A novel minimally invasive and press-fit method for symphysiodesis - a biomechanical analysis.

PURPOSE: Does the cylindrical shaped bone block allow a stable construct for the arthrodesis of the pubic symphysis compared to a rectangular shaped bone block. The cylindrical shaped bone block stabilized by a 3.5 symphyseal plate is inferior to the stabilization with an internal fixator. METHODS: This study analyzed the arthrodesis of the pubic symphysis on 24 synthetic pelvises, using a rectangular shaped bone block (control group) or a cylindrical shaped bone block, stabilized with a symphysis locking plate (n = 8) as the standard clinical procedure. Additionally we analyzed the stability using an internal fixator. RESULTS: This study showed that utilizing a cylindrical shaped synthetic bone graft results in a significant higher contact area and compression force compared to the classical rectangular shaped graft. Furthermore, the stabilization with an internal fixator had the tendency for increases of compression force and contact area, yet without a statistical significance, when compared to the plate fixation. CONCLUSION: The novel method of cylindrical symphysis resection and cylindrical bone block implantation allowed an increased biomechanical stability compared to using a classical rectangular bone graft, also resulting in higher contact area. Moreover, this technique would also allow a minimally invasive approach for this purpose, which in turn could preserve perisymphyseal ligaments, thereby improving healing in a clinical context.

A novel press-fit minimally-invasive symphysiodesis technique.

OBJECTIVE: Instability of the pubic symphysis often results in a poor outcome and reduced mobility of the patient. In some cases, an arthrodesis of the pubic symphysis is required. Until today, there is no data published how many of these procedures are performed annually and there is also no data about the outcome after this extensive surgery. METHODS: We developed a novel surgical technique to address the arthrodesis of the pubic symphysis in a minimally invasive approach. Therefore, we used for this purpose modified instruments and performed the transplantation of a cylindrical bone substitute into the pubic symphysis, without an extensive approach or dissecting the anterior or posterior symphyseal ligaments. RESULTS: Using this novel technique, a minimally invasive symphysiodesis was achieved in radiological findings, after the procedure. CONCLUSION: Thus, this actually minimally invasive surgical technique seems to be a promising advancement for the arthrodesis of the pubic symphysis.

A novel internal fixation method for open book injuries of the pubic symphysis- A biomechanical analysis.

BACKGROUND: Pelvic fractures in adults are common injuries and account for up to 3.64% of all fractures. Usually, the treatment of open book injuries (Types B1.1 and B1.2 AO-Classification) is open reduction and plate stabilization using dynamic compression plates, with or without interlocking screws. These implants seem to enhance the outcome of such injuries, but also variety of complications occurs. To reduce complications and achieve appropriate reduction and stabilization, this study compared established stabilization techniques to a novel minimally invasive internal fixation method using an internal fixator system that is already being utilized for spinal fractures. METHODS: This study was performed on 32 composite pelvises in a bilateral stance biomechanical model. The pelvises were variously stabilized with an internal fixator, a 4.5 mm dynamic compression plate and a 3.5 mm symphyseal locking dynamic compression plate. The contact area and loading forces were assessed by a sensor film inside the symphyseal gap. FINDINGS: This study showed significantly greater reduction and loading capabilities of the internal fixator compared to the other implants (p < 0.05). There was also significantly greater contact area with the use of an internal fixator compared to the other implants (p < 0.05). The 3.5 mm interlocking plate showed significantly greater contact area compared to the 4.5 mm plate (p < 0.05). INTERPRETATION: The internal fixator that is already proven in spinal surgery is biomechanically superior to conventional implants used in pelvic surgery. The contact area analysis furthermore showed a more physiological loading pattern, which can improve ligamentous healing in a clinical context.

Stabilization of a Type B1.1 Injury in a Morbidly Obese Patient Using an Internal Fixator in a Minimally Invasive Technique: A Case Report.

CASE: In this case report, we present a novel stabilization technique of the pubic symphysis using an internal spinal fixator in a 78-year-old morbidly obese woman having a pelvic disruption type B1.1 (AO classification). We treated the disruption using an internal fixator to reduce the extent of the incision and soft-tissue damage. CONCLUSIONS: The use of an internal fixator, known from percutaneous spinal fixation, for the stabilization of the pubic symphysis in cases of disruption ("open book" injuries) may be an alternative to the standard plate fixation as a novel minimally invasive stabilization technique.

C-arm fluoroscopy in orthopaedic surgical practice.

