Treatment of refractory symphysitis pubis with intravenous pamidronate

Osteitis pubis is a noninfectious painful inflammatory disorder of the symphysis pubis. Etiologic factors include urologic procedures, abdomino-perineal and gynecological surgery, and spondyloarthropathies, although many cases are idiopathic. Most respond to conservative measures consisting primarily of rest and analgesic/antiinflammatory agents. We describe 3 cases, 2 with idiopathic osteitis pubis and one that was associated with a spondyloarthropathy, that failed to respond to conservative measures but experienced clinical remission with 3 to 6 monthly courses of intravenous pamidronate. Remission was also evident in 2 patients on isotope bone scan. Followup has revealed no recurrence. Intravenous pamidronate may constitute a safe and effective treatment option for patients with refractory osteitis pubis.

[Pregnancy-associated symphysis damage from the orthopedic viewpoint--studies of changes of the pubic symphysis in pregnancy, labor and post partum]

AIM

Is the sonographic measurement of the symphysis pubis enough to enable a prognosis of the occurrence of symphyseal pain during pregnancy and birth?

METHOD

First of all, a simplified definition of symphyseal pain was categorized in order to make the classification more easy. The symphyseal widths of 171 pregnant women were measured during pregnancy and after birth. Our control group consisted of 25 non-pregnant women. 15 of the 171 patients suffered from symphyseal pain; however, 156 of the 171 did not. Additionally, we measured the intrapartal symphyseal width in 11 of the women.

RESULTS

The average symphyseal width of non-pregnant women was 4.07 mm (s = 0.79; n = 25). Pre- and postpartally we measured 6.32 mm (s = 1.71; variation of 3 to 16 mm) in pregnant asymptomatic women. A significant increase in width was recorded in the 15 women with pain in the symphysis: the symphyseal width was 10.62 mm (s = 2.37; Variation from 6.7 to 15.25 mm). Intrapartally the symphyseal width varied between 5.8 and 1.2 mm.

CONCLUSION

Ultrasound measurement of the symphyseal width shows around 4 mm in non-pregnant women. Asymptomatic pregnant women have an average width of 6.3 mm. The majority of pregnant women with 9.5 mm or more have symphyseal pain. If that is the case then conservative treatment is usually sufficient to cure this complaint.

Bowel herniation after traumatic symphysis pubis diastasis

The authors describe a patient with small bowel herniation after traumatic symphysis disruption. Although gastrointestinal problems occur rarely with pelvic fractures, in a patient with a pubic diastasis and paralytic ileus, the development of abdominal hernia through torn peritoneum should be considered. Treatment of the patient with a pubic diastasis and a bowel problem should include early careful exploration and management of the gastrointestinal tract during pelvic surgery.

[Rupture of the symphysis after spontaneous delivery. Surgical treatment of four cases]

Rupture of the symphysis pubis is a rare, but known, complication during labour. We describe four cases of rupture of the symphysis, for which surgical treatment was chosen shortly after labour (2-30 days). Internal fixation was done in two cases and external fixation in the other two. There were no postoperative complications. The patients were mobile soon after the operation, and had no pain and normal function at follow-up 6-12 months later.

Bilateral anterior pubic osteotomy in bladder exstrophy repair: report of increasing success

Bilateral posterior iliac osteotomy is performed in most patients undergoing primary closure of an exstrophic bladder; the aims are to facilitate abdominal-wall closure, prevent postoperative wound dehiscene, and possibly, to achieve better urinary control in older age. A new technique, anterior pelvic osteotomy of the superior pubic ramus, seems to obtain tension-free symphysis approximation safely and quickly. We report our initial experience with this osteotomy. Five neonates, four males and one female from 1 to 4 days old, all underwent closure surgery for bladder exstrophy (BE) and subsequent bilateral osteotomy of the superior pubic ramus (SPRO). Postoperatively, Bryant's traction was applied. Tension-free, complete approximation of the symphysis and uncomplicated healing were achieved in all five cases without palsy of the obturator nerve or postoperative hemorrhage. Follow-up revealed partial rediastasis with a stable anterior pelvic ring. Tension-free closure and immobilization are important factors in both initial and subsequent closure of BE. Several osteotomy techniques are currently in use. SPRO presents numerous advantages, namely, ease and rapidity, minimal blood loss, and no requirement for an extra skin incision or need to turn the patient on the operating table. A certain degree of rediastasis with growth was subsequently observed: although undesirable, this complication is common to all osteotomy techniques. We believe that SPRO is a valid and uncomplicated method to facilitate BE closure.

