Symphysis Disruption Research Articles

Locked versus standard unlocked plating of the symphysis pubis in a Type-C pelvic injury: A cadaver biomechanical study

IntroductionThe benefits of locked plating for pubic symphyseal disruption have not been established. The purpose of this biomechanical study was to determine whether locked plating offers any advantage over conventional unlocked plating of the pubic symphysis in the vertically unstable, Type-C pelvic injury. MethodsIn each of eight embalmed cadaver pelvis specimens, sectioning of the pubic symphysis in conjunction with a unilateral release of the sacroiliac, sacrospinous, and sacrotuberous ligaments and pelvic floor was performed to simulate a vertically unstable Type-C (Orthopaedic Trauma Association 61-C1.2) pelvic injury. The disrupted SI joint was then reduced and fixed using two 6.5mm cannulated screws inserted into the S1 body. Using a six-hole 3.5mm plate specifically designed for the symphysis pubis having both locked and unlocked capability, four pelvises were fixed with locked screws and four pelvises were fixed with standard unlocked bicortical screws. Both groups were similar based on a dual-emission X-ray absorptiometry evaluation (P=0.69). Each pelvis was then mounted on a servohydraulic materials-testing apparatus using a bilateral stance model to mainly stress the symphyseal fixation and was cycled up to 1 million cycles or failure, whichever occurred first. ResultsFive specimens experienced failure at the jig mounting/S1 vertebral body interface, occurring between 360,000 and 715,000 cycles. Frank failure of the anterior or posterior instrumentation did not occur. However, end-trialing diastasis of the initial pubic symphysis reduction was found in all pelvises. There were no differences between the groups with respect to this loss of symphyseal reduction (P=0.69) or average cycles to failure (P=1.0). ConclusionPubic symphyseal locked plating does not appear to offer any advantage over standard unlocked plating for a Type-C (OTA 61-C1.2) pelvic ring injury.

Management of pubic symphysis diastasis with locking plates: A report of 11 cases

IntroductionThe optimal method of fixation of symphyseal disruptions in pelvic ring injuries and post-operative rehabilitation is still debated. Options include two-hole, multi-hole and multiplanar plates. Post-operative rehabilitation can range from non-weight bearing bilaterally to full weight-bearing with crutches. Locking symphyseal plates have recently been introduced. There is a paucity of literature evaluating their use in such injuries. We present the first clinical case series of symphyseal diastasis managed with locking plates. MethodsA retrospective analysis of a single centre case series between August 2008 and December 2011 was conducted. A total of 11 patients; 2 females and 9 males with a mean age of 42 years were included. The mean radiological follow up was 27 weeks. Radiological failure and need for revision were evaluated. Results4 patients sustained their injury as a result of a motorcycle accident, 3 patients following a car accident, 2 fell from a height and 2 had crush injuries. 9 patients had other concomitant injuries. The mechanism of injury was classified as anterior–posterior compression injury in 6 patients, vertical shear in 4 patients and combined mechanism in 1 patient. 6 patients required posterior pelvic fixation. Patients were mobilised fully or partially weight bearing. One patient had a significant radiological failure. All patients were asymptomatic at last follow-up and none required revision surgery. ConclusionOur series represents the first published clinical series of patients with symphyseal diastasis managed with locking plates. We have found the use of locking plates across the pubic symphysis to be safe with low complication rates despite early weight bearing.

Biomechanical analysis of a new minimally invasive system for osteosynthesis of pubis symphysis disruption

IntroductionWe analysed the effectiveness of a new percutaneous osteosynthesis system for the treatment of pelvis fractures with rotational instability. MethodsA pre-clinical cross-sectional experimental study wherein Tile type B1 injuries (open-book fractures) were produced in 10 specimens of fresh human cadavers, including the L4–5 vertebrae, pelvic ring, and proximal third of the femur, keeping intact the capsular and ligamentous structures, is presented in this paper. The physiological mobility of the intact pelvis in a standing position post-injury was compared to that following the performance of a minimally invasive osteosynthesis of the symphysis with two cannulated screws. A specially designed test rig capable of applying loads simulating different weights, coupled with a photogrammetry system, was employed to determine the 3D displacements and rotations in three test cases: intact, injured and fixed. ResultsAfter applying an axial load of 300 N, no differences were observed in the average displacement (mm) of the facet joints of the intact pubic symphysis in comparison to those treated with screws (p >0.7). A statistical difference was observed between the average displacements of the sacroiliac facet joints and pelvises with symphyseal fractures treated with screws after the application of a load (p <0.05). ConclusionThe symphyseal setting with two crossed screws appears to be an effective alternative to osteosynthesis in pelvic fractures with rotational instability.

