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Background: It has been posited that the osseous pelvic anomalies seen in patients with classic bladder exstrophy (CBE) result from disruption of the pubic symphysis. This hypothesis, however, has not been tested. In the present animal study, our objective was to determine whether the tension of the pubic symphysis helps maintain the shape of the pelvic ring, or whether the growing bones maintain a ring shape even without the tension of the symphysis., Methods: In total, 12 neonatal New Zealand White rabbits underwent pubic symphysiotomy (experimental group, n=9) or sham surgery (control group, n=3) on days 3 or 4 of life. Rabbits were scanned with cone-beam computed tomography at 1, 4, 12, and 20 weeks postoperatively to monitor changes in the following pelvic parameters, which are known to be altered in CBE: anterior segment angle, anterior segment length, intertriradiate distance, interpubic distance, and posterior segment angle. Changes within the experimental and control groups were evaluated using repeated-measures analysis of variance and post hoc Tukey honest significant difference testing. Two-tailed t tests were used to compare treatment groups at each time point., Results: Both groups showed increases in anterior segment length and intertriradiate distance during the study period; rabbits in the experimental group also showed a steady increase in interpubic distance (F=43.9; P<0.001). Experimental rabbits had significantly larger mean values for anterior segment angle, intertriradiate distance, interpubic distance, and posterior segment angle than did control rabbits at all time points. We found no difference in mean anterior segment length between control and experimental groups at any time point. The difference in interpubic distance was particularly pronounced by 20 weeks (experimental group, 13±2.7 mm; control group, 1.1±0.1 mm; P<0.001)., Conclusions: The pubic symphysis is essential for normal pelvic development. Its absence led to early pelvic angulation and progressive pubic separation in a rabbit model. However, we found no significant difference in the mean anterior segment length, and it is likely that other factors are also implicated in the growth disturbance seen in CBE., Level of Evidence: Level V., Competing Interests: E.C. discloses grant support from National Institute on Aging (non–study-related). P.D.S. discloses personal fees from DePuy Synthes, Globus Medical, OrthoPediatrics, and the Journal of Bone and Joint Surgery (all non–study-related). The remaining authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Congenital prepubic sinus is a very rare urogenital anomaly that manifests as a tubular structure of varying histological findings that drains to the skin overlying the pubic symphysis. This tract has been observed to course above, below or, in only a handful of cases, directly through the pubis. We report a case of congenital prepubic sinus with this unusual transpubic course in an 18-year-old man. The patient was initially taken to the operating room for excision of a presumed inclusion cyst. At the time of surgery, the collection was found to track proximally and was excised down to the level of the pubic symphysis. Subsequent magnetic resonance (MR) imaging established the diagnosis of congenital prepubic sinus. We describe the different anatomical courses of congenital prepubic sinus, hypotheses of its pathogenesis, and the use of MR imaging in both diagnosis and surgical planning.

Background: The decreased hip range of motion seen in femoroacetabular impingement syndrome (FAIS) may lead to compensatory increased motion at the symphysis pubis (SP) with resultant increased stress on the joint, which can subsequently lead to osteitis pubis., Purpose: To quantify the prevalence of SP abnormalities in patients with FAIS through the use of imaging modalities and to compare outcomes based on the presence of SP abnormalities., Study Design: Cohort study; Level of evidence, 3., Methods: Radiographs and magnetic resonance imaging (MRI) scans of 1009 consecutive patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. Exclusion criteria were patients undergoing revision or bilateral surgery, patients with dysplasia, and patients with less than 2-year follow-up. On radiographs, SP joints were reviewed for joint surface erosions, subchondral sclerosis and cysts, and ankylosis. MRI scans were reviewed for marrow edema in the subarticular pubic bone, subchondral sclerosis and cysts, joint surface erosions, and ankylosis. Patients with SP abnormalities were matched 1:2 to patients without SP abnormalities by age and body mass index. Outcomes included the Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scales (VAS) for pain and satisfaction., Results: 830 patients were included; 23 (2.8%) demonstrated SP abnormalities. Of the 726 (72%) MRI scans reviewed, 15 (1.8%) showed bone marrow edema, subchondral sclerosis, erosions, or ankylosis. After matching, patients without SP abnormalities had significantly greater HOS-ADL (95.7 vs 83.0; P = .008), HOS-SS (91.6 vs 61.9; P = .003), iHOT-12 (89.5 vs 74.6; P = .046), and VAS satisfaction (91.3 vs 58.8; P = .004) scores, in addition to less postoperative pain (6.3 vs 23.5; P < .001). No significant differences were found in the mHHS (92.5 vs 82.2; P = .08). Patients without SP abnormalities had higher odds of achieving the minimal clinically important difference for the HOS-ADL (odds ratio [OR], 4.5; 95% CI, 1.3-14.1; P = .010), the HOS-SS (OR, 7.2; 95% CI, 1.8-18.5; P = .006), and the mHHS (OR, 14.5; 95% CI, 1.8-24.7; P = .013)., Conclusion: A low prevalence (1.8%-2.6%) of SP joint abnormality is seen on imaging in patients with FAIS. These patients may demonstrate significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment.

