Sportsmen’s groin, also called sports hernia and Gilmore groin,
is one of the most frequent sports injuries in athletes and may place
an athletic career at risk. It presents with acute or chronic groin pain
exacerbated with physical activity. So far, there is little consensus
regarding pathogenesis, diagnostic criteria, or treatment. There have
been various attempts to explain the cause of the groin pain. The
assumption is that a circumscribed weakness in the posterior wall of the
inguinal canal, which leads to a localized bulge, induces a compression
of the genital branch of the genitofemoral nerve, considered
responsible for the symptoms.
Methods:
The
authors developed an innovative open suture repair—the Minimal Repair
technique—to fit the needs of professional athletes. With this
technique, the circumscribed weakness of the posterior wall of the
inguinal canal is repaired by an elastic suture; the compression on the
nerve is abolished, and the cause of the pain is removed. In contrast
with that of common open suture repairs, the defect of the posterior
wall is not enlarged, the suture is nearly tension free, and the patient
can return to full training and athletic activity within a shorter
time. The outcome of patients undergoing operations with the Minimal
Repair technique was compared with that of commonly used surgical
procedures.
Results:
The
following advantages of the Minimal Repair technique were found: no
insertion of prosthetic mesh, no general anesthesia required, less
traumatization, and lower risk of severe complications with equal or
even faster convalescence. In 2009, a prospective cohort of 129 patients
resumed training in 7 days and experienced complete pain relief in an
average of 14 days. Professional athletes (67%) returned to full
activity in 14 days (median).
Conclusion:
The Minimal Repair technique is an effective and safe way to treat sportsmen’s groin.
Keywords: sportsmen’s groin, Minimal Repair technique, sports hernia, pubalgia, chronic groin pain, innovative surgery
Sportsmen’s groin, also called sports hernia and Gilmore groin,
is one of the most frequent sports injuries and represents a severe
clinical problem, especially in athletes. Currently, there is little
consensus regarding pathophysiology, diagnostic criteria, or treatment.
Pathophysiology
There
have been many attempts to explain the cause of groin pain, such as
imbalance between the comparatively stronger hip adductor muscles and
the comparatively weaker lower abdominal muscles.5,12
Weakness, poor endurance, reduced extensibility, or poor coordination
of the muscular synergists necessary for effective dynamic hip motion
control may precipitate functional instability, overuse, and injury at
comparatively weaker noncontractile structures.5
Among
the existing theories, one suggests that the entrapment of the genital
branch of the genitofemoral nerve or the ilioinguinal, lateral femoral
cutaneous, and obturator nerves may be responsible for the pain.2,7,34
We principally agree with this assumption that the genital branch of
the genitofemoral nerve is compressed by a localized bulge because of a
circumscribed weakness in the posterior wall of the inguinal canal
during the Valsalva maneuver (Figure 1).
Cranial and medial displacement of the rectus abdominis muscle with increasing tension at the pubic bone.
As
a consequence of the widened groin canal, the rectus muscle is
retracted medially and cranially. This retraction causes an increased
tension at the pubic bone. This pathomechanism is responsible for the
pain at the symphysis pubis (Figure 1), also known as athletic pubalgia.
Sportsmen’s
groin, a localized bulge in the posterior inguinal wall with
compression of the genital branch of the genitofemoral nerve.
Diagnosis
Diagnosis
should be made by an experienced examiner because it may be difficult
to distinguish the symptoms among different problems. Through a careful
history, physical examination, and dynamic ultrasonography, a correct
diagnosis can be obtained.
Medical History
Sportsmen’s
groin presents with acute or chronic groin pain exacerbated with
physical activity. The patient usually reports pain in the groin (dull,
diffuse, sharp, and burning), often with radiation down the inner thigh,
the scrotum, the testicle, and the pubic bone. In the early stages, the
pain does not typically occur during competition but gives rise to
aching afterward. Pain is aggravated by kicking, sudden changes in
movement, coughing, and other Valsalva-type maneuvers.15,40
The pain can be so intense that athletes are impaired, severely
constrained, or even completely disabled from training and practicing
sport.
Physical Examination
The
examination is carried out with the patient in upright position. When
the inguinal canal is palpated, the patient usually confirms that the
pain is getting worse. A sportsmen’s groin is diagnosed when no inguinal
hernia can be found but there is a localized bulge in the posterior
wall of the inguinal canal during the Valsalva maneuver (Figure 2).
