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.

Long-term functional prognosis of posterior injuries in high-energy pelvic disruption

OBJECTIVE

This study sought to identify the long-term functional results of various posterior pelvic lesions and to determine whether such injuries benefit from exact reduction.

DESIGN

Consecutive cohort of patients admitted for pelvic disruption between 1980 and 1990.

SETTING

University hospital.

PATIENTS

Eighty-eight pelvic fractures in eighty-eight patients were classified according to the instability and anatomy of the posterior injury. Simple fractures of the pubic rami, minimally displaced fractures with pubic diastasis of less than 2.5 centimeters, and fractures without other pelvic lesions (type B1 lesions, stage 1 in the Tile classification) were all excluded. Patients with sequelae of associated lesions that could render functional evaluation difficult were also excluded.

INTERVENTIONS

The initial status of the patient and the type of fracture determined the treatment. In the anteroposterior compression injuries group, an external fixator using the double-frame Hoffmann device was applied in twenty-eight cases to reduce a large external horizontal displacement, either immediately to control bleeding or later as definitive treatment when anterior internal fixation was not possible. Anterior internal fixation with a plate was used six times to repair a symphyseal disruption. In vertical shear injuries, tibial skeletal traction was used for six weeks as an attempt to stabilize vertical instability. In ten patients, traction alone was used. In other cases, traction was used in conjunction with an external fixator or internal pubic fixation. In impacted lateral compression injuries, simple bed rest for six weeks was used in cases of stable lesions. Skeletal traction was applied in ten patients of this group because of a potential vertical instability, particularly in cases with a comminuted sacral lesion.

MAIN OUTCOME MEASURES

Anatomic diagnosis and evaluation of the reduction were made using anteroposterior, inlet, and outlet radiographs of the pelvic ring. To assess reduction, vertical, anteroposterior, and rotatory displacement was measured. Functional results were qualified based on the injury pattern and the quality of the final reduction and were then quantified according to the grading proposed by Majeed.

RESULTS

Functional results varied according to injury anatomy, with fractures of the iliac wing and sacroiliac (SI) fracture-dislocations having the best prognosis. The quality of reduction did not affect the functional results. Conservative methods such as skeletal traction and external fixation generally gave satisfactory functional results. Conversely, however, pure SI lesions were associated with poor functional results, especially if reduction was not exact.

CONCLUSIONS

This study shows that when the posterior injury is a fracture of the iliac wing or a mixed fracture with SI propagation, a long-term satisfactory functional result can be obtained without an exact reduction even in cases of vertical instability. Simple methods are usually sufficient, and it seems unnecessary to propose more aggressive treatment. It is important, however, to recognize that SI fracture-dislocations (17 percent in this series) seem to be quite different from pure SI disruptions in terms of persistent pain. Moreover, it appears that exact reduction of pure SI lesions is critical for good functional results, something that is difficult to obtain with conservative procedures. Sacral fractures represent a special problem for the surgeon because of the frequency of fair results in which neurologic lesions whose pathophysiology is poorly known seem to be responsible.

Internal fixation in postpartum symphysis pubis rupture: report of three cases

We present three patients with postpartum symphysis pubis rupture whose severe complaints persisted after conservative treatment. All three ruptures were stabilized with open reduction and internal fixation. There were no postoperative problems, and implants were removed after a mean period of six months. Patients were free of complaints after implant removal. In select cases, operative treatment of postpartum symphysiolysis may be indicated.

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.

Two-hole plate fixation for traumatic symphysis pubis diastasis

Techniques for managing traumatic diastasis of the pubic symphysis include bed rest, hip spica casting, pelvic slings, external fixation, and internal fixation. We report herein our experience with 14 consecutively managed patients in whom we successfully stabilized traumatic pubic diastasis with a single two-hole plate fixation. The average age of the 13 men and one woman was 30 years; followup averaged 17 months. Most of the patients had associated injuries (Injury Severity Score average, 19). Nine patients had concomitant disruption of the sacroiliac joint requiring either delayed open reduction and internal fixation or prolonged skeletal traction; among the five remaining patients, time to mobilization (bed to chair) averaged 1 day. There were no complications attributable to the procedure; i.e., no infections, and no failures of fixation. In this small series of patients early two-hole plate fixation of the traumatic diastasis of the pubis satisfactorily restored the disrupted anterior pelvic ring, contributed to early mobilization of the patients, and made reduction of a concomitantly disrupted sacroiliac joint easier, whether accomplished by skeletal traction or open reduction and internal fixation during a second procedure.