Introduction  Abnormalities of the bony pelvis in exstrophy-epispadias complex (EEC) and their possible relation to hip disease are well described. However, there is a lack of information about long-term orthopedic consequences and hip function in patients with EEC. Therefore, we investigated clinical and radiological results in an EEC patient cohort after long-term follow-up. Patients and Methods  We conducted a cross-sectional study using standardized radiography, clinical investigation, and the Harris hip score. Seventeen postpuberty consecutive unselected EEC patients (3 female, 14 male; mean age 18.2 years) that presented to our clinic due to urological procedures or routine check-up from 2010 to 2011 were included. All had undergone symphysis approximation with a traction bandage without osteotomy in early childhood. Radiological analysis was conducted offline by two independent investigators. Results  Radiological analysis showed a mean pubic diastasis of 5.1 cm (range 2.8-8.5 cm). Borderline hip dysplasia was present in four patients, one of them having had co-occurring developmental hip dysplasia in previous history. No severe dysplasia, subluxation, or luxation of the hip was found; however, one patient showed early hip arthrosis. Clinical examination revealed no relevant restriction of range of motion, although rotation and abduction were slightly altered in five patients. None of the EEC patients complained about pain or restriction in sports or daily activities. Harris hip score was perfect for all but one study participants. Conclusion  Despite EEC-specific hip morphology, long-term hip function is not impaired in patients after symphyseal approximation without osteotomy in the newborn period. The symphysis diastasis after this procedure is comparable to available postosteotomy data. The large majority of EEC patients did not show dysplastic or degenerative hip disease. Functional hip score results confirmed reasonable age-related hip function in nearly all examined patients. However, postnatal ultrasound hip screening is recommended to prevent and adequately treat potential co-occurring developmental hip dysplasia., (Georg Thieme Verlag KG Stuttgart · New York.)

The symphysis pubis is demonstrated on many conventional radiographic and cross-sectional examinations and abnormality of the symphysis pubis is a common imaging finding with numerous possible causes. Many significant disorders that affect the symphysis pubis cause it to appear widened, eroded, or destroyed on imaging studies. It is useful for radiologists to have a working differential diagnosis for these appearances, to use when reporting such studies. This review briefly describes the anatomy of the symphysis pubis and presents examples of the various developmental, inflammatory, infectious, neoplastic, traumatic, and metabolic disorders that may cause it to become widened, eroded, or destroyed. Some disorders have pathognomonic imaging features. Others give rise to similar findings that depend more on overall disease activity, rather than the specific diagnosis itself. In such cases, correlation with clinical and laboratory findings will help narrow the differential diagnosis., (Copyright © 2012. Published by Elsevier Ltd.)

Background: Bladder extrophy malformation includes outward rotation of the innominate bones, pubic symphysis diastasis and acetabular retrovertion. We have corrected the pelvic deformation during the reconstruction of the bladder neck and the urethra in older children., Methods: From 1/01/2002 to 1/01/2006 in the Department of Pediatric Urology and the Department of Pediatric Orthopedics in Katowice 4 children were operated on for bladder extrophy. The age of the patients ranged from 2.3 to 4.1 years; an average of 3.6 years. In the patients with bladder extrophy we performed the urological reconstruction and simultaneously the bilateral Salter's osteotomy was done., Results: The follow up was 52 months (48-84).The consolidation of the osteotomy was obtained in all patients after 62 days (48-72) with the correction of the retroversion of the hips and symphysis to 2.4 cm (0.9-5.8)., Conclusion: The innominate Salter's osteotomy is helpful in the bladder neck reconstruction and allows to achieve the proper anatomy of the pelvic ring.

