RELATIONSHIP OF PELVIC ALIGNMENT WITH BALANCE AND GAIT IN PATIENTS WITH STROKE: A SYSTEMATIC REVIEW

Background- Pelvis is the key structure that connects the spine and the lower limbs. Altered Pelvic Alignment and asymmetrical weight bearing on affected lower limbs is a common problem leading to pelvic instability which may have an effect on balance and gait in patients with stroke. Hence, it was aimed to investigate the interdependence of these three components in patients with stroke. Methods- Four databases (PubMed, Google Scholar, Cochrane, Science Direct) were searched to identify eligible studies using the keywords Pelvic Alignment, Gait, Balance, Stroke. Only observational studies published in last 10 years (2010-2020) were included in this review. Results- Thirteen studies were included in the review conducted on sub-acute and chronic stage. All studies investigated the affection of pelvic mal-alignment, balance and gait in combination of two variables except 3 studies which investigated the combined effect of pelvic inclination on both balance and gait. The abnormal pelvic tilt results in lateral displacement of the pelvis on affected side, altered Base of Support, reduced balance control, asymmetry in weight bearing leading to altered gait. Conclusion- Pelvic tilt, anterior and lateral has a significant impact on static balance, gait variables, weight bearing symmetry.

Orthopedic management of pubic symphysis osteomyelitis: a case series

Objectives: The purpose of this case series is to describe the orthopedic management of pubic symphysis osteomyelitis with an emphasis on the key principles of treating bony infection. Furthermore, we sought to identify whether debridement of the pubic symphysis without subsequent internal fixation would result in pelvic instability. Methods: A retrospective chart review was performed to identify all cases of pubic symphysis osteomyelitis treated at both institutions from 2011 to 2020. Objective outcomes collected included infection recurrence, change in pubic symphysis diastasis, sacroiliac (SI) joint diastasis, and ambulatory status. Subjective outcome measures collected included the numeric pain rating scale (NPRS) and the 36-Item Short Form Survey (SF-36). Pubic symphysis diastasis was measured as the distance between the two superior tips of the pubis on a standard anterior–posterior (AP) view of the pelvis. SI joint diastasis was measured bilaterally as the joint space between the ileum and sacrum approximately at the level of the sacral promontory on the inlet view of the pelvis. A paired t test was utilized to compare the differences in outcome measures. An α value of 0.05 was utilized. Results: Six patients were identified, of which five were males and one was female (16.7 %), with a mean ± standard deviation (SD) follow-up of 19 ± 12 months (range 6–37 months). Mean ± SD age was 76.2 ± 9.6 years (range 61.0–88.0 years) and body mass index (BMI) was 28.0 ± 2.9 kg/m2 (range 23.0–30.8 kg/m2). When postoperative radiographs were compared to final follow-up radiographs, there were no significant differences in pubic symphysis diastasis (P = 0.221) or SI joint diastasis (right, P = 0.529 and left, P = 0.186). All patients were ambulatory without infection recurrence at final follow-up. Mean improvement for NPRS was 5.6 ± 3.4 (P = 0.020) and mean improvement for SF-36 physical functioning was 53.0 ± 36.8 (P = 0.032). Conclusion: This case series highlights our treatment strategy for pubic symphysis osteomyelitis of aggressive local debridement with local antibiotic therapy. Additionally, debridement of the pubic symphysis without subsequent internal fixation did not result in pelvic instability, as determined by pelvic radiographs and ability to fully weight bear postoperatively.

Global Motor, Oral and Deglutition Characteristics in Children with Cerebral Palsy

