Abstract
Purpose
Open curettage of the symphysis has shown promising results in patients with recalcitrant osteitis pubis. However, this has been bedevilled with an extended intraoperative morbidity. Aim of this study was to come up with a novel arthroscopic debridement of the pubic symphysis and to bring to the fore the potential risks of soft tissue damage.
Methods
This study was conducted on six human cadavers (mean age 83 years). CT scans were obtained for measurement of the symphyseal morphology. Consequent upon these measurements, four different potential arthroscopic portals were defined with the intention to gain adequate insight and to reach the whole joint space with instruments: one suprapubic portal and three anterior portals (antero-superior, antero-central and antero-inferior). Soft tissue, except for musculotendinous attachments and neurovascular structures, was dissected. A two-portal arthroscopic debridement under image intensifier control with resection of the symphyseal disc and abrasion of the subchondral bone were performed.
Results
Considering the narrow joint space, small instruments/scope (4.5/2.7 mm) is recommended. Correct portal placement and debridement procedure can only be reliably performed under fluoroscopic imaging in two radiographic projections (outlet and inlet view) with a mean total fluoroscopic time of 15–20 s and a dose area product between 100 and 120 cGy cm2. Two portals have proved beneficial: the suprapubic portal for instruments and the antero-central portal for the scope. Other portals had several limitations, e.g. potential instrumental conflict (anterior–superior) or damaging of neurovascular and other soft tissue structures (anterior–inferior).
Conclusion
With well-defined arthroscopic portals and adherence to basic principles of arthroscopic surgery, debridement of the pubic symphysis can be performed reproducibly without compromising important anatomical structures. This less invasive arthroscopic debridement is a safely applicable procedure and therefore might be a reasonable alternative to open curettage. One may assume that this technique will lead to a shorter rehabilitation time and will provide a successful therapy especially in the treatment of professional athletes in the future.
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References
Batt ME, McShane JM, Dillingham MF (1995) Osteitis pubis in collegiate football players. Med Sci Sports Exerc 27:629–633
Becker I, Woodley SJ, Stringer MD (2010) The adult human pubic symphysis: a systematic review. J Anat 217:475–487
Budd H, Patchava A, Kanduja V (2012) Establishing the radiation risk from fluoroscopic-assisted arthroscopic surgery of the hip. Int Orthop 36:1803–1806
Fricker PA, Taunton JE, Ammann W (1991) Osteitis pubis in athletes. Infection, inflammation or injury? Sports Med 12:266–279
Gamble JG, Simmons S, Freedman M (1986) The pubic symphysis: anatomic and pathologic considerations. Clin Orthop Rel Res 203:262–272
Garvey JFW, Read JW, Turner A (2010) Sportsmen hernia: what can we do? Hernia 14:17–25
Gaymer CE, Achten J, Auckett R, Cooper L, Griffin D (2013) Fluoroscopic radiation exposure during hip arthroscopy. Arthroscopy 29:870–873
Grace JN, Sim FH, Shives TC, Coventry MB (1989) Wedge resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Joint Surg Am 71:358–364
Hechtman KS, Zvijac JE, Popkin CA, Zych GA, Botto-van Bemden A (2010) A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes. Sports Health 2:211–215
Ibrahim A, El-Sherbini A (1961) The different ligaments of the symphysis pubis in the pregnant and the non-pregnant state. J Obstet Gynaecol Br Emp 68:592–596
Matsuda DK (2010) Endoscopic pubic symphysectomy for recalcitrant osteitis pubis associated with bilateral femoroacetabular impingement. Orthopedics 10:199–203
Mehin R, Meek R, O’Brien P, Blachut P (2006) Surgery for osteitis pubis. Can J Surg 49:170–176
Meissner A, Fell M, Wilk R, Bönik U, Rahmanzadeh R (1996) Biomechanics of the pubic symphysis. Which forces lead to mobility of the symphysis in physiological conditions? Unfallchirurg 99:415–421
Moore RS Jr, Stover MD, Matta JM (1998) Late posterior instability of the pelvis after resection of the symphysis pubis for the treatment of osteitis pubis. A report of two cases. J Bone Joint Surg Am 80:1043–1048
Mulhall KJ, McKenna J, Walsh A, McCormack D (2002) Osteitis pubis in professional soccer players: a report of outcome with symphyseal curettage in cases refractory to conservative management. Clin J Sport Med 12:179–181
Paajanen H, Syvähuoko I, Airo I (2004) Totally extraperitoneal endoscopic (TEP) treatment of sportsman’s hernia. Surg Laparosc Endosc Percutan Tech 14:215–218
Radic R, Annear P (2008) Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes. Am J Sports Med 36:122–128
Williams PR, Thomas DP, Downes EM (2000) Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail. Am J Sports Med 28:350–355
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Hopp, S., Culemann, U., Ojodu, I. et al. Arthroscopic debridement of the pubic symphysis: an experimental study. Knee Surg Sports Traumatol Arthrosc 23, 2568–2575 (2015). https://doi.org/10.1007/s00167-014-3105-3
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DOI: https://doi.org/10.1007/s00167-014-3105-3