Reduction and fixation capabilities of different plate designs for pubic symphysis disruption: A biomechanical comparison

BackgroundTypical stabilisation of pelvic open book injuries consists in plate fixation of the symphysis, leading to many different plate designs and procedures that have evolved. However, implant loosening and development of chronic instability are still evident and represent major complications after plate fixation of the symphysis. The aim of this study was to analyse reduction and fixation capabilities of different classical plate techniques with dynamic compression (DC), prebending or modern interlocking screws. MethodsCompression injuries (OTA B1.1) were simulated on synthetic composite pelvises. Sensor films placed in the disrupted symphysis allowed assessment of reduction and compression forces, as well as contact characteristics by implants at defined time points under static non loaded conditions. The commercially available steel plates used in our study differed in curved design, prebending and DC- or locking screw capabilities, as narrow large fragment (4.5) or small fragment plates (3.5). ResultsDC procedure clearly increased the compressive force in the symphysis and improved the reduction by enhanced contact areas. These effects were preserved to the end of the experiments only when the plates were prebended (10°). Anatomically contoured and prebended 3.5 plates had a similar effect, but the contact area was even more pronounced. Best results were observed using the “3.5 symphyseal plate” with DC-effect medially and locking screws laterally. Purely interlocking screw plates by themselves allowed an optimal contact area, yet failed to preserve the initial compressive reduction force. ConclusionsThe experimental results suggest a biomechanical advantage in using prebended plates for symphysis fixation compared to non-bended plates. Best results with regard to compression and increased contact area can be achieved by anatomically contoured plates with combined DC and locking screw capabilities. These findings are of special interest in pelvic surgery for choosing the right implant in severe displacements, obese patients and symphysiodesis techniques.

Pelvic infix. A new technique for the stabilisation of pelvic ring fractures. A case matched comparative series

Pelvic ring fractures usually result from significant trauma, frequently requiring operative stabilisation. The use of an anterior internal fixator (INFIX) is a new technique. This temporary construct is quick and easy to apply using pre-existing spinal implants. No reports of functional outcomes or compartive studies with existing surgical techniques exist in indexed literature. We present a prospective comparative case matched series of 21 patients treated with pelvic INFIX. 1:1 matching was achieved to a cohort of patients treated with open reduction and internal fixation (ORIF) based on fracture pattern. All patients with rotationally and/or vertically unstable pelvic ring fractures treated within our level 1 trauma centre were considered for inclusion. Patients were prospectively followed up with health outcome measures (SF-36, EQ-5D) and joint specific outcome scores (Oxford and Harris hip scores). Results No statistically significant differences in age (mean 42v38 p=0.3143), length of stay, or operative time were seen. The ISS was significantly higher in the INFIX group (32v22 p=0.0019). Mean INFIX removal was at 14 weeks. Baseline responses were obtained on admission where feasible. Although there was no significant difference between the treatment groups, the ORIF group showed a significantly greater deterioration from the baseline than the INFIX group, suggesting INFIX better maintains pre-injury function. 29% of patients experienced LCNT palsy whilst the INFIX was in situ. 6 patients in the INFIX group experienced some form of metal work failure (3 required surgical removal), compared with 7 ORIF patients (4 required removal). Conclusions Pelvic INFIX achieves bony stabilisation of unstable pelvic fractures, and should be considered for rotational or vertically unstable fractures requiring operative intervention. Despite higher ISS scores, INFIX patients performance in joint specific and global health functioning scores was not significantly different from ORIF patients. We do not use INFIX for pelvic fractures with symphyseal disruption.

