Recurrent benign fibrous histiocytoma of the bone benefits from denosumab followed by malignant transformation: a case report.

Benign fibrous histiocytoma of the bone (BFHB) is a rare mesenchymal tumor, representing less than 1% of all benign bone tumors. This controversial entity is characterized by a mixture of fibroblasts arranged in a storiform pattern, varying amounts of osteoclast-type giant cells and foamy macrophages. Curettage or simple resection is usually curative. However, it was reported that up to 11% of the patients suffer from relapse. Here, we report a case of malignant transformation of BFHB after long-lasting disease stabilization under denosumab therapy.

Comparison of clinical outcome between surgical treatment and particle beam therapy for pelvic bone sarcomas: A retrospective multicenter study in Japan.

BACKGROUND: Few studies have compared the clinical outcomes of patients with pelvic bone sarcomas treated surgically and those treated with particle beam therapy. This is a multicenter retrospective cohort study which compared the clinical outcomes of patients with pelvic bone sarcoma who underwent surgical treatment and particle beam therapy in Japan. METHODS: A total of 116 patients with pelvic bone sarcoma treated at 19 specialized sarcoma centers in Japan were included in this study. Fifty-seven patients underwent surgery (surgery group), and 59 patients underwent particle beam therapy (particle beam group; carbon-ion radiotherapy: 55 patients, proton: four patients). RESULTS: The median age at primary tumor diagnosis was 52 years in the surgery group and 66 years in the particle beam group (P < 0.001), and the median tumor size was 9 cm in the surgery group and 8 cm in the particle beam group (P = 0.091). Overall survival (OS), local control (LC), and metastasis-free survival (MFS) rates were evaluated using the Kaplan-Meier method and compared among 116 patients with bone sarcoma (surgery group, 57 patients; particle beam group, 59 patients). After propensity score matching, the 3-year OS, LC, and MFS rates were 82.9% (95% confidence interval [CI], 60.5-93.2%), 66.0% (95% CI, 43.3-81.3%), and 78.4% (95% CI, 55.5-90.5%), respectively, in the surgery group and 64.9% (95% CI, 41.7-80.8%), 86.4% (95% CI, 63.3-95.4%), and 62.6% (95% CI, 38.5-79.4%), respectively, in the particle beam group. In chordoma patients, only surgery was significantly correlated with worse LC in the univariate analysis. CONCLUSIONS: The groups had no significant differences in the OS, LC, and MFS rates. Among the patients with chordomas, the 3-year LC rate in the particle beam group was significantly higher than in the surgery group.

Effectiveness of RF ablation and cementoplasty in enhancing functional capacity in pelvic malignant bone metastases.

PURPOSE: Pelvic and sacral bone metastases cause significant morbidity. The primary aim of the study is to thoroughly evaluate the increase in functional capacity resulting from combined RF ablation and cementoplasty surgery applied to malignant bone metastases of the pelvic bones. METHODS: Twenty patients who underwent RF ablation and cementoplasty for malign pelvic bone and sacrum metastases between January 2014 and December 2021 were retrospectively identified. The inclusion criteria were having a life expectancy of more than 1 month, being > 18 years old, and having at least 1 month of follow-up. The Visual Anlogue Scale (VAS) pain, Karnofsky Performance Status (KP), and Musculoskelatal Tumor Society (MSTS) scores were calculated. RESULTS: VAS pain values decreased, and KP values increased postoperatively (p = 0.006 and p = 0,013). There was no statistically significant increase in MSTS (p > 0.05). The correlation relationships between lesion filling ratio and VAS pain, KP, and MSTS scores were not statistically significant (p > 0.05). Cement leakage was observed in 5 patients (25.0%), and no symptoms related to this leakage were observed. CONCLUSION: The pelvic region, given its close proximity to blood vessels, nerves, and joint areas, along with the distinct challenges associated with its surgery, requires separate evaluation. In studies evaluating applications in the isolated pelvic ring region, as in our study, functional gains have been most comprehensively assessed in this study, demonstrating that the procedure results in significant functional improvements.

Pelvic insufficiency fractures and pelvic bone metastases after neoadjuvant (chemo)radiotherapy for rectal cancer.

