Abstract:The spermatic cord is located lateral and immediately adjacent to the pubic tubercle after it exits the inguinal canal and passes into the scrotum. As such, the spermatic cord seems to be at a significant risk of sustaining injury when pointed forceps are placed on the tubercles, as is often recommended during the repair of pubic diastasis.
“…Our ndings showed that the exit point to symphysis pubis distance is smaller in male patients (16mm) than females (24.1mm), which is similar to what was previous reports [8, 10,11]. This nding makes pudendal nerve injury more likely in males than females since it exits 0.8 mm (range 0-2 mm) lateral to the pubic tubercle [14]. This is an important consideration to avoid potential sexual dysfunction in male patient.…”
Purpose
To measure the morphometric variables of the superior pubic ramus in a sub-set of an Arab population to establish a safe pubic screw fixation technique.
Methods
Cross sectional retrospective analysis of computed tomography (CT) pelvis images for 231 participants. The morphometric analysis included; pubic ramus axis length, insertion angles orientation, distance from the exit point to the pubic symphysis, distance from the entry point to acetabular joint surface and assessment of the narrowest pubic ramus diameter at three anatomical zones: para-symphyseal, mid-pubic and supra-acetabular areas. Pubic rami diameter correlation with age and sex was also analyzed.
Results
A total of 231 participants were included (55% male, 45% female). The mean screw length was between (104–127 mm) and it is significantly higher in males than females. The narrowest canal diameter was found at the para symphyseal area in both sexes were; 7.35mm in males and 4.75 mm in females. In females, all canal diameters at the three measured regions were significantly smaller than male’s diameters. The mediolateral insertion angle was significantly higher in females than males (49.4° vs. 41.8°, respectively), whereas the cephalic-caudal angle was significantly higher in males than females (49.9° vs. 42.1° respectively). The mean distance from the lateral ilium entry point to joint articular surface was higher in males (23.5 mm) than females (19.9 mm).The symphysis pubis to tubercle exit point was significantly higher in females than males (24.2 mm vs 16.6 mm respectively). Pearson’s correlation analysis revealed a statistically significant positive correlation between age and the pubic ramus diameter at the three measured regions in all age groups.
Conclusion
The results from this study suggest that percutaneous pubic rami screw fixation using the standard 6.5 or 7.3mm cannulated screw system may potentially be unsafe in female Arab patients. Thus, a closer evaluation in this subset of patients may require the alternative solid non-cannulated screws (3.5- 4.5mm) or plate fixation options. Further, female patients may have a higher risk of acetabular joint penetration, while males have a potentially higher risk of pudendal nerve injury
“…Our ndings showed that the exit point to symphysis pubis distance is smaller in male patients (16mm) than females (24.1mm), which is similar to what was previous reports [8, 10,11]. This nding makes pudendal nerve injury more likely in males than females since it exits 0.8 mm (range 0-2 mm) lateral to the pubic tubercle [14]. This is an important consideration to avoid potential sexual dysfunction in male patient.…”
Purpose
To measure the morphometric variables of the superior pubic ramus in a sub-set of an Arab population to establish a safe pubic screw fixation technique.
Methods
Cross sectional retrospective analysis of computed tomography (CT) pelvis images for 231 participants. The morphometric analysis included; pubic ramus axis length, insertion angles orientation, distance from the exit point to the pubic symphysis, distance from the entry point to acetabular joint surface and assessment of the narrowest pubic ramus diameter at three anatomical zones: para-symphyseal, mid-pubic and supra-acetabular areas. Pubic rami diameter correlation with age and sex was also analyzed.
Results
A total of 231 participants were included (55% male, 45% female). The mean screw length was between (104–127 mm) and it is significantly higher in males than females. The narrowest canal diameter was found at the para symphyseal area in both sexes were; 7.35mm in males and 4.75 mm in females. In females, all canal diameters at the three measured regions were significantly smaller than male’s diameters. The mediolateral insertion angle was significantly higher in females than males (49.4° vs. 41.8°, respectively), whereas the cephalic-caudal angle was significantly higher in males than females (49.9° vs. 42.1° respectively). The mean distance from the lateral ilium entry point to joint articular surface was higher in males (23.5 mm) than females (19.9 mm).The symphysis pubis to tubercle exit point was significantly higher in females than males (24.2 mm vs 16.6 mm respectively). Pearson’s correlation analysis revealed a statistically significant positive correlation between age and the pubic ramus diameter at the three measured regions in all age groups.
Conclusion
The results from this study suggest that percutaneous pubic rami screw fixation using the standard 6.5 or 7.3mm cannulated screw system may potentially be unsafe in female Arab patients. Thus, a closer evaluation in this subset of patients may require the alternative solid non-cannulated screws (3.5- 4.5mm) or plate fixation options. Further, female patients may have a higher risk of acetabular joint penetration, while males have a potentially higher risk of pudendal nerve injury
“…The distance between the cable and the obturator canal was 3.0–3.5 cm. Interference with the spermatic cord/round ligament or the femoral vessels should be considered 24 . Figure 6 Anatomical landmarks.…”
Operative treatment of ruptured pubic symphysis by plating is often accompanied by complications. Trans-obturator cable fixation might be a more reliable technique; however, have not yet been tested for stabilization of ruptured pubic symphysis. This study compares symphyseal trans-obturator cable fixation versus plating through biomechanical testing and evaluates safety in a cadaver experiment. APC type II injuries were generated in synthetic pelvic models and subsequently separated into three different groups. The anterior pelvic ring was fixed using a four-hole steel plate in Group A, a stainless steel cable in Group B, and a titan band in Group C. Biomechanical testing was conducted by a single-leg-stance model using a material testing machine under physiological load levels. A cadaver study was carried out to analyze the trans-obturator surgical approach. Peak-to-peak displacement, total displacement, plastic deformation and stiffness revealed a tendency for higher stability for trans-obturator cable/band fixation but no statistical difference to plating was detected. The cadaver study revealed a safe zone for cable passage with sufficient distance to the obturator canal. Trans-obturator cable fixation has the potential to become an alternative for symphyseal fixation with less complications.
“…As previously described by Hadeed et al, some important anatomical structures must be considered 49 . In particular, the spermatic cord and ligamentum suspensorium penis in men and the round ligament, clitoral body, and clitoral glans in women must be spared to prevent dyspareunia, erectile dysfunction, or infertility [50][51][52][53] . During our dissection, we identified no conflict with the abovementioned structures.…”
Background
Traumatic separation of the pubic symphysis can destabilize the pelvis and require surgical fixation to reduce symphyseal gapping. The traditional approach involves open reduction and the implantation of a steel symphyseal plate (SP) on the pubic bone to hold the reposition. Despite its widespread use, SP-fixation is often associated with implant failure caused by screw loosening or breakage.
Methods
To address the need for a more reliable surgical intervention, we developed and tested two titanium cable-clamp implants. The cable served as tensioning device while the clamp secured the cable to the bone. The first implant design included a steel cable anterior to the pubic symphysis to simplify its placement outside the pelvis, and the second design included a cable encircling the pubic symphysis to stabilize the anterior pelvic ring. Using highly reproducible synthetic bone models and a limited number of cadaver specimens, we performed a comprehensive biomechanical study of implant stability and evaluated surgical feasibility.
Results
We were able to demonstrate that the cable-clamp implants provide stability equivalent to that of a traditional SP-fixation but without the same risks of implant failure. We also provide detailed ex vivo evaluations of the safety and feasibility of a trans-obturator surgical approach required for those kind of fixation.
Conclusion
We propose that the developed cable-clamp fixation devices may be of clinical value in treating pubic symphysis separation.
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