Ernest Schilders

Cadaveric and MRI Study of the Musculotendinous Contributions to the Capsule of the Symphysis Pubis

OBJECTIVE The purpose of this article is to define the relations of the symphysis pubis and capsular tissues to the adductor and rectus abdominis soft-tissue attachments on cadaver dissection and correlate with MRI of the anterior pelvis. SUBJECTS AND METHODS Seventeen cadavers (8 males and 9 females; mean age, 80 years) were dissected bilaterally. Rectus abdominis and adductor muscles were traced to the pubis and further attachments to the pubic symphysis were defined. Ten asymptomatic (mean age, 17; age range, 16.5-29 years) male athletes underwent 1.5-T MRI of the anterior pelvis with two surface microcoils (each 42 mm in diameter). An axial T2-weighted turbo spin-echo (TSE) sequence (TR/TE, 2,609/106; voxel size, 0.4 mm) was obtained. Axial and sagittal 3D T1-weighted fast-field echo (FFE) sequences (25/4.9; voxel size, 0.3 mm) were obtained. Sequences were repeated incorporating fat suppression and i.v. gadolinium. The relation of the symphysis pubis, disk, and capsular tissues to the insertions of the rectus abdominis, adductor muscles, and gracilis were independently evaluated by two experienced radiologists blinded to all clinical details. RESULTS In all 17 cadaver specimens, the adductor longus and rectus abdominis attached to the capsule and disk of the symphysis pubis, whereas the adductor brevis had an attachment to the capsule in seven specimens and the gracilis in one. All adductor tendons attached to the pubis. In all 10 athletes, the adductor longus and rectus abdominis bilaterally contributed to the capsular tissues and disk. This was only the case for the adductor brevis in four athletes. No other tendons involved the capsular tissues. CONCLUSION Cadaver and MRI findings show an intimate relationship between the adductor longus; rectus abdominis; and symphyseal cartilage, disk, and capsular tissues.

Effectiveness of a Selective Partial Adductor Release for Chronic Adductor-Related Groin Pain in Professional Athletes

Background: Chronic adductor enthesopathy is a well-known cause of groin pain in athletes. Currently, percutaneous nonselective adductor tenotomies give mixed results and not always predictable outcomes. Hypothesis: A selective partial adductor longus release as treatment for recalcitrant chronic adductor longus enthesopathy provides excellent pain relief with a prompt and consistent return to preinjury levels of sport. Study Design: Case series; Level of evidence, 4. Methods: All athletes were assessed in a standard way for adductor dysfunction. They received radiographs and a specifically designed magnetic resonance imaging groin study protocol. Only professional athletes who received a selective partial adductor release were included. Pain and functional improvement were assessed with the visual analog scale (VAS) pain score and time to return to sport. Results: Forty-three professional athletes (39 soccer and 4 rugby) with chronic adductor-related groin pain were treated with a selective partial adductor release. The average follow-up time was 40.2 months (range, 25-72 months). Forty-two of 43 athletes returned to their preinjury level of sport after an average of  9.21 weeks (range, 4-24 weeks; SD, 4.68 weeks). The preoperative VAS score improved significantly (Wilcoxon signed-rank test, P < .001) from 5.76 ± 1.08 (range, 3-8) to 0.23 ± 0.61 (range, 0-3) postoperatively. Conclusion: A selective partial adductor longus release provides excellent pain relief for chronic adductor enthesopathy in professional athletes with a consistent high rate of return to the preinjury level of sport.

Acute Avulsion of the Fibrocartilage Origin of the Adductor Longus in Professional Soccer Players: A Report of Two Cases

Acute ruptures of the adductor tendons are uncommon injuries. Although most adductor injuries occur at the musculotendinous junction proximally, case reports have described injuries occasionally occurring at the proximal and distal aspects of the adductor longus. Acute tears of the adductor longus at the origin are extremely rare; only 3 cases have been reported. Acute avulsion of its origin through its fibrocartilagenous enthesis has not been previously described in the literature. It occurs most commonly in vigorous and uncoordinated sporting activity, such as soccer, football, ice hockey, and Australian rules football. The purpose of this article is to describe an avulsed injury with noncontact mechanism, to discuss the particular anatomy of the adductor longus origin, and to report the rehabilitation and functional outcome following an acute repair in elite players. Because in this special group this injury has the potential to be career threatening, an adequate reduction and secure fixation of the avulsed fibrocartilage enthesis of the adductor longus is necessary.

