SUPERIOR PUBIC RAMUS OSTEOTOMY TO TREAT LOCKED PUBIC SYMPHYSIS

Introduction: Overlapping pubic symphysis dislocation (OPSD) or a locked pubic symphysis is a compression of the pelvic ring with the intact pubis trapped into the contralateral obturator foramen. Reduction can be difficult and contralateral suprapubic osteotomy is a good way to address the irreducible OPSD. The technique has only been discussed thrice in the available literature. Case Report: We report the case of a 26-year-old man who had his right pubic ramus entrapped within the contralateral obturator foramen, having an overlap of >4 cm with associated ipsilateral sacroiliac joint (SI joint) disruption and urethral injury. When all the maneuvers of closed and instrumented open reduction failed, we performed a superior pubic ramus osteotomy on the left side and unlocked the incarcerated right pubic ramus. The osteotomy site was stabilized with a 6-hole recon plate and SI joint was stabilized with a 6.5mm percutaneous sacroiliac screw. The patient underwent delayed urethral repair at 10 weeks after the index surgery. At 3-year follow-up, the patient did not report any pubic discomfort, urinary and sexual problems. Conclusion: Locked OPSD is a rare injury and is frequently associated with sacroiliac and urethral injuries. Distraction osteotomy of the contralateral superior pubic ramus is a viable option for irreducible cases. Keywords: Lateral compression injury, locked symphysis pubis, superior pubic ramus osteotomy, overlapping pubic symphysis dislocation.

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Integrity of the pectineal ligament in MRI correlates with radiographic superior pubic ramus fracture displacement

Acta Radiologica ◽

10.1177/0284185120913002 ◽

2020 ◽

pp. 028418512091300

Author(s):

Alexis Klengel ◽

Hanno Steinke ◽

Philipp Pieroh ◽

Andreas Höch ◽

Timm Denecke ◽

...

Keyword(s):

Soft Tissues ◽

Pelvic Ring ◽

Compression Fracture ◽

Strong Positive Correlation ◽

Lateral Compression ◽

Pubic Ramus ◽

Radiographic Appearance ◽

Fracture Displacement ◽

Superior Pubic Ramus ◽

Magnetic Resonance Imaging Mri

Background Estimating the stability of pelvic lateral compression fractures solely by static radiographs can be difficult. In this context, the role of anterior pelvic soft tissues as potential secondary stabilizer of the pelvic ring has hardly been investigated. Purpose To correlate the initial radiographic appearance of the pubic ramus fracture with the integrity of the pectineal ligament, a strong ligament along the pecten pubis. Material and Methods In total, 31 patients with a pelvic lateral compression fracture (AO/OTA 61- B1.1/B2.1) with 33 superior pubic ramus fractures and available post-traumatic radiographs (pelvis anteroposterior, inlet, outlet) and magnetic resonance imaging (MRI) of the pelvis with fat-suppressed coronal images were reviewed retrospectively. Radiographic superior pubic ramus fracture displacement was measured and correlated to the degree of MR-morphologic alterations of the pectineal ligament (grade 0 = intact, grade 3 = rupture). Results In the majority of fractures (72.7%), associated MR-morphologic alterations of the pectineal ligament were present. Radiographic displacement and MRI grading showed a strong positive correlation (Spearman rho = 0.783, P < 0.001). The sensitivity and specificity for a radiographic displacement of >3 mm on plain radiographs to detect a structural ligament lesion on MRI (grade 2 and higher) were 73% and 100%, respectively. Conclusion Radiographic displacement of superior pubic ramus fractures >3 mm is a strong indicator for a structural lesion of the pectineal ligament. Future studies should investigate the potential biomechanical importance of this ligament for pelvic ring stability.

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Surgical management of chronic pelvic instability following periacetabular osteotomy nonunion

Hip International ◽

10.1177/1120700020922202 ◽

2020 ◽

Vol 30 (6) ◽

pp. 787-792

Author(s):

Alexander D Shearman ◽

Aresh Hashemi-Nejad ◽

Marcus JK Bankes ◽

Angus D Lewis

Keyword(s):

