CASE 1. A forty-two-year-old woman was involved in a skiing accident in 1978. At the time of the injury, the patient noted immediate pain in the area of the symphysis pubis. The pain gradually increased over the next six weeks, prompting her to seek medical attention. Osteitis pubis was subsequently diagnosed, but the patient was not offered any non-operative treatment. One month after she was seen, she was managed with wedge resection of the symphysis pubis, including the entire symphyseal joint and a total of fifteen millimeters of bone. Initially, the symptoms decreased; however, over the next five years the patient noted the onset of low-back pain centered over the sacroiliac joints. The symptoms were managed non-operatively with repeated injections of corticosteroids and oral administration of non-steroidal anti-inflammatory medications, but there was little relief. She was unable to tolerate narcotic analgesics because of multiple allergies.
The symptoms worsened, and, in 1995, the patient was seen by the senior one of us (J. M. M.) for debilitating low-back pain. She was no longer able to participate in her recreational activities, especially horseback riding, and she rated the pain as intolerable (8 of 10 on an analog scale). She did not have a history of fevers, chills, or other constitutional symptoms suggestive of infection. Physical examination revealed tenderness over the sacroiliac joints and pain in each sacroiliac joint with flexion, abduction, and external rotation of the hip while the contralateral hemipelvis was stabilized (the Patrick test). Pain was also elicited in the sacroiliac joints and the symphysis pubis by lateral compression of the pelvis with the patient in the lateral decubitus position. Plain anteroposterior, inlet, and outlet radiographs of the pelvis, as well as radiographs with the patient standing on one limb, were made. A review of these studies revealed a fifteen-millimeter gap at the symphysis and severe sclerosis of the sacroiliac joint bilaterally (Fig. 1-A). The radiograph made with the patient standing on one limb revealed one centimeter of cephalad translation through the symphysis with weight-bearing. Computed tomography confirmed the severe sacroiliac sclerosis (Fig. 1-B). The patient elected to proceed with bilateral arthrodesis of the sacroiliac joint and the symphysis pubis in the hope of obtaining a fusion and restoring pelvic stability.
At the two-year postoperative follow-up evaluation, the symptoms were substantially decreased, with the patient rating back pain as 1 to 10 on the analog scale. However, she had pain and stiffness in the left hip secondary to idiopathic avascular necrosis. She had returned to horseback riding. Radiographic evaluation revealed fusion of the right sacroiliac joint and the symphysis pubis, with the hardware intact and no evidence of loosening (Fig. 1-C).
CASE 2. A sixty-one-year-old woman was seen by one of us (J. M. M.) ten years after she was treated with resection of the symphysis because of intractable osteitis pubis. A review of the pertinent medical history revealed that she had delivered four children vaginally, the last in 1963. Approximately ten years after the birth of the fourth child, pain developed at the symphysis pubis and progressively worsened over the next decade. In 1985, the patient was managed with exploration and excision of two centimeters from each side of the symphysis. She noted a decrease in symptoms for approximately one year and had a return of the symptoms in the region of the resection. This was followed by the onset of low-back pain.
When she was seen by one of us, the patient had pain that was exacerbated by activity and relieved by rest. She was unable to sit for prolonged periods of time and needed a cane to walk. She was taking ibuprofen (600 milligrams orally, three times daily) and occasionally propoxyphene napsylate and acetaminophen tablets (for example, Darvocet-N 100, one or two tablets orally, every six hours) or hydrocodone bitartrate and acetaminophen tablets (Vicodin 9, one or two tablets orally, every six hours) as needed, as prescribed by her local physician. The pain was debilitating and was rated by the patient as 7 of 10 on an analog scale. The patient had no history of fevers, chills, or other constitutional symptoms suggestive of infection. A physical examination demonstrated a slow, waddling gait; tenderness over the sacroiliac joints; and pain with provocative maneuvers to stress the sacroiliac joint.
