Regional Distribution of Bone Mineral Density in the Pubic Symphysis: A Study of Sex and Age Differences
AméliePoilliot1✉Emailamelie.poilliot@unibas.ch
NielsHammer2,4
MagdalenaMüller-Gerbl1
1Department of Biomedicine, Musculoskeletal ResearchUniversity of BaselBaselSwitzerland
2Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research CenterMedical University of GrazAuenbruggerplatz 25GrazAustria
3Department of Orthopedic and Trauma SurgeryUniversity of LeipzigLeipzigGermany
4Division of BiomechatronicsFraunhofer Institute for Forming ToolsDresdenGermany
Amélie Poilliot1*, Niels Hammer2–4, Magdalena Müller-Gerbl1
1 Anatomy, Department of Biomedicine, Musculoskeletal Research, University of Basel, Basel, Switzerland
2 Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Auenbruggerplatz 25, Graz, Austria
3 Department of Orthopedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
4 Division of Biomechatronics, Fraunhofer Institute for Forming Tools, Dresden, Germany
* corresponding author: amelie.poilliot@unibas.ch, ORCID: 0000-0003-1835-4344
Anatomical Department
Pestalozzistrasse 20
4056 Basel
Switzerland
Keywords
Bone mineral density
computed tomography osteoabsorptiometry
Hounsfield units
pubic symphysis
subchondral bone
Abstract
Background
The subchondral bone (SCB) remodels in response to long-term mechanical loading, with mineralisation patterns reflecting chronic stress. Computed tomography osteoabsorptiometry (CT-OAM) enables non-invasive visualisation of these adaptations. While CT-OAM has been widely applied to several joints, its use in the pubic symphysis is limited. This study aimed to identify sex- and age-related differences in mineralisation patterns and quantify bone mineral density (BMD) distribution across the symphyseal surfaces.
Methods
CT scans from 85 individuals (51 males, 34 females; age range 18–97 years) were analysed, generating 170 symphyseal surfaces. Segmented three-dimensional reconstructions were processed into HU-based densitograms. Mineralisation was classified qualitatively into three patterns: diffuse across the surface (Pattern 1), ventral border with/without inferior apex involvement (Pattern 2), and dorsal border with/without inferior apex involvement (Pattern 3). Quantitatively, each surface was subdivided into six anatomical subregions, and mean HU values were compared by sex, side, and age.
Results
Across all specimens, Pattern 2 predominated (58%), with Pattern 2 most frequent in males (76%) and Pattern 3 in females (55%). High bilateral conformity (81%) was observed. Males exhibited significantly higher mean HU values than females (554 ± 180 HU vs. 374 ± 111 HU, p < 0.01), with greater BMD across all subregions. Region-specific analyses revealed highest mineralisation anteriorly and inferiorly in males, while females displayed increased posterior mineralisation. No significant correlation was found between overall BMD and age; however, females demonstrated a weak negative correlation in the ventral middle region (r = − 0.24, p < 0.05).
Conclusion
This study provides the first systematic CT-OAM analysis of pubic symphyseal SCB mineralisation. Findings highlight sex-specific patterns, with males demonstrating greater anterior and inferior mineralisation, and females exhibiting posterior dominance. Males also displayed higher overall BMD, reflecting greater chronic loading. These results deepen understanding of pelvic biomechanics and may inform future research on conditions such as osteitis pubis.
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Introduction
The subchondral bone (SCB) adapts to repetitive mechanical loading by increasing its mineral density, a process detectable via computed tomography (CT) osteoabsorptiometry (OAM) [2–5]. This adaptation aligns with Wolff’s law, where bone remodels according to the mechanical stresses it endures [2, 4, 6]. CT-OAM offers a non-invasive method to visualize Hounsfield Unit (HU)-based densitograms derived from standard CT scans, allowing to visualize mineral distribution below the articular surfaces [2, 3, 5, 7–10]. The principle of “morphology reveals biomechanics” reflects how bone morphology can indicate long term loading patterns [1]. CT-OAM has been used to study mineral density patterns in various joints, including the glenohumeral and ankle joints, helping to identify areas of stress adaptation [1–7]. These analyses are frequently supplemented with mechanical indentation tests to examine the correlation between mineral density and mechanical properties of the SCB [1, 8, 9].