Objective: To present the early results of pelvic osteotomies performed for repair of exstrophy bladder., Methods: Five cases of exstrophy bladder were treated with closure following bilateral iliac osteotomies. Three patients underwent closure of pubic symphysis diastasis by use of external fixator, one by screws and cerclage wires, and one by use of K-wires and suture. The patients were followed up by the pediatric urologist and orthopedic surgeon., Results: All patients achieved a closure of diastasis and a tension free repair after the index surgery. The average follow-up was 3.6 years with range of 4 months to 6 years. All osteotomies healed within two months and had closure of the diastasis, except one which had a partial failure with loss of 50% correction. No patient had any wound dehiscence or breakdown of the bladder repair. Preoperative mean diastasis of symphysis pubis was 6 cm (range; 4.5 cm to 7 cm) and post operative mean diastasis was 3.5 cm with the range of 2.5 cm to 4 cm at 12 months follow up. All patients achieved urinary continence post operatively and were passing urine per-urethra with satisfactory urinary control as followed-up with the pediatric urologists., Conclusion: Bilateral iliac osteotomies and use of external fixator in our series was found to be helpful in achieving a tension free closure and preventing dehiscence of the repair.

Purpose: Radiographic abnormalities in the pubic bone and symphysis are often seen in athletes with groin pain. The aim was to create a grading scale of such radiologic changes., Material and Methods: Plain radiography of the pelvic ring including the pubic bone and the symphysis was performed in 20 male athletes, age 19-35, with long-standing uni- or bilateral groin pain. We used two control groups: Control group 1: 20 healthy age-matched men who had undergone radiologic examination of the pelvis due to trauma. Control group 2: 120 adults (66 men and 54 women) in 9 age groups between 15 and 90 years of age. These examinations were also evaluated for interobserver variance., Results and Conclusion: The grading scale was based on the type and the amount of the different changes, which were classified as follows: No bone changes (grade 0), slight bone changes (grade 1), intermediate changes (grade 2), and advanced changes (grade 3). The grading scale is easy to interpret and an otherwise troublesome communication between the radiologist and the physician was avoided. There was a high interobserver agreement with a high kappa value (0.8707). Male athletes with long-standing groin pain had abnormal bone changes in the symphysis significantly more frequently and more severely (p>0.001) than their age-matched references. In asymptomatic individuals such abnormalities increased in frequency with age both in men and women.

One-stage combined surgery in a female patient with total extrophy of the urinary bladder after uretherosigmostomy was performed for the first time with participation of surgeons, gynecologists and urologists. Corrective surgeries in these patients must be performed for the purpose of creation of isolated urinary reservoir for prophylaxis of pyelonephritis and chronic renal insufficiency. Correction of symphysis defect was carried out with polypropylene endograft. This surgery was performed to provide quality of life and reproductive function of the patient.

Background: Classic bladder exstrophy is a developmental defect presenting at birth with a wide pubic separation and an exposed bladder; cloacal exstrophy involves, in addition, intestinal prolapse. Reconstruction requires several surgical procedures. The use of anterior iliac osteotomies in this process has not been reviewed in a large series., Methods: We reviewed the results of eighty-six anterior innominate osteotomies performed in conjunction with genitourinary repair of classic and cloacal bladder exstrophy in eighty-two patients. Clinical outcome measures were successful bladder closure, achievement of continence, and maintenance of a normal gait. Radiographs of the pelvis were reviewed, and the pubic intersymphyseal diastasis (a measure of the reduction in tension on the anterior closure) was measured preoperatively and at three time-points postoperatively. Children with classic exstrophy who had undergone osteotomy and bladder neck reconstruction but not bladder augmentation were divided into four groups on the basis of the degree of continence. In addition, children with classic exstrophy were stratified according to age at the time of the osteotomy. The mean postoperative percent reduction in the amount of the original diastasis was determined for all groups., Results: Children with classic exstrophy and those with cloacal exstrophy had correction of the diastasis after the osteotomy, with greater correction in those with classic exstrophy, presumably because of better bone quality. Daytime continence was achieved with anterior osteotomy and bladder neck reconstruction in 74% of the children for whom continence was a goal. However, no difference in the symphyseal diastasis or in the percentage of pubic reduction was detected among the four continence groups. Children who were older at the time of the osteotomy maintained better correction over time. Wound dehiscence or bladder prolapse occurred in 4% of the patients who had osteotomy and primary closure, and the only important complication of the osteotomies was transient palsy of the left femoral nerve in seven children., Conclusions: Anterior innominate osteotomy is an effective part of reconstructive repair of bladder exstrophy. The primary goals of the osteotomy are to reduce the tension in the closed bladder and the lower abdominal wall and to promote continence by restoring the sling of the pelvic floor muscles. These goals can be achieved in the majority of patients.

