Regional Distribution of Bone Mineral Density in the Pubic Symphysis: A Study of Sex and Age Differences

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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. Bone mineral density computed tomography osteoabsorptiometry Hounsfield units pubic symphysis subchondral bone Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 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 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 Institutional approval was acquired for the use of patient datasets used in research studies for diagnostic and therapeutic purposes. Approval committee: H17/020, by the Human Research Ethics Committee of the University of Otago New Zealand. 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. All methods were carried out in accordance with relevant guidelines and regulations. 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). 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 ]. Quantitative pattern classification (dup: abstract ?) 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. 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 . 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). Table 1 Mean Hounsfield Unit (HU) values of each subregion with 95% confidence interval (CI) in males and females. 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 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. 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 0.46). In males, there were no significant correlations between HU values and age in any of the regions ( p > 0.1). 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. 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 Declarations Consent for publication Not applicable Acknowledgements 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. Author contributions A.P.: Data curation, Formal analysis, Writing—original draft, Investigation, Conceptualization. N.H: Writing- review and editing. M.M: Writing—review & editing., Conceptualization. Data availability The data acquired in the course of this study are available from the corresponding author on request. Funding None. Competing interests None declared. 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Cite Share Download PDF Status: Published Journal Publication published 07 Feb, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 12 Nov, 2025 Reviews received at journal 11 Nov, 2025 Reviewers agreed at journal 19 Oct, 2025 Reviews received at journal 16 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers invited by journal 15 Oct, 2025 Editor assigned by journal 14 Oct, 2025 Editor invited by journal 13 Oct, 2025 Submission checks completed at journal 13 Oct, 2025 First submitted to journal 13 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Poilliot","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIie3PsWrDMBCA4QuBdGnjVaHUfoUTHrLkYSQK8ZKmQxcPHVQCytS1kLfwmk3B0CkPYFAHe+nUoaMHUSoVJx1SmY4Z9C8+Dn9IAgiFzrOBYu4zHD65IbYL+bPHHtORgbADpv8j3WnCDsgFwKiXRC+lUnUOy+jCkjo3WaFXsm4NJFMPIXrOFNvDw2TlLrbHu+Jtt6bPEuhWeIxeoOISeFFawqUlFZfkSgBD9bdI9P2n4l+/JENLJsb4CeoFKPvkI2GOXF+O/ITqOSr2Sg5vSemm4uv0RhJaeEisb5umfZwto6jcNW0eJ+Mqe28+zCzxndJF2Mmm93/XCQmFQqHQsW962mkTLln9eQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Basel","correspondingAuthor":true,"prefix":"","firstName":"Amélie","middleName":"","lastName":"Poilliot","suffix":""},{"id":534882759,"identity":"0d3201fd-06d0-40e4-9fda-49b89c4e0a89","order_by":1,"name":"Niels Hammer","email":"","orcid":"","institution":"Medical University of 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07:50:34","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10974,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/859e7a7427a33bb36ebd571d.png"},{"id":94641022,"identity":"6378121e-48a5-4bdb-8dbf-646423ef3cba","added_by":"auto","created_at":"2025-10-29 07:50:29","extension":"xml","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94219,"visible":true,"origin":"","legend":"","description":"","filename":"40fa433932554c499b709a00234bcccb1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/2df35876b7d60195411edd33.xml"},{"id":94639143,"identity":"b35466fa-fbaf-4cb0-9446-5a7cd88c075c","added_by":"auto","created_at":"2025-10-29 07:36:02","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":102733,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/17232ba6405ca396bfd72504.html"},{"id":94639121,"identity":"445ac226-dca0-46f9-9923-5b3a10839a7e","added_by":"auto","created_at":"2025-10-29 07:36:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":82594,"visible":true,"origin":"","legend":"\u003cp\u003eMedial 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\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/a81362acbcda358449edc7cd.png"},{"id":94641026,"identity":"f3f5c859-5b44-47a5-abd8-09227ec235ae","added_by":"auto","created_at":"2025-10-29 07:50:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":128830,"visible":true,"origin":"","legend":"\u003cp\u003ePubic 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\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/eb25c43f015f45a459cf6209.png"},{"id":94639123,"identity":"36b12c07-0d79-452a-88aa-cdf2f92d96cd","added_by":"auto","created_at":"2025-10-29 07:36:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":219656,"visible":true,"origin":"","legend":"\u003cp\u003eGrid 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.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/4fca1b517aa790a57ba20e32.png"},{"id":94672030,"identity":"79813831-7092-4595-87b8-aa42ac4effe7","added_by":"auto","created_at":"2025-10-29 13:37:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":114979,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of patterns found in the cohort of pubic symphyses n=170.