Biomechanical Study of 4-hole Pubic Symphyseal Plating: Locked Versus Unlocked Constructs

To the authors' knowledge, no published studies have examined the use of locking plates on injuries of the anterior pelvic ring. The purpose of this study was to determine whether locked plates provide enhanced stability in the treatment of pubic symphyseal disruptions. Completely unstable pelvic injuries were simulated in pelvic Sawbones (model 1301; Pacific Research Laboratories, Vashon, Washington) and 2 different fixation constructs used for anterior fixation (4-hole, 3.5-mm pubic symphysis plate with all locked or all unlocked screws). Adjunctive sacroiliac screw fixation with a single 7.3-mm screw placed into S1 was used in all specimens. Specimens were analyzed for motion at the pubic symphysis and sacroiliac joints using a Material Testing System (MTS Systems Corporation, Eden Prairie, Minnesota). Each specimen was subjected to compressive loading in a single-limb stance. Side loading was also examined. The main outcome measurement was motion at the pubic symphysis and sacroiliac joints and overall construct stiffness. No significant difference existed in overall construct stiffness between the 2 methods of pubic symphysis fixation. The motions at the pubic symphysis or injured sacroiliac joints were not significantly different. In addition, motion at the pubic symphysis joint with lateral load was not improved with a locking construct.No significant difference existed between 4-hole locked or unlocked constructs used for fixation of the pubic symphysis. No apparent advantage of locking screws exists for disruptions of the pubic symphysis, and recent reports have questioned the possibility of catastrophic failure.

Locked Versus Standard Unlocked Plating of the Pubic Symphysis

Although locked plating has been shown to have advantages for diaphyseal and metaphyseal fracture fixation, its benefits for pubic symphyseal disruption have not been established. With traditional plate fixation of the disrupted pubic symphysis, normal physiological symphyseal pelvic motion eventually results in plate breakage, screw breakage, and loosening of screws. A concern exists that common modes of locked plate construct failure could result in abrupt and complete loss of symphyseal fixation. The purposes of this study were to determine, using an open-book pelvic injury model, whether locked plating of the pubic symphysis 1) offers any advantage over standard unlocked plating; and 2) results in a potential increased risk of abrupt fixation failure. Twelve osteopenic cadaver pelvic specimens were acquired and dual-energy x-ray absorptiometry scans were obtained to ensure uniformity of the specimens' bone density. Sacrospinous, sacrotuberous, and anterior sacroiliac ligaments were released and the symphysis pubis was transected to simulate a partially stable open book (AO/Orthopaedic Trauma Association 61-B3.1) injury. Using a six-hole 3.5-mm plate specifically designed for the symphysis pubis with the capability of fixation in locked or unlocked mode, six pelvises were fixed with locked screws and six pelvises were fixed standard unlocked bicortical screws. There was no significant difference between these 2 groups with regard to bone density (P = 0.47). Two equally osteopenic pelvic specimens from each fixation group were selected for the purpose of obtaining failure data and determining an acceptable load for trialing. Both specimens failed at 1985 N. The remaining 10 pelvises were then mounted on a materials testing apparatus using the bilateral stance model as described by Tile. In accordance with the failure data, each pelvis was stressed at 440 N for a total of one million cycles (equivalent to 6.5 months of daily walking) or until fixation failure. All pelvic specimens in both fixation groups completed one million cycles without plate or screw failure. However, diastasis of the initial pubic symphysis reduction was found in all pelvises (mean, 2.45 mm; range, 1.5-4.0 mm) regardless of fixation method. This loss of reduction was not significantly different between the 2 fixation groups (P = 0.914). No abrupt failures occurred in either plating group. Consequently, any fear of catastrophic (ie, abrupt and complete) failure of locked symphyseal plates appears to be unfounded for open-book injuries treated in patients with low bone density. However, minor loss of the symphyseal reduction was evident in all pelvises regardless of the fixation method. Therefore, locked plating of the pubic symphysis does not appear to offer any advantage over the standard unlocked technique for an AO/Orthopaedic Trauma Association 61-B3.1 partially stable open-book pelvic injury pattern in osteopenic bone.

Is Fixation Failure After Plate Fixation of the Symphysis Pubis Clinically Important?

