Pubic Ligament Research Articles

New Anatomical Concepts regarding Pubic-Related Groin Pain: A Dissection Study

ObjectivePubis-related groin pain remains a difficult topic in orthopedic and sports medicine. A better understanding of the anatomy of the adductors and the pubic ligaments is necessary. The aim of this study is to map all the musculotendinous attachments to the pubic ligaments and to investigate in detail all the possible inter-adductor fusions. MethodsThe pubic symphyses were dissected in eight male and fourteen female embalmed cadavers (mean age 85 years), focusing on the fusion between the adductors, pubic ligaments, and musculotendinous attachments at the pubic ligaments. The 95% confidence intervals for the prevalence of the different conjoint tendons and tendon attachment to ligament were calculated. ResultsThe presence of three types of conjoint tendons was found: adductor brevis and gracilis (AB/G) 90.9 [72.2 – 97.5]%; adductor brevis and adductor longus (AB/AL) 50.0 [30.7 – 69.3]%; adductor longus and gracilis (AL/G) 50.0 [30.7 – 69.3]%. The AL, AB and G were in every cadaver attached to the anterior pubic ligament (APL). 64% of the AB and 100% of the G were attached to the inferior pubic ligament (IPL). ConclusionThe proximal anatomy of the adductors is more complex than initially described. This study identified three possible conjoint tendons between the proximal adductors. The AB/G conjoint tendon was significantly more present than the AB/AL or AL/G conjoint tendon. The IPL has attachments only from the AB and G. Rectus Abdominis (RA) and AL were not attached to IPL. Mapping the musculotendinous attachments on the pubic ligaments creates more clarity on the pathophysiology of lesions in this area.

(062) The Physiological Health of the Penile Fibro-Vascular Assembly Requires the Integrity of Ten Fibro-ligaments in the Human Penis

Abstract Introduction Although the human penis has existed on earth for 3000 centuries and extensive studies have been conducted for many recent centuries, there is still room for improvement, particularly in the fibro-ligaments' role in maintaining physiological sexual health. Thus far, there needs to be more interpretation concerning these ligaments. Objective We aimed to explore the penile fibrous ligaments thoroughly to fill this research gap. Methods We excluded cadaveric penises that had both sides of the corpora cavernosa (CC) and corpus spongiosum (CS) damaged. However, penises with one undamaged side of the CC, including the Colles' fascia and the corpus spongiosum, were included. A total of 15 out of 46 penises were meticulously examined. Dissection findings were supplemented with 101 cadaveric photos and data from 263 penile vascular surgeries, 11 CT imaging scans, 8 MRI imaging scans, eight hypospadias surgeries, and eight penile elongation surgeries performed elsewhere internationally. Results Bilaterally, the penile CC is primarily anchored to the pelvis wall through the unilateral cavernosal ligament bilaterally (CL=2), while the CS is connected to the urinary sphincter. The suspensory, fundiform, and arcuate pubic ligament (two anatomically and one functionally) assist in stabilizing and holding the penile shaft to the pelvic wall. Distally, a distal ligament (DL=1) and spongiosal ligament (SL=1) extend the CC and CS to the glans penis and frenulum, ensuring urethra patency when required. The CC is encircled by a bi-layered tunica consisting of a 360° inner circular tunica and a 300° outer longitudinal coat. The ischiocavernosus muscle wraps around the penile crus and envelops the CL connecting to the ischial tuberosity. The CS is partially secured by the bulbospongiosus muscle proximally and receives the SL distally. The entire penis interconnects with the skeletal muscle of the urogenital diaphragm eventually. Conclusions The physiologically sexual health of the human penis's hydraulic system relies on the integrity of ten anatomically and six functionally fibro-muscular ligaments. Disclosure No.