Symphysis syndrome in athletes: surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes

OBJECTIVE

To investigate the results of surgical treatment on athletes presenting with chronic symphysis syndrome (lower abdominal, groin, and adductor pain).

DESIGN

Retrospective nonrandomized study.

SETTING

Swiss Olympic Medical Center associated with Institute of Sports Sciences.

PATIENTS

Twenty-four athletes who were treated for chronic symphysis syndrome, a combination of abdominal, groin, and adductor pain, were evaluated for an average of 6.6 years after surgery. All athletes were males, with a mean age of 25.8 years. The average duration of chronic symptoms was 17 months.

INTERVENTIONS

Of patients, 20 underwent spreading of the lateral border of the sheath of the rectus abdominis muscle together with an epimysial adductor release, and 4 had only the reconstruction of the rectus abdominis muscle.

MAIN OUTCOME MEASURES

Subjective (questionnaire) and objective (clinical examination) follow-up data using point scores were obtained at a mean of 6.6 years posttreatment.

RESULTS

The mean point score in the subjective overall rating was 10.2 (maximum 12) and in the objective rating was 12.0 (maximum 13). Of athletes, 21 were very content, 2 were content, and 1 was not content. Full sports activity was noted in 23 of 24 athletes.

CONCLUSIONS

Surgical treatment of chronic symphysis syndrome is successful and can salvage the career of athletes.

Fleur-de-lis abdominoplasty

An abdominoplasty technique is described that combines vertical and horizontal resection to restore abdominal contour to upper and lower abdomen and mons pubis. The results of this technique in 16 patients (13 women and 3 men) are reviewed. The procedure is suggested for patients with massive weight loss, obesity with a panniculus, and supra-umbilical dermatochalasis with or without multiple abdominal scars. A polio patient with an unexpected improvement in pulmonary function following this procedure is included in this series.

Effects of pubic symphysiodesis in dysplastic puppies

OBJECTIVE

To determine the long-term effects of juvenile pubic symphysiodesis (JPS) in dysplastic puppies.

STUDY DESIGN

Prospective, randomized, clinical trial.

ANIMALS

Seven dysplastic Chesapeake Bay retrievers and 2 beagle-crosses (BX1 and 2).

METHODS

Five puppies had JPS performed with electrocauterization at 12, 16, 20, 22, and 24 weeks of age, respectively. Two puppies served as controls. BX1 and BX2 were used to obtain biopsies of the symphysis. Hips were evaluated for: pelvic development (transverse computerized tomography for acetabular angle [AA] and dorsal acetabular rim angle [DARA]); laxity [hip extended and stress radiography [distraction index (DI)]); Ortolani maneuver with reduction angles; acetabular coverage (Norberg angles); and function (coxofemoral range of motion, hip pain, and gait analysis by force-plate technique at 44 and 137 weeks of age).

RESULTS

The pubis fused prematurely in every puppy that was operated on with the JPS technique. Greater acetabular responses were related to younger ages at surgery. The final mean AA in dogs that had JPS was 25 degrees greater than preoperative values; 40% increased over control. The DARA final mean was 10 degrees, 52% less than preoperative values and 46% less than control. The final mean DI in dogs having JPS was 0.28, 47% improved over preoperative values and 58% better than control. Mean pelvic dimensions in dogs that had JPS were 18% less than control. Gait analyses were normal for all dogs at 137 weeks. No urinary or bowel complications occurred.

CONCLUSIONS

Significant ventrolateral acetabular rotation, increased hip coverage, diminished hip laxity, normal pain-free gait, and insignificantly reduced pelvic size occurred after JPS.

CLINICAL SIGNIFICANCE

Dysplastic hips in young dogs were significantly improved by JPS.

Use of the transpubic approach for urethroplasty in children

The management of traumatic strictures of the posterior urethra in children poses several problems owing to the limitations of perineal exposure, and the small size and delicacy of the structures involved. We have used a transpubic approach in the repair of strictures of the posterior urethra in 5 children, 4 of whom had previously undergone unsuccessful attempts at repair by other routes. In 2 of the transpubic repairs a patch graft technique was used, and 3 consisted of excision and primary reanastomosis. Two repairs were accompanied by concomitant closure of a failed first-stage Turner-Warwick scrotal inlay. The transpubic approach offered excellent exposure and visualization of the involved anatomy, and facilitated accurate suture placement and tissue realignment in all 5 patients. Final results have been satisfactory in 4 patients. There have been no clinically detectable effects on gait and there have been no significant complications or morbidity associated with this approach.

