Aims. Venous tumour thrombus (VTT) is a rare finding in osteosarcoma. Despite the high rate of VTT in osteosarcoma of the pelvis, there are very few descriptions of VTT associated with extrapelvic primary osteosarcoma. We therefore sought to describe the prevalence and presenting features of VTT in osteosarcoma of both the pelvis and the limbs. Methods. Records from a single institution were retrospectively reviewed for 308 patients with osteosarcoma of the pelvis or limb treated between January 2000 and December 2022. Primary lesions were located in an upper limb (n = 40), lower limb (n = 198), or pelvis (n = 70). Preoperative imaging and operative reports were reviewed to identify patients with thrombi in proximity to their primary lesion. Imaging and histopathology were used to determine presence of tumour within the thrombus. Results. Tumours abutted the blood vessels in 131 patients (43%) and encased the vessels in 30 (10%). Any form of venous thrombus was identified in 31 patients (10%). Overall, 21 of these thrombi were determined to be involved with the tumour based on imaging (n = 9) or histopathology (n = 12). The rate of VTT was 25% for pelvic osteosarcoma and 1.7% for limb osteosarcoma. The most common imaging features associated with histopathologically proven VTT were enhancement with contrast (n = 12; 100%), venous enlargement (n = 10; 83%), vessel encasement (n = 8; 66%), and visible intraluminal osteoid matrix (n = 6; 50%). Disease-specific survival (DSS) for patients with VTT was 95% at 12 months (95% CI 0.87 to 1.00), 50% at three years (95% CI 0.31 to 0.80), and 31% at five years (95% CI 0.14 to 0.71). VTT was associated with worse DSS (hazard ratio 2.3 (95% CI 1.11 to 4.84). Conclusion. VTT is rare with osteosarcoma and occurs more commonly in the pelvis than the limbs. Imaging features suggestive of VTT include enhancement with contrast, venous dilation, and vessel encasement. VTT portends a worse prognosis for patients with osteosarcoma, with a similar survivability to metastatic disease. Cite this article: Bone Joint J 2024;106-B(8):865–870

Aims. Controversy exists as to what should be considered a safe resection margin to minimize local recurrence in high-grade pelvic chondrosarcomas (CS). The aim of this study is to quantify what is a safe margin of resection for high-grade CS of the pelvis. Methods. We retrospectively identified 105 non-metastatic patients with high-grade pelvic CS of bone who underwent surgery (limb salvage/amputations) between 2000 and 2018. There were 82 (78%) male and 23 (22%) female patients with a mean age of 55 years (26 to 84). The majority of the patients underwent limb salvage surgery (n = 82; 78%) compared to 23 (22%) who had amputation. In total, 66 (64%) patients were grade 2 CS compared to 38 (36%) grade 3 CS. All patients were assessed for stage, pelvic anatomical classification, type of resection and reconstruction, margin status, local recurrence, distant recurrence, and overall survival. Surgical margins were stratified into millimetres: < 1 mm; > 1 mm but < 2 mm; and > 2 mm. Results. The disease-­specific survival (DSS) at five years was 69% (95% confidence interval (CI) 56% to 81%) and 51% (95% CI 31% to 70%) for grade 2 and 3 CS, respectively (p = 0.092). The local recurrence-free survival (LRFS) at five years was 59% (95% CI 45% to 72%) for grade 2 CS and 42% (95% CI 21% to 63%) for grade 3 CS (p = 0.318). A margin of more than 2 mm was a significant predictor of increased LRFS (p = 0.001). There was a tendency, but without statistical significance, for a > 2 mm margin to be a predictor of improved DSS. Local recurrence (LR) was a highly significant predictor of DSS, analyzed in a competing risk model (p = 0.001). Conclusion. Obtaining wide margins in the pelvis remains challenging for high-grade pelvic CS. On the basis of our study, we conclude that it is necessary to achieve at least a 2 mm margin for optimal oncological outcomes in patients with high-grade CS of the pelvis. Cite this article: Bone Joint J 2021;103-B(6):1150–1154

Aims . Osteosarcoma of the pelvis is a particularly difficult tumour to treat as it often presents late, may be of considerable size and/or associated with metastases when it presents, and is frequently chondroid in origin and resistant to chemotherapy. The aim of this study was to review our experience of managing this group of patients and to identify features predictive of a poor outcome. Patients and Methods. Between 1983 and 2014, 121 patients, (74 females and 47 males) were treated at a single hospital: 74 (61.2%) patients had a primary osteosarcoma and 47 (38.8%) had an osteosarcoma which was secondary either to Paget’s disease (22; 18.2%) or to previous pelvic irradiation (25; 20.7%). . The mean age of those with a primary osteosarcoma was 29.3 years (nine to 76) and their mean follow-up 2.9 years (0 to 29). The mean age of those with a secondary sarcoma was 61.9 years (15 to 85) and their mean follow-up was one year (0 to 14). . A total of 22 patients with a primary sarcoma (52.4%) and 20 of those with a secondary sarcoma (47.6%) had metastases at the time of presentation. . Results. The disease-specific survival at five years for all patients was 27.2%. For those without metastases at the time of diagnosis, the five-year survival was 32.7%. Factors associated with a poor outcome were metastases at diagnosis and secondary tumours. In primary osteosarcoma, sacral location, surgical margin and a diameter > 10 cm were associated with a poor outcome. Conclusion. In this, the largest single series of patients with an osteosarcoma of the pelvis treated in a single hospital, those with secondary tumours and those with metastases at presentation had a particularly poor outcome. For those with a primary sarcoma, sacral location, an intralesional margin and a diameter of > 10 cm were poor prognostic indicators. Cite this article: Bone Joint J 2016;98-B:555–63

