Clinical and radiological outcomes for percutaneous reduction and fixation of symphyseal diastasis.

PurposeSymphyseal diastasis accounts for 13–16% of pelvic ring injuries. Symphyseal plating via a Pfannenstiel approach was the standard method of fixation for symphysis diastasis. Recently, percutaneous reduction and fixation of pelvic fractures have been employed to treat various pelvic ring and acetabulum injuries. The current study aims to compare the clinical and radiological results of treatment of symphysis pubis diastasis using symphyseal plating and percutaneous symphyseal screws.MethodsIt is a retrospective study conducted at a trauma centre at academic level I. One hundred and ten patients were identified in our records. Sixty patients were excluded according to our exclusion criteria. Fifty patients were included in this study. Among which were 26 patients treated with anterior symphyseal plating (Group A) and 24 patients treated with percutaneous symphyseal screws (Group B). Posterior pelvic injury was fixated according to the existing pathology. In both groups, we recorded operation time, intraoperative blood loss, length of the incision, number of x-ray shots, changes in symphysis distance (preoperative, immediate postoperative, and in the last follow-up), and time for union. At the last follow-up, the clinical evaluation was conducted using the Visual Analogue Scale (VAS), and the functional evaluation was conducted using the Majeed scoring method for both groups.ResultsAll patients have followed up for at least two years. According to the Majeed Score, group A’s functional classification was excellent for fourteen patients, good for seven, fair for two, and poor for three cases. Group B’s functional classification was excellent for seventeen patients, good for six, and poor for one. The operative time and intraoperative time were significantly different between both groups, while the symphysis diastasis at the last follow-up was insignificant. Five patients in group A showed metal failure in the form of plate breakage, screw loosening, and screw backing out. In Group B, one case showed implant failure and loss of reduction in the form of screw backing out and widening of the symphysis pubis. Two patients in group A had infections at the incision site, which were treated with antibiotics and daily dressings and resolved adequately. No recorded cases of infection in group B.ConclusionBoth techniques showed favourable results. The group with symphyseal plating showed a higher failure rate than the group with percutaneous screw fixation. The symphyseal screw group had shorter operative time, smaller incision, and less intraoperative blood loss than the symphyseal plating group but more radiation exposure. The symphyseal screw technique is a technically demanding technique and requires a high learning curve. It involves more radiation exposure, especially in inexperienced surgeons.

Introduction Unstable pelvic ring disruptions result from high-energy trauma and are often associated with multiple concomitant injuries. Internal fixation has become the preferred treatment for unstable posterior pelvic ring injuries. Several methods of fixation of posterior pelvic injuries have been described, including anterior pelvic plating, posterior sacroiliac plating, lumbopelvic fixation, and percutaneous fixation with iliosacral screws.Aim The aim of this study was to report on the clinical and radiological results of plate osteosynthesis for fixing posterior pelvic injuries in Tile's C completely unstable pelvic ring injuries.Patients and methods This study involved 21 patients with Tile type C pelvic injuries who had their posterior injuries fixed by plate osteosynthesis. The mean duration of postoperative follow-up was 25.29±9.93 (13–48) months. The clinical outcome was assessed with postoperative Majeed's score and the rate of postoperative complications. The radiological outcome was assessed through the measurement of posterior displacement as per the method of Matta and Tornetta.Results The mean±SD postoperative Majeed score was 76.57±11.21. There was a statistically significant improvement in the postoperative vertical displacement of the posterior injury (P<0.001). The incidence of postoperative complications was 38.1%.Conclusion Pelvic plating is an effective procedure in the management of completely unstable posterior pelvic ring injuries. The treatment of these complex injuries is associated with a relatively high incidence of postoperative complications.