Stress Fracture ◽

Soft Tissues ◽

Periacetabular Osteotomy ◽

Case Series ◽

Stress Fractures ◽

Pubic Ramus ◽

Ilioinguinal Approach ◽

Superior Pubic Ramus ◽

Stoppa Approach ◽

Pelvic Instability

Introduction: Periacetabular osteotomy (PAO) is an established treatment for symptomatic acetabular dysplasia in skeletally mature individuals without arthritis. Pelvic nonunion and associated stress fractures are under-reported. Nonunited stress fractures can cause continued buttock pain and pelvic instability. The aim of this study is to report on our experience managing patients with ongoing pain following nonunion of PAO. Patients and methods: 8 patients presented to a tertiary referral pelvic service with symptomatic PAO nonunion between 2015-2018. All patients underwent open reduction internal fixation of the superior pubic ramus nonunion, with ipsilateral iliac autograft, at an average of 48.1 (15–82) months following initial osteotomy. Demographic and perioperative data were recorded. Follow-up was on average to 9.9 months, once union was confirmed radiographically. Results: All patients were female and average age was 31.8 (18–41) years. In 7/8 (87.5%) patients a modified Stoppa approach was successfully utilised. 1 patient required an ilioinguinal approach due to the amount of rotational correction. All patients went on to union at the superior pubic ramus and reported improvement in mechanical symptoms. 5/8 (62.5%) patients were noted to develop union of the posterior column or inferior pubic ramus stress fracture indirectly. 2/8 (25%) patients developed progression of intra-articular pain, despite restoration of pelvic stability. 1 patient required intraoperative transfusion due to femoral vein injury. There were no other complications seen in this series. Conclusions: To our knowledge, this is the largest case series of surgically managed PAO nonunion. Pelvic instability resulting from nonunion and stress fracture can be satisfactorily addressed by mobilising, grafting and plating the nonunion at the superior pubic ramus. The modified Stoppa approach is suitable in most cases, allowing excellent exposure whilst minimising the insult to soft tissues. The altered anatomy of the pelvis following PAO should be anticipated to reduce the risk to nearby neurovascular structures.

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Periacetabular osteotomy using three-dimensional cutting and reposition guides: a cadaveric study

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnz051 ◽

2019 ◽

Author(s):

Stephan H Wirth ◽

Stefan Rahm ◽

Atul F Kamath ◽

Claudio Dora ◽

Patrick O Zingg

Keyword(s):

Bone Quality ◽

Periacetabular Osteotomy ◽

Three Dimensional ◽

3D Models ◽

Posterior Column ◽

Pubic Ramus ◽

Superior Pubic Ramus ◽

Lateral Centre Edge Angle ◽

Operative Result ◽

Posterior Column Fracture

Abstract The goal of periacetabular osteotomy (PAO) is to reorient the acetabulum in a more physiological position. Its realization remains challenging regarding the final position of the acetabulum. Assistance with custom cutting- and reorientation-guides would thus be very helpful. Our purpose is to present a pilot study on such guides. Eight cadaveric hemipelvis were scanned using CT. After segmentation, 3D models of each specimen were created, a PAO was virtually performed and reorientation of the acetabula were defined. A specific guide was designed aiming to assist in iliac, posterior column and superior pubic ramus cuts as well as in acetabulum reorientation. Furthermore, the acetabular position was planned. Three-dimensional printed guides were used to perform PAO using the modified Smith-Peterson approach. The post-operative CT images and virtually planned acetabulum reorientation were compared in terms of acetabular index (AC), lateral centre edge angle (LCE), acetabular anteversion angle (AcetAV). There was no intra-articular or posterior column fracture seen. Two cadavers showed very low bone quality with insufficient stability of fixation and were excluded from further analysis. Correlation between the post-operative result and planning of the six included cadavers revealed the following mean deviations: 5° (SD ±3°) for AC angle, 6° (SD ±4°) for LCE angle and 15° (SD ±11°) for AcetAV angle. The use of 3D cutting and reorientation blocks for PAO was possible through a modified Smith-Peterson approach and revealed accurate fit to bone, accurate positioning of the osteotomies and acceptable planned corrections in cadavers with good bone quality.

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The Influence of Pelvic Ramus Fracture on the Stability of Fixed Pelvic Complex Fracture

Computational and Mathematical Methods in Medicine ◽

10.1155/2015/790575 ◽

2015 ◽

Vol 2015 ◽

pp. 1-11 ◽

Cited By ~ 10

Author(s):

Jianyin Lei ◽

Yue Zhang ◽

Guiying Wu ◽

Zhihua Wang ◽

Xianhua Cai

Keyword(s):

Pelvic Fracture ◽

Pelvic Ring ◽

Stable Condition ◽

Pubic Symphysis ◽

Pelvic Bone ◽

Anterior Plate ◽

Fe Method ◽

Pubic Ramus ◽

Complex Fracture ◽

The Stability

This study aims to evaluate the biomechanical mechanism of pelvic ring injury for the stability of pelvis using the finite element (FE) method. Complex pelvic fracture (i.e., anterior column with posterior hemitransverse lesion) combined with pelvic ramus fracture was used to evaluate the biomechanics stability of the pelvis. Three FE fracture models (i.e., Dynamic Anterior Plate-Screw System for Quadrilateral Area (DAPSQ) for complex pelvic fracture with intact pubic ramus, DAPSQ for complex pelvic fracture with pubic ramus fracture, and DAPSQ for complex pelvic fracture with fixed pubic ramus fracture) were established to explore the biomechanics stability of the pelvis. The pubic ramus fracture leads to an unsymmetrical situation and an unstable situation of the pelvis. The fixed pubic ramus fracture did well in reducing the stress levels of the pelvic bone and fixation system, as well as displacement difference in the pubic symphysis, and it could change the unstable situation back to a certain extent. The pelvic ring integrity was the prerequisite of the pelvic stability and should be in a stable condition when the complex fracture is treated.

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