Aims. Due to the complex anatomy of the pelvis, limb-sparing resections of pelvic tumours achieving adequate surgical margins, can often be difficult. The advent of computer navigation has improved the precision of resection of these lesions, though there is little evidence comparing resection with or without the assistance of navigation. Our aim was to evaluate the efficacy of navigation-assisted surgery for the resection of pelvic bone tumours involving the posterior ilium and sacrum. . Patients and Methods. Using our prospectively updated institutional database, we conducted a retrospective case control study of 21 patients who underwent resection of the posterior ilium and sacrum, for the treatment of a primary sarcoma of bone, between 1987 and 2015. The resection was performed with the assistance of navigation in nine patients and without navigation in 12. We assessed the accuracy of navigation-assisted surgery, as defined by the surgical margin and how this affects the rate of local recurrence, the disease-free survival and the effects on peri-and post-operative morbidity. . Results. The mean age of the patients was 36.4 years (15 to 66). The mean size of the tumour was 10.9 cm. In the navigation-assisted group, the margin was wide in two patients (16.7%), marginal in six (66.7%) and wide-contaminated in one (11.1%) with no intralesional margin. In the non-navigated-assisted group; the margin was wide in two patients (16.7%), marginal in five (41.7%), intralesional in three (25.0%) and wide-contaminated in two (16.7%). Local recurrence occurred in two patients in the navigation-assisted group (22.2%) and six in the non-navigation-assisted group (50.0%). The disease-free survival was significantly better when operated with navigation-assistance (p = 0.048). The blood loss and operating time were less in the navigated-assisted group, as was the risk of a foot drop post-operatively. Conclusion . The introduction of navigation-assisted surgery for the resection of tumours of the posterior ilium and sacrum has increased the safety for the patients and allows for a better oncological outcome. . Cite this article: Bone Joint J 2017;99-B:261–6

Resection of malignant bony tumours of the pelvis creates large bone and soft-tissue defects, and is frequently associated with complications such as wound dehiscence and deep infection. We present the results of six patients in whom a rectus abdominis myocutaneous (RAM) flap was used following resection of a malignant tumour of the pelvis. Bony reconstruction was performed using a constrained hip tumour prosthesis in three patients, vascularised fibular graft in two and frozen autograft in one. At a mean follow-up of 63 months (16 to 115), no patients had a problem with the wound. Immediate reconstruction using a RAM flap may be used after resection of a malignant tumour of the pelvis to provide an adequate volume of tissue to eliminate the dead space, cover the exposed bone or implants with well-vascularised soft tissue and to reduce the risk of complications. Cite this article: Bone Joint J 2014;96-B:270–3

Aims

Limb salvage for pelvic sarcomas involving the acetabulum is a major surgical challenge. There remains no consensus about what is the optimum type of reconstruction after resection of the tumour. The aim of this study was to evaluate the surgical outcomes in these patients according to the methods of periacetabular reconstruction.

Aims. It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis. Methods. In all, 91 nonambulatory patients with neuromuscular scoliosis were included. All underwent surgery using bilateral, segmental, pedicle screw instrumentation. A total of 40 patients underwent fusion to L5 and 51 had their fixation extended to the pelvis. The two groups were assessed for differences in terms of clinical and radiological findings, as well as complications. Results. The main curve (MC) was a mean of 90° (40° to 141°) preoperatively and 46° (15° to 82°) at two-year follow-up in the L5 group, and 82° (33° to 116°) and 19° (1° to 60°) in the pelvic group (p < 0.001 at follow-up). Correction of MC and pelvic obliquity (POB) were statistically greater in the pelvic group (p < 0.001). There was no statistically significant difference in the operating time, blood loss, or complications. Loss of MC correction (> 10°) was more common in patients fixated to the pelvis (23% vs 3%; p = 0.032), while loss of pelvic obliquity correction was more frequent in the L5 group (25% vs 0%; p = 0.007). Risk factors for loss of correction (either POB or MC) included preoperative coronal imbalance (> 50 mm, odds ratio (OR) 11.5, 95%confidence interval (CI) 2.0 to 65; p = 0.006) and postoperative sagittal imbalance (> 25 mm, OR 11.0, 95% CI1.9 to 65; p = 0.008). Conclusion. We found that patients undergoing pelvic fixation had a greater correction of MC and POB. The rate of complications was not different. Preoperative coronal and postoperative sagittal imbalance were associated with increased risks of loss of correction, regardless of extent of fixation. Therefore, we recommend pelvic fixation in all nonambulatory children with neuromuscular scoliosis where coronal or sagittal imbalance are present preoperatively. Cite this article: Bone Joint J 2020;102-B(2):261–267

