Assessment of enthesopathy in conventional pelvis radiography: Another tool for spondyloarthritis diagnosis beyond sacroiliitis.

INTRODUCTION/OBJECTIVES: Enthesitis is a cardinal feature of spondylarthritis (SpA), and the pelvis is a common site of enthesitis. This study aimed to establish the association between pelvic enthesis involvement on pelvic X-ray and SpA diagnosis through a radiographic enthesis index (REI) and to assess the reliability and accuracy of this REI. MATERIALS AND METHODS: The participants were SpA patients and a control group composed of patients with chronic lumbar pain without SpA. Three blinded observers assessed each pelvic radiography three times. Three zones were used: Zone I (ZI), the iliopubic ramus; Zone II (ZII), the pubic symphysis, and Zone III (ZIII), the ischiopubic ramus. A grading system was created from 0 to 3 [Grade 0, normal; Grade 1, minimal changes (subcortical bone demineralization and/or periosteal wishkering, seen as radiolucency and trabeculation of the cortical bone upon tendon insertion); Grade 2, destructive changes (Grade 1 findings and erosions at the enthesis site); and Grade 3, findings of Grade 2 plus >2 mm whiskering out of the cortical bone) for the REI. The sum of the results of the three zones was called the total REI. For statistical analysis, we used the weighted kappa statistic adjusted for prevalence and bias using Gwet's agreement coefficient. RESULTS: We enrolled 161 patients, 111 of them with SpA (39.6 % with axial SpA and 47.7 % with peripheral SpA) and 50 without SpA. In the SpA group, 36.7 % and 25.7 % had REI Grades 2 and 3 in ZIII, respectively, while only 6 % of the controls had these grades. For ZI, the frequency of Grades 1 to 3 was 42.3 % in the SpA group (8.1 %, 14.4 %, and 19.8 %, respectively), compared to only 2 % in the controls. ZII was unaffected in most of the patients with SpA (82.9 %) and in the controls (98 %). In the control group, Grade 0 was the most common REI grade in all three zones. The agreement was almost perfect for each zone and between the independent readers. The ROC-curve analysis showed that the highest performance areas were the total REI, ZIII, and ZI. Most (75 %) of the SpA patients without sacroiliitis on X-ray were REI-positive. The sensitivity of the REI for SpA diagnosis was 82 %, while the sensitivity of sacroiliitis on X-ray was 38.7 %. CONCLUSIONS: The assessment of pelvic enthesis using the REI on pelvic radiography may be useful for SpA diagnosis. Total REI, ZIII, and ZI had the highest accuracy and almost perfect reliability. The REI is especially helpful in patients without sacroiliitis on imaging.

Variables Associated With Loss of Fixation of Retrograde Rami Screws in Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries.

OBJECTIVES: To evaluate variables associated with loss of fixation of retrograde rami screws in the treatment of stress-positive minimally displaced lateral compression type 1 (LC1) injuries. DESIGN: Retrospective comparative study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Stress-positive minimally displaced (<1 cm) LC1 pelvic ring injuries treated with retrograde rami screws. OUTCOME MEASURES AND COMPARISONS: Loss of fixation, defined as >5 mm of pelvic fracture displacement based on the radiographic tear-drop distance or >5 mm of implant displacement on follow-up radiographs; revision surgery for loss of fixation. RESULTS: Thirty-eight patients with 40 retrograde rami screws were analyzed. Median patient age was 64 years (interquartile range 42.5-73.3 years), 71.1% (n = 27/38) were female, and 52.6% (n = 20/38) of injuries were secondary to low-energy mechanisms. Loss of fixation occurred in 17.5% (n = 7/40) of screws with 10% (n = 4/40) requiring revision surgery. On univariate analysis, patients who had a loss of fixation were more likely to have greater dynamic displacement on stress radiographs (22.0 vs. 15.2 mm; median difference 5.6 mm, confidence interval [CI] -19.2 to 10.3; P = 0.04), unicortical rami screws (71.4% vs. 9.1%; proportional difference 62.3%, CI 8.8%-22.6%; P = 0.001), and partially threaded rami screws (71.4% vs. 21.2%; proportional difference 50.2%, CI 10.0%-77.6%; P = 0.01). The remaining variables had no observed association ( P ≥ 0.05) with loss of fixation, including age, sex, body mass index, energy of injury mechanism, tobacco use, American Society of Anesthesiologist score, sacral fracture type, distal rami fractures, rami comminution, number of sacral screws, fully threaded sacral screws, transsacral screws, or rami screw diameter. On multivariate analysis, only unicortical rami screws ( P = 0.01) remained associated with loss of fixation. CONCLUSIONS: Retrograde rami screws had a high rate of loss of fixation in minimally displaced LC1 pelvic ring injuries, and this was associated with unicortical screws. These screws should be avoided when possible. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Geriatric Patients Presenting With Isolated Pubic Rami Fractures and Inability to Mobilize May Have Occult Lateral Compression Pelvic Ring Injuries With Dynamic Instability.