BACKGROUND: Pelvic insufficiency fractures (PIFs) are a late complication of radiotherapy for pelvic malignancies. We evaluated the incidence, radiologic findings, clinical course, and outcome of PIFs in patients treated with neoadjuvant (chemo)radiotherapy ((C)RT) for rectal cancer. MATERIAL AND METHODS: Data of patients diagnosed with rectal cancer from a large teaching hospital treated from 2002 to 2012 were extracted from the Dutch Cancer Registry. All hospital records were reviewed for the diagnosis of PIFs or pelvic bone metastases. An expert radiologist reassessed all imaging procedures of the lower back, abdomen, and pelvis. RESULTS: A total of 513 rectal cancer patients were identified of whom 300 patients (58.5%) were treated with neoadjuvant (C)RT (long- vs. short-course radiotherapy: 91 patients [17.7%] vs. 209 [40.7%], respectively). Twelve PIFs were diagnosed initially according to hospital records and imaging reports of all 513 patients. These 12 patients were treated with neoadjuvant (C)RT. After reassessment of all pelvic imaging procedures done in this patient group (432 patients (84.2%)), 20 additional PIFs were detected in patients treated with neoadjuvant (C)RT, resulting in a 10.7% PIF rate in irradiated patients. One PIF was detected in the group of patients not treated with neoadjuvant (C)RT for rectal cancer. This patient had palliative radiotherapy for prostate cancer and is left out of the analysis. Median follow-up time of 32 PIF patients was 49 months. Median time between start of neoadjuvant (C)RT and diagnosis of PIF was 17 months (IQR 9-28). Overall median survival for patients with PIF was 63.5 months (IQR 44-120). CONCLUSION: PIFs are a relatively common late complication of neoadjuvant (C)RT for rectal cancer but are often missed or misdiagnosed as pelvic bone metastases. The differentiation of PIFs from pelvic bone metastases is important because of a different treatment and disease outcome.

Numerical Evaluations of an Uncemented Acetabular Component in Total Hip Arthroplasty: Effects of Loading and Interface Conditions.

Using finite element (FE) models of intact and implanted hemipelvises, the study aimed to investigate the influences of musculoskeletal loading and implant-bone interface conditions on preclinical analysis of an uncemented acetabular component after total hip arthroplasty (THA). A new musculoskeletal loading dataset, corresponding to daily activities of sitting up-down, stairs up-down and normal walking, for a pelvic bone was generated based on previously validated Gait2392 model. Three implant-bone interface conditions, fully bonded and debonded having two rim press-fits (1 mm and 2 mm), were analyzed. High tensile (2000-2415 µÏµ) and compressive strains (900-1035 µÏµ) were predicted for 2 mm press-fit, which might evoke microdamage in pelvic cortex. Strain shielding in periprosthetic cancellous bone was higher for bonded condition during sitting up activity, compared to other combinations of interface and loading conditions. Only the nodes around acetabular rim (less than 6%) were susceptible to interfacial debonding. Although maximum micromotion increased with increase in press-fit, postoperatively for all load cases, these were within a favorable range (52-143 µm) for bone ingrowth. Micromotions reduced (39-105 µm) with bone remodeling, indicating lesser chances of implant migration. Bone apposition was predominant around acetabular rim, compared to dome, for all interface conditions. Periprosthetic bone resorption of 10-20% and bone apposition of 10-15% were predicted for bonded condition. Whereas for press-fit (1 mm and 2 mm), predominant bone apposition of 200-300% was observed. This study highlights the importance of variations in loading and interface conditions on in silico evaluations of an uncemented acetabular component.

Interaction between Pelvic Bone Mineral Density and Sex Steroid Hormone on the Risk of Urinary Incontinence from National Health and Nutrition Examination Survey 2013-2014.

