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Management outcomes in pubic diastasis: our experience with 19 patients.

Aggarwal S, Bali K, Krishnan V, Kumar V, Meena D, Sen RK - J Orthop Surg Res (2011)

Bottom Line: The radiological outcomes were also similar in these.Complications included implant failure in 3 patients, postoperative infection in 2 patients, deep venous thrombosis in one patient and bladder herniation in one of the patients with implant failure.Limited dissection ensuring adequate intactness of rectus sheath is important to avoid long term post-operative complications.

View Article: PubMed Central - HTML - PubMed

Affiliation: Dept of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh-160 012, India.

ABSTRACT

Background: Pubic diastasis, a result of high energy antero-posterior compression (APC) injury, has been managed based on the Young and Burguess classification system. The mode of fixation in APC II injury has, however, been a subject of controversy and some authors have proposed a need to address the issue of partial breach of the posterior pelvic ring elements in these injuries.

Methods: The study included a total of 19 patients with pubic diastasis managed by us from May 2006 to December 2007. There was a single patient with type I APC injury who treated conservatively. Type II APC injuries (13 patients) were treated surgically with symphyseal plating using single anterior/superior plates or double perpendicularly placed plates. Type III injuries (5 patients) in addition underwent posterior fixation using plates or percutaneous sacro-iliac screws. The outcome was assessed clinically (Majeed score) and radiologically.

Results: The mean follow-up was for 2.9 years (6 months to 4.5 years). Among the 13 patients with APC II injuries, the clinical scores were excellent in one (7.6%), good in 6 (46.15%), fair in 4 (30.76%) and poor in 2 (15.38%). Radiological scores were excellent in 2 (15.38%), good in 8 (61.53%), fair in 2 (15.38%) and poor in one patient (7.6%). Among the 5 patients with APC III injuries, there were 2 patients each with good (50%) and fair (50%) clinical scores while one patient was lost on long term follow up. The radiological outcomes were also similar in these. Complications included implant failure in 3 patients, postoperative infection in 2 patients, deep venous thrombosis in one patient and bladder herniation in one of the patients with implant failure.

Conclusions: There is no observed dissimilarity in outcomes between isolated anterior and combined symphyseal (perpendicular) plating techniques in APC II injuries. Single anterior symphyseal plating along with posterior stabilisation provides a stable fixation in type III APC injuries. Limited dissection ensuring adequate intactness of rectus sheath is important to avoid long term post-operative complications.

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Surgical Approach. Draping of the patient from 2 fingers below the pubis symphysis to 2 fingers superior to the umbilicus and a transverse Pfannenstiel incision (7-12 cms) being used.
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Figure 1: Surgical Approach. Draping of the patient from 2 fingers below the pubis symphysis to 2 fingers superior to the umbilicus and a transverse Pfannenstiel incision (7-12 cms) being used.

Mentions: The draping of the patient was from 2 fingers below the pubis symphysis to 2 fingers superior to the umbilicus. A transverse Pfannensteil incision, typically 7 - 12 cm long, was used exposing the anterior abdominal wall with the strong fascia of rectus muscle (Figure 1). In severe APC injuries, one head of rectus abdominis muscle might be avulsed. Linea alba was divided anteriorly in the midline, with the elevation of abdominis muscle at its insertion laterally. Transverse resection of the rectus abdominis muscle should be avoided (as this would impair further healing and repair of the abdominal wall). The reduction was usually achieved using a pointed reduction forceps or the pelvic reduction clamp (after the insertion of screws) (Figure 2). The fixation was achieved in our cases using an anterior or superior symphyseal plate (3.5 mm Low Contact Dynamic Compression Plates) (Figure 3) or double plating method (3.5 mm Low Contact Dynamic Compression Plates superiorly and a 3.5 mm reconstruction plate anteriorly) (Figure 4). A posterior plate/iliosacral screw was added in cases of Type III APC injuries.


