Inferior Pubic Ramus Research Articles

Ipsilateral pubic ramus fracture during total hip arthroplasty is not rare: does it matter?

IntroductionPeriprosthetic fractures in total hip arthroplasty (THA) have been well described and studied. However, there is a lack of reports on ipsilateral pubic ramus fractures during THA due to the rare occurrence of such fractures and ambiguity of symptoms. With the use of postoperative computed tomography (CT) examinations, we have identified that asymptomatic ipsilateral pubic ramus fractures occur frequently during THA. This study aims to evaluate the incidence, location, clinical outcomes, and risk factors of ipsilateral pubic ramus fractures during THA.MethodsFrom May 2022 to March 2023, a single surgeon performed 203 THAs in 183 patients at a single institution. All patients underwent postoperative CT scans three days after THA. The patients with ipsilateral pubic ramus fractures were followed up for a minimum of six months. Basic demographics, osteoporosis, general conditions of the operations, and outcomes of THA were investigated in all patients.ResultsTwenty-two cases (10.8%) of ipsilateral pubic ramus fractures were identified on postoperative CT scans. All fractures were located near the origin of the superior or inferior pubic ramus. Five fractures were detected on simple postoperative radiographs. The fractures did not cause any further complications at a minimum of six-month postoperative follow-up. Univariate and multivariate analyses did not identify any risk factors associated with these fractures.ConclusionsAlthough the incidence of ipsilateral pubic ramus fractures during THA is high, treatment is not required as they do not cause any significant clinical symptoms or affect the prognosis of THA. However, the possibility of occurrence of these fractures must be explained to the patients before surgery.

(037) Trans Obturator Repositioning Sling (TOROS); Novel Proximal Fixation of Penile Prosthesis Cylinder in Neophallus

Abstract Introduction The placement of Penile Prosthesis (PP) in transgender men with a neophallus is technically demanding and poses challenges specifically related to the extracorporal proximal anchoring of the cylinders owing to the lack of proximal corpora. We herein designed a novel Trans-Obtutrator Repositioning Sling (TOROS) for the proximal PP cylinder anchoring in a phallus of cisgender man or a neophallus of transgender man. Objective To assess the safety and efficacy of this novel surgical approach for the extracorporal proximal PP cylinder anchoring (TOROS) in two patients (cisgender and transgender) through refashioned use of the AdVanceTM Male Sling System (Boston Scientific). We herein present one video (first patient) to demonstrate step by step surgical technique. Methods Two patients were included. First patient is a 38-year-old cisgender male with a history of micropenis who underwent anterolateral thigh phalloplasty in 2017 presents for PP insertion. Second patient is 35 year old transgender with history of right free flap forearm phalloplasty 2019 with prior failed PP revision presents with perineal pain at level of proximal PP cylinder. Both patients consented and elected to proceed. Results After careful identification of neophallus vascular pedicle with handheld doppler, a perineal midline incision was made. The space within the neophallus was carefully dissected, dilated up to 11mm with Hegar dilator and measured for upcoming PP cylinder. Next and similar AdVance Male Sling surgical approach, the Adductor Longus tendon identified as a landmark, a trocar was inserted carefully through the obturator foramen around the inferior ischiopubic ramus. The sling was pulled via perineal incision and refashioned into socket-like sling to house the proximal end of PP cylinder or Rear Tip Extender (RTE) (in this case). To further reinforce this connection, sling flanges wrapped around and suture fixated. Next a single-cylinder Ambicor PP (Boston Sci) is inserted. PP pump placed into the left perineal side. Total PP length was 15cm+2cm RTE. PP appeared cycling well. Skin closed in layers. Patient had an uneventful post-op course and discharged on POD #3. At the 6-week mark, the patient had no post-op complaints or complications. The patient has been able to cycle the penile implant twice daily without issue and satisfied with the outcome of the procedure. Conclusions Extra-corporal anchoring of PP cylinders using TOROS is a novel, feasible and potentially changing approach in cisgender or transgender men. Proximal anchoring of the cylinders on the inferior pubic ramus and ramus of the ischium through the modified and refashioned use of trans-obturator male sling mimic natural anatomical attachment of the proximal corpora, and the same approach can applied in a transgender man neophallus with apparent good stability with and without axial loading. Disclosure No.