Recent studies have begun exploring the subchondral bone plate of the pubic symphysis, a region historically understudied compared to other joints [10]. Using CT imaging, R Putz and M Müller-Gerbl [11] conducted one of the first quantitative assessments, revealing sex- and region-specific variations in subchondral bone density. Other work noted increased porosity after age 50, suggesting an age-related decline in mechanical integrity [12]. While CT-osteoabsorptiometry (CT-OAM) has been extensively applied to analyse subchondral adaptations in other joints such as the sacroiliac joint and shoulder [1, 4], its application to the pubic symphysis remains limited. Morphometric analyses combining CT and magnetic resonance imaging have provided further morphological detail, identifying variations in subchondral plate thickness and correlating these with disc morphology and ligamentous attachments [4]. Additionally, pathological imaging studies, particularly in cases of osteitis pubis, have described subchondral alterations such as sclerosis, marginal erosions, and cystic alterations, indicating a reactive remodelling response to chronic mechanical stress or inflammation [13, 14].
An important clinical correlate of these structural and biomechanical features is groin pain, which is frequently associated with pubic symphyseal pathology [13, 15]. The sex-specific morphologies of the pelvis may result in distinct loading regimes across the anterior ring. Such loading differences might explain not only the sex-specific adaptations observed in mineralisation patterns but also the clinical presentation of groin pain [11, 16]. Despite these advances, comprehensive functional analyses of the subchondral bone plate in healthy and pathological states remain sparse, underscoring the need for further biomechanical and histomorphometric research.
The objectives of this given study were to quantify and visualise the bone mineral density (BMD) distribution patterns of the subchondral bone plate of the pubic symphyseal surface using CT-OAM densitograms similar to the study by R Putz and M Müller-Gerbl [11]. These densitograms represent the distribution of subchondral mineralisation across the surface displayed as a HU-based colour maps. The HU values would be used to create a qualitative scoring system to understand the mineralisation of the two corresponding symphyseal surfaces supplemented also by quantitative analyses of the HU in various regions across the joint surfaces.
Based on previous papers that account for sex-related differences in mineralisation and groin pain between males and females [11, 16], the following hypotheses were investigated:
Pubic symphyseal surfaces exhibit sex-dependent mineralisation patterns
Males show higher anterior mineralisation, females exhibit greater posterior mineralisation.
Age negatively correlates with bone mineralisation density
Materials and methods
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Eighty-five (51 males, 34 females, age range: 18–97 years, mean age: 65.3 ± 17 years) CT scans were used for this study, resulting in 170 individual pubic symphyses to be analysed. Thirty scans (16 males, 14 females, age range: 18–82 years, mean age: 58 ± 17.1 years) were acquired from Dunedin Hospital These were acquired for the diagnosis of non-musculoskeletal pathologies or to rule out injury related to acute trauma. None of these cases had a current or past history of lower back or groin pain, sacroiliac joint related pathology or abnormalities on previous medical records.A further, 55 pelvic CT-scans (35 males, 20 females; age range: 39–97 years, mean age: 69.4 ± 15.6 years) were also analysed. The scans were acquired from individuals who donated their bodies to research at the Anatomical department at Basel University. No apparent prior pathologies of the pelvis were found radiologically upon inspection before the inclusion of the specimens for this study.
Human Ethics and Consent to Participate declarations
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Institutional approval was acquired for the use of patient datasets used in research studies for diagnostic and therapeutic purposes. A
Approval committee: H17/020, by the Human Research Ethics Committee of the University of Otago New Zealand. A
Approval was granted for the use of existing datasets. Informed consent was obtained from all participants of this study in which their data can be used in an anonymous way. A
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All methods were carried out in accordance with relevant guidelines and regulations.A
All procedures performed were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards for body donations.CT-osteoabsorptiometry of the subchondral endplates
Data sets for CT-OAM were derived from conventional CT (Siemens Somatom S4, Siemens AG, Forchheim, Germany) from Basel and from Dunedin (scanner: SOMATOM as64 open, Siemens, Munich, Germany).
