PROGRESS IN TREATMENT OF PUBIC SYMPHYSIS DIASTASIS_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

MAKunlong ¹ ^# , ZHULei ² ^Δ ,  FANGYue ¹

1. Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;
2. Department of Anatomy, College of Basic and Forensic Medicine, Sichuan University;

Corresponding author：

FANGYue, Email: fangyue1968@163.com

Keywords：

Pubic symphysis diastasis; External fixator; Plate; Cannulated screw; Biomechanics

DOI：

10.7507/1002-1892.20140054

Video：

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Objective To summarize the progress in treatment of pubic symphysis diastasis. Methods Related literature concerning treatment of pubic symphysis diastasis was extensively reviewed and comprehensively analyzed in terms of anatomy, biomechanics, and treatment. Results There are many fixation methods for treatment of pubic symphysis diastasis, which aims at restoring the stability of the anterior pelvic ring. External fixator is often used as a temporary fixation; tension band wire has been abandoned due to its poor biomechanical stability; screw loosening and plate breakage often appears when a single reconstruction plate is used; box plate significantly increases the biomechanical stability of anterior pelvic ring but it leads to a considerable surgical trauma; locking plate has been used for pubic symphysis diastasis recently, especially for osteoporotic fractures; percutaneous cannulated screw has the advantages of less trauma, less bleeding, and good stability, so it is good choice for treatment of pubic symphysis diastasis. Conclusion There is no uniform standards about the treatment of pubic symphysis diastasis, but the minimally invasive treatment is an undeniable trend. Percutaneous cannulated screw has achieved satisfactory effectiveness, however, its biomechanical stability and anatomic channels need to be further studied.

Citation： MAKunlong, ZHULei, FANGYue. PROGRESS IN TREATMENT OF PUBIC SYMPHYSIS DIASTASIS. Chinese Journal of Reparative and Reconstructive Surgery, 2014, 28(2): 250-254. doi: 10.7507/1002-1892.20140054 Copy