Aims. The aim of this study was to identify factors that determine outcomes of treatment for patients with chondroblastic osteosarcomas (COS) of the limbs and pelvis. Patients and Methods. The authors carried out a retrospective review of prospectively collected data from 256 patients diagnosed between 1979 and 2015. Of the 256 patients diagnosed with COS of the pelvis and the limbs, 147 patients (57%) were male and 109 patients (43%) were female. The mean age at presentation was 20 years (0 to 90). Results. In all, 82% of the patients had a poor response to chemotherapy, which was associated with the presence of a predominantly chondroblastic component (more than 50% of tumour volume). The incidence of local recurrence was 15%. Synchronous or metachronous metastasis was diagnosed in 60% of patients. Overall survival was 51% and 42% after five and ten years, respectively. Limb localization and wide surgical margins were associated with a lower risk of local recurrence after multivariable analysis, while the response to chemotherapy was not. Local recurrence, advanced patient age, pelvic tumours, and large volume negatively influenced survival. Resection of pulmonary metastases was associated with a survival benefit in the limited number of patients in whom this was undertaken. Conclusion. COS demonstrates a poor response to chemotherapy and a high incidence of metastases. Wide resection is associated with improved local control and overall survival, while excision of pulmonary metastases is associated with improved survival in selected patients. Cite this article: Bone Joint J 2019;101-B:739–744

A self-control ratio, the spine-pelvis index (SPI), was proposed for the assessment of patients with adolescent idiopathic scoliosis (AIS) in this study. The aim was to evaluate the disproportionate growth between the spine and pelvis in these patients using SPI. A total of 64 female patients with thoracic AIS were randomly enrolled between December 2010 and October 2012 (mean age 13 years, standard deviation (. sd. ) 2.17; 9 to 18) and a further 73 healthy female patients with a mean age of 12.4 years (mean age 12.4 years, . sd. 2.24; 9 to 18), were randomly selected from a normal control database at our centre. The radiographic parameters measured included length of spine (LOS), height of spine (HOS), length of thoracic vertebrae (LOT), height of thoracic vertebrae (HOT), width of pelvis (WOP), height of pelvis (HOP) and width of thorax (WOT). SPI was defined as the ratio LOS/HOP. The SPI and LOT/HOP in patients with AIS showed a significant increase when compared with normal girls (p < 0.001 and p < 0.001 respectively), implying an abnormal pattern of growth of the spine relative to the pelvis in patients with AIS. . No significant difference in SPI was found in different age groups in the control group, making the SPI an age-independent parameter with a mean value of 2.219 (2.164 to 2.239). We also found that the SPI was not related to maturity in the control group. . This study, for the first time, used a self-control ratio to confirm the disproportionate patterns of growth of the spine and pelvis in patients with thoracic AIS, highlighting that the SPI is not affected by age or maturity. Cite this article: Bone Joint J 2015;97-B:1668–74

Magnification of anteroposterior radiographs of the pelvis is variable. To improve the accuracy of templating, reliable and radiographer-friendly methods of scaling are necessary. We assessed two methods of scaling digital radiographs of the pelvis: placing a coin of known diameter in the plane of interest between the patient’s thighs, and using a caliper to measure the bony width of the pelvis. A total of 39 patients who had recently undergone hemiarthroplasty of the hip or total hip replacement were enrolled in the study. The accuracy of the methods was assessed by comparing the actual diameter of the head of the prosthesis with the measured on-screen value. The coin method was within a mean of 1.12% (0% to 2.38%) of the actual measurement, the caliper group within 6.99% (0% to 16.67%). The coin method was significantly more accurate (p < 0.001). It was also reliable and radiographer friendly. We recommend it as the method of choice for scaling radiographs of the pelvis before hip surgery

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world. Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage. Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism

1. The strength of the pelvic arch depends on the integrity of the anterior interpubic ligament, whose strength has been demonstrated by dissections. Once that ligament is divided the sacro-iliac ligaments offer little resistance to opening out of the pelvis. 2. The structure of the pelvis and hips is compared to an arcade formed by a central and two lateral arches. The weight of the trunk is transmitted to the lower limbs through this arcade. 3. Fractures of the pelvis are classified according to the mechanism of production. The case for anatomical reposition and internal fixation is stated, and case histories are given to illustrate the disabilities due to persistent deformity. 4. Reduction can be achieved as late as two or three weeks after injury. However, if early operation for visceral injury is necessary, there is a strong case for combining this with open reduction and fixation. In some cases the patient's general condition may preclude such procedures, but more usually the additional manipulations cause little additional operative shock and are fully justified by the subsequent increased comfort of the patient and the greater ease of nursing

The Unified Classification System (UCS) emphasises the key principles in the assessment and management of peri-prosthetic fractures complicating partial or total joint replacement. We tested the inter- and intra-observer agreement for the UCS as applied to the pelvis and femur using 20 examples of peri-prosthetic fracture in 17 patients. Each subtype of the UCS was represented by at least one case. Specialist orthopaedic surgeons (experts) and orthopaedic residents (pre-experts) assessed reliability on two separate occasions. For the pelvis, the UCS showed inter-observer agreement of 0.837 (95% confidence intervals (CI) 0.798 to 0.876) for the experts and 0.728 (95% CI 0.689 to 0.767) for the pre-experts. The intra-observer agreement for the experts was 0.861 (95% CI 0.760 to 0.963) and 0.803 (95% 0.688 to 0.918) for the pre-experts. For the femur, the UCS showed an inter-observer kappa value of 0.805 (95% CI 0.765 to 0.845) for the experts and a value of 0.732 (95% CI 0.690 to 0.773) for the pre-experts. The intra-observer agreement was 0.920 (95% CI 0.867 to 0.973) for the experts, and 0.772 (95% CI 0.652 to 0.892) for the pre-experts. This corresponds to a substantial and ‘almost perfect’ inter- and intra-observer agreement for the UCS for peri-prosthetic fractures of the pelvis and femur. We hope that unifying the terminology of these injuries will assist in their assessment, treatment and outcome. Cite this article: Bone Joint J 2014;96-B:1472–7

