Osteitis Pubis Surgery


Osteitis pubis

Basic features Cultures Treatment Causes

Clinical features Investigations


Positive (Staphylococcus aureus most common)

Antibiotics, rest, debridement surgery

Direct vs. indirect inoculation

Fever, tenderness, waddling gait, painful adduction and abduction

X-ray, MRI, bone scan, CT-guided biopsy

Inflammatory/microtrauma/instability No organism

Rest, NSAIDS, steroid injections, surgery

Overuse, microtrauma, pubic symphysis instability

Tenderness, waddling gait, painful adduction and abduction

X-ray, MRI, bone scan

ultimately challenging the physician, patient, trainers, and coaching staff. The importance of rest and cross-training cannot be overemphasized. The symptoms last from several weeks to months.2,17,23,31 Fricker et al.9 reported full recovery averaged 9.5 months in men and 7.0 months in women after conservative treatment. A study by Holt et al.17 found that patients returned to full activities within 16 weeks after conservative treatment. The mainstay of treatment for athletic osteitis pubis remains nonop-erative.2,4,8,17 The full spectrum of conservative measures has been documented and includes rest, physical therapy, ultrasonography, nonsteroidal anti-inflammatory medication, oral glucocorticoids, bracing, radiation therapy, anticoagulation, and cortico-steroid injections into the pubic symphysis.1,2,4,17,26 The effectiveness of the majority of these treatments has not been validated scientifically. In the athlete, the first line of treatment should be reducing the activity level. Choosing nonpainful and nonimpact exercises is central in the treatment. Shock-absorbing footwear may also diminish the shear forces across the symphysis pubis. Stretching exercises of the trunk and lower extremity should be done, paying particular attention to hip range of motion and adductor stretching and strengthening.31 A study by Harris and Mur-ray4 of 37 athletic patients found that spontaneous remission was the most likely outcome and that rest from physical exertion was the most effective treatment. The ideal physical therapy program has not been clearly determined for osteitis pubis. For patients with chronic adductor-related groin pain, active physiotherapy training with a training program aimed at improving strength and coordination of the muscles acting on the pelvis, in particular the abdominal musculature and the adductor muscles, has been proven the most effective40 (Figure 5.2). Studies evaluating the effectiveness of intraarticular pubic symphysis steroids are limited. Holt et al.17 suggested that a quicker return to full sports activities could be accomplished with early judicious use of intraarticular corticosteroid injections in a study evaluating 12 intercollegiate athletes. Three of 8 athletes returned to play within 3 weeks of the injection and 3 more athletes within 16 weeks after a repeated injection. The authors recommended a treatment algorithm that began with conservative treatment and then an intraar-ticular injection of 4 mg dexamethasone, 1 mL 1% li-docaine, and 1 mL bupivacaine if the symptoms persisted after 7 to 10 days of treatment. The injection was done by prepping and draping a shaved area over the pubic symphysis. Fluoroscopic guidance was not used. The pubic symphysis was palpated and then penetrated with the needle. The needle is then gently advanced until a characteristic pop is appreciated. The 3-mL anesthetic mixture freely flows into the joint at this point. The authors warned that advancing the needle more than 1 inch may cause injury to the spermatic cord or lead to penetration of the bladder. This study reported encouraging results; however, the addition of a control group composed of noninjected patients would have strengthened their results.

