Surgical Technique: Osteosynthesis for Pelvic Instability and Osteitis Pubis

  • Jason J. Halvorson
  • David L. Helfet
Living reference work entry


Pelvic instability, including osteitis pubis, can be challenging for physicians to diagnose and treat. While initial management of these conditions is almost a universally conservative treatment (including physical therapy, injections, anti-inflammatories, etc.), a subset of patients appear to benefit from surgical intervention as guided by the proposed treatment algorithm. When planning surgery, it is important to remember “the ring” structure of the pelvis, taking into account both the anterior and the posterior pelvic ring. Numerous surgical techniques for both anterior and posterior fixation, with or without formal fusion, have been proposed with varying results in the literature. A brief overview of pelvic instability is provided followed by review of the currently published surgical techniques. Finally, surgical technique regarding both anterior and posterior fixation is described.


  1. 1.
    Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008;17(6):794–819.PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Beatty T. Osteitis pubis in athletes. Curr Sports Med Rep. 2012;11(2):96–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Bradshaw CJ, Bundy M, Falvey E. The diagnosis of longstanding groin pain: a prospective clinical cohort study. Br J Sports Med. 2008;42(10):851–4.PubMedCrossRefGoogle Scholar
  4. 4.
    Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med. 2011;45(1):57–64.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Fricker PA, Taunton JE, Ammann W. Osteitis pubis in athletes. Infection, inflammation or injury? Sports Med. 1991;12(4):266–79.PubMedCrossRefGoogle Scholar
  6. 6.
    Lovell G, Galloway H, Hopkins W, Harvey A. Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad. Clin J Sport Med. 2006;16(2):117–22.PubMedCrossRefGoogle Scholar
  7. 7.
    Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players. Med Sci Sports Exerc. 1995;27(5):629–33.PubMedCrossRefGoogle Scholar
  8. 8.
    Rodriguez C, Miguel A, Lima H, Heinrichs K. Osteitis pubis syndrome in the professional soccer athlete: a case report. J Athl Train. 2001;36(4):437–40.PubMedCentralPubMedGoogle Scholar
  9. 9.
    Omar IM, Zoga AC, Kavanagh EC, Koulouris G, Bergin D, Gopez AG, Morrison WB, Meyers WC. Athletic pubalgia and “sports hernia”: optimal MR imaging technique and findings. Radiographics. 2008;28(5):1415–38.PubMedCrossRefGoogle Scholar
  10. 10.
    Macintyre J, Johson C, Schroeder EL. Groin pain in athletes. Curr Sports Med Rep. 2006;5(6):293–9. Review.Google Scholar
  11. 11.
    Cunningham PM, Brennan D, O’Connell M, MacMahon P, O’Neill P, Eustace S. Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am J Roentgenol. 2007;188(3):W291–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Wollin M, Lovell G. Osteitis pubis in four young football players: a case series demonstrating successful rehabilitation. Phys Ther Sport. 2006;7:153–60.CrossRefGoogle Scholar
  13. 13.
    Larsen EC, Wilken-Jensen C, Hansen A, Jensen DV, Johansen S, Minck H, Wormslev M, Davidsen M, Hansen TM. Symptom-giving pelvic girdle relaxation in pregnancy. I: Prevalence and risk factors. Acta Obstet Gynecol Scand. 1999;78(2):105–10.PubMedCrossRefGoogle Scholar
  14. 14.
    Reis RA, Baer JL, Arens RA, Stewart E. Traumatic separation of the symphysis pubis during spontaneous labor: with a clinical and x-ray study of the normal symphysis pubis during pregnancy and the puerperium. Surg Gynecol Obstet. 1932;55:336–54.Google Scholar
  15. 15.
    Taylor RN, Sonson RD. Separation of the pubic symphysis. An underrecognized peripartum complication. J Reprod Med. 1986;31:203–6.PubMedGoogle Scholar
  16. 16.
    Snow RE, Neubert AG. Peripartum pubic symphysis separation: a case series and review of the literature. Obstet Gynecol Surv. 1997;52(7):438–43. Review.Google Scholar
  17. 17.
    Ostgaard HC, Andersson GB, Karlsson K. Prevalence of back pain in pregnancy. Spine (Phila Pa 1976). 1991;16(5):549–52.CrossRefGoogle Scholar
  18. 18.
    Albert H, Godskesen M, Westergaard J. Prognosis in four syndromes of pregnancy-related pelvic pain. Acta Obstet Gynecol Scand. 2001;80(6):505–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Moore Jr RS, Stover MD, Matta JM. Late posterior instability of the pelvis after resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Joint Surg Am. 1998;80(7):1043–8.PubMedGoogle Scholar
  20. 20.