OBJECTIVES: To determine the incidence of patients with isolated pubic rami fractures on computed tomography scans who have dynamic instability secondary to occult lateral compression pelvic ring injuries. DESIGN: Retrospective comparison study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: This study included geriatric patients with isolated pubic rami fractures and inability to mobilize secondary to pain. INTERVENTION: Lateral stress radiographs of pelvis to evaluate for ≥1 cm dynamic instability. MAIN OUTCOME MEASUREMENTS: Physical therapy clearance, hospital length of stay, and discharge location. RESULTS: A total of 19 patients were identified over 12 months. Patients were predominantly geriatric (median age: 75 years, interquartile range: 67 to 90), woman (11/19), with unilateral (17/19) comminuted distal rami fractures (12/19) sustained in ground-level falls (12/19). Dynamic instability was identified in 42% of patients (8/19). Magnetic resonance imaging, obtained in 6 of these patients, demonstrated occult posterior ring fractures in all cases. Patients with dynamic instability were more likely to have comminuted distal rami fractures (Nakatani type 1b) and a longer hospital length of stay. There was also a trend for these patients to be unable to clear physical therapy by discharge (63% (5/8) versus 36% (4/11)). The 90-day mortality rate of the cohort was 16% (3/19). CONCLUSIONS: Patients presenting with seemingly isolated pubic rami fractures on radiographs and computed tomography scans who are unable to mobilize may have occult lateral compression injuries with dynamic instability. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fixation failure in patients with traumatic diastasis of pubic symphysis: impact of loss of reduction on early functional outcomes.

BACKGROUND: Failure of fixation (FF) in pubic symphysis diastasis (SD) ranges between 12 and 75%, though whether it influences functional outcomes is still debated. The objective of this study is to evaluate the impact of anterior pelvic plate failure and loss of reduction on Majeed's functional scores. METHODS: Single center retrospective review of consecutive patients with acute SD treated by means of anterior pubic plating. Thirty-seven patients with a mean age 45.7 ± 14.4 years were included. Demographics, AO classification, pelvic fixation and secondary procedures were recorded. Majeed's functional scores at minimum 6 months follow-up were compared according to the presence of FF and loss of reduction. RESULTS: Fifteen patients presented FF. Eight presented an additional loss of symphyseal reduction. Mean Majeed´s score (MMS) in patients with and without FF was 64.4 ± 13.04 and 81.8 ± 15.65, respectively (p = 0.0012). Differences in MMS in patients without FF and those with FF and maintained or loss of anterior reduction were 11.3 [70.5 vs 81.8] (p = 0.092) and 22.7 [59.1 vs 81.8] (p = 0.001), respectively. Significant association of FF with AO classification was noted. (OR 12.6; p = 0.002). CONCLUSIONS: Differences in MMS in the analyzed groups suggest that loss of reduction might be more relevant than failure of the anterior osteosynthesis in functional outcomes.

