Injury, Int. J. Care Injured (2005) 36, 827—831

www.elsevier.com/locate/injury

Implant retention and removal after internalfixation of the symphysis pubis

Raghu Raman a, Craig S. Roberts b, Hans-Christoph Pape c,Peter V. Giannoudis a,*

a St. James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UKbUniversity of Louisville School of Medicine, Department of Orthopaedic Surgery,Louisville, Kentucky, USAcDepartment of Trauma, Hannover Medical School, Hannover, Germany

Accepted 23 November 2004

KEYWORDSSymphysis pubis;Plating;Failure;Infection;Dyspareunia;Pregnancy;Implant removal

* Corresponding author. Tel.: +44 11fax: +44 113 2065156.

E-mail address: pgiannoudi@aol.co

0020–1383/$ — see front matter # 20doi:10.1016/j.injury.2004.11.012

Summary Although internal fixation of diastasis of the symphysis pubis is commonlyperformed, there are no clear guidelines regarding the indications for removal ofthese implants. The long-term physiologic effects of retaining these internal fixationdevices are not well described. We surveyed the literature to assess the currentthinking and recommendations regarding implant retention and removal. Twenty-fourcase series and two case reports were found, for a total of 482 cases. Complicationsarose as a result of implant retention in 7.5% of patients, with infection the mostcommon complication. There is no consensus in the literature regarding implantretention and removal after internal fixation of diastasis of the symphysis pubis.# 2004 Elsevier Ltd. All rights reserved.

Introduction

Pelvic ring injuries account for more than 10% of theinjuries to the human skeleton, with motor vehicleaccidents responsible for over 68% of the cases.7,18

Anterior pelvic disruptions are seen in more thanhalf of all pelvic ring injuries.7,18 Stabilisation of theanterior pelvic ring, particularly the pubic symphy-sis, is an essential part of the definitivemanagementof these injuries.

The preferred method of stabilisation of diastasisof the pubic symphysis is internal stabilisation which

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m (P.V. Giannoudis).

04 Elsevier Ltd. All rights rese

is rapidly replacing forms of external fixation as adefinitive procedure.34 Internal stabilisation of theanterior pelvic ring has been achieved using two-holed plates,36 four-holed plates (2.5—4.5 mm),20,26,29,34,37 curved plates,29,37 dynamic compressionplates,2,27,29,37 reconstruction plates,27,29,37 retro-grademedullary screws with wires,28,34 tension bandwiring31 and cord sutures.5,34 The techniques of sin-gle plating,27 double plating,17,27,34 biplanar fixa-tion27 and box fixation27 have also been described.

To our knowledge, there are no clear recommen-dations in the current literature databases (Med-line, CINAHL, Cochrane, Embase) regarding thelong-term effects of retaining these internal fixationdevices following bony union or the indications forimplant removal. The purpose of this study was to

rved.

828 R. Raman et al.

review the current literature on the subject in orderto identify the long-term physiologic effects (e.g.residual suprapubic pain, sexual disturbance, impo-tence) of implant retention, to review indicationsfor implant removal, to correlate any long-termeffects with implant failure and to examine theissue of implant removal in pregnant women.

Methods

We surveyed the literature using Medline, CINAHL,OVID, ADITUS search engines and Cochrane data-bases from 1966 to the present. The following keywords were used in the search: ‘symphysis rupture’,‘plate removal’, ‘symphysis plating’, ‘pubic plate’,‘effects of plate’, ‘sex and plate’, ‘pregnancy andplate’, ‘impotence and plate’, ‘pubic diastasis’,‘implant failure’ and ‘pelvic fracture’.

The inclusion criteria for references were thefollowing: references describing internal stabilisa-tion of the anterior pelvis, follow-up of at least 6months, case reports with a review of the literature,case series, prospective studies and retrospectivestudies. The exclusion criteria were: isolated casereports, cases with less than 6 months follow up andreferences, which did not fulfil at least one of theinclusion criteria.

Each reference was analysed. The following para-meters were recorded: the number of patients inthe study, type of injury, method of stabilisation ofthe anterior pelvic ring, complications, implant fail-ure, residual pain at latest follow-up, sexual dis-turbances and impotence, and the relationship ofpregnancy to implant removal.

Results

Based on these criteria, we found 24 case series and2 case reports included in the 26 references that weidentified.1,3,6,8—16,19—26,30,32,33,36—38 Twenty-onereferences reported on traumatic diastasis of thesymphysis while three articles described rupture ofsymphysis at labour.22,25,32 Two referencesdescribed stabilisation of the symphysis secondaryto osteitis.1,38 All patients in the selected studieshad the anterior ring internally stabilised. Stabilisa-tion by plate osteosynthesis was reported in 24articles, while one article described stabilisationusing tension band wires31 and another using Kirsch-ner wires, PDS suture material and PDS bands.13 Atotal of 482 cases were identified. The mean follow-up was 68 months (6—154 months).

