Anterior Iliac Research Articles

Posterior Wall Fragments in Acetabular Both-Column Fractures: Morphology, Type, and the Significance of its Projection.

Most both-column acetabular fractures are combined with posterior wall fragments. However, the morphology of this posterior wall is varied, and how to fix this posterior wall remains a controversial topic. To investigate the morphological characteristics of posterior wall fragments of both-column acetabular fractures and select corresponding fixation methods. Data from 352 patients with acetabular fractures admitted to the level one trauma centre in our hospital between January 2006 and December 2022 were collected. The morphology of posterior wall fragments was observed and analyzed in 83 cases of both-column acetabular fractures and classified according to the consistency of posterior wall morphology. A fracture map of the posterior wall was created on a normal template according to the three morphological types of posterior wall fragments. Finally, the high-incidence area of the posterior wall fracture was projected onto the iliac fossa and the medial side of the posterior column to guide the fixation of the posterior wall fragment using the anterior intrapelvic approach. Fractures were divided into four types: I, large posterior wall fragment which was high in the ilium bone (34 cases, 41.0%); II, posterior wall fragment in the acetabular parietal region (18 cases, 21.7%); III, posterior wall marginal fracture (10 cases, 12.0%); and IV, non-combined posterior wall fracture (21 cases, 25.3%). The most common morphologies of the posterior wall fragments of the first two types were mapped and projected onto the anterior iliac inner plate and medial side of the posterior column, where the corresponding area could be used to guide the insertion of the internal fixation. Both-column acetabular fractures combined with posterior wall fractures can be divided into four types according to the morphology of the posterior wall fragment. Understanding the corresponding three-dimensional morphology and projection position of different types of these fragments can help surgeons determine the position and orientation of internal fixation of posterior wall fractures.

Identification of safe channels for screws in the anterior pelvic ring fixation system

BackgroundMinimally invasive surgery for pelvic fracture using anterior ring internal fixator system is increasing gradually, and the way to insert the fixation screws in the fixation system is the key technical points of the method. However, there have been few studies on insertion of fixation screws for the anterior pelvic ring internal fixator system.ObjectiveTo identify safe channels for fixation screws in the anterior pelvic fixator system and provide the anatomical basis for insertion of fixation screws in clinical operation.MethodsScrew insertion was simulated into a total of 40 pelvic finite element models as well as 16 fresh pelvic specimens, and the channel parameters were measured.ResultsFinite elements (male, female) include: screws in ilium: length 114.4 ± 4.1 and 107.6 ± 8.3 mm, respectively; diameter 11.7 ± 0.5 and 10.0 ± 0.6 mm, distance between screw and anterior inferior iliac spine: 5.5 ± 1.0 and 5.6 ± 1.0 mm, angle of coronal plane 55.8° ± 2.4° and 50.6° ± 3.1°, angle of sagittal plane 26.6° ± 1.0° and 24.5° ± 1.9° and angle of horizontal plane 64.9 ± 3.7 and 58.1 ± 3.1; screws in pubis: length 47.0 ± 2.0 and 39.8 ± 3.9 mm, diameter 7.1 ± 0.4 and 6.1 ± 0.4 mm. Specimens (male, female) include: distance between screw and anterior inferior iliac spine: 5.5 ± 0.5 and 5.6 ± 0.7 mm, angle of coronal plane 55.9° ± 1.3° and 50.7° ± 1.5°, angle of sagittal plane 26.7° ± 0.5° and 24.1° ± 0.9° and angle of horizontal plane 64.8° ± 0.6° and 58.8° ± 0.8°. In the comparison between female and male in each group, differences in distances between screws and anterior inferior iliac spine and median line of symphysis pubis (P > 0.05) were not statistically significant; differences in the remaining parameters were statistically significant (P < 0.05).ConclusionsIf surgeons paid attention to sex differences, select screws of appropriate diameter and length and hold the insertion position and direction, screws in the anterior pelvic ring fixation system could be safely inserted.

Characteristics of the patellofemoral joint of patients with DDH and the effects of Bernese periacetabular osteotomy on the patellofemoral joint