Spontaneous pubic symphysial diastasis following vaginal delivery

Public symphysis diastasis is an uncommon condition which is caused mostly by severe trauma like road traffic accidents and fall from heights. We present cases of pubic symphysis diastasis following spontaneous vaginal delivery. This is to reiterate the fact that this type of public symphysis diastasis is different from other types of traumatic pubic symphysis diastasis and can be managed successfully with absolute bed rest.

Anterior innominate osteotomy in repair of bladder exstrophy

BACKGROUND

Classic bladder exstrophy is a developmental defect presenting at birth with a wide pubic separation and an exposed bladder; cloacal exstrophy involves, in addition, intestinal prolapse. Reconstruction requires several surgical procedures. The use of anterior iliac osteotomies in this process has not been reviewed in a large series.

METHODS

We reviewed the results of eighty-six anterior innominate osteotomies performed in conjunction with genitourinary repair of classic and cloacal bladder exstrophy in eighty-two patients. Clinical outcome measures were successful bladder closure, achievement of continence, and maintenance of a normal gait. Radiographs of the pelvis were reviewed, and the pubic intersymphyseal diastasis (a measure of the reduction in tension on the anterior closure) was measured preoperatively and at three time-points postoperatively. Children with classic exstrophy who had undergone osteotomy and bladder neck reconstruction but not bladder augmentation were divided into four groups on the basis of the degree of continence. In addition, children with classic exstrophy were stratified according to age at the time of the osteotomy. The mean postoperative percent reduction in the amount of the original diastasis was determined for all groups.

RESULTS

Children with classic exstrophy and those with cloacal exstrophy had correction of the diastasis after the osteotomy, with greater correction in those with classic exstrophy, presumably because of better bone quality. Daytime continence was achieved with anterior osteotomy and bladder neck reconstruction in 74% of the children for whom continence was a goal. However, no difference in the symphyseal diastasis or in the percentage of pubic reduction was detected among the four continence groups. Children who were older at the time of the osteotomy maintained better correction over time. Wound dehiscence or bladder prolapse occurred in 4% of the patients who had osteotomy and primary closure, and the only important complication of the osteotomies was transient palsy of the left femoral nerve in seven children.

CONCLUSIONS

Anterior innominate osteotomy is an effective part of reconstructive repair of bladder exstrophy. The primary goals of the osteotomy are to reduce the tension in the closed bladder and the lower abdominal wall and to promote continence by restoring the sling of the pelvic floor muscles. These goals can be achieved in the majority of patients.

Meralgia paresthetica is related to degenerative pubic symphysis

OBJECTIVE

To investigate the relationship between meralgia paresthetica, a mononeuropathy of the lateral femoral cutaneous nerve that often starts in middle age, and radiological degeneration of the pubic symphysis.

METHODS

A case-control study of patients aged 40 years and older with meralgia paresthetica who underwent surgical release of the lateral femoral cutaneous nerve; cases were included only when a pelvic radiograph was available. The control group was from a population study including persons aged 55 years and older and was matched to cases (4 controls per case) for sex and age as far as possible. We checked patient records from general practice to ensure control subjects had no symptoms of meralgia paresthetica during the previous 10 years. Radiological degeneration of the pubic symphysis was defined as present when 2 of 3 independent observers noted degeneration on the radiograph.

RESULTS

Mantel-Haenszel procedure (stratified for age group and radiological osteoarthritis of the hip) showed a positive relationship (p = 0.004, OR = 4.38) between radiological degenerative pubic symphysis and meralgia paresthetica. In a separate analysis limited to men we also found this positive relationship.

CONCLUSION

This study confirmed a positive relationship between radiological degeneration of the pubic symphysis and meralgia paresthetica.

A clinical evaluation of setup errors for a prostate immobilization system

A prostate treatment immobilization system was evaluated with respect to setup errors and efficiency for a specific treatment setup. Prostate patients were treated in the prone position with a rectal catheter using the NOMOS intensity modulated radiotherapy system. Immobilization and setup consisted of a Vac-Loktrade mark bag (MED-TEC, Orange City, IO) fitted within a registration carrier box where patients were aligned to the bag using skin marks along the lower leg. Daily setup errors were analyzed using lateral portal films, registration plates mounted to the carrier box, and the pubic symphasis as a bony reference. Two studies were conducted to evaluate setup technique. In the first study, patient setup required 3-5 minutes for patient positioning and the corresponding superior/inferior errors were found to have a standard deviation of 3.5 mm. In the second study, the technique standards were reduced to allow for faster setup times and, consequently, larger errors; setup times were 1-2 minutes and the mean and standard deviation errors were approximately 2 and 5 mm, respectively.