The characteristic of duplicated exstrophy is the presence of a patch of exstrophic bladder mucosa in the infraumbilical region with a low-set umbilicus, in addition to the normal bladder. Musculoskeletal defects, diastasis pubis, and rectus abdominis can also be found in these patients. We report the first case of a female twin baby with appearance of a low-set umbilicus and diastasis pubis associated with a pubic sinus. The external genitalia and urinary continence were normal. Duplicated exstrophic mucosal remnant was excised, and the histopathologic study of the specimen confirmed urothelium.

A rare exstrophy variant in a 1(1/2)-year-old girl is reported. The child had a wide, scar-like lesion over the lower central abdomen with divarication of the recti and a spread symphysis pubis. The underlying bladder was divided into two unequal chambers by a complete sagittal septum with only the right chamber communicating with the single urethra and the left draining by a vesicocutaneous fistula. Both kidneys were normal. The clitoris was bifid and the anus anteriorly placed. Preliminary surgical management consisted of dissection of the bladder from its prevesical covering, excision of the sagittal septum, and cystocystostomy. Postoperatively, the child had normal urinary continence. The literature is reviewed with special reference to the various forms of duplicate exstrophy.

Symphyseal diastasis in the absence of exstrophy or epispadias is rare. We reviewed 11 reported cases and present 2 of our own. Based upon our findings, we recommend a thorough physical examination in all patients. A voiding cystourethrogram in those with the radiographic finding of symphyseal diastasis in the absence of exstrophy or epispadias may be helpful. A significant number of patients have associated congenital anomalies.

The authors present an illustrative case report of "pelvic digit" and discuss this benign skeletal anomaly. The similarity of this condition to posttraumatic myositis ossificans, avulsion injuries of the pelvis, and osteochondroma is pointed out.

A patient with the "13q-" syndrome is reported. The typical association of congenital malformations was found. Multiple and unusual skeletal anomalies included absent thumbs, club-feet, coxa vara, diastasis of the pubic symphisis and extensive spina bifida occulta. These appear to be part of the multiple system involvement due to the chromosomal deletion. Chromosome analysis is indicated in patients with multiple skeletal anomalies, especially if the thumbs and radial axis are involved.

In the split symphysis variant, a rare anomaly of bladder exstrophy, the bladder is closed with varying degrees of skin covering it. A good prognosis does exist for surgically produced continence in patients with a single bladder, although patients with bladder duplication have a greater risk of renal damage.

A group of syndromes is presented whose common characteristic is the absence of pubic ossification at birth with very slow posterior mineralization. This is a radiological finding of interest as it has not been described in other entities. In all the cases shown, moreover, a variable degree of delay in bone age is observed. The increase of space between the pubic bones described in these syndromes is fictious, as it really signifies the existence of non-ossified cartilage. Therefore, they must be differentiated from those which deal with real widening of the symphysis of pubis.

The symphysis pubis is a nonsynovial amphiarthrodial joint that is situated at the confluence of the two pubic bones. A thick intrapubic fibrocartilaginous disc is sandwiched between thin layers of hyaline cartilage. The inferior pubic ligament provides most of the joint's stability. Anatomic sections demonstrate a symphysis by the end of the second month of gestation. Thick cartilaginous end-plates are present at birth but become thin by the time of skeletal maturity. Congenital diseases resulting in failure of symphysis formation include exstrophy of the bladder and cleidocranial dysostosis. Both pyogenic and tuberculous infectious diseases involve the symphysis. Metabolic disease, such as renal osteodystrophy, produces widening, while ochronosis results in calcific deposits in the symphysis. Inflammatory disease, such as ankylosing spondylitis, results in bony fusion of the symphysis. Osteitis pubis, the most common inflammatory disease, is treated with anti-inflammatory medication and rest. Degenerative joint disease of the symphysis, which can cause groin pain, results from instability or from abnormal pelvic mechanics. As is the case with most joints, the symphysis serves as a barrier to tumor invasion. The patterns of trauma include diastasis, straddle fracture, intraarticular fracture and overlapping dislocation, and combinations of injuries.