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Meuzelaar RR, Visscher L, den Hartog FPJ, Goedhart EA, Verleisdonk EJMM, Schiphorst AHW, Burgmans JPJ. Athletes treated for inguinal-related groin pain by endoscopic totally extraperitoneal (TEP) repair: long-term benefits of a prospective cohort. Hernia 2023; 27:1179-1186. [PMID: 37391498 PMCID: PMC10533610 DOI: 10.1007/s10029-023-02815-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/25/2023] [Indexed: 07/02/2023]
Abstract
PURPOSE Inguinal-related groin pain (IRGP) in athletes is a multifactorial condition, posing a therapeutic challenge. If conservative treatment fails, totally extraperitoneal (TEP) repair is effective in pain relief. Because there are only few long-term follow-up results available, this study was designed to evaluate effectiveness of TEP repair in IRGP-patients years after the initial procedure. METHODS Patients enrolled in the original, prospective cohort study (TEP-ID-study) were subjected to two telephone questionnaires. The TEP-ID-study demonstrated favorable outcomes after TEP repair for IRGP-patients after a median follow-up of 19 months. The questionnaires in the current study assessed different aspects, including, but not limited to pain, recurrence, new groin-related symptoms and physical functioning measured by the Copenhagen Hip and Groin Outcome Score (HAGOS). The primary outcome was pain during exercise on the numeric rating scale (NRS) at very long-term follow-up. RESULTS Out of 32 male participants in the TEP-ID-study, 28 patients (88%) were available with a median follow-up of 83 months (range: 69-95). Seventy-five percent of athletes were pain free during exercise (p < 0.001). At 83 months follow-up, a median NRS of 0 was observed during exercise (IQR 0-2), which was significantly lower compared to earlier scores (p <0.01). Ten patients (36%) mentioned subjective recurrence of complaints, however, physical functioning improved on all HAGOS subscales (p <0.05). CONCLUSION This study demonstrates the safety and effectivity of TEP repair in a prospective cohort of IRGP-athletes, for whom conservative treatment had failed, with a follow-up period of over 80 months.
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Affiliation(s)
- R R Meuzelaar
- Department of Surgery/Hernia Clinic, Diakonessenhuis, Utrecht/Zeist, The Netherlands.
| | - L Visscher
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F P J den Hartog
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E A Goedhart
- Sports Medical Centre Royal Netherlands Football Association/FIFA Medical Centre of Excellence, Zeist, The Netherlands
| | - E J M M Verleisdonk
- Department of Surgery/Hernia Clinic, Diakonessenhuis, Utrecht/Zeist, The Netherlands
| | - A H W Schiphorst
- Department of Surgery/Hernia Clinic, Diakonessenhuis, Utrecht/Zeist, The Netherlands
| | - J P J Burgmans
- Department of Surgery/Hernia Clinic, Diakonessenhuis, Utrecht/Zeist, The Netherlands
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Kraeutler MJ, Mei-Dan O, Dávila Castrodad IM, Talishinskiy T, Milman E, Scillia AJ. A proposed algorithm for the treatment of core muscle injuries. J Hip Preserv Surg 2021; 8:337-342. [PMID: 35505804 PMCID: PMC9052413 DOI: 10.1093/jhps/hnab084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/25/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022] Open
Abstract
In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
| | - Omer Mei-Dan
- Department of Orthopedics, University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO 80045, USA
| | - Iciar M Dávila Castrodad
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
| | - Toghrul Talishinskiy
- Department of Surgery, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
| | - Edward Milman
- Department of Radiology, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
| | - Anthony J Scillia
- Department of Orthopaedic Surgery, St. Joseph’s University Medical Center, 973 Main St, Paterson, NJ 07503, USA
- New Jersey Orthopaedic Institute, 504 Valley Rd, Wayne, NJ 07470, USA
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Hatem M, Martin RL, Bharam S. Surgical Outcomes of Inguinal-, Pubic-, and Adductor-Related Chronic Pain in Athletes: A Systematic Review Based on Surgical Technique. Orthop J Sports Med 2021; 9:23259671211023116. [PMID: 34541009 PMCID: PMC8442511 DOI: 10.1177/23259671211023116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes. Purpose: To investigate the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed. Results: Overall, 47 studies published between 1991 and 2020 were included. There were 2737 patients (94% male) with a mean age at surgery of 27.8 years (range, 12-65 years). The mean duration of symptoms was 13.1 months (range, 0.3-144 months). The most frequent sport involved was soccer (71%), followed by rugby (7%), Australian football (5%), and ice hockey (4%). Of the 47 articles reviewed, 44 were classified as level 4 evidence, 1 study was classified as level 3, and 2 randomized controlled trials were classified as level 1b. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return to play at preinjury or higher level was observed in 92% (95% CI, 88%-95%) of the athletes after surgery to the inguinal area, 75% (95% CI, 57%-89%) after surgery to the adductor origin, 84% (95% CI, 47%-100%) after surgery to the pubic symphysis, and 89% (95% CI, 70%-99%) after combined surgery in the inguinal and adductor origin. Conclusion: Return to play at preinjury or higher level was more likely after surgery for inguinal-related CGP (92%) versus adductor-related CGP (75%). However, the majority of studies reviewed were methodologically of low quality owing to the lack of comparison groups.