Plate fixation is a recognized treatment for pelvic ring injuries involving disruption of the pubic symphysis. Although fixation failure is well known, it is unclear whether early or late fixation failure is clinically important. We therefore determined (1) the incidence and mode of failure of anterior plate fixation for traumatic pubic symphysis disruption; (2) whether failure of fixation was associated with the types of pelvic ring injury or pelvic fixation used; (3) the complications, including the requirement for reoperation or hardware removal; and (4) whether radiographic followup of greater than 1 year alters subsequent management. We retrospectively reviewed 148 of 178 (83%) patients with traumatic symphysis pubis diastasis treated by plate fixation between 1994 and 2008. Routine radiographic review, pelvic fracture classification, method of fixation, incidence of fixation failure, timing and mode of failure, and the complications were recorded after a minimum followup of 12 months (mean, 45 months; range, 1-14 years). Hardware breakage occurred in 63 patients (43%), of which 61 were asymptomatic. Breakage was not related to type of plate, fracture classification, or posterior pelvic fixation. Five patients (3%) required revision surgery for failure of fixation or symptomatic instability of the symphysis pubis, and seven patients (5%) had removal of hardware for other reasons, including late deep infection in three (2%). Routine radiographic screening as part of annual followup after 1 year did not alter management. Our observations suggest the high rate of late fixation failure after plate fixation of the symphysis pubis is not clinically important.

Radiographic Changes of Implant Failure After Plating for Pubic Symphysis Diastasis: An Underappreciated Reality?

Implant failure after symphyseal disruption and plating reportedly occurs in 0% to 21% of patients but the actual occurrence may be much more frequent and the characteristics of this failure have not been well described. We therefore determined the incidence and characterized radiographic implant failures in patients undergoing symphyseal plating after disruption of the pubic symphysis. We retrospectively reviewed 165 adult patients with Orthopaedic Trauma Association (OTA) 61-B (Tile B) or OTA 61-C (Tile C) pelvic injuries treated with symphyseal plating at two regional Level I and one Level II trauma centers. Immediate postoperative and latest followup anteroposterior radiographs were reviewed for implant loosening or breakage and for recurrent diastasis of the pubic symphysis. The minimum followup was 6 months (average, 12.2 months; range, 6-65 months). Failure of fixation, including screw loosening or breakage of the symphyseal fixation, occurred in 95 of the 127 patients (75%), which resulted in widening of the pubic symphyseal space in 84 of those cases (88%) when compared with the immediate postoperative radiograph. The mean width of the pubic space measured 4.9 mm (range, 2-10 mm) on immediate postoperative radiographs; however, on the last radiographs, the mean was 8.4 mm (range, 3-21 mm), representing a 71% increase. In seven patients (6%), the symphysis widened 10 mm or more; however, only one of these patients required revision surgery. Failure of fixation with recurrent widening of the pubic space can be expected after plating of the pubic symphysis for traumatic diastasis. Although widening may represent a benign condition as motion is restored to the pubic symphysis, patients should be counseled regarding a high risk of radiographic failure but a small likelihood of revision surgery. Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Functional Outcomes in Women After High-Energy Pelvic Ring Injury

Residual dysfunction after pelvic trauma has been previously described, but limited functional outcome data are available in the female population after high-energy pelvic ring injury. The purposes of this study were to determine functional outcomes and to characterize factors predictive of outcome. Prospective collection of functional outcomes data. Level I trauma center. Eighty-seven women with mean age of 33.5 years and mean Injury Severity Score of 23.1 were included. The Orthopaedic Trauma Association classification included 32 B-type and 55 C-type fractures. Four were open fractures and six had bladder ruptures. Forty-nine patients were treated operatively and 38 nonoperatively. Musculoskeletal Functional Assessment (MFA) questionnaires were completed after a minimum of 16 months and a mean of 41 months of follow-up. The mean MFA score was 33. Only 15 women (17.2%) had MFA scores comparable with an uninjured reference value (9.3), and 34 (39.1%) had better than the reference value for prior hip injury (25.5). Anteroposterior compression injuries had worse scores versus other patterns (48.3 vs 31.0, P = 0.01), and trends toward worse outcomes were noted after symphyseal disruption (P = 0.11) and transsymphyseal plating (P = 0.09). Sacral fracture or sacroiliac injury, amount of initial or final displacement, and type of posterior ring treatment were not associated with MFA scores. Mean scores were 32.3 after surgery and 34.0 after nonoperative management (P = 0.67). Functional outcomes were not related to age or Injury Severity Score, but isolated pelvis fractures had better MFA scores (21.1 vs 35.5, P = 0.008) and worse MFA scores (41.7 vs 29.1, P = 0.004) were seen with other lower extremity fractures. Those with bladder ruptures (n = 6) also had poor outcomes, mean MFA 50.0 (P = 0.078). Wide variation is seen in functional outcome of women after high-energy pelvic ring fracture as measured by the MFA with mean scores demonstrating substantial residual dysfunction. Better outcomes were noted after isolated fractures and in women who had not sustained other fractures in their lower extremities. History of bladder rupture or anteroposterior compression injury was associated with poor MFA scores. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pelvic Ring Injury Is Associated With Sexual Dysfunction in Women