Effectiveness of ultrasonographic parameters for documenting the severity of anatomic stress incontinence

BACKGROUND

To assess the correlation between the severity of incontinence and some ultrasonographic parameters used to document the mobility of bladder neck.

METHODS

The severity of the incontinence and mobility the bladder neck were evaluated by pad test and perineal ultrasonography respectively in 74 patients with pure anatomic stress incontinence. During perineal ultrasonography, distances from the bladder neck to the lower tip (A) and to the posterior midpoint of symphysis pubis (B) were measured at rest and during stress. The first bladder neck mobility was obtained by two caliper method (Mu). After superimposing the symphysis pubis of the frozen images, the bladder neck positions at rest and during stress were plotted on an x-y coordinate system by using computer programs and the corresponding X and Y values were calculated. The second bladder neck mobility was measured on this x-y coordinate system (Mc). Paired t-test and correlation analysis were used for statistical analysis of the data.

RESULTS

The mean Mc was significantly higher than the mean Mu (p<0.01). Compared to the values at rest, the mean distance A did not change significantly; however, the mean distance B increased, and X and Y values decreased significantly during stress (p<0.01). The amount of urine leaked per hour had significant positive correlation with distance B-stress and Mc and significant negative correlation with Y-rest, X-stress and Y-stress (p<0.05-0.001).

CONCLUSION

These data suggested that the bladder neck mobility was underestimated when it was measured by two caliper method and the absolute positions or mobility of the bladder neck measured by computer on an x-y coordinate system could effectively document the severity of the decreased support of bladder neck.

Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail

Seven rugby players with osteitis pubis and vertical instability at the pubic symphysis were treated operatively after nonoperative treatment had failed to improve their symptoms. The vertical instability was diagnosed based on flamingo view radiographs showing greater than 2 mm of vertical displacement. The players had undergone at least 13 months of nonoperative therapy before surgery was considered. Operative treatment consisted of arthrodesis of the pubic symphysis by bone grafting supplemented by a compression plate. At a mean follow-up of 52.4 months, all patients were free of symptoms and flamingo views confirmed successful arthrodesis with no residual instability of the pubic symphysis. Based on our results with this procedure, we believe that arthrodesis of the pubic symphysis has a role in the treatment of osteitis pubis that is recalcitrant to nonoperative treatment. The combination of osteitis pubis and vertical pubis symphyseal instability may be the cause of failure of nonoperative treatment.

[Fever of unknown origin as a sign of calcium pyrophosphate deposition disease]

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease may manifest clinically as septic fever (40 degrees C), acute pseudogout attack of knee, wrist and shoulders, or as a variety of patterns of chronic inflammatory or degenerative joint disease. The association of pseudogout with fever is less widely recognised and may lead to over-investigation, delay in appropriate treatment and disproportionate costs. We report on a 67-year-old woman with a history of recurrent episodes of fever and polyarthritis every 2 months for the last 3 years. Because of this she was hospitalised several times, finally with suspected culture-negative endocarditis, and was treated for 6 weeks with gentamicin, rifampicin and vancomycin. During this therapy the patient again developed septic fever and acute arthritis of the right wrist. Radiographs of the wrist, knee and symphysis pubis revealed prominent chondrocalcinosis and destructive arthropathy.

Effect of public symphysiodesis on pelvic development in the skeletally immature greyhound

OBJECTIVE

To evaluate the effect of pubic symphysiodesis (PS) on pelvic development in skeletally immature dogs.

STUDY DESIGN

Prospective randomized clinical trial.

ANIMALS

Eight 4 month-old, sexually intact female Greyhounds.

METHODS

Initial PS was performed at 4 months of age using a powered stapling device. Because of failure of the initial surgery, a second PS was performed 1 month later by resecting the pubic symphysis with a rongeur followed by placement of handmade bone staples in four dogs. Sham PS was performed in four control dogs at 4 months of age. Pubic growth rate and pelvic development were evaluated using standard plane radiography and computed tomography. Specific measurements included acetabular ventroversion, Norberg angle, lateral center-edge angle, and pelvic inlet dimensions. Hip distraction indices were determined as well.