Greater trochanteric pain syndrome in women: Analysis of magnetic resonance, sagittal alignment, muscular strength and endurance of the hip and trunk.

INTRODUCTION: There are many studies on the Greater Trochanteric Pain Syndrome (GTPS), however its relationship with radiographic and biomechanics parameters is not established. OBJECTIVE: To compare the magnetic resonance images (MRI) of the hip, radiographic parameters of sagittal alignment (pelvic incidence, sacral slope and lumbar lordosis), muscular strength and endurance in women with and without GTPS. METHODS: Forty women, age over 45, IMC <30 Kg/m2 and sedentary, were recruited and distributed in two groups: GTPS group (GTPSG, n = 20) and Control group (CG, n = 20). All participants underwent MRI scans and X-ray for sagittal alignment analysis in the hip and performed tests for muscular strength and endurance of the hip and trunk. RESULTS: No differences were found between the GTPSG and CG for the frequency of tendinopathy (P = .30), peritendinitis (P = .10), bursitis (P = .68) and enthesitis (P = .15), however the gluteus medius tendon tear was more prevalent in GTPSG (P = .05). There were no differences in radiographic parameters for pelvic incidence (P > .05), sacral slope (P > .05) and lumbar lordosis (P > .05). The GTPSG showed lower strength of all hip muscle groups (abductors, adductors, flexors, extensors and rotators; P < .01 for all), as well as lower endurance in the Supine Bridge test and Prone bridge test (P < .01). CONCLUSION: The results of the MRI and radiographic parameters did not differentiate women with and without GTPS. However, the evaluation of muscle strength and endurance can establish the difference between groups.

Sacral Fracture Completeness in Lateral Compression Type 1 Pelvic Ring Injuries Has Weak Interobserver Reliability.

OBJECTIVES: To determine the agreement between fellowship-trained orthopaedic trauma surgeons in evaluating sacral fracture completeness in the setting of minimally displaced lateral compression type 1 pelvic ring injuries. DESIGN: Survey study. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: This study included 10 fellowship-trained orthopaedic trauma surgeons reviewing 10 cases of minimally displaced lateral compression type 1 injuries with proven occult instability (≥10 mm of fracture displacement on lateral stress radiographs). Sacral fractures were considered complete (n = 5; fracture line exiting posterior cortex of sacrum) or incomplete (n = 5). INTERVENTION: Participants reviewed videos of all axial computed tomography images of the sacrum and were asked if the sacral fracture was complete or incomplete. MAIN OUTCOME MEASUREMENTS: Interobserver reliability of completeness of sacral fracture. RESULTS: Interobserver reliability among surgeons for completeness of sacral fractures was considered to be weak (k = 0.46) with a 95% confidence interval that ranged from minimal (k = 0.37) to weak (k = 0.55). None of the 5 unstable sacral fractures that were considered to be complete garnered 100% agreement among surgeons. Agreement for each of these cases ranged from 40% to 90%. In contrast, 4 of the 5 unstable sacral fractures considered to be incomplete had 100% agreement. CONCLUSIONS: Completeness of sacral fractures had weak interobserver reliability among fellowship-trained orthopaedic trauma surgeons. Sacral fractures that were considered incomplete by all surgeons did have occult instability. These results highlight the large potential for error created by using sacral fracture completeness as a criterion to rule out occult instability. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

An international survey of pelvic trauma surgeons on the management of pelvic ring injuries.

INTRODUCTION: There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement. METHODS: A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question. RESULTS: Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement. DISCUSSION: This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.