Previous studies have reported a negative effect of pelvic trauma on genitourinary and reproductive function of women. However, fracture pattern, injury severity, and final fracture alignment have not been well studied. The purpose of this project was to describe sexual function in women after pelvic ring injury. Cohort study: a prospective collection of sexual function data for women with prior pelvic ring injury versus control groups of uninjured women and other women from the orthopaedic trauma clinic. Level I trauma center. One hundred eighty-seven women younger than age 55 years with pelvic ring injury, including 101 B-type (61-B1: n = 25, B2: n = 69, B3: n = 7) and 86 C-type (61-C1: n = 56, C2: n = 18, C3: n = 12) fractures. Four had open fractures, and 23 had associated genitourinary injury. Seventy-four were treated operatively. Surgical treatment was percutaneous in 62: iliosacral screws (n = 58), external fixation (n = 4), or both (n = 19). Open reduction and internal fixation was performed for the pubis symphysis (n = 27), sacroiliac joint (n = 2), and posterior ileum (n = 3). Sexual function questionnaires were completed for 92 patients (49%) with minimum 12 months and mean 46 months follow-up. Forty-eight patients (56%) reported pain with intercourse. Their mean Musculoskeletal Function Assessment was 44.3 versus 20.9 without dyspareunia (P < 0.0001). Seventy-eight percent of patients with B-type fractures and 43% of patients with C-type fractures had dyspareunia (P = 0.002). Dyspareunia occurred after 91% of anteroposterior compression injuries (P = 0.02) and in 79% with a symphyseal disruption treated with plate fixation (P = 0.005). All patients with bladder ruptures (n = 5) reported dyspareunia. Sacral fracture or sacroiliac injury, type of posterior treatment, and residual malalignment of the posterior ring were not associated with dyspareunia. Fourteen patients each had associated femur fractures and/or tibia fractures. Seventeen of them had pain during intercourse (P = 0.19 for association of femoral or tibial fractures with dyspareunia). Dyspareunia is common in women after pelvic ring fracture. Women with pelvic ring injury are more likely to report dyspareunia than other female patients with musculoskeletal trauma. Dyspareunia was related to anteroposterior compression and B-type injuries. Symphyseal plate fixation is also associated with dyspareunia. Pain with intercourse was also noted in all patients with a history of bladder rupture. Poor functional outcomes as measured by Musculoskeletal Function Assessment scores were reported in women with dyspareunia. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Internal Fixation of Symphyseal Disruption Resulting From Childbirth

To investigate the clinical and radiographic results after operative treatment of complete symphyseal disruption resulting from childbirth and to evaluate residual pain and implant failure in relation to the timing of surgery. Retrospective study. Tertiary pelvis and acetabulum care unit at a general hospital. Ten consecutive women with complete symphysis disruption associated with childbirth were included from a database of 603 patients with pelvic fracture. No patients with this diagnosis were excluded. All patients were followed until clinical healing of the symphysis or union of the fusion. Open reduction and internal fixation in acute (less than 2 weeks from childbirth, four patients) and after failed nonoperative treatment in subacute cases (2 weeks to 6 months after childbirth, three patients). Fusion of the symphysis with iliac crest bone graft and plate fixation after failed nonoperative treatment in chronic cases (greater than 6 months, three patients). Analyzed variables included the Lindahl score, maintenance of postoperative reduction, implant failure, malunion, and necessity of reoperation. Mean age of the patients was 32 years (range, 24-37 years). Mean follow up was 29 months (range, 5-139 months). The mean postoperative Lindahl score was 68 ± 14.6 points (range, 38-80 points). There were three excellent, four good, two fair, and one poor result. Fair or poor results occurred in one subacute and two chronic cases. There were two revision surgeries. One patient underwent implant removal resulting from dyspareunia 3.1 years postoperatively. One subacute patient had conversion to symphyseal fusion after implant failure as a result of a fall 11 years after index surgery. Major complications occurred in two and minor complications in three patients. Radiographic loosening of implants was observed in all subacute cases. All fusions healed and symptoms improved at last follow up. Operative management significantly improved the functional outcomes of all three subgroups and can be an acceptable treatment option for labor-induced complete symphysis pubis disruption.

