This is the first reported case of the completely endoscopic management of osteitis pubis with pubic symphysectomy. A 31-year-old woman suffered from recalcitrant osteitis pubis that had progressed to an end-stage auto-fused condition. Ossified pubic symphyseal fibrocartilage and adjacent heterotopic bone were endoscopically removed as part of a comprehensive surgery that also involved bilateral arthroscopic surgery for symptomatic femoroacetabular impingement. An innovative dual-portal (anterior and supra-pubic) endoscopic technique is presented along with the rationale for the preservation of the inferior (arcuate) pubic ligament and the posterior pubic ligament. Twelve months following this single-stage surgery, the patient reported high satisfaction with decreased pain, improved function, and resolution of a classic waddling gait. The association of intra-articular hip pathology with osteitis pubis is noted. We believe that this minimally invasive bone-conserving surgery may be useful in the management of recalcitrant osteitis pubis and perhaps find broader application in the outpatient endoscopic treatment of athletes afflicted with this condition.
Osteitis pubis is an inflammatory condition of the pubic symphysis first described in the urologic literature in 19241 and since shown to have multiple etiologies. Athletic patients, postpartum women,2,3 and patients who have undergone various urologic, gynecologic, or general surgical procedures1,4-9 may present with osteitis pubis. Many experts consider osteitis pubis to be one of a constellation of pathologic conditions called athletic pubalgia,10-14 also known as sportman’s hernia, none of which actually involve a classic hernia. A detailed discussion of athletic pubalgia is beyond the scope of this article. As more is learned about these conditions, it appears that there may be a causative relationship between the musculotendinous structures attaching to the pubic bone and symphysis, with perhaps an imbalance between those inserting above (eg, rectus abdominis) and originating below (eg, adductors).15 Moreover, there may be a significant association and interplay between pathologic conditions of the hip and those of the more central pelvis.
The pain, disability, and classic waddling gait seen in osteitis pubis typically resolve with conservative treatment. Most current regimens include some combination of rest, modified activity, nonsteroidal anti-inflammatory drugs (NSAIDs) and/or analgesics, physiotherapy (more recently aimed at the aforementioned musculotendinous imbalance), and corticosteroid injections.16-18 For recalcitrant cases, various bone-stabilizing (eg, arthrodesis), bone- and symphyseal-resecting (eg, wedge resection or curettage), or mesh augmentation surgeries have been described.19-23 This article presents a case of a patient with symptomatic bilateral femoroacetabular impingement and recalcitrant osteitis pubis.
An otherwise healthy 31-year-old woman presented with painful central and bilateral groin pain. Her central groin pain began soon after the birth of her first child 7 years prior. Her left and right groin pain began subsequently without any history of traumatic onset. She had tried conservative measures consisting of rest, physical therapy, NSAIDs, and pubic symphyseal corticosteroid injections, all without any significant or lasting benefit.
Relevant physical findings included an obvious waddling gait, tenderness to palpation over the pubic symphysis without tenderness over the rectus abdominis, adductors muscle group, or sacroiliac joints. She reported no pain with resisted adduction of her hips. She had positive anterior impingement tests, and testing of each hip with flexion/abduction/external rotation maneuvers elicited groin pain (presumably from intra-articular hip pathology), but no pain in either sacroiliac joint.
Radiographs showed subtle bilateral coxa profunda along with decreased anterior offset of her proximal femora consistent with bilateral cam-pincer femoroacetabular impingement with normal joint spaces. The pubic symphysis was calcified and a prominent superior bone spur was visualized on preoperative radiographs (Figure 1). Preoperative hip magnetic resonance arthrography showed bilateral anterosuperior labral tears and subtle anterior cam lesions, whereas suboptimal views of the pubic symphysis showed narrowing and irregularity of bony margins without periarticular edema. Preoperative computed tomography scans showed more dramatic pubic symphyseal narrowing with partial obliteration of the joint space, irregularity of the bony margins, and a posterosuperior osteophyte.
Figure 1: Preoperative supine AP pelvis radiograph showing the pubic symphysis with marginal sclerosis, regional ossification, and superior bone spur (arrow) and bilateral hips showing mild coxa profunda without appreciable joint space narrowing. The decreased anterior offset visualized on lateral views and MRA of both hips is not appreciated on this AP view.
The patient underwent initial arthroscopic surgery for her most symptomatic right hip in 2006, including arthroscopic femoral head-neck resection osteoplasty; we did not begin performing acetabular rim reductions until early 2007. She had persistent pain in both hips and the pubic symphyseal region (her most severe pain), and after 26 months of conservative postoperative management, we performed arthroscopic femoroacetabular impingement surgery, which included bilateral rim trimmings with labral preservation and femoral head-neck resection osteoplasties (revision on the right hip), followed immediately by endoscopic pubic symphysectomy and resection of the aforementioned bone spur.