Aims. Morphological abnormalities are present in patients with developmental dysplasia of the hip (DDH). We studied and compared the pelvic anatomy and morphology between the affected hemipelvis with the unaffected side in patients with unilateral Crowe type IV DDH using 3D imaging and analysis. Methods. A total of 20 patients with unilateral Crowe-IV DDH were included in the study. The contralateral side was considered normal in all patients. A coordinate system based on the sacral base (SB) in a reconstructed pelvic model was established. The pelvic orientations (tilt, rotation, and obliquity) of the affected side were assessed by establishing a virtual anterior pelvic plane (APP). The bilateral coordinates of the anterior superior iliac spine (ASIS) and the centres of hip rotation were established, and parameters concerning size and volume were compared for both sides of the pelvis. Results. The ASIS on the dislocated side was located inferiorly and anteriorly compared to the healthy side (coordinates on the y-axis and z-axis; p = 0.001; p = 0.031). The centre of hip rotation on the dislocated side was located inferiorly and medially compared to the healthy side (coordinates on the x-axis and the y-axis; p < 0.001; p = 0.003). The affected hemipelvis tilted anteriorly in the sagittal plane (mean 8.05° (SD 3.57°)), anteriorly rotated in the transverse plane (mean 3.31° (SD 1.41°)), and tilted obliquely and caudally in the coronal plane (mean 2.04° (SD 0.81°)) relative to the healthy hemipelvis. The affected hemipelvis was significantly smaller in the length, width, height, and volume than the healthy counterpart. (p = 0.014; p = 0.009; p = 0.035; p = 0.002). Conclusion. Asymmetric abnormalities were identified on the affected hemipelvis in patients with the unilateral Crowe-IV DDH using 3D imaging techniques. Improved understanding of the morphological changes may influence the positioning of the acetabular component at THA. Acetabular component malpositioning errors caused by anterior tilt of the affected hemi pelvis and the abnormal position of the affected side centre of rotation should be considered by orthopaedic surgeons when undertaking THA in patients with Crowe-IV DDH. Cite this article: Bone Joint J 2020;102-B(10):1311–1318

The aim of this retrospective cohort study was to identify any difference in femoral offset as measured on pre-operative anteroposterior (AP) radiographs of the pelvis, AP radiographs of the hip and corresponding CT scans in a consecutive series of 100 patients with primary end-stage osteoarthritis of the hip (43 men and 57 women with a mean age of 61 years (45 to 74) and a mean body mass index of 28 kg/m. 2. (20 to 45)). Patients were positioned according to a standardised protocol to achieve reproducible projection and all images were calibrated. Inter- and intra-observer reliability was evaluated and agreement between methods was assessed using Bland-Altman plots. In the entire cohort, the mean femoral offset was 39.0 mm (95% confidence interval (CI) 37.4 to 40.6) on radiographs of the pelvis, 44.0 mm (95% CI 42.4 to 45.6) on radiographs of the hip and 44.7 mm (95% CI 43.5 to 45.9) on CT scans. AP radiographs of the pelvis underestimated femoral offset by 13% when compared with CT (p < 0.001). No difference in mean femoral offset was seen between AP radiographs of the hip and CT (p = 0.191). Our results suggest that femoral offset is significantly underestimated on AP radiographs of the pelvis but can be reliably and accurately assessed on AP radiographs of the hip in patients with primary end-stage hip osteoarthritis. We, therefore, recommend that additional AP radiographs of the hip are obtained routinely for the pre-operative assessment of femoral offset when templating before total hip replacement

The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring. As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases

Aims. The purpose of this study was to investigate the potential for achieving local and systemic control after local recurrence of a chondrosarcoma of bone. Patients and Methods. A total of 126 patients with local recurrence (LR) of chondrosarcoma (CS) of the pelvis or a limb bone were identified from a prospectively maintained database, between 1990 and 2015 at the Royal Orthopaedic Hospital, Birmingham, United Kingdom. There were 44 female patients (35%) and 82 male patients (65%) with a mean age at the time of LR of 56 years (13 to 96). The 126 patients represented 24.3% of the total number of patients with a primary CS (519) who had been treated during this period. Clinical data collected at the time of primary tumour and LR included the site (appendicular, extremity, or pelvis); primary and LR tumour size (in centimetres); type of operation at the time of primary or LR (limb-salvage or amputation); surgical margin achieved at resection of the primary tumour and the LR; grade of the primary tumour and the LR; gender; age; and oncological outcomes, including local recurrence-free survival and disease-specific survival. A minimum two years’ follow-up and complete histopathology records were available for all patients included in the study. Results. For patients without metastases prior to or at the time of local recurrence, the disease-specific survival after local recurrence was 62.5% and 45.5% at one and five years, respectively. After univariable analysis, significant factors predicting disease-specific survival were grade (p < 0.001) and surgical margin (p = 0.044). After multivariable analysis, grade, increasing age at the time of diagnosis of local recurrence, and a greater time interval from primary surgery to local recurrence were significant factors for disease-specific survival. A secondary local recurrence was seen in 26% of patients. Wide margins were a good predictor of local recurrence-free survival for subsequent recurrences after univariable analysis when compared with intralesional margins (p = 0.002) but marginal margins did not reach statistical significance when compared with intralesional margins (p = 0.084). Conclusion. In cases of local recurrence of a chondrosarcoma of bone, we have shown that if the tumour is non-metastatic at re-staging, an increase in disease-specific survival and in local recurrence-free survival is achievable, but only by resection of the local recurrence with a wide margin. Cite this article: Bone Joint J 2019;101-B:266–271

