Posterior Pelvis Research Articles

Ultrasound antenatal detection of urinary tract anomalies in the last decade: outcome and prognosis

Objective: This study has been undertaken to determine the frequency and pattern of urinary tract anomalies diagnosed by ultrasound, to correlate the prenatal with postnatal diagnoses and to identify prognostic factors.Methods: The Ultrasound Unit's database was reviewed for fetal urinary tract anomalies detected between January 2002 and June 2012. Prenatal diagnoses made by ultrasound were confirmed by postnatal ultrasound, as well as with surgical reports. Statistical analysis was performed using the Mann–Whitney U-test, Chi-square and Fisher’s exact tests. p values <0.05 were considered significant.Results: A total of 838 fetal malformations were prenatally diagnosed by ultrasound with a frequency of 21% of urinary tract anomalies (177/838). Renal pelvis dilatation and hydronephrosis accounted for more than half of the cases (52%). The most frequent postnatal diagnoses were also urinary tract dilatations. The prenatal diagnoses corresponded to the postnatal ones in 88.8% of cases. There was a highly significant association between anterior–posterior renal pelvis diameter above 10 mm in the last ultrasound performed before the birth and the need for surgery (p < 0.01).Conclusion: We emphasize the high degree of reliability of prenatal ultrasound in the establishment of diagnosis of urinary tract malformations and the prediction of postnatal outcomes.

Displaced inferior ramus fractures as a marker of posterior pelvic injury.

Injuries to the anterior or posterior pelvic ring rarely occur in isolation. Disruption to the anterior pelvic ring, indicated by a fracture of the superior or inferior pubic ramus, or injury to the pubic symphysis, may be indicative of additional pelvic ring disruption. The purpose of this retrospective study was to determine whether displaced inferior pubic ramus fractures warrant a more detailed investigation of the posterior ring in an effort to predict unstable posterior pelvic ring injuries. All patients with a displaced inferior ramus fracture on AP pelvic radiograph were identified at a single level I trauma center over a 5-year period. Complete pelvic radiographs and computed tomography scans were then evaluated for additional pelvic ring injuries. The data were analyzed using the chi-square test to determine the association between inferior ramus fractures and posterior pelvic ring injury. Sixty-three of the 93 patients with a fracture of the inferior ramus (68 %) were found to have a posterior ring injury; 60 % of these injuries were unstable. Patients with concurrent superior ramus fractures were more likely to have a posterior ring injury (p < 0.001) and an unstable pelvis (p = 0.018). Of those with a displaced unilateral inferior ramus fracture, parasymphyseal involvement was associated with higher incidence of posterior ring injury (p = 0.047) and pelvic instability (p = 0.028). The anterior pelvic ring can be used to help identify unstable injuries to the posterior pelvis. Patients with displaced inferior pubic ramus fractures warrant a detailed examination of their posterior ring to identify additional injuries and instability.

Management of Pelvic Ring Fractures in the Geriatric Patient

Pelvic fractures in the geriatric population are increasing in incidence. Those resulting from high-energy trauma result in increased mortality rates and can be challenging to manage due to polypharmacy and multiple patient comorbidities. Low energy pelvic fractures can be difficult to diagnose and exceptionally painful for patients. Injury to the posterior pelvis guides management. All patients with fragility fractures should be evaluated for osteoporosis and managed according to established guidelines.