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/eb536ae384654ea71ea2015b.png"},{"id":94639119,"identity":"349eef10-12fd-4df7-9231-d770094cdc8f","added_by":"auto","created_at":"2025-10-29 07:36:02","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":24290,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDistribution of mean Hounsfield Units of each region in males and females\u003c/em\u003e.\u003cem\u003e 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.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/8ee2c84426d043430d36f741.png"},{"id":94640950,"identity":"6a6c4f28-58b6-42ad-84e1-a017f42b971f","added_by":"auto","created_at":"2025-10-29 07:50:24","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":76390,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution 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\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/de6bb4684188de6ab8147db7.png"},{"id":94640969,"identity":"f796caa6-00e1-4497-a340-d26607c8cc16","added_by":"auto","created_at":"2025-10-29 07:50:24","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":26090,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCorrelation of mean HU values in the ventral middle region of the pubic symphyses in females.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/35bb03cb79a2353ea3e1a891.png"},{"id":102234035,"identity":"2725be22-c49c-4a68-8c39-fbab8c07164d","added_by":"auto","created_at":"2026-02-09 16:04:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2844120,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7712524/v1/1629808e-fa19-4d0d-8dff-21d517c2d92a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Regional Distribution of Bone Mineral Density in the Pubic Symphysis: A Study of Sex and Age Differences","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe subchondral bone (SCB) adapts to repetitive mechanical loading by increasing its mineral density, a process detectable via computed tomography (CT) osteoabsorptiometry (OAM) [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This adaptation aligns with Wolff\u0026rsquo;s law, where bone remodels according to the mechanical stresses it endures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The principle of \u0026ldquo;morphology reveals biomechanics\u0026rdquo; reflects how bone morphology can indicate long term loading patterns [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. 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 [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These analyses are frequently supplemented with mechanical indentation tests to examine the correlation between mineral density and mechanical properties of the SCB [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecent studies have begun exploring the subchondral bone plate of the pubic symphysis, a region historically understudied compared to other joints [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Using CT imaging, R Putz and M M\u0026uuml;ller-Gerbl [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] 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 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. While CT-osteoabsorptiometry (CT-OAM) has been extensively applied to analyse subchondral adaptations in other joints such as the sacroiliac joint and shoulder [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], 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 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAn important clinical correlate of these structural and biomechanical features is groin pain, which is frequently associated with pubic symphyseal pathology [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. 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.\u003c/p\u003e\u003cp\u003eThe 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 M\u0026uuml;ller-Gerbl [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. 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.\u003c/p\u003e\u003cp\u003eBased on previous papers that account for sex-related differences in mineralisation and groin pain between males and females [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the following hypotheses were investigated:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePubic symphyseal surfaces exhibit sex-dependent mineralisation patterns\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMales show higher anterior mineralisation, females exhibit greater posterior mineralisation.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAge negatively correlates with bone mineralisation density\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eEighty-five (51 males, 34 females, age range: 18\u0026ndash;97 years, mean age: 65.3\u0026thinsp;\u0026plusmn;\u0026thinsp;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\u0026ndash;82 years, mean age: 58\u0026thinsp;\u0026plusmn;\u0026thinsp;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.\u003c/p\u003e\u003cp\u003eA further, 55 pelvic CT-scans (35 males, 20 females; age range: 39\u0026ndash;97 years, mean age: 69.4\u0026thinsp;\u0026plusmn;\u0026thinsp;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.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eHuman Ethics and Consent to Participate declarations\u003c/h2\u003e\u003cp\u003e Institutional approval was acquired for the use of patient datasets used in research studies for diagnostic and therapeutic purposes. Approval committee: H17/020, by the Human Research Ethics Committee of the University of Otago New Zealand. 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. All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e\u003cp\u003e 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.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCT-osteoabsorptiometry of the subchondral endplates\u003c/h3\u003e\n\u003cp\u003eData 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).\u003c/p\u003e\u003cp\u003eCT-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 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The maximum intensity projection revealed HU values to a depth of 3 mm, with thresholds set at \u0026le;\u0026thinsp;200 to \u0026ge;\u0026thinsp;1200 HU.