Pelvis, Hip and Groin

Medical imaging has an extremely valuable role in the differentiation between the wide range of potential causes of hip and groin pain in athletes. Without such differentiation effective treatment is difficult to achieve especially where considering overuse injuries which may even be exacerbated by treatment based on diagnostic inaccuracy.

Anatomical and morphological characteristics may explain why groin pain is more common in male than female athletes

Groin pain is prevalent in athletes who play field sports that involve repetitive agility and kicking (eg, soccer, rugby and Australian Rules football). It is prone to recurrence and chronicity, thus can be challenging to overcome. A recent review found that men are 2.5 times more likely to sustain a groin injury than women when participating in the same sport.1 This observation is probably attributable to various factors. Contrasting training and/or match workloads could potentially exist between male and female athletes. Hormonal differences may be relevant too. While acknowledging these factors, we suggest that the higher risk of groin injury for male compared with female athletes may also be attributable to sex-related differences in groin anatomy as well as pelvic and hip joint morphology. The confluence of aponeurotic tissues across the anterior surface of the pubic symphysis, comprising fibres from the adductor and abdominal musculature, is a potential site of pathology in athletes with groin pain. Schilders2 dissected 16 embalmed cadavers (8 males and 8 females) and observed a sex-related difference in the …

Clinical tip: Achilles tendon repair with accelerated rehabilitation program.

The management of acute Achilles tendon ruptures is much-debated. Conservative management has been advocated by some who reported that strength and function were similar whether the rupture was treated by operative or nonoperative methods.6,11 However, others have recommended operative treatment, because they found lower rerupture rates and improved power after repair.1,3,4 Various techniques of Achilles tendon repair are used. The classic method of repair uses a Kessler stitch that may be reinforced with the plantaris tendon, which is released proximally and passed in a loop proximal and distal to the Achilles rupture. Many other modifications and variations have been described, including fanning out and tacking the plantaris tendon over the repair;6 using a ‘rotation flap’ of proximal Achilles tendon and gastrocnemius;9 and using a ‘dynamic loop suture’ of peroneus brevis tendon to itself.13 Numerous suture techniques also have been described.5 Percutaneous repair was first described in the 1970s10 and has recently attracted renewed interest. Advocates of this technique cite improved cosmesis, fewer wound complications,7 and the possibility of repair with local anesthesia as advantages. However, rerupture rates have been found to be higher than with open techniques.2 More recently, ‘‘mini-open’’ techniques have been used.12 Despite the variety of operative techniques, postoperative management and

Traumatic false aneurysm of a saphenous vein tributary in a cricketer.

The formation of a venous false aneurysm is an uncommon but well-recognized complication of trauma. Partial disruption of a vessel wall, after trauma, causes an outpouching of the traumatized portion of the vessel. Because of the blood flow from a feeder vein, this segment gradually expands, forming a false aneurysm. Patients with a venous false aneurysm may remain asymptomatic for a long period or report swelling over the area of recent injury. Alternatively, they may be seen with a complication of the false aneurysm, such as deep vein thrombosis, pulmonary embolism, rupture, or pain. Once a venous false aneurysm has been diagnosed, the management may vary from nonoperative treatment to surgical excision in symptomatic cases. A traumatic false aneurysm of the saphenous vein is a rare entity. We describe a case of a traumatic false aneurysm of a saphenous vein tributary, in which the patient, a cricketer, came in with swelling over the left medial malleolus. It is rare for a traumatic false aneurysm to occur in this area; nevertheless, this diagnosis should be among the differential diagnosis of a posttraumatic swelling.

The pyramidalis-anterior pubic ligament-adductor 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.

Current concepts of inguinal-related and adductor-related groin pain.

Groin pain encompasses a number of conditions from the lower abdomen, inguinal region, proximal adductors, hip joint, upper anterior thigh and perineum. The complexity of the anatomy, the heterogeneous terminology and the overlapping symptoms of different conditions that may co-exist epitomise the challenges in diagnosis and treatment. Inguinal-related and adductor-related pain is the most common cause of groin pain and will be discussed in this article.

Hip Arthroscopy for Femoroacetabular Impingement (FAI)

Femoroacetabular impingement (FAI) is a condition reintroduced by Ganz in 2003. The overall incidence has been estimated to be around 10–15%, and there is growing scientific evidence that FAI leads to arthritis of the hip.