BackgroundSome patients with developmental dysplasia of the hip (DDH) complained of anterior knee pain (AKP) before and after Bernese periacetabular osteotomy (PAO) surgery. The purpose of this study was to (1) identify the characteristics of patellofemoral joint (PFJ) deformities in patients with DDH and (2) to determine the effects of PAO on the PFJ.MethodsSeventy patients (86 hips) were included in the DDH group. Thirty-three patients (33 knees) without AKP and hip pain were included in the control group. All patients underwent simultaneous CT scans of the hip and knee joints before PAO and after hardware removal surgery. The distance from the anterior inferior iliac spine to the ilioischial line (DAI), was measured in DDH patients. Imaging parameters of knees, including the sulcus angle (SA), femoral trochlear depth (FTD), patellar width (PW), tibial tuberosity-trochlear groove (TT-TG), patellar tilt angle (PTA) and lateral shift of the patella (LSP) were measured in patients in both the DDH and control group. TT-TG, PTA, and LSP of DDH patients were measured before PAO and after hardware removal. The DAI, PTA, LSP and TT-TG of all DDH patients before and after Bernese PAO were compared using paired t-tests. The FTD, PW, and SA of the DDH patients and the control group were analyzed using independent t-tests. PTA, TT-TG, and LSP between the control group and preoperative DDH patients, between the control group and post PAO patients were compared using independent t-tests.ResultsThe DAI changed from 4.04 ± 0.61 mm before PAO surgery to 5.44 ± 0.63 mm after PAO surgery. The SA of the DDH group (140.69 ± 11.30 degree) was greater than that of the control group (130.82 ± 6.43 degree). The FTD and the PW of the DDH group (5.45 ± 1.59 mm, 4.16 ± 0.36 mm) were smaller than that of the control group (7.39 ± 1.20 mm, 4.24 ± 0.38 mm). The changes in LSP, PTA, and TT-TG before and after surgery were not statistically significant. Both before and after PAO, there was no statistically significant difference in the parameters of LSP, PTA, and TT-TG compared with the control group.ConclusionThe knee joints of DDH patients presented a certain degree of femur trochlear groove dysplasia and patellofemoral instability. PAO surgery did not change PFJ stability, although the origination point of the rectus femoris muscle moved laterally during PAO surgery.

An exploratory study of pelvis anatomy to revise the bony canal used for LC2 screw insertion

BackgroundPercutaneous screw placement, especially the insertion of LC2 screws, is technically demanding. Although the traditional LC2 bony canal spans the anterior inferior iliac spine (AIIS) to the posterior superior iliac spines (PSIS), a high perforation rate has been reported.ObjectionThe aim of this research was to design a revised bony canal, measure the canal width and length and guide the insertion of LC2 screws for pelvic fractures.Materials and methodsThe plane tool in the Mimics analysis menu was used to draw a midplane connecting the midpoint between the anterior inferior spine and the PSIS upper flat region with pelvic CT data. The minimum widths of the upper, middle, lower surfaces of the tunnel and perforation rate were measured and compared. The ideal screw length was also measured along the longitudinal axis running through the midpoint of the midplane.ResultsThe minimum widths of the upper, middle and lower surfaces of the revised canal were 3.63 mm, 7.7 mm, and 11.93 mm, respectively, in males and 5.97 mm, 9.93 mm, and 12.45 mm, respectively, in females. Significant differences were observed among the upper, middle and lower surfaces of the revised canal in male patients (P < 0.001). In female subjects, the upper canal surface was significantly different from the middle and lower canal surfaces (P < 0.001). The perforation rate was significantly decreased especially in females pelvic. The channel length passing through the midpoint of the narrowest position of the pelvis was 130.85 ± 8.02 mm in males and 124.30 ± 7.71 mm in females and was significantly different for male and female pelvises (P = 0.004).ConclusionThe LC2 screw should be inserted along the intersection line of the AIIS lateral wall and the iliac body. The screw should be inserted under the line between the midpoint of the AIIS and the PSIS upper flat region to ensure accuracy of placement. LC2 screws can be more easily inserted in males than in females, and the rate of cortical perforation can be significantly decreased under the guidance of the newly proposed canal.

Spatial distribution of loose connective tissues on the anterior hip joint capsule: a combination of cadaveric and in-vivo study

Recently, pathological changes in the fat pad on the anterior inferior iliac spine (AIIS), between the proximal rectus femoris and joint capsule, have been highlighted as a cause of anterior hip pain. However, precise fat pad features, such as the spatial distribution distal to the AIIS, histological features, and in vivo tissue elasticity, remain unclear. This study aimed to investigate the morphological characteristics of the fat pad on the AIIS. Four hips from four cadaveric donors were both macroscopically and histologically investigated, and eight hips from four volunteers were assessed using ultrasonography. The fat pad on the AIIS was also surrounded by the iliopsoas and gluteus minimus, extending distally to the superficial portion of the vastus lateralis, and the anterior portion of the gluteus maximus tendon. Histological analysis revealed that the fat pad was composed of loose connective tissue. Based on the ultrasonography, the shear wave velocity in the fat pad was significantly lower than that in the joint capsule. Conclusively, the pathological adhesion between the joint capsule and pericapsular muscles, if caused by fat pad fibrosis, may occur following the abovementioned fat pad spatial distribution.