CAUSES OF INGUINAL HERNIAS RECURRENCE DURING THE LIECHTENSTEIN OPERATION

Numerous methods of plastic surgery of inguinal hernias with own tissues, which were developed by surgeons, gave relapses up to 35%. A large number of relapses in the treatment of inguinal hernias with tension methods forced surgeons to look for new ways to solve this problem.
 Without pathological changes in the deep inguinal ring, a hernia cannot occur, and this leads to the conclusion that all existing methods, which are aimed at strengthening only the front wall of the inguinal canal, are pathogenetically unfounded and often a recurrence of the hernia can be expected.
 Therefore, a justified operation for various types of inguinal hernia is the strengthening of the deep ring and the back wall of the inguinal canal.
 Changing the concept of the approach to the treatment of inguinal hernias should be aimed at minimizing trauma and take into account the pathogenetic features of the development of hernias.
 The reason for the development of inguinal hernias is expansion, destruction, functional insufficiency of deep inguinal openings: medial and lateral.
 The back wall of the inguinal canal does not have a protective function when intraperitoneal pressure increases and cannot resist hernia formation. At the same time, its weakening, destruction can contribute to the increase of the internal inguinal opening. Although we did not come across any publication that gave an example of a hernia exiting directly through the back wall of the inguinal canal.
 Based on our own clinical experience, as well as the processing of a large number of literary sources, we offer a modified type of Lichtenstein's operation in the following interpretation: a typical incision of the skin and subcutaneous tissue with the opening of the aponeurosis of the external oblique abdominal muscle; mobilization of the spermatic cord; mobilization of the hernia sac, its opening, stitching at the base and removal. With a direct inguinal hernia, if the bag is small, there is no need to remove it. Revision of the internal inguinal ring in case of an oblique hernia and, if necessary, sewing it to the required size (the tip of the little finger should pass between the cord and the ring).
 Revision of the medial deep ring in direct inguinal hernia and its suturing "tightly" over the hernial protrusion.
 Prepare a mesh implant so that its dimensions cover both deep holes, dissect it according to our proposed method. Fix the net to the deep ring using the described method. Sew the lower part of the mesh with an overlap of 1-1.5 cm to the pubic bone, fix the lateral edge of the implant to the pubic ligament with a wrapping suture or knotted single sutures.
 Above the spermatic cord, the legs of the dissected implant are sewn together and sewn to the aponeurosis of the external oblique muscle of the abdomen from below.
 The medial edge of the mesh is sewn to the internal oblique muscle and to the aponeurosis of the external oblique muscle in the manner described above.
 The middle part of the mesh is fixed to the sewn medial deep inguinal ring and to the middle of the inguinal canal with separate knotted stitches. We lay the spermatic cord on the mesh, over which we sew the aponeurosis of the external oblique muscle of the abdomen, subcutaneous tissue and skin.
 In our opinion, the method of surgery proposed by us for direct and oblique inguinal hernias is the most optimal, minimally traumatic, which best meets the modern requirements of the pathogenesis of the disease. But even this method of plastic inguinal hernias is not ideal and needs constant improvement.

New insights into the musculotendinous and ligamentous attachments at the pubic symphysis: A systematic review

ObjectiveCollection and meta-analysis of all relevant anatomical studies related to the pubic symphysis to provide a state of the art review of its musculotendinous and ligamentous attachments from 2010 to date. MethodsA systematic search of published literature databases (PubMed, Web of Science and Embase) was conducted according to the PRISMA guidelines from January 2010 up until now. All papers investigating the anatomy of the musculotendinous attachments of the pubis and the pubic ligaments were eligible. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS scale). A narrative analysis approach was adopted to synthesize the findings. ResultsAfter screening and review of 1313 papers, a total of six studies investigating the anatomy of the pubic ligaments and tendons were included. Of the six articles included in this systematic review, five articles performed a macroscopic anatomical dissection, three articles performed a microscopic (histological) study, and one article combined microscopic examination with an MRI imaging examination. The anatomy of the pubic symphysis was examined in 76 anatomical cadavers (60 embalmed, 16 fresh frozen). In total 44 male cadavers (58%), 28 female cadavers (37%) and four cadavers whose gender was not stated were dissected. ConclusionThe age-old accepted concept of the fusion of the rectus abdominis with the adductor longus via the aponeurotic plate is outdated. New anatomical concepts like the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC), recto-gracilis tendon, fusion of adductor brevis with gracilis, etc. are recently introduced. The awareness of anatomy and morphology of the pubic ligaments plays a significant role in understanding the diagnosis and treatment of groin pain.