Stress Radiograph to Detect True Extent of Symphyseal Disruption in Presumed Anteroposterior Compression Type I Pelvic Injuries

The differentiation between anteroposterior compression (APC)-I and APC-II pelvic fracture patterns is critical in determining operative versus nonoperative treatment. We instituted a protocol in which a stress examination was performed for patients presenting with an APC-I injury diagnosed with static radiographs to reveal the true extent of the injury. During a 4-year study period, we performed 22 stress radiographs in patients with a presumed APC-I injury, which showed symphyseal diastasis ≥ 1.0 cm but <2.5 cm on initial anteroposterior (AP) radiographs of the pelvis or on axial images of the pelvis on computed tomography (CT) scans. In the operating room, a radiopaque marker of known diameter was placed on the skin over the pubic symphysis. A direct AP load was manually applied to both anterior superior iliac spines, and diastasis of the pubic symphysis was measured on stress fluoroscopic images. The mean distance of symphyseal diastasis was 1.8 cm on the AP radiographs, 1.4 cm on the CT scans, and 2.5 cm on fluoroscopic images under a stress examination. Six of 22 patients (27.2%) demonstrated a symphyseal diastasis of >2.5 cm during the stress examination, which changed their treatment from nonoperative to operative. Measurements of symphyseal diastasis can significantly vary depending on the radiographic modality (CT vs. plain films) and during application of a stress force. The use of stress examination under general anesthesia in the acute setting of pelvic injury can be beneficial in accurately diagnosing the severity of injury and choosing appropriate treatment.

The diagnosis of acute urethral trauma

Background During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury. Methods A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted. Results There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0–82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4–100.0) for urethral trauma. Discussion Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.

Pelvic ring disruption secondary to psoas abscess formation

This report describes pelvic ring disruption in a 34-year-old female, following bilateral psoas abscess formation secondary to multifocal pneumococcal septicaemia of unknown origin. This previously unreported complication of psoas abscess formation was associated with pubic symphysis disruption, sacroiliac joint infection, disruption and latterly arthrosis of the hip joint secondary to infection. The authors believe that aggressive surgical and medical treatment and a high index of suspicion for orthopaedic complications is necessary in patients with a psoas abscess. Repeated X-rays and long term follow-up is suggested.

Fixation of Pubic Symphyseal Disruptions: One or Two Plates?

Plating a pubic diastasis following a pelvic ring disruption improves pelvic stability. Using a second plate may be beneficial in cases with significant posterior instability.

Comparative Radiographic and Clinical Outcome of Two-Hole and Multi-Hole Symphyseal Plating

To report on the radiographic and clinical outcome of symphyseal plating techniques, with specific attention to the incidence of implant failure, reoperation secondary to implant complication, and ability to maintain reduction of the pelvic ring. Retrospective chart and radiographic review. Level 1 trauma center. A total of 229 skeletally mature patients with traumatic pelvic disruptions associated with pubic symphysis diastasis requiring open reduction internal fixation. Symphyseal plating: (1) group THP, a two-hole plate; (2) group MHP, a multi-hole plate (minimum 2 holes/screws on either side of the symphysis). Patients were analyzed with respect to technique of anterior ring fixation and posterior ring injury pattern and fixation. Retrospective review of charts and radiographs immediately after the index procedure to latest follow-up was performed. Analysis included pelvic ring injury, type of anterior and/or posterior fixation, maintenance of postoperative reduction, rate of implant failure, and need for reoperation secondary to implant complication. Additionally, logistic regression analysis was performed to detect correlation between any other variable (posterior injury pattern, presence or absence of posterior fixation, time to surgery) and failure or malunion. Statistical analyses were performed using SPSS software. A total of 92 complete data sets were available for review. There were 51 patients in group THP and 41 patients in group MHP. When comparing the results of the 2 different methods of anterior fixation (THP versus MHP), the rate of fixation failure was greater in group THP (17 of 51; 33%) than group MHP (5 of 41; 12%). This was statistically significant (P = 0.018). When evaluating the presence of a malunion as a result of these 2 treatment methods, there were more present in the THP group (29 of 51; 57%) than in the MHP group (6 of 41; 15%). Again, this was highly statistically significant (P = 0.001). Although the reoperation rate was slightly higher in the THP group (16%) as compared to the MHP group (12%), this was not statistically significant (P = 0.67). Logistic regression analysis did not reveal any other variables to correlate as a risk factor for failure or malunion in this group of patients. In this group of patients, the two-hole symphyseal plating technique group had a higher implant failure rate and, more importantly, a significantly higher rate of pelvic malunion. On the basis of these findings, we recommend multi-hole plating of unstable pubic symphyseal disruptions.