\u003c/p\u003e\n\u003ch3\u003eQualitative pattern classification\u003c/h3\u003e\n\u003cp\u003eThe anatomy of the pubic symphysis is visualised here in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, where the areas of interest are highlighted as the apexes (superior and inferior) and the borders (ventral and dorsal).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe 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:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePattern 1 presented a diffused mineralization across the surface with no specific maxima,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePattern 2 had highest mineralization located at ventral border with or without the inferior apex region,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePattern 3 had highest mineralization located at the dorsal border with or without the inferior apex region (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eAll 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 \u0026lsquo;conforming\u0026rsquo; or \u0026lsquo;non-conforming\u0026rsquo; as seen in previous studies [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eQuantitative pattern classification (dup: abstract ?)\u003c/h3\u003e\n\u003cp\u003eBMD 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 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. 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.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). 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 \u0026lsquo;region of interest\u0026rsquo; function. These values were subsequently statistically compared between the different groups.\u003c/p\u003e\u003cp\u003eFor statistical analyses GraphPad Prism (version 9, San Diego, CA, USA) was used. Statistical significance was defined at the 5% (p\u0026thinsp;\u0026le;\u0026thinsp;0.05) level. Gaussian distribution was first assessed using a Shapiro\u0026ndash;Wilk test. Depending on the distribution, a one-way ANOVA or a Kruskal\u0026ndash;Wallis test with Dunn\u0026rsquo;s post-hoc correction was undertaken for the multiple assessment of the data between the six regions. Mean HU values were reported\u0026thinsp;\u0026plusmn;\u0026thinsp;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\u0026thinsp;\u0026ge;\u0026thinsp;0.7, moderate 0.7\u0026thinsp;\u0026gt;\u0026thinsp;r\u0026thinsp;\u0026ge;\u0026thinsp;0.5, weak 0.5\u0026thinsp;\u0026gt;\u0026thinsp;r\u0026thinsp;\u0026ge;\u0026thinsp;0.2.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePattern analyses\u003c/h2\u003e\u003cp\u003eOf 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.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eConformity analyses of the patterns between corresponding left and right symphyses (n\u0026thinsp;=\u0026thinsp;85) revealed that a majority of individuals had identical patterns on both sides of the pubic symphysial SCB (81%).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQuantitative pattern classification\u003c/h3\u003e\n\u003cp\u003eMean HU values of the pubic symphysis SCB of males and females were lower for females than males (females; 374\u0026thinsp;\u0026plusmn;\u0026thinsp;111 HU; 95% CI: 363\u0026ndash;385 HU, males; 554\u0026thinsp;\u0026plusmn;\u0026thinsp;180 HU; 95% CI: 540\u0026ndash;569 HU; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Males demonstrated significantly higher HU values in all subregions than females (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No difference was found when comparing the mean HU values of the left and right symphyseal surfaces (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.9).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean Hounsfield Unit (HU) values of each subregion with 95% confidence interval (CI) in males and females.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eVentral superior\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eVentral middle\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eVentral inferior\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI (HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI (HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e95% CI (HU)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e320\u0026nbsp;\u0026plusmn;\u0026nbsp;99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e296\u0026ndash;343\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e390\u0026nbsp;\u0026plusmn;\u0026nbsp;104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e365\u0026ndash;415\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e360\u0026nbsp;\u0026plusmn;\u0026nbsp;106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e335\u0026ndash;386\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e495\u0026nbsp;\u0026plusmn;\u0026nbsp;164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e462\u0026ndash;528\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e598\u0026nbsp;\u0026plusmn;\u0026nbsp;173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e563\u0026ndash;633\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e654\u0026nbsp;\u0026plusmn;\u0026nbsp;170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e619\u0026ndash;688\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDorsal superior\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003eDorsal middle\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003cb\u003eDorsal inferior\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI (HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI (HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003cp\u003e(HU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e95% CI (HU)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e360\u0026nbsp;\u0026plusmn;\u0026nbsp;117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e332\u0026ndash;389\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e421\u0026nbsp;\u0026plusmn;\u0026nbsp;110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e395\u0026ndash;418\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e393\u0026nbsp;\u0026plusmn;\u0026nbsp;106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e368\u0026ndash;418\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e475\u0026nbsp;\u0026plusmn;\u0026nbsp;156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e444\u0026ndash;510\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e515\u0026nbsp;\u0026plusmn;\u0026nbsp;155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e483\u0026ndash;546\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e629\u0026nbsp;\u0026plusmn;\u0026nbsp;166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e595\u0026ndash;662\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mean HU value patterns are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e 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.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eCorrelations between age and mean HU densities of the complete SCB were nondifferent between males (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.34; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.10) and females (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.31; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.13). However, when looking at the specific subregions, age yielded a weak negative correlation in the ventral middle region in females (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003cem\u003er\u003c/em\u003e = -0.24) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). There were non the other subregions there were no significant correlations between HU values and age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.46). In males, there were no significant correlations between HU values and age in any of the regions (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.1).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis 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.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eQualitative analyses reveal stark pattern differences between females and males\u003c/h2\u003e\u003cp\u003eThe original findings by R Putz and M M\u0026uuml;ller-Gerbl [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] 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.\u003c/p\u003e\u003cp\u003eThe 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 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. N Hammer, M Scholze, T Kibsgard, S Klima, S Schleifenbaum, T Seidel, M Werner and R Grunert [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u0026rsquo;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 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. On average, females exhibit a modest anterior pelvic tilt of approximately 4\u0026deg; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] whereas males typically maintain a pelvic orientation which is closer to neutral [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. 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\u0026mdash;most notably the broader female pelvis with its longer anterior lever arm\u0026mdash;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 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMean bone mineralisation was found to be significantly different between sexes\u003c/h2\u003e\u003cp\u003eIt 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 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, biomechanical differences between males and females remained poorly documented to date, and contemporary literature suggests that sex does not have an influence [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] than females which would explain the significant difference in mineralisation between the sexes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAge has a small influence on subchondral bone mineralisation in females but none in males\u003c/h2\u003e\u003cp\u003eAlthough 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 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. 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 (\u003cem\u003er\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;\u0026minus;\u0026thinsp;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.\u003c/p\u003e\u003cp\u003eRegarding 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.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCT-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.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebone mineral density\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003econfidence interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT-OAM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputed tomography osteoabsorptiometry\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edorsal inferior\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edorsal middle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edorsal superior\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHounsfield Units\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSCB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003esubchondral bone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eventral inferior\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eventral middle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eventral superior\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank and acknowledge the patients\u0026nbsp;who contributed to this research\u0026nbsp;project. For the procuration of the patient cohort, acknowledgement and thanks are further extended to Prof. Terence Doyle at Dunedin Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.P.: Data curation, Formal analysis, Writing—original draft, Investigation, Conceptualization. N.H: Writing- review and editing. M.M: Writing—review \u0026amp; editing., Conceptualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData availability\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data acquired in the course of this study are available from the corresponding author on request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeumann A, Valderrabano V, Hoechel S, Gopfert B, M\u0026uuml;ller-Gerbl M: \u003cstrong\u003eMineral density and penetration strength of the subchondral bone plate of the talar dome: high correlation and specific distribution patterns\u003c/strong\u003e. \u003cem\u003eJ Foot Ankle 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\u003cstrong\u003e300\u003c/strong\u003e(4):633-642.