Ipsilateral pubic ramus fracture during total hip arthroplasty is not rare: does it matter?

INTRODUCTION: Periprosthetic fractures in total hip arthroplasty (THA) have been well described and studied. However, there is a lack of reports on ipsilateral pubic ramus fractures during THA due to the rare occurrence of such fractures and ambiguity of symptoms. With the use of postoperative computed tomography (CT) examinations, we have identified that asymptomatic ipsilateral pubic ramus fractures occur frequently during THA. This study aims to evaluate the incidence, location, clinical outcomes, and risk factors of ipsilateral pubic ramus fractures during THA. METHODS: From May 2022 to March 2023, a single surgeon performed 203 THAs in 183 patients at a single institution. All patients underwent postoperative CT scans three days after THA. The patients with ipsilateral pubic ramus fractures were followed up for a minimum of six months. Basic demographics, osteoporosis, general conditions of the operations, and outcomes of THA were investigated in all patients. RESULTS: Twenty-two cases (10.8%) of ipsilateral pubic ramus fractures were identified on postoperative CT scans. All fractures were located near the origin of the superior or inferior pubic ramus. Five fractures were detected on simple postoperative radiographs. The fractures did not cause any further complications at a minimum of six-month postoperative follow-up. Univariate and multivariate analyses did not identify any risk factors associated with these fractures. CONCLUSIONS: Although the incidence of ipsilateral pubic ramus fractures during THA is high, treatment is not required as they do not cause any significant clinical symptoms or affect the prognosis of THA. However, the possibility of occurrence of these fractures must be explained to the patients before surgery.

Can Nondisplacement Osteoporotic Pubic Rami Fracture Be Life-Threatening Injuries? A Case Report, Overview, and Algorithm Protocol for Management.

Pubic rami fractures in the geriatric population are usually osteoporotic fractures resulting from low energy trauma and are characterized as stable injuries. Established treatment of these injuries is conservative, including rest, analgesic medication, and progressive active mobilization. These injuries are life-threatened when pubic rami fractures are accompanied by acute bleeding, either from an injury to a vessel (corona mortis) or from medication (anticoagulant or antiplatelet) for comorbidities, then. In this case study, we present the unusual case of an 82-year-old woman admitted to the emergency department 24 hours after a simple fall, causing nondisplacement osteoporotic pubic rami fracture, who, after 48 hours, developed a hematoma on the contralateral side of the pelvis, with progressive anemia and acute abdominal pain. This study has 2 objectives: to increase awareness of this life-threatening injury in the emergency department and to describe diagnosis and treatment modalities.

Mid-term follow-up of superior pubic ramus osteotomy in locked symphysis pubis with urethral injury: A case report.

A locked pubic ramus body is an unusual variant of lateral compression injury. Till date, there have been only 25 cases reported in the published literature. We herein described a case where the right pubic ramus was entrapped within the opposite obturator foramen with an overlap of greater than 4 cm, with associated urethral injury. When all maneuvers of closed and instrumented 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. The patient underwent delayed urethral repair 10 weeks after the index surgery. At 3-year follow-up, the patient has sexual dysfunction especially difficulty in maintaining erection, secondary urethral stricture, heterotopic ossification, and breakage of implants.

Novel use of continuous pericapsular nerve group (PENG) block technique for traumatic superior and inferior pubic rami fractures: a case report.

BACKGROUND: Pubic rami fractures are painful injuries more commonly seen in the elderly with osteoporosis after high velocity trauma. In the most cases, management is conservative and non-operative with the goal to provide optimal pain relief to facilitate early mobilization and hospital discharge. Unfortunately, opioids remain the mainstay analgesic option and regional anesthesia techniques are limited but may include lumbar epidural anesthesia. CASE PRESENTATION: A female patient in her 80s presented to the emergency department of a level 1 trauma center following a high-speed motor vehicle collision. The patient suffered multiple non-life-threatening injuries. Notably, the patient was experiencing severe right groin and leg pain secondary to superior and inferior pubic rami fractures. Due to the severity of this pain, the patient was unable to mobilize or participate with physiotherapy. A lumbar epidural anesthesia technique was not deemed suitable and instead, we inserted a continuous pericapsular nerve group (PENG) block with a programmed intermittent bolus regimen. Immediate relief of pain was achieved and 48 hours later, the patient still reported satisfactory pain control and started to independently mobilize. CONCLUSION: Analgesia options are limited in pubic rami fractures. We present the first published case of a novel use of the PENG block with a continuous catheter technique for the analgesic management of a traumatic superior and inferior pubic rami fracture. The clinical utility of this technique in pubic ramus fractures warrants further clinical investigation.

Relationship between Femoroacetabular Impingement and Pubalgia in Professional Soccer Players / Relação do impacto femoroacetabular e pubalgia em jogadores profissionais de futebol de campo

Abstract Objective To analyze the relationship between pubalgia and femoroacetabular impingement (FAI) in professional athletes of a soccer club, defining the prevalence of these conditions in the sample studied. Methods It is an epidemiological, cross-sectional, and analytical study including 90 professional soccer players active from 2019 to 2021. We accessed the medical records of the subjects to retrieve information from the modified Pre-Competition Medical Assessment (PCMA) protocol, orthopedic physical examination, and anteroposterior pelvic radiographs to assess pubalgia and FAI, respectively. Inclusion criteria were athletes playing in the professional soccer club in the 2019 to 2021 season, who underwent a modified PCMA upon admission, and who signed an informed consent form. Results FAI was highly prevalent (85.6%) in the sample. This prevalence may occur because, in Brazil, people start playing sports early, not always in suitable fields, or with no proper equipment and supervision. In addition, the CAM-type impingement was the most frequent (62.2%). These injuries are related to high-intensity movements, including those associated with soccer. Furthermore, there is no dependency correlation between pubalgia and FAI. FAI was present in only 20% of athletes with pubalgia complaints. Conclusion There was a high prevalence of FAI in professional soccer players in the studied population (85.6%) but with no relationship between FAI and pubalgia.

Resumo Objetivo Analisar a relação entre a pubalgia e o impacto femoroacetabular (IFA) em atletas profissionais de um clube de futebol, definindo a prevalência de pubalgia e de impacto femoroacetabular na casuística estudada. Métodos É um estudo epidemiológico, transversal e analítico. Foram selecionados 90 atletas profissionais de futebol atuantes no período de 2019-2021. Foram acessados os prontuários para obtenção do protocolo PCMA modificado, além de exame físico ortopédico e de radiografias da bacia com incidência anteroposterior para avaliação de pubalgia e IFA, respectivamente. Critérios de Inclusão: Atletas que atuaram no clube de futebol de campo profissional na temporada de 2019 a 2021, que foram submetidos a aplicação do PCMA modificado na admissão e que assinaram o TCLE. Resultados O IFA apresentou elevada prevalência na amostra (85.6%), o que pode ocorrer pois, no Brasil, os jovens iniciam a prática esportiva em idade muito precoce, além do fato de os jogadores nem sempre praticarem o esporte em campos adequados ou com equipamentos e supervisão adequada. Ademais, o impacto tipo CAM foi o mais frequente (62.2%). O surgimento dessas lesões é relacionado a movimentos de alta intensidade, como os vistos no futebol. Outrossim, observou-se que não há correlação de dependência entre a pubalgia e o IFA. Foi visto que o IFA estava presente em apenas 20% dos atletas queixosos de pubalgia. Conclusão Há elevada prevalência de IFA em atletas de futebol profissional na população estudada (85.6%) e não houve relação entre o IFA e a presença de pubalgia.

[Arthroscopically assisted minimally invasive symphysioplasty for the treatment of pubic related groin pain]. / Arthroskopisch assistierte minimal-invasive Symphysioplastik zur Behandlung des schambeinbezogenen Leistenschmerzes.