Open reduction and internal fixation for floating symphysis pubis

Objective To explore the clinical characteristics of the floating injury of symphysis pubis and clinical outcome of open reduction and internal fixation.Methods A retrospective study was conducted to analyze the 48 patients who had been treated in our department with open reduction and internal fixation for the floating injury of Symphysis pubis from January 2008 to January 2013.There were 31 males and 17 females,with an average age of 36.5 years (range,20 to 61 years).Thirty-five patients were injured in traffic accidents and 8 were injured by falling injuries,and the other 5 were crushed by maehine.Fortyfive cases were complicated with fractures of the posterior pelvis ring; 14 cases were complicated with acetabular fractures; 17 cases were complicated with extremity fractures; 1 1 cases were complicated with thoracic and abdominal injuries and 6 cases were associated with urogenital system injury.The average period from trauma to operation was 7 days (range,3 to 25 days).Operation was performed under general anesthesia.The bilateral pubic ramus fractures were fixed with reconstruction plate in 41 cases,and 7 cases were fixed with cannulated screw through minimally invasive method.Forty-one cases with posterior ring fractures were fixed simulaneously.Results There were 44 patients being followed up with an average period of 16 months (range,12 to 30 months).All the fractures of the pelvis were clinically healed with an average period of 12.6 weeks (range,10 to 16 weeks).According 图o the Majeed score system,the functional results were exc ellent in 30 cases,good in 10 cases,and fair in 4 cases; The average score was 81.5 (range,60 to 100).Two patients who had wound fat liquefaction at 3 days after operation were healed by dressing changing; 8 patients got deep vein thrombosis at 10 days (range,5 to 15 days) after operation were cured by conservative treatment; 3 patients got supra pubic pain at 6 days (range,5 to 7 days) after operation were healed by oral non steroidal anti-inflammatory analgesic drugs and physical therapy in one year.Conclusion Floating injury of symphysis pubis is a kind of severe pelvic fracture which affects the stability of pelvic ring.Open reduction and internal fixation is a good method to stabilize the pelvis ring and to get early rehabilitation.This may contribute to good clinical resuls and good function. Key words: Pelvis; Pubic symphysis; Fractures; Fracture fixation, internal

Pregnancy-related Lumbopelvic Pain

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Phase II trial of short‐course radiotherapy followed by delayed surgery for locoregionally advanced rectal cancer

A prospective phase II study to investigate the feasibility and the rate of complete pathological response (ypT0) after short-course radiotherapy (SCRT) followed by surgery at 8weeks. Operable patients with localized rectal cancer staged T3-4N0/+ or T2N+ were eligible and received 25Gy (in one-third of patients, the gross tumor volume received a simultaneous integrated boost up to a total of 30Gy) in five consecutive fractions to the posterior pelvis followed by surgery 8weeks later. Pathological response and surgical toxicity were assessed in all patients. Fifty-two patients (median age 68years) completed the study. The median distance of the tumour from the anal verge was 6.5cm. The median interval to surgery was 52days. Three-quarters of patients underwent a low anterior resection. All underwent complete surgical resection and 100% had pathological negative margins. Ten per cent had stage ypT0 after radiotherapy. The median length of hospital stay was 8days. Toxicity was comparable with the rates reported in the literature. In this study, SCRT followed by delayed surgery was feasible and had acceptable toxicity. All patients underwent complete surgical resection and 100% had negative pathological margins. The rate of ypT0 was 10%.

Fluorouracil-based adjuvant chemotherapy after preoperative chemoradiotherapy in rectal cancer: long-term results of the EORTC 22921 randomised study