    Wu WH, Meijer OG, Uegaki K, Mens JM, van Djeen JH, Wuisman PI, Ostgaard HC. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J. 2004;13(7):575–89. Epub 2004 Aug 27.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Albert HB, Godskesen M, Korsholm L, Westergaard JG. Risk factors in developing pregnancy-related pelvic girdle pain. Acta Obstet Gynecol Scand. 2006;85(5):539–44.PubMedCrossRefGoogle Scholar
  22. 22.
    Hansen A, Jensen DV, Wormslev M, Minck H, Johansen S, Larsen EC, Wilken-Jensen C, Davidsen M, Hansen TM. Symptom-giving pelvic girdle relaxation in pregnancy. II: Symptoms and clinical signs. Acta Obstet Gynecol Scand. 1999;78(2):111–5.PubMedCrossRefGoogle Scholar
  23. 23.
    van Zwienen CM, van den Bosch EW, Snijders CJ, van Vugt AB. Triple pelvic ring fixation in patients with severe pregnancy-related low back and pelvic pain. Spine (Phila Pa 1976). 2004;29(4):478–84.CrossRefGoogle Scholar
  24. 24.
    Owens K, Pearson A, Mason G. Symphysis pubis dysfunction–a cause of significant obstetric morbidity. Eur J Obstet Gynecol Reprod Biol. 2002;105(2):143–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Damen L, Buyruk HM, Güler-Uysal F, Lotgering FK, Snijders CJ, Stam HJ. The prognostic value of asymmetric laxity of the sacroiliac joints in pregnancy-related pelvic pain. Spine (Phila Pa 1976). 2002;27(24):2820–4.CrossRefGoogle Scholar
  26. 26.
    Coventry MB, Mitchell WC. Osteitis pubis: observations based on a study of 45 patients. JAMA. 1961;178:898–905.PubMedCrossRefGoogle Scholar
  27. 27.
    Siegel J, Templeman DC, Tornetta 3rd P. Single-leg-stance radiographs in the diagnosis of pelvic instability. J Bone Joint Surg Am. 2008;90(10):2119–25.PubMedCrossRefGoogle Scholar
  28. 28.
    Garras DN, Carothers JT, Olson SA. Single-leg-stance (flamingo) radiographs to assess pelvic instability: how much motion is normal? J Bone Joint Surg Am. 2008;90(10):2114–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Najibi S, Tannast M, Klenck RE, Matta JM. Internal fixation of symphyseal disruption resulting from childbirth. J Orthop Trauma. 2010;24(12):732–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Hagen R. Pelvic girdle relaxation from an orthopaedic point of view. Acta Orthop Scand. 1974;45(4):550–63.PubMedCrossRefGoogle Scholar
  31. 31.
    Kharrazi FD, Rodgers WB, Kennedy JG, Lhowe DW. Parturition-induced pelvic dislocation: a report of four cases. J Orthop Trauma. 1997;11(4):277–81.PubMedCrossRefGoogle Scholar
  32. 32.
    Hou Z, Riehl JT, Smith WR, Strohecker KA, Maloney PJ. Severe postpartum disruption of the pelvic ring: report of two cases and review of the literature. Patient Saf Surg. 2011;5(1):2.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Garagiola DM, Tarver RD, Gibson L, Rogers RE, Wass JL. Anatomic changes in the pelvis after uncomplicated vaginal delivery: a CT study on 14 women. AJR Am J Roentgenol. 1989;153(6):1239–41.PubMedCrossRefGoogle Scholar
  34. 34.
    Elgafy H, Semaan HB, Ebraheim NA, Coombs RJ. Computed tomography findings in patients with sacroiliac pain. Clin Orthop Relat Res. 2001;382:112–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Major NM, Helms CA. Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes. Skeletal Radiol. 1997;26(12):711–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Wurdinger S, Humbsch K, Reichenbach JR, Peiker G, Seewald HJ, Kaiser WA. MRI of the pelvic ring joints postpartum: normal and pathological findings. J Magn Reson Imaging. 2002;15(3):324–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Paajanen H, Hermunen H, Karonen J. Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training. Am J Sports Med. 2008;36(1):117–21.PubMedCrossRefGoogle Scholar
  38. 38.
    Verrall GM, Slavotinek JP, Fon GT. Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med. 2001;35(1):28–33.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Björklund K, Nordström ML, Bergström S. Sonographic assessment of symphyseal joint distention during pregnancy and post partum with special reference to pelvic pain. Acta Obstet Gynecol Scand. 1999;78(2):125–30.PubMedCrossRefGoogle Scholar
  40. 40.
    Scriven MW, Jones DA, McKnight L. The importance of pubic pain following childbirth: a clinical and ultrasonographic study of diastasis of the pubic symphysis. J R Soc Med. 1995;88(1):28–30.PubMedCentralPubMedGoogle Scholar
  41. 41.