Use of 3D Printed Models to Determine Accurate Bone Cuts during a Periacetabular Osteotomy for Developmental Hip Dysplasia

AbstractThe periacetabular osteotomy (PAO) is a powerful tool to delay the progression of hip arthritis by reorienting the acetabulum. This study aimed to use three-dimensional (3D)-printed models of the pelvis, reconstructed from the computed tomography (CT) scans of patients, to model how the level of dysplasia and its location ilium osteotomy affect radiographic outcomes following PAO. This pilot study aims to determine if preoperative 3D printing/planning can assist in predicting radiographic outcomes. We performed a retrospective review of five patients with differing levels of hip dysplasia for whom we had obtained CT scans before PAO surgery. For each patient, we printed two pelvis models that would undergo standardized cuts of the PAO procedure, with variations only in the distance of the ilium start point (one-third of the distance between the anterior superior iliac spine and anterior inferior iliac spine [AIIS] vs. two-thirds of the distance). We then mobilized the acetabular fragment into eight reproducible positions in space by moving the ilium cut a combination of 0, 1, or 2 cm anterior/lateral. Each position of the newly realigned acetabula was examined under fluoroscopy to obtain a standardized anteroposterior view, and to obtain standardized radiographic measurements in the form of lateral center edge angle (CEA), acetabular depth, Tonnis angle, and acetabular inclination. We performed 80 simulations of the PAO with varying degrees of acetabular mobilization. On average, in the models where the supra-acetabular cut was closer to the AIIS, we found more significant degrees of radiographic correction, regarding Tonnis angles (12.91 vs. 7.95, p = 0.0175), acetabular inclination (20.25 vs. 9.875, p = 0.027), and lateral CEA (11.75 vs. 2.5, p = 0.061). Patients who had greater dysplasia also had more significant degrees of radiographic Tonnis angle correction with the same mobilization movements of the acetabula (p = 0.005). When utilizing 3D printing to model PAO in dysplasia pelvises, we found that both a higher level of preoperative dysplasia and starting the supra-acetabular osteotomy closer to the AIIS were associated with more powerful corrections following smaller manipulations.

Arteriovenous Malformations of the Uterus: A Case Report and Review and Update of the Literature

Arteriovenous malformation of the uterus (AVMU) is a terminology that is used for an abnormal and non-functional connections between the uterine arteries and uterine veins. Even though patients who have AVMU typically tend to manifest with vaginal bleeding, some patients tend to experience life-threatening massive bleeding in some circumstances. Cases of AVMU had previously been safely and effectively treated by means of hysterectomy which meant that the patients would no longer have the ability to conceive and have their own babies in the future. Less than 100 cases of AVMU have been reported in the literature. Recently a minimal invasive procedure of Uterine Artery Embolization has been utilized to safely and effectively treat some patients who had AVMU that was associated with severe bleeding that led to cessation of their bleeding and associated symptoms as well as which enabled the patients to maintain their fertility. We report the case of a 27-year-old woman. Gravida 1. Para 0, who was known to have irregular menstrual periods pursuant to her per vaginal passage of conception products. She was diagnosed as having AVMU based upon various radiology imaging options including: ultrasound scan of the pelvis; magnetic resonance imaging of the pelvis, and percutaneous left anterior internal iliac angiography. The AVMU was safely and effectively treated by means of percutaneous interventional radiology embolization of the AVMU and the final angiogram demonstrated satisfactory embolization which led to cessation of her vaginal bleeding and subsequently her retained products of conception were evacuated completely. As a result of the successful embolization of her AVMU, hysterectomy which was the alternative treatment option that was discussed, her uterus has remained intact which has given her the chance to be pregnant again in the future which would enable her have her own child. Considering that less than 100 cases of AVMUs have been reported in the literature, there is the chance that some clinicians may not be familiar with the manifestation, diagnosis, and management of AVMUs, in view of this we have also included miscellaneous narrations and discussions related to some case reports, case series, and studies related to AVMUs. Considering that there are few well-trained interventional radiologists globally as well as few interventional radiology units globally with fewer unts in the developing countries, we would recommend that more interventional radiologists should be trained globally and more interventional radiology units should be established globally especially in the developing countries.

The distance between the femoral nerve and anterior acetabulum is significantly shorter in hip osteoarthritis than in non-osteoarthritis hip

BackgroundThe appropriate position of retractors to minimize the risk of femoral nerve palsy remains uncertain. The purpose of this imaging study was to evaluate the distance between the femoral nerve (FN) and anterior acetabulum (AA) in hip osteoarthritis (OA).MethodsForty-one patients with unilateral hip OA underwent magnetic resonance imaging. Three measurement levels were defined and the minimum distance between the femoral nerve (FN) margin and anterior acetabulum (AA) rim was measured on axial T1-weighted images on the OA and normal sides at each level, with reference to an advanced neurography view. The cross-sectional area (CSA) of the iliopsoas muscle was also measured at each level bilaterally by three observers. Distances and CSAs were compared between the OA and normal side. Multiple regression analysis was performed to identify variables associated with the distance in OA.ResultsThe mean minimum FN to AA distances in OA were 19.4 mm at the top of the anterior inferior iliac spine (AIIS), 24.3 mm at the bottom of the AIIS, and 21.0 mm at the tip of the greater trochanter. These distances were significantly shorter than in normal hips at the top and bottom of the AIIS, with mean differences of 1.6 and 5.8 mm, respectively (p = 0.012, p < 0.001). CSAs of the iliopsoas in OA were significantly smaller at all levels (all p < 0.001), with reductions of 10.5 to 17.9%. The CSA of the iliopsoas at the bottom of the AIIS was associated with the FN to AA distance at the same level (p = 0.026). Interobserver reliabilities for measurements were very good to perfect (intraclass correlation coefficients 0.897 to 0.966).ConclusionsTo minimize the risk of femoral nerve palsy, surgeons should consider the change of the femoral nerve to anterior acetabulum distance in osteoarthritic hip surgery.

