Assessment of interobserver reliability for the letournel and judet classification / Avaliação da confiabilidade interobservadores para a classificação de letournel e judet

ABSTRACT Introduction: The Judet and Letournel classification is the most widely used classification system for acetabular fractures. Some complex fractures couldn't be classified according to this classification. The main purpose of this study was to evaluate the reliability of the Letournel and Judet classification system for acetabular fractures. Material and methods: 10 acetabular fractures were analyzed among 17 orthopedic surgeons. The surgeons were asked to classify the fractures according to the Judet and Letournel classification. Their experience, the number of surgeries, and the incision type that the surgeon uses for the anterior part of the acetabulum were recorded. Results: The overall interobserver agreement for the Letournel classification was found to be poor, with a Kappa value of 0.287. The Kappa value for interobserver agreement was 0.224 for plain radiographs, 0.293 for 2D-CT, and 0.321 for 3D-CT scans. There was no significant difference between the incision types used by the surgeons. The highest reliability was determined among the surgeons who operate on 10-20 acetabular fractures per year, with a Kappa value of 0.309. Conclusion: This results revealed that the Judet and Letournel Judet classification is not sufficient to classify acetabular fractures because of unclassified fractures and the complex algorithm of the system. Level of Evidence III; Comparative Retrospective Study.

RESUMO Introdução: A classificação de Judet e Letournel é o sistema de classificação mais amplamente utilizado para fraturas acetabulares. Algumas fraturas complexas, porém, não puderam ser classificadas de acordo com esta classificação. O principal objetivo deste estudo foi avaliar a confiabilidade do sistema de classificação de Judet e Letournel para fraturas acetabulares. Material e métodos: Foram selecionadas aleatoriamente 10 fraturas acetabulares de um banco de dados. Participaram do estudo 17 cirurgiões ortopédicos. Foi solicitado aos cirurgiões que classificassem as fraturas de acordo com a classificação de Judet e Letournel. Suas experiências, o número de cirurgias e o tipo de incisão que o cirurgião utiliza para a parte anterior do acetábulo foram registrados. Resultados: A concordância interobservadores geral para a classificação de Judet e Letournel foi considerada fraca, com um valor de Kappa de 0,287. O valor de Kappa para a concordância interobservadores foi de 0,224 para radiografias simples, 0,293 para tomografias computadorizadas em 2D e 0,321 para tomografias computadorizadas em 3D. Não houve diferença significativa entre os tipos de incisão utilizados pelos cirurgiões. A maior confiabilidade foi determinada entre os cirurgiões que operam de 10 a 20 fraturas acetabulares por ano, com um valor de Kappa de 0,309. Conclusão: Os resultados revelaram que a classificação de Judet e Letournel não é suficiente para classificar fraturas acetabulares devido a fraturas não classificadas e ao algoritmo complexo do sistema. Nível de Evidência III; Estudo Comparativo Retorpectivo.

Evaluation of the Association between Pelvic Diameters and Pelvic Types on Computed Tomography Images in Healthy Turkish Females / Evaluación de la Asociación entre Diámetros Pélvicos y Tipos de Pelvis en Imágenes de Tomografías Computarizadas en Mujeres Turcas Sanas

SUMMARY: Pelvis contributes to both human locomotion and obstetrics, and normal vaginal delivery is associated with a spacious inlet, a large interspinosus diameter. This paper aimed to measure crucial diameters of pelvic ring, and to determine both the prevalence of pelvic types, and labor types including normal vaginal delivery or caesarean section in Turkish healthy females. Additionally, it was aimed to evaluate presence of relationship between pelvic types and pelvic diameters. Labor shape of subjects was obtained from hospital records. This retrospective study was carried out on 165 healthy subjects aged between 18 and 45 years. Anteroposterior diameter of the pelvic inlet (APDI), anteroposterior diameter of the pelvic outlet, sacrum length (SL), sacrum depth, conjugata vera, obstetrical conjugate, the diagonal conjugate, diameter transversa, diameter bispinous, intertuberous diameter were measured. From these measurements, brim index was calculated and decided to gynecoid, anthropoid and platypelloid type. Also, the andoid type was calculated to the ratio of posterior sagittal diameter of the inlet to conjugata obstetrica. 50.91 % of participants has gynecoid type pelvis, followed by 24.85 % anthropoid type, 14.55 % platypelloid, and 9.70 % android type pelvis. There was a significant difference in APDI, SL, SD, Conjugata vera, Conjugata obstetrica, Conjugata diagonalis, Conjugata transversa, diameter bispinous, diameter intertubercularis and Brim index measurements according to pelvic types. the first degree of narrowing (conjugata vera from 11 to 9) was found in 18 pelvises and 12 pelvises with the pathological degree of narrowing bellonged to the platypelloid type followed by android type pelvis with 6 pelvices. The android type pelvis is not appropriate for natural labor and a good assessment of birth canal can reduce the labor risks. Also, only 7 females who delivered with cesarean have gynecoid type pelvic type. The APDI and SL were significantly lower in subjects having pathological narrowing according to conjugata obstetrica values.

La pelvis contribuye tanto a la locomoción humana como a la obstetricia. El parto vaginal normal se asocia con una entrada espaciosa y un diámetro interespinoso grande. Este artículo tuvo como objetivo medir diámetros cruciales del anillo pélvico y determinar tanto la prevalencia de los tipos pélvicos como los tipos de parto, incluido el parto vaginal normal o la cesárea en mujeres turcas sanas. Además, se buscó evaluar la presencia de relación entre los tipos de pelvis y los diámetros de la pelvis. La forma laboral de los sujetos se obtuvo de los registros hospitalarios. Este estudio retrospectivo se llevó a cabo en 165 mujeres sanas con edades comprendidas entre 18 y 45 años. Se midieron el diámetro anteroposterior de la entrada pélvica (APDPI), el diámetro anteroposterior de la salida pélvica, la longitud del sacro (SL), la profundidad del sacro, la conjugada vera, el conjugado obstétrico, el conjugado diagonal, el diámetro transverso, el diámetro biespinoso y el diámetro intertuberoso. A partir de estas mediciones se calculó el índice del ala y se decidió tipo ginecoide, antropoide y platipoide. Además, el tipo androide se calculó en función de la relación entre el diámetro sagital posterior de la entrada y la conjugada obstétrica. El 50,91 % de los participantes tenía pelvis de tipo ginecoide, seguida del 24,85 % de pelvis de tipo antropoide, el 14,55 % de tipo platipeloide y el 9,70 % de tipo androide. Hubo una diferencia significativa en las mediciones de APDPI, SL, SD, Conjugada vera, Conjugada obstétrica, Conjugada diagonal, Conjugata transversa, diámetro biespinoso, diámetro intertubercular e índice de ala según los tipos de pelvis. El primer grado de estrechamiento (conjugada vera del 11 al 9) se encontró en 18 pelvis y 12 pelvis, siendo el grado patológico de estrechamiento del tipo platipeloide seguido de pelvis tipo androide con 6 pelvis. La pelvis tipo androide no es apropiada para el parto natural y una buena evaluación del canal del parto puede reducir los riesgos. Además, solo 7 mujeres que dieron a luz por cesárea tenían un tipo pélvico de tipo ginecoides. El APDPI y SL fueron significativamente más bajos en mujeres que tenían estrechamiento patológico según los valores obstétricos conjugados.