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Affiliation(s)
- Munif Hatem
- Hip Preservation Center-Baylor Scott and White Research Institute, Dallas, Texas, USA
| | | | - Srino Bharam
- New York Hip Preservation and Groin Center at Lenox Hill Hospital of Northwell Health, New York, New York, USA
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Kraeutler MJ, Mei-Dan O, Belk JW, Larson CM, Talishinskiy T, Scillia AJ. A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption. Arthroscopy 2021; 37:2377-2390.e2. [PMID: 33845134 DOI: 10.1016/j.arthro.2021.03.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption. METHODS A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported. RESULTS Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication. CONCLUSIONS A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location. LEVEL OF EVIDENCE Level V, systematic review of Level I to V studies.
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Affiliation(s)
- Matthew J Kraeutler
- Department of Orthopaedic Surgery, St Joseph's University Medical Center, Paterson, New Jersey, U.S.A..
| | - Omer Mei-Dan
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | | | - Toghrul Talishinskiy
- Department of Surgery, St Joseph's University Medical Center, Paterson, New Jersey, U.S.A
| | - Anthony J Scillia
- Department of Orthopaedic Surgery, St Joseph's University Medical Center, Paterson, New Jersey, U.S.A.; New Jersey Orthopaedic Institute, Wayne, New Jersey, U.S.A
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Kler A, Sekhon N, Antoniou GA, Satyadas T. Totally extra-peritoneal repair versus trans-abdominal pre-peritoneal repair for the laparoscopic surgical management of sportsman's hernia: A systematic review and meta-analysis. Surg Endosc 2021; 35:5399-5413. [PMID: 34008111 DOI: 10.1007/s00464-021-08554-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Open and laparoscopic modalities are employed for treatment of sportsman's hernia with totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) laparoscopic approaches both currently being utilised. At present, neither subtype has demonstrated a beneficial superiority for sportsman's hernia repair, as concluded in the most recent systematic review comparing the outcomes of each technique. The aim of this review was to evaluate current evidence to ascertain whether there was a difference in laparoscopic techniques following sportsman's hernia repair. METHODS A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Databases searched included PubMed, Scopus and Web of Science to identify all randomised controlled trials (RCTs) and observational studies Risk of bias was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale for RCTs and observational studies, respectively.The assessed outcomes included median time to return to sporting activity, complications and the degree of postoperative pain reduction within three months. Random effects model was used to calculate pooled proportion data where feasible. Subgroup analyses were also performed. RESULTS 28 studies were identified including 2 RCTs and 26 observational studies. No significant differences were observed between techniques in the primary or secondary outcomes. Significant heterogeneity was observed in all outcomes. This was more pronounced for return to sporting activity meaning that meta-analysis was not feasible in this domain. Median time to return to sporting activity was 28 days for both techniques. CONCLUSIONS There is no observed difference in the primary and secondary outcomes in either technique. An RCT comparing TEP and TAPP repair is needed to provide definitive data on this matter.