Navigated iliac screw placement may reduce radiation and OR time in lumbopelvic fixation of unstable complex sacral fractures

PurposeInstability of the posterior pelvic ring may be stabilized by lumbopelvic fixation. The optimal osseous corridor for iliac screw placement from the posterior superior iliac spine to the anterior inferior iliac spine requires multiple ap- and lateral-views with additional obturator-outlet and -inlet views.The purpose of this study was to determine if navigated iliac screw placement for lumbopelvic fixation influences surgical time, fluoroscopy time, radiation exposure, and complication rates.MethodsBilateral lumbopelvic fixation was performed in 63 patients. Implants were inserted as previously described by Schildhauer. A passive optoelectronic navigation system with surface matching on L4 was utilized for navigated iliac screw placement. To compare groups, demographics were assessed. Operative time, fluoroscopic time, and radiation were delineated.ResultsConventional fluoroscopic imaging for lumbopelvic fixation was performed in 32 patients and 31 patients underwent the procedure with navigated iliac screw placement. No differences were found between the groups regarding demographics, comorbidities, or additional surgical procedures.Utilization of navigation led to fluoroscopy time reduction of more than 50% (3.2 vs. 8.6 min.; p < 0.001) resulting in reduced radiation (2004.5 vs. 5130.8 Gy*cm2; p < 0.001). Operative time was reduced in the navigation group (176.7 vs. 227.4 min; p = 0.002) despite the necessity of additional surface referencing.ConclusionFor iliac screws, identifying the correct entry point and angle of implantation requires detailed anatomic knowledge and multiple radiographic views. In our study, additional navigation reduced operative time and fluoroscopy time resulting in a significant reduction of radiation exposure for patients and OR personnel.

Anatomical variation of the Psoas Valley: a scoping review

BackgroundThis scoping review aimed to investigate the literature on the anatomy of the psoas valley, an anterior depression on the acetabular rim, and propose a unified definition of the anatomical structure, describe its dimensions, anatomical variations and clinical implications.MethodsA systematic computer search of EMBASE, PubMed and Cochrane for literature related to the psoas valley was undertaken using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Clinical outcome studies, prospective/retrospective case series, case reports and review articles that described the psoas valley and its synonyms were included. Studies on animals as well as book chapters were excluded.ResultsOf the 313 articles, the filtered literature search identified 14 papers describing the psoas valley and its synonyms such as iliopsoas notch, a notch between anterior inferior iliac spine and the iliopubic eminence, Psoas-U and anterior wall depression. Most of these were cross-sectional studies that mainly analyzed normal skeletal hips. In terms of anatomical variation, 4 different configurations of the anterior acetabular rim have been identified and it was found that the curved type was the most frequent while the straight type may be nonexistent. Additionally, the psoas valley tended to be deeper in males as compared with females. Several papers established the psoas valley, or Psoas-U in a consistent location at approximately 3 o’clock on the acetabular rim which may have implications with labral pathology.ConclusionThis review highlights the importance of the anatomy of the psoas valley which is a consistent bony landmark. The anatomy and the anatomical variations of the psoas valley need to be well-appreciated by surgeons involved in the management of young adults with hip pathology and also joint replacement surgeons to ensure appropriate seating of the acetabular component.

Comparison of thoracic paravertebral nerve block and transverse abdominal plane block for multiple costal margins in anal-gesia after open liver surgery

