|Year : 2019 | Volume
| Issue : 4 | Page : 152-156
A case for the laparoscopic approach for rectus-adductor tendonopathy-athletic pubalgia
David S Edelman, Harlan Selesnick
Miami Orthopedics and Sports Medicine Institute, Baptist Health Doctors Hospital, Coral Gables, FL, USA
|Date of Submission||13-Jul-2019|
|Date of Decision||04-Aug-2019|
|Date of Acceptance||20-Aug-2019|
|Date of Web Publication||22-Oct-2019|
Dr. David S Edelman
Miami Orthopedics and Sports Medicine Institute, Baptist Health Doctors Hospital, 5000 University Drive, Coral Gables, FL 33146
Source of Support: None, Conflict of Interest: None
Athletes with athletic pubalgia from core muscle injuries have many options available for treatment. Magnetic resonance imaging (MRI) can show pubic bone edema, rectus muscle insertion atrophy, and/or adductor tendonopathy. Our surgical repair using laparoscopically placed biologic mesh placed posteriorly with an open mini-incision to the anterior adductor longus tendon has had excellent results. This presentation will review the injury, a failed open repair followed by a biologic repair involving the rectus-adductor tendon injury onto the pubic bone of a recently treated athlete. A 28-year-old professional athlete presented 4 weeks after an open core muscle injury (CMI) repair. MRI showed disruption of the adductor tendon from the pubis and persistent opposing side rectus abdominis muscle insertion atrophy. After rehabilitation, his complete recovery prompted a retrospective review of all patients with laparoscopic biologic mesh. The laparoscopic, posterior, preperitoneal repair of the rectus-adductor tendon with biologic mesh is effective in treating athletes with athletic pubalgia. The laparoscopic approach to a rectus-adductor tendon injury using biologic mesh has not been well defined. A postoperative MRI found complete regeneration of the rectus and adductor muscles after a failed open CMI surgery (Meyer Repair). The peri-operative MRI shows the surgical progression of this condition.
Keywords: Adductor tendonitis, athletic pubalgia, core muscle injury, osteitis pubis, rectus abdominis strain, sports hernia
|How to cite this article:|
Edelman DS, Selesnick H. A case for the laparoscopic approach for rectus-adductor tendonopathy-athletic pubalgia. Int J Abdom Wall Hernia Surg 2019;2:152-6
| Introduction|| |
Core muscle injury (CMI) in athletes has been the subject of many articles over the past 30 years. It can be a very debilitating injury in athletes preventing them from playing at the high level necessary for competitive sports. Sports hernias were described in 1966 by Cabot and popularized in the 1980s by Gilmore. The term “sports hernia” has fallen out of favor for more descriptive terms, yet the general public knows the term “sports hernia” to define a tear in the posterior inguinal floor or transversalis fascia with associated pubic edema or osteitis pubis. Surgeons treating this condition have noted a tender, possibly dilated internal ring in athletes who did not clinically have an inguinal hernia. Other pathologic findings have been noted including a torn conjoined tendon, torn external oblique aponeurosis, and chronic osteitis pubis that did not improve with conservative treatment. The rectus abdominis and adductor longus muscles share a common tendinous attachment onto the pubis and are a source of many complaints in the groin. This is most likely related to the repetitive movement, explosive activation, and torque at the pubic attachment of the adductor longus and rectus abdominis associated with twisting and hyperextension of the hip joint needed for kicking, jumping, running, or quickly turning. More and more physicians treating this condition are transitioning to “CMI” or athletic pubalgia as a more descriptive and accurate term to describe this problem.
Many approaches to the treatment of this condition have been described in the literature and not one approach has been confirmed to be superior to any other. Rest along with nonsteroidal anti-inflammatory medication and physical therapy to stretch and strengthen the core muscles is the initial, honored approach to the treatment. When nonoperative treatments fail, injection of stem cells or plasma, open conjoined tendon repair, or laparoscopic inguinal hernia repair with mesh followed by physical therapy has been shown to be safe and effective. Santilli in 2016 looked at 1450 athletes who presented with groin pain to the Orthopedic and Sports Medicine Center and found 590 had sports hernias along with adductor muscle strain and other injuries of the groin. Guidelines for the laparoscopic treatment of inguinal hernia and sportsman hernia were developed by the International Endohernia Society in 2011 and updated in 2015., There has been no study that one treatment is superior or applicable to all patients or hernia repairs.