(185) Trans Obturator Repositioning Sling (TOROS); Novel Proximal Fixation of Penile Prosthesis Cylinder in Neophallus

Abstract Introduction The placement of Penile Prosthesis (PP) in transgender men with a neophallus is technically demanding and poses challenges specifically related to the extracorporal proximal anchoring of the cylinders owing to the lack of proximal corpora. We herein designed a novel Trans-Obtutrator Repositioning Sling (TOROS) for the proximal PP cylinder anchoring in a phallus of cisgender man or a neophallus of transgender man. Objective To assess the safety and efficacy of this novel surgical approach for the extracorporal proximal PP cylinder anchoring (TOROS) in two patients (cisgender and transgender) through refashioned use of the AdVanceTM Male Sling System (Boston Scientific). We herein present one video (first patient) to demonstrate step by step surgical technique. Methods Two patients were included. First patient is a 38-year-old cisgender male with a history of micropenis who underwent anterolateral thigh phalloplasty in 2017 presents for PP insertion. Second patient is 35 year old transgender with history of right free flap forearm phalloplasty 2019 with prior failed PP revision presents with perineal pain at level of proximal PP cylinder. Both patients consented and elected to proceed. Results After careful identification of neophallus vascular pedicle with handheld doppler, a perineal midline incision was made. The space within the neophallus was carefully dissected, dilated up to 11mm with Hegar dilator and measured for upcoming PP cylinder. Next and similar AdVance Male Sling surgical approach, the Adductor Longus tendon identified as a landmark, a trocar was inserted carefully through the obturator foramen around the inferior ischiopubic ramus. The sling was pulled via perineal incision and refashioned into socket-like sling to house the proximal end of PP cylinder or Rear Tip Extender (RTE) (in this case). To further reinforce this connection, sling flanges wrapped around and suture fixated. Next a single-cylinder Ambicor PP (Boston Sci) is inserted. PP pump placed into the left perineal side. Total PP length was 15cm+2cm RTE. PP appeared cycling well. Skin closed in layers. Patient had an uneventful post-op course and discharged on POD #3. At the 6-week mark, the patient had no post-op complaints or complications. The patient has been able to cycle the penile implant twice daily without issue and satisfied with the outcome of the procedure. Conclusions Extra-corporal anchoring of PP cylinders using TOROS is a novel, feasible and potentially changing approach in cisgender or transgender men. Proximal anchoring of the cylinders on the inferior pubic ramus and ramus of the ischium through the modified and refashioned use of trans-obturator male sling mimic natural anatomical attachment of the proximal corpora, and the same approach can applied in a transgender man neophallus with apparent good stability with and without axial loading. Disclosure No.

(057) Destabilising Evidence: A Micro-Anatomical Investigation of Penile Suspensory Ligaments (PSL) Using Epoxy Sheet Plastination and Confocal Microscopy

Abstract Introduction Precise anatomy of the PSL remains controversial. It is routinely described as having 3 components: The fundiform (FL), Suspensory (SL) and Arcuate Ligaments (AL). Proponents of penile enlargement surgery (PES) ensure that division of the “superficial” PSL (FL, SL), allows desired distraction between phallus and pubic symphysis (PS) without risking instability. Seemingly in support of this rationale, many publications imply the FL and SL provide less structural integrity as they connect only superficial fascias (Origin: Scarpa’s fascia or linea alba; Insertion: Penile Dartos or Buck’s fascia). AL is reported to be the primary support structure as it connects the corporal tunica albuginea (TA) directly to the bone and preserved in PES given its deeper location. Despite this, significant sexual dysfunction (SD) from PSL deficiency after PES has been reported. An improved understanding of this anatomy is paramount for quality surgical care in both pre-operative counselling and rectification of adverse functional outcomes. Objective (1) To present initial findings of the in-situ PSL anatomy (2) To propose a new anatomical classification system Methods Data from six male cadavers (46-87 years; mean 75) were used in present study. There was no history of genitourinary operations and cause of death were either respiratory or vascular. Following deep-freeze and 0.9mm whole-mount sectioning, specimens were impregnated with epoxy-resin mixture (E12/E1/AE10/AE30). Without specific labelling, this process allows endogenous autofluorescence of collagen/elastin/myofilaments when excited using 488nm-confocal-laser microscope. Select areas were examined using stereoscopic microscopy and scanned at high-resolution. This technique ensures preservation of anatomy in-situ and allowed enhanced examination at both macroscopic and microscopic levels (Figure 1). Results Proposed classification divides PSL by anatomical location: Prepubic, Subpubic, Retropubic. While corresponding to the same distinct structures, it avoids the misnomers and discrepancies that are embedded in existing nomenclature. Findings are summarised in Table 1. The AL does not appear to the PSL apparatus. It fuses with the interosseus fibrocartilaginous lamina deep to it and attaches laterally to the inferior pubic rami. Inferiorly, its semicircular free edge rounds off the apex of the pubic arch but has no corporal attachment. Conclusions Findings of the present study do not support an anatomical rationale for PES, without risking instability. Contrary to previous reports, the subpubic PSL (or suspensory ligament) is the only component that directly connects TA with PS. The purported role of AL appears unfounded. Furthermore, perpendicular fibrous orientation of the subpubic and retropubic PSL suggests a dynamic support mechanism, not dissimilar to the knee’s cruciate ligaments. To the author’s knowledge, this is the first description of the musculotendinous origin of the retropubic PSL, whose fibres extend anteriorly from the urogenital diaphragm. Further studies are required to better characterise the retropubic PSL insertion and may lead to new insights into the origin and architecture of deep penile fascia. Based on present findings, the TA likely consists of multiple fibrous components originating from the musculotendinous aponeuroses of superficial perineal musculature. Disclosure No.