INTRODUCTION: The correlation between sex hormone levels and pelvic bone mineral density in people with urinary incontinence (UI) has not been evaluated. This study explored the association between sex hormones, pelvic bone mineral density, and UI, and analyzed the association between pelvic bone mineral density-combined sex hormones and UI in women. METHOD: The data of the National Health and Nutrition Examination Survey (NHANES) 2013-2014 were used in this cross-sectional study. Women aged 20 years and older with complete sex steroid hormone and pelvic bone mineral density data were included. Outcomes were stress UI (SUI), urgency UI (UUI), and mixed UI (MUI). Sex steroid hormone included testosterone, estradiol, and sex hormone binding globulin (SHBG). Multivariate logistic regression analyses with the odds ratios (ORs) and 95% confidence intervals (CIs) were used. RESULTS: Of 2,442 women, 579 had SUI, 202 had UUI, and 344 had MUI. The estimated multiplicative interactions were significantly between testosterone and pelvic bone mineral density, between SHBG and pelvic bone mineral density on UI (p = 0.002, p = 0.003), MUI (p = 0.036, p < 0.001), and SUI (p = 0.008, p = 0.044), respectively. High pelvic bone mineral density was associated with UI (p = 0.022) and MUI (p = 0.028) in the age <45-year-old subgroup. Multiplicative interactions were between testosterone and pelvic bone mineral density on all types of UI in the age <45-year-old subgroup, on SUI in women who did not have vaginal deliveries, and on UI in women who had more than one-time vaginal delivery. CONCLUSION: Our study found negatively multiplicative interactions between testosterone, SHBG, and pelvic bone mineral density on UI, MUI, and SUI. Similar results were found in women aged <45 years old and in women who had more than one-time vaginal delivery. Clinicians may consider testosterone or SHBG supplementation and pelvic density enhancement in women with SUI, MUI, and low endogenous testosterone levels.

Is a Washer a Mandatory Component in Young Trauma Patients with S1-S2 Iliosacral Screw Fixation of Posterior Pelvis Ring Injuries? A Biomechanical Study.

Background and purpose: Cannulated screws are standard implants for percutaneous fixa-tion of posterior pelvis ring injuries. The choice of whether to use these screws in combination with a washer is still undecided. The aim of this study was to evaluate the biomechanical competence of S1-S2 sacroiliac (SI) screw fixation with and without using a washer across three different screw designs. Material and Methods: Twenty-four composite pelvises were used and an SI joint injury type APC III according to the Young and Burgess classification was simulated. Fixation of the posterior pelvis ring was performed using either partially threaded short screws, fully threaded short screws, or fully threaded long transsacral screws. Biomechanical testing was performed under progressively increasing cyclic loading until failure, with monitoring of the intersegmental and bone-implant movements via motion tracking. Results: The number of cycles to failure and the corresponding load at failure (N) were significantly higher for the fully threaded short screws with a washer (3972 ± 600/398.6 ± 30.0) versus its counterpart without a washer (2993 ± 527/349.7 ± 26.4), p = 0.026. In contrast, these two parameters did not reveal any significant differences when comparing fixations with and without a washer using either partially threaded short of fully threaded long transsacral screws, p ≥ 0.359. Conclusions: From a biomechanical perspective, a washer could be optional when using partially threaded short or fully threaded long transsacral S1-S2 screws for treatment of posterior pelvis ring injuries in young trauma patients. Yet, the omission of the washer in fully threaded short screws could lead to a significant diminished biomechanical stability.

The Association of Pelvic Bone Mineral Density and With Proximal Femoral and Spine Bone Mineral Density in Post-menopausal Women.

Pelvic fragility fractures result in significant morbidity and their incidence has increased over the past 30 years. One of the main risk factors in skeletal fragility is bone mineral density (BMD). Most of the current literature has focused on understanding spine and hip BMD. We aimed to measure the BMD of pelvis in a cohort of post-menopausal women and compare it to BMD at other skeletal sites. A questionnaire regarding risk factors for osteoporosis was completed by each participant. DXA scan of the pelvis was performed using research software. Three areas of the pelvis corresponding to common fractures were defined on pelvic DXA: R1 = symphysis public, R2 = inferior public rami, R3 = superior public rami. Pelvic BMD was calculated as the average BMD of R1-3. BMD at each location was reported as mean and standard deviation (SD). ANOVA was used to compare BMD between R1-R3 and pelvis, femoral neck, total hip, and spine. Pearson correlation was used to correlate pelvic BMD to BMD of proximal femur and spine. BMD was compared in four participant groups: 1- osteoporosis in spine and hip, 2- osteoporosis in spine only, 3-osteoporosis in hip only, and 4- no osteoporosis in spine and hip. The effect of diabetes and obesity on BMD at various skeletal sites was analyzed. Among the one hundred postmenopausal women enrolled in the study, age was: 64 ± 8, 31% were obese (BMI ≥ 30), and 8% had a diagnosis of type 2 diabetes. Pelvic area R3 had significantly higher BMD than R1 or R2 (p < 0.001). Pelvic BMD (0.50 ± 0.16) was significantly lower than total hip (0.70 ± 0.20) and spine BMD (0.97 ± 0.19) (p < 0.001). Pelvic BMD correlated with BMD at other skeletal locations, with the highest correlation with total hip (total hip: R2: 0.70, femoral neck R2: 0.50, spine R2: 0.65). Pelvic BMD was significantly lower in patients with osteoporosis of both hip and spine compared to the group without osteoporosis at both locations (p = 0.02). Obesity and type 2 diabetes were both associated with significantly higher BMD at pelvis, spine, and total hip. Pelvic BMD is lower than at other skeletal sites and is highly correlated with total hip area bone density. Obesity and type 2 diabetes are associated with higher pelvic BMD. To establish guidelines for the treatment pelvic BMD, studies defining the association of pelvic BMD with pelvic fracture risk are needed.