1.	Rommens PM,Hessmann MH.Staged reconstruction of pelvic ring disruption:differences in morbidity,mortality,radiologic results,and functional outcomes between B1,B2/B3,and C-type lesions.J Orthop Trauma,2002,16(2):92-98.
2.	Ertel W,Keel M,Eid K,et al.Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption.J Orthop Trauma,2001,15(7):468-474.
3.	Brandes S,Borrelli J Jr.Pelvic fracture and associated urologic injuries.World J Surg,2001,25(12):1578-1587.
4.	Pohlemann,Boseh U,Tseheme A,et al.The Hannover experience in management of pelvic fractures.Clin Orthop Relat Res,1994,(305):69-80.
5.	刘洋,陈方舟,梅红军,等.静止站立位正常骨盆的生物力学研究.临床医学工程,2010,17(6):7-11.
6.	李明辉,刘洋,张红旗.不同部位骨盆骨静态弹性模量及其相关生物力学性质的测定.生物医学工程研究,2012,31(2):95-98.
7.	Meissner A,Fell M,Wilk R,et al.Biomechanics of the pubic symphysis.Which forces lead to mobility of the symphysis in physiological conditions? Unfallchirurg,1996,99(6):415-421.
8.	Pohlemann T,Angst M,Schneider E,et al.Fixation of transforaminal sacrum fractures:a biomechanical study.J Orthop Trauma,1993,7(2):107-117.
9.	Tile M.Pelvic ring fractures:should they be fixed? J Bone Joint Surg (Br),1988,70(1):1-12.
10.	Guyton JL,Perez EA.Fractures of acetabulum and pelvis//Campbell's Operative Orthopaedics.11th ed.Philadelphia:Elsevier's Health Sciences,2007:3334-3338.
11.	Scaglione M,Parchi P,Digrandi G,et al.External fixation in pelvic fractures.Musculoskeletal Surg,2010,94(2):63-70.
12.	Giannoudis PV,Pape HC.Damage control orthopaedics in unstable pelvic ring injuries.Injury,2004,35(7):671-677.
13.	Bircher MD.Indications and techniques of external fixation of the injured pelvis.Injury,1996,27 Suppl 2:B3-19.
14.	Solomon LB,Pohl AP,Chehade MJ,et al.Surgical anatomy for pelvic external fixation.Clin Anat,2008,21(7):674-682.
15.	Kim WY,Hearn TC,Seleem O,et al.Effect of pin location on stability of pelvic external fixation.Clin Orthop Relat Res,1999,(361):237-244.
16.	Gardner MJ,Nork SE.Stabilization of unstable pelvic fractures with supraacetabular compression external fixation.J Orthop Trauma,2007,21(4):269-273.
17.	Solomon LB,Pohl AP,Sukthankar A,et al.The subcristal pelvic external fixator:technique,results,and rationale.J Orthop Trauma,2009,23(5):365-369.
18.	Ponsen K,Joosse P,Van Dijke GA,et al.External fixation of the pelvic ring:an experimental study on the role of pin diameter,pin position,and parasymphyseal fixator pins.Acta Orthop,2007,78(5):648-653.
19.	张建新,徐展望,贾连顺,等.骨盆外固定支架治疗骨盆骨折.中国矫形外科杂志,2005,13(2):105-108.
20.	Routt ML Jr,Falicov A,Woodhouse E,et al.Circumferential pelvic antishock sheeting:a temporary resuscitation aid.J Orthop Trauma,2002,16(1):45-48.
21.	Varga E,Hearn T,Powell J,et al.Effects of method of internal fixation of symphyseal disruptions on stability of the pelvic ring.Injury,1995,26(2):75-80.
22.	Bottlang M,Krieg JC,Mohr M,et al.Emergent management of pelvic ring fractures with use of circumferential compression.J Bone Joint Surg (Am),2002,84-A Suppl 2:S43-47.
23.	Webb LX,Bosse MJ,Mayo KA,et al.Results in patients with craniocerebral trauma and an operatively managed acetabular fracture.J Orthop Trauma,1990,4(4):376-382.
24.	Lange RH,Hansen ST Jr.Pelvic ring disruptions with symphysis pubis diastasis:indications,technique,and limitations of anterior internal fixation.Clin Orthop Relat Res,1985,(201):130-137.
25.	Tornetta P 3rd,Dickson K,Matta JM.Outcome of rotationally unstable pelvic ring injuries treated operatively.Clin Orthop Relat Res,1996,(329):147-151.
26.	Sagi HC,Papp S.Comparative radiographic and clinical outcome of two-hole and multi-hole symphyseal plating.J Orthop Trauma,2008,22(6):373-378.