A Morphologic Analysis of the Pubic Symphysis Using CT and MRI.

The goal of this study was to investigate prevalence and morphometric parameters of pubic ligaments and the interpubic disk and its cavity using imaging methods for use in clinical medicine. Pubic symphysis morphology was investigated in 652 patients (348 women and 304 men), from which 449 CT scans and 203 MR scans were available. The average age of men was 48 years and women 39 years. Investigated parameters included dimensions of the interpubic disk, visibility and width of the reinforcing ligaments, and visibility, dimensions, and location of the symphysial cavity. The results were compared with MR scans of 20 healthy volunteers and 21 dissected anatomic specimens. The craniocaudal, ventrodorsal, and mediolateral diameters of the pubic disk were 36 to 37.7, 14.8 to 15.2, and 2.2 to 4.2 mm in women and 42 to 42.3, 18.6 to 19, and 2.4 to 4.5 mm in men, respectively. Higher age correlated with shorter mediolateral diameter and larger craniocaudal and ventrodorsal diameters. The superior pubic ligament was visible in 93.1% of men (1.44 mm thick) and in 100% of women (1.7 mm); the inferior pubic ligament in 89.7% of men (1.74 mm) and 88% of women (1.95 mm), the anterior pubic ligament in 96.6% of men (1.5 mm) and 82% of women (1.34 mm); and the posterior pubic ligament in 65.5% of men (1.18 mm) and 63.7% of women (0.83 mm). A symphysial cavity was found in 24% of men and 22.9% of women, with craniocaudal, ventrodorsal, and mediolateral dimensions of 13, 10.7, and 3.2 mm in men and 9.5, 10.7, and 3 mm in women, respectively. The presented morphologic parameters provide an anatomic reference for diagnostics of pathologic conditions of the pubic symphysis. The following anatomic structures should be added to the official anatomic terminology: symphysial cavity (cavitas symphysialis), retropubic eminence (eminentia retropubica), anterior pubic ligament (ligamentum pubicum anterius), and posterior pubic ligament (ligamentum pubicum posterius). II-III.

Anatomic basics and technical approaches: sacral preauricular extensions, preauricular sulci and dorsal pubic pits in modern anatomical specimens.

The aim of this study is the evaluation of three selected osseous pelvic features in modern anatomical specimen - the sacral preauricular extension, the preauricular sulcus and pits on the dorsal side of the pubic bone laterally to the symphysis. The specificity and significance of these features are under debate and their genesis is largely unclear. Descriptive data of specific soft tissue structures surrounding the anterior sacroiliac joint gap and the pubic symphysis were generated by assessing 20 fresh pelves and 12 embalmed hemipelves from human body donors. Computed tomography (CT) was performed on all specimens and three-dimensional (3D) surface models were generated and analysed. Afterwards, all the specimens underwent anatomical dissection and finally maceration. During dissection, it became apparent that the anterior sacroiliac ligament, due to its position, shape and potential impact on the sacroiliac joint and adjacent osseous structures, requires a detailed analysis of its dimension. The most promising result, in terms of the sacral preauricular extension, was that the measurements of the triangular part of the anterior sacroiliac ligament were significantly longer in females than in males. Pelvic floor muscle fibres and fascial parts were directly connected to this ligament in some specimens, which is an important starting point for a larger in-depth study. The evaluation of the anatomic structures in connection to dorsal pitting refutes the assumption that the pelvic floor muscles or fasciae could exert influence on its formation. A histological evaluation of the ligaments of the pubic symphysis, especially the dorsal pubic ligament, would be expedient to clarify the etiology of this feature.