Pedículo Renal: Análisis de sus Variantes / Renal Pedicle: Analysis of their Variants

Testut & Latarjet (1980), Bouchet & Cuilleret (1986), Latarjet & Liard (2005) y Rouvière & Delmas (2005) describen las relaciones intrínsecas del pedículo renal (PR) a partir de dos planos coronales, siendo la PER el elemento que limita entre ambos. Trivedi et al. (2011) demostró relaciones entre los elementos del PR que no coinciden con las descripciones aportadas por dichos autores.Conocer las posibles variantes en las relaciones intrínsecas del PR es de suma importancia en prácticas quirúrgicas como el trasplante renal (García de Jalón Martínez et al., 2003; Batista Hernández et al., 2010). Por lo tanto, el objetivo del presente trabajo fue analizar las variables relaciones entre los elementos que conforman el PR en la región yuxtahiliar del riñón. Se estudiaron 23 PR, formolizados al 10 % y provistos por el Equipo de Disección de la Segunda Cátedra de Anatomía de la Universidad de Buenos Aires. Se clasificaron los PR en dos grupos. En el Grupo I, las afluentes de origen de la vena renal (AOVR) se hallaban en el mismo plano coronal. En el grupo II, las AOVR se encontraban en diferentes planos coronales. Cada grupo fue subdividido en distintos patrones. Los patrones I y II, de mayor incidencia, fueron asociados al grupo I y los patrones III, IV y V al grupo II. En el patrón I, las AOVR eran anteriores a la pelvis renal (PER) y posteriores a la arteria prepiélica (APP). En el patrón II, las AOVR eran anteriores a la PER y a la APP. Los patrones I y II conforman el grupo I y presentaron mayor número de incidencia en nuestra investigación. Existen también variantes que inciden con menor frecuencia que dichos patrones, estas comprenden el grupo II de la clasificación planteada en el presente trabajo.

SUMMARY: Testut & Latarjet (1980), Bouchet & Cuilleret (1986), Latarjet & Liard (2005) y Rouvière & Delmas (2005) describe the intrinsic relationships of the renal pedicle (PR) from two coronal planes, the renal pelvis (PER) being the element that limits between both. Trivedi et al. (2011) showed relationships between the elements of the RP that do not coincide with the descriptions provided by these authors. Knowing the possible variants in the intrinsic relationships of the RP is of the utmost importance in surgical practices such as renal transplantation (García de Jalón Martínez et al., 2003). Therefore, the objective of this study is to analyze the variable relationships between the elements that make up the RP in the juxtahilar region of the kidney. 23 RP were studied, formalized at 10 % and provided by the Dissection Team of the Second Chair of Anatomy of the University of Buenos Aires. PRs were classified into two groups. In Group I, the tributaries of origin of the renal vein (RVOA) were in the same coronal plane. In group II, the AOVRs were in different coronal planes. Each group was subdivided into different patterns. Patterns I and II, with the highest incidence, were associated with group I and patterns III, IV and V with group II. In pattern I, the VROA were anterior to the renal pelvis (PER) and posterior to the prepelvic artery (PPA). In pattern II, AOVRs were prior to PER and APP. Patterns I and II make up group I and presented a higher number of incidence in our investigation. There are also variants that occur less frequently than these patterns, these comprise group II of the classification proposed in this work.

Axial Axis Metastasis / Metástase do eixo axial

Abstract Axial axis metastasis remains a challenge for surgical as well as other treatment modalities, like chemotherapy, immunotherapy, and radiotherapy. It is unequivocal that surgery provides pain improvements and preservation of neurological status, but this condition remains when associated with radiotherapy and other treatment modalities. In this review, we emphasize the current forms of surgical treatment in the different regions of the spine and pelvis. The evident possibility of percutaneous treatments is related to early or late cases, and in cases in which there are greater risks and instability to conventional surgeries associated with radiotherapy and have been shown to be the appropriate option for local control of metastatic disease.

Resumo As metástases no eixo axial permanecem um desafio para o tratamento cirúrgico bem como para outras modalidades, como quimioterapia, imunoterapia e radioterapia. É inequívoco que a cirurgia proporciona melhorias na dor e na preservação do status neurológico; porém, há permanência desta condição quando associada à radioterapia e a outras modalidades de tratamento. Nesta revisão damos ênfase às formas de tratamento cirúrgico atuais nas diferentes regiões da coluna vertebral e pelve. A evidente possibilidade de tratamentos percutâneos está relacionada a casos iniciais ou tardios, bem como a casos em que há maiores riscos e instabilidade às cirurgias convencionais associadas à radioterapia, e tem se mostrado a opção adequada para o controle local da doença metastática.

