Surgery should be considered only when conservative treatment fails. A trial of nonoperative therapy should be attempted for at least 3 months in the initial phase of injury (if seen within 6 months of initial symptoms) including therapy, injections, and anti-inflammatories. However, after 4–6 months from injury or onset of symptoms, less significant improvements with conservative therapy are typically seen (especially with postpartum instability) [18, 30], and a discussion with the patient as to continued conservative vs surgical management is appropriate. Clinical history and physical exam are key for surgical planning. If the patient has pain subjectively in the anterior pelvis/groin as well as posteriorly (right or left SI joint), then consideration to anterior pelvic stabilization as well as posterior SI joint stabilization should be given. Flamingo views are routinely used for assessment and documentation of hemi-pelvic instability, with focus on differential hemi-pelvic motion as opposed to exact numerical measurements of that motion. The one exception to the above “watchful waiting” is the case of acute traumatic pelvic disruption following childbirth. In this case, many authors have suggested this pelvic injury sustained during parturition should be considered along the same lines as traumatic pelvic disruption and classified within the spectrum of open book pelvic injuries [49]. Figure 2 shows a patient without pain prior to delivery. Given the wide separation anteriorly as well as disruption of bilateral SI joints (essentially an anterior-posterior compression type II injury), surgical intervention was undertaken with good early results. Table 1 lists potential surgical indications.

Surgical treatment of pelvic instability and osteitis pubis is limited to case series alone and can be divided into anterior and posterior fixation strategies. Anteriorly, reports of surgery including curettage of the symphysis, polypropylene mesh, and stabilization with or without bone grafting have been reported [26, 50]. Choi et al. identified six case series of surgical intervention for osteitis pubis [4]. A total of 25 athletes have been reported as treated with simple curettage of the pubic symphysis [4]. Of those patients, 72 % were able to return to sport at an average of 5.6 months [4]. Radic et al. examined the role of pubic symphysis curettage in 23 patients who had failed conservative therapy [51]. While pain scores did not statistically differ pre- and postoperatively, 61 % of patients were able to return to full sporting activity. However, 26 % of patients had recurrence of symptoms which resolved with rest and therapy in a range of 8–18 months postoperatively. At final follow-up, 30 % of patients following the procedure were unable to return to their previous level of sporting activity. Surgical stabilization of the anterior pelvic ring with or without bone grafting has been reported in two series with eight patients [4]. Return to sport was noted an average of 6.6 months in those eight patients. Williams et al. treated seven rugby players with osteitis pubis over the course of 12 years who were recalcitrant to conservative therapy [52]. Surgery consisted of pubic symphysis resection, tricortical iliac crest autograft, and plate fixation. Return to play ranged from 5 to 9 months and all patients reported their pain had disappeared and no recurrences were noted at an average of 64 months postoperatively. No major complications were reported. Wedge resection alone of the pubic symphysis has been advocated by some [26, 50]. Grace et al. identified 10 patients with recalcitrant osteitis pubis in which wedge resection of the pubic symphysis was undertaken. While all 10 patients were able to return to their previous level of activities and all reported subjective decreases in pain in the short term, three patients continued to complain of groin pain and one patient had instability at the SI joint following their anterior Resection [26]. It should also be noted there have been reports of posterior instability following anterior wedge resection of the pelvis, resulting in arthrodesis of the SI joints [19]. While the use of bone graft with decortication of the pubic symphysis has been reported with good clinical outcomes in some series [52], it should be noted that series report that up to 30 % of patients may have evidence of hardware loosening with/without hardware failure [29]. Therefore, some authors advocate pubic symphyseal plate fixation with compression alone, finding no benefit or need of formal fusion [19, 53]. Rommens presented three patients in which conservative therapy failed following birth trauma, one of which included posterior instability/injury diagnosed on CT scan [49]. In all patients, anterior plating (with one patient receiving sacral bars) lead to resolution of pain and return to function [49]. In the specific case of osteitis pubis, there is some data to suggest that elite athletes operatively managed fair better and return to sport quicker than those treated conservatively [37]. In Paajanen et al.’s examination of eight patients treated operatively vs eight patients treated conservatively, all eight surgically treated patients had returned to their elite level of athletic competition at 1-year follow-up compared with only 50 % of those treated conservatively. In a separate evaluation, polypropylene mesh was placed in five patients with recalcitrant osteitis pubis [54]. All five patients were pain-free at one month and had returned to full activity by 1 year.

Numerous techniques for posterior fixation/fusion have been described. Buchowski et al. examined 20 patients in which a formal SI joint fusion via plating was performed through a Smith-Peterson approach [47]. Improvement in functional outcomes occurred in all patients after surgery. However, three nonunions occurred along with two deep infections, indicating the procedure is not without morbidity. Kibsgard et al. reported on open SI joint fusions (unilateral, bilateral, or with anterior plating) in which 84 % of patients had an underlying diagnosis of SI joint pain either secondary to pregnancy or “idiopathic” [55]. They noted no significant difference in functional outcomes between surgical and nonsurgical management with up to 23-year follow-up [55]. More importantly, long-term outcomes trended toward outcomes seen at 1-year follow-up, highlighting that recovery may progress for up to 1 year post surgery with little improvement after that time. Some authors have suggested percutaneous screw fixation alone is sufficient to limit motion as opposed to formal fusion with good clinical results [23, 53]. Van Zwienen et al. described their technique of anterior plating (either with or without wedge iliac crest grafting) along with posterior percutaneous screw placement in a cohort of 58 patients with postpartum pelvic pain [23]. In their series, statistical improvement in functional outcome was found at 12 and 24 months. Improvements from 20 wheelchair-bound and eight bed-bound patients fell to four in each group, respectively. However, 30 % of patients improved less than ten points in the Majeed score. Recently, hollow screws filled with bone graft have been utilized in a percutaneous fashion to treat SI joint pathology, including pelvic dysfunction and instability [56–58]. Improvements were seen in 87 % of patients utilizing validated outcome questionnaires with minimal complications [56]. In the patient with acute birth trauma and pelvic ring disruption, surgical decision-making should follow that of pelvic ring trauma. As these injuries are almost universally open book (anterior-posterior compression injuries), fixation of the anterior pelvis with or without sacral fixation is warranted. External fixation is typically reserved for patients who present immediately postpartum as the anterior approach/Pfannenstiel incision can cause significant bleeding secondary to venous engorgement within the space of Retzius immediately postpartum.