OBJECTIVE: Therapy of pubic related groin pain via minimally invasive symphysioplasty. INDICATIONS: Therapy of refractory pubic related groin pain based on osteitis pubis. CONTRAINDICATIONS: Groin pain from causes other than pubic related groin pain. SURGICAL TECHNIQUE: After a minimally invasive approach, an incision in the anterior capsule is made while protecting the dorsal capsule parts and the arcuate pubic ligament. The symphysis end plates are remodeled arthroscopically assisted using a surgical burr. The newly created pubic symphysis joint is filled with autogenous fibrin to support the formation of a new discus interpubicus. POSTOPERATIVE MANAGEMENT: Partial weight-bearing for 4 weeks with 20 kg using crutches is recommended. During the first 4 weeks the range of motion should be restricted. RESULTS: Since 2010, 10 athletes (7 men, 3 women; average age 34.1 ± 7.8 (23-47) years) have undergone arthroscopically assisted minimally invasive symphysioplasty and treatment of femoroacetabular impingement syndrome. The average follow-up time was 5.1 (2-9) years. All patients returned to their sport level. The mean preoperative Nonarthritic Hip Score (NAHS) of 64.4 ± 15.1 (32.1-86.5) points improved to a mean postoperative NAHS of 91.4 ± 9.8 (62.4-98.75) points (p < 0.0001). The average patient satisfaction (scale 0 to 10; 10 highest satisfaction) was 9.8 ± 0.4 (9-10).

A novel nomogram for the delayed transperineal anastomotic urethroplasty based on relative position between the proximal urethra and the pubic ramus in pelvic fracture injury patients: a retrospective analysis.

PURPOSE: Many reconstructive urologists have observed that higher urethra injuries lead to potentially less successful repairs. This article introduces a novel prognostic factor for pelvic fracture caused urethral injury (PFUI) to predict stricture recurrence after delayed transperineal anastomotic urethroplasty (TAU) patients with PFUI based on urethra injury locations. MATERIALS AND METHODS: Patients who underwent suprapubic cystostomy tube placement and delayed TAU for PFUI by a single surgeon between 2009 and 2018 were screened. A total of 151 patients completed the follow-up. The relative location between the proximal urethra and the pubic ramus (PUE-PR), a novel stricture length classification method based on the anatomical landmark, was divided into a lower, middle, and upper group reflected by urethrogram. The nomogram was developed based on significant coefficients identified by multivariable Cox regression. RESULTS: Based on the relative position between the proximal urethra end and the pubic ramus (PUE-PR), 47 (31%), 66 (44%), and 38 (25%) patients were assigned to the lower, middle, and upper group, respectively. A total of 33 patients (22%) patients had a recurrence. The median (IQR) follow-up was 49 months (28-75). Smoking, endoscopic treatment history, and PUE-PR were identified as independent risk factors for stricture recurrence. The nomogram showed good discrimination with a C-index of 76.67%. The decision curve analysis (DCA) indicated that the model could bring more clinical net benefit when a threshold probability is larger than 8%. CONCLUSIONS: PUE-PR is a new prognostic factor for PFUI to predict stricture recurrence after TAU. A novel nomogram incorporating PUE-PR could be applied to facilitate the prediction of stricture recurrence after delayed TAU for PFUI.

Stress Fractures of the Hip and Pelvis.

Stress fractures refer to overuse injuries of bone resulting from repetitive mechanical stress. Stress fractures of the hip and pelvic region, while relatively uncommon, have become increasingly recognized in certain populations, particularly long-distance runners and military recruits. The diagnosis of such injuries can be challenging, often hampered by a nonspecific physical examination and limited sensitivity of plain radiography. Early recognition is important to direct appropriate management, lessen time lost from sport, and avoid potential complications. The present article reviews the epidemiology, diagnosis, and management of bone stress injuries of the hip and pelvis, specifically the sacrum, pubic ramus, and femoral neck.

Rare pathology in a trauma patient: air embolism following peripheral intravenous access.