Complications were described in all but onereference.14 Superficial infection was reported in

nine (2.2%) patients13,19,21,23,24,37 and deep infec-tion in six (1.6%).13,19,32 Implant failure wasdescribed in only 12 articles (46.1%).6,13,16,19,21—24,31,32,36,38 A total of 16 (5.7%) implant failureshave been described out of 277 cases in these 12articles. Residual pain (suprapubic pain) wasaddressed in 19 (73%) articles.3,6,8,11—13,16,19—25,31,33,36—38 There were 32 cases of residual painattributed to the anterior symphysis stabilisationdevice. Problems during sexual intercourse andimpotence were described in five references(21.2%).16,21,23,24,33 Twelve patients had sexual dys-function: five patients had deep dyspareunia andseven had erectile impotence.4 Of the 12 patientswith sexual problems, 9 patients had coexistentgenitourinary injuries.

Only two (7.6%) articles addressed the issue ofpregnancy in their patient groups.19,24 The platewas removed electively in one patient24 and twopatients had an uneventful ante and postnatal per-iod with the implant in situ.19,21

Plate removal was discussed in 15 studies(58%).3,8—10,12—15,19,21,23—25,32,33 Implants wereremoved in 17 patients.8,15,21,23—25 Fifteen of thesepatients had significant anterior pain. Implant failurewas reported in nine patients and infection in onepatient.21,24 Four patients had their implantsremoved electively (three females and onechild).8,15,24,25

Discussion

There is a plethora of information in the literatureon the biomechanics of the symphysis pubis andmethods of stabilisation of the symphysis. The beha-viour of various modes of fixation and their failureshas been extensively studied. For the stabilisation ofthe ruptured pubic symphysis, rigid forms of fixationsuch as plate osteosynthesis and flexible fixationssuch as wire loops or PDS banding have been recom-mended (Table 1).5,26,27,29—31,35—37

Long-term effects of implant retention and its rolein pregnant women have only been given cursoryattention in the current literature. Sharp havedescribed plate osteosynthesis of the symphysis dia-stasis as early as 1973.26However, subsequent studieshave failed to highlight the effects of plate retentionin patients with respect to pain, impotence andpregnancy. Four references were case series, withpatient numbers greater than 50.19,21,23,24 This pau-city of information in the current literature makes itdifficult to reach a definitive answer to the questionof implant removal following bony union.

Complications arose as a result of implant reten-tion in 7.5% of the patients, with infection the most

Implant retention and removal after internal fixation of the symphysis pubis 829

Table 1 Methods of stabilization

Author No. ofpatients

Type offixation

Albertson et al. 2 PlateCole et al. 48 PlateDelauney et al. 1 PlateGansslen et al. 1 PlateGoldstein et al. 15 PlateGruen et al. 48 PlateHirvensalo et al. 13 PlateKamhin et al. 2 PlateKothe et al. 10 Plate, K-wire, PDSKovalkovitis et al. 7 PlateLange et al. 24 PlateLee et al. 1 PlateLetournel 27 PlateLewis et al. 7 PlateMatta 72 PlateMau et al. 4 PlateMonfort et al. 50 PlatePohlemann et al. 58 PlateRommens 3 PlateSharp et al. 5 PlateStuart et al. 6 Tension bandTaylor et al. 3 PlateVan den Bosch et al. 36 PlateWebb et al. 14 PlateWen et al. 18 PlateWilliam et al. 7 Plate

Table 3 Infection

Author No. ofpatients

Plan/treatment

Hirvensalo et al. 2 —Kothe et al. 2 AntibioticsLetournel 3 AntibioticsMatta 1 Antibiotics and

revision stabilizationMonfort et al. 2 Antibiotics-plate

removedPohlemann et al. 2 AntibioticsWen et al. 2 —

common complication (Table 2). Implant failure wasseen in 5.7% (16 out of 277 patients). Neither ofthese two groups of patients had significant residualmorbidity (Table 3).

The incidence of suprapubic pain does not appearto directly relate to the implant or implant failure.Eighty-two percent of patients with residual painhad associated pelvic floor injury (soft tissue injuryinvolving the pelvis, urological and perineal region).

Table 2 Implant failure

Author Yes (cases) No (cases)

Delauney et al. 0Kothe et al. 1 9Lange 4Lee et al. 0Letournel 2 25Matta 3 69Mau et al. 0Montfort et al. 2Pohlemann et al. 2Stuart et al. 2Taylor et al. 0Webb et al. 14William et al. 0

In all of these patients, the pain was not isolated inthe suprapubic area. In only three cases, the painwas related to the suprapubic implant. However,these patients had solid fixation of the symphysispubis and no radiological evidence of implant fail-ure. None of the patients with implant failure hadresidual pain as a presenting feature. The implantswere removed in 17 patients. Anterior symphysispain, which was present in 15 patients improvedonly in 5 (29%) patients following removal of theimplant. Of the 17 patients, 11 had significant pelvicpain which improved in 5 patients following implantremoval.

