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.	劉洋,陳方舟,梅紅軍,等.靜止站立位正常骨盆的生物力學研究.臨床醫學工程,2010,17(6):7-11.
6.	李明輝,劉洋,張紅旗.不同部位骨盆骨靜態彈性模量及其相關生物力學性質的測定.生物醫學工程研究,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.	張建新,徐展望,賈連順,等.骨盆外固定支架治療骨盆骨折.中國矯形外科雜志,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.	陳兵乾,杜偉中,薛峰,等.雙鈦板系統治療創傷性恥骨聯合分離.臨床骨科雜志,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.	李連欣,王曉梅,周東生,等.鎖定鋼板治療創傷性恥骨聯合分離17例.中華創傷雜志,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,章銀燦,石高才,等.恥骨聯合分離的治療策略.中國骨傷,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,洪建軍,陳臨煒,等.空心螺釘與重建鋼板固定恥骨聯合分離的生物力學穩定性比較.醫用生物力學,2010,25(6):475-478.
47.	石成弟,郭曉山,胡煒,等.經皮空心釘固定治療創傷性恥骨聯合分離.中華骨科雜志,2011,31(11):1218-1222.
48.	郭曉山,池永龍.經皮閉合內固定治療骨盆環損傷.中華外科雜志,2006,44(4):260-263.
49.	唐廣滿,水小龍,戴志兵,等.空心拉力螺釘與重建鋼板治療恥骨聯合分離的療效比較.創傷外科雜志,2011,13(6):515-519.
50.	黃高,王金華,張軍,等.經皮復位螺釘固定與切開復位內固定治療恥骨聯合分離的療效比較.創傷外科雜志,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. 劉洋,陳方舟,梅紅軍,等.靜止站立位正常骨盆的生物力學研究.臨床醫學工程,2010,17(6):7-11.
6. 李明輝,劉洋,張紅旗.不同部位骨盆骨靜態彈性模量及其相關生物力學性質的測定.生物醫學工程研究,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. 張建新,徐展望,賈連順,等.骨盆外固定支架治療骨盆骨折.中國矯形外科雜志,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. 陳兵乾,杜偉中,薛峰,等.雙鈦板系統治療創傷性恥骨聯合分離.臨床骨科雜志,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. 李連欣,王曉梅,周東生,等.鎖定鋼板治療創傷性恥骨聯合分離17例.中華創傷雜志,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,章銀燦,石高才,等.恥骨聯合分離的治療策略.中國骨傷,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,洪建軍,陳臨煒,等.空心螺釘與重建鋼板固定恥骨聯合分離的生物力學穩定性比較.醫用生物力學,2010,25(6):475-478.
47. 石成弟,郭曉山,胡煒,等.經皮空心釘固定治療創傷性恥骨聯合分離.中華骨科雜志,2011,31(11):1218-1222.
48. 郭曉山,池永龍.經皮閉合內固定治療骨盆環損傷.中華外科雜志,2006,44(4):260-263.
49. 唐廣滿,水小龍,戴志兵,等.空心拉力螺釘與重建鋼板治療恥骨聯合分離的療效比較.創傷外科雜志,2011,13(6):515-519.
50. 黃高,王金華,張軍,等.經皮復位螺釘固定與切開復位內固定治療恥骨聯合分離的療效比較.創傷外科雜志,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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