Objective To evaluate the analgesic application of thoracic paravertebral blockade (TPVB) and transverse abdom-inal plane block (TAPB) for multiple costal margins after open liver surgery. Methods A total of sixty patients [American Society Anesthesiologists (ASA) Ⅰ-Ⅲ ]who were scheduled for open liver surgery (with a classical reverse L-shaped incision) were enrolled. The patients were divided into two groups according to the random number table method (n=30): a TPAB group (group TP) and a group of TAPB for multiple costal margins (group TA). Both groups received ultrasound guided nerve block before surgery. Group TP under-went bilateral TPVB at T7-T8 and T8-T9, while group TA underwent TAPB under bilateral costal margins and the classical site between the costal margin and the anterior inferior iliac spine, with a total of four block points. Then, both groups were compared and recorded for the duration of block procedures; the mean arterial pressure (MAP) and heart rate before incision (T0), after incision (T1), and at the times of block of the superior vena cava (T2), liver removal (T3) and stitching (T4); surgical duration, the inflow of liquid during surgery, the consumption of remifentanil, and the length of post-anesthesia care unit (PACU) stay after surgery; the Visual Analogue Scale (VAS) scores at resting and during movement immediately after surgery (when patients were awaken after extubation and able to communicate normally), and 2 h and 6 h after surgery; and the number of patients requiring opioids within 6 h after surgery and the time when opioids were first given after surgery. Results Group TA presented shorter duration of block procedures than group TP (P 0.05). Conclusions During open liver surgery, compared with TAPB for multiple costal margins, TPVB can maintain more stable hemody-namics, require less doses of opioids and improve perioperative analgesia. Key words: Open liver surgery; Thoracic paravertebral nerve block; Transverse abdominal plane block; Postoperative analgesia

Imaging study of second sacral alar-iliac screw placement in adult degenerative scoliosis

Objective To discuss the imagingcharacteristics of S2AI screw trajectory in ADS patients. Methods Forty patients with degenerative scoliosis were scanned with Simens Sliding 40-slice spiral CT scanner. Three-dimensional scanning and reconstruction were performed in these patients with the scanning range including thoracolumbar spine, lumbar spine, lumbosacral region, pelvis and bilateral hip joints. The base of the lateral sacral crest on the midline between the lower edge of S1 dorsal foramina and the upper edge of S2 dorsal foramina was the starting point. The placement plane of S2AI screw trajectory was determined from the starting point to the lower margin of anterior inferior iliac spine. A 10mm diameter screw was the design template. A circle with a diameter of 5 mm as the center of the lowest point of the ilium inner cortex was made, and a tangent line from the starting point to the outer diameter of the circle (the inner part of the ilium) was selected as the axis of the screw trajectory. The lateral angle and the length of the axis of the screw trajectory and iliac width were measured in transverse plane. The caudal angle, the distance from the axis of the screw trajectory to iliosciatic notch, and the caudal angle, the distance from the axis of the screw trajectory to the upper edge of the acetabulum were measured in sagittal plane. These parameters were recorded and analyzed. Results The trajectory length of S2AI screw in ADS patients was 12.00±0.99 cm, the lateral angle was 41.24°±3.92°, the caudal angle was 27.73°±6.45°, and the distance from the axis of the screw trajectory to iliosciatic notch was 1.05±0.81 cm, the distance from the axis of the screw trajectory to the upper edge of the acetabulum was 1.85 ± 0.33 cm, and the iliac width was 2.12±1.65 cm. The trajectory length, lateral angle, caudal angle, distance from the axis of the screw trajectory to iliosciatic notch, distance from the axis of the screw trajectory to the upper edge of the acetabulum and iliac width of S2AI screw was respectively 12.40±0.83 cm, 39.47°±1.76°, 28.00°±6.39°, 1.08±0.32 cm, 1.76±0.34 cm, 2.26±0.25 cm in male patients, and was respectively 11.75±1.01 cm, 42.30°±4.48°, 27.56°±6.61°, 1.21±1.00 cm, 1.90±0.32 cm, 2.04±0.18 cm in female patients. The screw length and lateral angle had statistically difference between male and female patients(P<0.05). Compared with non-ADS patients in previous studies, female patients with ADS had significant differences in increased lateral angle and decreased caudal angle of S2AI screw. Conclusion There is ideal trajectory of S2AI screws in ADS patients. There was no significant difference of the length of S2AI screws between ADS patients and non-ADS population. Different direction was noticed in the placement of S2AI screws, especially in female patients. Increased lateral angle and decreased caudal angle would be obtained in the procedure of placing S2AI screws in female ADS patients during operation. Key words: Adult; Lumbar vertebrae; Intervertebral disc degeneration; Scoliosis; Spinal fusion; Pelvis; Tomography scanners, X-ray computed

Imaging finding and arthroscopic treatment of isolated contracture of the rectus femoris muscle: a case report

BackgroundIsolated rectus femoris (RF) contracture is encountered very rarely in orthopaedic practices. There are few reports on its imaging manifestations and no cases reported to be treated with arthroscopy.Case presentationA 11-year-old girl with a more than 7 years history of restricted left knee flexion was presented. The clinical assessment and magnetic resonance imaging (MRI) findings were detailed here. A strip-like induration was palpated in the left thigh, which tends to be more obvious with knee flexion. MRI demonstrated a hypointensity band connected the anterior inferior iliac spine with the patella, and marked atrophy of the left RF muscle. Fibrosis contracture band was confirmed with arthroscope, then divided by radiofrequency ablation (RFA) under arthroscopic observation. Followed by debridement of the fibrillar connective tissue and hemostasis around the broken ends. The movement of left knee joint significantly improved after the operation, and the patient recovered nearly full range of motion of this joint after 6 months.ConclusionThe specific MRI findings could assist in confirming clinical early diagnosis of isolated RF contracture. Arthroscopic RFA treatment is an effective technique to treat this disorder with minimally incision.