RESULTS

PS at 4 months of age using a stapling device failed. Pubic symphysiodesis using hand made staples was successful at 5 months of age and did not result in any clinically significant intraoperative or postoperative complications. Pubic symphysiodesis markedly decreased pubic symphysis growth in the treatment group. Hip distraction indices and pelvic inlet circumference, area, and width significantly decreased in treated dogs compared to those in the control group. Acetabular ventroversion was significantly increased in treated dogs compared to those in the control group.

CONCLUSIONS

PS decreases pelvic canal size, increases acetabular ventroversion, and does not appear to have any clinically significant complications.

CLINICAL RELEVANCE

PS performed in skeletally immature dogs with hip dysplasia may provide an effect similar to a triple pelvic osteotomy and warrants further investigation.

A method to measure acetabular cup anteversion after total hip replacement

The authors propose a simple and practical method to measure radiologically the angle of ante- or retroversion of the acetabular cup using a goniometer. It only necessitates an anteroposterior radiograph centered on the femoral head and another one centered on the public symphysis. Special x ray equipment, compass, conversion table, mathematical formulas, or a pocket calculator are not required. The opening of the prosthetic cup is projected on the film as an ellipse. According to the rules of descriptive geometry, the true size of the angle of anteversion is easily obtained. The geometric constructions consist in drawing four lines. The adequate positioning on a hip radiograph of the protractor, drawn on the goniometer, permits the direct reading of the true and planar anteversion angles of the cup.

Superficial thrombophlebitis of pubic collateral veins after gynecological surgery: a case report

Superficial pubic collateral veins are the result of iliac vein occlusion due to previous thrombosis. They can be accompanied by deep crossover veins. We present a patient with thrombophlebitis of superficial pubic collateral veins after a hysteroscopic procedure.

Pseudomonas osteomyelitis of the symphysis pubis after inguinal hernia repair

Osteitis pubis (OP) is a term used to describe an entity characterised by severe pelvic pain, a wide-based gait and bony destruction of the margins of the pubic symphysis. It is usually assumed that OP is a non-infectious, self-limiting, relatively benign condition. Infectious osteomyelitis of the symphysis pubis (IOSP) is very unusual and the clinical presentation can resemble OP. IOSP following inguinal hernia repair is extremely rare. A case of IOSP caused by Pseudomonas aeruginosa is described. We reiterate the assumption that IOSP can be misdiagnosed as OP.

Sonographic assessment of symphyseal joint distention during pregnancy and post partum with special reference to pelvic pain

OBJECTIVE

To elucidate whether there is a relationship between pregnancy-related pelvic pain and degree of symphyseal laxity.

METHODS

Forty-nine women were interviewed and examined and ultrasonographic measurement of symphyseal width and vertical shift was conducted at 12 and 35 weeks of pregnancy and at 5 months post partum. The patients were retrospectively classified into four groups on the basis of presence and degree of pain in late pregnancy and presence or absence of pain at follow up.

RESULTS

The prevalence of pelvic pain of any degree during pregnancy was 49%, of pronounced pain 16.3% and of severe pain 6.1%. Nineteen percent had any remaining pain at 5 months post partum. The median symphyseal width at 12 and 35 weeks of pregnancy and at 5 months post partum was 3.5 mm, 4.6 mm and 2.8 mm, the median vertical shift 0.0 mm, 0.8 and 0.9 mm respectively. Those with disabling pain during pregnancy and no pain at follow up had greater symphyseal width (6.3 mm) and vertical shift (1.8 mm) at 35 weeks of pregnancy than controls; 4.5 mm (p<0.01) and 0.5 mm (p<0.01) respectively. Those with disabling pain during pregnancy and persistent pain at follow up did not differ significantly from controls in symphyseal width or shift. The most severe cases were in this group.

CONCLUSION

There is a minor pregnancy-induced physiological increase in laxity of the symphyseal soft tissue. There is no evidence that the degree of symphyseal distention determines the severity of pelvic pain in pregnancy or after childbirth.