CT-OAM was evaluated using ANALYZE (v11.0, Biomedical Imaging Resources, Mayo Foundation, Rochester, NY, USA). The left and right surfaces of the pubic symphysis were first manually segmented within the CT datasets to create 3D reconstructions of the individual hemipelves. These 3D models were then orientated into the optimal view of the pubic symphysis. Mineralisation data were then extracted from the manually isolated pubic symphysis surface and were then false color-coded and superimposed on the 3-dimensionally reconstructed pelvis for anatomical localization of the BMD. This creates a so-called colour densitogram as in prior studies [3, 17–22]. The maximum intensity projection revealed HU values to a depth of 3 mm, with thresholds set at ≤ 200 to ≥ 1200 HU.
Qualitative pattern classification
The anatomy of the pubic symphysis is visualised here in Fig. 1, where the areas of interest are highlighted as the apexes (superior and inferior) and the borders (ventral and dorsal).
Fig. 1
Medial view of a right innominate bone showcasing the pubic symphysis anatomy and terminology of its surface. A: anterior, I: inferior, AIIS: anterior inferior iliac spine, P: posterior, S: superior
The assessment of patterns was made based on a semi-quantitative analysis of the entire surface region colour map of each joint surface. Based on the distribution of the highest mineralisation zones across the entire surface, the analysis revealed three main pattern types:
Pattern 1 presented a diffused mineralization across the surface with no specific maxima,
Pattern 2 had highest mineralization located at ventral border with or without the inferior apex region,
Pattern 3 had highest mineralization located at the dorsal border with or without the inferior apex region (Fig. 2).
All of the specimens were categorised into each of the three pattern categories. The patterns of the contralateral sides of each specimen (left and right comparison) were compared to observe at whether the patterns were ‘conforming’ or ‘non-conforming’ as seen in previous studies [17, 23].
Fig. 2
Pubic symphysis pattern classification into five main pattern groups. Highest mineralisation zones (see scale on the right) show three distinct patterns: (a) diffused, (b) ventral border and inferior apex, (c) dorsal border and inferior apex. A: anterior, I: inferior, P: posterior, S: superior
Quantitative pattern classification
BMD of the individual pubic symphyseal sides was assessed based on the mean HU values of the regions on the densitograms for each dataset as done previously in the sacroiliac joint [19]. The pubic symphysis surfaces were subdivided into six regions: ventral superior (VS), ventral middle (VM), ventral inferior (VI), dorsal superior (DS), dorsal middle (DM) and dorsal inferior (DI). These were defined as being six sections of roughly equal size split via a line down the middle of the surface from superior to inferior and another two horizontal lines equidistant from the apexes (Fig. 3). A grid tool was used to conform the shape of each specimen and create the six regions. Calculation of the mean HU value for each region was computed using non-calibrated CT grey values in ANALYZE, v11.0 using the ‘region of interest’ function. These values were subsequently statistically compared between the different groups.
For statistical analyses GraphPad Prism (version 9, San Diego, CA, USA) was used. Statistical significance was defined at the 5% (p ≤ 0.05) level. Gaussian distribution was first assessed using a Shapiro–Wilk test. Depending on the distribution, a one-way ANOVA or a Kruskal–Wallis test with Dunn’s post-hoc correction was undertaken for the multiple assessment of the data between the six regions. Mean HU values were reported ± standard deviation. Age correlations with mean HU values in the three regions between sexes, sides and within the bone were assessed using a two-tailed Spearman r test for non-parametric data or a two-tailed Pearson r test for parametric data. Correlations were defined as follows: strong r ≥ 0.7, moderate 0.7 > r ≥ 0.5, weak 0.5 > r ≥ 0.2.