Osteomyelitis of the pubic symphysis after urologic surgery

Osteomyelitis represents a pyogenic infection of the bone and marrow. The diagnosis is based on specific criteria and often is difficult to make. Herein we present 2 cases initially thought to represent osteitis pubis but subsequently proved to be osteomyelitis and compare the 2 entities with emphasis on differential diagnosis and treatment. Despite certain differentiating characteristics the correct diagnosis is often uncertain without histologic examination. Since the treatment of these 2 entities is quite different equivocal cases should undergo surgical exploration and bone curettage. This procedure will enable definite diagnosis to be made and proper treatment to be instituted.

Osteitis pubis and adductor tendinopathy in athletes: a novel arthroscopic pubic symphysis curettage and adductor reattachment

INTRODUCTION

Various surgical treatment options have been described in athletes with degenerative osteitis pubis who fail to respond to conservative treatment modalities. Although adductor longus tendinopathy often represents an additional pain generator in chronic groin pain associated with osteitis pubis, this has not been acknowledged in the surgical literature, to our knowledge. We present the results of a novel surgical technique for combined degenerative lesions of the pubic symphysis joint and the adjacent adductor longus tendon in a series of athletes with osteitis pubis.

METHODS

During 2009 and 2010, five competitive non-professional soccer players with considerable groin and pubic pain were referred to our clinic, after conservative therapy over a period of at least 12 months had failed. According to our clinical protocol for patients with groin pain, physical examination, pelvic radiographs and arthrography of the pubic symphysis to detect microlesions of the adjacent adductor longus tendons were performed. The patients diagnosed with degenerative osteitis pubis and concomitant lesion of the adductor longus origin were indicated for surgery. Surgery consisted of resection of the degenerative soft and bone tissue and subsequent reattachment with suture anchors. With regard to stability of the symphysis pubis, a two-portal arthroscopic curettage of the degenerative fibrocartilaginous disc tissue was performed. The patients were followed prospectively at medium term with assessment of general pain level (VAS score) and sport activity with pain (NIPPS score) pre- and postoperatively.

RESULTS

All patients recovered to full activity sports after an average period of 14.4 weeks. VAS and NIPPS scores markedly improved and overall satisfaction with the postoperative result was high. One intraoperative bleeding occurred, needing revision surgery. None of the patients developed pubic instability due to pubic symphysis curettage in the sequel.

CONCLUSIONS

This novel surgical technique combines successfully stability-preserving arthroscopic pubic symphysis curettage with adductor debridement and reattachment in well-selected cases of athletes suffering from degenerative osteitis pubis and concomitant adductor pathology, being refractory to conservative treatment. Diligent preoperative evaluation of the specific pathology will lead to successful outcome.

The pubourethral ligaments--an anatomical and histological study in the live patient

The aim of the study was to analyze the structure, relations and insertions of the pubourethral ligament in the living female. Thirty-five women, mean age 44 years, were studied. The intravaginal slingplasty (IVS) procedure, as performed via two paraurethral incisions, allowed immediate access to the structures in this area, the urethra, vaginal hammock, pubourethral ligaments and anterior portion of the pubococcygeus muscle. Histological biopsies were performed from the structures identified as ligaments. The pubourethral ligament descends like a fan from the lower part of the pubic bone. It consists of vaginal and urethral parts, joined together by thin fibrous threads, giving the appearance of a continuous sheet of amorphous connective tissue. Each part generally varies between 5 and 7 mm in width and 3-4 mm in thickness. The urethral part is approximately 2 cm long and inserts into the midpart of the urethra. The vaginal part is approximately 3-4 cm long. It inserts into the vaginal hammock posterolaterally, approximately 1 cm short of the bladder neck. Histologically the ligaments consist of smooth muscle, elastin, collagen, nerves and, blood vessels. The dissections confirm that the pubourethral ligaments are strong finite structures. Allowing for differences between cadavers and live patients, relationships and insertions are much as described by Robert Zacharin.

Juvenile pubic symphysiodesis in dysplastic puppies at 15 and 20 weeks of age

OBJECTIVE

To examine the effects of juvenile pubic symphysiodesis (JPS) on hip joint conformation, hip laxity, gait, and the development of degenerative joint disease (DJD) in dysplastic puppies operated at 15 and 20 weeks of age.