Percutaneous posterior transiliac plate versus iliosacral screw fixation for posterior fixation of Tile C-type pelvic fractures: a retrospective comparative study.

BACKGROUND: This study aimed to compare the clinical outcomes and complications between two minimally invasive surgical techniques: percutaneous transiliac plate fixation and iliosacral (IS) screw fixation for the treatment of Tile C-type pelvic bone fractures. METHODS: We retrospectively reviewed the data of 77 consecutive patients with Tile C pelvic ring injuries who underwent either percutaneous transiliac plate fixation or IS screw fixation in a single academic center between November 2007 and January 2018. We recorded patients' demographics, surgery-related data, and postoperative surgical outcomes and compared the incidence of complications and revision surgery rates between the two groups. RESULTS: Overall, 14 patients were included in the plate group, while 63 were included in the IS screw fixation group. No significant differences were observed in the patients' demographics between the two groups except for a longer interval from injury to surgery (13.5 days vs. 5.4 days, P = 0.001). Both groups acquired fracture union in all cases. There was one case of infection requiring surgical debridement in the plating group. Notably, nerve injury (n = 3) and implant loosening (n = 5) occurred in the IS screw group, but the difference was not significant. CONCLUSIONS: Both percutaneous posterior transiliac plating and IS screw fixation in patients with Tile C-type pelvic bone fractures showed good results. We recommend IS screw fixation as the primary treatment and propose posterior plating as treatment for sacral dysmorphism and bilateral sacral alar fractures in patients with spinopelvic dissociation. LEVEL OF EVIDENCE: III.

Internal Hemipelvectomy for primary bone sarcomas using intraoperative patient specific instruments- the next step in limb salvage concept.

BACKGROUND: During pelvic Sarcoma resections, Surgeons often struggle to obtain negative margins while minimizing collateral damage and maintaining limb function. These complications are usually due to the complex anatomy of the pelvis. Here we present an accurate 3D surgical approach, including pre-operative printing of models and intraoperative patient-specific instruments (PSIs) for optimizing pelvic sarcoma resections. METHODS: This single-center retrospective study (N = 11) presents surgical, functional, and oncological outcomes of patients (average age 14.6 +/- 7.6 years, 4 males) who underwent pelvic sarcoma resections using a 3D surgical approach between 2016 and 2021. All patients were followed up for at least 24 months (mean = 38.9 +/- 30.1 months). RESULTS: Our results show promising surgical, oncological, and functional outcomes. Using a 3D approach, 90.9% had negative margins, and 63.6% did not require reconstruction surgery. The average estimated blood loss was 895.45 ± 540.12 cc, and the average surgery time was 3:38 ± 0.05 hours. Our results revealed no long-term complications. Three patients suffered from short-term complications of superficial wound infections. At 24 month follow up 72.7% of patients displayed no evidence of disease. The average Musculoskeletal Tumor Society (MSTS) score at 12 months was 22.81. CONCLUSION: 3D technology enables improved accuracy in tumor resections, allowing for less invasive procedures and tailored reconstruction surgeries, potentially leading to better outcomes in function and morbidity. We believe that this approach will enhance treatments and ease prognosis for patients diagnosed with pelvic sarcoma and will become the standard of care in the future.

The use of a non-biological, bridging, antiprotrusio cage in complex revision hip arthroplasty and periacetabular reconstructive oncologic surgery. Is still today a valid option?: A mid/long-term survival and complications' analysis.