Fig. 3
Grid analysis example using a 20 x 30 grid system positioned over the pubic symphysis in a sagittal plane to separate the six regions. A: anterior, DI: dorsal inferior, DM: dorsal middle, DS: dorsal superior, I: inferior, P: posterior, S: superior, VI: ventral inferior, VM: ventral middle, VS: ventral superior.
Results
Pattern analyses
Of the 170 surfaces analysed, the most common pattern found was pattern 2 (58%) when assessing at all pubic symphysis SCB. When separating these by sex, the most common in females was pattern 3 (55%), and pattern 2 (76%) for males. The distribution of patterns found are presented in Fig. 4.
Fig. 4
Distribution of patterns found in the cohort of pubic symphyses n = 170.
Conformity analyses of the patterns between corresponding left and right symphyses (n = 85) revealed that a majority of individuals had identical patterns on both sides of the pubic symphysial SCB (81%).
Quantitative pattern classification
Mean HU values of the pubic symphysis SCB of males and females were lower for females than males (females; 374 ± 111 HU; 95% CI: 363–385 HU, males; 554 ± 180 HU; 95% CI: 540–569 HU; p < 0.01). Males demonstrated significantly higher HU values in all subregions than females (Fig. 5 and Table 1). No difference was found when comparing the mean HU values of the left and right symphyseal surfaces (p > 0.9).
Ventral superior | Ventral middle | Ventral inferior | ||||
|---|---|---|---|---|---|---|
Mean (HU) | 95% CI (HU) | Mean (HU) | 95% CI (HU) | Mean (HU) | 95% CI (HU) | |
Females | 320 ± 99 | 296–343 | 390 ± 104 | 365–415 | 360 ± 106 | 335–386 |
Males | 495 ± 164 | 462–528 | 598 ± 173 | 563–633 | 654 ± 170 | 619–688 |
Dorsal superior | Dorsal middle | Dorsal inferior | ||||
Mean (HU) | 95% CI (HU) | Mean (HU) | 95% CI (HU) | Mean (HU) | 95% CI (HU) | |
Females | 360 ± 117 | 332–389 | 421 ± 110 | 395–418 | 393 ± 106 | 368–418 |
Males | 475 ± 156 | 444–510 | 515 ± 155 | 483–546 | 629 ± 166 | 595–662 |
Fig. 5
Distribution of mean Hounsfield Units of each region in males and females. Outlines of the boxes indicate the 25- and 75-percentile, the solid black horizontal line, the median. Whiskers indicate the 5–95 percentiles. The dotted lines separate the cohorts in the figure.
The mean HU value patterns are presented in Fig. 6 showing the differences in mineralisation across the symphyseal SCB subregions in males and females. Patterns show higher mineralisation in the dorsal regions in females, whilst the ventral-inferior apex region is higher in males.
Fig. 6
Distribution of mean Hounsfield Units of each region in males and females. DI: dorsal inferior, DM: dorsal middle, DS: dorsal superior, VI: ventral inferior, VM: ventral middle, VS: ventral superior
Correlations between age and mean HU densities of the complete SCB were nondifferent between males (p = 0.34; r = 0.10) and females (p = 0.31; r = − 0.13). However, when looking at the specific subregions, age yielded a weak negative correlation in the ventral middle region in females (p < 0.05; r = -0.24) (Fig. 7). There were non the other subregions there were no significant correlations between HU values and age (p > 0.46). In males, there were no significant correlations between HU values and age in any of the regions (p > 0.1).
Fig. 7
Correlation of mean HU values in the ventral middle region of the pubic symphyses in females.
Discussion
This study qualitatively analysed the SCB mineralisation patterns of the pubic symphysial surfaces in a large cohort of patients with no known pelvic pain or dysfunction. It provides insights into the mechanical difference between individuals of different sex and at a broad age range. The results presented here are likely representative of the long-term loading conditions of the individuals which demonstrate the biomechanical stresses applied to the pubic symphysis.