The orientation of the acetabular component is influenced not only by the orientation at which the surgeon implants the component, but also the orientation of the pelvis at the time of implantation. Hence, the orientation of the pelvis at set-up and its movement during the operation, are important. During 67 hip replacements, using a validated photogrammetric technique, we measured how three surgeons orientated the patient’s pelvis, how much the pelvis moved during surgery, and what effect these had on the final orientation of the acetabular component. Pelvic orientation at set-up, varied widely (mean (± 2, standard deviation (. sd. ))): tilt 8° (2. sd . ±32), obliquity –4° (2. sd . ±12), rotation –8° (2. sd . ±14). Significant differences in pelvic positioning were detected between surgeons (p < 0.001). The mean angular movement of the pelvis between set-up and component implantation was 9° (. sd. 6). Factors influencing pelvic movement included surgeon, approach (posterior >  lateral), procedure (hip resurfacing > total hip replacement) and type of support (p < 0.001). Although, on average, surgeons achieved their desired acetabular component orientation, there was considerable variability (2. sd. ±16) in component orientation. We conclude that inconsistency in positioning the patient at set-up and movement of the pelvis during the operation account for much of the variation in acetabular component orientation. Improved methods of positioning and holding the pelvis are required. Cite this article: Bone Joint J 2014; 96-B:876–83

Four cases of osteomyelitis of the pelvis are reported to demonstrate the several clinical syndromes to which this disease can give rise. Extensive surgical drainage and antibiotic treatment led to recovery in all cases

Over a 25-year period we have treated 36 patients with osteosarcoma of the pelvis. Of the tumours, 24 (67%) were primary osteosarcomas and 12 (33%) arose either after irradiation or in association with Paget’s disease. Six patients had a hindquarter amputation and 12 were treated by a limb-salvage procedure with intrapelvic excision. The five-year survival rate of all the patients with pelvic osteosarcoma was 18%, while for 17 treated by chemotherapy and surgery it was 41%. The prognosis for patients presenting with metastases or with secondary osteosarcoma was appalling and none survived after 29 months. No patient over the age of 50 years when seen initially survived for a year. Youth and a good response to chemotherapy along with complete surgical excision offer the best chance of cure

We hypothesised that the use of computer navigation-assisted surgery for pelvic and sacral tumours would reduce the risk of an intralesional margin. We reviewed 31 patients (18 men and 13 women) with a mean age of 52.9 years (13.5 to 77.2) in whom computer navigation-assisted surgery had been carried out for a bone tumour of the pelvis or sacrum. There were 23 primary malignant bone tumours, four metastatic tumours and four locally advanced primary tumours of the rectum. The registration error when using computer navigation was <  1 mm in each case. There were no complications related to the navigation, which allowed the preservation of sacral nerve roots (n = 13), resection of otherwise inoperable disease (n = 4) and the avoidance of hindquarter amputation (n = 3). The intralesional resection rate for primary tumours of the pelvis and sacrum was 8.7% (n = 2): clear bone resection margins were achieved in all cases. At a mean follow-up of 13.1 months (3 to 34) three patients (13%) had developed a local recurrence. The mean time alive from diagnosis was 16.8 months (4 to 48). . Computer navigation-assisted surgery is safe and has reduced our intralesional resection rate for primary tumours of the pelvis and sacrum. We recommend this technique as being worthy of further consideration for this group of patients. Cite this article: Bone Joint J 2013;95-B:1417–24

Endoprosthetic replacement of the pelvis is one of the most challenging types of limb-salvage surgery, with a high rate of complications. In an attempt to reduce this and build greater versatility into the reconstruction process, a new type of pelvic endoprosthesis was developed in 2003, based on the old McKee-Farrar prosthesis. This study reviews the outcomes in 27 patients who had an ice-cream cone pelvic prosthesis inserted at two different specialist bone tumour centres in the United Kingdom over the past six years. The indications for treatment included primary bone tumours in 19 patients and metastatic disease in two, and six implants were inserted following failure of a previous pelvic reconstruction. Most of the patients had a P2+P3 resection as classified by Enneking, and most had resection of the ilium above the sciatic notch. The mean age of the patients at operation was 49 years (13 to 81). Complications occurred in ten patients (37.0%), of which dislocation was the most common, affecting four patients (14.8%). A total of three patients (11.1%) developed a deep infection around the prosthesis but all were successfully controlled by early intervention and two patients (7.4%) developed a local recurrence, at the same time as widespread metastases appeared. In one patient the prosthesis was removed for severe pain. This method of treatment is still associated with high morbidity, but early results are promising. Complications are diminishing with increasing experience

We investigated the variables which determine the outcome after triple osteotomy of the pelvis for the treatment of congenital dysplasia of the hip. We reviewed 51 patients (61 hips) with a median age at operation of 23 years who were treated with a Tönnis triple osteotomy. The median follow-up was six years with a minimum of two years. Eight patients (eight hips) required a revision procedure. Of the remaining 53 hips, the results were good or excellent in 36 (68%) when evaluated according to the Harris hip score (median 90 points), and 33 patients (65%) were satisfied with the procedure. Logistic regression analysis indicated that the incidence of complications such as nonunion at an osteotomy site influenced patient satisfaction (p = 0.079). The incidence of complications correlated positively with increasing patient age at operation (p = 0.004). The amount of acetabular correction did not correlate with patient satisfaction. In univariate analysis, the groups of ’satisfied’ and ‘not satisfied’ patients differed significantly in Harris hip score, age, incidence of nonunion at the osteotomy sites, complications and late revisions. In conclusion, the patient’s age at operation and the incidence of complications influence patient satisfaction after triple osteotomy, but the amount of radiologically evident acetabular correction shows no correlation to outcome