Dynamic Ultrasonography
Every
patient should be explored with a dynamic ultrasound scan in supine
position using a high-frequency transducer (5 MHz to 13 MHz). Care
should be taken not to compress the inguinal canal with excessive
transducer pressure. The motion of the inguinal canal and its walls is
observed during the Valsalva maneuver, and the size of the defect can be
measured (about 2 cm on average). Sportsmen’s groin is diagnosed if a
convex anterior bulge of the posterior inguinal wall is observed during
stress. Magnetic resonance imaging (MRI) is reported to have good
diagnostic potential,27,40
but the examination is done with the patient in the recumbent position.
In our opinion, this explains the high rate of false-negative results
with MRI and supports dynamic ultrasound scan as a diagnostically
conclusive option, if it is done by an experienced examiner.
Common Treatment
The literature suggests that sportsmen’s groin rarely improves without surgery.11,12,15,17,28,33
To avoid the development of chronic groin pain, surgical repair should
be considered when conservative treatment over a period of 6 to 8 weeks
has failed and when careful examination has excluded other potential
pain sources.8,10,18,41
Both open and laparoscopic techniques produce excellent results, with
most patients being able to return to their previous levels of activity.†
So far, laparoscopic repair is believed to enable a faster recovery and
return to unrestricted sports activities than that of open repair.8,16,24,37,40
The Minimal Repair Technique
In 2003, we introduced an innovative open suture repair called the Minimal Repair technique.29
We developed it to fit the needs of professional athletes. The aim of
this surgical intervention is to eradicate groin pain by decompression
of the genital branch of the genitofemoral nerve. The posterior wall is
stabilized by a nearly tension-free suture without enlarging the defect
of the posterior wall of the inguinal canal by the dissection. This
allows the patient to return immediately to full activity without pain.
As a general rule, we never use prosthetic mesh for athletes because
they require, after surgery, the full elasticity and slide-bearing
function of their abdominal muscles (ie, mobility of the 3 layers of the
abdominal wall).
The Minimal Repair
technique is performed under local anesthesia. The approach is carried
out through a small inguinal incision, dissection of subcutaneous
tissue, and splitting of the external oblique aponeurosis. The repair
starts with testing the strength of the posterior inguinal wall by
digital palpation. A circumscribed weakness is typically found in the
posterior wall, with the surrounding tissue firm and intact. The fascia
transversalis is split, beginning in the area of the defect toward the
deep internal ring. The length of the incision encloses only the area of
fascial weakness; the surrounding tissue is kept intact (Figure 3).
The genital branch of the genitofemoral nerve should be assessed and,
if necessary, partly removed (ie, because of nerve damage). Then a
continuous suture is placed from medial toward the deep inguinal ring,
creating a free fascia lip out of the iliopubic tract (suture 1; Figure 4).
There, the suture reverses toward the pubic bone. The free lip is
included in the suture and brought to the inguinal ligament (Figure 5).
The rectus abdominis muscle is lateralized with suture to counteract
the increased tension at the pubic bone caused by the retraction of the
rectus muscle in the superior and medial direction (suture 2; Figure 6).
The pampiniform plexus is protected against mechanical irritation by
creating a muscular collar at the deep ring with the lateral section of
the internal oblique muscle (Figure 7).
In contrast to the Shouldice repair, only the circumscribed weakness of
the posterior wall is opened. Sound tissue next to the defect remains
intact.
Only the defect is opened and, if necessary, resection of the genital branch of the genito-femoral nerve is performed.
Suture 1: continuous suture (Prolene 2-0) from medial toward the deep inguinal ring, creating a free lip.
The
suture now reverses its course toward the pubic bone, and the free
border is included in the suture and brought to the inguinal ligament.
The
lateral section of the internal oblique muscle creates a muscular
collar to protect the pampiniform plexus and nerves from mechanical
irritation.
Postoperative Treatment
Conventional
nonsteroidal anti-inflammatory drugs are used for postoperative pain
relief. All patients are discharged on the day of operation. Patients
are allowed to lift up to 20 kg (44 lb) immediately after surgery,
resume running or cycling on the second postoperative day, begin
specific training on the third or fourth day, and fully train on the
fifth. This is possible because the nearly tension-free suture does not
cause pain.
Results
Outcome at 4 Weeks
In 2009, a prospective cohort study was carried out to evaluate the clinical outcome of the Minimal Repair technique.29
We report the results for the 4-week evaluation postoperatively.
Further analysis will follow, given that the study is ongoing. The
primary endpoints were time to resume low-level training, full training
and competing, and complete pain relief.