Sex Estimation of Medial Aspect of the Ischiopubic Ramus in Adults Based on Deep Learning / 法医学杂志

OBJECTIVES@#To investigate the reliability and accuracy of deep learning technology in automatic sex estimation using the 3D reconstructed images of the computed tomography (CT) from the Chinese Han population.@*METHODS@#The pelvic CT images of 700 individuals (350 males and 350 females) of the Chinese Han population aged 20 to 85 years were collected and reconstructed into 3D virtual skeletal models. The feature region images of the medial aspect of the ischiopubic ramus (MIPR) were intercepted. The Inception v4 was adopted as the image recognition model, and two methods of initial learning and transfer learning were used for training. Eighty percent of the individuals' images were randomly selected as the training and validation dataset, and the remaining were used as the test dataset. The left and right sides of the MIPR images were trained separately and combinedly. Subsequently, the models' performance was evaluated by overall accuracy, female accuracy, male accuracy, etc.@*RESULTS@#When both sides of the MIPR images were trained separately with initial learning, the overall accuracy of the right model was 95.7%, the female accuracy and male accuracy were both 95.7%; the overall accuracy of the left model was 92.1%, the female accuracy was 88.6% and the male accuracy was 95.7%. When the left and right MIPR images were combined to train with initial learning, the overall accuracy of the model was 94.6%, the female accuracy was 92.1% and the male accuracy was 97.1%. When the left and right MIPR images were combined to train with transfer learning, the model achieved an overall accuracy of 95.7%, and the female and male accuracies were both 95.7%.@*CONCLUSIONS@#The use of deep learning model of Inception v4 and transfer learning algorithm to construct a sex estimation model for pelvic MIPR images of Chinese Han population has high accuracy and well generalizability in human remains, which can effectively estimate the sex in adults.

Procedimiento clínico-quirúrgico en una paciente embarazada con una derivación urológica compleja. Reporte de un caso / Clinical-surgical approach in a pregnant patient with complex urological diversion. A case report

Resumen ANTECEDENTES: El mielomeningocele es el defecto del tubo neural más frecuente; se registra un caso por cada 1000 nacidos vivos. Es más frecuente en mujeres, que resultan con secuelas discapacitantes, entre ellas las urológicas. Pueden subsanarse con diferentes técnicas quirúrgicas y derivaciones urológicas complejas que las predispone a infecciones de vías urinarias de repetición y, cuando hay embarazo, complicaciones materno-fetales y dificultad para el acceso quirúrgico, en caso de cesárea. CASO CLÍNICO: Paciente con 14 semanas de embarazo, 27 años de edad, con diagnóstico de mielomeningocele y vesicoplastia, con múltiples infecciones urinarias y ruptura de membranas pretérmino. Finalización del embarazo por cesárea a las 33 semanas, por indicación de las condiciones fetales. La técnica de la cesárea se modificó para no dañar la cistoplastia y evitar complicaciones con las adherencias en la pelvis. CONCLUSIONES: El mejor pronóstico materno-fetal en pacientes con derivación urológica compleja se consigue con la búsqueda intencionada de infecciones urinarias y tratamiento oportuno y adecuado, además de una planificación multidisciplinaria al momento de la finalización del embarazo.

Abstract BACKGROUND: Myelomeningocele is the most common neural tube defect; one case per 1000 live births is reported. It is more frequent in females, resulting in disabling sequelae, including urological sequelae. They can be corrected with different surgical techniques and complex urological derivations that predispose them to repeated urinary tract infections and, when there is pregnancy, maternal-fetal complications and difficulty for surgical access, in case of cesarean section. CLINICAL CASE: Patient 14 weeks pregnant, 27 years old, diagnosed with myelomeningocele and vesicoplasty, with multiple urinary tract infections and preterm rupture of membranes. Termination of pregnancy by cesarean section at 33 weeks, due to fetal conditions. The cesarean section technique was modified so as not to damage the cystoplasty and to avoid complications with adhesions in the pelvis. CONCLUSIONS: The best maternal-fetal prognosis in patients with complex urologic diversion is achieved with the intentional search for urinary tract infections and timely and adequate treatment, in addition to multidisciplinary planning at the time of termination of pregnancy.

The relationship between fractures in pediatric polytrauma patients: evaluation of clinical outcomes / Relação das fraturas no paciente politraumatizado pediátrico: avaliação de desfechos clínicos

ABSTRACT Objective: To evaluate children and adolescents with polytrauma and fractures of the pelvis and proximal and diaphyseal femur and correlate the impact of these conditions and clinical outcomes. Methods: Retrospective study carried out in a public hospital in Taboão da Serra (SP), with pediatric patients with polytrauma from January 2012 to December 2021. In total, 44 patients were evaluated, 70.44% boys and 29.55% girls, aged from 12 to 17 years. Results: Diaphyseal fracture of the femur affected 70.44% of the patients, mainly caused by a fall from a height (56.81%). Linear external fixation was the most used treatment (45.45%). All patients were discharged from hospital. Conclusion: We found essential sociodemographic information: 84.11% of patients did not have associated injuries; 88.63% were hospitalized from 3 to 11 days; 90.91% did not need to be admitted to an ICU, 77.27% did not need reoperation, and 22.73% underwent another surgery; 45.45% used the external fixator to stabilize injuries; 11.36% converted the external fixator to the intramedullary nail; 9.09% needed an intramedullary nail remover; 2.27% converted to a plate (bilateral) and 2.27% to a rigid nail; 2.27% had loss of reduction and revision with rod; 2.27% underwent corrective osteotomy; 2.27% had clinical hospitalization; 2.27% had osteonecrosis of the femoral head and screws removed; 2.27% removed the plate. No deaths were recorded. Level of Evidence II, Retrospective Study.

RESUMO Objetivo: Avaliar crianças e adolescentes politraumatizados com fraturas da pelve, proximal e diafisária do fêmur e correlacionar o impacto dessas condições e desfechos clínicos. Métodos: Estudo retrospectivo realizado em hospital público de Taboão da Serra (SP), com pacientes pediátricos politraumatizados entre janeiro de 2012 e dezembro de 2021. Avaliaram-se 44 pacientes, 70,44% meninos e 29,55% meninas, de 12 a 17 anos. Resultados: A fratura diafisária fechada do fêmur acometeu 70,44%, sendo causada principalmente por queda de altura (56,81%). A fixação externa linear foi o tratamento mais utilizado (45,45%). Todos os pacientes receberam alta hospitalar. Conclusão: Identificaram-se importantes informações sociodemográficas: 84,11% dos pacientes não apresentaram lesões associadas; 88,63% ficaram internados de 3 a 11 dias; 90,91% não necessitaram de internação em unidade de terapia intensiva (UTI), 77,27% não precisaram ser reoperados; 22,73% realizaram nova cirurgia; 45,45% utilizaram fixador externo para estabilização de lesões;11,36% converteram o fixador externo para a haste intramedular; 9,09% precisaram remover as hastes intramedulares; 2,27% converteram para placa (bilateral) e 2,27% para haste rígida; 2,27% tiveram perda de redução e revisão com haste; 2,27% realizaram osteotomia corretiva; 2,27% tiveram internação clínica; 2,27% tiveram osteonecrose da cabeça femoral e parafusos removidos; e 2,27% retiraram a placa. Não foram observados óbitos. Nível de Evidência II, Estudo Retrospectivo.