1. Fifty dislocations and fracture-dislocations of the pelvis have been reviewed. 2. Complications were unusual. Two patients with rupture of the bladder died; two with rupture of the urethra survived. Of eight patients with retroperitoneal haemorrhage four died; the treatment advised is controlled blood transfusion maintaining a blood-pressure of not more than 100 mm. 3. Two types of pelvic disruption should be distinguished: 1) pubic injury with sacro-iliac dislocation; 2) pubic injury with fracture near the sacro-iliac joint. The first is twice as common as the second. 4. In each type, displacement is maintained by extension of the hip and outward roll of the limb. This may be controlled by the Watson-Jones plaster method but the pelvic sling technique is preferred and was used in all cases in this series. 5. The prognosis in fracture-dislocations is very good; nearly all patients went back to heavy work. 6. The prognosis in sacro-iliac dislocations is not so good; only half the patients went back to heavy work and there was often persistent sacro-iliac pain. Sacro-iliac arthrodesis is advised in those cases

1. Three cases of severe retroperitoneal haemorrhage complicating fractures of the pelvis are described. In two patients haemorrhage was immediately controlled by ligation of the internal iliac artery. The third patient died before the bleeding could be controlled. 2. Ligature of the internal iliac artery may be a life-saving measure when fracture of the pelvis is complicated by severe haemorrhage

Aims. Few studies dealing with chondrosarcoma of the pelvis are currently available. Different data about the overall survival and prognostic factors have been published but without a detailed analysis of surgery-related complications. We aimed to analyse the outcome of a series of pelvic chondrosarcomas treated at a single institution, with particular attention to the prognostic factors. Based on a competing risk model, our objective was to identify risk factors for the development of complications. Patients and Methods. In a retrospective single-centre study, 58 chondrosarcomas (26 patients alive, 32 patients dead) of the pelvis were reviewed. The mean follow-up was 13 years (one week to 23.1 years). Results. A total of 26 patients (45%) were alive and 32 patients (55%) had died. Overall survival was 76%, 55% and 45% at one, five and ten years post-operatively, respectively. In a competing risk model the cumulative risk of the development of a surgery-related complication was 64% at six months and 69% at one year, post-operatively, respectively. Endoprosthetic reconstruction was a significant risk factor for the development of complications (p = 0.006). Complications were not significantly related to age or the location or grade of the tumour (p = 0.823, p = 0.976, p = 0.858). The development of complications did not have a negative effect on survival (p = 0.147). Conclusion. This is the first study with competing risk analysis of surgery-related complications in patients with a pelvic chondrosarcoma. The surgery in these patients remains prone to complications. Endoprosthetic reconstruction significantly increases the risk of the development of complications (p = 0.006). A competing risk model showed that the development of complications does not have a negative influence on overall survival (p = 0.147). An aggressive, surgical resection with the goal of achieving wide margins whenever possible remains the mainstay of treatment. . Cite this article: Bone Joint J 2017;99-B:686–96

1. Seventy-five patients sustained fractures of the pelvis with associated soft-tissue complications. Twenty died, and of these, thirteen died within forty-eight hours of admission to hospital. 2. The initial resuscitation and clinical assessment of these patients are discussed, and attention is drawn to the significance of the concomitant retroperitoneal haematoma as a cause of oligaemic shock, and as a dissembler of internal visceral injury. 3. The morphological fracture patterns are classified into six categories, but the fracture patterns are not correlated with specific visceral injuries. 4. Forty-six patients sustained urinary tract injuries. Of these, nineteen had suffered rupture of the urethra; fourteen had rupture of the bladder; two had both urethral and vesical disruption, and one patient had a torn ureter. The diagnosis and management of these injuries is discussed. 5. Twelve patients had a traumatic laceration or perforation of the ano-rectum. Nine of these patients had associated urethral or vesical injuries. 6. Four patients were involved in accidents and sustained pelvic fractures while in the last three months of pregnancy. The tragic outcome of this combination of circumstances is noted. 7. Attention is drawn to peripheral nerve injuries in association with pelvic fractures, and the difficulty of localising these lesions is stressed. 8. Eight instances of damage to the abdominal parietes are recorded. Four patients suffered skin and soft-tissue loss, two patients had diaphragmatic disruptions and two patients had abdominal wall dehiscences. 9. Major accident victims frequently have multiple injuries. This series of patients has been analysed to draw attention to the association of pelvic fractures with bizarre visceral injuries

We reviewed 43 patients treated from 1984 to 1988 for open fractures of the pelvis. There were four Gustilo type I wounds, seven type II and 32 type III; 22 fractures were stable and 21 unstable. The overall mortality was 30%; the average Injury Severity Score was 30, being 26 in the survivors and 40 in the fetal cases. We analysed the influence of a number of factors on the mortality rate. The most important were the ISS and the age in years, while the presence of a type III wound and instability of the fracture also had an influence. We describe two simple methods of assessment of the prognosis in individual cases, based on these factors

