TO THE EDITOR:
We read with interest "Disruption of the Symphysis Pubis during Vaginal Delivery. A Case Report" (78-A: 1746—1748, Nov. 1996), by Kowalk et al. However, we disagree with some points. First, this is not the second case of its type as Kowalk et al. stated. Numerous cases of similar injuries have been reported2-6. Second, contrary to their claim, we found that the same ligaments are damaged in obstetric and traumatic disruptions of the symphysis pubis, with the posterior sacroiliac ligament remaining intact3,8. The method of treatment, therefore, should be the same for both types of injury. Third, Kowalk et al. claimed that the spontaneous tightening of ligaments in the postpartum period contributes to the stability of the pelvis and that the patient can be mobilized as early as the second day after delivery. We believe that the pelvis should be stabilized and gait-training should be postponed for six weeks after the traumatic type of disruption8 and until the patient becomes comfortable after the obstetric type of disruption4,6.
P. P. Kotwal, M.S.(Orth); Ravi Mittal, M.S.(Orth): All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India
Dr. Kowalk, Dr. Perdue, Dr. Bourgeois, and Dr. Whitehill reply:
Mr. Kotwal and Mr. Mittal state that our case report was not the second of its type. It certainly is not the second reported case of disruption of the symphysis pubis after delivery, as we cited several reports in our paper1-3,6,8. These articles, as well as those cited by Mr. Kotwal and Mr. Mittal, however, all concern closed disruption of the symphysis pubis, with the exception of the case report by Blum and Orovano1. The case that we described was that of open disruption and is still, to the best of our knowledge, only the second reported case of its kind. This could have been emphasized more clearly, but the word open was unfortunately omitted from the title and from the second sentence of the second paragraph of the published article.
Second, Mr. Kotwal and Mr. Mittal state that they have found the ligament disruptions that occur during separation of the symphysis pubis in pregnancy to be the same as those that occur during traumatic injury and they go on to cite two articles. Callahan3, in 1953, described the anatomy, presented case reports, and then made suggestions regarding treatment. Tile8, in 1988, offered an excellent review of patterns of injury and treatment but addressed traumatic injuries as opposed to those incurred during delivery. We have speculated that, because of hormonal effects, disruptions of the symphysis pubis incurred during vaginal delivery may result in stretching of the pelvic (sacrotuberous, sacrospinous, and sacroiliac) ligaments rather than in complete disruption of these ligaments, as may be seen in a traumatic injury. This allows the ligaments to tighten and provide stability after cessation of the hormonal effects. To answer this question definitively, anatomical dissection and inspection of the ligaments after prolonged hormonal relaxation and disruption of the symphysis pubis would be required.
Finally, Mr. Kotwal and Mr. Mittal state that the pelvis should have been stabilized and walking should have been postponed for six weeks. Our patient was fitted with a pelvic binder and was able to begin walking with a walker on the second postoperative day. She made steady progress with regard to walking and comfort and was asymptomatic at the most recent follow-up examination. We believe that this was because the ligaments were stretched rather than completely disrupted as would have been the case in a traumatic injury with that degree of separation.
David L. Kowalk, M.D.: Department of Orthopaedics, New England Baptist Hospital, 125 Parker Hill Avenue, Boston, Massachusetts 02120
Philip S. Perdue, M.D.; F. John Bourgeois, M.D.; Richard Whitehill, M.D.: Departments of Orthopaedics and Rehabilitation (P. S. P. and R. W.) and Obstetrics and Gynecology (F. J. B.), University of Virginia Health Sciences Center, Charlottesville, Virginia 22901