Effects of 450 nm diode blue laser on the vaporization and incision of renal pelvis tissue ex vivo / 现代泌尿外科杂志

【Objective】 To investigate the effects of 450 nm diode blue laser on the morphological changes and thermal damage of renal pelvis under different conditions. 【Methods】 An ex vivo study was conducted on a fresh porcine pelvis model (7 cm×5 cm×3 cm). The laser fiber was fixed on the mechanical arm perpendicular to the renal pelvis tissue, and the distance between them was 1-2 mm. The renal pelvis tissue was incised at a speed of 1-2 mm/s and power of 5-30 W. After the incised tissue was fixed in formalin (4%), the morphology, depth, width and coagulation thickness were observed with naked eyes and a microscope. 【Results】 The different powers had different vaporization and incision effects. When the operating distance was 2 mm, the speed was 2 mm/s and power was 5 W, the vaporization depth, width and coagulation thickness were approximately 0 9 mm, 0.25 mm and 0.35 mm, respectively. With the increase of power, the vaporization width and depth increased, and the coagulation thickness was 0.35-0.50 mm. When the power was more than 10 W, the renal pelvis tissue was easily penetrated. When the laser power was 20 W, the section of the renal pelvis showed an irregular shape of vaporization. When the operating distance was 1 mm, the whole renal pelvis tissue was easily vaporized. When it was 2 mm, a wide and safe energy treatment window was produced. 【Conclusion】 The 450 nm diode blue laser can vaporize and incise renal pelvis tissue safely and effectively, with high precision and little thermal damage. It is expected to be a new surgical tool in the treatment of renal pelvis lesions.

Analysis of 7 cases of delayed diagnosis of primary upper tract urothelial carcinoma with calculi / 现代泌尿外科杂志

【Objective】 To reduce the misdiagnosis rate by analyzing the clinical data of patients with primary upper tract urothelial carcinoma (UTUC) complicated with calculi. 【Methods】 Clinical data of 7 UTUC with calculi patients treated during Sep.2018 and Apr.2022 were retrospectively analyzed, including general data, time from visit to diagnosis, imaging data, urine exudation cytological results, surgical methods, pathological stages and follow-up data. 【Results】 The ratio of male to female was 3∶4, and the mean age was 66.4 (55-72) years. The initiate imaging examination results only showed calculi, but did not indicate suspicious tumor (including 1 case with missing data). The median time from the first visit to diagnosis was 12 months (5-36 months). Of all 7 cases, 2 (2/4) were clinically diagnosed by enhanced CT, 3 (3/4) by MRI, and 2 (2/7) by positive urine exudation cytology. All patients received surgical treatment. Postoperative pathology showed 85.71% (6/7) were high-grade UTUC. Postoperative staging was T1N0M0 in 4 cases, T3N0M0 in 2 cases, and T4N2M0 in 1 case. Adjuvant chemotherapy was conducted in 2 cases. During the median follow-up of 12 months (6-41), 1 case developed multiple systemic metastases in month 9, while the other cases had no recurrence or metastasis. 【Conclusion】 For UTUC patients without obvious filling defect on imaging, especially when ipsilateral calculi were complicated, misdiagnosis should be alerted for timely treatment and better prognosis.

Sarcomatoid carcinoma of renal pelvis: a case report / 中华泌尿外科杂志

Sarcomatoid carcinoma of the renal pelvis is rare. One case of sarcomatoid carcinoma of the left renal pelvis was reported. The patient was diagnosed as sarcomatoid carcinoma of left pyelonephrosis by left percutaneous nephrolithotripsy (PCNL) and biopsy of left pyelonephrosis in another hospital due to left lumbar pain.The patient came to our hospital for laparoscopic left hemiculturectomy and was pathologically diagnosed as left renal pelvic sarcomatoid carcinoma. The patient suffered left retroperitoneal recurrence and bilateral lung metastasis 7 months after surgery and died of cachexia 10 months later.

Comparison of modified "double flaps" pyeloplasty and traditional pyeloplasty in the treatment of special types of hydronephrosis in children / 中华泌尿外科杂志

Objective:To compare the efficacy of modified "double flaps" pyeloplasty and traditional dismembered pyeloplasty in the treatment of special types of hydronephrosis with small pelvis and long proximal ureteral stricture in children.Methods:The data of 39 children with special types of hydronephrosis treated in Seventh Medical Center, General Hospital of PLA from June 2018 to June 2019 were retrospectively analyzed. Among them, 33 were boys and 6 were girls. The median age of the patients was 12.0(4.5, 63.5) months. Nine of them had left hydronephrosis and four children had right hydronephrosis. These patients with small pelvis existed the characteristics that the anteroposterior diameter of pelvis was smaller than 2.5 cm and these patients existed the symptom of hematuria, flank pain or recurrent urinary tract infection with the imaging revealing ureteral obstruction. The length of proximal ureteral stenosis ranged from 2.0 to 4.0 cm. Among 39 cases, 19 cases were operated with modified "double flaps" pyeloplasty, which was the modified "double flaps" pyeloplasty group. 20 cases were operated with traditional Anderson-Hynes pyeloplasty, which was traditional pyeloplasty group. The technique of modified "double flaps" pyeloplasty mainly included that the renal pelvis was cut into double flaps, the inferior flap was anastomosed with the spatulated ureter and the superior was covered, so that the length and caliber of the ureter were partial extended. The median age of two groups were 12.0 (6.0, 44.0) months and 12.0 (4.8, 62.8) months respectively, the anterior and posterior diameter of renal pelvis were (2.8±0.8)cm and (2.6±0.6)cm respectively, and split renal function were (36.7±5.1)% and (36.0±6.8)% respectively. There were no statistically significant differences in above parameters between the two groups( P>0.05). The clinical efficacy of the two groups were compared by collecting and comparing the operation related data and postoperative follow-up data. Results:The operation of 39 children in this study was successfully completed without conversion to open surgery.The operation time of "double flap" pyeloplasty group and traditional pyeloplasty group were (142.6±9.6) min and (124.5±8.6) min respectively, and the intraoperative anastomosis time were (56.1±7.2) min and (47.6±4.8) min respectively. There were significant difference in operation time and intraoperative anastomosis time between the two groups( P<0.05). Thirty-nine children were followed up normally without loss. The mean follow-up time was (27.7±2.5) months after surgery. In the "double flaps" pyeloplasty group, 2 cases suffered with fever who were diagnosed as urinary tract infection and improved after antibiotic treatment. In the traditional pyeloplasty group, 2 cases suffered with fever who were diagnosed as urinary tract infection and improved after antibiotic treatment. Two children had flank pain during follow-up to more than one year and the examination revealed that the anteroposterior diameter of the renal pelvis gradually increased. So surgery were performed again and the two children recovered. There were no significant differences in complication rate (2/19 and 4/20) and short-term surgical success rate(19/19 and 18/20) between the two groups ( P>0.05). Conclusions:The operation time and anastomosis time of the modified "double flap" technique for treating hydronephrosis are longer than those of the traditional method. But in the treatment of special types of hydronephrosis with small renal pelvis or long proximal ureteral stricture, it may have application prospects in reducing complications.