EORTC trial 22921 examined the addition of preoperative or postoperative chemotherapy to preoperative radiotherapy in patients with rectal cancer. After a median follow-up of 5 years, chemotherapy-irrespective of timing-significantly improved local control. Adjuvant chemotherapy did not improve survival, but the Kaplan-Meier curves diverged, suggesting possible delayed benefit. Here, we report the updated long-term results. We randomly assigned patients with clinical stage T3 or T4 resectable rectal cancer to receive preoperative radiotherapy with or without concomitant chemotherapy before surgery followed by either adjuvant chemotherapy or surveillance. Randomisation was done using minimisation with factors of institution, sex, T stage, and distance from the tumour to the anal verge. Study coordinators, clinicians, and patients were aware of assignment. Radiotherapy consisted of 45 Gy to the posterior pelvis in 25 fractions of 1·8 Gy over 5 weeks. Each course of chemotherapy consisted of fluorouracil (350 mg/m(2) per day intravenous bolus) and folinic acid (leucovorin; 20 mg/m(2) per day intravenous bolus). For preoperative chemotherapy, two courses were given (during weeks 1 and 5 of radiotherapy). Adjuvant chemotherapy was given in four cycles, every 3 weeks. The primary endpoint was overall survival. This analysis was done by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00002523. 1011 patients were randomly assigned to treatment between April, 1993, and March, 2003 (252 to preoperative radiotherapy and 253 to each of the other three groups). After a median follow-up of 10·4 years (IQR 7·8-13·1), 10-year overall survival was 49·4% (95% CI 44·6-54·1) for the preoperative radiotherapy group and 50·7% (45·9-55·2) for the preoperative radiotherapy and chemotherapy group (HR 0·99, 95% CI 0·83-1·18; p=0·91). 10-year overall survival was 51·8% (95% CI 47·0-56·4) for the adjuvant chemotherapy group and 48·4% (43·6-53·0) for the surveillance group (HR 0·91, 95% CI 0·77-1·09, p=0·32). 10-year disease-free survival was 44·2% (95% CI 39·5-48·8) for the preoperative radiotherapy group and 46·4% (41·7-50·9) for the preoperative radiotherapy and chemotherapy group (HR 0·93, 95% CI 0·79-1·10; p=0·38). 10-year disease-free survival was 47·0% (95% CI 42·2-51·6) for the adjuvant chemotherapy group and 43·7% (39·1-48·2) for the surveillance group (HR 0·91, 95% CI 0·77-1·08, p=0·29). At 10 years, cumulative incidence of local relapse was 22·4% (95% CI 17·1-27·6) with radiotherapy alone, 11·8% (7·8-15·8) with neoadjuvant radiotherapy and chemotherapy, 14·5% (10·1-18·9) with radiotherapy and adjuvant chemotherapy and 11·7% (7·7-15·6) with both adjuvant and neoadjuvant chemotherapy (p=0·0017). There was no difference in cumulative incidence of distant metastases (p=0·52). The frequency of long-term side-effects did not differ between the four groups (p=0·22). Adjuvant fluorouracil-based chemotherapy after preoperative radiotherapy (with or without chemotherapy) does not affect disease-free survival or overall survival. Our trial does not support the current practice of adjuvant chemotherapy after preoperative radiotherapy with or without chemotherapy. New treatment strategies incorporating neoadjuvant chemotherapy are required. EORTC, US National Cancer Institute, Programme Hospitalier de Recherche Clinique, Ligue contre le Cancer Comité du Doubs.

The Incarcerated Uterus: A Review of MRI and Ultrasound Imaging Appearances

The objective of this article is to review the MRI and ultrasound appearances of incarcerated uterus. Incarcerated uterus is a rare but serious complication of pregnancy in which the gravid uterus becomes trapped in the posterior pelvis. Characteristic MRI and ultrasound imaging features enable definitive diagnosis of incarcerated uterus, which reduces risks of complications that can lead to maternal and fetal morbidity and mortality.

What is slumped sitting? A kinematic and electromyographical evaluation

Slumped sitting is a commonly used reference posture when comparing effects of upright sitting in both clinical and non-clinical populations alike. The exact nature of slumped sitting has not been clearly defined, including regional differences within the posture, and how the passive nature of slumped sitting compares to an active-flexion posture. Kinematic and electromyographical (EMG) data were collected from 12 males during three repeats of slumped sitting and seated maximum forward flexion. Spine angles were defined in four regions (three thoracic and lumbar) as well as for the pelvis, and EMG was collected from eight muscles bilaterally. Kinematic data were expressed as a range of motion (in degrees), and as a percent of full forward flexion while seated (%SIT-FF) and standing (%STAND-FF). EMG data were normalized to a percent maximum contraction (%MVC). Results showed that slumped sitting is characterized by 10° posterior pelvis rotation, near end-range flexion of the mid- (90%SIT-FF) and lower- (81%SIT-FF) thoracic regions, and mid-range flexion of the upper-thoracic (51%SIT-FF) and lumbar (43%SIT-FF) regions. Comparison of slumped by %STAND-FF showed the upper- and mid-thoracic regions to have high variability and large values (over 100%STAND-FF). Muscle activation showed a significant 3%MVC reduction in the lower-thoracic erector spinae muscle when moving from upright to slumped sitting. These data highlight the postural differences occurring within different spine regions, and interpretations that could be drawn, depending on which normalization (sit or stand) method is used.