The use of C-arm fluoroscopy in intraoperative orthopaedic procedures has become an important tool in modern orthopaedic surgical practice. It enhances the technical proficiency of the surgeon in addition to reducing the morbidity and length of hospital stay of the patient. Despite the documented benefits of this device, there has been a growing concern about the increased radiation exposure to the surgical team. We therefore present the review of the literature on the usefulness of C-arm fluoroscopy, pitfalls in application of the machine as well as the harmful radiation effects and precautionary measures that need to be observed when using the C-arm fluoroscopy in orthopaedic surgical procedures.

Novel pathomorphologic classification of capsulo-articular lesions of the pubic symphysis in athletes to predict treatment and outcome.

INTRODUCTION: Radiographic abnormalities of the symphysis as well as the formation of accessory clefts, indicating injury at the rectus-adductor aponeurosis, reportedly relate to longstanding groin pain in athletes. However, yet, no systematic classification for clinical and scientific purposes exists. We aimed to (1) create a radiographic classification based on symphysography; (2) test intra- and interobserver reliability; (3) characterise clinical significance of the morphologic patterns by evaluating success of injection therapy. PATIENTS AND METHODS: We retrospectively reviewed symphysography, AP radiographs, and MRI of the pelvis from 70 consecutive competitive athletes, with chronic groin pain. Symphysographs were evaluated for intra- and interobserver variance using cohen's kappa statistics. Morphologic studies of the different contrast distribution patterns and their clinical and radiological correlation with symptom relief were investigated. All patients were followed up to evaluate immediate and long-term response to the initial therapeutic injection with steroid. RESULTS: Four reproducible symphysographic patterns were identified: type 0, no changes; type 1, symphyseal disk degeneration; types 2a with unilateral clefts, bilateral clefts (2b), suprapubic clefts (2c); and type 3, with expanded or multidirectional clefts. Analysis revealed excellent intra (0.94)-and interobserver (0.90) reliability. Our findings showed that 78.6% of our patients had significant short-term improvement enabling early resumption of physiotherapy, only in types 1 and 2 (p = 0.001), while type 0 and 3 did not respond. At follow-up, only 21.8% had permanent pain relief. Regarding the detection of pathologic clefts with symphysography, sensitivity (88%) and specifity (77%) were superior to that of MRI. CONCLUSIONS: A reproducible symphysography-based classification of distinct morphologic patterns is proposed. It serves as a predictive tool for response to injection therapy in a select group of pathologic lesions. Complete recovery after injection can only be expected in a lesser percentage, as this might indicate surgical treatment for long-term non-responders.

[What do we know about osteitis pubis in athletes?] / Was wissen wir über die Osteitis pubis bei Sporttreibenden?

BACKGROUND: Osteitis pubis is a common cause of chronic groin pain. Due to high clinical uncertainty and varying etiopathology, the diagnosis is often delayed. Especially athletes suffer from this disease, but patients with orthopaedic, traumatological, neurological, urological, gynaecological, and rheumatic complaints can also be affected. Osteitis pubis can be treated by conservative as well as surgical techniques. MATERIAL AND METHODS: Systematic literature research, descriptive presentation of the studies, and interpretation of evidence-based medicine results. RESULTS: The scientific level of studies about osteitis pubis and the number of athletes included are low overall. A statistical comparison is methodically difficult due to the heterogeneity of publications. The leading clinical symptom of osteitis pubis is an aching symphysis pubica. Unfortunately, there are no characteristic clinical pathognomonic signs. The medical diagnosis is based on an exclusion of various differential diagnoses (e. g. sports hernia, femoroacetabular impingement, adductor lesion) and a comparison of medical history, clinical examination, and imaging methods. After a period of rest, osteitis pubis is quite often a self-limiting disease and will initially be treated conservatively. If this fails, surgical intervention has to be considered depending on concurrent pathologies. CONCLUSION: Specific guidelines for the diagnosis and treatment of osteitis pubis do not exist as yet. But there is consensus that a surgical intervention should only be performed if conservative treatment fails. The level of evidence for the studies is low. A meta-analytical evaluation based on the existing publications is not possible as yet. The number of recorded athletes in relation to the socio-economic consequences of the disease, especially in professional sport, is low.

Predictors of mortality for complex fractures of the pelvic ring in the elderly: a twelve-year review from a German level I trauma center.