Arthroscopically assisted minimally invasive symphysioplasty for the treatment of pubic related groin pain

Therapy of pubic related groin pain via minimally invasive symphysioplasty. Therapy of refractory pubic related groin pain based on osteitis pubis. Groin pain from causes other than pubic related groin pain. After aminimally invasive approach, an incision in the anterior capsule is made while protecting the dorsal capsule parts and the arcuate pubic ligament. The symphysis end plates are remodeled arthroscopically assisted using asurgical burr. The newly created pubic symphysis joint is filled with autogenous fibrin to support the formation of anew discus interpubicus. Partial weight-bearing for 4weeks with 20 kg using crutches is recommended. During the first 4weeks the range of motion should be restricted. Since2010, 10athletes (7men, 3women; average age 34.1 ± 7.8 (23-47) years) have undergone arthroscopically assisted minimally invasive symphysioplasty and treatment of femoroacetabular impingement syndrome. The average follow-up time was 5.1 (2-9) years. All patients returned to their sport level. The mean preoperative Nonarthritic Hip Score (NAHS) of 64.4 ± 15.1 (32.1-86.5) points improved to amean postoperative NAHS of 91.4 ± 9.8 (62.4-98.75) points (p < 0.0001). The average patient satisfaction (scale0 to10; 10highest satisfaction) was 9.8 ± 0.4 (9-10).

The topography and morphometrics of the pubic ligaments

BackgroundConflicting anatomical reports and the little attention given to the pubic ligaments impede the interpretation of radiological and clinical examinations on groin pain. Morphometric data on the pubic ligaments are lacking. MethodsThe muscular relations of the symphysis pubis were examined in layered dissection (n = 10), hemipelves (n = 60) and (un)stained plastinated body slices of body donors (n = 3). The sagittal and coronal areas, width, mean and maximum thickness of pubic ligaments were determined. ResultsThe adductor longus, brevis, rectus abdominis and pyramidalis muscles are attached to the anterior pubic ligament (APL). The adductor brevis and gracilis muscle are connected to the inferior pubic ligament (IPL). The IPL and superior pubic ligament (SPL) are thicker than the APL and posterior pubic ligament (PPL). The PPL is the thinnest pubic ligament. The APL has a larger sagittal area in women than in men compared to the IPL. The SPL and IPL are thicker in men compared to women. ConclusionThe APL is the ligamentous anchor for the originating and inserting muscles. Investigations of the pubic ligaments might help to determine symphysis instability or severity of injury and should be included as a further criterion for surgical management.

Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes

PurposeThe purpose of the study is to review the MRI findings in a cohort of athletes who sustained acute traumatic avulsions of the adductor longus fibrocartilaginous entheses, and to investigate related injuries namely the pyramidalis–anterior pubic ligament–adductor longus complex (PLAC). Associated muscle and soft tissue injuries were also assessed.MethodsThe MRIs were reviewed for a partial or complete avulsion of the adductor longus fibrocartilage, as well as continuity or separation of the adductor longus from the pyramidalis. The presence of a concurrent partial pectineus tear was noted. Demographic data were analysed. Linear and logistic regression was used to examine associations between injuries.ResultsThe mean age was 32.5 (SD 10.9). The pyramidalis was absent in 3 of 145 patients. 85 of 145 athletes were professional and 52 competed in the football Premier League. 132 had complete avulsions and 13 partial. The adductor longus was in continuity with pyramidalis in 55 athletes, partially separated in seven and completely in 81 athletes. 48 athletes with a PLAC injury had a partial pectineus avulsion. Six types of PLAC injuries patterns were identified. Associated rectus abdominis injuries were rare and only occurred in five patients (3.5%).ConclusionThe proximal adductor longus forms part of the PLAC and is rarely an isolated injury. The term PLAC injury is more appropriate term. MRI imaging should assess all the anatomical components of the PLAC post-injury, allowing recognition of the different patterns of injury.Level of evidenceLevel III.

Three-Dimensional Finite Element Analysis of the Effects of Ligaments on Human Sacroiliac Joint and Pelvis in Two Different Positions.