Management outcomes in pubic diastasis: our experience with 19 patients.

Aggarwal S, Bali K, Krishnan V, Kumar V, Meena D, Sen RK - J Orthop Surg Res (2011)

Surgical Approach. Draping of the patient from 2 fingers below the pubis symphysis to 2 fingers superior to the umbilicus and a transverse Pfannenstiel incision (7-12 cms) being used.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3108341&req=5

Figure 1: Surgical Approach. Draping of the patient from 2 fingers below the pubis symphysis to 2 fingers superior to the umbilicus and a transverse Pfannenstiel incision (7-12 cms) being used.
Mentions: The draping of the patient was from 2 fingers below the pubis symphysis to 2 fingers superior to the umbilicus. A transverse Pfannensteil incision, typically 7 - 12 cm long, was used exposing the anterior abdominal wall with the strong fascia of rectus muscle (Figure 1). In severe APC injuries, one head of rectus abdominis muscle might be avulsed. Linea alba was divided anteriorly in the midline, with the elevation of abdominis muscle at its insertion laterally. Transverse resection of the rectus abdominis muscle should be avoided (as this would impair further healing and repair of the abdominal wall). The reduction was usually achieved using a pointed reduction forceps or the pelvic reduction clamp (after the insertion of screws) (Figure 2). The fixation was achieved in our cases using an anterior or superior symphyseal plate (3.5 mm Low Contact Dynamic Compression Plates) (Figure 3) or double plating method (3.5 mm Low Contact Dynamic Compression Plates superiorly and a 3.5 mm reconstruction plate anteriorly) (Figure 4). A posterior plate/iliosacral screw was added in cases of Type III APC injuries.

Bottom Line: The radiological outcomes were also similar in these.Complications included implant failure in 3 patients, postoperative infection in 2 patients, deep venous thrombosis in one patient and bladder herniation in one of the patients with implant failure.Limited dissection ensuring adequate intactness of rectus sheath is important to avoid long term post-operative complications.

View Article: PubMed Central - HTML - PubMed

Affiliation: Dept of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh-160 012, India.

ABSTRACT

Background: Pubic diastasis, a result of high energy antero-posterior compression (APC) injury, has been managed based on the Young and Burguess classification system. The mode of fixation in APC II injury has, however, been a subject of controversy and some authors have proposed a need to address the issue of partial breach of the posterior pelvic ring elements in these injuries.

Methods: The study included a total of 19 patients with pubic diastasis managed by us from May 2006 to December 2007. There was a single patient with type I APC injury who treated conservatively. Type II APC injuries (13 patients) were treated surgically with symphyseal plating using single anterior/superior plates or double perpendicularly placed plates. Type III injuries (5 patients) in addition underwent posterior fixation using plates or percutaneous sacro-iliac screws. The outcome was assessed clinically (Majeed score) and radiologically.

Results: The mean follow-up was for 2.9 years (6 months to 4.5 years). Among the 13 patients with APC II injuries, the clinical scores were excellent in one (7.6%), good in 6 (46.15%), fair in 4 (30.76%) and poor in 2 (15.38%). Radiological scores were excellent in 2 (15.38%), good in 8 (61.53%), fair in 2 (15.38%) and poor in one patient (7.6%). Among the 5 patients with APC III injuries, there were 2 patients each with good (50%) and fair (50%) clinical scores while one patient was lost on long term follow up. The radiological outcomes were also similar in these. Complications included implant failure in 3 patients, postoperative infection in 2 patients, deep venous thrombosis in one patient and bladder herniation in one of the patients with implant failure.

Conclusions: There is no observed dissimilarity in outcomes between isolated anterior and combined symphyseal (perpendicular) plating techniques in APC II injuries. Single anterior symphyseal plating along with posterior stabilisation provides a stable fixation in type III APC injuries. Limited dissection ensuring adequate intactness of rectus sheath is important to avoid long term post-operative complications.

Show MeSH
Related in: MedlinePlus