Qualitative analyses reveal stark pattern differences between females and males
The original findings by R Putz and M Müller-Gerbl [11] yielded sex- and region-specific variations in SCB density. They state that males typically exhibit higher density anteriorly, while females show increased posterior density. This result was confirmed qualitatively in the here given study, where pattern 3 (dorsal border and apex mineralisation) was the most common for the female specimens (55% of females). Pattern 2 (anterior border and apex mineralisation) was the most common occurring in male specimens (76% of males). Furthermore, mineralisation patterns showed region-specific variations in SCB density across the surface dependant on the sex. When subdividing the area into six subregions, the mineralisation density distribution could be assessed based on the mean HU values which represent the mean mineralisation of that specific region. Highest mineralisation in females was localized in all dorsal regions as well as the ventral middle region, whilst in males it was concentrated antero-inferiorly in the ventral middle, ventral inferior and dorsal inferior regions. These results are in accordance with the qualitative results in which males have more inferior apex involvement (corresponding to the ventral and dorsal inferior regions) when females had concentrated mineralisation in the dorsal border region. These findings directly support the first hypothesis, confirming that pubic symphyseal surfaces exhibit clear sex-dependent mineralisation patterns. They also support the second hypothesis, with males demonstrating predominantly anterior mineralisation while females showed relatively higher posterior mineralisation.
The pubic symphysis is a cartilaginous, synarthrodial joint featuring a fibrocartilaginous interpubic disc and it allows only slight translational and rotational motion but is adapted to absorb both compressive and tensile stresses [10]. The pelvic ring is a closed-chain structure so any motion at the pubic symphysis must be accompanied by corresponding movement at the sacroiliac joint, and vice versa [24, 25]. The disc is wedged within the interpubic cavity between the two corresponding symphyseal surfaces and contains fibres of differing orientations. The upper and lower edges of the symphysis are reinforced mostly anteriorly by oblique running bundles of fibres, which can be viewed as solid bands. Due to the interweaving of the fibres within the interpubic disc, it also has the capacity to absorb vertical shear stresses in particular [11]. N Hammer, M Scholze, T Kibsgard, S Klima, S Schleifenbaum, T Seidel, M Werner and R Grunert [25]’s kinematic study has described the movement of the innominate bones and pubic symphysis under physiological loading conditions. These are small movements, composed mainly of rotations in the vertical axis. The superior pubic ramus is rotated anteromedially relative to the ilium, and both pubic rami laterally, forming a counter movement effectively compressing the interpubic disc. However, no comment is made as to which specific areas of the pubic symphysis are more or less compressed within this movement owing their experimental setup with surface deformations assessed exclusively. Sex-related differences in pelvic kinematics have been documented, which may, in part, reflect the influence of the generally wider female pelvis [24, 26]. On average, females exhibit a modest anterior pelvic tilt of approximately 4° [24] whereas males typically maintain a pelvic orientation which is closer to neutral [27]. This difference could explain the stark differences in mineralisation of the symphysis in males and females. The anterior pelvic tilt in females may impact the symphysis in that the anterior part has a tendency to gape under chronic compressive loading which would in turn lower anterior mineralisation but heighten it posteriorly. The opposite would then be possible in males. A key clinical implication of these structural and biomechanical characteristics is the occurrence of groin pain, which is often linked to pathology of the pubic symphysis such as osteitis pubis. The distinct pelvic morphologies of the sexes—most notably the broader female pelvis with its longer anterior lever arm—are likely to generate different loading conditions across the anterior pelvic ring. In females, this geometry may amplify bending moments at the pubic symphysis, leading to compressive stresses in the posterior (dorsal) region of the joint. In contrast, the narrower male pelvis may favor the development of higher shear forces at the symphysis. These sex-dependent loading patterns could account not only for observed differences in mineralisation but also for variations in the clinical presentation of groin pain. Furthermore, osteophyte formation, commonly seen in degenerative changes of the symphyseal surface, may serve as an indirect morphological indicator of these repetitive mechanical stresses [16].