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Affiliation(s)
- Aaron Kler
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, UK. .,, Flat 2, 8 Moorfield Road, Manchester, M20 2UY, UK.
| | - Nisa Sekhon
- Department of General Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, UK
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Thomas Satyadas
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
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Affiliation(s)
- Brian S. Zuckerbraun
- Division of General and Trauma Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Anthony R. Cyr
- Division of General and Trauma Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Craig S. Mauro
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Early recovery after endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption: A prospective cohort study. PLoS One 2019; 14:e0226011. [PMID: 31805137 PMCID: PMC6894863 DOI: 10.1371/journal.pone.0226011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/17/2019] [Indexed: 11/30/2022] Open
Abstract
Background Groin pain is a common problem in athletes which results in loss of playing time. Moreover, it can be for the cause of athletic career termination. A common cause of groin pain in athletes is inguinal disruption; pain in the groin area near the pubic tubercle were no obvious other pathology exists to explain the symptoms. Aim of this study was to evaluate the effect of endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption. Methods Thirty-one athletes with chronic groin pain due to inguinal disruption, who had undergone conservative therapy without any effect, were included in this prospective cohort study. Prior to surgery patients were assessed by clinical examination, ultrasound of the inguinal region, x-ray and a radionuclide bone scan with single photon-emission computed tomography and CT (SPECT-CT). TEP hernia repair was performed and a lightweight polypropylene mesh was placed pre-peritoneally. Additionally the athletes’ perception about their groin disability was assessed preoperatively and 6 weeks postoperatively by means of the Hip and Groin Outcome Score (HAGOS). The HAGOS consists of six subscales: Pain, Symptoms, Physical function in daily living, Physical function in Sport and Recreation, Participation in Physical Activities, and hip and/or groin-related Quality of Life. Results No complications occurred during and after surgery. After six weeks patients improved in all the separate subscales of the Hip and Groin Outcome Score (HAGOS). Within 6 weeks of surgery, 26 patients (84%) returned to sports activities with no or less groin pain. Conclusions This study showed that endoscopic totally extraperitoneal (TEP) hernia repair is an effective surgical treatment of inguinal disruption in athletes with chronic groin pain.
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Sheen AJ, Montgomery A, Simon T, Ilves I, Paajanen H. Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman's hernia. Br J Surg 2019; 106:837-844. [DOI: 10.1002/bjs.11226] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/22/2019] [Accepted: 04/04/2019] [Indexed: 12/31/2022]
Abstract
Abstract
Background
Sportsman's hernia/athletic pubalgia is a recognized cause of chronic groin pain in athletes. Both open and laparoscopic surgical repairs have been described for treatment, but there are no comparative studies. The hypothesis here was that relief of pain would be achieved earlier in patients treated with open minimal suture repair than totally extraperitoneal repair.
Methods
A randomized multicentre trial in four European countries was conducted to compare open minimal suture repair with totally extraperitoneal repair. The primary endpoint was complete relief of pain (visual analogue scale (VAS) score 20 or less on a scale from 0 to 100 mm) at 1 month. Secondary endpoints included complications, time to return to sporting activity, and number of patients returning to sport within 1 year.
Results
A total of 65 athletes (92 per cent men) with a median age of 29 years were enrolled (31 open repair, 34 totally extraperitoneal repair). By 4 weeks after surgery, median preoperative VAS scores had dropped from 70–80 to 10–20 in both groups (P < 0·001). Relief of pain (VAS score 20 or less) during sports activity 4 weeks after surgery was achieved in 14 of 31 patients after open repair and 24 of 34 after totally extraperitoneal repair (P = 0·047). Return to full sporting activity was achieved by 16 and 18 patients respectively after 1 month (P = 0·992), and by 25 versus 31 after 3 months (P = 0·408).
Conclusion
Totally extraperitoneal repair was less painful than open repair in the first month, but otherwise both procedures were similarly effective in treating chronic pain due to sportsman's hernia. Registration number: NCT02297711 ( http://www.clinical.trials.gov).
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Affiliation(s)
- A J Sheen
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
- Centre of Biomedicine Manchester Metropolitan University, Manchester, UK
- Fortius Clinic, London, UK
| | - A Montgomery
- Department of Surgery, Institution for Clinical Science, Lund University, Skåne University Hospital, Malmö, Sweden
| | - T Simon
- Department of General Surgery, GRN-Klinik Sinsheim, Heidelberg University Hospital, Heidelberg, Germany
| | - I Ilves
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - H Paajanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
- School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Treatment of longstanding groin pain: a systematic review. Hernia 2019; 23:1035-1044. [DOI: 10.1007/s10029-019-01919-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/22/2019] [Indexed: 10/27/2022]
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