Pubic symphysis osteomyelitis is a rare complication of hernia repair. It is associated with significant morbidity following open or laparoscopic inguinal hernia repair. Despite the phenomenal number of hernia repair surgeries being performed around the world, the reported incidence of osteomyelitis is relatively less [1, 2, 3, 4]. It is often misdiagnosed as osteitis pubis (OP) and due to its relatively rare nature, the diagnosis and treatment are often delayed. We present a case of pubic symphysis osteomyelitis after a laparoscopic bilateral inguinal hernia in a 41-year-old male.

A 41-year-old male was referred to the orthopedic outpatient with complaints of diffuse lower back pain, perineal pain, and lower limb pain for the past 8 weeks in February 2022. Bilateral laparoscopic hernia repair with mesh was performed in November 2021 for bilateral inguinal hernia. The patient had been complaining of pain after 2 weeks of surgery and there had been no pain-free interval since. The pain was dull, throbbing in nature, and non-specific with no aggravating or relieving factors. The patient did not have fever or any constitutional symptoms. The pain did not resolve with over-the-counter medications. He had not suffered from similar symptoms before the surgery. The patient had congenital deafness and no other significant past history of illness. Initial management with analgesics and fomentation did not relieve the pain. The patient was referred to the pain clinic for management but the pain was not relieved. On examination, there was no abdominal tenderness. Tenderness was present over the ischial tuberosity on the left side, there was no joint line tenderness around the hip, and movements around the hip and knee were painless. There were no spinal tenderness and no neurological involvement. There were no sinuses, wounds, or areas of discharge present around the hip and thigh region. A plain radiograph in December 2021 of the pelvis revealed no obvious bony abnormality with mesh tacks seen on the bilateral superior pubic rami (Fig. 1). A repeat X-ray in February 2022 revealed marginal erosions with few sclerotic areas (right more than left) in both the pubic symphysis suggestive of OP/osteoarthritic changes (Fig. 2). A magnetic resonance imaging (MRI) scan revealed an altered marrow signal in the pubic symphysis, edema in the gluteus maximus on the right side, and collection in the peri-vesicalspace. Contrast-enhanced MRI of the pelvis showed a collection adjacent to the right ischial tuberosity and marrow edema in the symphysis and bilateral pubic rami (Fig. 3). CT-guided aspiration yielded 5 ml of seropurulent fluid. Cytology after aspiration from the collection showed a mixed inflammatory infiltrate with predominant neutrophils with histiocytes some lymphocytes and plasma cells. The fluid culture did not show any growth and CBNAAT for mycobacterium tuberculosis was negative. The patient was started on oral clindamycin and clarithromycin for 6 weeks. At the end of 4 weeks, the patient was painless and signs of healing in previously lytic areas were noted on plain radiographs (Fig. 4). The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) also decreased with therapy (Graph 1). The patient reported that he was able to perform his normal activities as well.

Osteomyelitis of pubic symphysis has been described following urosurgical and gynecological procedures, cardiac
catheterization, intravenous drug use, pregnancy, and invasive procedures such as cardiac catheterization [1, 4, 5, 6, 7, 8, 9, 10]. In a review of pubic osteomyelitis by Ross and Hu, only two out of 100 cases of pubic osteomyelitis were attributed following herniorrhaphy ^[10]. The role of anchoring the posterior wall repair to the periosteum of the tubercle has been attributed to be a significant risk factor in the development of pubic symphysis osteomyelitis ^[1]. This relative rarity makes its diagnosis and subsequent management challenging causing a significant delay in the initiation of treatment. Typical presenting features are inguinal or thigh pain and fever with tenderness in the pubic region and waddling or antalgic gait with described risk factors ^[10]. Laboratory parameters show an increased total lymphocyte count with increased inflammatory markers and radiological evidence of osteomyelitis on plain radiographs, CT scans, or MRIs [1, 2, 3, 4, 10]. The most common differential diagnosis to pubic osteomyelitis is OP which is a non-infective self-resolving inflammation of the pubic joints which is often managed conservatively with analgesics. With the similar presentation and contrasting management of both these clinical entities, it is important to recognize and differentiate these entities. Symmetrical involvement increased time from surgery to clinical manifestations, normal inflammatory markers, and lack of resolution following antibiotic therapy differentiate OP from pubic osteomyelitis ^[2]. OP is managed with analgesics, bed rest, and corticosteroids, and surgery is rarely indicated ^[2]. The comparison between the two clinical entities has been summarized in Table 1 [11, 12]. Increased levels of inflammatory markers such as ESR and CRP as well as positive blood / aspirate cultures are highly suggestive of pubic osteomyelitis. Pubic osteomyel it is is managed effectively using or alorintravenous antibiotics for 6 week s, surgery is indicated when frank abscess formation occursor when foreign bodies like meshorsuture anchors are left in situ [ 2 , 3 , 4 , 1 0 ]. In contrast, OP oral or injectable steroids along with analgesics are the recommended treatment. It is imperative to obtain a correct diagnosis before initiating management. A review of studies reporting infective pubic osteomyelitis is shown in Table 2.

Pubic symphysis osteomyelitis and OP are clinically similar entities. Making the appropriate and timely diagnosis, as well as initiation of appropriate treatment, is essential for the effective resolution of both.

Pubic symphysis osteomyelitis is a relatively rare complication of hernia repair. Persistence of pain and increased inflammatory markers provide a clue to the diagnosis. Obtaining tissue cultures are the gold standard to direct antibiotic therapy.