The pubic symphysis is a unique joint consisting of a fibrocartilaginous disc sandwiched between the articular surfaces of the pubic bones. It resists tensile, shearing and compressive forces and is capable of a small amount of movement under physiological conditions in most adults (up to 2 mm shift and 1°rotation). During pregnancy, circulating hormones such as relaxin induce resorption of the symphyseal margins and structural changes in the fibrocartilaginous disc, increasing symphyseal width and mobility. This systematic review of the English, German and French literature focuses on the normal anatomy of the adult human pubic symphysis. Although scientific studies of the joint have yielded useful descriptive data, comparison of results is hampered by imprecise methodology and ⁄ or poorly controlled studies. Several aspects of the anatomy of the pubic symphysis remain unknown or unclear: the precise attachments of surrounding ligaments and muscles; the arrangement of connective tissue fibres within the interpubic disc and the origin, structure and function of its associated interpubic cleft; the biomechanical consequences of sexual dimorphism; potential ethnic variations in morphology; and its precise innervation and blood supply. These deficiencies hinder our understanding of the normal form and function of the joint, which is particularly relevant when attempting to understand the mechanisms underlying pregnancy-related pubic symphyseal pain, a neglected and relatively common cause of pubic pain. A better understanding of the normal anatomy of the human pubic symphysis should improve our understanding of such problems and contribute to better treatments for patients suffering from symphyseal pain and dysfunction.
Anterior knee pain or patellofemoral pain syndrome is commonly encountered by clinicians, but the pathogenesis of this condition is not well understood. While much research has centred around the relationship between vastus medialis and anterior knee pain, little is known about the most lateral of the quadriceps muscle group, vastus lateralis (VL). Knowledge of the anatomical organization of VL is not only necessary to understand its precise function, but to also assist in the development of clinical and biomechanical models of knee dysfunction. The purpose of this study was to investigate the detailed morphology of VL, specifically to provide data relating to architecture, attachment sites, innervation, and the presence of anatomical partitioning within the muscle. The VL muscle was examined in 10 cadaveric lower limbs using macrodissection techniques. On the basis of architecture and innervation, this muscle comprised four partitions with each receiving its own unique nerve branch. The mean fascicular length of VL was 7 cm and the mean fascicular and muscle physiological cross-sectional areas were 1.2 cm(2) and 21.6 cm(2), respectively. In addition to inserting proximally at the base of the greater trochanter and distally into the superolateral border and base of the patella, three additional attachment sites were identified: the lateral intermuscular septum, iliotibial band, and the rectus tendon. The results of this study suggest that the gross morphology of VL is more complex than previously described, and the information provided regarding architecture will contribute to knowledge regarding the function of VL as well as its role in knee joint dysfunction.
To understand the role of the vastus lateralis (VL) muscle in the pathogenesis of common knee disorders such as patellofemoral joint syndrome, knowledge of its anatomical structure is essential. The aim of this study was to review currently available information on the gross morphology of VL. A structured literature review was undertaken and 36 references, comprising 22 scientific papers and 14 anatomical textbooks, were included. Results of this literature review show that most of the included studies exhibited methodological limitations, and focused on different parameters of the VL muscle. Hence, reproducibility of these studies and comparison of results was difficult. This review also demonstrates a dearth of information on the muscle architecture, compartmentalization, nerve supply and fusion of VL, and that there has been no investigation of the muscle as a whole unit. Further research is required of the architecture and innervation of the VL muscle to better understand its function.
Pregnancy-related symphyseal pain is a condition commonly encountered by clinicians but its pathogenesis is poorly understood. The pubic symphysis is readily visualized with ultrasound, yet the normal sonographic anatomy of the joint has not been accurately documented. This study aimed to describe the anatomy of the pubic symphysis in healthy, nulliparous women using ultrasound. An experienced and inexperienced sonographer scanned the joint in 30 female volunteers (mean age 26 years). Interobserver and intraobserver reliability of ultrasound measurements were examined and the accuracy of these measurements was validated by ultrasound and dissection of six female cadaver pelves (mean age 75 years). In healthy young women, pubic symphysis morphology varied, and six categories of anterosuperior joint shape were defined. Mean values of several anatomic parameters were obtained in supine and standing positions: joint width (widest 10.1 mm, narrowest 2.6 mm); superior pubic ligament (SPL) length and depth (41.4 and 3.4 mm, respectively); and pubic crest length (left 24.4 mm, right 24.4 mm). Statistically significant relationships between SPL width and depth and anthropometric variables (body mass index, pelvic width, and body fat percentage) were established. Larger ultrasonographic measurements, such as wide joint width and SPL length, could be measured more reliably than smaller measurements, such as narrow joint width and SPL depth, in both healthy volunteers and cadavers. Findings from this study provide normative reference data for examination of the pubic symphysis in pregnant women and may therefore be relevant to understand pregnancy-related symphyseal pain.
We thank Drs. Galdames and Manterola (2009) for their interest and kind comments regarding our systematic review, a publication which we hope will advance the field, and supplement similar reviews that have begun to appear in the morphological literature (Lee et al., 2008;Smith et al., 2009). We too advocate for a shift from expert-based (also called eminence-based) to evidencebased morphology, not only to raise the scientific profile of clinical anatomy but also to better inform clinical decisions. However, as highlighted by Drs. Galdames and Manterola, we were unable to perform a meta-analysis on the data obtained in our study, and so were somewhat restricted to a systematic review. A meta-analysis can be defined as ''a mathematical synthesis of the results of two or more primary studies that addressed the same hypothesis in the same way'' (Greenhalgh, 1997, p 315); the heterogeneity of the studies to date precluded such an approach. Furthermore, given the diversity and complexity of human morphology it seems likely that metaanalyses of anatomical data will only rarely be possible. This should not necessarily represent a limitation in our chosen field of research, but instead provide a stimulus to conduct high-quality, morphological studies that are clinically and functionally relevant. I. Becker
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