All
but 5 patients (124 of 129; 96.1%) had resumed training (median, 7
days; interquartile range [IQR], 4 to 14). A full return to preinjury
sports activity levels was reported by 75.8% (median, 18.5 days; IQR,
1.75 to 28.0), and 78.9% reported that they were completely free of pain
(median, 14 days; IQR, 6 to 28 days). In professional athletes (67%),
the time to return to preinjury sports activity was 14 days (IQR, 10 to
28).29 Pain scores indicated a marked improvement in level of pain (P < .0001). The pain score decreased from 6 to 1 (IQRs, 3-7 and 0-2, respectively).29
All patients thought that the operation had improved their symptoms
considerably. Histologically, after nerve resection (genital branch of
the genitofemoral nerve in 20%), a perineural fibrosis was shown in 100%
of the patients.
Advantages of the Minimal Repair Technique
The
Minimal Repair technique is a novel open repair technique where the
preparation and doubling of the fascia transversalis encloses only the
area of fascial weakness and does not affect surrounding sound tissue,
as in standard suture repairs (eg, Shouldice repair).29
Commonly used surgical procedures include open repairs (eg, Shouldice
and Lichtenstein repairs) as well as laparoscopic repairs (eg,
transabdominal preperitoneal procedure, total extraperitoneal
procedure).
In comparison with the latter methods, the
Minimal Repair technique has the following advantages: no insertion of
prosthetic mesh, general anesthesia is not required, less
traumatization, lower risk of severe complications, and equivalent or
even faster convalescence.
Especially in athletes who
require full elasticity and movement in their abdominal muscles, meshes
should be avoided because, once inserted, they result in localized
stiffening of the abdominal muscles and, therefore, restricted movement.
Because Minimal Repair technique does not make use of meshes, patients
are not prone to mesh-related complications, such as infections with
chronic groin sepsis and fistula formation (which sometimes requires the
removal of mesh3), mesh migration and penetration into the bladder or bowel,6,23 and foreign body reaction with decrease of arterial perfusion and testicular temperature32 with consecutive secondary azoospermia.36 Of note, 35% of open procedures and 100% of laparoscopic procedures use mesh.8
Concerning the recurrence of pain so far, we have not had one case
within our uncontrolled clinical review. In reviewing nearly 2000
minimal repairs in athletes since 2003, we have only 3 patients in which
pain could not be permanently alleviated.
The
laparoscopic approach always requires general anesthesia. This is not
the case with open procedures, including the Minimal Repair technique;
as such, patients are not exposed to the side effects of general
anesthesia. Existing data from large consecutive patient series and
randomized studies have shown local anesthesia to be advantageous.19
Open repairs were shown to be less traumatic than laparoscopic approaches.35
Schwab et al determined the systemic inflammatory response after
endoscopic versus Shouldice groin repair by monitoring cytokine
activities (C-reactive protein, prostaglandin F1a, neopterin,
interleukin-6). The immune trauma was significantly higher in the group
with laparoscopic hernia repair than in the group who received a
Shouldice repair. Therefore, the repair of groin hernias using a
laparoscopic technique should not be regarded as a minimally invasive
procedure that is less traumatic than conventional approaches.35
Because the Minimal Repair technique does not split the whole posterior
inguinal wall, as in the case with a Shouldice repair, it can be
considered less invasive with respect to tissue damage.
Severe visceral and vascular complications were more often reported with laparoscopic techniques14
than with open repair techniques. A common problem after laparoscopic
repair is postoperative urinary retention (22.2% after laparoscopic
inguinal hernia procedures).21 The number of surgeons using laparoscopic procedures has increased in the past few years.13,17,20,30,39,42 With the Minimal Repair technique, neither minor nor major complications were observed during follow-up.
After laparoscopic repair, recovery generally took 6 to 8 weeks before full return to competition was permitted.1,8,15,22,42 The recovery times in other studies varied from 2 to 3 weeks,4,13 4 weeks,31 3 to 6 weeks,9 and up to 12 weeks.20,42
In a meta-analysis, Caudill et al found postsurgical recovery times
(based on sports activity) of 17.7 weeks for patients who underwent open
approaches and 6.1 weeks for laparoscopic repairs.8
Based on these data, the convalescence after operation under the
Minimal Repair technique is faster than that after the customary
procedures.
Conclusion
The Minimal Repair technique is an effective and safe way to treat sportsmen’s groin.
Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445105/
Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445105/
0 commentaires:
Enregistrer un commentaire