Cerebral palsy (CP) is a disorder in postural and movement tone resulting from involvement in the motor centers of the immature brain. Thus, this work sought to expose the global motor, oral, and deglutition characteristics in children with CP. To this end, it performed a cross-sectional study of 100 children with CP. The data collection consisted in the detection of the main global motor and oral alterations, their repercussions on the deglutition process, and the main manifestations of dysphagia according to different consistencies of food and types of cerebral palsy. All children exhibited global motor and oral alterations. There were significant differences between age and global motor alterations. Alterations in the tongue mobility were more present in spastics (p=<0.031). The main manifestations of dysphagia, in decreasing order of occurrence were: premature liquids spillage (70%), cough (60%), decreased bolus formation in solids (57,9%), presence of food residues in the oral cavity (47,4%), increased pasty oral transit (47,1%) and presence of wet voice after the liquids swallowing (30%). Therefore, the influence of pelvic instability and compensatory patterns was observed in the presence of clinical signs of tracheal aspiration. Regardless the type of CP, the global and oral motor alterations lead to deglutition disorders. Keywords: Cerebral Palsy. Child. Deglutition Disorders. Posture ResumoA paralisia cerebral (PC) é uma desordem no tônus postural e de movimento decorrentes de um acometimento nos centros motores do cérebro imaturo. Com isso buscou apresentar as características motoras globais, orais e de deglutição em crianças com PC. Assim, realizou um estudo transversal com amostra de 100 crianças com PC. A coleta de dados consistiu na detecção das principais alterações motoras globais e orais, a repercussão na dinâmica da deglutição e as principais manifestações disfágicas em diferentes consistências alimentares. Todas as crianças apresentaram comprometimentos motores globais e orais. Houve diferença significante entre a idade e as alterações globais. Alteração na mobilidade da língua esteve mais presente em espásticos (p=<0,031). As principais manifestações disfágicas, em ordem decrescente de ocorrência, foram: escape anterior de líquidos (70%), tosse (60%), diminuição da formação do bolo alimentar no sólido (57,9%), presença de resíduos alimentares na cavidade oral após a deglutição de sólidos (47,4%), aumento do trânsito oral de pastoso (47,1%) e presença da voz molhada após a deglutição de líquidos (30%). Então, observou-se a influência das alterações tônicas e posturais na presença de sinais clínicos de aspiração traqueal. Alterações tônicas e posturais com comprometimentos motores orais acarretam transtornos da deglutição em crianças com PC. Palavras-chave: Paralisia Cerebral. Criança. Transtornos da Deglutição. Postura

Chronic Anterior Pelvic Instability

Introduction: Chronic anterior pelvic instability means pathologic movement of the symphysis pubis with axial load. It is not a common pathology and its diagnosis is often delayed and difficult increasing the disability of affected patients. The pain is localized in the suprapubic area or groins, increasing with physical activity, direct palpation or compression. Main known causes are pregnancy, delivery, trauma, fractures, intense physical activity, infection, or previous surgeries. Treatment algorithms have not been standardized. Initially, it is managed with an orthosis, physical activity modification, medication, and rehabilitation. Surgical treatment with symphyseal arthrodesis is the last option. The literature on symphyseal plating for chronic instability found is sparse. Case Report: We report the case of a 33-year-old female presenting lower abdominal pain after her third delivery. Several months after, magnetic resonance imaging and scintigraphy suggested chronic symphysitis. Single leg stance pelvic X-rays indicated chronic anterior pelvic instability. Pain-relievers, physical rehabilitation, and local corticosteroid injection were noneffective; surgery was indicated, performing a double plate symphyseal arthrodesis with iliac bone graft. Conclusion: Pelvic instability should be ruled out when persistent abdominal or lower back pain are present. Thorough physical examination and specific provocative maneuvers need to be assessed. In our presented case, symphyseal arthrodesis was performed without complications. After a two-year follow-up, the patient has recovered her previous functional status and bone scintigraphy is negative. Radiologic controls rule out loosening or material breaking as a complication. We hope this case report may give a clue in surgical options management. Keywords: Arthrodesis, pelvic instability, symphysis.

Surgical management of chronic pelvic instability following periacetabular osteotomy nonunion

Introduction: Periacetabular osteotomy (PAO) is an established treatment for symptomatic acetabular dysplasia in skeletally mature individuals without arthritis. Pelvic nonunion and associated stress fractures are under-reported. Nonunited stress fractures can cause continued buttock pain and pelvic instability. The aim of this study is to report on our experience managing patients with ongoing pain following nonunion of PAO. Patients and methods: 8 patients presented to a tertiary referral pelvic service with symptomatic PAO nonunion between 2015-2018. All patients underwent open reduction internal fixation of the superior pubic ramus nonunion, with ipsilateral iliac autograft, at an average of 48.1 (15–82) months following initial osteotomy. Demographic and perioperative data were recorded. Follow-up was on average to 9.9 months, once union was confirmed radiographically. Results: All patients were female and average age was 31.8 (18–41) years. In 7/8 (87.5%) patients a modified Stoppa approach was successfully utilised. 1 patient required an ilioinguinal approach due to the amount of rotational correction. All patients went on to union at the superior pubic ramus and reported improvement in mechanical symptoms. 5/8 (62.5%) patients were noted to develop union of the posterior column or inferior pubic ramus stress fracture indirectly. 2/8 (25%) patients developed progression of intra-articular pain, despite restoration of pelvic stability. 1 patient required intraoperative transfusion due to femoral vein injury. There were no other complications seen in this series. Conclusions: To our knowledge, this is the largest case series of surgically managed PAO nonunion. Pelvic instability resulting from nonunion and stress fracture can be satisfactorily addressed by mobilising, grafting and plating the nonunion at the superior pubic ramus. The modified Stoppa approach is suitable in most cases, allowing excellent exposure whilst minimising the insult to soft tissues. The altered anatomy of the pelvis following PAO should be anticipated to reduce the risk to nearby neurovascular structures.