Significant relationship between musculoaponeurotic attachment of the abdominal and thigh adductor muscles to the pubis: implications for the diagnosis of groin pain.

Groin pain is prevalent in orthopedic and sports medicine, causing reduced mobility and limiting sports activity. To effectively manage groin pain, understanding the detailed anatomy of supporting muscles is crucial. This study aimed to investigate the musculoaponeurotic attachments on the pubis and the relationship among intramuscular aponeuroses of abdominal and thigh adductor musculatures. Macroscopic analyses were performed in 10 pelvic halves. The bone morphology of the pubis was assessed in two pelvic halves using microcomputed tomography. Histological investigations were conducted in two pelvic halves. The external oblique aponeurosis extended to the adductor longus aponeurosis, forming conjoined aponeurosis, which attached to a small impression distal to the pubic crest. The gracilis aponeurosis merges with the adductor brevis aponeurosis and is attached to the proximal part of the inferior pubic ramus. The rectus abdominis and pyramidalis aponeuroses were attached to the pubic crest and intermingled with the gracilis-adductor brevis aponeurosis, forming bilateral conjoined aponeurosis, which attached to a broad area covering the anteroinferior surface of the pubis. Histologically, these two areas of conjoined aponeuroses were attached to the pubis via the fibrocartilage enthesis. Microcomputed tomography revealed two distinctive bone morphologies, a small impression and an elongated osseous prominence on pubis, corresponded to the two areas of conjoined aponeuroses. This study demonstrated close relationships between the aponeurotic attachment of the external oblique and adductor longus, and between the rectus abdominis, pyramidalis, gracilis, and adductor brevis. The findings of aponeurotic complexes would aid in diagnostic and surgical approaches for athletic groin pain.

THU456 Beyond Guidelines: Treatment Of Concurrent Osteogenesis Imperfecta And Metastatic Bone Disease

Abstract Disclosure: M. Kanin: None. M. Lechner: None. Introduction: Osteogenesis imperfecta (OI) is a rare inherited skeletal dysplasia characterized by bone fragility and skeletal malformation predisposing patients to multiple, recurrent fractures. Treatment of OI is challenging and requires a multidisciplinary approach with emphasis on physical therapy and exercise in addition to medications. There is limited guidance on treatment in adults given truncated life expectancy. Furthermore, guidance on the treatment of OI in the setting of cancer bone metastases is lacking. We present the unique case of a woman with OI and new fracture in the setting of bone-metastatic endometrial cancer. Clinical Case: A 70 year old woman with Type I OI and endometrial adenocarcinoma initially presented to clinic with left hip and groin pain. Prior OI therapy included at least 10 years of bisphosphonate therapy and 3 years of intranasal calcitonin in her fifties. CT imaging revealed a lytic lesion in the L inferior pubic ramus with an associated pathologic fracture. She was treated with denosumab 120mg s.c. every 3 months for six total doses and palliative radiation to the pubic ramus. She developed osteonecrosis of the jaw and further treatment was terminated. She represented 2 years later with right hip pain and was found to have cancer involvement of her right iliac bone. Labs showed creatinine of 0.48 mg/dL, Calcium 9.8 mg/dl, bone specific alkaline phosphatase 17.9ug/L (7.0-22.4 ug/L), n-telopeptide 18.6 nM BCE (6.2-19.0 nM BCE), and vitamin D-25 48ng/ml. DEXA scan showed T scores at the AP spine of -3.2, LFN of -2.1, and RFN of -2.5. Our patient had a high functional status, minimal pain and acceptable quality of life. Given the presence of active bone metastases, we favored treatment with zolendronic acid 4mg i.v. monthly given her high fracture risk, combined with continued cancer therapy targeted to bone metastases. Clinical Lesson: To our knowledge, there are no guidelines or case reports for optimal treatment of patients with concurrent OI and bone metastases. While bisphosphonates are typically a first line treatment for OI, osteoporosis and metastatic bone disease, the duration and dosing of bisphosphonates varies for each condition. For example, zolendronic acid 4mg i.v. monthly is recommended for cancer patients with metastatic bone disease, while a dose of 5mg i.v. yearly is used for osteoporosis, depending on the severity. Additionally, no clear consensus exists for how often or how long bisphosphonates may be given in adults with OI and treatment durations vary markedly. Other agents that may be considered include denosumab, with indications across bone metastases, osteoporosis, and OI, though this was not available to our patient given her prior complication. Data for newer agents PTH analogs and romosuzumab are lacking. We present this case to highlight the need for an individualized treatment approach in these patients. Presentation: Thursday, June 15, 2023