STUDY DESIGN

Randomized controlled prospective study. ANIMALS-Eighteen female hound puppies with increased hip laxity.

METHODS

Puppies were randomized to 1 of 4 treatment groups: JPS at 15 weeks of age (n = 6), sham-operated control at 15 weeks of age (n = 3), JPS at 20 weeks of age (n = 6), and sham-operated control at 20 weeks of age (n = 3). Hip extension with pain scoring, Ortolani palpation, hip reduction angle measurement (HRA), PennHIP radiography (University of Pennsylvania) with measurement of distraction index, Norberg angle measurement, and transverse computed tomographic imaging to measure acetabular angle (AA) and dorsal acetabular rim angle (DARA), were tested preoperatively, and at 1 and 2 years of age.

RESULTS

JPS resulted in significant changes in AA, HRA, DARA, and conversion to Ortolani negative status. Larger and more rapid changes in hip conformation were seen when surgery was performed at 15 weeks of age. No significant changes were identified in control dogs. Twenty-five percent of JPS dogs developed DJD whereas 83% of control dogs developed DJD.

CONCLUSIONS

JPS resulted in significant improvements in hip joint conformation and hip laxity in dysplastic puppies treated at 15 and 20 weeks of age. Improvements in conformation were significantly greater when surgery was performed at 15 weeks of age.

CLINICAL RELEVANCE

JPS appears to be a promising treatment for hip dysplasia and is a safe and technically simple procedure to perform.

Transpelvic Urethrostomy in 11 Cats Using an Ischial Ostectomy

OBJECTIVE

To investigate the feasibility and long-term outcome of a modified subpubic urethrostomy technique termed transpelvic urethrostomy (TPU) in cats.

STUDY DESIGN

Prospective clinical study.

ANIMALS

Eleven male cats with obstructive lower urinary tract disease that could not be relieved, and requiring a surgical urinary diversion, were selected for TPU.

METHODS

With the cat in dorsal recumbency, the penis was exposed and the ventral pelvis was denuded by median adductor muscle elevation. An approximately 12 mm x 15 mm area of ischium was removed. The pelvic urethra, 8-20 mm cranial to the bulbourethral glands, was incised longitudinally and sutured to the skin to create a urethrostomy.

RESULTS

All cats were neutered males (2-9 years); none were uremic or hyperkalemic at admission. Urine was cultured if there was leukocyturia, nitrituria, and/or bacteriua. Bacteria were isolated from 2 specimens. A patent urethrostomy was created in all cats without operative complications. Except for 1 cat without associated clinical signs, stricture was not evident between 9 and 42 months after urethrostomy. One cat had postoperative urinary incontinence (UI) that resolved within 4 weeks. Two cats each had 1 episode of idiopathic lower urinary tract disease after 6-month follow-up; both responded to medical therapy.

CONCLUSIONS

TPU was used as a successful urinary diversion procedure relieving signs of urinary tract obstruction and preventing further obstruction, with few complications. The incidence of UI after TPU remains minimal.

CLINICAL RELEVANCE

TPU should be considered as a salvage urinary diversion procedure in cats (as an alternative to prepubic and subpubic techniques). TPU may also be considered as a possible primary urinary diversion solution (an alternative to perineal urethrostomy) for obstructive lower urinary tract disease in cats.

Use of bone morphogenetic proteins in arthrodesis: clinical results

Bone grafting is not routinely required in primary arthrodesis in the absence of infection, avascular necrosis, bone defect or previous non-union; when any of the above factors is present, autograft is the gold-standard method. However, donor site morbidity and the quantitative and qualitative limitations of autograft have led to the development of alternatives. This study documents the use of the bone morphogenetic protein BMP-7 in a total of 19 joint fusions (ankle, subtalar, talonavicular, pubic and sacroiliac). Healing rates of 90% and satisfactory subjective functional outcome in 70% of cases were recorded over a minimum follow-up of 15 months. These data should provide a sound foundation for future clinical trials evaluating the application of BMP-7 in the fusion of joints.

Symphysiodesis with a new compression plate

A specially designed compression plate has been used in symphysiodesis for chronic symphysiolysis with pelvic pain and discomfort suspected to be due to pelvic instability. Eight patients have been operated with this technique, and stable symphysiodesis was achieved in all. No signs of plate loosening were observed in any case.

Traumatic separation of the symphysis pubis during pregnancy: a case report

OBJECTIVE

To present an unusual case of traumatic extensive separation of the symphysis pubis during pregnancy and rationale for mode of treatment.