Morphometric, anatomic and radiographic study of bone of the pelvic limb of endangered Patagonian huemul deer (Hippocamelus bisulcus) / Estudio morfométrico, anatómico y radiográfico de los huesos del miembro pélvico del huemul patagónico en peligro de extinción (Hippocamelus bisulcus)

Currently, the Patagonian huemul (Hippocamelus bisulcus) is endangered. Anatomical studies focused on understanding the anatomy of the deer most threatened by extinction in South America is a challenge for anatomists, veterinarians and biologists. Research carried out for its conservation has focused mainly on its ecology and pathology, leaving gaps in anatomical knowledge, which is basic and important for a comprehensive understanding of this species. Gross anatomy and radiography of the skeleton of the pelvic limb was performed in three adult Patagonian huemul. Bone specimens of three skeletally mature Patagonian huemul deer were used for gross osteological and radiographic studies. This study was conducted to reveal the morphometric and morphological features of the ossa membri pelvini of the Patagonian huemul. The main findings suggest the presence of powerful extensor muscles in the coxofemoral, femorotibial and tarsal joints, useful during walking, jogging and propulsion in deer. In general, the MNF of Patagonian huemul differ in position with respect to domestic ungulates. In addition, the presence of a notch or obturator canal was observed, with variability in morphology and development among the specimens.

Actualmente, el Huemul Patagónico (Hippocamelus bisulcus) está en peligro de extinción. Los estudios morfológicos centrados en comprender su anatomía han sido un desafío para morfólogos, veterinarios y biólogos. Investigaciones enfocadas en su conservación, se han centrado principalmente en su ecología, patología y en la descripción de sus principales agentes infecciosos, dejando vacíos en el conocimiento anatómico básico, y por ende, su comprensión morfofisiológica. El objetivo de este estudio fue describir la anatomía, morfometría y radiología macroscópica normal y detallada del ossa membri pelvini en tres especímenes de Huemul Patagónico, incluida una interpretación funcional como referencia para uso clínico y conservacionista, investigación biomédica y fines de enseñanza. Los principales hallazgos sugieren la presencia de potentes músculos extensores en las articulaciones coxofemoral, femorotibial y tarsal, útiles durante la marcha, el trote y la propulsión en los ciervos. En general, los forámenes nutricios principales del Huemul patagónico difieren en posición con respecto a los ungulados domésticos. Además, se observó la presencia de una muesca o canal obturador, con variabilidad morfológica y de desarrollo entre los especímenes.

Effect of Extra Virgin Olive Oil and Traditional Brazilian Diet on the Bone Health Parameters of Severely Obese Adults: A Randomized Controlled Trial.

Dietary interventions can stabilize and/or reverse bone mass loss. However, there are no reports on its effects on bone mineral density (BMD) in severely obese people, despite the vulnerability of this group to bone loss. We examine the effect of extra virgin olive oil supplementation and the traditional Brazilian diet (DieTBra) on BMD and levels of calcium, vitamin D, and parathyroid hormone (PTH) in severely obese adults. A randomized controlled trial followed-up with severely obese adults (n = 111, with mean body mass index 43.6 kg/m2 ± 4.5 kg/m2) for 12 weeks. Study participants received either olive oil (52 mL/day), DieTBra, or olive oil + DieTBra (52 mL/day + DieTBra). BMD was assessed by total spine and hip dual-energy X-ray absorptiometry. After interventions, BMD means for total spine (p = 0.016) and total hip (p = 0.029) were higher in the DieTBra group than in the olive oil + DieTBra group. Final mean calcium levels were higher in the olive oil group compared to the olive oil + DieTBra group (p = 0.026). Findings suggest that DieTBra and extra virgin olive oil have positive effects on bone health in severely obese adults. The major study was registered at ClinicalTrials.gov (NCT02463435).

Differential diagnosis and treatment of enchondromas and atypical cartilaginous tumours of the pelvis: analysis of 21 patients.