There is a theoretical advantage of using biologic mesh for athletic pubalgia as there is limited amount of foreign material left behind once healing is complete. Two studies have shown that biologic mesh is safe when used in the inguinal region to repair hernias,, but their study population was small and follow-up time was short. However, when biologic mesh is used in incisional hernias, late recurrences have been reported. The benefits of biologic mesh in the athlete relate to not leaving behind any permanent suture or polypropylene that could become infected or rejected, thereby affecting the high level of athletic activity that is placed in this region. Selecting the most appropriate treatment to repair a CMI and minimizing the failure rate while optimizing the return of the athlete to their sport is required.
| Case Report|| |
The patient was a 31-year-old professional athlete who presented with a 6-month history of bilateral groin pain, left greater than the right. He is right hand dominant. His examination was remarkable for superb muscular definition, and no inguinofemoral hernia or tenderness was noted. Magnetic resonance imaging (MRI) was obtained [Figure 1] and [Figure 2] and revealed bilateral osteitis pubis, right rectus muscle insertion atrophy, and microtears of both the adductor longus tendons onto the inferior pubis. Surgical correction using laparoscopic guidance was offered. He and his agent elected for an open repair by another surgeon and he had bilateral pelvic floor reconstruction and bilateral adductor tenotomy with a steroid injection into the adductor tendon. One month after the surgery, while getting out of bed to pick up his son, he developed acute left groin pain. MRI [Figure 3] revealed a high-grade, left adductor longus tendon tear, a large hematoma, and a partial tear of the right adductor tendon. There was no change in the atrophy of the right rectus muscle insertion onto the pubis [Figure 4].
|Figure 2: Preoperative magnetic resonance imaging, osteitis pubis and adductor microtears|
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|Figure 3: Magnetic resonance imaging adductor tear after open Meyer Repair|
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|Figure 4: Magnetic resonance imaging, no change in left rectus injury post Meyer Repair|
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Two weeks later, the patient underwent a hematoma evacuation in the left femoral region and suture reattachment with 4 cm × 7 cm biologic mesh reinforcement of the left adductor tendon onto the inferior pubic bone. Operative cultures of the hematoma showed Propionibacterium acnes. The right rectus muscle was approached laparoscopically via the preperitoneal space using the umbilicus for a 12-mm balloon-Hasson cannula. Accessory 5-mm portals were placed under direct vision in the midline below the umbilicus and above the pubis. After dissecting the internal ring to confirm there were no indirect hernias, dissection was carried down from the arcuate ligament onto and then below the pubic bone exposing the adductor brevis muscle insertion, posteriorly. Two pieces of 7 cm × 10 cm biologic mesh were attached posteriorly from the rectus muscle insertion onto the pubis and below onto the adductor longus insertion, bilaterally. Absorbable tacks held the mesh in place (six on each side), and fibrin sealant was sprayed on the repair [Figure 5] and [Figure 6]. In addition to preoperative cephazolin 2 g, he was treated for 6 weeks with oral Amoxicillin 875 mg twice a day.
Physical therapy was initiated 8 days postoperatively. Six weeks after the second operation, a repeat MRI [Figure 7] and [Figure 8] showed significant improvement in the entire injury process with near-normal right rectus muscle and left adductor longer tendon re-attachment. He was cleared for practice and play. With careful, controlled conditioning, he is presently at full, unrestricted activity.
|Figure 7: Postoperative magnetic resonance imaging with left rectus hypertrophy|
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| Discussion|| |
Athletic pubalgia or CMI involves injury related to hyperextension and rotational forces at the pubic bone. The rectus abdominis muscle and adductor longus muscle share a common tendon insertion into the pubic bone. Injury of this tendinous insertion is one of the most common findings seen on MRI when investigating groin pain in the athletes. Whether this injury is from hyperextension of the rectus or the adductor or both, there are many theories that torque and twisting associated with jumping, accelerating, or change of direction in athletes whose muscle strength and tone is at a peak is the cause. Some authors describe a weakness of the posterior inguinal wall, but it is the chronic, repetitive, activity related injury that is worsened by turning or twisting movements that lead to pain. Athletes can usually endure the discomfort, but by the following day, the discomfort increases. Rest is beneficial, but the resumption of activity causes the discomfort to recur. Not uncommon, the athlete will compensate by using the muscles on the opposite side and complain of discomfort on the noninjured side. Once the athlete cannot perform at a level needed for their sport, it is brought to the attention of the trainers or team physicians.