INTRODUCTION: Burch-Schneider-like antiprotrusio cages (B-SlAC) still remain helpful implants to bridge severe periacetabular bone losses. The purpose of this study was to evaluate outcomes and estimate both cages' failures and complication risks in a series of B-SlAC implanted in revision of failed total hip arthroplasties (THA) or after resection of periacetabular primary or secondary bone malignancies. Risk factors enhancing the chance of dislocations and infections were checked. MATERIALS AND METHODS: We evaluated 73 patients who received a B-SlAC from January 2008 to January 2018. Group A, 40 oncological cases (22 primary tumors; 18 metastases); Group B, 33 failed THAs. We compared both Kaplan-Meier estimates of risk of failure and complication with the cumulative incidence function, taking account the competing risk of death. Cox proportional hazards model was utilized to identify possible predictors of instability and infection. Harris hip score HHS was used to record clinical outcomes. RESULTS: Medium follow-up was 80 months (24-137). Average final HHS was 61 (28-92), with no differences within the two groups (p > 0.05). The probabilities of failure and complications were 57% and 26%, respectively, lower in the oncologic group than in the rTHA group (p =0 .176; risk 0.43) (p = 0.52; risk 0.74). Extended ileo-femoral approach and proximal femur replacement (p =0.02, risk ratio = 3.2; p = 0.04, rr = 2.1) were two significant independent predictors for dislocations, while belonging to group B (p = 0.04, rr = 2.6) was predictable for infections. CONCLUSION: Burch-Schneider-like antiprotrusio cages are a classical non-biological acetabular reconstruction method that surgeons should bear in mind when facing gross periacetabular bone losses, independently of their cause. However, dislocation and infection rates are high. Whenever possible, we suggest preserving the proximal femur in revision THA, and to use a less-invasive postero-lateral approach to reduce dislocation rates in non-oncologic cases.

Combination therapy with percutaneous osteoplasty and transcatheter arterial chemoembolization for the treatment of pelvic bone metastases: preliminary report.

PURPOSE: To compare the clinical efficacies of percutaneous osteoplasty (POP) and combination therapy with percutaneous osteoplasty and transcatheter arterial chemoembolization (POPTACE) for the treatment of pelvic bone metastases. METHODS: A retrospective study of 100 patients with pelvic bone metastases who had been treated by POP (n = 50) and POPTACE (n = 50) was conducted in this work. The clinical efficacies of these two treatments were evaluated by comparing their pain and functional abilities and bone metastases ability at the pre- and post-operative time points. RESULTS: POPTACE and POP treatments had no significant differences (P > 0.05) in VAS scores and KPS scores. Concerning tumor response, a partial response in 37 of 50 (74%) patients at 1 month for the POPTACE group and a partial response in 26 of 50 (52%) patients at 1 month for the POPC group were observed (P = 0.04). Although POPTACE and POP treatments had significant and similar ability in pain relief and functional recovery ability for the treatment of pelvic bone metastases, POPTACE treatment had a significantly better tumor response ability (partial response and stable response) compared with POP treatment. CONCLUSION: Both POP and POPTACE were effective methods for the treatment of pelvic bone metastases. Moreover, these initial outcomes suggest POPTACE treatment may be better than POP treatment. POPTACE treatment has great value and is worth promoting vigorously in orthopedics clinics.

Relationship of aortic bifurcation with sacropelvic anatomy: Application to anterior lumbar interbody fusion.

INTRODUCTION: Various sacropelvic parameters such as the pelvic Incidence (PI) are used to predict ideal lumbar lordosis and aid surgical planning. The objective of this study was to establish the relationship between the location of the aortic bifurcation from the sacral promontory and sacropelvic measures including the PI. MATERIALS AND METHODS: One hundred sixty five computed tomography (CT) scans obtained for major trauma including the entire spine were identified. Sacropelvic parameters including PI, sacral anatomic orientation, pelvic thickness (PTH), and sacral table angle were measured. Aortic bifurcation was identified on sagittal and coronal imaging and the distance from the sacral promontory (bifurcation-promontory distance [BPD]) measured (mm). RESULTS: Mean age of the cohort was 44.3 years (SD 18.5; range 16-88 years); 61.8% male. The mean PI was 49.2° (SD 10.2°; range 30°-80°). The mean BPD was 66.4 mm (SD 13.1 mm; range 38.3-100 mm). In the majority, the bifurcation was at the level of the L4 vertebral body (72.7%). Only age (r = -.389; p < .0001) and PTH (r = .172; p = .027) correlated with the BPD to a significant degree. PI did not correlate with BPD (r = .061; p = .435). Linear regression analysis provided the following predictive equation: BPD = 34.3 mm + 0.30 × PTH. CONCLUSION: This study demonstrates a lack of any meaningful correlation between sagittal pelvic parameters and the distance of the aortic bifurcation from the sacral promontory. Surgical planning for fusion surgery in the lumbar spine should include assessment of spinopelvic parameters and if anterior access to the lumbar disc(s) necessary, vascular anatomy should be carefully assessed independent of these measures.

