Endoscopic Pubic Symphysectomy for Recalcitrant Osteitis Pubis

Abstract

Recalcitrant osteitis pubis presents a challenging problem for orthopaedic surgeons. Various surgical interventions have been described for treatment, including opening-wedge resection, symphysiodesis, and curettage. We propose that endoscopic pubic symphysectomy offers an effective method of treating such a challenging problem. This article describes in detail the technique used to perform endoscopic pubic symphysectomy, and a companion video demonstrating the procedure is included. Our experience suggests that removal of the interpubic fibrocartilaginous lamina and resection of approximately 1 cm of bone can successfully eliminate all sources of pain and dysfunction caused by the recalcitrant osteitis pubis.

Rates of sports-related injury to the groin range from 0.5% to 6.2%.¹ Rates of groin pain in specific sports, such as soccer, have been shown to be as high as 8%.² Causes of groin pain in athletes include musculotendinous strains, sports hernias, stress fractures, intra-articular hip pathology, referred low-back pain, genitourinary pathology, and osteitis pubis.³ Osteitis pubis is an inflammatory condition first described in the urologic literature in 1924.⁴ It is generally regarded as a result of overuse and functional anterior instability of the pelvis.^1,5-7 The typical patient history includes gradually worsening unilateral or bilateral discomfort or pain in the pubic area, 1 or both adductor attachment areas, and the area of insertion of the rectus abdominis muscle.^8-11 Physical examination findings include tenderness to palpation of the pubic symphysis and adjacent pubic bodies/rami and pain on resisted adduction of the hip.^5,7,11,12 Radiographs in acute or severe cases may show cystic changes of the margins of the symphysis with widening of the joint. In more chronic cases, there may be sclerosis and joint space narrowing.¹³ Instability of the pubic symphysis may be detected on an anteroposterior radiograph of the pelvis with the patient standing on 1 leg (“flamingo view”).^5,7 Bone scans can show increased uptake in the symphysis pubis region in association with osteitis pubis. Magnetic resonance imaging (MRI) has been shown to be a useful tool in diagnosing osteitis pubis. Verrall et al.¹⁴ found increased signal intensity on MRI in athletes due to pubic bone marrow edema. They concluded that a stress injury to the pubic bone is the most likely explanation for these imaging findings and may be the clinical cause of osteitis pubis.

Nonoperative management has been the mainstay of treatment. This includes physical therapy including core and abdominal musculature strengthening, improvement in range of motion, and activity modification. Nonsteroidal anti-inflammatory drugs are usually prescribed in conjunction with various nonoperative modalities.^8,12 In addition, corticosteroid injection has shown good results for symptom relief; however, it has not been shown to conclusively promote recovery.⁵

Recently, endoscopic pubic symphysectomy has been reported as a surgical alternative for recalcitrant osteitis pubis. In his case report, Matsuda¹⁵ reported improved clinical outcomes at 12 months postoperatively with resolution of waddling gait. We propose that endoscopic pubic symphysectomy with removal of any offending osteophytes can be effectively performed with resolution of symptoms relating to osteitis pubis. This technical note and the accompanying images and video will describe in detail our methods for performing endoscopic pubic symphysectomy.

Surgical Technique

All hip arthroscopies are performed at a tertiary referral center dedicated to hip arthroscopy and preservation. We perform hip arthroscopy with the patient in the modified supine position using a standard traction table in a slight Trendelenburg position to decrease perineal pressure on the post. A urethral catheter is placed for decompression of the bladder.

After standard preparation and draping of the patient, dual-portal endoscopy is performed. Two midline portals are created: A superior pubic portal is created at the superior border of the symphysis, and an anterior pubic portal is created at the inferior border of the pubic symphysis (Fig 1). Under fluoroscopic guidance, a 30° arthroscope is introduced into the anterior portal with the pump pressure set at 60 mm Hg and hypotensive general anesthesia. Initially, all bursal tissue overlying the anterior and superior pubic symphysis is removed using cautery (Fig 2, Video 1). Once the pubic symphysis has been clearly demarcated, a 5-mm round burr (Arthrex, Naples, FL) is used to perform the symphysectomy under direct visualization with removal of all fibrocartilage and bone (Fig 3). The resection is performed with approximately 5 mm of bone taken from either side, creating a 1-cm total resection. All bony resection is performed under fluoroscopic guidance to ensure appropriate bone removal. Care is taken to preserve the deep posterior and inferior arcuate ligaments (Fig 4). Table 1 presents pearls and pitfalls for this procedure.

Fig 1.

Portal placement at midline. (O, anterior pubic portal; X, superior pubic portal.)

Fig 2.

Removal of bursal tissue overlying pubic symphysis with cautery wand.

Fig 3.

Pubic symphysectomy performed with a 5-mm round burr, with articular cartilage (asterisk) and both ends of physeal plate (plus signs) visible.

Fig 4.

Completion of pubic symphysectomy with preservation of deep posterior ligament (asterisk) and inferior arcuate ligament (plus sign).

Table 1.

Pearls and Pitfalls

Pearls

Placement of urethral catheter for decompression of bladder, thereby diminishing risk of bladder injury during symphysectomy

Removal of overlying soft tissue for complete visualization of pubic symphysis

Careful preservation of deep posterior and inferior arcuate ligaments to avoid posterior instability

Regular fluoroscopic imaging to avoid under- or over-resection

Resection of 1 cm to ensure adequate decompression of symphysis

Pitfalls

Over-resection of pubic symphysis

Posterior sacroiliac joint instability

Peripheral nerve dysesthesia/hyperesthesia

Infection

Chronic pain

Discussion

Osteitis pubis remains a challenging problem for patients who do not respond to conservative treatment. Traditionally, surgery has been reserved for recalcitrant cases of osteitis pubis in which conservative treatment has failed.^5,11 Various surgical procedures have been described in the literature, including wedge resection, symphysiodesis, and curettage of the pubic symphysis, with mixed results.^7,10,16 Radic and Annear¹⁷ performed curettage of the pubic symphysis in 23 athletes who presented with osteitis pubis refractory to initial nonoperative therapies. They reported that 21 patients returned to pain-free running at a mean of 3.14 months, with improvement of bone marrow edema on postoperative MRI. More recently, Matsuda¹⁵ published a case report of recalcitrant osteitis pubis treated with endoscopic pubic symphysectomy with a successful outcome at 1 year of follow-up.

This report describes our endoscopic technique for pubic symphysectomy for treatment of recalcitrant osteitis pubis. Care should be taken to avoid the vascular retropubic space of Retzius by preserving the deep posterior ligamentous structures. In addition, the inferior (arcuate) pubic ligaments are maintained for preservation of the pubic arch and avoidance of the urogenital diaphragm fascia. The advantages of this technique are as follows: The surgeon can preserve more of the capsule and ligaments around the pubic symphysis, there is reduced pain after the operation, excellent functional results are provided, and the postoperative recovery time is limited. In our experience with this technique, we have encountered transient postoperative edema of the scrotum in men and the labia in women, which resolved within 24 hours in all cases. Apart from such edema, we have not encountered any complications. Endoscopic pubic symphysectomy is a safe and feasible technique for resection of diseased endplates of the pubic symphysis and may provide a minimally invasive treatment for recalcitrant cases of osteitis pubis.

Supplementary Data

Video 1

Endoscopic pubic symphysectomy with overlying soft-tissue removal with cautery to outline pubic symphysis. A 5-mm round burr is introduced to perform the symphysectomy. After approximately 1 cm of decompression, the symphysectomy is visualized.