STUDY OBJECTIVE: To document mortality rate and predictors of mortality in elderly patients with complex pelvic fractures. METHODS: We reviewed a total of 84 subjects whose ages were above 70 years with complex pelvic fractures, admitted to our hospital from January 2001 to December 2012. A multivariate linear regression model was used to determine the predictors of mortality in the study population. The median age of the patients was 80.4 years (range 70-94 years). 65 of 84 (77%) patients were females. There were 72 Tile Type B fractures (86%) and 12 Type C fractures (14%). The most common associated injuries were thoracic, extremity and head injuries, with incidence of 13 (15%), 11 (13%), and 9 (11%), respectively. RESULTS: The mortality rate was 10% in our study population. The initial haemoglobin on admission (p<0.01), the presence of blood vessel injuries (p<0.01) and the number of PRBCs transfused within the first six hours after admission (p<0.01) independently predicted mortality in elderly patients with complex pelvic fractures. CONCLUSION: Although there is a downward trend in mortality in elderly patients with complex pelvic fractures, haemodynamic instability still has a significant impact on survival of those patients.

Posterior symphyseal spurs--an unusual differential diagnosis in athletes with groin pain.

We set out to highlight the significance of posterior symphyseal spurs as an unusual diagnostic possibility in athletes with chronic groin pain and to demonstrate that operative resection was successful in quickly and safely returning the patients to sporting activities. Five competitive nonprofessional male athletes, three soccer players, and two marathon runners (median age: 30 [26/33] years), who presented to us with significant groin and central pubic pain with duration of at least 12 months, and who had failed conservative or surgical interventions (symphyseal plating), were evaluated. Physical examination as well as pelvic radiographs confirmed the diagnosis of posterior symphyseal spurs. Four out of five athletes underwent complete resection of the spur. Size of spurs was 2.2 (1.3/2.9) cm (median) with four of them posterosuperiorly and one posterocentrally located. All of them had uneventful postoperative recovery period and were still pain-free at the latest follow up after 26.6 months (24/30). Median time-to-return to competitive sports level was 10 weeks (8/13). None of the patients developed pubic instability due to symphyseal spur resection. The results of considerable postoperative improvement in our patients highlight the significance of posterior symphyseal spurs as a diagnostic possibility in athletes with chronic groin pain.

Arthroscopic debridement of the pubic symphysis: an experimental study.

PURPOSE: Open curettage of the symphysis has shown promising results in patients with recalcitrant osteitis pubis. However, this has been bedevilled with an extended intraoperative morbidity. Aim of this study was to come up with a novel arthroscopic debridement of the pubic symphysis and to bring to the fore the potential risks of soft tissue damage. METHODS: This study was conducted on six human cadavers (mean age 83 years). CT scans were obtained for measurement of the symphyseal morphology. Consequent upon these measurements, four different potential arthroscopic portals were defined with the intention to gain adequate insight and to reach the whole joint space with instruments: one suprapubic portal and three anterior portals (antero-superior, antero-central and antero-inferior). Soft tissue, except for musculotendinous attachments and neurovascular structures, was dissected. A two-portal arthroscopic debridement under image intensifier control with resection of the symphyseal disc and abrasion of the subchondral bone were performed. RESULTS: Considering the narrow joint space, small instruments/scope (4.5/2.7 mm) is recommended. Correct portal placement and debridement procedure can only be reliably performed under fluoroscopic imaging in two radiographic projections (outlet and inlet view) with a mean total fluoroscopic time of 15-20 s and a dose area product between 100 and 120 cGy cm(2). Two portals have proved beneficial: the suprapubic portal for instruments and the antero-central portal for the scope. Other portals had several limitations, e.g. potential instrumental conflict (anterior-superior) or damaging of neurovascular and other soft tissue structures (anterior-inferior). CONCLUSION: With well-defined arthroscopic portals and adherence to basic principles of arthroscopic surgery, debridement of the pubic symphysis can be performed reproducibly without compromising important anatomical structures. This less invasive arthroscopic debridement is a safely applicable procedure and therefore might be a reasonable alternative to open curettage. One may assume that this technique will lead to a shorter rehabilitation time and will provide a successful therapy especially in the treatment of professional athletes in the future.

Arthroscopic pubic symphysis debridement and adductor enthesis repair in athletes with athletic pubalgia: technical note and video illustration.

We elaborately describe our novel arthroscopic technique of the symphysis pubis in athletes with osteitis pubis and concomitant adductor enthesopathy who fail to conservative treatment modalities. The symphysis pubis is debrided arthroscopically and the degenerated origin of adductor tendon (enthesis) is excised and reattached. With our surgical procedure the stability of the symphysis pubis is successfully preserved and the adductor longus enthesopathy simultaneously addressed in the same setting.

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.