Plain anteroposterior, inlet, and outlet radiographs of the pelvis, as well as radiographs with the patient standing on one limb, were made. A review of these studies revealed a five-centimeter diastasis of the anterior portion of the pelvic ring and subchondral sclerosis of both sacroiliac joints. There was widening of the sacroiliac joints, with the widening on the left larger than that on the right. No cephalad displacement of either hemipelvis was noted. The radiograph made with the patient standing on one limb revealed two centimeters of cephalad translation of the anterior portion of the pelvic ring with weight-bearing (Fig. 2-A). Computed tomography confirmed sacroiliac widening on the left and severe degenerative changes.
The patient elected to have operative stabilization of the pelvic ring, and bilateral arthrodesis of the sacroiliac joint and the symphysis pubis was performed as described for our first patient. At six months postoperatively, she had occasional pain in the left side of the groin with prolonged standing and had had complete resolution of the back pain (0 of 10 on the analog scale). She no longer needed assistive devices for walking and had begun walking for exercise. She also had stopped taking any analgesic medication. An anteroposterior radiograph made at six months demonstrated fusion of both the sacroiliac joints and the anterior aspect of the pubis (Fig. 2-B).
Stabilization is accomplished through a transverse incision in the abdomen (a Pfannenstiel incision) that is extended into bilateral ilioinguinal incisions in the skin, as described by Letournel and Judet. Access to the anterior aspect of the pelvic ring is through a longitudinal split in the linea alba, separating the two bellies of the rectus abdominis. The area of the previous resection is cleaned of scar tissue, with care taken to protect the bladder. The posterior and superior surfaces of the pubis are exposed subperiosteally, and the medial body of the pubis is decorticated and shaped with an osteotome. Each sacroiliac joint is sequentially exposed by releasing the abdominal muscles subperiosteally along the iliac crest. Visualization of the anterior aspect of the sacroiliac joint improves with release of the external oblique fascia approximately two inches (five centimeters) medial to the anterior superior iliac spine. The inguinal ligament is identified in the usual ilioinguinal interval and then is incised longitudinally to the anterior superior iliac spine, with care taken to preserve the lateral femoral cutaneous nerve. The anterior and cephalad portions of the sacroiliac diarthrodial joint are removed with an osteotome, with care taken not to entirely destroy the interosseous ligaments situated posterior and superior to the cartilaginous surfaces. An eight to ten-millimeter gap is left in the area of the resected joint. The caudad and posterior portions of the joint are also excised, although access to these areas is difficult. These portions must be excised through the anterior gap because exposure of the sacroiliac joint beyond the pelvic brim is associated with a risk of injury to the superior gluteal artery and the fifth lumbar nerve root. Also, it is usually impossible from the anterior approach to excise the most posterior portion of the joint, which is adjacent to the posterior inferior iliac spine. The surgeon should not attempt to remove too much of the anterior cortex of the sacral ala during excision of the joint. Removal of this cortex will affect screw purchase in the sacrum. The excision of the bone and the joint then allows the rotation and adduction of the innominate bone necessary to close the symphyseal bone defect. Pointed reduction forceps are then placed on the anterior-caudad surface of the pubic bones to bring the symphysis together gradually, usually against considerable resistance. A ten-hole, 3.5-millimeter curved pelvic compression plate is then applied to ensure adequate fixation of the symphysis. A three by five-centimeter section of bone consisting of the inner cortex of the ilium and its underlying cancellous bone is removed from the internal iliac fossa at the anterior pillar of bone for use as a graft. Additional cancellous bone is also obtained at this time. The cancellous graft is placed between the two sides of the pubis and in the small gap underneath the plate. The corticocancellous graft is secured to the posterior-cephalad aspect of the pubis with screw or wire fixation. Bone chips from the excised sacroiliac joints and removed cancellous bone are placed into the resected sacroiliac joints. Posterior fixation is achieved with two three-hole compression plates placed across both joints. Screws, approximately fifty seventy millimeters in length, are placed in the sacral ala, medial to the resected sacroiliac joint but lateral to the sacral foramina. One plate is situated along the pelvic brim, and the second is placed oblique to the first to ensure adequate fixation into the posterior aspect of the ilium.
