The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries a new anatomical concept Schilders, Ernest; Bharam, Srino; Golan, Elan; Dimitrakopoulou, Alexandra; Mitchell, Adam; Spaepen, Mattias; Beggs, Clive; Cooke, Carlton; Holmich, Per Published in: Knee Surgery, Sports Traumatology, Arthroscopy DOI: 10.1007/s00167-017-4688-2 Publication date: 2017 Document version Publisher's PDF, also known as Version of record Document license: CC BY Citation for published version (APA): Schilders, E., Bharam, S., Golan, E., Dimitrakopoulou, A., Mitchell, A., Spaepen, M., Beggs, C., Cooke, C., & Holmich, P. (2017). The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept. Knee Surgery, Sports Traumatology, Arthroscopy, 25(12), 3969- 3977. https://doi.org/10.1007/s00167-017-4688-2 Download date: 03. okt.. 2021 Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-017-4688-2 HIP The pyramidalis–anterior pubic ligament–adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept Ernest Schilders1,2,3 · Srino Bharam3,4 · Elan Golan5 · Alexandra Dimitrakopoulou2,6 · Adam Mitchell7 · Mattias Spaepen8 · Clive Beggs2 · Carlton Cooke9 · Per Holmich10,11 Received: 29 April 2017 / Accepted: 16 August 2017 © The Author(s) 2017. This article is an open access publication Abstract Results The pyramidalis is the only abdominal muscle Purpose Adductor longus injuries are complex. The anterior to the pubic bone and was found bilaterally in all confict between views in the recent literature and various specimens. It arises from the pubic crest and anterior pubic nineteenth-century anatomy books regarding symphyseal ligament and attaches to the linea alba on the medial border. and perisymphyseal anatomy can lead to difculties in MRI The proximal adductor longus attaches to the pubic crest and interpretation and treatment decisions. The aim of the study anterior pubic ligament. The anterior pubic ligament is also is to systematically investigate the pyramidalis muscle and a fascial anchor point connecting the lower anterior abdomi- its anatomical connections with adductor longus and rec- nal aponeurosis and fascia lata. The rectus abdominis, how- tus abdominis, to elucidate injury patterns occurring with ever, is not attached to the adductor longus; its lateral tendon adductor avulsions. attaches to the cranial border of the pubis; and its slender Methods A layered dissection of the soft tissues of the internal tendon attaches inferiorly to the symphysis with fas- anterior symphyseal area was performed on seven fresh-fro- cia lata and gracilis. zen male cadavers. The dimensions of the pyramidalis mus- Conclusion The study demonstrates a strong direct con- cle were measured and anatomical connections with adduc- nection between the pyramidalis muscle and adductor longus tor longus, rectus abdominis and aponeuroses examined. tendon via the anterior pubic ligament, and it introduces the 1 * Ernest Schilders Fortius Clinic, 17 Fitzhardinge Street, W1H 6EQ London, [email protected] UK 2 Srino Bharam School of Sport, Leeds Beckett University, Leeds, [email protected] West Yorkshire, UK 3 Elan Golan Orthopaedics, Lennox Hill Hospital, New York, NY, USA [email protected] 4 Mount Sinai School of Medicine, New York, NY, USA Alexandra Dimitrakopoulou 5 Orthopaedics, Maimonides Medical Center, Brooklyn, NY, USA [email protected] 6 The Wellington Hospital, The London Hip Arthroscopy Adam Mitchell Centre, London, UK [email protected] 7 Radiology, Fortius Clinic, London, UK Mattias Spaepen 8 [email protected] Radiology, GZA, Antwerpen, Belgium 9 Clive Beggs Leeds Trinity University, Leeds, West Yorkshire, UK [email protected] 10 Sports Orthopedic Research Center ‑ Copenhagen (SORC‑C), Carlton Cooke Department of Orthopedic Surgery, Copenhagen University [email protected] Hospital, Amager-Hvidovre, Copenhagen, Denmark 11 Per Holmich Aspetar Orthopaedic and Sports Medicine Hospital, Sports [email protected] Groin Pain Center, Doha, Qatar Vol.:(0123456789)1 3 Knee Surg Sports Traumatol Arthrosc new anatomical concept of the pyramidalis–anterior pubic books [4, 8, 13, 15–17, 22, 29, 33] and one cadaver study ligament–adductor longus complex (PLAC). Knowledge of in 2007 [25] which found the pyramidalis to be the only these anatomical relationships should be employed to aid abdominal muscle encountered anterior to the pubic in image interpretation and treatment planning with proxi- symphysis. mal adductor avulsions. In particular, MRI imaging should The pyramidalis muscles are paired and lie between the be employed for all proximal adductor longus avulsions to anterior surface of the rectus abdominis and the posterior assess the integrity of the PLAC. surface