INTRODUCTION: Studies focusing on enchondroma and atypical cartilaginous tumour (ACT) of the pelvis are lacking. The purpose of this study was to verify possible clinical and radiological findings with regard to distinguishing enchondromas from ACT of the pelvis. In addition, this study analysed functional and oncological outcomes in patients with enchondromas or ACT of the pelvis treated with curettage or resection. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 21 patients with confirmed enchondroma or ACT of the pelvis treated by curettage or resection from 1985 to 2018. The minimum follow-up was 18 months. The relationship between clinical and radiological factors and tumour type or local recurrence was assessed using Fisher exact test and Mann-Whitney U test. RESULTS: Endosteal scalloping (p = 0.039), tumour size (0.005) and age (0.006) were shown to statistically favour ACT over enchondroma; by contrast, enchondroma and ACT patients had no difference in pain frequency (p = 0.5528). All patients with enchondroma had no local recurrence; in contrast, local recurrence occurred in one patient with ACT, initially treated with resection. The patient with local recurrence had a disease progression with a higher histological grade than the original tumour. Patients treated with curettage had better functional outcomes than patients treated with resection (p = 0.001). DISCUSSION: Endosteal scalloping, tumour size and age could be helpful in the differential diagnosis between enchondroma and ACT of the pelvis. In addition, our study showed that ACT of the pelvis can be safely treated with curettage due to a low risk of local recurrence and better functional results compared with resection. In case of recurrence, we suggest to treat these patients with resection for the risk of disease progression.

Long-Term Treatment Effect and Predictability of Spinopelvic Alignment After Surgical Correction of Adult Spine Deformity With Patient-Specific Spine Rods.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To evaluate the short- and long-term treatment effect (TE) of spinopelvic parameters after surgical correction of adult spine deformity (ASD) utilizing preoperative planning and patient-specific spine rods (PSSRs), and to assess the correspondence between planned and real outcomes. SUMMARY OF BACKGROUND DATA: PSSR have been used in ASD correction for the last decade. However, a TE and predictability of spinopelvic alignment at long-term follow-up has not been studied. METHODS: Inclusion criteria: male or female; age more than 20 years; correction of ASD with PSSR; 24-month follow-up (or revision surgery). Studied parameters: sagittal vertical axis; lumbar lordosis (LL); pelvic tilt (PT); sacral slope; pelvic incidence (PI); and PI-LL. The measurement error, TE (the differences between postoperative and preoperative values), standardized TE, and predictability of the studied parameters assessed. The variables included categorical (optimal/nonoptimal) and continuous obtained by direct measurements and weighted by individual optimal values. Statistical significance was set at P ≤ 0.05. RESULTS: Thirty-four patients were included: 56% women; the mean age, 63.4 (standard deviation, 12.7); at each follow-up: 32 at 1 to 3 months, 34 at 11 to 13, and 14 at 23 to 25 with 9 followed to the revision surgery. Strong or moderate TE was shown for sagittal vertical axis, LL, and PI-LL. The TE of PT and sacral slope was less significant and lower than planned. PI was not stable in 18%. The changes of continuous variables were more prominent and statistically significant then categorical. The mean values did not show significant differences between planned and postoperative outcomes except for PT. However, the individual deviations were substantial for all parameters. Significant predictability was shown only for LL and PI. CONCLUSION: Use of PSSR showed strong and relatively stable TE in ASD during 2 postoperative years. However, improvement of the planning accuracy may contribute to further enhancement of the method's efficacy. LEVEL OF EVIDENCE: 4.

Association between high levels of gynoid fat and the increase of bone mineral density in women.