Posteriore Zugänge zum Beckenring

The posterior pelvic ring is critical for the mechanical stability of the pelvis. There is considerable variability in the degree of traumatic injury to the posterior pelvis which results in damage to the ligaments, the bones or a combination of these two functional structures. For management of combined posterior and anterior pelvic ring injuries it is crucial to decide which side has to be treated with priority. Surgical approaches for the posterior pelvic ring include transiliacal plate osteosynthesis, local plate osteosynthesis, iliosacral screw ostheosynthesis and spinopelvic stabilization. The degree of soft tissue damage represents an important criterion that should be considered when determining the surgical approach because extensive soft tissue damage often prevents enlarged explorative surgical access. Especially in posterior pelvic ring injuries, soft tissues should be preserved as much as possible because long periods of immobilization in severely injured patients can compromise wound healing. The aim of this paper is to provide an overview of the most commonly used posterior surgical approaches for pelvic ring injuries.

Estimation of sacroiliac joint index in normal subjects of various age groups: comparative evaluation of four different methods of quantification in skeletal scintigraphy

To estimate and compare the sacroiliac joint (SIJ) index in skeletal scintigraphy by four different methods of quantification employed in normal subjects of different age groups. The whole-body skeletal survey of 100 subjects, who underwent skeletal scintigraphy three hours after injection of 99mTc-Methylene Diphosphonate (MDP), were selected for this analysis. The patients having previous history of low back pain, joint pain or any benign bone joint disorders (e.g. ankylosing spondylitis, metabolic bone disease, and osteoarthritis), documented bone lesions or tumors within the pelvis region were excluded from the study. All subjects had normal posterior pelvis view on visual assessment in the respective study. Sacroiliac joint index was calculated by quantitative sacroiliac scintigraphy. In each subject, four different methods of quantification were carried out: 1. irregular region of interest (ROI) method, 2. rectangular ROI method, 3. profile peak counts (PPC) method and 4. profile integrated counts (PIC) method and applied to calculate SIJ index. SIJ indices for left and right sacroiliac joints were calculated by dividing the count for each joint by the count for the sacrum. Results obtained by the four methods were compared statistically. The overall SIJ index was found to range from 1.06 to 1.36 in the study population of 100 subjects encompassing all age groups. There was no significant difference in the estimated SIJ index within each age group obtained by the four different methods employed in this study. The values of SIJ index were as follows: in patients aged 2-20 years - they ranged from 1.22 to 1.36; in patients aged 21-40 years - from 1.07 to 1.19; for patients aged 41-60 years - from 1.08 to 1.19 and in patients aged 61 years and older, SIJ values were slightly lower than in other groups and ranged from 1.06 to 1.13. Methods of selecting a region of interest have no significant effect on the calculation of SIJ index and in healthy subjects its values range between 1.06 and 1.36, depending on the age of the subject. The maximum value was observed in patients aged 2-20 years and minimum values were noted in patients aged 61 and older.

Intramural Metastases of Rectum From Carcinosarcoma (Malignant Müllerian Mixed Tumor) of Uterine Cervix

A 25-year-old woman had carcinosarcoma of uterine cervix after definitive treatment. One year later, local recurrent disease was found in the right posterior pelvis on FDG PET/CT. FDG PET/CT also disclosed an incidental intramural hypermetabolic lesion in the rectum, which seemed separate from the right pelvic lesion on contrast-enhanced CT. The rectal lesion was confirmed as metastatic carcinosarcoma from uterine cervix after endoscopic biopsy.

Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum

We sought to study the association between mode of delivery and persistent pelvic girdle syndrome (PGS) (pain in anterior and bilateral posterior pelvis) 6 months postpartum. We followed up 10,400 women with singleton deliveries in the Norwegian Mother and Child Cohort Study who reported PGS in pregnancy week 30 (1999 through 2008). Data were obtained by 3 self-administered questionnaires and linked to the Medical Birth Registry of Norway. Planned cesarean section was associated with the presence of severe PGS 6 months postpartum (adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.4-3.9). In women who used crutches during pregnancy, emergency (adjusted OR, 2.0; 95% CI, 1.0-4.0) and planned (adjusted OR, 3.3; 95% CI, 1.9-5.9) cesarean section were each associated with severe PGS. The results suggest an increased risk of severe PGS 6 months postpartum in women who underwent a cesarean section vs women who had an unassisted vaginal delivery.