of the rectus sheath. The muscle exhibits a mixed fbre-type composition [18]. The function of the pyramidalis Keywords Adductor longus avulsions · Anterior pubic muscle is to tension the linea alba [8, 18] and stretch the ligament · Pyramidalis–anterior pubic ligament–adductor abdominal aponeurosis [17] to assist the rectus abdominis longus complex (PLAC) · Pyramidalis · Groin pain in so as to give greater power to the oblique and transverse athletes · Rectus abdominis · Adductor injuries · Groin muscles [4]. anatomy Adductor longus injuries are complex, and MRI inter- pretation can be difcult. The aim of the study is to sys- tematically investigate and describe the anatomy anterior to Introduction the pubic symphysis and pubic bones with special focus on the pyramidalis muscle and its anatomical connections with The symphyseal and perisymphyseal area has become of adductor longus and rectus abdominis, to elucidate injury increasing interest for hip surgeons, sports physicians and patterns occurring with adductor avulsions. radiologists dealing with hip impingement and complex pain The pyramidalis muscle is the only muscle lying anterior syndromes of the inguinal/adductor and lower abdominal to the pubic symphysis and pubic bones. The pyramidalis area. An anatomical explanation has been sought for ingui- muscle has a strong direct anatomical connection with the nal, adductor related and pubic pain experienced by athletes adductor longus. There is no signifcant connection between [32]. the rectus abdominis and the adductor longus. Several anatomy studies have been performed to examine the adductor tendons [11, 30, 31] and the connection with the distal rectus sheath [23, 25, 27]. Some studies suggest Materials and methods that a direct anatomical connection exists between the cau- dal rectus abdominis muscle and the proximal origin of the Dissection technique and observations adductor longus [6, 14, 19, 20, 34]. It has been the frst author’s clinical observation that ath- Two orthopaedic surgeons (ES, SB) with a vast experience letes with traumatic adductor longus avulsions often pre- in athletic groin injuries worked jointly to systematically sent with associated unilateral abdominal pain and lower dissect the anterior pubic soft tissues in seven fresh-frozen abdominal haematomas. When examined on MRI scans or cadaveric male pelvises [median age 67 years (60–79)]. intraoperatively, it is the frst author’s experience that in Standard surgical dissection techniques were used to per- such patients, it is the pyramidalis muscle, and not the rec- form a meticulous layer-by-layer dissection from the skin tus abdominis, that remains attached to the adductor longus down to the anterior pubic bone with macroscopic fndings preventing caudal and lateral retraction. discussed and reported. All specimens dissected included If correct, this fnding demonstrates that there is a direct the pelvis to mid-diaphyseal femur. The skin and subcuta- anatomical connection between the pyramidalis muscle and neous fat were excised from the level of anterior superior the adductor longus muscle, suggesting that the role of the iliac spines (ASIS) to mid-thigh exposing the anterior rec- pyramidalis in this type of injury may have been underes- tus sheath, external oblique fascia and fascia lata. Care was timated. The involvement of the pyramidalis in groin pain taken to preserve the integrity of the fbres of the individual or pubic-related pain in athletes has not previously been fascial plains. The linea alba was inspected for anatomical reported. Indeed, in a study reviewing 347 abdominal mus- variation (i.e. fat or cord-like). cle strains in professional baseball, no injuries to the pyrami- The fbre orientation of the anterior rectus sheath, exter- dalis were reported [7]. nal oblique fascia, anterior pubic ligament and fascia lata There are conficting views in the literature with regard was noted, with a window subsequently made in the anterior to the anatomical position of the rectus abdominis: several rectus fascia adjacent to the linea alba, allowing access to imaging and anatomy studies [6, 11, 20] reported the rec- the deeper fascia anterior to the pyramidalis muscle. The tus abdominis muscle to lie anterior to the pubic symphy- fbre orientation of this fascia was also recorded, with all sis. This description lies in direct contrast to the fndings such fascial fbre orientations noted based on orientation in of numerous eighteenth- and nineteenth-century anatomy a frontal plane. 1 3 Knee Surg Sports Traumatol Arthrosc The fascia was then completely excised from the level of signifcant. The rationale was to assess symmetry of