Although the arthroscopic management of the concurrent femoroacetabular impingement was the bulk and first stage of this single operative session, the endoscopic management of the central pelvis is the focus of this case report.
After sterile shaving and skin preparation, we performed outpatient dual-portal endoscopic surgery in the supine lithotomy position on the fracture table used for the preceding arthroscopic femoroacetabular impingement surgical procedures. Although not normally used in our arthroscopic femoroacetabular impingement cases, we intentionally used a urethral catheter, not only because of the longer anticipated operative time needed for all of these procedures, but also to decompress the bladder so as to minimize intrusion into the operative field and possible iatrogenic damage. Two midline portals were made, one 2 cm proximal to the palpable superior border of the pubic symphysis (suprapubic portal), and one directly anterior to the mid-level of the pubic symphysis (anterior portal). A 30° arthroscope and fluid pump were used with careful attention to maintaining pump pressures below 90 mm Hg with hypotensive general anesthesia.
The anterior and superior aspects of the pubic symphysis were endoscopically visualized after initial removal of overlying veil of bursal tissue. The symphyseal fibrocartilage was ossified in the anterior and superior regions, and there was no inducible motion at the pubis symphysis, confirming an autofused stage. The ossified fibrocartilage and the superior heterotopic bone spur were cleared of overlying soft tissue using a radiofrequency probe and shaver.
Once well visualized (Figure 2), resection of the superior bone spur was performed with a 5.5-mm round burr under endoscopic visualization without incident (Figure 3). After demarcating the area of planned resection on the anterior surface of the pubic symphysis with the radiofrequency probe, pubic symphysectomy was performed from anterior to posterior under endoscopic visualization with intermittent fluoroscopic guidance. The resection was somewhat wider anterior than posterior. We removed all of the osseous tissue that had bridged the pubic symphysis and then intentionally resected all of the ligamentous tissue around the pubic symphysis except the deep (posterior) and thick arcuate (inferior) ligaments (Figure 4). We were able to visualize micromotion at the pubic symphysis after the aforementioned procedure. All instruments and the urethral catheter were then atraumatically removed and routine portal closures were performed.
Figure 2: Intraoperative endoscopic view from the inferior pubic portal of the anterior aspect of the pubic symphysis showing its superior border (black arrow) and a large heterotopic bone exostosis (red arrow). The estimated margins (black lines) of the original pubis symphysis fibrocartilage were added with Photoshop (Adobe, San Jose, California) for illustrative purposes.
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Figure 3: Intraoperative endoscopic view showing the initial anterior resection trough made with a 5.5-mm round bur. The 30° arthroscope is in the superior pubic portal on this supine patient (lithotomy position). The superior bone exostosis has been resected. The symphyseal fibrocartilage (blue arrow) is seen. Figure 4: Intraoperative endoscopic view from the anterior pubic portal after resection of bone spur, ossified pubic symphyseal tissue, and medial aspects of adjacent pubic bones. Note the retention of the important inferior arcuate (yellow arrow) as well as posterior ligaments (blue arrow).
This surgery was performed on an outpatient basis. The patient had some noticeable soft tissue swelling near the mons pubis and some vaginal numbness, both which resolved within 3 weeks. As per our postoperative protocol for arthroscopic femoroacetabular impingement surgery, she complied with protected weight bearing with crutches for 2 weeks and an anti-inflammatory medication (to minimize heterotopic ossification as well as possible deep venous thrombosis prophylaxis) for 4 weeks.
She reported noticeable improvement of pain over the central groin at 1-week follow-up and reported no sacroiliac pain. Radiographs obtained 10 months postoperatively showed no detectable regrowth of heterotopic bone or ossification of the intervening space between the pubic bones (Figure 5). Vertical symphyseal excursion of 3 mm was seen on a flamingo view radiograph while standing on the left leg (Figure 6); there was no appreciable vertical translation when standing on the right leg. At 12-month follow-up, her central groin pain had improved from a maximum of 9/10 preoperative intensity to an occasional 3/10 with most periods being painless. She had no pubic deformity, swelling or tenderness to palpation, and has no tenderness at either sacroiliac joint. The waddling gait has completely resolved, and she is pleased with this short-term outcome.
Figure 5: Postoperative standing AP pelvis radiograph showing a radiolucent pubic symphyseal region (absence of previous ossified appearance and heterotopic bone spur) and no vertical translation of pubic symphysis (yellow arrow). Also note the postoperative bilateral acetabular rim reductions (red arrows), some heterotopic bone proximal to the right hip, and femoral osteoplastic recontouring of the proximal femora. Figure 6: Postoperative flamingo views standing on left leg. Notice the 3-mm vertical translation (blue arrows) seen that was not detectable on right leg flamingo views.