FRI369 SDHB Hereditary Pheochromocytoma Paraganglioma Syndrome With Biochemically Silent Pheochromocytoma

Abstract Disclosure: A.M. Skariah: None. C.C. Zacharia: None. Background: Paragangliomas are rare neuroendocrine tumors arising from extra-adrenal autonomic paraganglia. Majority of cases are sporadic but 30-50% are associated with genetic mutations. Patients with SDHB mutations can present with pheochromocytoma, paragangliomas or both. Lesions are usually extra-adrenal and typically secrete norepinephrine and occasionally dopamine. These cases are often associated with higher malignancy rates (up to 79%) compared to other SDH-x associated mutation cases. Clinical Case: Our patient is a 64-year-old female with history of secondary adrenal insufficiency, hypothyroidism, osteoporosis, GAD who presented in 2005 with left occipital headache and dysphagia. Workup was notable for a glomus tumor. She underwent tumor embolization, resection, radical neck dissection and radiation therapy. Genetic testing was not performed at the time of diagnosis. Routine biochemical surveillance was done postoperatively. In 2018, the patient was found to have a mild elevation of normetanephrine 248 pg/ml (<148 pg/ml) and total metanephrine 297 pg/ml (<205 pg/ml) levels. Subsequent plasma, urinary metanephrine/catecholamine studies were negative. In 2021, her brother was diagnosed with pheochromocytoma. Genetic testing was then pursued in the patient, and she was found to have a pathogenic mutation c.724C>A (p.R242S) in the SDHB gene. In June 2022, CT chest, abdomen and pelvis with contrast was ordered, and she was found to have a homogeneously enhancing 1.3 x 1.1x 1.4 cm left adrenal nodule with indeterminate imaging characteristics. Following this CT, DOTATATE PET CT scan was done and demonstrated somatostatin avidity in the region of previously resected left glomus jugular tumor, right adrenal gland nodule and left inferior pubic ramus sclerotic lesion. Repeat biochemical testing remained negative for catecholamine excess. Despite being asymptomatic, there was concern for a biochemically silent pheochromocytoma. Alpha blockade was completed prior to right adrenalectomy in November 2022 and surgical pathology confirmed pheochromocytoma. The patient remains clinically stable, and she is now undergoing radiation therapy of her left pubic ramus lesion. Conclusion: It is important to have genetic evaluation early in the workup for a newly diagnosed PPGL. Additionally, suspicion for biochemically silent pheochromocytoma should be present even in the setting of negative biochemical workup and positive SDHB mutation. Presentation: Friday, June 16, 2023

Radiologic blind spots in hip and pelvic radiographs.

The purpose of our study was to identify the locations at which hip and pelvic fractures are commonly missed on radiographs. A retrospective study was performed at four non-Level 1 trauma center emergency departments. IRB approval was obtained. All emergency department hip or pelvic radiographs with subsequent CT performed within 48h were identified from 2017 to 2022. Reports for each radiograph and CT were scored for the presence or the absence of fracture in the following locations: ilium, sacrum, superior pubic ramus, inferior pubic ramus, pubis, acetabulum, subcapital femoral, femoral neck, greater trochanter, lesser trochanter, intertrochanteric, and subtrochanteric. The CT report was used as the gold standard. The false-negative radiography cases were reviewed on a PACS workstation to determine whether the case had an "unexpected miss" of a fracture, a subtle fracture, radiographically occult fracture, or exam was limited by artifact. The percentage of missed fractures at each location was calculated. Nine hundred seventy-five radiography cases with subsequent CT were identified. One hundred forty-six cases did not meet entry criteria; therefore, 829 cases were analyzed further. Seventy-four percent of patients were female with age of 74 ± 16 (mean ± standard deviation) years (range 1-103). Three hundred fifty-two cases had at least one fracture, and many cases had multiple fractures. There were 68 false-negative cases. The most commonly missed fractures by percentage were pubis, ilium, and greater trochanter. The most common unexpectedly missed fractures were greater trochanter and femoral subcapital. A careful systematic evaluation of hip and pelvic radiographs, with particular attention to the pubis, ilium, greater trochanter, and subcapital region, may improve radiographic fracture detection and decrease delays in diagnosis.

