Ramiplasty

The pelvis is a ring of bone. At the front, two thin bars of bone on each side, called the pubic rami, connect the hip area to the pubic bone in the middle. These bars are narrow, and when bones are weak, they can break.

Symptoms are pain in the groin, the front of the pelvis or the inner thigh, sharply worse when you stand, walk or put weight on one leg. Many people cannot walk without a walker, and some cannot get out of bed. Pubic ramus fractures often come with a hidden crack in the sacrum at the back of the pelvis, because the pelvis is a ring and tends to break in more than one place.

On CT, the fracture appears as a thin dark line or a break across the narrow bar of pubic bone. MRI shows swelling around a fresh break and can reveal cracks elsewhere in the pelvis that X-rays miss.

Ramiplasty, also called pubic ramus cementoplasty, is a cousin of kyphoplasty and sacroplasty. Using CT scans, and sometimes live X-ray, the doctor guides a needle into the broken bone and slowly injects medical-grade bone cement (PMMA). The cement hardens within minutes and acts like an internal splint. It reduces movement at the break, which is the main source of pain, and supports the bone so you can put weight on it.

We want to be clear: ramiplasty is a specialized procedure. It is done at relatively few centers, and the evidence for it comes from smaller studies, not large randomized trials. It is considered when standard care has not worked well enough, or when cancer has weakened the bone.

Most pubic ramus fractures from osteoporosis heal on their own over 6 to 12 weeks with pain medicine, physical therapy, a walker and time. That remains the first choice for most people. Ramiplasty may be considered in specific situations.

For cancer in the bone, radiation therapy is often used to control pain and the tumor. Cement can be combined with radiation, and sometimes with a tumor ablation in the same session. Your oncologist, orthopedic surgeon and our team decide together what is best.

More general advice is on before your procedure and sedation.

1. 1
   Preparing

   You lie on the CT table, usually on your back. You receive sedation or general anesthesia and antibiotics through your IV. The skin is cleaned and numbed.

2. 2
   Placing the needle

   Using CT images, the doctor guides a hollow needle into the broken pubic bone, often from the side of the hip or near the groin, staying clear of the hip joint, bladder, nerves and blood vessels.

3. 3
   Injecting the cement

   Thick bone cement is injected slowly while CT or X-ray images check that it stays in the bone. Sometimes a bone sample is taken first if cancer is suspected.

4. 4
   Finishing

   The needle is removed and the puncture is covered with a small bandage or skin glue. The procedure usually takes about 1 hour, longer if other fractures are treated in the same session.

You lie flat for about 1 to 2 hours while the cement fully hardens. Many people go home the same day. Those who were already in the hospital, or who need help getting walking again, may stay a night or longer.

1. First day
   Rest. Soreness at the needle site is normal. A nurse or therapist helps you stand and walk with your walker when ready. No driving after sedation.
2. First week
   Walk several times a day with support. Many people notice easier standing and walking within days. Shower after 24 hours, but no baths or pools for 1 week.
3. Weeks 2 to 6
   Continue physical therapy and slowly reduce the walker as balance and strength allow. Your doctor may taper pain medicines.
4. Longer term
   Treating bone strength or the cancer becomes the focus, to prevent more fractures.

In published case series, most people treated with ramiplasty reported less pain and easier walking, often within days. These studies are small and not all compare against standard care, so we cannot promise a specific result. Some people have little change.

I see ramiplasty as a problem-solving tool for a small group of patients, often older adults who were independent until a fall and are now stuck in bed because every step hurts. I look closely at the CT to make sure the break is in a spot I can reach safely and that there is not a second fracture that is really causing the pain. I am honest that the evidence is limited, and I only recommend it when I think the chance of helping someone walk again outweighs the risks.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos