0, 2, 4, 6, 8, 10 and 20 ml/min during continuous measurement of the pelvic pressure. A phasic pressure response was identified with the highest pressure increase between 2 and 4 ml/min. Two groups were analyzed. One consisting of the 10 pyeloureters with the highest pressure increase and the other of the 10 pyeloureters with the lowest pressure increase to a perfusion rate of 4 ml/min. The peristaltic frequency was significantly higher (about 6/min) in the high pressure group than in the low pressure group (about 3.5/min). It is concluded that a high peristaltic frequency is at least partly responsible for the high pressure response to increasing flow because the peristaltic contraction ring opposes the filling flow through ureter.     

The use of external fixators in the definitive stabilisation of the pelvis in polytrauma patients: Safety,efficacy and clinical outcomes

ObjectivesTo analyse the complications and outcomes (functional/radiographic) of Pelvic External Fixators applied as part of the definitive fixation in polytrauma patients.DesignA single center retrospective chart review.SettingA level-1 trauma center.Patients and methodsWe reviewed all the polytrauma patients (ISS > 16) between 2007 and 2012 that had a PEF applied more than 30 days. Complications including infection, aseptic loosening, neurological injury, loss of reduction, non-union and mal-union were recorded. Pelvic asymmetry and Deformity Index (DI) were measured at the immediate postoperative radiographs and final follow-up. The functional outcome at final follow up was estimated using a scale previously reported by Chiou et al.Results59 patients with mean age of 38.4 (16 − 81) years and mean ISS score 28 (16- 66) were included. The PEFs were applied for mean duration of 56 (30–104) days. The average follow-up was 403 days. 22 injuries were type B and 37 type C (AO/OTA). The most common symptomatic complications were pin site infection in 11 (18.6%) and loosening in 5 (8.5%) cases. 44 (74.5%) patients had satisfactory functional outcome. The immediate post-operative and final asymmetry and DI were compared between the two pelvic injury groups (type B and C fractures). The difference in displacement progression was more for type C injuries (p = 0.034) but no correlation to the functional outcome was evident.ConclusionPEF can be used as definitive alternative stabilization method in specific situations at polytrauma setting. Radiological displacement occurred in both type B and C injuries but the clinical outcome was not correlated to this displacement. Complications related to PEF do not affect the final clinical outcome.Level of evidenceTherapeutic Level III.     

Effect of a new pelvic stabilizer (T-POD®) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures

Background

Pelvic fractures, often the result of high energy blunt trauma, are associated with severe morbidity and mortality. A new pelvic stabilizer (T-POD^®) provides secure and effective simultaneous circumferential compression of the pelvis.

Methods

In this study we describe 15 patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the T-POD^®. Before and 2 min after applying the T-POD^®, heart rate and blood pressure were measured. An X-ray before and directly after applying the T-POD^® was made to measure the effect on reduction in symphyseal diastasis.

Results

Application of the T-POD^® reduced the symphyseal diastasis with 60% (p = 0.01). The mean arterial pressure (MAP) increased significant from 65.3 to 81.2 mm Hg (p = 0.03) and the heart rate declined from 107 beats per minute to 94 (p = 0.02). Out of ten patients in whom the circulatory response before and after the T-POD^® was recorded, seven were good responders, one had a transient response and two responded poor.

Conclusion

In the acute setting, the T-POD^® device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. The T-POD^® is therefore an effective and easy to use device in (temporarily) stabilizing the pelvic ring in haemodynamically unstable patients.     

Effects of examination technique modifications on pelvic organ prolapse quantification (POP-Q) results

The pelvic organ prolapse quantification system (POP-Q) is currently the most quantitative, site-specific system for describing pelvic organ prolapse. To ensure that anatomic outcomes can be optimally assessed, investigators in the Pelvic Floor Disorders Network evaluated the impact of specific technique variations on POP-Q measurements performed on 133 patients by 16 examiners at seven sites. Values for genital hiatus and perineal body were higher when measured with maximal strain than on resting. With the exception of TVL, internal points did not differ significantly when measured with or without a speculum. The maximum extent of prolapse was best seen with the patient standing. These results suggest that genital hiatus and perineal body should be measured at rest and during straining, as the measurements may assess different aspects of pelvic floor function, and that internal points can be measured with or without a speculum. They also emphasize the value of the standing examination to observe the maximum extent of pelvic organ prolapse.Abbreviations POP pelvic organ prolapse - GH genital hiatus - PB perineal body - TVL total vaginal length An erratum to this article can be found at For the Pelvic Floor Disorders Network (PFDN)Supported by grants from the National Institute of Child Health and Human Development (U01HD41249,U10 HD41268, U10 HD41248, U10 HD41250, U10 HD41261, U10 HD41263, U10 HD41269, and U10 HD41267). Editorial Comment: This is a well conceived and clearly described study by the investigators of the Pelvic Floor Dysfunction Network. It carefully evaluates whether some of the most common variations in investigator use of the POP-Q examination results in any important differences in the measured POP-Q points. The authors demonstrate that use of a speculum rather than fingers for retraction when measuring POP-Q points does not result in any frequent or any important changes in those measurements when small numbers of patients from multiple examiners are combined for analysis. They also confirm that the standing examination is probably preferable when trying to evaluate the maximum extent of prolapse.