Surgical procedures such as partial wedge resections of the symphysis pubis and arthrodesis, with and without hardware, should be reserved for those patients with recalcitrant osteitis pubis and who are disabled by their symptoms.2,4,8,23 Harris and Murray4 found that surgery was rarely indicated but when necessary their arthrodesis of choice was one using a bone block. These investigators, however, did not publish their surgical data. Wedge resection of the symphysis has also been recommended for treatment of recalcitrant osteitis pubis (Figure 5.3). Some investigators believe that removal of the superior bony pubic sym-physis wedge preserves the strong inferior arcuate ligaments, thereby preventing future instability.2,8 Coventry and William2 noted rapid resolution of symptoms in 2 patients who underwent a trapezoidal wedge resection and concluded that surgical measures may shorten the clinical course of recalcitrant osteitis pubis. Grace et al.8 published their work on 10 patients who underwent a similar wedge resection after completing at least 6 months of conservative treatment. At an average postoperative follow-up of 92 months, 7 of the 10 patients were very satisfied with their results, but 3 were not. Interestingly, 2 of these 3 patients had pelvic instability. The authors concluded wedge resection of the symphysis pubis is useful as a first-line surgical procedure because of its short operative time, reliability, and low complication risk. Williams et al.23 evaluated the benefits of pubic sym-physis bone grafting supplemented by compression plating in a group of rugby players with pelvic instability (Figure 5.4). These patients had undergone at least 13 months of conservative treatment and were all found to have pelvic instability seen on flamingo views (>2 mm vertical motion). At a mean follow-up of 52.4 months, all patients were free of symptoms, and follow-up flamingo views confirmed a successful arthrodesis without residual pubic symphysis instability. The authors concluded their technique yielded an excellent arthrodesis and offered a low complication rate. The caveat in this study was that a bone block graft arthrodesis, without the supplementation of a compression plate, was prone to fusion mass stress fractures and, therefore, did not provide the necessary durability. Additionally, these authors echoed other authors' concerns that pubic symphysis wedge resection did indeed predispose patients to late pelvis instability, and hence they discourage its use.41 We have had some success treating primary osteitis pubis with athletic pubalgia procedures.

Most of the literature regarding surgical management of osteitis pubis has focused exclusively on bony

FIGURE 5.2. Strengthening and flexibility exercises aimed at eliminating the muscle imbalance between the abdominal musculature and the hip adductors. (Courtesy of Dr. Ross G. Davidson.)

procedures. The available reports on soft tissue procedures are limited to case reports or small retrospective reviews. A case report by Wiley16 reported favorable results after surgically excising cortical avulsion of the gracilis tendon at the pubic symphysis. Miguel14 presented his results of adductor muscle release off the pubis bone with adjunctive drilling into the symphyseal bone. Thirty-three (68%) of 48 athletes (mostly soccer players) who underwent this procedure returned to an acceptable level of sports and 6 (12%) were failures.

In summary, groin pain has a broad differential diagnosis including orthopedic and medically related causes. Once the differential diagnosis is narrowed and the clinician is certain that urologic, gynecologic, and surgical causes are not the root cause, a focused and methodical management approach can be undertaken. To improve our diagnostic precision and to clearly define the pain complaint, we have instituted a zone-specific approach to this problem (Figure 5.5, Table 5.3). The abdominal, pubic, and thigh areas of the hip are separated into pathoanatomic zones (I, II, III, and IV). By focusing on the specific symptomatic zone, we are able to narrow the differential diagnosis and treatment strategy effectively. The workup would include a referral to a general surgeon, a herniography, and/or MRI to evaluate for the possibility of a posterior abdominal wall defect. The limitation to this approach

Osteitis Pubis Surgery

FIGURE 5.3. Partial wedge resection of the pubic symphysis for the treatment of recalcitrant osteitis pubis. A trapezoidal wedge of pubic symphysis bone is excised while sparring the strong inferior arcuate ligament. Theoretically, sparring the arcuate ligament prevents postsurgical pelvic instability.

FIGURE 5.3. Partial wedge resection of the pubic symphysis for the treatment of recalcitrant osteitis pubis. A trapezoidal wedge of pubic symphysis bone is excised while sparring the strong inferior arcuate ligament. Theoretically, sparring the arcuate ligament prevents postsurgical pelvic instability.

Surgery Osteitis Pubis
FIGURE 5.4. Pubic symphysis compression plate arthrodesis and inlaid tricortical bone graft for the treatment of recalcitrant osteitis pubis.
don/inguinal ring; zone III, directly over bony prominence of pubic symphysis; zone IV, over the insertion and musculotendinous junction of the hip adductors.

TABLE 5.3. Groin Pain Pathoanatomic Zones and Their Respective Differential Diagnosis.

Zone I

Zone II

Zone III

Zone IV

(hip joint region)

(suprapubic region)

(pubic region)

(adductor region)

Labral tears, osteochondral loose

Athletic pubalgia

Osteitis pubis

Adductor/gracilis tears

bodies, and articular cartilage

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