The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept.

PURPOSE: Adductor 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. METHODS: A 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. RESULTS: The 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. CONCLUSION: The 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

Hip injuries

Sommaire du numéro : 'Neuromuscular hip biomechanics and pathology in the athlete' (M.R.Torry, M.L.Schenker, H.D.Martin, D.Hogoboom,M.J.Philippon) ; 'Clinical examination of the athletic hip' (B.A.Braly, D.P.Beall, H.D.Martin) ; 'Radiographic and MR imaging of the athletic hip' (D.R.Armfield, J.D.Towers, D.D.Robertson) ; 'Pediatric athlete hip disorders' (M.S. Kocher, R. Tucker) ; 'The role of hip arthroscopy in the athletic hip' (J.W.Thomas Byrd) ; 'Labral tears, extra-articular injuries, and hip arthroscopy in the athlete' (S.Bharam) ; 'A new method for acetabular rim trimming and labral repair' (M.J.Philippon, M.L. Schenker) ; 'Arthroscopy for the treatment of femoroacetabular impingement in the athlete' (M.J.Philippon, M.L.Schenker) ; 'Diagnosis and management of traumatic and atraumatic hip instability in the athletic patient ' (M.K.Shindle, A.S.Ranawat, B.T.Kelly) ; 'Microfracture of the hip in athletes' (K.Crawford, M.J.Philippon, J.K.Sekiya, W.G.Rodkey, J.R.Steadman) ; 'Rehabilitation following hip arthroscopy' (S.Stalzer, M.Wahoff, M. Scanlan) ; 'Sports after total hip replacement' (A.G. Yun

Surgical Outcomes of Inguinal-, Pubic-, and Adductor-Related Chronic Pain in Athletes: A Systematic Review Based on Surgical Technique

Background: Controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes. Purpose: To investigate the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level 1 to 4 evidence, mean patient age \u3e15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed. Results: Overall, 47 studies published between 1991 and 2020 were included. There were 2737 patients (94% male) with a mean age at surgery of 27.8 years (range, 12-65 years). The mean duration of symptoms was 13.1 months (range, 0.3-144 months). The most frequent sport involved was soccer (71%), followed by rugby (7%), Australian football (5%), and ice hockey (4%). Of the 47 articles reviewed, 44 were classified as level 4 evidence, 1 study was classified as level 3, and 2 randomized controlled trials were classified as level 1b. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return to play at preinjury or higher level was observed in 92% (95% CI, 88%-95%) of the athletes after surgery to the inguinal area, 75% (95% CI, 57%-89%) after surgery to the adductor origin, 84% (95% CI, 47%-100%) after surgery to the pubic symphysis, and 89% (95% CI, 70%-99%) after combined surgery in the inguinal and adductor origin. Conclusion: Return to play at preinjury or higher level was more likely after surgery for inguinal-related CGP (92%) versus adductor-related CGP (75%). However, the majority of studies reviewed were methodologically of low quality owing to the lack of comparison groups

Decision Making in Borderline Cases between Hip Preservation and Reconstruction Surgery

The hip joint is the center of human body movement. An optimal hip function is critical for general health, mental health and well-being. A frequent dilemma in orthopedic practice is what to recommend to a patient with hip pain who is neither the ideal candidate for hip preservation surgery nor for total hip arthroplasty. What are the factors to be considered when deciding between a hip preservation or replacement surgery? This chapter aims to help orthopedic surgeons to decide between hip preservation or total hip arthroplasty as the primary surgery for borderline cases. Chondral damage, age, acetabular dysplasia, femoral torsion abnormality, lumbar spine disease, patient expectation, abnormalities in more than one hip layer, comorbidities, and psycho-social determinants are the main factors to be considered on decision-making for hip surgery. Conservative management, hip arthroscopy, hip osteotomy, and total hip arthroplasty can also be seen as a continuum of treatment