Objective To establish a three-dimensional finite element model of pelvic anteroposterior compression (APC) for analysis of mechanisms for related ligamentous damages. Methods A finite element model and a laboratory mechanical model of APC were established using the same pelvic specimens. In a finite element model of normal pelvic bones and ligaments, after the right pelvis was fixated the pubic symphysis (PS) was sectioned. Next, a manual external mobile force was gradually applied to the left hemipelvis to make the PS diastasis 10, 20, 30, 40, 60, 80 and 100 mm apart. The mechanical experiment revealed the anterior sacroiliac ligament (ASIL) was ruptured when the PS diastasis reached 28 mm. After the strain value of ASIL was calculated through the finite element model, it was applied to the other pelvic ligaments. The displacement in front of the sacroiliac joint (SIJ), stress, strain and extent of injury and disruption of sacrotuberous/sacrospinous ligaments (STL/SSL) with a corresponding PS diastasis were observed and recorded. Results ASIL failed at the point when the PS diastasis was 28 mm and the displacement in front of SIJ was 7.41±1.14 mm. The strain and maximum principal stress of ASIL calculated in the finite element model were 259.5% and 543.24 MPa respectively. The maximum principal stress value of SSL was 35.00 MPa at the point of failure when the PS diastasis and the displacement in front of SIJ were 51 mm and 15.23±2.88 mm, respectively. When the PS diastasis and the displacement in front of SIJ were 100 mm and 7.5 mm respectively, the maximum principal stress value of STL was 16.17 MPa but the strained ligament was not ruptured. When the pelvis was rotated externally step by step, the ASIL failure was followed by the rupture of SSL but not necessarily by the STL failure. Conclusion As the finite element pelvic bone-ligament model established in this study can effectively simulate the mechanisms for APC injury, it can be used to evaluate different extents of pelvic ligamentous injury, providing a basis for the biomechanical study of pelvic bones and ligaments. Key words: Pelvis; Ligaments; Wound and injuries; Biomechanics; Finite element analysis

Objective With the isocentric C-arm (Iso-C) three-dimensional computerized navigation system, cadaveric pelvic specimens were used to imitate double screw fixation of the symphysis pubic. Practicability and safety of the screw trajectory were examined postoperatively by local cadaveric dissections and imaging tests. Methods Pelvic specimens were harvested from 8 male and 7 female adult cadavers. Double screw placement in symphysis pubic was performed using the Iso-C three-dimensional navigation and entry point and safety trajectory was achieved. With the detailed local dissection postoperatively, distances from screw entry and exit points to unilateral structures (spermatic cord, femoral artery and vein, femoral nerve, obturator artery and vein, obtrurator nerve, and so on) were measured respectively. After complete removal of surrounding soft tissues of the specimen with only bony structure kept, the entry angle and length were calculated. Accuracy of double screw fixation of symphysis pubic was further checked using X-ray and CT. Results Entry point of the first screw was at the junction of unilateral pubic tubercle and transitional site of superior pubic ramus. Mean angle of the first screw with the horizontal plane was (7.7±1.9)° in men and (8.1±1.7)° in women. Mean angle between the first screw and coronal plane was (7.8±1.8)° in men and (7.7±2.0)° in women. Entry point of the second screw was in the same place in the contralateral pubic tubercle. Mean angle between the second screw and horizontal plane was (30.6±4.0)° in men and (30.8±3.4)°in women. Mean angle between the second screw and coronal plane was (9.1±3.0)°in men and (9.2±3.3)°in women. Conclusions With the three-dimensional computerized navigation system, the bony channels of double screws implanted in the symphysis pubic are achieved and reliable. Percutaneous double screw fixation is feasible to treat the pubic symphysis diastasis. Key words: Pubic symphysis diastasis; Bone nails; Anatomy, regional; Surgery, computer-assisted

BACKGROUND This study aimed to assess the functional outcomes of percutaneous ilio-sacral screw fixation in the treatment of posterior pelvic ring injuries. METHODS A total of 34 (out of 42) adult patients treated with percutaneous ilio-sacral screw fixation for posterior pelvic ring injuries, with or without associated anterior ring injuries between January 2020 and December 2023, were included in this study. There were 35% females and 65% males, all of whom completed follow-up evaluation. Clinical and radiological follow-up assessments were performed at six months, and functional outcomes were evaluated using the Majeed Functional Score. RESULTS The mean age of patients was 34.29 years ±13.29. The average hospital length of stay was 22.88 days ±18.63. Patients were categorized by Tile classification, with B3 injuries being the most common (26.47%), followed by C2 injuries (20.59%). Injury mechanisms included two-wheeler accidents (35.29%), pedestrian accidents (17.65%), and falls from height (14.71%). Functional outcomes assessed using the Majeed Functional Score showed excellent results in 79.41% of patients, good in 8.82%, fair in 8.82%, and poor in 2.94%. There was no incidence of neurological injury in this cohort. CONCLUSION The findings suggest that, if executed correctly, percutaneous ilio-sacral screw fixation is a safe and effective method for managing posterior pelvic ring injuries. Most patients achieved excellent functional outcomes, aligning with previous research on this treatment modality. KEYWORDS Majeed functional score, percutaneous ilio-sacral fixation, unstable posterior pelvic injuries