Robot-assisted screws fixation for the treatment of fragility fractures of the pelvis / 中华骨科杂志

Objective:To investigate the clinical outcomes of fragility fractures of the pelvis (FFP) treated with robot-assisted screws, minimally reduction according to the pelvic osseous pathways.Methods:A retrospective analysis was performed on the data of 50 elderly patients with FFP treated by the Department of Trauma and Pelvic Trauma of Tianjin Hospital from March 2016 to October 2021, and the 50 patients with FFP were divided into robotic-assisted screw fixation group (robot group) and open reduction steel plate fixation group (open group) according to the fixation method. There were 30 patients in the Robot group, 6 males and 24 females, average age 75.03±7.32 years (range, 60-90 years). According to Rommens and Hofmann FFP classification, there were 4 cases of IIc type, 8 cases of IIIa type, 1 case of IIIb type, 12 cases of IIIc type, 3 cases of IVa type, 2 cases of IVb type. There were 20 patients in the open group, 5 males and 15 females, average age 71.90±5.51 years (range, 62-85 years). According to Rommens and Hofmann FFP classification, there were 2 cases of IIc type, 6 cases of IIIa type, 9 cases of IIIc type, 3 cases of IVa type. The two groups were compared with age, pelvic fracture classification, operation time, intraoperative blood loss, fracture reduction quality, visual analogue scale (VAS), Majeed score, and wound healing or not.Results:All patients were followed up for 12.72 months (range, 6-24 months). In the robot group, the operation time was 50.17±19.32 min (range, 30-120 min), and intraoperative blood loss was 55.50±28.60 ml (range, 10-150 ml); in the open group, the operation time was 92.25±27.55 min (range, 60-180 min), and intraoperative blood loss was 217.50±67.20 ml (range, 150-400 ml), there were statistical differences ( t=6.36, P<0.001; t=11.72, P<0.001). According to Mears and Velyvis imaging evaluation criteria, in the robot group, anatomical reduction were achieved in 10 cases, satifactory reduction were achieved in 20 cases; in the open group, anatomical reduction were achieved in 14 cases, satifactory reduction were achieved in 6 cases, there were statistical differences (χ 2=6.46, P=0.011). In the robot group, VAS for pelvic pain was 7.33±1.32 points (range, 4-9 points) before operation, 4.13±1.07 points (range, 3-8 points) one week after surgery, and 2.30±0.84 points (range, 1-5 points) at the last follow-up; in the open group, VAS for pelvic pain was 7.45±1.23 points (range, 5-9 points) before operation, 5.25±1.25 points (range, 3-8 points) one week after surgery, and 2.80±1.24 points (range, 1-6 points) at the last follow-up, the difference between the two groups was statistically significant ( F=162.18, P<0.001; F=70.18, P<0.001), the difference between the two groups was statistically significant 1 week after surgery ( t=3.37, P=0.001), and there was no statistically significant difference between the two groups before surgery and the last follow-up ( P>0.05). The Majeed score was 82.10±4.80 (range, 65-95) in the robot group, 77.60±5.40 (range, 70-93) in the open group at the last follow-up, there were statistical differences ( t=3.09, P=0.003). There was no wound complication in the robot group, there were 4 cases with wound infection or rupture in the open group. One LC-II screw loosen in the robot group, which needed reoperation with cement, there was also 1 screw of plate loosening in the open group with no reoperation. Conclusion:Robot-assisted screws fixation with minimally reduction based pelvic osseous pathways shows satisfactory clinical outcomes, satisfactory reduction, effective pain relief, and fewer postoperative complications in treatment of elderly FFP.

Surgical method and clinical effect of modified LC-II screws for fragility fractures of the pelvis in the elderly / 中华骨科杂志

