Periostitis of the Pubic Symphysis in Inguinal and Femoral Hernia: An Uninterpreted Source of Chronic Groin Pain.

Background and Objectives: Severe chronic postoperative inguinal pain (CPIP) affects 2-5% of patients after hernia repair, yet most published explanations remain neuropathic. The pubic periosteum, including the tubercle and adjacent symphyseal zone, lies within the operative field and may be engaged by medial mesh fixation. Its contribution to CPIP has not been tested. This narrative review brings together anatomical, imaging and clinical evidence and defines a hypothesis that can be examined prospectively. Materials and Methods: PubMed/MEDLINE, Embase and the Cochrane Library were searched without date restriction, with the final search run in April 2026. Thirty-three publications met the eligibility criteria. Evidence was classified using the 2011 OCEBM Levels of Evidence, with indirectness recorded when the population, exposure or outcome did not match the review question. The review was narrative, so no PRISMA flow diagram or formal risk-of-bias assessment was undertaken. Results: Direct evidence is limited. Among 1633 patients in one retrospective study, six underwent reoperation for severe late pain, and two had a staple placed in the periosteum. Pain resolved after staple removal. Two further cases of MRI-confirmed osteitis pubis followed laparoscopic repair with a titanium tacker. CT found pubic spurs in 17 of 20 patients, although their clinical meaning was uncertain. Fixation trials, CPIP reviews and groin-pain imaging studies repeatedly examined adjacent outcomes but did not define a periosteal endpoint. Conclusions: Pubic periosteal pathology is a plausible and testable pain generator, not an established cause of CPIP. Prospective studies should pair preoperative MRI and standardised pain mapping with explicit recording of fixation at the pubic tubercle. This design would show whether periosteal findings identify a distinct pain phenotype and whether penetrating fixation modifies its course.