Predictive value of dynamic F-wave In surgical treatment of Hirayama disease

Objective To investigate the predictive value of dynamic F wave in the treatment of Hirayama disease (HD) after anterior cervical fusion and internal fixation. Methods From February 2014 to January 2016, thirty-six patients with HD were included in this study (age: 17.9±2.6 years, height: 173.1±6.2 cm, disease duration: 20.1±13.1 months; male to female ratio: 35∶1), and all of these 36 patients underwent anterior cervical autogenous iliac fusion and internal fixation. All of these patients underwent bilateral dynamic F-wave detection (The F-wave was tested on the cervical standard position and at least 30 minutes after cervical flexion) on the median nerve before operation and 3-5 days after operation. The latency and maximum amplitude of M-wave, the persistence of F-wave, the shortest latency of F-wave, the ratio of F/M and the persistence of repeated F-wave were measured. Dynamic F-wave abnormalities were defined when repeated F-wave was only found during neck flexion or the standard-flexion difference of each measurements of F-wave was more than 2 standard deviations from the normal value (the shortest latency of F-wave: 0.6±0.5 ms, persistence of F-wave: 7.3%±5.7%, the ratio of F/M: 1.1±1.0). Furthermore, these patients with HD accepted both bilateral grip strength and hand function score (disabilities of arm, shoulder and hand, DASH) before and 1 year after operation. According to the presence of abnormal dynamic F-wave before operation, patients were divided into abnormal dynamic F-wave group and normal dynamic F-wave group. Fisher exact test was used to compare the percentage of the patient with improved DASH score in both patient groups after operation. Both DASH score and bilateral grip strength were analyzed by paired sample t test before and after operation. Results Before operation, eleven (11/36, 30.6%) patients with HD had abnormal dynamic F-wave, and there was no significant difference of age (t=-0.849, P=0.412), duration (t=1.110, P=0.282), DASH scores (t=2.002, P=0.055) and handgrips (more-symptomatic side: t=-0.673, P=0.507; symptomatic side: t=-1.729, P=0.094) between the patients with or without preoperative dynamic F-wave abnormalities. One-year follow-up demonstrated that significantly greater number of the patients presented with reduced DASH scores in the patients with preoperative dynamic F-wave abnormalities (10/11, 90.9% vs 12/25, 48.0%; P=0.025). Compared with the patients without preoperative dynamic F-wave abnormalities, the patients with preoperative dynamic F-wave abnormalities showed reduced DASH scores after operation (t=2.347, P=0.041). Furthermore, abnormal dynamic F-waves disappeared soon after operation in ten patients (90.9%, 10/11) with preoperative dynamic F-wave abnormalities, and DASH scores reduced significantly in these ten patients after operation (4.4±3.8 vs 1.5±0.4, t=3.094, P=0.013), and the DASH score in another patient whose dynamic F wave did not disappear after operation increased significantly one year after operation (preoperative vs. postoperative: 6.66 vs 9.87). Conclusion Dynamic F-wave can be used as a preoperative evaluation method for HD to predict the recovery of upper limb function after operation. At the same time, the comparison of dynamic F-wave before and after operation is an effective and immediate method to evaluate the effectiveness of surgical treatment of HD. Key words: Cervical vertebrae; Spinal cord compression; Upper extremity; Muscular atrophy; Spinal fusion; Electromyography

Clinical analysis of invasive natural killer cell leukemia with focal bone marrow lesions and hemophagocytic syndrome

Objective To investigate clinical characteristic and prognosis of aggressive natural killer cell leukemia (ANKL) with focal bone marrow lesions and hemophagocytic syndrome. Methods On 29 August 2016, a case of ANKL with focal bone marrow lesions and hemophagocytic syndrome who were admitted to Department of Hematology, Huai′an First People′s Hospital was included in this study. The patient was diagnosed based on clinical features and related examinations. The patient refused to receive chemotherapy. Dexamethasone 10 mg/d×12 d was given intravenously to control hemophagolysis; sodium foscarinate sodium chloride 2.4 g/time×2 times/d×4 d was given intravenously for antiviral treatment; cefoperazone sodium sulbactam sodium 1.5 g/time×3 times/d×3 d was given intravenously. The anti-infective effect was not good, and the replacement drug was teicoplanin 400 mg/time×2 times/d on the first day, and then 400 mg/d×7 d from the second day; imipenem sodium butyrate 1 g/time×3 times/d×3 d was given intravenously. At the same time, 5 U of the infusion red blood cell preparation, 2 U of the platelet preparation, and 325 mL of fresh plasma were administered. The laboratory test results, diagnosis, therapeutic effect and other clinical data of ANKL patients with focal bone marrow lesions and hemophagocytic syndrome were analyzed retrospectively, and the research progress on diagnosis and treatment of ANKL was discussed in combination with relevant literature. Results ① After admitted, patients′ abnormal index of blood routine examination showed that white blood cell count was 2.28×109/L, neutrophil count was 1.32×109/L, red blood cell count was 2.75×109/L, hemoglobin (Hb) level was 68 g/L, platelet count was 89×109/L, monocyte count was 0.42×109/L, and lymphocyte count was 0.52×109/L. Abnormal index of coagulation function test showed that international normalized ratio (INR) was 1.18, prothrombin activity (PTA) was 77%, activated partial prothrombin time (APTT) was 46.2 s, and other indicators were within the normal reference range. EB virus (EBV) quantitative test results were 8.74×103 copies/mL (normal reference value range <3.00×103 copies/mL). Cytomegalovirus (CMV) detection result was negative. Results of liver function tests showed that level of lactate dehydrogenase (LDH) was 293 U/L, and other indicators were within the normal reference range. Abdominal CT results showed splenomegaly. Ultrasound examination showed that the liver and spleen were large. The smear of the patient′s bone marrow (right anterior iliac) on 30 August 2016 showed a ratio of 4% of ANKL cells. Bone marrow cell immunophenotyping results showed 2 subpopulations, P1 with a ratio of 8.4% and P2 with a ratio of 3.8%. P1 antigen included myeloperoxidase (MPO) (0.1%), cCD3 (81.7%), CD2 (79.6%), CD5 (80.3%), CD7 (70.2%), CD56 (5.9%); P2 antigens included MPO (0.1%), CD2 (98.2%), CD7 (97.8%), CD56 (92.0%), human leukocyte antigen (HLA)-DR (98.4%). Thirty-three common leukemia fusion genes and 4 myeloid gene mutations were negative. TCR/IGH gene rearrangement was also negative. On 1 September 2016, the smear of the bone marrow (left posterior sputum) showed a ratio of ANKL cells (tissue cell-like) of 1.5%. No obvious abnormalities caught in bone biopsy results. On 5 September 2016, the results of smear examination of bone marrow (left anterior) showed that the proportion of ANKL cells was 70.5%, and result of peroxidase (POX) staining was negative with hematopoietic cells. Results of immunophenotypic analysis showed that proportion of 1 subpopulation cells was 50.1%, and the antigens included MPO (0.1%), CD2 (92.6%), CD7 (92.2%), CD56 (82.2%), HLA-DR (85.9%), CD38(85.1%). Karyotype analysis results show that 46XX, add(4)(q35), add(13)(q34)[1]/46, XX[19]. In addition, the patient repeatedly suffered from high fever with a heat peak of 39 ℃ for more than one week. ② The patient was diagnosed as ANKL with focal bone marrow lesions accompanied by hemophagocytic syndrome. ③After treatment, on 8 September 2016, Hb level, platelet count, and red blood cell count of the patient decreased progressively; on 12 September 2016, white blood cell count, bilirubin level, aminotransferase level, and LDH level increased progressively. On 15 September 2016, re-examination of fibrinogen level was 1.61 g/L, and this suggested abnormal coagulation function; on 13 September 2016, EBV quantitative test results were 8.74×103 copies/mL; multiple lymph nodes were enlarged; liver and spleen progressively enlarged. On 16 September 2016, the patient developed respiratory failure, and pulse oxygen decreased with cardiac dysfunction. The patient′s family gave up further treatment, and the patient died. Conclusion ANKL with focal bone marrow lesions and hemophagocytic syndrome has an invasive clinical course, and disease deteriorates in a short period of time with poor prognosis. Key words: Leukemia, large granular lymphocytic; Epstein-Barr virus infections; Diagnosis; Prognosis; Bone marrow with focal type

Extra-articular Hip Impingement: Anterior Inferior Iliac Spine/Subspine Impingement, Ischiofemoral, and Anterior and Lateral Greater Trochanteric-Pelvic Impingement

