1. Chronic Symptomatic Symphyseal Instability M.L. Chip Routt, Jr., M.D.

2. Patient #1 28 yo Female G1P1 2.5 Years after NSVD of Term Baby Son Anterior and Posterior Chronic Pain Unable to Walk > 100 ft Unable to Lift/Carry Son Dyspareunia & Stress Urinary Incontinence Employed-Sedentary Job-Computer Work-Fulltime “Relatively Comfortable” Sitting 45-60 Minute Intervals Takes No Medications – “Nothing Works, Why Take Them?” Pelvic Instability on Compression Exam, Causes Pain

3. Presentation Pelvic Films AP

4. Presentation Pelvic Films Alternating LE Standing Films

5. Pelvic CT Scan In Binder

6. Pelvic CT Scan Axials @ S1 & S2 SI Joints

7. Surgery Supine Pfannenstiel Unstable Symphysis Compressive Reduction Clamped Symphyseal Plating – Frail Bone Perc Upper and 2 nd Sacral Segment IS Screws

8. Postop CT Imaging

9. Axials @ S1 & S2 Levels

10. Rehabilitation 1 st 6 Weeks - Bed or Chair Restricted and Isometrics “Marginally Compliant” Due to “Comfort” 2 nd 6 Weeks - Tandem Bilateral Protected WB, Stretching, Strengthening Program, Aquatic Program Non-Compliant Due to “Comfort”

11. 4 Months After Surgery Plain Films Notable Plate Segmental Breakage

12. 4 Months After Surgery No Pain Complaints Normal Gait without Distance Limit Lifts/Carries Son “Normal” Sexual Activity No GU Complaints Still Working FT

13. Patient #2 51yo Male Was D1 College Baseball Player “back in the day” Remained Fit & Active Executive - Employed FT 8-12+ Years Progressive Pelvic-Groin-Back Pain Anterior Pelvic “Grinding” Bilateral Posterior Pelvic Pain Worsened By Essentially Any Activities Antalgic Gait Dyspareunia (But Fights Thru It!) Has Had Spinal Injections Without Relief – Body MRI In Hand ? Pelvic Instability on Exam

14. Plain Films Inlet-Outlet

15. Initial Plain Films Single LE Alternating Stance Films

16. Pelvic CT Imaging SI Joints

17. Surgery Supine Pfannenstiel Fluid Filled “Cyst” Around Unstable Symphysis Compressive Reduction Clamped Symphyseal Plating Perc Bilat IS Screws at Upper Sacral Segment

18. Postop Imaging CT Scan

19. Rehabilitation 1 st 6 Weeks - Bed or Chair Restricted and Isometrics 2 nd 6 Weeks - Tandem Bilateral Protected WB, Stretching, Strengthening Program, Aquatic Program “Very” Compliant Due to “Fear of Pain Return”

20. 3 Months After Surgery Left Adductor Sporadic “Cramping” No Prior Pelvic & Low Back Symptoms “Slowly Evolving Normal-Pareunia” “Scared and Cautious Recoverer” Back to Work Durable Implants Thus Far

21. 3 Months After Surgery Plain Films No Implant Breakage….Yet!