Successful Management of a Polytrauma with Open Complex Pelvic Fracture

Abstract Pelvic fractures frequently result from powerful external forces and carry a high risk of concurrent injuries. In these patients, fatalities are often caused by associated injuries. Pelvic fractures cause substantial morbidity and can lead to long-term impairment in physical functioning, as well as difficulties with daily activities and negative psychological health. Surgical intervention is necessary for treating unstable pelvic fractures, which may involve isolated posterior or combined posterior and anterior fixation utilizing screws and plates to restore anatomical alignment and promote natural healing. A 19-year-old female road traffic accident victim in hemorrhagic shock was hemodynamically stabilized and investigated for associated injuries. She was diagnosed with bilateral sacroiliac joint dislocations, bilateral superior and inferior pubic rami fractures and crescent fracture of the right iliac wing, Grade III liver injury, Grade III splenic infarction and hemoperitoneum, lung contusion, and bilateral hemothorax with multiple rib fractures, fracture of the transverse process of L4 and L5 vertebrae. A secondary survey revealed a right sciatic nerve injury, admitted to intensive care and managed by a multidisciplinary approach. Abdomen and thorax injuries were managed conservatively, and meanwhile, the pelvic fracture was stabilized by a damage control protocol, and definitive surgical intervention includes iliac crest wound debridement and pelvic ring open reduction and internal fixation by the Modified Stoppa approach. Abdomen and chest injuries were managed conservatively. Monthly regular follow-up was the first 6 months, was able to walk and sit comfortably at the end of 4 months, and was able to resume her normal routine work and job at 6 months without any pain and limitation of movements. It is essential to promptly identify and assess the injuries and implement appropriate perioperative management by a multidisciplinary team. Temporary stabilization of fracture followed by the management of associated injuries and delayed definite fixation yields the best result in polytrauma patients with pelvic fracture.

A Novel Implant for Superior Pubic Ramus Fracture Fixation-Development and a Biomechanical Feasibility Study.

Background and Objectives: Pubic ramus fractures are common in compound pelvic injuries known to have an increased rate of morbidity and mortality along with recurrent and chronic pain, impeding a patient's quality of life. The current standard treatment of these fractures is percutaneous screw fixation due to its reduced risk of blood loss and shorter surgery times. However, this is an intricate surgical technique associated with high failure rates of up to 15%, related to implant failure and loss of reduction. Therefore, the aim of this biomechanical feasibility study was to develop and test a novel intramedullary splinting implant for fixation of superior pubic ramus fractures (SPRF), and to evaluate its biomechanical viability in comparison with established fixation methods using conventional partially or fully threaded cannulated screws. Materials and Methods: A type II superior pubic ramus fracture according to the Nakatani classification was created in 18 composite hemi-pelvises via a vertical osteotomy with an additional osteotomy in the inferior pubic ramus to isolate the testing of three SPRF fixation techniques performed in 6 semi-pelvises each using either (1) a novel ramus intramedullary splint, (2) a partially threaded ramus screw, or (3) a fully threaded ramus screw. Results: No significant differences were detected among the fixation techniques in terms of initial construct stiffness and number of cycles to failure, p ≥ 0.213. Conclusion: The novel ramus intramedullary splint can be used as an alternative option for treatment of pubic ramus fractures and has the potential to decrease the rate of implant failures due to its minimally invasive implantation procedure.

Percutaneous fixation of bilateral anterior column fracture and bladder repair in a single setting

Abstract Patients sustaining pelvic fractures following trauma are known to be at risk for an associated bladder and/or urethral injury. In an attempt to overcome the morbidity of extensile surgical approaches, percutaneous fixation of the pelvis has been receiving increasing attention. We report the case of a 30-year-old male who presented to a tertiary care trauma center for fractured bilateral acetabulum with bilateral fracture superior and inferior pubic rami with bladder injury. In pelvic trauma patients, percutaneous techniques have been specially recommended in patients with polytrauma, severe open injuries, extensive closed degloving injuries, and in elderly with medical comorbid conditions. Percutaneous screw fixation of acetabulum fractures is a relatively new procedure, and the indication for its use is not fully defined and needs to be explored.

Langerhans Cell Histiocytosis Presenting as a Lesser Trochanter Fracture in an Adolescent: A Case Report.