Mean bone mineralisation was found to be significantly different between sexes
It was also discovered that males have a significantly higher mean subchondral bone density than females (374 HU in females vs. 554 HU in males). This was made further apparent when separated by region. This finding suggests that males appear to have more chronic stress upon their joint than females. The pubic symphysis is subjected to various forces in daily chronic loading conditions, which include traction on the inferior part of the joint and compression of the superior region when standing, compression when sitting, and shearing and compression during single-leg stance [10, 28]. However, biomechanical differences between males and females remained poorly documented to date, and contemporary literature suggests that sex does not have an influence [28]. These results combined with the pattern analysis between males and females reflect the differences in chronic loading conditions that the pelvis is subjected to daily. Differences in pelvic morphology between males and females may stem from obstetric requirements, variations in growth trajectories, or a combination of both. However, there is no evidence supporting the idea that increased pelvic width affects locomotor efficiency in females [29]. The pubic symphysis is a region which supports a greater body weight load and is subject to more bone remodelling changes which is directly related to sex as males typically have higher body mass and greater muscle forces, increasing joint reaction forces transmitted through the pelvic ring and sacroiliac joint [30, 31] than females which would explain the significant difference in mineralisation between the sexes.
Age has a small influence on subchondral bone mineralisation in females but none in males
Although the correlations between age and mineralisation yielded no significance in both sexes, when looking into each region specifically, there was a weak negative correlation in the ventral middle region in females with age. Previous studies have reported significant correlations with biological age resulting from bone density and chronological age [30, 32]. These reports however, specifically looked into pubic cancellous bone and excluded the subchondral bone plate. No other study has investigated into the SCB of the pubic symphysis and correlated it with age as the given study does so these results are novel. It was expected, based on the literature that there would be evidence of a negative correlation of BMD with age especially in females due to the numerous morphological changes that may occur (hormonal factors, osteoporosis or hormone replacement treatment). The results show evidence of weak correlations (r < − 0.2) but these findings were not significant. These findings therefore refute the third hypothesis, as no consistent or significant negative correlation between age and subchondral bone mineralisation density was identified.
Regarding the limitations of the study, the donations and patient scans were initially two different cohorts both living and the post-mortem condition. Therefore, this merge of specimens may not account for population difference and potential variables between them, except, age and sex. However, the cadaveric cohort was not influenced by decomposition in any way as the CT scans were undertaken in the following hours after death upon arrival at the institute. In addition, the overlapping of the grid system was performed by one investigator only. Consequently, the reproducibility of this measurement remains untested. The assessment of patterns remains qualitative, although agreement between two authors was sought for the final classification.
Conclusion
CT-osteoabsorptiometry of the pubic symphysis reveals sex- and region-specific mineralisation patterns that reflect long-term biomechanical loading. These adaptations help explain differences in susceptibility to groin pain and degenerative changes. By linking subchondral mineral density to pelvic morphology and clinical presentation, this study establishes CT-OAM as a valuable tool for investigating pubic symphyseal biomechanics and provides a basis for future functional and pathological research.
List of abbreviations
BMD
bone mineral density
CI
confidence interval
CT-OAM
computed tomography osteoabsorptiometry
DI
dorsal inferior
DM
dorsal middle
DS
dorsal superior
HU
Hounsfield Units
SCB
subchondral bone
VI
ventral inferior
VM
ventral middle
VS
ventral superior
Consent for publication
Not applicable
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Acknowledgement
The authors would like to thank and acknowledge the patients who contributed to this research project. For the procuration of the patient cohort, acknowledgement and thanks are further extended to Prof. Terence Doyle at Dunedin Hospital.
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Author Contribution
A.P.: Data curation, Formal analysis, Writing—original draft, Investigation, Conceptualization. N.H: Writing- review and editing. M.M: Writing—review & editing., Conceptualization.