27.	Simonian PT,Routt ML Jr,Harrington RM,et al.Box plate fixation of the symphysis pubis:biomechanical evaluation of a new technique.J Orthop Trauma,1994,8(6):483-489.
28.	陈兵乾,杜伟中,薛峰,等.双钛板系统治疗创伤性耻骨联合分离.临床骨科杂志,2010,13(5):551-553.
29.	MacAvoy MC,McClellan RT,Goodman SB,et al.Stability of open-book pelvic fractures using a new biomechanical model of single-limb stance.J Orthop Trauma,1997,11(8):590-593.
30.	van den Bosch EW,van Zwienen CM,Hoek van Dijke GA,et al.Sacroiliac screw fixation for tile B fractures.J Trauma,2003,55(5):962-965.
31.	Tile M,Helfet D,Kellam J.Management of pelvic ring injuries//Smith WR,Ziran BH,Morgan SJ.Fractures of the pelvis and acetabulum.3rd ed.Philadelphia:Lippincott Williams&Wilkins,2003:168-202.
32.	Giannoudis PV,Chalidis BE,Roberts CS.Internal fixation of traumatic diastasis of pubic symphysis:is plate removal essential? Arch Orthop Trauma Surg,2008,128(3):325-331.
33.	Spagnolo R,Pace F,Bonalumi M,et al.Anterior pelvic ring fractures:a proposal of a variant of osteosynthesis of the pubic symphysis.European Journal of Orthopaedic Surgery&Traumatology,2011,21(1):33-37.
34.	Strauss EJ,Schwarzkopf R,Kummer F,et al.The current status of locked plating:the good,the bad,and the ugly.J Orthop Trauma,2008,22(7):479-486.
35.	Tan SL,Balogh ZJ.Indications and limitations of locked plating.Injury,2009,40(7):683-691.
36.	Lujan TJ,Henderson CE,Madey SM,et al.Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation.J Orthop Trauma,2010,24(3):156-162.
37.	Hamad A,Pavlou G,Dwyer J,et al.Management of pubic symphysis diastasis with locking plates:a report of 11 cases.Injury,2013,44(7):947-951.
38.	李连欣,王晓梅,周东生,等.锁定钢板治疗创伤性耻骨联合分离17例.中华创伤杂志,2011,27(6):545-547.
39.	Moed BR,Grimshaw CS,Segina DN.Failure of locked design-specific plate fixation of the pubic symphysis:a report of six cases.J Orthop Trauma,2012,26(7):e71-75.
40.	Micic ID,Kim KC,Shin DJ,et al.Analysis of early failure of the locking compression plate in osteoporotic proximal humerus fractures.J Orthop Sci,2009,14(5):596-601.
41.	Grimshaw CS,Bledsoe JG,Moed BR.Locked versus standard unlocked plating of the pubic symphysis:a cadaver biomechanical study.J Orthop Trauma,2012,26(7):402-406.
42.	Prasarn ML,Zych G,Gaski G,et al.Biomechanical study of 4-hole pubic symphyseal plating:locked versus unlocked constructs.Orthopedics,2012,35(7):e1028-1032.
43.	Pizanis A,Garcia P,Santelmann M,et al.Reduction and fixation capabilities of different plate designs for pubic symphysis disruption:a biomechanical comparison.Injury,2013,44(2):183-188.
44.	周建明,章银灿,石高才,等.耻骨联合分离的治疗策略.中国骨伤,2008,21(1):58-59.
45.	Routt ML Jr,Simonian PT,Grujic L.The retrograde medullary superior pubic ramus screw for the treatment of anterior pelvic ring disruption:a new technique.J Orthop Trauma,1995,9(1):35-44.
46.	余可和,洪建军,陈临炜,等.空心螺钉与重建钢板固定耻骨联合分离的生物力学稳定性比较.医用生物力学,2010,25(6):475-478.
47.	石成弟,郭晓山,胡炜,等.经皮空心钉固定治疗创伤性耻骨联合分离.中华骨科杂志,2011,31(11):1218-1222.
48.	郭晓山,池永龙.经皮闭合内固定治疗骨盆环损伤.中华外科杂志,2006,44(4):260-263.
49.	唐广满,水小龙,戴志兵,等.空心拉力螺钉与重建钢板治疗耻骨联合分离的疗效比较.创伤外科杂志,2011,13(6):515-519.
50.	黄高,王金华,张军,等.经皮复位螺钉固定与切开复位内固定治疗耻骨联合分离的疗效比较.创伤外科杂志,2013,15(1):36-40.
51.	Chen L,Zhang G,Song D,et al.A comparison of percutaneous reduction and screw fixation versus open reduction and plate fixation of traumatic symphysis pubis diastasis.Arch Orthop Trauma Surg,2012,132(2):265-270.
52.	Mu WD,Wang H,Zhou DS,et al.Computer navigated percutaneous screw fixation for traumatic pubic symphysis diastasis of unstable pevic ring injuries.Chin Med J (Engl),2009,122(14):1699-1703.
53.	Cano-Luis P,Giráldez-Sanchez MA,Martínez-Reina J,et al.Biomechanical analysis of a new minimally invasive system for osteosynthesis of pubis symphysis disruption.Injury,2012,43 Suppl 2:S20-S27.