To present the ligament effects on sacroiliac joint (SIJ) stability and human pelvis biomechanical characteristics in two different positions by using three-dimensional (3D) finite element (FE) models of pelvis. Based on the computed tomography (CT) data of human pelvis, three-dimensional FE models of human pelvis in sitting and standing positions were established, which include the bone (sacrum, ilium, and coccyx) and six ligaments (sacroiliac, sacrospinous, sacrotuberous, inguinal, superior pubic, and arcuate pubic ligaments). 600 N vertical load was applied at the upper surface of sacrum to analyze the stress and displacement distribution of pelvis and SIJ. The simulation results demonstrated that the maximum stresses of sacrum and ilium on SIJ contact surface were 5.63 MPa and 7.40 MPa in standing position and 7.44 MPa and 7.95 MPa in sitting position. The stresses of ligament dysfunction group were higher than that of health group, which increased by 22.6% and 35.7% in standing position and 25.2% and 43.6% in sitting position in sacrum and ilium. The maximum displacements located on the upper surface of sacrum, which were 0.13 mm and 1.04 mm in standing and sitting positions. Ligaments dysfunction group increased 30.7% and 9.6% than health group in standing and sitting positions. The integral displacement of pelvis was greater in sitting position. The location of stress concentration and displacement distribution of pelvic bone are closely resembled previous research results in two different positions. The simulation results may provide beneficial information and theoretical models for clinical research of pelvic fracture, joint movement, and ligament functional injuries, and so on.

MR imaging-anatomical-histological evaluation of the abdominal muscles, aponeurosis, and adductor tendon insertions on the pubic symphysis: a cadaver study

PurposeTo perform an MR(magnetic resonance) imaging, anatomical, and histological evaluation of the abdominal muscles and adductor tendon insertions. MethodFour fresh cadaveric pelvis specimens were imaged at 3 T with the following imaging parameters: TE (echo time)/TR (repetition time): 20, 4090, slice thickness: 2 mm, FOV: 270 × 90, matrix size: 512. Anatomical slices were obtained with a band saw and photographed. MR images and photographs were evaluated by an anatomist and radiologist. Selected 3 mm thick slices were placed in formalin and decalcified, cut, placed on large slides, and stained with hematoxylin eosin stain (HES). ResultsThe main adductor tendon insertions are: the anterosuperior aspect of the pubic bone for the adductor longus, the anteroinferior aspect of the pubic bone - for the adductor brevis, and the inferior aspect of the pubic bone for the adductor magnus. On histology, the adductor longus tendon fibers inserted perpendicularly into the bone at a fibrocartilage enthesis and cross connected along the anterior pubic ligament into the controlateral tendon. The rectus abdominis-pyramidalis unit was covered by a thin anterior and posterior aponeurosis. The posterior aponeurosis inserted into the superior aspect of the anterior pubic ligament, whereas the anterior aponeurosis fused distally with the adductor longus tendons. ConclusionOur findings demonstrate the insertions of the adductor tendons, on the pubic ligament and pubic bone.Histologically, the adductor longus tendon fibers inserted perpendicularly into the bone through a fibrocartilage enthesis, and cross connected along the anterior pubic ligament into the contralateral tendon.

Design and Synthesis of Potent, Long-Acting Lipidated Relaxin-2 Analogs.

Peptide hormone relaxin-2, a member of the insulin family of peptides, plays a key role in hemodynamics and renal function and has shown preclinical efficacy in multiple disease models, including acute heart failure, fibrosis, preeclampsia, and corneal wound healing. Recently, serelaxin, a recombinant version of relaxin-2, has been studied in a large phase 3 clinical trial (RELAX-AHF-2) for acute decompensated heart failure patients with disappointing outcome. The poor in vivo half-life of relaxin-2 may have limited its therapeutic efficacy and long-term cardiovascular benefit. Herein, we have developed a semisynthetic methodology and generated potent, fatty acid-conjugated relaxin analogs with long-acting pharmacokinetic (PK) profile in rodents. The enhanced PK properties translated into improved and long-lasting pharmacodynamic effect in pubic ligament elongation (PLE) studies. The resultant novel relaxin analog, R9-13, represents the first long-acting relaxin-2 analog and could potentially improve the clinical efficacy and outcome for this important peptide hormone. This semisynthetic methodology could also be applied to other cysteine-rich peptides and proteins for half-life extension.