Added Value of CT Pelvic Bone Unfolding Software to Radiologist Performance in Detecting Osteoblastic Pelvic Bone Lesions in Patients With Prostate Cancer.

PURPOSE: To evaluate the contribution of CT Bone Unfolding software to the diagnostic accuracy and efficiency for the detection of osteoblastic pelvic bone lesions in patients with prostate cancer. METHODS: A total of 102 consecutive (January 2016-September 2019) patients who underwent abdominopelvic CT with prostate cancer were retrospectively evaluated for osteoblastic pelvic bone lesions, using commercially available the post-processing-pelvic bone flattening-image software package "CT Bone Unfolding." Two radiologists with 3 and 15 years of experience in abdominal radiology evaluated CT image data sets independently in 2 separate reading sessions. At the first session, only MPR images and at the second session MPR images and additionally unfolded reconstructions were assessed. Reading time for each patient was noted. A radiologist with 25 years of experience, established the standard of reference. RESULTS: In the evaluations performed with the MPR-Unfold method, the diagnostic accuracy were found to be 2.067 times higher compared to the MPRs method (P < 0.001). The location of the lesions or the reader variabilities did not show any influence on accuracy (P > 0.05) For all readers the reading time for MPR was significantly longer than for MPR-Unfold (P < 0.05). For both methods substantial to almost-perfect inter-reader agreement was found (0.686-0.936). CONCLUSIONS: The use of unfolded pelvic bone reconstructions increases diagnostic accuracy while decreasing the reading times in the evaluation of pelvic bone lesions. Therefore, our findings suggest that utilizing unfolded reconstructions in addition to MPR images may be preferable in patients with prostate cancer for the screening of osteoblastic pelvic bone lesions.

Our experience of treating adult bone lymphoma, A retrospective cross-sectional study in a tertiary care center, Aga Khan University Hospital, Karachi.

OBJECTIVE: To determine the experience at the Aga Khan University Hospital in diagnosing and treating adult patients with primary lymphoma of bone. METHODOLOGY: All patients with Primary lymphoma of bone (PLB) that were diagnosed and/or treated at Aga Khan University Hospital, Karachi from 2005 to 2019 were included as part of this study. RESULTS: There were 17 patients with PLB including 13 (76.5%) males and 4 (23.5%) females with a mean age of 44 ± 16.5 years. Nine patients were between 30-59 years of age at diagnosis. The mean follow-up time of patients was 80±46.7 months. Six patients had tumours of pelvic bone followed by tibia (5) and femur (4). Four patients had a pathological fracture at the time of presentation whereas 2 (11.8%) required surgical fixation of the pathological fracture. The stage of the tumour was based on Ann Arbor classification. Nine (52.9%) cases had Stage 1 disease, 7 (41.2%) had stage IV disease with metastasis in extra nodal tissues. As for treatment, every patient received chemotherapy whereas 5 (29.4%) received adjuvant radiotherapy. Complete remission in the size of the tumour was seen in 11 (64.7%) patients while 6 (35.3%) had partial remission. Post-treatment, 4 (23.5%) patients expired. The mean Overall Survival (OS) time was 80.18 ± 46.71months with a survival rate of 76.5. CONCLUSIONS: Primary lymphoma of the bone can be treated with medical regime and good prophylactic surgeries to avoid pathological fracture such as intramedullary nailing.

Cage or Pelvic Graft-Study on Bony Fusion of the Ventral Thoracic and Lumbar Spine in Traumatic Vertebral Fractures.

Background and Objectives: Stabilization of the spine by cage implantation or autologous pelvic bone graft are surgical methods for the treatment of traumatic spine fractures. These methods serve to stably re-adjust the spine and to prevent late detrimental effects such as pain or increasing kyphosis. They both involve ventral interventions using interbody fusion to replace the intervertebral disc space between the vertebral bodies either by cages or autologous pelvic bone grafts. We examined which of these methods serves the patients better in terms of bone fusion and the long-term clinical outcome. Materials and Methods: Forty-six patients with traumatic fractures (12 cages; mean age: 54.08/34 pelvic bone grafts; mean age: 42.18) who received an anterior fusion in the thoracic or lumbar spine were included in the study. Postoperative X-ray images were evaluated, and fusion of the stabilized segment was inspected by two experienced spine surgeons. The time to discharge from hospital and gender differences were evaluated. Results: There was a significant difference of the bone fusion rate of patients with autologous pelvic bone grafts in favor of cage implantation (p = 0.0216). Also, the stationary phase of patients who received cage implantations was clearly shorter (17.50 days vs. 23.85 days; p = 0.0089). In addition, we observed a significant gender difference with respect to the bony fusion rate in favor of females treated with cage implantations (p < 0.0001). Conclusions: Cage implantations after spinal fractures result in better bony fusion rates as compared to autologous pelvic bone grafts and a shorter stay of the patients in the hospital. Thus, we conclude that cage implantations rather than autologous pelvic bone grafts should be the preferred surgical treatment for stabilizing the spine after fracture.

CT-guided fixation of pelvic fractures after high-energy trauma, by interventional radiologists: technical and clinical outcome.

OBJECTIVE: The aim of our study was to evaluate screw placement accuracy, safety, complications, and clinical outcomes including functional and pain score, in 32 patients treated with CT-guided pelvic ring fixation after high-energy trauma. MATERIALS AND METHODS: Consecutive patients who were treated by CT-guided fixation of sacral or acetabular fractures after high-energy trauma were included. All procedures were performed under general anesthesia, with dual CT and fluoroscopic guidance, by interventional radiologists. Fractures were minimally displaced or reduced unstable posterior pelvic ring disruptions, with or without sacroiliac disjunction (Tile B or C) and minimally displaced acetabular fractures. The primary outcome evaluated was screw accuracy. Secondary outcomes included patient radiation exposure, duration of the procedure, complications, clinical functional score (Majeed score), and pain scale (VAS, visual analog scale) evaluation during a follow-up period from 4 to 30 months postoperatively. RESULTS: Thirty-two patients were included (mean age 46) and 62 screws were inserted. Screw placement was correct in 90.3% of patients (95% of screws). Mean procedure duration was 67 min and mean patient radiation exposure was 965 mGy cm. Mean follow-up was 13 months and no complications were observed. The mean Majeed score at final follow-up was 84/100 and the mean VAS was 1.6/10. CONCLUSION: This technique is an effective and safe procedure in specific cases of pelvic ring and acetabulum fractures. It allows accurate screw placement in a minimally invasive manner, leading to effective management of poly-traumatized patients. KEY POINTS: • CT-guided pelvic ring fixation, including sacroiliac and acetabular fractures, is an effective and safe procedure. • It allows accurate and minimally invasive screw placement, leading to effective management of poly-traumatized patients. • Multidisciplinary cooperation is essential to ensure efficiency and safety.

Cementoplasty of pelvic bone metastases: systematic assessment of lesion filling and other factors that could affect the clinical outcomes.

OBJECTIVES: To evaluate lesion filling and other factors that could affect the clinical outcomes of cementoplasty for pelvic bone metastases. METHODS: We retrospectively reviewed the files of 40 patients treated for 44 pelvic bone metastases, collected the parameters related to patients (pain relief evaluated on a visual analog scale, subsequent fractures, and need for surgery), lesions (size, cortical breach score, fracture, soft-tissue extension), and cementoplasty procedures (number of needles, volume of cement, percentage of lesion filling, cement leaks, residual acetabular roof defect), and performed a statistical analysis. RESULTS: The lesions were on average 43.2 mm in diameter and the mean cortical breach score was 2.5 out of 6, with a pathological fracture in 14 lesions. The number of needles inserted was one in 32 out of 44, two in 10 out of 44, and three in 2 out of 44. On average, the volume of cement injected per lesion was 10.3 ml and the filling was 54.8%. Mild or moderate asymptomatic cement leakage occurred in 20 lesions (45.5%). The mean pain score was 84.2 mm before the procedure (with no correlation with lesion size, cortical breach score or fracture) and 45.6 mm at follow-up. The pain relief of 38.6 mm was statistically significant (p < 0.001) and did not correlate with the filling percentage. There were no fractures of the treated lesions at a mean follow-up of 355 days. CONCLUSIONS: Cementoplasty of pelvic bone metastases appears effective for providing pain relief and may prevent subsequent fractures. We were unable to demonstrate a correlation between the lesion filling and the degree of pain relief.