A 62-year-old man presented as a trauma alert after a farm tractor accident. He was managed according to ATLS protocol. During initial trauma resuscitation, he developed an iatrogenic air embolus. The patient was treated conservatively by positioning him head down and tilted to the left (Durant's manoeuvre). Repeat CT scan performed 4 hours later showed resolution of the air embolus. He had no sequelae.

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

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.

Team Approach: Evaluation and Management of Pelvic Ring Injuries.

A multidisciplinary approach to the management of pelvic ring injuries has been shown to decrease mortality rates. The primary goals within the emergency room are to assess, resuscitate, and stabilize the patient. The Advanced Trauma Life Support protocol guides the initial assessment of the patient. A pelvic binder or sheet should be applied to help to provide reduction of the fracture and temporary stabilization. The trauma team becomes the primary service for the patient as he or she transitions away from the emergency department. The trauma team must effectively communicate with and serve as the liaison between other specialists as injuries are identified. emodynamic stability should be closely monitored in patients with pelvic ring injuries, involving the assessment of vital signs, imaging findings, and clinical judgment. Angioembolization and peritoneal packing may play a role in helping to control hemorrhage. Urologists should be consulted if a Foley catheter cannot be passed or there is concern for urethral or bladder injury. Further imaging or urologic intervention may be necessary. Orthopaedic surgeons can help to assess the patient, classify the injury, and assist in temporary stabilization while planning definitive fixation.

Dorsal root ganglion stimulation for the treatment of severe intractable pain related to obturator nerve entrapment neuropathy: A case report.

A 61-year-old Caucasian female, with severe obturator neuropathy following a left pubic ramus fracture was treated successfully with dorsal root ganglion stimulation (DRGS). Both conservative management and a dual-lead dorsal column spinal cord stimulator did not provide effective long-term results. The dorsal root ganglion (DRG) trial was completed five years following the initial fracture, resulting in 90 % pain relief. A permanent device was implanted and after one year, 90 % pain relief was still sustained. DRGS has applicability in future treatment algorithms for patients with mixed nociceptive and neuropathic groin pain refractory to conservative management.

Management and retrospective analysis of pelvic ramus tumors and tumor-like lesions: Evaluation with 31 cases.

OBJECTIVES: This study aims to investigate the characterization, treatment approaches, and follow-up results of tumors and tumor-like lesions located in the pelvic ramus. PATIENTS AND METHODS: Thirty-one patients (9 males, 22 females; mean age 48.9 years; range, 7 to 79 years) with benign and malignant tumors or tumor-like lesions in the pelvic ramus region treated and followed-up in our clinic between January 2005 and January 2019 were evaluated retrospectively. Surgical procedures were performed with anterior approach or inner-thigh approach. Twelve patients were diagnosed with malignant tumors, 12 patients with benign tumors, and seven patients with tumor-like lesions. RESULTS: Seventeen patients who underwent surgical treatment were followed-up for a mean period of 61.7 months. The diameters of benign and malignant tumors were similar (p=0.425). Of all lesions, 64.5% were located in the pubis. Ischium location was significantly higher in patients with malignant lesions than tumor-like lesions. The most common complication was diffuse subcutaneous edema in the inguinal region and thigh (8.3%). CONCLUSION: There are many different tumoral lesions in the pelvic ramus. Pelvic ramus tumors tend to settle more frequently in pubic ramus, whereas ramus ischium tumors are more likely to be malignant. In addition, the diagnosis of insufficiency fracture should be considered primarily in pathologic fractures of pubic ramus in females over 50 years of age. In the postoperative follow-up of pelvic ramus tumors, diffuse edema may occur even if there is no intraoperative vascular damage.

A new frontier in pelvic fracture pain control in the ED: Successful use of the pericapsular nerve group (PENG) block.