Effects of Cutting the Sacrospinous and Sacrotuberous Ligaments.

The sacrospinous (SS) and sacrotuberous (ST) ligaments form a complex at the posterior pelvis, with an assumed role as functional stabilizers. Experimental and clinical research has yielded controversial results regarding their function, both proving and disproving their role as pelvic stabilizers. These findings have implications for strategies for treating pelvic injury and pain syndromes. The aim of the present simulation study was to assess the influence of altered ligament function on pelvis motion. A finite elements computer model was used. The two-leg stance was simulated, with the load of body weight applied via the fifth lumbar vertebra and both femora, allowing for nutation of the sacroiliac joint. The in-silico kinematics were validated with in-vitro experiments using the same scenario of load application following SS and ST transection in six human cadavers. Modeling of partial or complete ligament failure caused significant increases in pelvis motion. This effect was most pronounced if the SS and ST were affected with 164% and 182%, followed by the sacroiliac and iliolumbar ligaments with 123% and 147%, and the pubic ligaments with 113% and 119%, for partial and complete disruption, respectively. Simultaneous ligament transection multiplied the effects on pelvis motion by up to 490%. Unilateral ligament injury altered the motion at the pelvis contralaterally. The experiments presented here provide strong evidence for the stabilizing role of the SS and ST. A fortiori, the instability resulting from partial or complete SS and ST injury merits consideration in treatment strategies involving these ligaments as important stabilizers. Clin. Anat. 32:231-237, 2019. © 2018 Wiley Periodicals, Inc.

Improvement of continence with preservation of pelvic stabilized structure in patients undergoing robot-assisted laparoscopic radical prostatectomy

Objective To investigate the effect of pelvic floor stabilized structure preservation (PPSS) during robot-assisted laparoscopic radical prostatectomy (RARP) on postoperative continence recovery. Methods From October 2017 to April 2018, 86 patients with prostatic cancer who underwent traditional RARP and RARP plus PPSS were included. There were 31 patients in non-PPSS group and 55 patients in PPSS group. In non-PPSS group, patients age was (68.48±7.79) years old, BMI was (24.79±3.05) kg/m2, median prostate volume was 63.54 (53.00-99.36)cm3, clinic T-stage T1-T2, T3, T4 accounted for 49.39%, 22.58%, 6.45% and ISUP grade 1, 2, 3, 4, 5 accounted for 22.58%, 22.81%, 12.90%, 12.90%, 19.35% respectively. In PPSS group, patients age was (69.53±6.81) years old, BMI was (23.95±3.03) kg/m2, median prostate volume was 73.39 (54.88-94.23)cm3, clinic T-stage T1-T2, T3, T4 accounted for 72.73%, 7.27%, 3.64% and ISUP grade 1, 2, 3, 4, 5 accounted for 21.82%, 18.18%, 23.64%, 18.18%, 10.91% respectively. The preoperative PSA, BMI, clinical T-stage, ISUP grade, and postoperative hospital days had no significant differences(P>0.05) between the two groups.Both groups were operated via transperitoneal approach. In the non PPSS group, endo-pelvic fascia and pubic prostate ligament was cut, and dorsal vessel complex was ligated. In PPSS group, the partial endo-pelvic fascia was bluntly pushed to the pelvic wall to preserve tendon arch, and pubic prostate ligament also was preserved without suturing and ligating dorsal vascular complex. The catheter was removed 7 d after RARP. The continence recovery were compared between the two groups, including pad number on the day of 1, 7, 14, 30, 90 and ICI-Q-SF scores on the day of 30 and 90 after catheter removal. Results There was no significant difference in pad numbers used between the two groups on the day of 1, 7, 14, 30 after catheter removal. On the 90th day, the proportions of using pad ≥4 in PPSS group were significantly lower than those in non-PPSS group (1.89% vs. 20.69%, P=0.004). No significant difference was found in ICI-Q-SF scores on the 30th and 90th day between the two groups. Univariate analysis showed that PPSS group used less pads than non-PPSS group on the 90th day [OR=0.07(95%CI 0.01-0.65), P=0.019]; T3 patients used more pads than T1-T2 patients [OR=9.19(95%CI 1.32-63.87), P=0.025]. After adjusting for age, ISUP grading, T staging, and PSA, multivariate regression analysis showed that the risk of using pad ≥4 in PPSS group compared with non-PPSS group was 0.46, 0.34, 0.27, 0.25, and 0.03 on the day of 1 , 7, 14 , 30 and 90 after catheter removal, respectively. The PPSS approach didn′t increase the risk of positive surgical margin. Conclusions Preservation of pelvic stabilized structure in RARP is very efficient in term of continence rate after RARP, and it does not increase the risk of positive surgical margin. Key words: Prostatic neoplasms; Robotic assisted laparoscopic radical prostatectomy; Pelvic stabilized structure; Continence