High Signal in Bone Marrow on Diffusion-Weighted Imaging of Female Pelvis: Correlation With Anemia and Fibroid-Associated Symptoms.

BACKGROUND: The diffusion-weighted imaging (DWI) signals of the female pelvic bone marrow show great variability and are usually high in female patients with fibroid-associated symptoms and anemia. PURPOSE: To ascertain clinical factors contributing to high signal intensity in the bone marrow of the female pelvis on DWI. STUDY TYPE: Retrospective case-control study. SUBJECTS: A single-institution review of 221 female patients underwent a pelvic magnetic resonance study from December 2012 to July 2014. FIELD STRENGTH/SEQUENCE: 1.5T/DWI (b = 0 and 1000) and apparent diffusion coefficient (ADC). ASSESSMENT: The ADC of pelvic bone marrow and the muscle-normalized signal intensity (SI) on DWI (mnDWI) were measured. A brightness grading scale ranging from 0 to 4 was used for pelvic bone assessment. Clinical factors, namely, age, the lowest hemoglobin level in the last 6 months, the presence of large uterine fibroids, and/or adenomyosis and fibroid-associated symptoms were recorded. STATISTICAL TESTS: The relationships between the brightness grade and clinical factors were evaluated through multinomial logistic regression, and correlations of mnDWI and the ADC with the clinical factors were analyzed through the Kruskal-Wallis test, Jonckheere's trend test, and the Mann-Whitney U-test with Bonferroni correction. RESULTS: Age and the hemoglobin level were inversely associated with the bone marrow brightness grade on DWI (both P < 0.05), whereas the presence of fibroid-associated symptoms showed a positive association (P = 0.028). The ADC and mnDWI in women younger than 50 years were significantly higher than those in older women (both P < 0.0001). The ADC had no significant correlation with anemia (P = 0.511), whereas mnDWI increased as the severity of anemia increased (P = 0.00154). DATA CONCLUSION: Our study showed an association of high DWI SI of pelvic bone marrow with anemia in premenopausal women. LEVEL OF EVIDENCE: 4 Technical Efficacy Stage 3 J. Magn. Reson. Imaging 2018;48:1024-1033.

Factors affecting mortality and reoperations in high-energy pelvic fractures.

AIM: Factors affecting mortality during the first year following high-energy pelvic fractures has not been reported previously. Nor has surgical complications leading to reoperations been reported in a cohort with only high-energy pelvic trauma patients. OBJECTIVES: The aim of this study was to report and analyse factors affecting outcome, in terms of mortality and reoperations, up to 1 year after the injury in patients with a traumatic pelvic ring injury due to a high-energy trauma. MATERIALS AND METHODS: Data from the SweTrau (Swedish National Trauma Registry) on patients admitted to the Trauma Centre Karolinska in Stockholm, Sweden, were collected. Inclusion criteria were adults (age ≥ 18), trauma with a high-energy mechanism, alive on arrival, Swedish personal identification number, reported pelvic fracture on CT scan. Patient records and radiographies were reviewed. The study period was 2011-2015 with 1-year follow-up time. Univariate and regression analysis on factors affecting mortality was performed. Risk of reoperation was analysed using univariate and case-by-case analysis. RESULTS: We included 385 cases with mean age 47.5 ± 20.6 years (38% females): 317 pelvic fractures, 48 acetabular fractures and 20 combined injuries. Thirty-day mortality was 8% (30/385), and 1-year mortality was 9% (36/385). The main cause of death at 1 year was traumatic brain injury (14/36) followed by high age (> 70) with extensive comorbidities (8/36). Intentional fall from high altitude (OR 6, CI 2-17), GCS < 8 (OR 12, CI 5-33) and age > 70 (OR 17, CI 6-51) were factors predicting mortality. Thirty patients (22%, 30/134) were further reoperated due to hardware-related (n = 18) or non-hardware-related complications (n = 12). Hardware-related complications included: mal-placed screws (n = 7), mal-placed plate (n = 1), implant failure (n = 6), or mechanical irritation from the implant (n = 4). Non-hardware-related reasons for reoperations were: infection (n = 10), skin necrosis (n = 1), or THR due to post-traumatic osteoarthritis (n = 1). CONCLUSION: Non-survivors in our study died mainly because of traumatic brain injury or high age with extensive comorbidities. Most of the mortalities occurred early. Intentional injuries and especially intentional falls from high altitude had high mortality rate. Reoperation frequency was high, and several of the hardware-related complications could potentially have been avoided.