Introduction: In women, bone mineral density (BMD) is related to age, estrogenic action, and appendicular skeletal muscle mass (ASMM). The gynoid fat distribution is linked to estrogenic action.Objective: This study aimed to assess whether an increase of gynoid fat is associated with high BMD independent of age and ASMM.Methods: An observational study was performed in women aged between 20 and 79 years. Fat mass, ASMM, and BMD were measured with dual-energy X-ray absorptiometry. The binned scatterplots and multivariate linear regression models were used to study the relationship between hip BMD and age, height, android fat, gynoid fat, and ASMM.Results: Of 673 women invited, 596 accepted to participate. Their mean age was 55.4 ± 12.8 years, weight 63.4 ± 9.4 kg, height 1.61 ± 0.06 m, body mass index 24.54 ± 3.59 kg/m2, average hip BMD 0.914 ± 0.122 g/cm2, android fat 2.12 ± 0.83 kg, gynoid fat 4.54 ± 1.07 kg, and ASMM 15.15 ± 1.97 kg. The final regression model included age (linear coefficient -0.004; 95% confidence interval [CI]: -0.005 to -0.003; p < 0.001), ASMM (linear coefficient 0.013; 95% CI: 0.009 to 0.018; p < 0.001), and gynoid fat (linear coefficient 0.013; 95% CI: 0.005 to 0.022; p < 0.002).Conclusion: Gynoid fat is associated with BMD in the hip independently of age and ASMM.

Exercise Mitigates Bone Loss in Women With Severe Obesity After Roux-en-Y Gastric Bypass: A Randomized Controlled Trial.

CONTEXT: Bone loss after bariatric surgery potentially could be mitigated by exercise. OBJECTIVE: To investigate the role of exercise training (ET) in attenuating bariatric surgery-induced bone loss. DESIGN: Randomized, controlled trial. SETTING: Referral center for bariatric surgery. PATIENTS: Seventy women with severe obesity, aged 25 to 55 years, who underwent Roux-en-Y gastric bypass (RYGB). INTERVENTION: Supervised, 6-month, ET program after RYGB vs. standard of care (RYGB only). OUTCOMES: Areal bone mineral density (aBMD) was the primary outcome. Bone microarchitecture, bone turnover, and biochemical markers were secondary outcomes. RESULTS: Surgery significantly decreased femoral neck, total hip, distal radius, and whole body aBMD (P < 0.001); and increased bone turnover markers, including collagen type I C-telopeptide (CTX), procollagen type I N-propeptide (P1NP), sclerostin, and osteopontin (P < 0.05). Compared with RYGB only, exercise mitigated the percent loss of aBMD at femoral neck [estimated mean difference (EMD), -2.91%; P = 0.007;], total hip (EMD, -2.26%; P = 0.009), distal radius (EMD, -1.87%; P = 0.038), and cortical volumetric bone mineral density at distal radius (EMD, -2.09%; P = 0.024). Exercise also attenuated CTX (EMD, -0.20 ng/mL; P = 0.002), P1NP (EMD, -17.59 ng/mL; P = 0.024), and sclerostin levels (EMD, -610 pg/mL; P = 0.046) in comparison with RYGB. Exercise did not affect biochemical markers (e.g., 25(OH)D, calcium, intact PTH, phosphorus, and magnesium). CONCLUSION: Exercise mitigated bariatric surgery-induced bone loss, possibly through mechanisms involving suppression in bone turnover and sclerostin. Exercise should be incorporated in postsurgery care to preserve bone mass.

Trabecular bone score: a useful clinical tool for the evaluation of skeletal health in women of short stature.

PURPOSE: Areal bone mineral density (aBMD) by DXA is underestimated in those with smaller bones and overestimated in those with larger bones. Trabecular bone score (TBS) predicts fracture risk, and is not influenced by bone size. The aim of this study was to evaluate TBS and BMD in women with short stature. METHODS: We retrospectively analyzed DXA scans of all women aged 50-90 years with short stature (<144 cm) obtained in a single center, from 2006 to 2016. The comparison group comprised women >161 cm in height, matched for age and LS BMD, selected from the same database. RESULTS: The study population included 342 women. The two groups were similar in age, and aBMD at the LS and total hip. Femoral neck aBMD was lower in cases than in taller women. In contrast, TBS was higher in women with short stature than in their taller counterparts (1.347 ± 0.102 vs. 1.250 ± 0.110; p < 0.001). Bone mineral apparent density (BMAD) and the LS TBS-adjusted BMD T-score were also significantly higher in shorter than in taller women. From the entire cohort, 121 women (67 cases) were osteoporotic by aBMD determinations. Among these subjects, TBS was also greater in cases (1.303 ± 0.103) than in women with standard height (1.190 ± 0.099; p < 0.001). Despite being considered osteoporotic, 36% of short women, but none of the taller ones, had a normal TBS. CONCLUSIONS: TBS can be a useful adjunct to aBMD for assessing bone quality in short women, in whom aBMD measurement tends to read lower, and, thus could overestimate fracture risk.