Objective:To investigate the surgical method of LC-II screws for fragility fractures of the pelvis (FFP) in the elderly and evaluate its clinical efficacy.Methods:A retrospective analysis was performed on 45 patients with FFPs operated in our department from January 2011 to January 2022. The clinical information was as follows. The FFP classification of pelvic fracture was IIIA in 26 cases and IIIB in 19 cases. Among them, 22 cases were fixed with closed reduction and modified LC-II screws (experimental group), and 23 cases were fixed with open reduction and reconstruction plates (control group). In the experimental group, there were 6 males and 16 females. The age range was 62-90 years, with an average of 73.2±9.2 years. The FFP classification of pelvic fracture was IIIA in 12 cases and IIIB in 10 cases. In the control group, there were 8 males and 15 females. The age range was 60-87 years, with an average of 72.8±6.6 years. FFP classification of pelvic fracture was IIIA in 14 cases and IIIB in 9 cases. After admission, pelvic X-ray and CT scan were performed, and the surgery was prepared. In the experimental group, after closed reduction of the posterior ring, the modified LC-II screw was inserted below the anterior inferior iliac spine (AIIS) toward the sacroiliac joint and penetrated the sacroiliac joint. For combined anterior ring fractures, the INFIX was used for anterior ring fixation. In the control group, the posterior ring was fixed with a reconstruction plate and/or sacroiliac screw after open reduction through the lateral rectus approach (LRA). The clinical efficacy was evaluated between the experimental group and the control group.Results:All 45 patients were successfully operated and followed up for 6 months to 3 years. All the pelvic fractures healed. In the experimental group of 22 cases, the time from injury to operation was 3-9 days, with an average of 5.8±1.9 days; the operation time was 25-70 min, with an average of 42.0±12.9 min. The intraoperative bleeding was 20-40 ml, with an average of 29.1±6.7 ml. According to the X-ray reduction evaluation criteria of Matta, 7 cases were excellent, 11 cases were good and 4 cases were medium, with an excellent and good rate of 81.8%. According to rehabilitation criteria of Majeed, 10 cases were excellent, 6 cases were good and 6 cases were fair, with a total excellent and good rate of 72.7%. At the last follow-up, sacroiliac joint pain was evaluated by VAS score: 0 in 10 cases, <3 in 7 cases, and 4-6 in 5 cases. No internal fixation loosening occurred. In the control group, the time from injury to operation was 5-20 days, with an average of 9.9±3.8 days; the operation time was 50-150 min, with an average of 89.1±29.5 min; the intraoperative bleeding was 220-1 000 ml, with an average of 509.2±214.3 ml. According to the X-ray reduction evaluation criteria of Matta, 16 cases were excellent, 4 cases were good and 3 cases was medium, with an excellent and good rate of 87.0%. According to rehabilitation criteria of Majeed, 12 cases were excellent, 6 cases were good and 7 cases were fair, with a total excellent and good rate of 78.3%. At the last follow-up, sacroiliac joint pain was evaluated by VAS score: 0 in 14 cases, <3 in 6 cases, and 4-6 in 3 cases. In the control group, posterior ring plate loosening was found in 2 cases and anterior ring pubic ramus plate and screw loosening was found in 4 cases, but there was no reduction loss.Conclusion:The modified LC-II screw is theoretically feasible in the treatment of FFP. Preliminary clinical results show good safety and efficacy, providing a new idea for minimally invasive treatment of FFP.

Surgical methods and treatment effects of the adult anterior dislocation of the sacroiliac joint / 中华骨科杂志

Objective:To explore the surgical methods and treatment effects of adult anterior dislocation of the sacroiliac joint (AADSJ).Methods:A multi-center retrospective case series study was conducted to analyze the clinical data of 25 cases admitted in 5 clinical centers (affiliations of authors in this article) from January 2016 to January 2021. There were 18 males and 7 females, aged 38.8±15.5 years (range, 18-83 years). The AADSJ clinical classification system was formulated based on the radiographic morphology of anterior dislocation of the sacroiliac joint, which includes two types. Type I: complete anterior dislocation of the sacroiliac joint, and displacement of the entire iliac auricular surface to the front of the sacrum. Type II: fracture of the sacroiliac joint combined with anterior dislocation, subdivided into 3 subtypes. Type IIa: iliac fracture involves the anterior 1/3 of the sacroiliac joint, and dislocation of the ilium anterior to the sacrum. Type IIb: iliac fracture involves the posterior 2/3 of the sacroiliac joint, and dislocation of the ilium anterior to the sacrum. Type IIc: iliac fracture involves the posterior 2/3 of the sacroiliac joint, and dislocation of the ilium anteromedial to the sacrum. The reliability and repeatability of the clinical classification, Tile classification and Young-Burgess classification were performed based on the results of two-phase assessments in four observers. The operations were performed by the lateral-rectus approach and the ilioinguinal approach. The operation time and intraoperative bleeding were recorded. Pelvic X-ray and CT scan were rechecked after the operation. The quality of fracture reduction was evaluated according to Matta score. The postoperative functional rehabilitation was evaluated according to the Majeed rehabilitation standard at one-year follow-up.Results:Among 25 cases in this study, there were 3 cases of Type I, 5 cases of Type IIa, 9 cases of Type IIb and 8 cases of Type IIc according to the clinical classification system. The Kappa values of reliability tests for the clinical classification, Tile classification and Young-Burgess classification were 0.681, 0.328 and 0.383, respectively. The Kappa values of repeatability tests for the clinical classification, Tile classification and Young-Burgess classification were 0.690, 0.221 and 0.395, respectively. The reliability and repeatability of the AADSJ clinical classification were significantly better than other classifications. There were 14 cases underwent lateral rectus abdominis approach and 11 cases underwent ilioinguinal approach. The operative time for managing anterior dislocation of the sacroiliac joint was 122.0±50.7 min (range, 65-148 min) through the lateral rectus abdominis approach, and through the ilioinguinal approach was 178.0±49.9 min (range, 110-270 min), with a significant difference ( t=2.76, P=0.011). The amount of intraoperative blood loss through the lateral rectus approach was 680±330 ml (range, 350-2,120 ml), which was significantly less than that through the ilioinguinal approach (1,660±968 ml, 680-3,300 ml), with a significant difference ( t=3.55, P=0.002). The follow-up period was 1-3 years. At one week after surgery, the quality of fracture reduction evaluated by Matta score showed that the excellent and good reduction rate of the lateral-rectus approach was 79% (11/14), and that of the ilioinguinal approach was 73% (11/14), with no statistically significant difference ( P=1.000). At a one-year follow-up, according to Majeed's criteria, the overall excellent and good rate of the lateral-rectus approach was 64% (9/14), which is similar to 64% (7/11) of that of the ilioinguinal approach. No fracture reduction loss or internal fixation loosening failure occurred. Conclusion:The AADSJ clinical classification system can accurately describe the imaging features and clinical manifestations of AADSJ, with high reliability and repeatability. The AADSJ can be treated by the lateral-rectus approach or the ilioinguinal approach, with similar therapeutic effects but the former having less trauma.