The physical examination is frequently not defining when examining the athlete. The pubic bone may be tender, the adductor longus tendon may be tight, and the floor of the inguinal canal may be lax. It is rare to find a true hernia on physical examination. However, if an ultrasound with Valsalva demonstrates an inguinal hernia, it is reasonable to proceed with an inguinal hernia repair. If the sonogram is inconclusive, an MRI of the pelvis without contrast is indicated prior to orthopedic evaluation. This study will show the hip and pelvis musculoskeletal structures extremely well as long as the radiologist is alerted to the suspicion of a “sport's hernia.” In the patient presented, the preoperative findings of adductor insertion tendonitis and atrophy of the rectus abdominis on the opposing side are something that I look for commonly in athletes with sports injuries. Pubic edema is a common finding in most patients with athletic pubalgias.
Injecting corticosteroids into the area of pain or into the adductor tenotomy, as was with the case presented, is not without complication. Infection is a known side effect of steroid injection and may have contributed to the complex postoperative disruption of the adductor tenotomy in this patient. I do not encourage corticosteroid injection but am not averse to nonsteroidal anti-inflammatory drugs given orally in the postsurgical period to control pain and swelling.
The finding at the first postoperative MRI that intrigued me was the persistent atrophy of the rectus abdominis muscle at the pubic insertion at 1 month following his first operation. That finding prompted me to access the preperitoneum behind the pubis to re-inforce this attachment while going below the pubis where the adductor inserts. The operative management of CMI involves the re-inforcement of the posterior abdominal wall using suture as described by Meyers et al. or Minnich et al. There is an excellent description of the mini-open incision sports hernia repair by Scilla which also describes the lengthening of the adductor longus from the conjoined tendon. Emblom recently described his open technique on the rectus-adductor aponeurotic plate. Brody reviewed the options to repair inguinal sport's hernias  in 2006. Alternatively, a laparoscopic repair as described by Paajanen et al. or Edelman , involves mesh placed behind the inguinal floor in the preperitoneal space. Sheen recently published a randomized study in Europe in 65 athletes and showed that the laparoscopic extraperitoneal repair was less painful in the 1st month but similarly effective to an open repair in the longer term. By placing biologic mesh behind the rectus abdominis and below the pubic bone allows these muscles to use the posterior pubic bone to assist in the repair and mimic these open repairs. Our technique accesses the posterior adductor muscle and rectus muscles using biologic mesh to re-attach the adductor-pubis-rectus triad. In addition, the anterior adductor longus tendon is approached open, anteriorly, with a 2″ incision placing 20–30 microcuts in the adductor tendon followed by biologic mesh reinforcement with suture and fibrin sealant over the cuts, onto the tendon, and attached to the pubis.
Hernias and surgery, in general, are known to induce atrophic changes in the abdominal wall muscular. In a study by De Silva et al., hypertrophy of the rectus muscle was observed on computed tomography scans obtained 6 months postoperatively when the midline was reconstructed. Bridging did not demonstrate any significant postoperative hypertrophic muscular changes. Due to the number of biologic meshes that are available, there remains no consensus about which biologic materials should be used for hernia reconstruction. However, bridging of defects for hernia reconstruction has been demonstrated to lead to high rates of recurrence., Ansaloni looked at 3-year data using porcine small intestine submucosa (SIS) for open inguinal hernia repair. In his randomized study, he found SIS to be safe and effective.
The biologic mesh acts as a scaffold for host tissue collagen to re-populate the injured area with excellent revascularization. However, over time, there has been a question of the long-term durability and strength with biologic mesh. In cases similar to the above-described procedure, SIS mesh is placed in direct contact to the muscle and bone, further secured with absorbable tacks and fibrin sealant which allows the mesh to be incorporated and acts in the manner that is desired with resultant muscular hypertrophy and excellent resumption of ability.
| Conclusions|| |
This case demonstrates with the aid of MRI, the improvement in muscle mass after biologic mesh placement using laparoscopic techniques along with the complete return of athletic function in a relatively short period of time. This was not observed after an open (Meyer) technique. Looking at our patients with long-term follow-up, laparoscopic retro-rectus biologic mesh is an acceptable technique for the repair of rectus-adductor tendopathy with a surprising complete return of rectus abdominis muscle and adductor longus muscle mass and function.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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