The pyramidalis\u2013anterior pubic ligament\u2013adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept

PurposeAdductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions.MethodsA layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined.ResultsThe pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis.ConclusionThe study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis–anterior pubic ligament–adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

Visualization of Penile Suspensory Ligamentous System Based on Visible Human Data Sets.

BackgroundThe aim of this study was to use a three-dimensional (3D) visualization technology to illustrate and describe the anatomical features of the penile suspensory ligamentous system based on the Visible Human data sets and to explore the suspensory mechanism of the penis for the further improvement of the penis-lengthening surgery.Material/MethodsCross-sectional images retrieved from the first Chinese Visible Human (CVH-1), third Chinese Visible Human (CVH-3), and Visible Human Male (VHM) data sets were used to segment the suspensory ligamentous system and its adjacent structures. The magnetic resonance imaging (MRI) images of this system were studied and compared with those from the Visible Human data sets. The 3D models reconstructed from the Visible Human data sets were used to provide morphological features of the penile suspensory ligamentous system and its related structures.ResultsThe fundiform ligament was a superficial, loose, fibro-fatty tissue which originated from Scarpa’s fascia superiorly and continued to the scrotal septum inferiorly. The suspensory ligament and arcuate pubic ligament were dense fibrous connective tissues which started from the pubic symphysis and terminated by attaching to the tunica albuginea of the corpora cavernosa. Furthermore, the arcuate pubic ligament attached to the inferior rami of the pubis laterally.ConclusionsThe 3D model based on Visible Human data sets can be used to clarify the anatomical features of the suspensory ligamentous system, thereby contributing to the improvement of penis-lengthening surgery.

Biomechanical characteristics of four fixation methods in treatment of pubic symphysis disruption: a finite element analysis

Objective To evaluate the biomechanical characteristics of 4 fixation methods (single reconstruction plate, dual reconstruction plates, single cannulated screw and dual cannulated screws) in the treatment of pubic symphysis disruption. Methods Miniature spiral CT scans were performed on the complete pelvis in 5 healthy volunteers. The primary two-dimensional CT scan data at DICOM format were imported into software Mimics 15.0 for three-dimensional reconstruction of bilateral hips and sacrums. The finite element model of skeletal pelvis was obtained by grid partitioning and assignment using software Abqus 6.13. Models of pubic symphysis disruption were simulated by cutting off the unilateral sacroiliac ligament, sacral spine ligament, sacral tuberosity ligament, pubic ligament and pubic arch. Four implants(single reconstruction plate, dual reconstruction plates, single cannulated screw and dual cannulated screws) were simulated and emplaced onto the models according to standard surgical procedures. Compressive and rotational loads were implemented in all models for finite element analysis. The biomechanical properties were recorded and analyzed, including construct stiffness, micromotion of the pubic symphysis and von Misses stress. Results Under vertical load, the space of pubic symphysis disruption >25 mm. The vertical stiffness and rotational construct stiffness of the pelvis decreased significantly from 442.738±29.946 N/mm and 10.118±1.432 N·m/Deg in the normal group to 14.754±0.876 N/mm and 0.328±0.119 N·m/Deg, respectively. Dual reconstruction plates and dual cannulated screws displayed the best vertical tensile strength; their construct stiffness achieved 117.647±9.193 N/mm and 131.443±4.348 N/mm, respectively. Under anti-rotation load, dual cannulated screws displayed the best performance because they rebuilt 68.6% of the whole structural stiffness. For the local stability of the pubic symphysis, dual reconstruction plates showed a strong local anti-rotation capability and dual cannulated screws a good local anti-tensile capability. The displacement in the dual cannulated screws group was only -0.240±0.119 mm under vertical load while the angular displacement in the dual reconstruction plates group only 0.218°±0.182°. Single reconstruction plate endured the maximum von Misses stress which was obviously concentrated. Conclusion Dual cannulated screws may have biome-chanical advantages for treatment of pubic symphysis disruption. Key words: Pelvis; Finite element analysis; Biomechanical characteristics; Fractures fixation, internal; Comparative study