1. Rommens PM,Hessmann MH.Staged reconstruction of pelvic ring disruption:differences in morbidity,mortality,radiologic results,and functional outcomes between B1,B2/B3,and C-type lesions.J Orthop Trauma,2002,16(2):92-98.
2. Ertel W,Keel M,Eid K,et al.Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption.J Orthop Trauma,2001,15(7):468-474.
3. Brandes S,Borrelli J Jr.Pelvic fracture and associated urologic injuries.World J Surg,2001,25(12):1578-1587.
4. Pohlemann,Boseh U,Tseheme A,et al.The Hannover experience in management of pelvic fractures.Clin Orthop Relat Res,1994,(305):69-80.
5. 刘洋,陈方舟,梅红军,等.静止站立位正常骨盆的生物力学研究.临床医学工程,2010,17(6):7-11.
6. 李明辉,刘洋,张红旗.不同部位骨盆骨静态弹性模量及其相关生物力学性质的测定.生物医学工程研究,2012,31(2):95-98.
7. Meissner A,Fell M,Wilk R,et al.Biomechanics of the pubic symphysis.Which forces lead to mobility of the symphysis in physiological conditions? Unfallchirurg,1996,99(6):415-421.
8. Pohlemann T,Angst M,Schneider E,et al.Fixation of transforaminal sacrum fractures:a biomechanical study.J Orthop Trauma,1993,7(2):107-117.
9. Tile M.Pelvic ring fractures:should they be fixed? J Bone Joint Surg (Br),1988,70(1):1-12.
10. Guyton JL,Perez EA.Fractures of acetabulum and pelvis//Campbell's Operative Orthopaedics.11th ed.Philadelphia:Elsevier's Health Sciences,2007:3334-3338.
11. Scaglione M,Parchi P,Digrandi G,et al.External fixation in pelvic fractures.Musculoskeletal Surg,2010,94(2):63-70.
12. Giannoudis PV,Pape HC.Damage control orthopaedics in unstable pelvic ring injuries.Injury,2004,35(7):671-677.
13. Bircher MD.Indications and techniques of external fixation of the injured pelvis.Injury,1996,27 Suppl 2:B3-19.
14. Solomon LB,Pohl AP,Chehade MJ,et al.Surgical anatomy for pelvic external fixation.Clin Anat,2008,21(7):674-682.
15. Kim WY,Hearn TC,Seleem O,et al.Effect of pin location on stability of pelvic external fixation.Clin Orthop Relat Res,1999,(361):237-244.
16. Gardner MJ,Nork SE.Stabilization of unstable pelvic fractures with supraacetabular compression external fixation.J Orthop Trauma,2007,21(4):269-273.
17. Solomon LB,Pohl AP,Sukthankar A,et al.The subcristal pelvic external fixator:technique,results,and rationale.J Orthop Trauma,2009,23(5):365-369.
18. Ponsen K,Joosse P,Van Dijke GA,et al.External fixation of the pelvic ring:an experimental study on the role of pin diameter,pin position,and parasymphyseal fixator pins.Acta Orthop,2007,78(5):648-653.
19. 张建新,徐展望,贾连顺,等.骨盆外固定支架治疗骨盆骨折.中国矫形外科杂志,2005,13(2):105-108.
20. Routt ML Jr,Falicov A,Woodhouse E,et al.Circumferential pelvic antishock sheeting:a temporary resuscitation aid.J Orthop Trauma,2002,16(1):45-48.
21. Varga E,Hearn T,Powell J,et al.Effects of method of internal fixation of symphyseal disruptions on stability of the pelvic ring.Injury,1995,26(2):75-80.
22. Bottlang M,Krieg JC,Mohr M,et al.Emergent management of pelvic ring fractures with use of circumferential compression.J Bone Joint Surg (Am),2002,84-A Suppl 2:S43-47.
23. Webb LX,Bosse MJ,Mayo KA,et al.Results in patients with craniocerebral trauma and an operatively managed acetabular fracture.J Orthop Trauma,1990,4(4):376-382.
24. Lange RH,Hansen ST Jr.Pelvic ring disruptions with symphysis pubis diastasis:indications,technique,and limitations of anterior internal fixation.Clin Orthop Relat Res,1985,(201):130-137.
25. Tornetta P 3rd,Dickson K,Matta JM.Outcome of rotationally unstable pelvic ring injuries treated operatively.Clin Orthop Relat Res,1996,(329):147-151.
26. Sagi HC,Papp S.Comparative radiographic and clinical outcome of two-hole and multi-hole symphyseal plating.J Orthop Trauma,2008,22(6):373-378.
27. Simonian PT,Routt ML Jr,Harrington RM,et al.Box plate fixation of the symphysis pubis:biomechanical evaluation of a new technique.J Orthop Trauma,1994,8(6):483-489.