Aims. This study of patients with osteoarthritis (OA) of the hip aimed to: 1) characterize the contribution of the hip, spinopelvic complex, and lumbar spine when moving from the standing to the sitting position; 2) assess whether abnormal spinopelvic mobility is associated with worse symptoms; and 3) identify whether spinopelvic mobility can be predicted from static anatomical radiological parameters. Patients and Methods. A total of 122 patients with end-stage OA of the hip awaiting total hip arthroplasty (THA) were prospectively studied. Patient-reported outcome measures (PROMs; Oxford Hip Score, Oswestry Disability Index, and Veterans RAND 12-Item Health Survey Score) and clinical data were collected. Sagittal spinopelvic mobility was calculated as the change from the standing to sitting position using the lumbar lordosis angle (LL), sacral slope (SS), pelvic tilt (PT), pelvic-femoral angle (PFA), and acetabular anteinclination (AI) from lateral radiographs. The interaction of the different parameters was assessed. PROMs were compared between patients with normal spinopelvic mobility (10° ≤ ∆PT ≤ 30°) or abnormal spinopelvic mobility (stiff: ∆PT < ± 10°; hypermobile: ∆PT > ± 30°). Multiple regression and receiver operating characteristic (ROC) curve analyses were used to test for possible predictors of spinopelvic mobility. Results. Standing to sitting, the hip flexed by a mean of 57° (. sd. 17°), the pelvis tilted backwards by a mean of 20° (. sd. 12°), and the lumbar spine flexed by a mean of 20° (. sd. 14°); strong correlations were detected. There was no difference in PROMs between patients in the different spinopelvic mobility groups. Maximum hip flexion, standing PT, and standing AI were independent predictors of spinopelvic mobility (R. 2. = 0.42). The combined thresholds for standing was PT ≥ 13° and hip flexion ≥ 88° in the clinical examination, and had 90% sensitivity and 63% specificity of predicting spinopelvic stiffness, while SS ≥ 42° had 84% sensitivity and 67% specificity of predicting spinopelvic hypermobility. Conclusion. The hip, on average, accounts for three-quarters of the standing-to-sitting movement, but there is great variation. Abnormal spinopelvic mobility cannot be screened with PROMs. However, clinical and standing radiological features can predict spinopelvic mobility with good enough accuracy, allowing them to be used as reliable screening tools. Cite this article: Bone Joint J 2019;101-B:902–909

We report a patient with a peri-acetabular chondrosarcoma which was treated by resection of part of the pelvis and the femoral head. This was followed by replacement with a custom-made titanium alloy pelvic portion and a conventional total hip prosthesis. The operation was carried out in two stages, and yielded a good functional and cosmetic result

In a series of 150 consecutive patients with unstable fractures of the pelvis, angiography was performed in 23 (15%) who had uncontrolled hypotension. There were three anteroposterior compression (APC), eight lateral compression (LC) and 12 vertical shear (VS) injuries. Arterial sources of haemorrhage were identified in 18 (78%) patients and embolisation was performed. Angiography was required in 28% of VS injuries. The morphology of the fracture was not a reliable guide to the associated vascular injury. Ten (43%) patients died, of whom six had had angiography as the first therapeutic intervention. Five of these had a fracture which was associated with an increase in pelvic volume (APC or VS) which could have been stabilised by an external fixator. Based on our findings we recommend skeletal stabilisation and, if indicated, laparotomy to deal with sources of intraperitoneal blood loss before pelvic angiography. Embolisation of pelvic arterial bleeding is a worthwhile procedure in patients with hypotension which is unresponsive to these interventions

We investigated the detailed anatomy of the gluteus maximus, gluteus medius and gluteus minimus and their neurovascular supply in 22 hips in 11 embalmed adult Caucasian human cadavers. This led to the development of a surgical technique for an extended posterior approach to the hip and pelvis that exposes the supra-acetabular ilium and preserves the glutei during revision hip surgery. Proximal to distal mobilisation of the gluteus medius from the posterior gluteal line permits exposure and mobilisation of the superior gluteal neurovascular bundle between the sciatic notch and the entrance to the gluteus medius, enabling a wider exposure of the supra-acetabular ilium. This technique was subsequently used in nine patients undergoing revision total hip replacement involving the reconstruction of nine Paprosky 3B acetabular defects, five of which had pelvic discontinuity. Intra-operative electromyography showed that the innervation of the gluteal muscles was not affected by surgery. Clinical follow-up demonstrated good hip abduction function in all patients. These results were compared with those of a matched cohort treated through a Kocher–Langenbeck approach. Our modified approach maximises the exposure of the ilium above the sciatic notch while protecting the gluteal muscles and their neurovascular bundle. Cite this article: Bone Joint J 2014;96-B:48–53

We aimed to evaluate the precision and longitudinal sensitivity of measurement of bone mineral density (BMD) in the pelvis and to determine the effect of bone cement on the measurement of BMD in femoral regions of interest (ROI) after total hip arthroplasty (THA). A series of 29 patients had duplicate dual-energy x-ray absorptiometry (DXA) scans of the hip within 13 months of THA. Pelvic analyses using 3- and 4-ROI models gave a coefficient of variation (CV) of 2.5% to 3.6% and of 2.5% to 4.8%, respectively. Repeat scans in 17 subjects one year later showed a significant change in BMD in three regions using the 4-ROI model, compared with change in only one region with the 3-ROI model (p < 0.05). Manual exclusion of cement from femoral ROIs increased the net CV from 1.6% to 3.6% (p = 0.001), and decreased the measured BMD by 20% (t = 12.1, p < 0.001). Studies of two cement phantoms in vitro showed a small downward drift in bone cement BMD giving a measurement error of less than 0.03 g/cm. 2. /year associated with inclusion of cement in femoral ROIs. Changes in pelvic periprosthetic BMD are best detected using a 4-ROI model. Analysis of femoral ROI is more precise without exclusion of cement although an awareness of its effect on the measurement of the BMD is needed