What Is the Infection Rate of the Posterior Approach to Type C Pelvic Injuries?

Pelvic ring injuries with complete disruption of the posterior pelvis (AO/OTA Type C) benefit from reduction and stabilization. Open reduction in early reports had high infectious complications and many surgeons began using closed reduction and percutaneous fixation. Multiple smaller studies have reported low infection rates after a posterior approach, but these rates are not confirmed in larger series of diverse fractures. We therefore determined (1) the incidence of surgical site infectious complications after a posterior approach to the pelvis; and (2) whether secondary procedures other than surgical débridement are necessary as a result of the approach-related complications. We retrospectively reviewed all 236 patients (268 surgical approaches) with C type injuries treated with a posterior approach at six institutions before 1998 and at one institution from 1998 to 2005. Posterior injuries were classified anatomically as described by Letournel and the AO/OTA system. We recorded wound complications after surgery. Surgical site infection occurred in eight of the 236 patients (3.4%) in the multicenter analysis. Treatment consisted of surgical débridement, wound closure, and antibiotics. No patients required soft tissue reconstruction as a result of the approach or infection. Our data suggest with proper patient selection and the described surgical technique, there should be minimal risk for catastrophic wound complications or high infection rates as reported by others. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fluorodeoxyglucose PET-CT Findings Following Bone Marrow Harvesting

Two patients demonstrated an unusual pattern of intense bone and surrounding soft tissue hypermetabolic uptake in the posterior pelvis on fluorodeoxyglucose positron emission tomography with computed tomography PET-CT scans. After further investigation, we found that both patients underwent uncomplicated autologous bone marrow harvesting several weeks before imaging. These two cases illustrate a distinctive PET-CT appearance following bone marrow harvesting that the radiologist needs to recognize to not confuse the findings with metastatic disease.

Hip and Spine Physical Examination and Radiographic Findings in Consecutive Patients Presenting With Low Back Pain Associated With Groin, Posterior Pelvis, or Leg Pain

Hip and Spine Physical Examination and Radiographic Findings in Consecutive Patients Presenting With Low Back Pain Associated With Groin, Posterior Pelvis, or Leg Pain

Radiological analysis, operative management and functional outcome of open book pelvic lesions: A 13-year cohort study

We present the clinical and radiological outcome of a 13-year cohort study of 38 open book pelvic lesions. All patients were treated in one Level I Trauma centre. In the posterior pelvis, sacro-iliac diastasis was seen in 31 patients, sacral fracture in 7. In all patients with sacro-iliac diastasis, the pubic bone was inferiorly displaced on the primary ap pelvic overview on the side of injury. All but one patient was treated with open reduction and internal fixation of the symphysis pubis. Additional stabilization of the posterior pelvis was done in 9 patients. 32 patients were seen after a median follow up of 84 months. Majeed score and SF-36 questionnaire were used. Functional outcome was excellent with a mean Majeed score of 95.7. Comparing our data with the SF-36 score of the normal German population, the mean value of the ‘role-physical’ and the ‘physical function’ categories was significantly lower for patients treated with an open book lesion. There was a tendency towards a better outcome in open book lesions with sacral fracture. There was a tendency towards worse outcome for the patients with additional dorsal stabilization. Male impotence was the single most important lesion of neurological origin which persisted two years after open book lesion. Conclusion Functional outcome after surgical treatment of open book pelvic lesions is good. External rotation and accompanying inferior displacement of the ipsilateral hemipelvis may be a sign of partial lesion of the posterior sacroiliac complex. Identification of patients who need additional posterior stabilization remains difficult.