Hemostatic effects of preperitoneal balloon tamponade with different volumes on hemodynamically unstable pelvic fracture-associated arterial and venous hemorrhage in a swine model / 中华创伤骨科杂志

Objective:To determine the effects of preperitoneal balloon (PPB) tamponade with different volumes of fluid on hemodynamically unstable pelvic fracture-associated arterial and venous hemorrhage in a swine model.Methods:A model of open-book pelvic fracture with injuries to external iliac vessels was established in 18 female 12-month old Bama miniature pigs. After the successful establishment of hemodynamically unstable pelvic fracture with vascular injury was confirmed by contrast agent imaging, the animals were randomized into 3 even groups ( n=6): a control group (group C) subjected to PPB tamponade with 0 mL fluid injected, group T1 subjected to PPB tamponade with 500-mL fluid injected, and group T2 subjected to PPB tamponade with 1,000-mL fluid injected. The 3 groups were compared in terms of 60-min survival rate, balloon pressure, peritoneal pressure, bladder pressure, 70-min survival rate, blood loss, and infusion volume. Results:There was no statistically significant difference in the basic hemodynamic or other experimental indicators among the 3 groups before experiment, indicating comparability ( P>0.05). The 60-min survival rate in group T2 was 100.0% (6/6), significantly higher than those in group C and group T1 [0.0% (0/6), 0.0% (0/6)] ( P<0.05). After fluid injection, the balloon pressure and preperitoneal pressure in group T2 were respectively (127.2±4.7) mmHg and (34.5±3.6) mmHg, significantly higher than those in group T1 [(78.7±3.8) mmHg and (13.7±2.8) mmHg] and in group C [0 mmHg and (9.0±1.4) mmHg], and the 2 indicators in group T1 were significantly higher than those in group C (all P<0.05). After fluid injection, there was no statistically significant difference among groups C, T1, and T2 in bladder pressure [(6.7±1.0) mmHg, (5.8±1.9) mmHg, and (6.0±1.1) mmHg] or in bleeding volume [(1,163.0±191.3) mL, (1,212.0±148.4) mL, and (975.0±133.2) mL] (all P≥ 0.05). The infusion volume in group T1 [(1,250.0±225.8) mL] was significantly larger than that in group C [(951.7±177.8) mL] ( P<0.05). No colorectal or bladder injuries were found by the anatomy of the experimental animals in 3 groups. Conclusions:PPB tamponade with 1,000-mL fluid injected in a swine model can efficiently control pelvic fracture-associated arterial and venous hemorrhage, and increase the 60-min survival rate with no colorectal or bladder injuries.

Progress in minimally invasive techniques for pelvic fractures / 中华创伤骨科杂志

Minimally invasive treatment is the development trend in surgical techniques for pelvic fractures. There have been numerous minimally invasive techniques for pelvic fractures, each having its own advantages. This paper reviews the literature recently published at home and abroad concerning minimally invasive treatment of pelvic fractures so as to summarize the existing minimally invasive techniques for the fractures and their supporting theories, hoping traumatic orthopedists to know more about the minimally invasive techniques. As a result, Chinese traumatic orthopedists may formulate personalized treatment protocols to suit the specific condition of each patient so that the surgical invasion can be minimized and the intraoperative and postoperative complications reduced.

Minimally invasive percutaneous anterior column screwing assisted by blocking screws for pelvic and acetabular fractures / 中华创伤骨科杂志

Objective:To investigate the feasibility and clinical efficacy of percutaneous anterior column screwing assisted by blocking screws for pelvic and acetabular fractures.Methods:A retrospective analysis was conducted of the 13 patients who had been admitted from July 2019 to April 2022 for pelvic and acetabular fractures. There were 8 males and 5 females with an age of (49.1±13.3) years, 7 acetabular fractures (6 on one side and 1 on both sides; by the Letournel-Judet classification: 5 anterior column fractures on 6 sides, and 2 transverse and posterior wall fractures on 2 sides), and 6 pelvic fractures (5 complicated with pelvic posterior ring fracture; by the Tile classification: 1 case of type B2, 3 cases of type C1, and 2 cases of type C2). According to the anatomic zones of the anterior column, 5 fractures were at zone Ⅲ, 3 ones at zone Ⅳ, and 6 ones at zone Ⅴ. The time from injury to surgery ranged from 3 to 14 days, averaging (8.2±2.9) days. Anterograde anterior column screwing assisted by blocking screws was performed for all the 13 patients; the posterior ring was fixated with percutaneous sacroiliac joint screws for the 5 patients complicated with pelvic posterior ring fracture. The surgical time, intraoperative fluoroscopy frequency, and intraoperative bleeding volume for insertion of anterior column screws, fracture reduction quality, and hip joint function at the last follow-up were recorded.Results:A total of 14 anterior column screws were inserted percutaneously in the 13 patients. For insertion of anterior column screws, the surgical time was (65.0±10.2) min, the intraoperative fluoroscopy frequency (63.5±14.5) times, and the intraoperative bleeding volume for each screw less than 30 mL. All the incisions healed primarily after surgery, without such complications as iatrogenic neurovascular injury or poor wound healing. All the 13 patients were followed up for (11.1±2.2) months after surgery. In the patient with bilateral acetabular anterior column fractures for which 2 anterior column screws had been inserted, one screw had to be removed due to its displacement at 1 month after surgery; no such complications as loosening of internal fixation or fracture re-displacement was found in the other patients. All fractures healed after (10.2±2.1) months. According to the Matta scoring for quality of fracture reduction, 7 sides were excellent, 5 sides good, and 2 sides poor; according to the Majeed scoring for the 6 patients with pelvic fracture at the last follow-up, the efficacy was rated as excellent in 4 cases and as good in 2 ones; according to the modified Merle d'Aubigné & Postel scoring for the 7 patients with 8 acetabular fractures at the last follow-up, the efficacy was rated as excellent in 4 hips, as good in 3 hips, and as fair in 1 hip.Conclusion:For pelvic and acetabular fractures, minimally invasive percutaneous anterior column screwing assisted by blocking screws can result in fine clinical efficacy, in addition to its easy procedures, safety and reliability.

Fixation with a retrograde pubic ramus intramedullary nail for anterior pelvic ring fractures / 中华创伤骨科杂志