Postoperatively, the fixation is protected for three months by limiting weight-bearing on both lower extremities to that required for bed-to-chair transfers. Progressive weight-bearing and strengthening of the lower extremities are instituted after this period.
Osteitis pubis was initially described in the English-language literature in 1924 by Beer, who reported on five patients after suprapubic operative procedures. With the proliferation of suprapubic prostatectomy, reports became more common. At first, the disorder was primarily regarded as a postoperative complication of urological procedures16,17. Osteitis pubis has subsequently been described after trauma, strenuous athletic activity, and pregnancy and has been associated with rheumatological disorders7-9. In some patients, no etiological factor can be identified.
The clinical presentation of osteitis pubis is characterized by localized pain and tenderness over the symphysis pubis. The onset can be abrupt or insidious and may be associated with pain in the adductors or the insertion of the rectus abdominis. The pain often radiates down the medial aspect of the thigh. Symptoms may be exacerbated by activities stressing the muscle groups that originate or insert at the symphysis and are sometimes elicited by the patient lying on his or her side or by lateral compression of the pelvic ring. Patients have a characteristic waddling gait because of pain and tightness of the adductor muscles. They often describe a grinding or clicking sensation in the region of the pubis during gait; this may be palpable to the examiner.
Symptoms associated with the sacroiliac joints can be localized with provocative testing by placing the flexed lower limb across the contralateral knee. This places the hip in a position of flexion, abduction, and external rotation. The contralateral hemipelvis is then stabilized, and placement of pressure on the flexed knee stresses the sacroiliac joint6. The joint can also be stressed by positioning the hip over the edge of the examining table and pressing downward on the iliac crest while stabilizing the contralateral hemipelvis.
Radiographic evaluation often reveals sclerosis, cystic changes, or rarefaction of the medial portions of the pubic rami. Although these changes are sometimes noted incidentally and are referred to as osteitis pubis, in the absence of symptoms they represent an entity that is distinct from that described in this paper5,18. Chamberlain described an anterior radiograph of the pelvis, made with the patient standing on one limb, that is used to demonstrate pelvic instability. Instability is manifested as cephalad translation of the weight-bearing, anterior portion of the pelvic ring. In individuals who have a stable pelvis, there should be less than two millimeters of translation. Inlet and outlet radiographs of the pelvic ring are useful for evaluation of the anatomical relationships of the innominate bones and the sacrum. Computed tomography may also be useful for evaluation of the posterior aspect of the pelvic ring and the symphysis pubis.
The treatment of osteitis pubis has primarily been non-operative. The lesion has been treated with an assortment of methods, including the use of heat, radiation, antibiotics, anti-inflammatory drugs, steroids, rest, physical therapy, and orthoses—all with varying degrees of success3,6,8,9,16. It is generally believed that, with non-operative treatment, symptoms usually resolve over time; however; the symptoms continue in some patients. Operative intervention has been advocated for this select population.
In 1961, Schnute reported on eight patients who had radiographic evidence of osteitis pubis. The symptoms ranged from no pain to debilitating pain. Non-operative management led to satisfactory results in five of these patients; however, the pain was unremitting in three patients. These three patients were managed with wedge resection of the posterior aspect of the symphysis pubis. Schnute reported nearly complete resolution of symptoms postoperatively, but the duration of follow-up was no provided.
Coventry and Mitchell reported on a series of forty-five patients who had osteitis pubis. Five of these patients were managed operatively. One had a complete symphyseal resection; two, a wedge resection (as described by Schnute); one, curettage; and one, a successful arthrodesis. All of the patients had relief of symptoms in the early postoperative period; however, long-term results were not reported.