DESIGN

Diagnosis for etiology of public and lower back pain following trauma in a 37-year-old woman in an advanced stage of pregnancy.

METHODS

Physical examination and plain anterioposterior X-rays.

CONCLUSION

Extensive traumatic separation of the symphysis pubis might result from a very forceful descent of the fetal head against the pelvic ring upon the mother's accidental falling. Propitious timing of a caesarian section permits the option of open reduction and internal fixation.

Long-term outcome of juvenile pubic symphysiodesis and triple pelvic osteotomy in dogs with hip dysplasia

OBJECTIVE

To compare long-term outcomes of juvenile pubic symphysiodesis (JPS) and triple pelvic osteotomy (TPO) in dogs with hip dysplasia.

DESIGN

Prospective clinical trial.

ANIMALS

18 dogs with hip dysplasia (ie, distraction index > or = 0.5 in at least 1 hip joint and no, mild, or moderate radiographic evidence of degenerative joint disease [DJD]).

PROCEDURES

Dogs between 4 and 5.5 months old at enrollment were assigned to undergo JPS, and dogs between 5 and 12 months old were assigned to undergo TPO. All dogs were reexamined at 2 years of age.

RESULTS

At 2 years of age, there were no significant differences between groups in regard to lameness scores, angle of extension of the hip joints, distraction index, peak vertical force, acetabular angle, radiographic DJD score, or owner-assigned scores of clinical function. Dorsal acetabular rim angle was significantly higher in dogs that underwent JPS than in dogs that underwent TPO. For dogs that underwent TPO, dorsal acetabular rim angle was significantly decreased and acetabular angle was significantly increased at 2 years of age, compared with values obtained prior to surgery.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that JPS and TPO have similar effects on hip joint conformation in dogs with moderate to severe hip dysplasia but that neither procedure eliminates the hip joint laxity characteristic of hip dysplasia or the progression of degenerative changes.

In situ anterior vaginal wall sling formation with preservation of the endopelvic fascia for treatment of stress urinary incontinence

The indications for sling procedures have evolved and encompass patients with either intrinsic sphincteric deficiency (ISD), anatomic incontinence or both. We have refined a technique that can be performed in a minimally invasive fashion with low attendant morbidity to provide a reproducible method of sling formation. Twenty patients with stress urinary incontinence underwent the in situ sling (ISS) with bone fixation. Subsequent evaluation at 24-29 months (mean = 26.2 months) revealed that 95% of patients were cured. No recurrent cystoceles, paravaginal defects or significant detrusor instability have been noted. Urinary retention appeared transiently in only 3 patients and resolved in under 3 weeks. We feel the in situ sling with bone fixation provides a safe and effective means of management for stress urinary incontinence. Furthermore, the reduced surgical dissection may minimize the incidence of postoperative ISD and recurrent paravaginal defects that may accompany more traditional needle suspension procedures.

Peripartum pubic symphysis separation--Current strategies in diagnosis and therapy and presentation of two cases

BACKGROUND

During spontaneous vaginal delivery, pubic symphyseal widening is normal. Common changes are reversible after complication-free birth. However, cases of peripartum symphysis separation are rare. There is no consensus in the literature on how to treat pregnancy-related pubic symphysis separation.

METHODS

This review used a literature-based search (PubMed, 1900-2013) and analysis of 2 own case reports. Studies with conclusions regarding management were particularly considered.

RESULTS

Characteristic symptoms, suprapubic pain and tenderness radiating to the posterior pelvic girdle or lower back, may be noted 48 h after delivery. Pain on movement, especially walking or climbing stairs, is often present. Conservative treatments, such as a pelvic brace with physiotherapy and local interventions such as infiltration, are successful in most cases. Symptom reduction within 6 weeks is the most common outcome, but can take up to 6 months in some cases. Surgical intervention is needed in cases of persistent separation. Anterior plate fixation is offered as a well-known and safe procedure. Minimally invasive SI joint screw fixation is required in cases of combined posterior pelvic girdle lesions.

SUMMARY

Postpartum symphyseal rupture can be indicated with the rare occurrence of pelvic pain post-delivery, with sciatica or lumbago and decreased mobility. The diagnosis is made on clinical findings, as well as radiographs of the pelvic girdle. Conservative treatment with a pelvic brace is the gold standard in pre- and postpartum cases of symphysis dysfunction.