Sagittal Spinopelvic Alignment After Posterior Spinal Fusion in Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-analysis.

STUDY DESIGN: A systematic review and meta-analysis. OBJECTIVE: The aim of this study was to determine the differences in the sagittal spinopelvic parameters between the nonscoliotic controls, preoperative, and different time points postoperative in Lenke 1 and 5 adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The postoperative changes in the sagittal profile of Lenke 1 and 5 AIS at varying time points after posterior spinal fusion (PSF) has not been rigorously demonstrated; studies performed have had conflicting results. METHODS: Sagittal spinal and pelvic parameters, T5-T12 thoracic kyphosis (TK), L1-S1 lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and sagittal vertical axis (SVA), for Lenke 1 and 5 preoperatively, at immediate, less than 2-year, and more than 2-year postoperatively, and for nonscoliotic adolescents were searched. Differences in the sagittal spinopelvic parameters between preoperative and the follow-ups and between the nonscoliotic and pre- and postoperative AIS subtypes were calculated through meta-analysis. RESULTS: A total of 22 studies on Lenke1 (1229 patients), 13 studies on Lenke5 (437 patients), and 18 studies on controls (1636 patients) were reviewed. Among all the measured variables, only PI in Lenke1 was significantly different between the final follow-up and controls, P < 0.05. In Lenke 1, SVA was significantly more anterior at the immediate postoperative than preoperative, but continued moving posteriorly up to 2-year postoperative resulting in no significant difference in the SVA position between the final follow-up and preoperative, P > 0.05. In Lenke 5, SVA was significantly more posterior at the immediate postoperative and more anterior at the final follow-up than the preoperative measurements, p < 0.05. CONCLUSIONS: Continuous changes in the sagittal spinal parameters should be expected after PSF. Normalization of the sagittal spinal parameters appears to be the rule after PSF, and watchful waiting appears to be appropriate in this population when viewing the lateral X-ray postoperatively. LEVEL OF EVIDENCE: 4.

The obturator oblique and iliac oblique/outlet views predict most accurately the adequate position of an anterior column acetabular screw.

OBJECTIVE: Percutaneous fixation of the acetabulum is a treatment option for select acetabular fractures. Intra-operative fluoroscopy is required, and despite various described imaging strategies, it is debatable as to which combination of fluoroscopic views provides the most accurate and reliable assessment of screw position. MATERIALS AND METHODS: Using five synthetic pelvic models, an experimental setup was created in which the anterior acetabular columns were instrumented with screws in five distinct trajectories. Five fluoroscopic images were obtained of each model (Pelvic Inlet, Obturator Oblique, Iliac Oblique, Obturator Oblique/Outlet, and Iliac Oblique/Outlet). The images were presented to 32 pelvic and acetabular orthopaedic surgeons, who were asked to draw two conclusions regarding screw position: (1) whether the screw was intra-articular and (2) whether the screw was intraosseous in its distal course through the bony corridor. RESULTS: In the assessment of screw position relative to the hip joint, accuracy of surgeon's response ranged from 52% (iliac oblique/outlet) to 88% (obturator oblique), with surgeon confidence in the interpretation ranging from 60% (pelvic inlet) to 93% (obturator oblique) (P < 0.0001). In the assessment of intraosseous position of the screw, accuracy of surgeon's response ranged from 40% (obturator oblique/outlet) to 79% (iliac oblique/outlet), with surgeon confidence in the interpretation ranging from 66% (iliac oblique) to 88% (pelvic inlet) (P < 0.0001). CONCLUSIONS: The obturator oblique and obturator oblique/outlet views afforded the most accurate and reliable assessment of penetration into the hip joint, and intraosseous position of the screw was most accurately assessed with pelvic inlet and iliac oblique/outlet views. EVIDENCE: Clinical Question.