We present the case of an 18-year-old man with right hip pain who was found to have a lytic lesion of the lesser trochanter of the right femur with cortical destruction and a lytic lesion of the left inferior pubic ramus. Additional imaging and pathology testing confirmed a diagnosis of multifocal, single-system Langerhans cell histiocytosis (LCH) of the bone. LCH is a rare pediatric disease most commonly diagnosed in toddlers and young school-age children. Its epidemiologic characteristics are poorly described for young adults and older adolescents, in whom clinical suspicion should be maintained when evaluating multifocal osseous lesions.

Anterior Pelvic Ring Fracture Pattern Predicts Subsequent Displacement in Lateral Compression Sacral Fractures.

To determine if anterior pelvic fracture pattern in lateral compression (LC) sacral fractures correlates with subsequent displacement on examination under anesthesia (EUA) or follow-up in both nonoperative and operative cases. Retrospective cohort study. Level 1 trauma center. Two hundred twenty-seven skeletally mature patients with traumatic LC (OTA/AO 61B1.1, 61B2.1-2, and 61B3.1-2) pelvic ring injuries treated nonoperatively, with EUA, or with pelvic fixation were included. The study intervention included retrospective review of patients' charts and radiographs. Displacement on EUA or follow-up radiographs (both operative and nonoperative) correlated with anterior pelvic ring fracture pattern. Independent of sacral fracture pattern (complete or incomplete), risk of subsequent displacement on EUA or at follow-up after both nonoperative and operative treatments correlated strongly with ipsilateral superior and inferior pubic rami fractures that were either comminuted (95.6%, P < 0.001) or oblique (100%, P < 0.001). Patients with transverse or lack of inferior pubic ramus fracture did not displace (0%, P < 0.001). Out of 21 LC injuries treated with posterior-only fixation, displacement at follow-up occurred in all 11 patients (100%) with comminuted and/or oblique superior and inferior pubic rami fractures. Nakatani zone I and II rami fractures correlated most with risk of subsequent displacement. Unstable anterior fracture patterns are characterized as comminuted and/or oblique fractures of ipsilateral superior and inferior pubic rami. EUA should be strongly considered in these patients to disclose occult instability, for both complete and incomplete sacral fracture patterns. Additionally, these unstable anterior fracture patterns are poor candidates for posterior-only fixation and supplemental anterior fixation should be considered. Irrespective of sacral fracture pattern (complete or incomplete), nonoperative management is successful in patients with transverse or lack of inferior pubic ramus fractures. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

GROIN PAIN - SOCCER

HISTORY:A 20 yo collegiate female soccer player presented with two weeks of insidious onset left groin pain. Pain was achy, without radiation, and intermittent. Pain with cutting and lateral ball dribbling/drills. No additional symptoms. She had decreased activity for a year due to the pandemic. Prior to preseason, she independently began a vigorous training program with hours of daily activity. She lost twenty pounds in two months and consuming about 1800 calories daily. Menses remained regular on oral contraceptives. PHYSICAL EXAMINATION: Inspection: Normal. Palpation: Nontender at all bony prominences and muscles of pelvis, hip, and lumbar spine. ROM: Full. Strength: Normal. Left groin pain with hip adduction and flexion. Neuro: Normal. Hip: Log roll, FABER, FADIR, Ober, Thomas, Ely’s, Scour all normal. Sacroiliac: normal including figure four, compression and thigh thrust. Lumbar : normal with negative straight leg raise. Single leg hop was nonpainful and nonantalgic gait with normal proprioception. DIFFERENTIAL DIAGNOSIS:1. Adductor Strain or Psoas Strain2. Pubic Rami Avulsion Fracture3. Sacral Ala Stress Fracture4. Femoral neck stress fracture5. Labral tear TEST AND RESULTS: AP Pelvis Xray: Sacroiliac joints, sacrum, lumbar spine, pelvis, and bilateral hips normal alignment without fracture. She completed one month of physical therapy with improvement initially, however, her pain then progressed to bilateral groin pain. MRI pelvis: symmetric transverse bilateral inferior pubic rami fractures. Nondisplaced with normal alignment. FINAL WORKING DIAGNOSIS:1)Bilateral Inferior Pubic Rami Transverse Stress Fractures2)Relative Energy Deficiency Syndrome TREATMENT AND OUTCOMES: Physical therapy and soccer were discontinued. Crutches provided. Calcium and vitamin D supplementation recommended. CBC, CMP, PTH, TSH, Ferritin, Vitamin D testing indicated iron deficiency anemia. Bone Density testing: normal. Referred to sports dietician•Repeat Pelvic AP xrays indicated interval progression of her stress fractures bilaterally, now radiographically present with evidence of callus formation at bilateral inferior pubic rami. No displacement. Plan: Slowly progress activity as tolerated over several months with repeat exam, lab work, and xrays to ensure healing and resolution.