Twenty-year Experience in the Management of Anal Carcinoma with Interstitial Brachytherapy

The management of anal cancer has undergone an interesting transformation over the last three decades. The idea of organ preservation emerged following the discovery of a high complete response rate from preoperative combined chemoradiation prior to abdominal-perineal resection. Radiotherapy, with concomitant chemotherapy for advanced tumors, is now the standard first-line treatment for anal carcinoma. The combination of external beam radiotherapy with interstitial brachytherapy increases the dose to the tumor volume and limits the volume of irradiated normal tissue, thereby decreasing late toxicity. We present an analysis of a series of patients treated with iridium 192 low-dose rate (LDR) or pulsed-dose rate (PDR) interstitial brachytherapy for anal carcinoma. From 1989 to 2009, 38 patients with anal carcinoma were treated with brachytherapy at the Catalan Institute of Oncology in Spain, in 26 cases with LDR and in 12 cases with PDR. The median age was 62 years (range, 38-86), with a male/female gender ratio of 20/18. The TNM classification was as follows: 10 T1, 22 T2, 5 T3, and 1 T4; 32 N0, 3 N1, and 3 N2. Treatment started with concomitant chemoradiotherapy in 22 patients or radiotherapy alone in 10 patients. The mean dose of external beam irradiation given to the posterior pelvis was 45 Gy (range, 32-50 Gy). The median dose for interstitial brachytherapy was 20 Gy (range, 15-35) for the boost and 60-65 Gy if monotherapy. Of the 38 patients, 34 (89.4%) were recorded as complete response, 2 (5.3%) as partial response and 2 (5.3%) as progression disease. The procedure was well tolerated. With a median follow-up of 30 months (range, 3.7-200.7), 2 and 5-year overall survival was 87% (95% CI: 74-98%) and 76% (95% CI: 59-93%), respectively. The 2, 5, and 10-year local progression-free survival rate was 91% (95% CI: 81-100%), 87% (95% CI: 75-99%), and 81% (95% CI: 67-97%), respectively. Twelve relapses occurred (3 regional and distant, 3 distant alone, 1 regional alone, and 5 local). Two patients had chronic mucositis grade III/IV (Radiation Therapy Oncology Group scale). No colostomy was required for necrosis. Two patients experienced serious late toxicity grade 3/4 mucositis and only three patients (7.8%) had incontinence after brachytherapy. No correlation was found between the dose rate and late mucositis (p = 1) or dermatitis (p = 0.4). LDR and PDR appear to be an effective treatment for anal carcinoma with good local tumor control at 10 years, low rates of late toxicity and preservation of the anal sphincter. Evaluating an optimized interstitial brachytherapy technique aimed at reducing toxicity to normal tissues and/or increasing the dose to the tumor volume remains to be done.

Factors influencing the accuracy of iliosacral screw placement in trauma patients

Correct placement of iliosacral screws remains a surgical challenge. The aim of this retrospective study was to identify parameters which impact the accuracy of this technically demanding procedure. Eighty-two patients with vertically unstable pelvic injuries treated with a total of 147 iliosacral screws were included. Assessment of postoperative CT scans revealed screw misplacement in 13 cases (8%), of which six occurred following insertion of two unilateral screws into S1. Six screw misplacements occurred in patients with dislocation injuries of the posterior pelvis. Comparison of a navigated and the standard technique revealed a decreased screw misplacement rate in the navigated group (15% standard vs. 3% navigation, p < 0.05). In addition, the malposition rate was influenced by the surgeon's individual experience (20% for low vs. 3.9% for high volume surgeons, p < 0.05). Overall, the accuracy of iliosacral screw placement depends on the number of screws inserted into S1 and the extent of dislocation. In experienced hands, the use of navigation represents a helpful tool to improve the placement accuracy.

Pelvic girdle pain in pregnancy: the impact of parity

The purpose of this study was to estimate the association of parity with pelvic girdle syndrome (PGS; pain in anterior and bilateral posterior pelvis). We included 75,939 pregnant women in the Norwegian Mother and Child Cohort Study. Data were obtained by self-administered questionnaires. By pregnancy week 30, 15% of the women had developed PGS. Among first-time mothers, 11% of the women reported PGS, compared with 18% of the women with 1 previous delivery and 21% of women with 2 previous deliveries. The odds ratios for PGS of having had 1 or 2 previous deliveries were 1.9 (95% confidence interval [CI], 1.9-2.0) and 2.4 (95% CI, 2.3-2.6), respectively, after adjustment for other study factors. For PGS with severe pain, the corresponding odds ratios were 2.6 (95% CI, 2.3-2.9) and 3.8 (95% CI, 3.3-4.3). The risk of the development of PGS increased with number of previous deliveries, which suggests that parity-related factors play a causal role.