Chronic Symptomatic Symphyseal Instability

M.L. Chip Routt, Jr., M.D.

Patient #1• 28 yo Female• G1P1• 2.5 Years after NSVD of Term Baby Son• Anterior and Posterior Chronic Pain• Unable to Walk > 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

Presentation Pelvic Films

• AP

Presentation Pelvic Films

• Alternating LE Standing Films

Pelvic CT Scan

• In Binder

Pelvic CT Scan

• Axials @ S1 & S2• SI Joints

Surgery

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

Postop CT Imaging

Postop CT Imaging

• Axials @ S1 & S2 Levels

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”

4 Months After Surgery

• Plain Films• Notable Plate Segmental Breakage

4 Months After Surgery

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

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

Plain Films

• Inlet-Outlet

Initial Plain Films

• Single LE Alternating Stance Films

Pelvic CT Imaging

• SI Joints

Surgery

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

Postop Imaging

• CT Scan

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”

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

3 Months After Surgery

• Plain Films• No Implant Breakage….Yet!