AbstractAlthough femoroacetabular impingement (FAI) is traditionally considered an intra-articular phenomenon, the result of abutment between the femoral head and/or neck and the acetabular rim, there are unique and relatively uncommon patterns of pathologic extra-articular hip impingement that can mimic the clinical presentation and clinical findings of traditional FAI. Anterior inferior iliac spine (AIIS) or “subspine” impingement may occur as a consequence of an abnormally anterior or distal prominence of the AIIS that may be developmental, posttraumatic, or the result of high range of motion (ROM) activities. This type of impingement can crush the capsule, labrum, and rectus femoris between the AIIS and distal femoral neck in straight hip flexion. Greater trochanteric/pelvic impingement is quite complex and can be further divided into three unique anatomic patterns. Anterior greater trochanteric–pelvic impingement is the result of impingement between the anterior hip soft tissue structures or the anterior facet/greater trochanter and anterolateral rim/lateral AIIS and pelvis when the hip is flexed, internally rotated, and abducted. This can occur in association with a prominent greater trochanter, short femoral neck, relative femoral retrotorsion, and high ROM activities. Lateral greater trochanteric–pelvic impingement is the result of impingement between an abnormally prominent or a high riding greater trochanter with a short femoral neck and the lateral pelvis when the hip is abducted. This type of impingement is characteristic of a Perthes-like hip and, in extreme cases, can be associated with severe leg length discrepancy (and abductor muscle dysfunction). Posterior greater trochanteric–pelvic/ischiofemoral impingement is the result of impingement of the quadratus femoris and/or proximal hamstring tendons between the lesser trochanter or posterior proximal femur and intertrochanteric line and the ischial tuberosity when the hip is extended and external rotated (ER). This can occur in association with deformities of the ischial tuberosity caused by prior avulsion fractures, lesser trochanteric overgrowth, extreme coxa valga, femoral antetorsion, complex proximal femoral developmental deformities, and activities requiring high degrees of extension and external rotation. A thorough understanding of these unique patterns of impingement, their clinical presentations, and complex treatment options can help in optimizing outcomes and minimizing complications in this very challenging patient population.

Biomechanical analysis of iliac crest loading following cortico-cancellous bone harvesting

BackgroundIliac crest bone harvesting is a frequently performed surgical procedure widely used to treat bone defects. The objective of this study is to assess the biomechanical quantities related to risk for pelvic fracture after harvesting an autologous bone graft at the anterior iliac crest.MethodsFinite element models with a simulated harvest site (sized 15 × 20 mm, 15 × 35 mm, 30 × 20 mm and 30 × 35 mm) in the iliac wing are created. The relevant loading case is when the ipsilateral leg is lifted off the ground. Musculoskeletal analysis is utilized to compute the muscle and joint forces involved in this motion. These forces are used as boundary conditions for the finite element analyses. Bone tissue stress is analyzed.ResultsCritical stress peaks are located between the anterior superior iliac spine (ASIS) and the anterior edge of the harvest site. Irrespective of the graft size, the iliac wing does not show any significant stress peaks with the harvest site being 20 to 25 mm posterior to the ASIS. The harvest area itself inhibits the distribution of the forces applied on the ASIS to extend to the posterior iliac wing. This leads to a lack of stress posterior to the harvest site. A balanced stress distribution with no stress peaks appears when the bone graft is taken below the iliac crest.ConclusionA harvest site located at least 20 to 25 mm posterior to the ASIS should be preferred to minimize the risk of iliac fatigue fracture.

Optimization of technique for insertion of implants at the supra-acetabular corridor in pelvis and acetabular surgery

The technique for application of implants at the sciatic buttress has been well described in the pelvic and acetabular fracture reconstruction literature. We described a new use of the inlet–obturator oblique view for the identification of the anterior inferior iliac spine, which is the entry point of implants, and we provide a detailed fluoroscopic and radiographic description of this view. A small series of 15 patients who underwent an application of an anterior inferior pelvic external (supra-acetabular) fixator via this technique is presented. We consider the use of the obturator oblique for the identification of the entry point unnecessary, and we advocate for the use of only the inlet–obturator oblique and iliac oblique views when implants are applied to the sciatic buttress.

Extrarticular HIP Impingement

Extrarticular causes of impingement have a current, interesting role in the complaint of groin pain in athletes. Subspine impingement is related to a prominent anterior inferior iliac spine (AIIS) and is actually described as a frequent cause of groin pain. Ischiofemoral impingement is described when the space between the lesser trochanter is decreased. Psoas impingement appears between the psoas tendon and the anterior labrum and anterior acetabular rim.

Aspects of expert opinions of avulsion fractures

The apophyses as secondary ossification centers are connected with the bone by cartilage. During the growth phase of puberty, the apophyseal plate is a mechanical weak spot. Especially, apophyses in the hip and pelvic area are exposed to considerable tensile and sheer stresses due to the strong muscles which are inserted here. The frequency of injuries to the apophyses correlates with the extent of sporting activities. For athletes participating in "Youth Train for the Olympics", this is the most common injury of all. Most often, the apophysis of the rectus femoris muscle is affected at the anterior inferior iliac spine. In adults, after complete ossification of the apophyseal plate such injuries are rare. However, in a very unusual mechanism of injury with maximum forced hip flexion and simultaneous maximum knee extension, avulsions of the ischial tuberosity are observed in adults. During the causality test-especially in the legal area of statutory accident insurance-the question is always whether the alleged course of events has to be regarded as a legally significant (partial) cause or if a longer period of time has been involved, so that the resulting morbid apophysis detachment was predominately due to fate, in which the alleged event must be interpreted as legally immaterial.