Traumatic rupture of the symphysis pubis during pregnancy that needed an emergency caesarean section and pelvis reconstruction: A case report

A37-year-oldwoman,inthe39thweekofherfirstpregnancy,fell from a standing position and landed on her buttocks withboth hips in flexion, abduction and external rotation. Shecomplainedofpubicandlumbarpain(mainlyontheleftside)and was unable to sit, walk or even perform active flexion ofthe hips.She complained of tenderness over the pubis and pubicpain with trochanteric pressure. Neurovascular exam wasnormal. Radiographs showed a traumatic disruption of thesymphysis pubis with a 7 cm diastasis and the fetal skull incephalic presentation, without apparent injury (Fig. 1).In the first hours, the mother remained stable. Repeatedtests showed a slight decrease in haemoglobin levels. Exter-nal fetal heart rate monitoring and ultrasound showed nosigns of abruption placentae nor fetal distress.After discussing the case with the obstetric team, vaginaldelivery was ruled out given the massive symphysis disrup-tion. Due to maternal and fetal stability it was decided todelay the intervention and perform a nonemergent C-sectionthe next day.Five hours after admission, the fetus started to show signsof distress, so it was necessary to perform the surgery inemergency. The patient underwent first a C-section and thenan open reduction and internal fixation through a Pfannen-stiel exposure. A great haematoma was found at Retzius’space. Synthesis was performed with a four-hole superiorplate with bicortical screws and an anterior three-hole platewith two cancellous screws. Muscle laceration was repairedand supplemented with mesh. Postoperative CT showed nosacral lesion and accurate synthesis (Fig. 2).The newborn weighed 3064 g and her Apgar score was 4, 5and8at1,5and10 min(anaestheticdepression),withapHof7.11,andsheneededintermittentpositivepressurefor5 min.The amniotic fluid was slightly haemorragic although theplacentawaswellinserted.Twohoursafterbirth,theneonatepresented with respiratory distress, which was treated withoxygen byhood and resolved in48 h.Shepresented alsoearlyhipoglycemia, with a capillary glucose of 39 mg/dL at 2 h ofage, which resolved with the administration of oral glucose.The mother was discharged 13 days after admission withan elastic support to contain the muscles of the anterior

Successful repair of a bladder herniation after old traumatic pubic symphysis diastasis using bone graft and hernia mesh

Bladder herniation associated with pubic symphysis diastasis is a very rare condition. We report a case with bladder herniation after traumatic pubic symphysis disruption. The patient was treated with open reduction of the bladder and definitive internal fixation of the pubis. We used a bone allograft for closure of the diastasis and a prolene mesh graft for supporting the abdominal wall. We obtained a successful outcome during a 12-month follow-up period.

Outcome of operatively treated type-C injuries of the pelvic ring

Background Internal fixation has become the preferred treatment for type-C pelvic ring injuries, but controversies persist regarding surgical approach and surgical technique.Patients We evaluated 101 consecutive patients with type C1-C3 pelvic ring injuries who had been treated with standardized reduction and internal fixation techniques.Results Our findings suggest a correlation between excellent reduction followed by sufficient fixation of the pelvic ring and functional outcome. Unsatisfactory reduction (displacement > 5 mm), failure of fixation, loss of reduction and a permanent lumbosacral plexus injury were the commonest reasons for an unsatisfactory functional result. All 40 patients with an associated lumbosacral plexus injury showed at least some evidence of neurological recovery. 14 underwent complete neurologic recovery. 8 had only sensory deficits and the remaining 18 also had motor deficits at the final followup. Complications were rare, but some of them were severe: loss of reduction in 8%, malunion in 10%, deep wound infection in 2%, and a lesion of the L5 nerve root in 1%.Interpretation Our results suggest that special attention should be paid to preoperative planning, reduction of the fracture, decompression of the nerve roots, and fixation of the most severe sacral fractures. Our results seem to favor internal fixation of displaced (> 10 mm) and unstable rami fractures and symphyseal disruptions in conjunction with posterior fixation, to achieve better stability of the whole pelvic ring.