Objective To investigate the reliability of using the pubic symphysis diastasis of 25 mm and anterior separation distance of sacroiliac joint to differentiate anteroposterior compression (APC) type I and II injuries as well as assess the injury severity. Methods A total of 11 (seven males and four females) fresh cadaver specimens with 22 hemipelvis were collected. The pelvic APC injury test models including fixed hemipelvis (restricted group) and unfixed hemipelvis (non-restricted group) were established, with 11 hemipelvis in each group according to the random number table method. Meanwhile the specimens were divided into male group (14 hemipelvis) and female group (eight hemipelvis), simulating APC type injury external rotation hemipelvis. The public symophysis interval and anterior interval of sacroiliac joint of the original pelvis, the pubic symphysis diastasis and anterior diastasis of sacroiliac joint after anterior tibiofibular ligament failure, as well as the affected pelvis ligament and sacral ligament injury were recorded and compared between the restricted and non-restricted groups, male and female groups. Results There were no significant differences in the public symphysis interval of the original pelvis and anterior interval of sacroiliac joint between the restricted group and the non-restricted group (P>0.05). The pubic symphysis interval of the original pelvis was [(5.13±0.61)mm] in male group and (4.03±0.84)mm] in female group (P 0.05). In terms of anterior interval of sacroiliac joint, there was significant difference between male and female groups (P 0.05). In the restricted group, sacrotuberous ligament injuries were found in four patients, and sacrospinous ligament injuries in five, whhile there were no obvious sacrospinous ligament and sacrotuberous ligament injuries in non-restricted group. There were 10 specimens with the pubic symphysis diastasis ≥23.36 mm and 10 specimens with the diastasis distance of anterior sacroiliac joint ≥9.82 mm (46%), and there were 15 specimens with at least the pubic symphysis interval ≥23.36 mm or the anterior interval of sacroiliac joint ≥9.82 mm (68%). Conclusions The public symphysis interval ≥ 23.36 mm or anterior interval of sacroiliac joint ≥ 9.82 mm can distinguish anteroposterior compression I from II injuries, and the combination of the two criteria can be beneficial to assessment of pelvic injury severity. Key words: Pelvis; Ligaments; Injury classification

Intramedullary screw and plate combination technique for stabilization of anterior pelvic ring: when and how? - A technical note and case series.

Plate fixation, the conventional treatment for traumatic symphysis pubis diastasis, carries the risk of extensive exposure, blood loss and postoperative infections. Percutaneous screw fixation is a minimally invasive treatment. The goal of the present study was to compare the outcome of plate fixation and percutaneous screw technique in the treatment of traumatic pubic symphysis diastasis. Ninety patients with traumatic symphysis pubis diastasis were treated from January 2003 to December 2009 at two level 1 regional trauma centers. The mean time of follow-up was 21 months (18 to 26). Forty-five patients were treated by percutaneous screw fixation. Forty-five patients were treated by plate and screws fixation. The demographic, distribution of fracture patterns, blood loss, incision length, fixation failure, malunion, revision surgery and functional scores were compared. Seven cases were lost during follow-up. Demographics (age and gender), fracture classification and Injury Severity Score were comparable in the two groups (P > 0.05). Blood loss and extensive exposure were much less in screw group (P < 0.01). Patients in screw group achieved better functional performance (P = 0.01). There were no significant differences favoring plate fixation in reduction quality (P = 0.32), implant failure (P = 0.39), malunion (P = 0.15), revision surgery rates (P = 0.27), percentage of impotence in the male patients (P = 0.2) and implant removal time (P = 0.12) between the two groups. Our results indicate that besides lower rate of iatrogenic injuries and better functional outcome, percutaneous screw fixation of the pubic symphysis is as strong as plate fixation.

Pubic symphysis diastasis is recognized as a possible complication of pregnancy. When this occurs, pubic symphysis diastasis may cause anterior widening and loss of stiffness within the pubic symphysis, causing potential instability in the pubic joint. The persistent loss of reduction can cause substantial disability in postpartum women. Pubic symphysis diastasis has previously been treated conservatively using a pelvic girdle and bedrest with some success. When a diastasis >3 cm is present, however, surgical intervention may be needed to preserve the integrity of the pubic symphysis joint. To date, most surgical procedures for reduction of pubic symphysis diastasis have been via internal fixation with plates and screws on the superior pubic rami. Although internal fixation provides good structural support, this method would be inadequate if a postpartum pubic symphysis diastasis patient has significant reproductive organ damage, due to the risk of soft tissue infection or osteomyelitis. External fixation is an alternate method of pubic symphysis diastasis treatment that has not received significant attention in the literature to date. We present the following case report to highlight a novel use of a pelvic frame external fixator for treatment of a severe postpartum pubic symphysis diastasis with organ damage. This article outlines a treatment alternative to internal fixation for cases of pubic symphysis diastasis with a contaminated pelvic environment.