Sexual disturbance and impotence secondary tointernal stabilisation of the symphysis seem to beassociated with the original injury rather than theimplant itself. Seventy-five percent of the patientswith sexual disturbance had coexisting genitourin-ary injuries. This might offer a significant contribu-tion to the subsequent disturbance of impotenceand dyspareunia. Copeland et al. in their recentreview have correlated sexual disturbance inpatients to residual displacement of the fracturesof >5 mm.

The effect on pregnancy and childbirth is verypoorly addressed in patients with symphysis plates.Although there appears to be no direct adverseeffect on pregnancy, it would be imprudent to reachsuch a conclusion with such a small number ofpatients. Furthermore, the psychological stressand anxiety of plate retention, and its potentialeffect on the method of delivery have not beenaddressed. A summary of all complications is shownin Table 4.

There are arguments for and against implantremoval in the literature. Implant removal has beenanecdotally recommended in patients where bonyunion has occurred or where implant failure is seen.In some articles, implant removal is described asroutine practice although there is no explanation forsuch a practice. Residual pain has not been a sig-nificant contributor to implant removal. Implant

830 R. Raman et al.

Table 4 Summary of complications

Author No. ofpatients

Indication Fixationdevice

Infection Implantfailure

Suprapubicpain

Sexualcompl

Pregnancy Removal(months)

Albertson et al. 2 Inflammation Plate 0 N/D N/D N/D N/D N/DCole et al. 48 Trauma Plate 0 N/D 3 N/D N/D 0Delaueney et al. 1 Trauma Plate N/D 0 1 N/D N/D N/DGansslen et al. 1 Trauma Plate 0 N/D 0 N/D N/D 1 (4)Goldstein et al. 15 Trauma Plate 1 N/D N/D N/D N/D 0Gruen et al. 48 Trauma Plate 0 N/D N/D N/D N/D 0Hirvensalo et al. 13 Trauma Plate 2 N/D 2 N/D N/D N/DKamhin et al. 2 Trauma Plate 0 N/D 1 N/D N/D 0Kothe et al. 10 Trauma Plate,

K-wire,PDS

2 1 3 N/D N/D 0

Kovalkovitiset al.

7 Trauma Plate N/D N/D N/D N/D N/D 0

Lange et al. 24 Trauma Plate 0 N/D N/D N/D N/D 3 (22)Lee et al. 1 Trauma Plate 0 0 1 1 N/D N/DLetournel 27 Trauma Plate 3 2 4 N/D 1 0Lewis et al. 7 Trauma Plate 0 N/D 2 N/D N/D N/DMatta 72 Trauma Plate 1 3 3 3 N/D 3 (18)Mau et al. 4 Post Partum Plate 0 0 2 N/D N/D N/DMonfort et al. 50 Various Plate 2 2 0 2 N/D 2 (19)Pohlemann et al. 58 Trauma Plate 2 2 2 3 1 4 (16)Rommens 3 Post Partum Plate 0 N/D 0 N/D N/D 3 (6)Sharp et al. 5 Trauma Plate 0 N/D N/D N/D N/D N/DStuart et al. 6 Trauma Tension

band0 2 0 N/D N/D N/D

Taylor et al. 3 Post Partum Plate N/D 0 N/D N/D N/D 0Van den Bosch

et al.36 Trauma Plate 0 N/D 4 12 N/D 0

Webb et al. 14 Trauma Plate 0 0 0 N/D N/D N/DWen et al. 18 Trauma Plate 2 N/D 3 N/D N/D N/DWilliam et al. 7 Inflammation Plate 0 0 1 N/D N/D N/D

removal in pregnant women has also been describedbut with no background explanation for the same.There is a paucity of information (two case reports)on the subject of implant retention in pregnantwomen. In these scarce reports, there has beenno significant morbidity described with plate reten-tion in pregnant women.

A firm recommendation regarding implant reten-tion and removal after internal fixation of the sym-physis pubis cannot be made based on the currentliterature. In light of the evidence available in thepresent literature. We recommend that implantremoval should be considered on an individual basisdepending on the presence of local symptoms whichmay be attributed to the retention of the implant.However, in these cases, the patient should beinformed about the low success rate with regardto symptom improvement after removal. The sub-ject of implant removal in pregnant women is stillambiguous. Further studies are necessary to providea definitive answer about implant retention in preg-nant women.

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