Objective:To explore the clinical efficacy of a retrograde pubic ramus intramedullary nail (RPRIN) in the treatment of anterior pelvic ring fractures.Methods:A retrospective study was conducted to analyze the 14 patients with anterior pelvic ring fracture who had been treated and followed up at Department of Traumatic Surgery, Tongji Hospital From June 2020 to February 2021. There were 10 males and 4 females with an age of (44.8±12.5) years. By the AO/OTA classification for pelvic fractures, 5 cases were type 61-A, 4 cases 61-B, and 5 cases type 61-C; by the Nakatani classification, 1 case belonged to unilateral zone Ⅰ fracture, 5 cases to unilateral zone Ⅱ fracture, 2 cases to unilateral zone Ⅲ fracture, 3 cases to right zone Ⅱ and left zone Ⅲ fracture, 2 cases to zone Ⅲ fracture on both left and right sides, and 1 case to zone Ⅱ fracture on both sides. The time from injury to operation was (7.8±1.8) days. All the anterior pelvic ring fractures were fixated with a RPRIN. The time and fluoroscopic frequency for placement of every single RPRIN, quality of fracture reduction, and pelvic function and incidence of postoperative complications at the last follow-up were recorded.Results:A total of 18 RPRINs were placed in the 14 patients. For placement of each RPRIN, the time was (35.9±8.6) min, and the fluoroscopic frequency (22.8±1.9) times. No complications such as infection occurred at any surgical incision after RPRIN placement. According to the Matta scoring, the quality of postoperative fracture reduction was assessed as excellent in 7 cases, as good in 5 cases and as fair in 2 cases. The 14 patients were followed up for (18.1+1.5) months. Their X-ray and CT images of the pelvis at the last follow-up showed that the fractures healed well and the intramedullary nails were placed in the cortical bone of the anterior ring of the pelvis. According to the Majeed scoring at the last follow-up, the pelvic function was assessed as excellent in 10 cases, as good in 3 cases and as fair in 1 case. One patient reported discomfort during squatting 2 months after operation but the symptom improved 3 months later without any special treatment. No patient experienced such complications as displacement or slippage of RPRIN, or pain at the insertion site.Conclusion:RPRIN is effective in the treatment of anterior pelvic ring fractures, showing advantages of small surgical incision, limited intraoperative fluoroscopy and short operation time.

Open versus closed reduction and internal fixation in treatment of unstable pelvic fractures: a multicenter cohort study of long-term prognosis / 中华创伤骨科杂志

Objective:To compare the long-term prognosis between open versus closed reduction and internal fixation in the treatment of unstable pelvic fractures.Methods:The data of 402 consecutive patients with unstable pelvic fracture were retrospectively analyzed who had been treated at The First Medical Center and The Fourth Medical Center, PLA General Hospital, and Strategic Support Force Specialty Medical Center from March 2011 to March 2017. This cohort was divided into 2 groups according to the reduction methods. In the open group of 194 cases subjected to open reduction and internal fixation, there were 133 males and 61 females with a median age of 43.0 (30.7, 51.0) years, and 35 cases of type B and 159 cases of type C by the Tile classification. In the closed group of 208 cases subjected to closed reduction and internal fixation, there were 115 males and 93 females with a median age of 45.5 (32.0, 56.0) years, and 40 cases of type B and 168 cases of type C by the Tile classification. The 2 groups were compared in terms of 12-items Short Form Health Survey (SF-12) scores [physical component summary (PCS) and mental component summary (MCS)] at the last follow-up, time from injury to operation, frequency of intraoperative X-ray fluoroscopy, intraoperative and postoperative blood transfusion, operation time, and quality of postoperative fracture reduction.Results:There was no statistically significant difference between the 2 groups in the preoperative general data except for the gender, showing the 2 groups were comparable ( P>0.05). This cohort of 402 patients was followed up for 7.8(6.2, 8.8) years. At the last follow-up, the PCS [49.9 (45.4, 55.4) points] and MCS [53.1 (46.4, 57.6) points] in the closed group were significantly higher than those in the open group [48.2 (41.4, 52.7) and 46.5 (40.6, 53.6) points] ( P<0.05). The closed group incurred significantly shorter time from injury to operation [6 (5, 8) d] and operation time [180 (126, 260) min] than the open group [9 (6, 13) d and 240 (165, 334) min], significantly less intraoperative and postoperative blood transfusion [1.5 (0, 4.0) U] than the open group [5.0 (2.9, 8.0) U], significantly higher frequency of intraoperative X-ray fluoroscopy [104.5 (85.0, 132.0) times] than the open group [21.0 (18.0, 26.0) times], and a significantly higher excellent and good rate of postoperative fracture reduction (92.8%, 193/208) than the open group (86.6%, 168/194) (all P<0.05). Conclusion:In the treatment of patients with unstable pelvic fractures, compared with open reduction and internal fixation, closed reduction and internal fixation can not only significantly shorten the waiting time and operation time of patients, reduce the transfusion during operation, but also achieve better fracture reduction to ultimately improve the quality of life of patients.

Gradual traction-unlocking closed reduction technique for Tile C old pelvic fractures / 中华创伤骨科杂志

Objective:To explore the technical points and efficacy of gradual traction-unlocking closed reduction technique (GT-UCRT) for Tile C old pelvic fractures.Methods:From August 2012 to June 2021, 6 patients with Tile C old pelvic fracture were treated and followed up at Department of Orthopedics, The Fourth Medical Center, General Hospital of Chinese PLA. They were 4 males and 2 females with an age of (35.8±10.5) years. By Tile classification: 4 cases of type C1.2, 1 case of type C1.3, and 1 case of type C2; time from injury to surgery: 153.8 (64.3, 204.8) days. The 6 patients were treated with GT-UCRT. The time for gradual traction reduction, operation time, hospital stay, intraoperative blood loss and complications were recorded. The modified Matta score was used to evaluate the reduction quality of pelvic fractures, and the Majeed score was used to evaluate the pelvic function at the last follow-up.Results:The 6 patients were followed up for (40.3±22.9) months (from 12 to 72 months) after surgery. The time for gradual traction reduction was (26.7±4.6) days, operation time (119.2±4.6) minutes, hospital stay (11.5±2.9) days, and intraoperative blood loss (533.3±189.6) mL. By the modified Matta score, the pelvic reduction after surgery was rated as satisfactory in 5 cases and as unsatisfactory in 1 case. The length disparity between both lower limbs in the 6 patients was (6.9±1.6) cm before surgery and (1.0±0.4) cm immediately after surgery, showing a statistically significant difference ( t=11.135, P<0.001). One fracture healed 3 months after surgery and 5 fractures 6 months after surgery. The Majeed pelvic score at the last follow-up was (80.8±9.0) points for the 6 patients, yielding 2 excellent cases, 3 good cases and 1 fair case. Delayed wound healing was reported in 1 patient, calf intermuscular venous thrombosis in 2 cases, and emotional anxiety and sleep disorder in 1 patient. No new lumbosacral plexus injury was found in any patient. Conclusions:In the treatment of Tile C old pelvic fractures, since our self-designed GT-UCRT combines the advantages of Ilizarov technique and unlocking closed reduction technique, it can not only protect the lumbosacral plexus but also obtain satisfactory reduction of the fracture.