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Data Availability
The data acquired in the course of this study are available from the corresponding author on request.
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Funding
None.
Competing interests
None declared.
References
1.
Leumann A, Valderrabano V, Hoechel S, Gopfert B, Müller-Gerbl M. Mineral density and penetration strength of the subchondral bone plate of the talar dome: high correlation and specific distribution patterns. J Foot Ankle Surg. 2015;54(1):17–22.
2.
Linsenmaier U, Kersting S, Schlichtenhorst K, Putz R, Pfeifer KJ, Reiser M, Müller-Gerbl M. Functional CT imaging: Load-dependent visualization of the subchondral mineralization by means of CT osteoabsorptiometry (CT-OAM). Rofo-Fortschr Rontg. 2003;175(5):663–9.
3.
Müller-Gerbl M, Putz R, Hodapp N, Schulte E, Wimmer B. Computed tomography-osteoabsorptiometry for assessing the density distribution of subchondral bone as a measure of long-term mechanical adaptation in individual joints. Skeletal Radiol. 1989;18(7):507–12.
4.
Müller-Gerbl M, Putz R, Hodapp N, Schulte E, Wimmer B. Die Darstellung der subchondralen Dichtemuster mittels der CT-Osteoabsorptiometrie (CT-OAM) zur Beurteilung der individuellen Gelenkbeanspruchung am Lebenden. Z Orthop Ihre Grenzgeb. 1990;128(2):128–33.
5.
Schulz CU, Pfahler M, Anetzberger HM, Becker CR, Müller-Gerbl M, Refior HJ. The mineralization patterns at the subchondral bone plate of the glenoid cavity in healthy shoulders. J Shoulder Elb Surg. 2002;11(2):174–81.
6.
von Eisenhart R, Adam C, Steinlechner M, Müller-Gerbl M, Eckstein F. Quantitative determination of joint incongruity and pressure distribution during simulated gait and cartilage thickness in the human hip joint. J Orthop Res. 1999;17(4):532–9.
7.
Zumstein V, Kraljevic M, Wirz D, Hugli R, Müller-Gerbl M. Correlation between mineralization and mechanical strength of the subchondral bone plate of the humeral head. J Shoulder Elb Surg. 2012;21(7):887–93.
8.
Mühlhofer H, Ercan Y, Drews S, Matsuura M, Meissner J, Linsenmaier U, Putz R, Müller-Gerbl M. Mineralisation and mechanical strength of the subchondral bone plate of the inferior tibial facies. Surg Radiol Anat. 2009;31(4):237–43.
9.
Pan J, Zhou X, Li W, Novotny JE, Doty SB, Wang L. In situ measurement of transport between subchondral bone and articular cartilage. J Orthop Res. 2009;27(10):1347–52.
10.
Becker I, Woodley SJ, Stringer MD. The adult human pubic symphysis: a systematic review. J Anat. 2010;217(5):475–87.
11.
Putz R, Müller-Gerbl M. Anatomische Besonderheiten des Beckenrings. Unfallchirurg. 1992;95(4):164–7.
12.
Sutro CJ. The pubic bones and their symphysis. Arch Surg. 1936;32:823–41.
13.
Ooi MWX, Marzetti M, Rowbotham E, Bertham D, Robinson P. MRI findings in athletic groin pain: correlation of imaging with history and examination in symptomatic and asymptomatic athletes. Skeletal Radiol. 2025;54(4):841–50.
14.
Paajanen H, Hermunen H, Karonen J. Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training. Am J Sports Med. 2008;36(1):117–21.
15.
Fricker PA, Taunton JE, Ammann W. Osteitis Pubis in Athletes - Infection, Inflammation or Injury. Sports Med. 1991;12(4):266–79.
16.
Branco R, da Costa Fontenelle C, Miranda L, Junior Y, Vianna E. Comparative study between the pubis of asymptomatic athletes and non-athletes with MRI. Rev Bras Ortop. 2015;45(6):596–600.
17.