Pubic pain in athletes: a case due to an abscess in the obturator muscle

Pubic pain is a common symptom in soccer players. Its cause can be difficult to determine. We report a case in a 19-year-old soccer player who had an abscess in the obturator internus muscle. We are aware of only one similar report in the literature. Painful limitation of internal rotation of the hip and evidence of infection suggested the diagnosis, which was confirmed by magnetic resonance imaging. In a soccer player, a fever and groin pain do not always indicate osteitis pubis. Limitation of internal rotation of the hip should suggest a lesion in the obturator internus muscle.

Osteitis pubis after Marshall-Marchetti-Krantz urethropexy: a pubic osteomyelitis

OBJECTIVE

Our purpose was to review cases of osteitis pubis encountered at our institution after Marshall-Marchetti-Krantz retropubic urethropexy.

STUDY DESIGN

The charts of patients diagnosed with osteitis pubis subsequent to Marshall-Marchetti-Krantz retropubic urethropexy from 1980 to 1994 were reviewed.

RESULTS

Fifteen cases of osteitis pubis were diagnosed after 2030 Marshall-Marchetti-Krantz procedures (0.74%). Onset of symptoms related to osteitis pubis began a mean of 69.8 days postoperatively (range 10 to 459 days). Although initial plain films of the symphysis pubis were normal in 7 (54%), radiographic abnormality was eventually demonstrated in all a mean of 25.7 weeks after surgery (range 4 to 78 weeks). A variety of conservative treatments resulted in symptomatic relief in 47%. Seven of the remaining patients underwent operative therapy with partial or complete relief noted in all. Subsequent bone cultures were positive in 5 (71%). At follow-up a mean of 58 months after the Marshall-Marchetti-Krantz procedure complete resolution of symptoms was noted in 33% and continued pain or ambulatory difficulty in the remainder. There was no relationship between postoperative urinary tract infections, postoperative complications, presenting sign of fever, elevated leukocyte count or sedimentation rate, and subsequent operative intervention (P > .05).

CONCLUSIONS

Osteitis pubis after urogynecologic surgery is an uncommon event requiring aggressive surgical and antibiotic therapy. When bone cultures are performed, a microbial cause may be demonstrated in as many as 71% of patients.

[Internal osteosynthesis after unstable pelvic ring fracture in a 3-year-old child]

A 3-year-old child was trapped under the heavy load of a forklift truck and sustained an unstable pelvic ring fracture (Tile type C) with complete SI disruption, disruption of the public symphysis and external rotation injury of the contralateral SI joint. An immediate internal fixation was performed, exposing the SI joint and the public symphysis simultaneously. For stabilization an H-plate was used for anterior plate fixation of the SI joint, while the public symphysis was stabilized by screws and cerclage wires. After one revision of the symphysis the clinical course was uneventful with anatomical healing of the pelvic ring. The implants were removed after 4 months. Clinical and radiological follow-up after 12 months showed no signs of maldevelopment of the pelvic ring.

Osteitis pubis: a diagnosis for the family physician

BACKGROUND

Osteitis pubis was first described in 1924 in patients who had had suprapubic surgery. Since that time many theories concerning the cause of the disease have been developed. Published case reports and retrospective record reviews of specific, isolated patient populations have been used to postulate an infectious, inflammatory, or traumatic cause of this condition. Such confusion reduces the likelihood of an accurate diagnosis of osteitis pubis, particularly in the primary care setting, where it is becoming increasingly likely that patients afflicted with this frustrating illness will initially seek treatment.

METHODS

This article describes a case report and provides a review of the literature. The medical literature was searched using the following key words: "abdominal pain," "pelvic pain," "inflammation," "symphysis pubis," and "enthesopathy."

RESULTS AND CONCLUSIONS

Osteitis pubis, considered to be the most common inflammatory disease of the pubic symphysis, is a self-limiting inflammation secondary to trauma, pelvic surgery, childbirth, or overuse, and it can be found in almost any patient population. Occurring more commonly in men during their 30s and 40s, osteitis pubis causes pain in the pubic area, one or both groins, and in the lower rectus abdominis muscle. The pain can be exacerbated by exercise or specific movements, such as running, kicking, or pivoting on one leg, and is relieved with rest. Pain can occur with walking and can be in one or several of many distributions: perineal, testicular, suprapubic, inguinal, and postejaculatory in the scrotum and perineum. Symptoms are described as "groin burning," with discomfort while climbing stairs, coughing, or sneezing. A greater understanding and awareness of osteitis pubis will reduce patient and physician frustration while improving overall outcomes.