Assessment of postpartum symphysis pubis distention with 3D ultrasonography: a novel method

ObjectivesDetermining the accuracy of three-dimensional (3D) sonographic measurement of symphysis pubis (SP) distension in comparison to plain X-ray pelvic radiographs and assessing the interperformer reliability of this method. MethodsPelvic X-ray was performed on 86 women who delivered singleton babies within 36h of delivery then each woman was examined by 3D transperineal ultrasound imaging by two sonogrographers. ResultsMeasurements of SP with 3D transperineal ultrasonography in comparison to pelvic X-ray showed 95% limits of agreement. Interperformer reproducibility was substantial (interclass correlation coefficient 0.66–0.70) for measures of SP. ConclusionsPubic symphysis width, superior pubic ligament length, and SP height can be reliably measured with 3D ultrasonography.

Conditional deletion of the relaxin receptor gene in cells of smooth muscle lineage affects lower reproductive tract in pregnant mice.

Relaxin hormone secreted into the circulation during pregnancy was discovered through its effects on pubic symphysis relaxation and parturition. Genetic inactivation of the relaxin gene or its cognate relaxin family peptide receptor 1 (RXFP1) in mice caused failure of parturition and mammary nipple enlargement, as well as increased collagen fiber density in the cervix and vagina. However, the relaxin effect on discrete cells and tissues has yet to be determined. Using transgenic mice with a knockin LacZ reporter in the Rxfp1 allele, we showed strong expression of this gene in vaginal and cervical stromal cells, as well as pubic ligament cells. We produced a floxed Rxfp1 allele that was used in combination with the Tagln-cre transgene to generate mice with a smooth muscle-specific gene knockout. In pregnant females, the ROSA26 reporter activated by Tagln-cre was detected in smooth muscle cells of the cervix, vagina, uterine artery, and in cells of the pubic symphysis. In late pregnant females with conditional gene ablation, the length of pubic symphysis was significantly reduced compared with wild-type or heterozygous Rxfp1(+/-) females. Denser collagen content was revealed by Masson trichrome staining in reproductive tract organs, uterine artery, and pubic symphysis. The cervical and vaginal epithelium was less developed than in heterozygous or wild-type females, although nipple size was normal and the dams were able to nurse their pups. In summary, our data indicate that relaxin/RXFP1 signaling in smooth muscle cells is important for normal collagen turnover and relaxation of the pubic symphysis during pregnancy.

Postpartum diastasis of the pubic symphysis: case report and literature review

Postpartum diastasis of the pubic symphysis has the incidence from 1 in 300 to 1 in 30,000 deliveries. Under the action of progesterone and relaxin, a 1 cm widening of pubic symphysis is considered to be physiological and necessary for normal delivery. However, any higher widening is always pathological, involving the damage of pubic and sacroiliac ligaments. Multiparity has been identified as the only independent risk factor. Because this pathology often manifests as chronic pain in the pubic symphysis region, it is often mistakenly stated as a normal postpartum occurrence. It is only later when the symptoms of pelvic instability and pubic osteitis appear. Postpartum symphysiolysis is a clinical challenge to a physician due to low awareness and the postpartum period important to both the patient and the newborn.