    Luger EJ, Arbel R, Dekel S. Traumatic separation of the symphysis pubis during pregnancy: a case report. J Trauma. 1995;38(2):255–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Kristiansson P, Svardsudd K, von Schoultz B. Serum relaxin, symphyseal pain, and back pain during pregnancy. Am J Obstet Gynecol. 1996;175:1342–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Bjorklund K, Bergstrom S, Nordstrom M-L. Symphyseal distension in relation to serum relaxin levels and pelvic pain in pregnancy. Acta Obstet Gynecol Scand 2000;79:269–275.Google Scholar
  44. 44.
    Katz V, Schofferman J, Reynolds J. The sacroiliac joint: a potential cause of pain after lumbar fusion to the sacrum. J Spinal Disord Tech. 2003;16(1):96–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Slipman CW, Patel RK, Whyte II WS, et al. Diagnosing and managing sacroiliac pain. J Musculoskelet Med. 2001;18:325–32.Google Scholar
  46. 46.
    O’Connell MJ, Powell T, McCaffrey NM, O’Connell D, Eustace SJ. Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes. AJR Am J Roentgenol. 2002;179(4):955–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Buchowski JM, Kebaish KM, Sinkov V, Cohen DB, Sieber AN, Kostuik JP. Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint. Spine J. 2005;5(5):520–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Elden H, Hagberg H, Olsen MF, Ladfors L, Ostgaard HC. Regression of pelvic girdle pain after delivery: follow-up of a randomised single blind controlled trial with different treatment modalities. Acta Obstet Gynecol Scand. 2008;87(2):201–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Rommens PM. Internal fixation in postpartum symphysis pubis rupture: report of three cases. J Orthop Trauma. 1997;11(4):273–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Grace JN, Sim FH, Shives TC, Coventry MB. Wedge resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Joint Surg Am. 1989;71(3):358–64.PubMedGoogle Scholar
  51. 51.
    Radic R, Annear P. Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes. Am J Sports Med. 2008;36(1):122–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Williams PR, Thomas DP, Downes EM. Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail. Am J Sports Med. 2000;28(3):350–5.PubMedGoogle Scholar
  53. 53.
    Weil YA, Hierholzer C, Sama D, Wright C, Nousiainen MT, Kloen P, Helfet DL. Management of persistent postpartum pelvic pain. Am J Orthop (Belle Mead NJ). 2008;37(12):621–6.PubMedGoogle Scholar
  54. 54.
    Paajanen H, Heikkinen J, Hermunen H, Airo I. Successful treatment of osteitis pubis by using totally extraperitoneal endoscopic technique. Int J Sports Med. 2005;26(4):303–6.PubMedCrossRefGoogle Scholar
  55. 55.
    Kibsgård TJ, Røise O, Sudmann E, Stuge B. Pelvic joint fusions in patients with chronic pelvic girdle pain: a 23-year follow-up. Eur Spine J. 2013;22(4):871–7.PubMedCentralPubMedCrossRefGoogle Scholar
  56. 56.
    Khurana A, Guha AR, Mohanty K, Ahuja S. Percutaneous fusion of the sacroiliac joint with hollow modular anchorage screws: clinical and radiological outcome. J Bone Joint Surg Br. 2009;91(5):627–31.PubMedCrossRefGoogle Scholar
  57. 57.
    Wise CL, Dall BE. Minimally invasive sacroiliac arthrodesis: outcomes of a new technique. J Spinal Disord Tech. 2008;21(8):579–84.PubMedCrossRefGoogle Scholar
  58. 58.
    Al-Khayer A, Hegarty J, Hahn D, Grevitt MP. Percutaneous sacroiliac joint arthrodesis: a novel technique. J Spinal Disord Tech. 2008;21(5):359–63.PubMedCrossRefGoogle Scholar
  59. 59.
    Miller AN, Routt Jr ML. Variations in sacral morphology and implications for iliosacral screw fixation. J Am Acad Orthop Surg. 2012;20(1):8–16.PubMedCrossRefGoogle Scholar
  60. 60.
    Routt Jr ML, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma. 1996;10(3):171–7.PubMedCrossRefGoogle Scholar
  61. 61.
    Gardner MJ, Morshed S, Nork SE, Ricci WM, Chip Routt Jr ML. Quantification of the upper and second sacral segment safe zones in normal and dysmorphic sacra. J Orthop Trauma. 2010;24(10):622–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Medical Center BoulevardHospital for Special Surgery, Wake Forest University School of MedicineWinston-SalemUSA
  2. 2.Weill Medical College of Cornell UniversityOrthopaedic Trauma Service, Hospital for Special Surgery/New York Presbyterian HospitalNew YorkUSA

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