The purpose of this study was to demonstrate a rare case of pelvic ring injury in a healthy man without a history of high energy damage. A 43-year-old man presented to the emergency with local pain in pubic symphysis and difficulty walking after horseback riding. The patient did not report any fall or injury during this recreational activity, and apart from tachycardia, he was hemodynamically stable with normal blood pressure. Additionally, no deficit of neurological function was observed. The radiological imaging demonstrated an injury of the pelvic ring APC II with a diastasis of pubic symphysis of 3.6 cm. After a temporary stabilization with a pelvic binder, a computed tomography scan was also executed. A closed reduction and stabilization of the pelvic ring with supraacetabular external fixation with two 6 mm pins was performed. Postoperatively, the diastasis of the pubic symphysis was reduced to 1.5 cm. The patient remained in bed for four weeks, and afterward, gradual mobilization with partial weight bearing was allowed with crutches. The external fixation was removed 10 weeks postoperatively, and he fully returned to his pre-injury activities without any discomfort four months after the injury. Pelvic ring injuries in young patients without high-energy injuries are extremely rare and might be misdiagnosed. As presented in this case, the sudden onset of pain in pubic symphysis, combined with difficulty walking after a similar low-energy task, should not be overlooked for pelvic injury.

Pubic symphysis is a non-synovial joint, made up of a fibrous cartilage disc connecting the two sides of pubic rami in the midline. During pregnancy under the influence of hormones particularly relaxin, the gap increases by 2 to3mm. When the diameter is more than 10 mm, it is considered as pubic symphysis diastasis. Pregnancy and childbirth are the most common causes of pubic symphysis diastasis followed by traumatic causes. Women with post-partum symphysis diastasis present during puerperium with inability to bear weight owing to severe supra-pubic and groin pain. They have complaint of severe excruciating pain while standing up or to perform any movement involving hip abduction. For the diagnosis, proper history regarding delivery should be sought followed by physical examination and radiological imaging. Most cases can be treated with conservative management which includes- use of analgesia and anti-inflammatory medicines for the pain management and stabilization of pelvis using brace/pelvic belt. Some may benefit from physiotherapy. In extreme cases, operative fixation may be required with the involvement of orthopedic surgeon. Keywords: post-partum symphysis diastasis; pubic symphysis; rare presentation.

SirWe read with great interest your case of postpartum symphy-sis pubis separation (1). We would like to present a case ofpubic symphysis diastasis that we diagnosed with a differentapproach.A 36-year-old gravida 1 para 0 at 39.6 weeks’ gestation wasadmitted with the onset of spontaneous contraction. After threehours and 18 min she delivered a 3170 g baby without compli-cations.Three hours after delivery, she complained of severe pain inthe symphysis pubic region. On examination, there was localtenderness in that region. We performed an ultrasound exami-nation, which revealed a 15.2-mm gap in the region of the sym-physis pubis (Figure 1), diagnosed as pubic symphysis diastasis.She was given analgesics and advised bed rest. The patient wasdischarged six days after delivery and advised to maintain activeambulation and start physiotherapy. Three months later she wasseen at the outpatient clinic. She was able to walk independentlyand was no longer experiencing any pain.Although the case presented is not particularly impressive inseverity, it still offers the opportunity to inform all cliniciansabout the possibility of diagnosing this condition with the useof the ultrasonography alone. The reported incidence of pubicsymphysis diastasis varies widely in the literature, from 1 in 300to 1 in 30 000 deliveries (2,3). Generally, it is a rare complica-tion and for this reason it is very difficult to perform random-ized controlled trials to compare different diagnostic tools. Thediagnosis is based primarily on clinical findings. The most con-sistent finding is pain in the symphyseal region that radiates tothe lower back and thighs and is exacerbated by leg movement(4). In addition, many women will have difficulty walking, infact the gait is described as waddling, or potentially be unableto stand or walk due to pain (3). Symptoms may be noted dur-ing labor and up to 48 h postpartum. Often the first diagnostictest used to identify the pubic diastasis is antero-posterior radi-ography. However, we think that ultrasound might be a goodchoice as an initial imaging study, rather than x–ray, due toabsence of exposure to ionizing radiation and its ease of opera-tion, and as it presents an optimal assessment of the extent ofsymphysis separation (3–5). We performed ultrasonography inthe following way: we placed the probe in transverse orientationon the pubic symphysis (identified by palpation) with an approx-imately 30° caudal scanning plane, with the purpose of measuringthe width of the symphyseal joint at its upper margin.Pubic symphysis diastasis is an uncommon injury that shouldbe considered when evaluating patients in the peripartum periodwho are experiencing suprapubic, sacroiliac or thigh pain. In addi-tion we would like to bring to the general attention the usefulnessof ultrasound in the diagnosis and management of this rare condi-tion. The literature is inconsistent on this topic, due to the lack ofrandomized controlled trials, but good suggestions are present (3–5). In our experience, ultrasound is simple, reproducible and with-out side effects, and should be used as an initial imaging studybecause the accuracy is at least as good as that of x-rays for esti-mating the width of the symphysis pubis diastasis.Alessandro Svelato