\u003c/li\u003e\n\u003cli\u003eHammer N, Scholze M, Kibsgard T, Klima S, Schleifenbaum S, Seidel T, Werner M, Grunert R: \u003cstrong\u003ePhysiological in vitro sacroiliac joint motion: a study on three-dimensional posterior pelvic ring kinematics\u003c/strong\u003e. \u003cem\u003eJ Anat \u003c/em\u003e2019, \u003cstrong\u003e234\u003c/strong\u003e(3):346-358.\u003c/li\u003e\n\u003cli\u003eBruening DA, Frimenko RE, Goodyear CD, Bowden DR, Fullenkamp AM: \u003cstrong\u003eSex differences in whole body gait kinematics at preferred speeds\u003c/strong\u003e. \u003cem\u003eGait \u0026amp; Posture \u003c/em\u003e2015, \u003cstrong\u003e41\u003c/strong\u003e(2):540-545.\u003c/li\u003e\n\u003cli\u003eCho SH, Park JM, Kwon OY: \u003cstrong\u003eGender differences in three dimensional gait analysis data from 98 healthy Korean adults\u003c/strong\u003e. \u003cem\u003eClin Biomech (Bristol, Avon) \u003c/em\u003e2004, \u003cstrong\u003e19\u003c/strong\u003e(2):145-152.\u003c/li\u003e\n\u003cli\u003eMeissner A, Fell M, Wilk R, Boenick U, Rahmanzadeh R: \u003cstrong\u003e[Biomechanics of the pubic symphysis. Which forces lead to mobility of the symphysis in physiological conditions?]\u003c/strong\u003e. \u003cem\u003eUnfallchirurg \u003c/em\u003e1996, \u003cstrong\u003e99\u003c/strong\u003e(6):415-421.\u003c/li\u003e\n\u003cli\u003eWarrener A, Lewton KL, Pontzer H, Lieberman D: \u003cstrong\u003eA wider pelvis does not increase locomotor cost in humans, with implications for the evolution of childbirth.\u003c/strong\u003e \u003cem\u003ePlos One \u003c/em\u003e2015, \u003cstrong\u003e10\u003c/strong\u003e(3):e0118903.\u003c/li\u003e\n\u003cli\u003eDubourg O, Faruch-Bilfeld M, Telmon N, Maupoint E, Saint-Martin P, Savall F: \u003cstrong\u003eCorrelation between pubic bone mineral density and age from a computed tomography sample\u003c/strong\u003e. \u003cem\u003eForensic Science International \u003c/em\u003e2019, \u003cstrong\u003e298\u003c/strong\u003e:345-350.\u003c/li\u003e\n\u003cli\u003eAbd-Eltawab AE, Ameer MA, Eladl MA, El-Sherbiny M, Ebrahim HA, Elsherbini DMA: \u003cstrong\u003eSexual 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\u003c/strong\u003e. \u003cem\u003eFront Bioeng Biotech \u003c/em\u003e2022, \u003cstrong\u003e10\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez-Alcaraz M, Gonz\u0026aacute;lez P, Aguilera I, L\u0026oacute;pez M: \u003cstrong\u003eImage analysis of pubic bone for age estimation in a computed tomography sample.\u003c/strong\u003e \u003cem\u003eInt J Legal Med \u003c/em\u003e2015, \u003cstrong\u003e129\u003c/strong\u003e(2):335-346.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bone mineral density, computed tomography osteoabsorptiometry, Hounsfield units, pubic symphysis, subchondral bone","lastPublishedDoi":"10.21203/rs.3.rs-7712524/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7712524/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe 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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCT scans from 85 individuals (51 males, 34 females; age range 18\u0026ndash;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.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAcross 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\u0026thinsp;\u0026plusmn;\u0026thinsp;180 HU vs. 374\u0026thinsp;\u0026plusmn;\u0026thinsp;111 HU, p\u0026thinsp;\u0026lt;\u0026thinsp;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 = \u0026minus;\u0026thinsp;0.24, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis 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.\u003c/p\u003e","manuscriptTitle":"Regional Distribution of Bone Mineral Density in the Pubic Symphysis: A Study of Sex and Age Differences","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 07:35:57","doi":"10.21203/rs.3.rs-7712524/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-12T08:11:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T08:20:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288573869144932324670437176723731037541","date":"2025-10-19T13:25:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-17T01:01:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163259511120355162996770590358196800482","date":"2025-10-16T05:34:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82440071092192421665636303240955233844","date":"2025-10-15T23:00:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-15T14:24:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-14T14:16:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-13T10:12:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-13T10:00:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-10-13T09:57:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"54ad8feb-a349-40d1-9f5b-b8a36be8d888","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:01:34+00:00","versionOfRecord":{"articleIdentity":"rs-7712524","link":"https://doi.org/10.1186/s12891-026-09566-7","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-02-07 15:58:06","publishedOnDateReadable":"February 7th, 2026"},"versionCreatedAt":"2025-10-29 07:35:57","video":"","vorDoi":"10.1186/s12891-026-09566-7","vorDoiUrl":"https://doi.org/10.1186/s12891-026-09566-7","workflowStages":[]},"version":"v1","identity":"rs-7712524","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7712524","identity":"rs-7712524","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}