Chronic Symptomatic Symphyseal Instability

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Chronic Symptomatic Symphyseal Instability

• M.L. Chip Routt, Jr., M.D.

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Patient 1

• 28 yo Female
• G1P1
• 2.5 Years after NSVD of Term Baby Son
• Anterior and Posterior Chronic Pain
• Unable to Walk gt 100 ft
• Unable to Lift/Carry Son
• Dyspareunia Stress Urinary Incontinence
• Employed-Sedentary Job-Computer Work-Fulltime
• Relatively Comfortable Sitting 45-60 Minute
  Intervals
• Takes No Medications Nothing Works, Why Take
  Them?
• Pelvic Instability on Compression Exam, Causes
  Pain

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Presentation Pelvic Films

• AP

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Presentation Pelvic Films

• Alternating LE Standing Films

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Pelvic CT Scan

• In Binder

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Pelvic CT Scan

• Axials _at_ S1 S2
• SI Joints

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Surgery

• Supine
• Pfannenstiel
• Unstable Symphysis
• Compressive Reduction Clamped
• Symphyseal Plating Frail Bone
• Perc Upper and 2nd Sacral Segment IS Screws

8
Postop CT Imaging
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Postop CT Imaging

• Axials _at_ S1 S2 Levels

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Rehabilitation

• 1st 6 Weeks - Bed or Chair Restricted and
  Isometrics
• Marginally Compliant Due to Comfort
• 2nd 6 Weeks - Tandem Bilateral Protected WB,
  Stretching, Strengthening Program, Aquatic
  Program
• Non-Compliant Due to Comfort

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4 Months After Surgery

• Plain Films
• Notable Plate Segmental Breakage

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4 Months After Surgery

• No Pain Complaints
• Normal Gait without Distance Limit
• Lifts/Carries Son
• Normal Sexual Activity
• No GU Complaints
• Still Working FT

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Patient 2

• 51yo Male
• Was D1 College Baseball Player back in the day
• Remained Fit Active
• Executive - Employed FT
• 8-12 Years Progressive Pelvic-Groin-Back Pain
• Anterior Pelvic Grinding
• Bilateral Posterior Pelvic Pain
• Worsened By Essentially Any Activities
• Antalgic Gait
• Dyspareunia (But Fights Thru It!)
• Has Had Spinal Injections Without Relief Body
  MRI In Hand
• ? Pelvic Instability on Exam

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Plain Films

• Inlet-Outlet

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Initial Plain Films

• Single LE Alternating Stance Films

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Pelvic CT Imaging

• SI Joints

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Surgery

• Supine
• Pfannenstiel
• Fluid Filled Cyst Around Unstable Symphysis
• Compressive Reduction Clamped
• Symphyseal Plating
• Perc Bilat IS Screws at Upper Sacral Segment

18
Postop Imaging

• CT Scan

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Rehabilitation

• 1st 6 Weeks - Bed or Chair Restricted and
  Isometrics
• 2nd 6 Weeks - Tandem Bilateral Protected WB,
  Stretching, Strengthening Program, Aquatic
  Program
• Very Compliant Due to Fear of Pain Return

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3 Months After Surgery

• Left Adductor Sporadic Cramping
• No Prior Pelvic Low Back Symptoms
• Slowly Evolving Normal-Pareunia
• Scared and Cautious Recoverer
• Back to Work
• Durable Implants Thus Far

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3 Months After Surgery

• Plain Films
• No Implant Breakage.Yet!