In 1989, Grace et al. reported on ten patients who were managed with wedge resection of the symphysis pubis for the treatment of osteitis pubis that had been recalcitrant to non-operative management. All of the patients had the characteristics gait, pain, and radiographic findings of sclerosis or rarefaction at the symphysis. The average duration of symptoms before the resection was thirty-two months. At an average of fourteen months postoperatively, all of the patients had considerable relief of the symptoms with no limitation of activities. However, at an average of ninety-two months postoperatively, three patients were not satisfied with the results of the procedure. One patient noted the return of aching in the groin and clicking at the symphysis at eighty-nine months after the operation. She had no discomfort in the posterior aspect of the pelvis. A second patient noted the return of pain in the groin and also pain in the sacroiliac joint, in addition to occasional clicking at the symphysis, seventy-two months after the procedure. A third patient had progressive bilateral instability of the sacroiliac joint, demonstrated on an anteroposterior radiograph made with the patient standing on one limb. The instability became painful at sixty-one months postoperatively and necessitated bilaterial arthrodesis of the sacroiliac joint seventy-nine months after the symphyseal resection. Both of the patients in whom back pain developed after the wedge resection had had at least five millimeters of cephalad displacement on the preoperative radiograph, made with the method described by Chamberlain, for evaluation of pelvic instability.
Three patients who had a failed wedge resection of the symphysis in the series reported by Grace et al. noted the return of symptoms at an average of six years postoperatively. The two patients described in our report noted a recurrence of symptoms at one and five years postoperatively. Of these five patients, the four in whom posterior symptoms developed after the resection had had considerable radiographic instability on preoperative evaluation. It would appear that the late symptoms were caused by progressive posterior instability related to disruption of the anterior part of the pelvic ring.
There is little discussion of the role of the symphysis pubis and anterior ligamentous support in pelvic stability in the orthopaedic literature. The crucial ligamentous support for the pelvic ring is thought to be provided by the posterior sacroiliac ligamentous complex. The strong posterior ligaments form a tension-band construct and prevent cephalad migration and rotation of the innominate bone in relation to the sacrum. With double-limb stance, this tension band produces a compressive force across the symphysis; however, single-limb stance during gait results in a vertical shear force at the symphysis. With locomotion, a small amount of rotatory movement occurs around a transverse axis at the sacroiliac joints4,12.
Disruption of the symphysis pubis, as in patients who have been managed with resection, results in an increase in the rotational force at the sacroiliac joints and, over time, this increased force may result in hypermobility of the joints and progressive arthrosis. This arthrosis may progress slowly over several years and can be seen in patients who have symphyseal instability of different etiologies10,17.
Although wedge resection of the symphysis pubis has been recommended for the operative treatment of osteitis pubis, the technique is associated with a risk of late posterior instability of the pelvis that may necessitate extensive future reconstruction. The surgeon and the patient should be aware of these risks when considering options for operative treatment, especially when there is clinical or radiographic evidence of instability.
Arthrodesis of the symphysis pubis has been described for the treatment of instability, degeneration, and inflammation13,15. We believe that this procedure may be a better option than wedge resection for a patient who has unremitting osteitis pubis. Resection of the cartilaginous surfaces, autogenous bone-grafting, and plate fixation can provide a high rate of fusion if the patient is limited to bed-to-chair transfers for as long as three months postoperatively. The advantage of this technique compared with symphyseal resection lies in the restoration of anterior stability and thus the possible prevention of progressive posterior instability.
A review of the literature and our case reports indicates that there is a risk of late posterior instability of the pelvis after resection of the symphysis pubis for the treatment of intractable osteitis pubis. This risk may be increased in the presence of preoperative radiographic or clinical evidence of instability. To avoid this potential late complication, the senior one of us currently performs a symphyseal arthrodesis, as described in the present report, as the primary operative approach to intractable osteitis pubis. Bilateral arthrodesis of the symphysis pubis and the sacroiliac joints was successful in restoring stability to the pelvic ring in our patients in whom bilateral posterior instability developed after resection of the symphysis pubis.
NOTE: The authors thank Niki Cossand for help in the preparation of this manuscript.