Co-Occurring Femoroacetabular Impingement and Osteitis Pubis: A Possible Solution

How to help athletic patients with co-occurring femoroacetabular impingement (FAI) and osteitis pubis (OP)? In what is the first multicenter case series on this topic, Dean K. Matsuda, M.D., director of Hip Arthroscopy at the DISC Sports and Spine Center, has just published a study called, “Multicenter Outcomes of Endoscopic Pubic Symphysectomy for Osteitis Pubis Associated With Femoroacetabular Impingement.” Dr. Matsuda indicates that symphysectomy involves excision of the hyaline endplates and fibrocartilage of the symphysis pubis. He notes, “Retention of the inferior arcuate ligament is key as it is a primary stabilizer and our patients displayed no post-operative radiographic instability.”

According to the American Academy of Orthopaedic Surgeons, femoroacetabular impingement is “a condition where the bones of the hip are abnormally shaped. Because they do not fit together perfectly, the hip bones rub against each other and cause damage to the joint.” Osteitis pubis is defined as “inflammation of the pubis symphysis”

The study involved seven consecutive adult patients with a mean age of 33 years who underwent arthroscopic surgery for FAI and endoscopic pubic symphysectomy for OP (mean follow-up period of 2.9 years). The mean preoperative VAS score of 6.7 improved to a mean postoperative visual analog scale (VAS) score of 1.5. The mean preoperative Non-Arthritic Hip Score (NAHS) of 50.2 points improved to a mean postoperative NAHS of 84.7 points. The mean patient satisfaction rating was 8.3.

Asked what led to this research, Dr. Matsuda told OTW, “In 2008, a young athlete presented to our clinic with symptomatic bilateral femoroacetabular impingement and recalcitrant osteitis pubis. She successfully underwent bilateral arthroscopic surgeries for FAI and endoscopic pubic symphysectomy for her athletic OP. After publishing this as a case report in 2010, we have noted much interest in the topic of FAI and OP, the latter being just one of several conditions called athletic pubalgia [sports hernia]. A causative relationship is hypothesized that constrained range of hip motion from FAI causes an increase in transfer stress to the pubis symphyseal region [area of the pubis symphysis] with resultant OP. But at least one study showed that just performing FAI surgery did not consistently eradicate the central pubic symptoms from associated athletic publagia; concomitant procedures for FAI and OP were recommended, which is the basis of our work.”

“From the patient’s perspective, the ability to choose outpatient surgery for FAI and OP in co-afflicted athletes is very attractive. Endoscopic pubic symphysectomy (EPS) appears to be a relatively safe procedure with promising outcomes and the procedure nicely complements arthroscopic FAI surgery in co-afflicted patients. Moreover, although historically used in recalcitrant cases, EPS may provide a quicker return to sport because athletes with OP tend to have a very protracted course with nonsurgical treatment.”

“From the provider’s perspective, this work, along with others, may help put athletic pubalgia on our radar screens and in our differential diagnoses. Many patients with FAI also have athletic pubalgia. Although OP is but one form of this, and a condition that we now prefer to treat using EPS, even adductor and rectus abdominis pathology may soon be treated using similar endoscopic techniques. At our hip preservation center, we realize the broader need for diagnostic and surgical expertise beyond conditions amenable to arthroscopy/endoscopy, which is why we collaborate with Dr. Craig Smith for athletic pubalgia/sports hernia surgery and Dr. Joel Matta for some of our osteotomy-based procedures.”

“This research, the first multicenter case series on this topic, is a preliminary work with 2-5 year outcomes from the United States and Spain. As more experience and numbers of patients is gained, we hope to continue to add to the orthopedic literature in hopes of benefiting our surgeon-colleagues across the globe…and the patients that they serve.”