The pericapsular nerve group (PENG) block is a novel ultrasound-guided regional anesthesia technique derived from recent anatomic studies detailing the sensory innervation of the hip. Targeting these terminal sensory branches, the PENG block was originally developed as a potentially more effective block for perioperative hip fracture anesthesia, with the added benefit of preserving motor function. Subsequent research with higher volumes of local anesthetic demonstrated the successful utilization of PENG block for perioperative acetabular fractures. This raises the possibility that the PENG block may have a role in the Emergency Department (ED) where regional anesthesia options for pelvic fractures are lacking. Herein, we present the first description of PENG blocks successfully used for pelvic fractures in the ED setting.

Surgical management of chronic pelvic instability following periacetabular osteotomy nonunion.

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.

Vacuum phenomenon in pelvic fractures.

BACKGROUND: Vacuum phenomenon (VP) in closed pelvic fracture is a rare disorder. This study aimed to examine the prevalence and clinical findings of VP in closed pelvic fracture. METHODS: We retrospectively reviewed 197 patients with closed pelvic fracture who presented to our institution from January 2012 to December 2018. Pelvic fractures were diagnosed by plain radiography and computed tomography (CT). First, we investigated the prevalence and clinical findings of VP in pelvic fractures. Second, we compared the clinical findings between pelvic fracture with and without VP. Finally, VP in pelvic fracture was evaluated clinically and radiologically. RESULTS: VP in pelvic fractures was detected by CT in 9 (3.6%) of the 197 patients with pelvic fractures. Patients with VP had a significantly greater proportion of fracture progression than those without VP (42.9% vs. 11.3%, P = 0.02). Patients with VP had a greater proportion of fragility fractures of the pelvis (FFP), and a lesser proportion of bone union than those without VP, although the differences were not significant. In nine pelvic fractures with VP, all sacral fractures were classified as type 1 according to the Denis classification, and all pubic fractures were classified as type 1 according to the Nakatani classification. Two (22.2%) nonunion in nine pelvic fractures with VP occurred at the pubic fracture site alone. CONCLUSIONS: Orthopedic clinicians should be aware of the potential of CT for detecting VP in pelvic fractures, especially in the course of FFP progression.

New Concealed-Incision Extrapelvic Approach for Pubic Symphysis Diastasis and Parasymphyseal Fractures: Preliminary Results.

BACKGROUND: The Pfannenstiel approach, which provides good surgical exposure, has been used for the treatment of pubic symphysis diastasis and parasymphyseal fractures. However, it requires a medium-length incision and moderate soft-tissue dissection, resulting in potential damage to anatomical structures and inferior aesthetic outcomes. Here, we introduce a new concealed-incision extrapelvic approach for the internal fixation of pubic symphysis diastasis and parasymphyseal fractures. METHODS: We retrospectively reviewed the records of 8 patients with pubic symphysis diastasis and parasymphyseal fractures that had been treated via the concealed-incision extrapelvic approach (the "Fu-Liu" approach). All patients presented for treatment during the period from January 2017 to November 2017. Six of the 8 patients had anterior column fractures, 1 patient had a double-column fracture, and 1 patient had parasymphyseal fractures. Operative time, the amount of blood loss, and postoperative radiographic and computed tomography (CT) findings were recorded. The degree of fracture-healing, complications, function, and satisfaction with the skin incisions were also evaluated. RESULTS: All patients were followed for at least 21 months (range, 21 to 30 months). Postoperative radiographs and CT scans showed good positioning of plates and screws. The average time before surgery, operative time, and intraoperative blood loss (and standard deviation) were 7.8 ± 3.25 days, 41.9 ± 8.99 minutes, and 18.8 ± 7.8 mL, respectively. No complications (including internal fixation failure, vascular injury, nerve palsy, wound infection, and hernia) occurred in any of the patients, and all patients were satisfied with the appearance of the scar. CONCLUSIONS: We can effectively stabilize pubic symphysis diastasis and parasymphyseal fractures with use of the Fu-Liu approach, which can also enable retrograde anterior column screw placement. The Fu-Liu approach is simple, safe, and minimally invasive, and the aesthetic outcome is more acceptable than that associated with the Pfannenstiel approach. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.