Quantification and visualization of anterior pelvis bone density to optimize screw fixation: A novel technique.

Plate fixation of anterior pelvic ring fractures is often a vital component when surgically treating unstable pelvis fractures. Certain plate and screw configurations can have premature implant loosening, potentially in part due to insufficient pullout strength in lower density bone. This study sought to define densities about the anterior pelvic ring using a novel computer-based technique. Thirty-three patients who received a computed tomography (CT) of the abdomen/pelvis for reasons other than pelvis fracture in a 1-month time period were included. Three statistically distinct density regions of the anterior pelvis were identified based on the three-dimensional (3D) density map. The densest regions included both the anterior and posterior aspects of the superior pubic ramus, along with the region of bone along the inferior cotyloid fossa. The intermediate density region included the caudal and medial pubic body. The least dense region included the anterior aspect of the inferior pubic ramus (IPR), the posterior pubic body, and the posterior/inferior IPR. This study presents specific quantification of anterior pelvis bone density based on a novel technique using opportunistic CT scans. Clinical Significance: Anterior surgical fixation of unstable pelvic ring injuries may benefit from targeting areas of higher density as described in this novel technique.

155 Fracture of Pubic Rami During Hip Fracture Fixation - a Rare Case of Traction Table Related Injury

Abstract Background Traction tables form the mainstay of closed reduction techniques for lower limb fracture and in particular hip fractures. They offer a versatile solution to continuous traction required in a variety of operations such as closed intramedullary femoral fixation and hip fixation. Counter traction on the table is provided by the perineal post, this has been associated with significant complications such as neuropraxia, erectile dysfunction, cutaneous necrosis, and urethral injuries. Case presentation We present a case of an elderly and co-morbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks as the patient was unfit to undergo this procedure. She was placed onto the traction table and intra-operatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table. Conclusions Closed reduction techniques using traction tables and perineal posts are not without morbidity. Risk factors such as osteoporosis and delayed fixation should be accounted for when managing this complex and often frail group of patients.

Modified Stoppa Approach For Concomitant Anterior And Posterior Pelvic Ring Fracture: A case report

BACKGROUNDModified Stoppa approach was performed to access the site of anterior column fracture instead of the Ilioinguinal approach to reduce morbidity.CASE SUMMARYA 24-year-old female suffered a serious traffic accident when she was riding a motor cycle collided with a car from the front and fell off when dodged a hole on the road. Then, the patient was beneath a moving car after falling. Several hours after accident at the hospital, she diagnosed as closed pelvic fracture of right superior inferior pubic rami and right sacroiliac joint disruption, closed fracture of right shaft femur. After improvement the condition in the ward, open reduction and internal fixation for the femoral fracture and for the pelvis fracture were performed using a modified stoppa approach to access the fracture site.CONCLUSION Treatment using the modified Stoppa approach was suitable for anterior column fracture, in which pelvic fractures were sufficiently exposed, the fracture was conveniently reduced, less complications occurred, and curative effect was satisfactory.

Effects of femoral offset and mechanical axis of the lower extremity on hip after osteotomy for adult developmental dysplasia of the hip