28. 陈兵乾,杜伟中,薛峰,等.双钛板系统治疗创伤性耻骨联合分离.临床骨科杂志,2010,13(5):551-553.
29. MacAvoy MC,McClellan RT,Goodman SB,et al.Stability of open-book pelvic fractures using a new biomechanical model of single-limb stance.J Orthop Trauma,1997,11(8):590-593.
30. van den Bosch EW,van Zwienen CM,Hoek van Dijke GA,et al.Sacroiliac screw fixation for tile B fractures.J Trauma,2003,55(5):962-965.
31. Tile M,Helfet D,Kellam J.Management of pelvic ring injuries//Smith WR,Ziran BH,Morgan SJ.Fractures of the pelvis and acetabulum.3rd ed.Philadelphia:Lippincott Williams&Wilkins,2003:168-202.
32. Giannoudis PV,Chalidis BE,Roberts CS.Internal fixation of traumatic diastasis of pubic symphysis:is plate removal essential? Arch Orthop Trauma Surg,2008,128(3):325-331.
33. Spagnolo R,Pace F,Bonalumi M,et al.Anterior pelvic ring fractures:a proposal of a variant of osteosynthesis of the pubic symphysis.European Journal of Orthopaedic Surgery&Traumatology,2011,21(1):33-37.
34. Strauss EJ,Schwarzkopf R,Kummer F,et al.The current status of locked plating:the good,the bad,and the ugly.J Orthop Trauma,2008,22(7):479-486.
35. Tan SL,Balogh ZJ.Indications and limitations of locked plating.Injury,2009,40(7):683-691.
36. Lujan TJ,Henderson CE,Madey SM,et al.Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation.J Orthop Trauma,2010,24(3):156-162.
37. Hamad A,Pavlou G,Dwyer J,et al.Management of pubic symphysis diastasis with locking plates:a report of 11 cases.Injury,2013,44(7):947-951.
38. 李连欣,王晓梅,周东生,等.锁定钢板治疗创伤性耻骨联合分离17例.中华创伤杂志,2011,27(6):545-547.
39. Moed BR,Grimshaw CS,Segina DN.Failure of locked design-specific plate fixation of the pubic symphysis:a report of six cases.J Orthop Trauma,2012,26(7):e71-75.
40. Micic ID,Kim KC,Shin DJ,et al.Analysis of early failure of the locking compression plate in osteoporotic proximal humerus fractures.J Orthop Sci,2009,14(5):596-601.
41. Grimshaw CS,Bledsoe JG,Moed BR.Locked versus standard unlocked plating of the pubic symphysis:a cadaver biomechanical study.J Orthop Trauma,2012,26(7):402-406.
42. Prasarn ML,Zych G,Gaski G,et al.Biomechanical study of 4-hole pubic symphyseal plating:locked versus unlocked constructs.Orthopedics,2012,35(7):e1028-1032.
43. Pizanis A,Garcia P,Santelmann M,et al.Reduction and fixation capabilities of different plate designs for pubic symphysis disruption:a biomechanical comparison.Injury,2013,44(2):183-188.
44. 周建明,章银灿,石高才,等.耻骨联合分离的治疗策略.中国骨伤,2008,21(1):58-59.
45. Routt ML Jr,Simonian PT,Grujic L.The retrograde medullary superior pubic ramus screw for the treatment of anterior pelvic ring disruption:a new technique.J Orthop Trauma,1995,9(1):35-44.
46. 余可和,洪建军,陈临炜,等.空心螺钉与重建钢板固定耻骨联合分离的生物力学稳定性比较.医用生物力学,2010,25(6):475-478.
47. 石成弟,郭晓山,胡炜,等.经皮空心钉固定治疗创伤性耻骨联合分离.中华骨科杂志,2011,31(11):1218-1222.
48. 郭晓山,池永龙.经皮闭合内固定治疗骨盆环损伤.中华外科杂志,2006,44(4):260-263.
49. 唐广满,水小龙,戴志兵,等.空心拉力螺钉与重建钢板治疗耻骨联合分离的疗效比较.创伤外科杂志,2011,13(6):515-519.
50. 黄高,王金华,张军,等.经皮复位螺钉固定与切开复位内固定治疗耻骨联合分离的疗效比较.创伤外科杂志,2013,15(1):36-40.
51. Chen L,Zhang G,Song D,et al.A comparison of percutaneous reduction and screw fixation versus open reduction and plate fixation of traumatic symphysis pubis diastasis.Arch Orthop Trauma Surg,2012,132(2):265-270.
52. Mu WD,Wang H,Zhou DS,et al.Computer navigated percutaneous screw fixation for traumatic pubic symphysis diastasis of unstable pevic ring injuries.Chin Med J (Engl),2009,122(14):1699-1703.
53. Cano-Luis P,Giráldez-Sanchez MA,Martínez-Reina J,et al.Biomechanical analysis of a new minimally invasive system for osteosynthesis of pubis symphysis disruption.Injury,2012,43 Suppl 2:S20-S27.

Chinese Journal of Reparative and Reconstructive Surgery

PROGRESS IN TREATMENT OF PUBIC SYMPHYSIS DIASTASIS

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