Poilliot A, Doyle T, Kurosawa D, Toranelli M, Zhang M, Zwirner J, Müller-Gerbl M, Hammer N. Computed tomography osteoabsorptiometry-based investigation on subchondral bone plate alterations in sacroiliac joint dysfunction. Sci Rep. 2021;11:8652.
18.
Poilliot A, Gay-Dujak M, Müller-Gerbl M. The quantification of 3D-trabecular architecture of the fourth cervical vertebra using CT osteoabsorptiometry and micro-CT. J Orthop Surg Res 2023, 18(297).
19.
Poilliot A, Li KC, Müller-Gerbl M, Toranelli M, Zhang M, Zwirner J, Hammer N. Subchondral bone strength of the sacroiliac joint- a combined approach using computed tomography osteoabsorptiometry (CT-OAM) imaging and biomechanical validation. JMBBM. 2020;111:103978.
20.
Gay M, Born G, Mehrkens A, Wittig H, Müller-Gerbl M. Computed tomography osteoabsorptiometry for imaging of degenerative disc disease. N Am Spine Soc J. 2022;9:100102.
21.
Hoechel S, Schulz G, Muller-Gerbl M. Insight into the 3D-trabecular architecture of the human patella. Annals Anatomy-Anatomischer Anzeiger. 2015;200:98–104.
22.
Müller-Gerbl M. The subchondral bone plate. Adv Anat Embryol Cell Biol. 1998;141:III–XI.
23.
Poilliot A, Kurosawa D, Toranelli M, Zhang M, Zwirner J, Müller-Gerbl M, Hammer N. Subchondral bone changes following sacroiliac joint arthrodesis – a morpho-mechanical assessment of surgical treatment of the painful joint. Pain Physician. 2021;24(3):E317–26.
24.
Lewis CL, Laudicina NM, Khuu A, Loverro KL. The Human Pelvis: Variation in Structure and Function During Gait. Anat Rec (Hoboken). 2017;300(4):633–42.
25.
Hammer N, Scholze M, Kibsgard T, Klima S, Schleifenbaum S, Seidel T, Werner M, Grunert R. Physiological in vitro sacroiliac joint motion: a study on three-dimensional posterior pelvic ring kinematics. J Anat. 2019;234(3):346–58.
26.
Bruening DA, Frimenko RE, Goodyear CD, Bowden DR, Fullenkamp AM. Sex differences in whole body gait kinematics at preferred speeds. Gait Posture. 2015;41(2):540–5.
27.
Cho SH, Park JM, Kwon OY. Gender differences in three dimensional gait analysis data from 98 healthy Korean adults. Clin Biomech (Bristol Avon). 2004;19(2):145–52.
28.
Meissner A, Fell M, Wilk R, Boenick U, Rahmanzadeh R. [Biomechanics of the pubic symphysis. Which forces lead to mobility of the symphysis in physiological conditions?]. Unfallchirurg. 1996;99(6):415–21.
29.
Warrener A, Lewton KL, Pontzer H, Lieberman D. A wider pelvis does not increase locomotor cost in humans, with implications for the evolution of childbirth. PLoS ONE. 2015;10(3):e0118903.
30.
Dubourg O, Faruch-Bilfeld M, Telmon N, Maupoint E, Saint-Martin P, Savall F. Correlation between pubic bone mineral density and age from a computed tomography sample. Forensic Sci Int. 2019;298:345–50.
31.
Abd-Eltawab AE, Ameer MA, Eladl MA, El-Sherbiny M, Ebrahim HA, Elsherbini DMA. Sexual Dimorphism Impact on the Ground Reaction Force Acting on the Mediolateral Direction During Level Walking: Hip Abductor Muscle Biomechanics and Its Correlation to GRF Moment Arm. Front Bioeng Biotech 2022, 10.
32.
López-Alcaraz M, González P, Aguilera I, López M. Image analysis of pubic bone for age estimation in a computed tomography sample. Int J Legal Med. 2015;129(2):335–46.