OF-Pelvis classification of osteoporotic sacral and pelvic ring fractures

Objectives Osteoporotic fractures of the pelvis (OFP) are an increasing issue in orthopedics. Current classification systems (CS) are mostly CT-based and complex and offer only moderate to substantial inter-rater reliability (interRR) and intra-rater reliability (intraRR). MRI is thus gaining importance as a complement. This study aimed to develop a simple and reliable CT- and MRI-based CS for OFP. Methods A structured iterative procedure was conducted to reach a consensus among German-speaking spinal and pelvic trauma experts over 5 years. As a result, the proposed OF-Pelvis CS was developed. To assess its reliability, 28 experienced trauma and orthopedic surgeons categorized 25 anonymized cases using X-ray, CT, and MRI scans twice via online surveys. A period of 4 weeks separated the completion of the first from the second survey, and the cases were presented in an altered order. While 13 of the raters were also involved in developing the CS (developing raters (DR)), 15 user raters (UR) were not deeply involved in the development process. To assess the interRR of the OF-Pelvis categories, Fleiss’ kappa (κF) was calculated for each survey. The intraRR for both surveys was calculated for each rater using Kendall’s tau (τK). The presence of a modifier was calculated with κF for interRR and Cohen’s kappa (κC) for intraRR. Results The OF-Pelvis consists of five subgroups and three modifiers. Instability increases from subgroups 1 (OF1) to 5 (OF5) and by a given modifier. The three modifiers can be assigned alone or in combination. In both surveys, the interRR for subgroups was substantial: κF = 0.764 (Survey 1) and κF = 0.790 (Survey 2). The interRR of the DR and UR was nearly on par (κF Survey 1/Survey 2: DR 0.776/0.813; UR 0.748/0.766). The agreement for each of the five subgroups was also strong (κF min.–max. Survey 1/Survey 2: 0.708–0.827/0.747–0.852). The existence of at least one modifier was rated with substantial agreement (κF Survey 1/Survey 2: 0.646/0.629). The intraRR for subgroups showed almost perfect agreement (τK = 0.894, DR: τK = 0.901, UR: τK = 0.889). The modifier had an intraRR of κC = 0.684 (DR: κC = 0.723, UR: κC = 0.651), which is also considered substantial. Conclusion The OF-Pelvis is a reliable tool to categorize OFP with substantial interRR and almost perfect intraRR. The similar reliabilities between experienced DRs and URs demonstrate that the training status of the user is not important. However, it may be a reliable basis for an indication of the treatment score.

Spontaneous Rupture of the Non Gravid Uterus: A Case Report

Uterine rupture can cause serious morbidity and mortality to the women. A complete uterine rupture is a diagnosis made when all three layers of the uterus are separated, while uterine dehiscence is a similar condition in which there is incomplete division of the uterus that does not penetrate all three layers of the uterus. Uterine dehiscence is most often an occult finding in asymptomatic patients. Mostly the uterine rupture is seen in gravid females however it has been reported in non gravid patients as well. Spontaneous uterine rupture is extremely rare to be seen in non gravid patients, but should be included in the differential diagnosis of acute abdomen and shock in a non pregnant woman of any age due to its catastrophic consequences. In non gravid uterus the most common cause of the uterine rupture is pelvic trauma, uterine myomas, infection or uterine carcinoma. We hereby report a case of 44 years old female with previous 4 caesarean sections who came on12th day of her cycle with heavy bleeding, lower abdominal pain and anaemia. She was found to have small fibroids which were blamed for the menorrhagia and she was admitted for the conservative management. She collapsed on day 2 of admission suddenly and after stabilization of the patient her exploratory laparotomy was done and uterine rupture was detected on the right side of the previous scar. The uterus was repaired as the patient refused for hysterectomy. Her post op recovery was uneventful. Her first periods after the surgery was normal with average amount of blood loss. Key words: Uterine rupture, haemorrhage, non -gravid, caesarean, hysterectomy, laparotomy.

Acute piriformis syndrome mimicking cauda equina syndrome: illustrative case

BACKGROUND This report depicts a rare case of acutely developed urinary retention as well as sensory and motor disturbances caused by formation of a large hematoma within the piriformis muscle, which caused compression of nerves within the suprapiriform and infrapiriform foramina, thus imitating cauda equina syndrome. Although cases of acute lumbosacral plexopathy have been described, this case is the first time both urinary retention and sensory and motor disturbances were present. OBSERVATIONS The most useful tools for diagnosis of acute piriformis syndrome are detailed patient history, magnetic resonance imaging (MRI) of the pelvic region, and electrophysiological testing performed by an experienced electrophysiologist. As a result of diligent rehabilitation, including physiotherapy and electrostimulation, the patient was able to successfully recover, regardless of acute compression of the sacral plexus that lasted 6 days. LESSONS Clinicians should actively ask about previous pelvic trauma when taking a patient history in similar cases, especially if the patient is receiving anticoagulation treatment. If MRI of the lumbar spine does not reveal any pathologies, MRI of the pelvic region should be performed. Acute surgical decompression is crucial for preserving neurological function. In similar cases, it is possible to differentiate between spinal cord, cauda equina, and pelvic lesions using electrophysiological studies.

Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma

Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.

Rationale for the use of the original classification of posttraumatic acetabular deformities in primary total hip replacement

Introduction Analysis of publications on primary hip replacement shows lower survival rates in patients with acetabular injuries. With the lack of a unified system for assessing post-traumatic acetabular deformities, authors tend to use the available classifications of acute pelvic trauma (AO/ ASIF, Young & Burgess, Tile, etc.) and acetabular osteolysis (AAOS, DGOT, Gross and Saleh, Paprosky), which we think can be inappropriate with the classifying systems meant for different patterns of acetabular deficiency. Material and methods CT scans of 117 patients with posttraumatic acetabular deformities were reviewed prior to total hip replacement (THR) performed for posttraumatic grade III coxarthrosis. The displacement of acetabular walls was determined with the measurements tabulated and analyzed. Results An original "ASPID" classification of post-traumatic deformities based on the findings obtained was offered with use of three assessment criteria: localization of the deformity, extent of displacement and the integrity of the pelvic ring. The ASPID classification can be used for the localization of the deformity with anterior (A), superior (S), posterior (P) and inner acetabular walls (I) to be identified. Measurements of displacement ranging 0-5 mm suggests grade 0 displacement; 6-15 mm, grade 1 displacement and greater than 15 mm, grade 2 displacement. The integrity of the pelvic ring evaluated from the involvement side as D0 suggests maintained pelvic integrity and D1, broken pelvic integrity. An acetabular hardware would be marked with 'H'. Conclusion ASPID classification is easy to use and has shown to be practical for planning of primary THR after acetabular fracture.

Definitive fixation of pelvic and acetabular fractures – current concepts

Introduction. The most challenging injury in orthopedic surgery is pelvic trauma. There are different concepts of treatment strategies, specially in final treatment of pelvic ring and acetabular fractures. Objectives. Analysis of recent studies and evaluation of treatment methods. Materials and Methods. Analysis of 22 recent studies. Five papers met our inclusion criteria, that equated 745 patients. Results. Patients hemodynamically unstable need to be resuscitated and „damage control” orthopedics is widely accepted method. Definitive treatment after fourth day should be performed. Some papers show that early, within 48 hours, definitive treatment of pelvic ring and acetabular fractures give similar or better results. Conclusions. Tendency to early definitive treatment is widely observed and decreases mortality rates and complications.