We performed Kawamura's dome osteotomy of the pelvis, with simultaneous distal transfer of the greater trochanter on 101 hips in 91 patients with osteoarthritis secondary to hip dysplasia. The mean age at operation was 30 years (15 to 55), and follow-up was for a mean of 8.3 years (5 to 14). Clinical evaluation using the Merle d'Aubigne score showed 92% excellent or good results. Radiologically, 91 hips had good acetabular remodelling and showed no signs of progression of osteoarthritis. In ten hips the osteoarthritic process progressed despite the osteotomy and six of these eventually underwent total hip replacement. Factors which were significantly associated with a poor outcome included an advanced stage of osteoarthritis, valgus deformity of the proximal femur, old age at the time of operation and postoperative persistence of abductor insufficiency

It is not uncommon to observe bone cement in the pelvis on radiographs after total hip replacement, a finding which is generally considered to be benign. This paper reviews some catastrophic late complications from intrapelvic methylmethacrylate. We also describe a case of progressive, unbearable dyspareunia beginning three years after total hip replacement. A possible explanation of the pathophysiology is suggested. Recommendations for prevention, diagnosis, and treatment of these late complications are offered

We present a patient who underwent delayed sub-periosteal hemipelvectomy for control of infection and to enable soft-tissue cover after trauma. At four months after amputation, clinical examination and radiographs demonstrated almost complete re-ossification of the hemipelvis. This has allowed the patient to regain sitting balance and to use a walking prosthesis designed for patients following disarticulation of the hip. After 14 months from injury, no perineal hernia has developed, and no dysfunction of pelvic organs is attributable to heterotopic bone formation or adhesions.

The patient’s mobility with a prosthesis is similar to that expected of a through-hip amputee.

A patient is described with a ligamentous disruption at the L4/L5 level in association with bilateral, traumatic dislocations of the hip. The diagnostic evaluation, acute intervention, and definitive stabilisation are reported. The unstable spine posed a problem in treatment with regard to the timing and technique of the reduction of the hips.

We report the long-term results of 51 pelvic osteotomies in 43 patients with a mean follow-up of 15 years (13 to 20). The mean age of the patients was 28 years (14 to 46). At review three patients were lost to follow-up, and six had received a total hip arthroplasty. Of 48 hips, 42 (88%) were preserved, with good to excellent clinical results in 27 (64%). Pre-operatively, 41 (80%) of the treated hips had shown no sign of osteoarthritis. Thirty-one (65%) hips showed no progression of osteoarthritis after follow-up for 15 years. Significant negative factors for good long-term results were the presence of osteoarthritic changes and a fair or poor clinical score pre-operatively. Pelvic reorientation osteotomy for symptomatic hip dysplasia can give satisfactory and reproducible long-term clinical results.

Reorientation of the acetabulum may be required in adolescents and young adults with developmental dysplasia of the hip. We have carried out a retrospective review of 51 hips after triple osteotomy with an average follow-up of ten years (8 to 15). Forty-eight hips (94%) were available for review and of these 39 (81%) were improved compared with before operation, 29 (60%) scoring good or excellent. Radiographic assessment showed improvement of the average centre-edge angle by 19°, the acetabular index by 12° and the anterior centre-edge angle by 26°. The degree of osteoarthritis progressed by one grade in ten hips (21%) over a period of ten years.

The satisfactory long-term clinical and radiographic results have encouraged us to continue this treatment for symptomatic acetabular dysplasia in these patients.

External fixation was used in 42 patients as the sole definitive treatment for their unstable pelvic fractures. At an average follow-up of 40 months, the anatomical outcome was related to the functional outcome using defined criteria. The functional results were better than the anatomical results. Function improved during the first 18 months and thereafter was stable. The stab and percutaneous techniques for pin insertion had lower rates of infection than the incisional technique. External fixation has a definite role in the treatment of unstable pelvic fractures. In contrast to internal fixation, this method has two major advantages: safety and simplicity.

Eighty patients who sustained a fracture of the floor of the acetabulum are reviewed, and the mechanism of the injury was investigated by clinical and experimental studies. The results of the injury in fifty patients are presented, with an account of the three clinical types of acetabular fracture.

We describe a case in which chronic oedema of a leg was due to pressure on the external iliac vein from an intrapelvic rheumatoid cyst. Ultrasound and CT scanning gave the clues to diagnosis.

Aims

This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent.

Malignant transformation of fibrous dysplasia to chondrosarcoma is rare. We report a case in which malignancy developed in an area of fibrous dysplasia in the ilium. We believe this to be the second reported case at this site. Treatment was by excision of the hemipelvis including the ala of the sacrum. A review of the literature is presented.

Modern anthropometric techniques were used to investigate two groups of subjects, one with various syndromes associated with pain in the lower back and the other a control group. Analysis confirmed previous reports that people prone to pain in the back have a greater standing height than people who are not. To investigate this further two new components of height, namely pelvic height and suprapelvic height, were calculated in addition to the established calculation of subischial height. Consecutive components, namely suprapelvic height, pelvic height and subischial height, together constituted the standing height of a subject. The main finding of this investigation was that the relatively large standing height of the subject prone to back pain was due only to the pelvic component.