Current concepts in spondylopelvic dissociation.

INTRODUCTION: Spondylopelvic dissociation is an uncommon and complex injury that results from high-energy trauma with axial overloading through the sacrum. Due to the life-threatening nature of these injuries, standard Advanced Trauma Life Support® (ATLS) protocol must be used in the trauma setting as part of the initial management of these patients. The key to diagnosis is a good physical exam coupled with high level of suspicion. Radicular neurological deficits commonly are present in spondylopelvic dissociation (L5's roots) and should be documented for future evaluations. Radiographic views and CT-scan is preferred for the diagnosis. BIOMECHANICS AND CLASSIFICATION: The authors briefly describe the anatomy and biomechanics of the pelvis, and present the main classifications used to define this rare lesion. TREATMENT: Discussion about setting the boundaries of surgical stabilization, if there is still a role for conservative treatment, the importance of the initial treatment and the timing of intervention. Decompression is mandatory in the presence of canal compromise and progressive neurological deficit, regardless of biomechanical criteria for surgery. Kyphotic deformity occurs at the site of sacral transverse fracture and also reduces anteroposterior pelvis diameter. The technique of reduction and posterior surgical stabilization is emphasized. If residual kyphosis remains after bilateral lumbopelvic fixation by shifting of the lower sacral segment, we use S2 and/or S3 screws connected to transitional rods to additional reduction. An illustrated case is shown. COMPLICATIONS: The infection of the wound and the failure of the implants are the most frequent complications of this surgical treatment. CONCLUSION: Posterior stabilization is widely recognized as crucial in the treatment of pelvic disruptions. The concept of circumferential restoration of pelvic ring by bilateral lumbopelvic fixation and anterior fixation seems to be a nice option to increase stabilization and avoid bone misalignment.

Osteology and radiology of the Maned Wolf (Chrysocyon brachyurus) pelvic limb.

This study describes the osteology and radiology of the pelvic limb in maned wolves. Ten (five live and five dead) maned wolves (Chrysocyon brachyurus), five males and five females, aged from 2 to 7 years old were used. Digital radiographs were taken and recorded for both pelvic limbs in all animals. Osteology was correlated with the radiographic images. The pelvis had a rectangular shape, and the obturator foramen (foramen obturatum) was oval. The femoral neck (collum femoris) was short and thick. The greater trochanter (trochanter major) extended proximally to near the dorsum of the femoral head (caput ossis femoris). The lateral femoral condyle (condylus lateralis) was larger than the medial condyle (condylus medialis), and the intercondylar fossa (fossa intercondylaris) had a slightly oblique orientation. The proximal tibia displayed medial and lateral condyles with the medial larger. The femur was slightly shorter than the tibia. Seven tarsal bones (ossa tarsi) were present, four long metatarsal bones (ossa metatarsalia II - V) and a short first metatarsal bone (os metatarsal I).

Percutaneous Sacroiliac Screw Technique.

Remembering that preoperative planning, surgical indications, and fracture reduction are paramount for this procedure, presented here is our technique for performing percutaneous sacroiliac screws, both transiliac-transsacral and sacral style. A combination of video, still pictures, and fluoroscopy images will guide the viewer through the process we routinely use highlighting specific details. Patient positioning and intraoperative fluoroscopy imaging are critical to a successful procedure. Although inlet and outlet films remain important, we find the procedure best started on the lateral sacral view to reduce the need for start site, trajectory, and imaging position changes during the case. A cannulated pig sticker (drill guide) used with long drill tip guide wires provide improved manual control to both finding a good start site and directing the trajectory. For patient safety, sacral anatomy and safe zones are discussed as well. Using these technical points will help make this a successful procedure.