Our review of the literature (PUBMED and OVID) revealed multiple open procedures in the treatment of recalcitrant osteitis pubis and an endoscopic extraperitoneal insertioplasty using a mesh graft. We believe this to be the first documented instance of the endoscopic pubic symphysectomy for recalcitrant osteitis pubis.
Currently no consensus exists as to the best operative procedure to treat recalcitrant osteitis pubis. A recent systematic review of mainly evidence-level 4 studies was unable to determine whether curettage, mesh, or pubic bone stabilization procedures gave significantly better outcomes with regards to pain relief and functional outcome.24 They found no convincing evidence of one surgical procedure being significantly better than the others in terms of pain relief and functional outcome. In a recent notable study25 that was not included in the aforementioned systematic review, open pubic symphysis curettage was found to provide satisfactory outcomes in athletes that either had recalcitrant osteitis pubis, or simply did not want to wait protracted lengths of time with more conservative measures.25
At 12 months, we are encouraged by this patient’s postoperative clinical improvement and radiographic findings. This patient exhibited 3 mm of symphyseal excursion seen on left standing flamingo view radiographic. A recent study reports up to 5 mm excursion to be physiologic, especially in multiparous women such as this patient.26 Late development of posterior pelvic instability manifesting itself with sacroiliac pain has been reported, sometimes occurring up to 20 years after open wedge resection of the pubic symphysis.27,28 Long-term follow-up is indicated to determine if this complication will develop in this patient.
Our patient with presumed end-stage osteitis pubis had progressed to essentially an autofused state. It is interesting that she had more pain over time rather than less. Surgical arthrodesis of the pubic symphysis has been described as a therapeutic option for osteitis pubis,19 whereas surgical resection of an autofused pubic symphysis, as described in our case report, has given at least short-term significant symptomatic improvement.
The pubic symphysis is a non-synovial secondary articulation consisting of a thin layer of hyaline cartilage on each of the adjacent pubic bones and an interpubic disk composed of fibrocartilage, thicker in women than in men. A central thin cavity exists that is larger in women, especially during pregnancy. We were able to visualize a vertical cleft in this patient’s interpubic disk once the superior and anterior ossified tissues were removed. The prominent posterosuperior exostosis seen on preoperative radiographs was verified on endoscopic examination. It is conceivable that a herniation of the interpubic disk may have occurred, perhaps aided by the effects of relaxin, temporally and spatially related to the onset of this patient’s symptoms during the normal spontaneous delivery of her first child. A progressive ossific metaplasia of these tissues may have produced the large bone spur, which was endoscopically removed.
The original open wedge resection procedure and more recent limited bone resection procedures such as curettage have emphasized the importance of retaining the thick inferior arcuate pubic ligament.28 Although most of the standing weight-bearing forces are transmitted through the femorosacral arch, the anterior tie arch is considered an important ancillary support. The inferior (arcuate) pubic ligament was preserved with our endoscopic resection (Figure 4). Moreover, we preserved the posterior ligament, not only to minimize any further compromise to pelvic stability, but to prevent any potential iatrogenic damage to anatomic structures at risk, such as the urethra and bladder.
Although resection of most of the superior pubic ligament and some of the decussating tendinous fibers of the rectus abdominis and external obliques was performed, there was no appreciable detachment of the pectineus, adductor longus and brevis, or gracilis origins.
That this patient had both femoroacetabular impingement (bilateral) and osteitis pubis is anecdotal evidence of a possible connection between more peripheral hip and central groin pathology. At most, we can say that an association without any proven causal relationship may exist. Meyers et al15 reported a 27% overlap of hip labral tears and athletic pubalgia in hockey players and commented that “this co-occurrence of pathology should not be too surprising considering the proximity of the hip and pubic joints as well as the interplay of musculoskeletal structures that probably serve both joints.”
Further investigation is merited as early detection of at-risk patients and/or preventative measures may prove beneficial. Moreover, if a causative relationship is established, surgical management of femoroacetabular impingement may positively impact the incidence and/or progression of athletic pubalgia. Historically, orthopedic surgeons have typically managed hip pathology but often referred patients with more central groin pathology to general surgeons specializing in the management of athletic pubalgia. A trend towards the management of these conditions by orthopedic surgeons is occurring as our knowledge and awareness of these conditions expands.
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- Paajanen H, Syvahuoko I, Airo I. Totally extraperitoneal endoscopic (TEP) treatment of sportsman’s hernia. Surg Laparosc Endosc Percutan Tech. 2004; 14(4):215-218.
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Dr Matsuda is from the Department of Orthopedics, Southern California Permanente Medical Group, Los Angeles, California.
Dr Matsuda has no relevant financial relationships to disclose.
Correspondence should be addressed to: Dean K. Matsuda, MD, Department of Orthopedics, Southern California Permanente Medical Group, 6041 Cadillac Ave, Los Angeles, CA 90034 (firstname.lastname@example.org).