Migration of orthopedic screws into the bladder is a rare postoperative complication following surgical fixation of pelvic fractures. We present a case of a 61-year-old man who sustained a type 3 anteroposterior compression injury with pubic symphysis diastasis, left sacroiliac joint dislocation, and lumbar spine transverse process fracture. At the time of presentation open-reduction internal fixation of his pubic symphysis and closed-reduction percutaneous screw fixation of the left sacroiliac joint was performed. At his 6 month post operative visit, the patient was seen for follow up and reported mild pelvic pain and new urinary symptoms, including hematuria and recurrent urinary tract infections, which lead to further investigation. Imaging revealed findings concerning for migration of one of the pubic symphysis screws with bladder involvement. Cystoscopy confirmed the presence of a foreign body in the bladder. The patient subsequently underwent removal of the pelvic hardware, definitive bladder repair and left sacroiliac arthrodesis, followed by an uneventful postoperative course. This report describes the delayed presentation of spontaneous screw migration after repair of an open book pelvic fracture and describes the diagnostic and management considerations for patients with urinary symptoms after pubic symphysis open reduction internal fixation.

It has been proposed that 2.5 cm of diastasis of the symphysis pubis corresponds with injury to the anterior sacroiliac ligament and differentiates Young-Burgess anteroposterior compression Type I and II pelvic ring injuries. We hypothesized that if a pelvis has greater than 2.5 cm of symphysis pubis diastasis, the anterior sacroiliac ligaments are disrupted and the pelvic floor has failed. Pure torsional moment was applied to cadaveric human pelves with the hemipelvis either unconstrained (n = 10) or constrained to move only in the plane of rotation (n = 10). We recorded displacement of the symphysis pubis and sacroiliac joint and the applied torque that corresponded with failure of the anterior sacroiliac ligaments. Average symphysis pubis diastasis at the point of anterior sacroiliac ligament failure was 2.2 cm (n = 20; range, 1-4.5 cm); however, 80% of the values were outside the range of 2 to 3 cm. Symphysis pubis diastasis in male specimens averaged 2.5 cm and in female specimens, 1.8 cm (P = 0.06). The sacrospinous and sacrotuberous ligaments that make up the pelvic floor were not injured in unconstrained testing (zero of 10 specimens) but were at least attenuated in constrained testing (10 of 10 specimens), either simultaneously or after anterior sacroiliac ligament failure. We were not able to confirm 2.5 cm of symphysis pubis diastasis as a valid differentiation point between anteroposterior compression I and II injuries because significant morphologic variation seems to exist. Our data support that anterior sacroiliac ligament disruption is likely for displacement greater than 4.5 cm and unlikely for values less than 1.8 cm. Our study suggests that sacrospinous and sacrotuberous ligaments might not rupture at the same time as the anterior sacroiliac ligament.

BackgroundThe aim of the study was to introduce a new percutaneous technique for the treatment of traumatic pubic symphysis diastasis using a TightRope and external fixator. A comparison between this technique and percutaneous fixation using a cannulated screw was performed.MethodsFrom January 2009 to December 2013, 26 patients with type II traumatic pubic symphysis diastasis were treated at two level 1 regional trauma centers. Among them, 10 patients were treated with a percutaneous TightRope and external fixator and 16 patients were treated with percutaneous cannulated screw fixation. Functional outcomes were evaluated using the Majeed scoring system. Patient satisfaction was evaluated using the modified visual analog scale. Radiological results were assessed based on the width of pubic symphysis preoperatively, immediately postoperatively, and at the final follow-up. Postoperative complications were also recorded.ResultsThere were no significant differences between the groups in Majeed scores and patient satisfaction (p > 0.05). There were no significant differences in the width of pubic symphysis preoperatively, immediately postoperatively, and at the final follow-up (p > 0.05). No significant differences were found regarding infection, fixation failure, or the need for revision surgery (p > 0.05).ConclusionsThe new percutaneous technique using a TightRope and external fixator is a successful alternative for the treatment of type II traumatic pubic symphysis diastasis, which results in similar outcomes comparing to percutaneous cannulated screw fixation.