To investigate the effects of femoral offset and mechanical axis of the lower extremity on hip after osteotomy for adult developmental dysplasia of the hip (DDH). A clinical data of 62 adult patients with DDH (62 hips), who underwent periacetabular osteotomy combined with femoral osteotomy between January 2016 and May 2019 and met selective criteria, was retrospectively analyzed. There were 6 males and 56 females. The age ranged from 18 to 38 years, with an average of 24.4 years. Body mass index ranged from 15.8 to 31.8 kg/m 2, with an average of 21.8 kg/m 2. There were 44 cases of Hartofilakidis typeⅠ and 18 cases of typeⅡ. According to the modified Tönnis osteoarthritis staging, 46 cases were stage 0 and 16 cases were stageⅠ. There were 13 cases with pelvic anteversion, 40 cases with normal pelvis, and 9 cases with pelvic retroversion. Intraoperative blood loss, length of hospital stay, and complications were recorded. Postoperative hip function was evaluated by Harris score and International Hip Outcome Tool (iHOT) score. The femoral offset, collo-diaphyseal angle, hip-knee-ankle angle (HKA), knee valus angle, CE (Wiberg central-edge angle), anterior CE angle, and acetabular index angle were measured and the osteotomy healing was observed on X-ray films. Patients were grouped according to postoperative femoral offset (≥48 mm or <48 mm) and HKA [varus group (HKA<177°), normal group (HKA 177°-183°), and valgus group (HKA>183°)]. Harris score and iHOT score were compared between groups. Intraoperative blood loss ranged from 200 to 1 550 mL, with an average of 476 mL. The length of hospital stay ranged from 8 to 21 days, with an average of 13.3 days. All incisions healed by first intention. All patients were followed up 2.0-4.5 years, with an average of 2.8 years. At 1 year after operation, the Harris score and iHOT score of the hip joint significantly increased when compared with those before operation ( P<0.05); there were significant differences in the femoral offset, collo-diaphyseal angle, HKA, knee valus angle, CE angle, anterior CE angle, and acetabular index angle between pre- and post-operation ( P>0.05). According to the modified Tönnis osteoarthritis staging, 38 cases were stage 0 and 24 cases were stageⅠ; and there was no significant difference between pre- and post-operation ( χ 2=2.362, P=0.124). There were 11 cases with pelvic anteversion, 38 cases with normal pelvis, and 13 cases with pelvic retroversion, showing no significant difference when compared with that before operation ( χ 2=0.954, P=0.623). The pubic branch osteotomy did not heal in 9 cases, proximal femur osteotomy did not heal in 2 cases, and inferior pubic ramus stress fracture occurred in 5 cases. There were significant differences ( P<0.05) in the Harris score and iHOT score between femoral offset≥48 mm group ( n=10) and femoral offset<48 mm group ( n=52). There was no significant difference ( P>0.05) in Harris score and iHOT score between varus group ( n=13), normal group ( n=40), and valgus group ( n=9). Periacetabular osteotomy combined with femoral osteotomy can improve the femoral offset and mechanical axis of the lower extremity of patients with DDH, and improve the functional score of the hip. However, excessive increase of femoral offset during femoral osteotomy is not desirable, resulting in low postoperative functional score.

Bilateral Testicular Evisceration Sequel to Trauma: Challenges of Management in Emergency Department

Introduction The Genitourinary (GU) tract injury is rare with an annual incidence of less than one percent. We present a rare case of traumatic degloving injury of male external genitalia with complete evisceration of bilateral testicles following motor vehicle accident. Case description 29-year-old lorry driver was brought to Emergency department following head-on crash of his lorry into a ravine resulting in chest, abdomen and pelvis slamming onto dashboard. The driver was trapped for 4.5 hours. On arrival, he was conscious but hemodynamically unstable. Clinical examination and Focused Assessment with Sonography in Trauma (FAST) was suggestive of left pneumothorax and no evidence of intraabdominal injury. Chest tube was inserted. Genital examination showed scrotal degloving wound with complete evisceration of bilateral testis. He also sustained open fracture of right tibia, fibula and left inferior pubic rami fracture. Upon stabilization, was sent for operation and intraoperatively found to have bilateral testicular rupture. He underwent scrotal exploration, and bilateral orchidopexy. Postoperatively, multiple dialysis sessions were done for rhabdomyolysis. Hormonal study yielded low levels of testosterone. He was discharged home after 2 weeks with testosterone pills. Discussion Challenges in Emergency Department setting would be prompt identification and management of life-threatening injuries along simultaneous management of degloving external genitalia injury and associated injuries. FAST and extended FAST play a key role in managing life threatening conditions. Conclusion Total evisceration of bilateral testis injury are rare. Although not life threatening, should be treated promptly and thoroughly in order to avoid long-term functional and psychological damage.

EP.FRI.680 “Avulsion of the Corona Mortis following low energy pubic rami fracture: a rare but life-threatening injury.”

Abstract We describe the case of an 81 year old gentleman who presented after a trivial fall with haemodynamic instability and worsening abdominal pain and swelling. An initial trauma CT identified superior and inferior pubic rami fractures associated with a large intra-pelvic collection. A subsequent CT angiogram confirmed a large pelvic haematoma with an active arterial bleeding from a ruptured vessel adjacent to the superior pubic rami fracture. This was managed by resuscitating him with fluids and blood transfusions followed by fluoroscopic guided Internal Iliac artery embolisation. The “Corona Mortis” is an aberrant arterial connection between the inferior epigastric artery and obturator artery and is prevalent in the hemipelvis of more than 49.3% of the population. Very rarely it can be damaged during low energy pubic rami fractures leading to haemodynamic compromise and potential death. For this reason and the fact there is a high chance that it could be missed, we wish to highlight this case, and management and emphasise the need to consider this life-threatening complication even in cases when the mechanism of injury may seem trivial.