Arch Orthop Trauma Surg (2014) 134:1595–1599 DOI 10.1007/s00402-014-2065-x
ARTHROSCOPY AND SPORTS MEDICINE
Arthroscopic pubic symphysis debridement and adductor enthesis repair in athletes with athletic pubalgia: technical note and video illustration Sascha Hopp • Masjudin Tumin • Peter Wilhelm Tim Pohlemann • Jens Kelm
•
Received: 8 March 2014 / Published online: 24 July 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract We elaborately describe our novel arthroscopic technique of the symphysis pubis in athletes with osteitis pubis and concomitant adductor enthesopathy who fail to conservative treatment modalities. The symphysis pubis is debrided arthroscopically and the degenerated origin of adductor tendon (enthesis) is excised and reattached. With our surgical procedure the stability of the symphysis pubis is successfully preserved and the adductor longus enthesopathy simultaneously addressed in the same setting. Keywords Arthroscopy Pubic symphysis Osteitis pubis Debridement Adductor enthesopathy Athletes
Introduction Osteitis pubis in athletes still presents a diagnostic and therapeutic challenge. Although it is described as a noninfectious, inflammatory condition to the symphysis pubis
Electronic supplementary material The online version of this article (doi:10.1007/s00402-014-2065-x) contains supplementary material, which is available to authorized users. S. Hopp (&) P. Wilhelm T. Pohlemann Department of Trauma, Hand and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg/ Saar, Germany e-mail: [email protected] M. Tumin Department of Orthopaedic and Trauma Surgery, Sultanah Aminah Hospital, 80100 Johor Bahru, Johor, Malaysia J. Kelm Center of general and Orthopedic Surgery, Illingen, Germany
and its supporting structures [1], the actual aetiology and pathogenesis remain obscure. It is postulated that increased biomechanical stress during sports activities with stop and go movements, sharp sprints as well as pivoting manoeuvres leads to an overuse injury at the symphysis pubis and the stabilizing ligaments with subsequent degeneration of the fibrocartilaginous disc tissue, resulting in anterior pelvic instability in the end stage [2]. The most favourite sports associated with these activities include soccer, Australian-rules football and to a lesser degree, distance running [1–3]. Athletes with osteitis pubis commonly present with anterior and medial groin pain and, in some cases, may have pain centred directly over the pubic symphysis. Pain may also be felt in the adductor region, lower abdominal muscles, perineal region, inguinal region or scrotum [2]. Furthermore, recent radiological investigations speculated that the adjacent adductor tendinopathy is also implicated in the aetiology of osteitis pubis and both often coexist [4, 5]. Usually the majority of the cases with osteitis pubis respond well to conservative programs of rest, physiotherapy with core muscle strengthening, oral medication or local injection therapy with corticoids; however, they may often take a considerable period of time to heal [1, 3]. However, a small number of athletes may be refractory to these conservative measures and need surgical intervention. A variety of surgical procedures with varying efficacies have been reported in the literature, such as wedge resection [6], total resection [7], pubic symphysis stabilization with compression plate and bone grafting [8] and also the least violating surgery which is symphysis pubis curettage [3, 9]. However, sole pubic symphysis curettage only resulted in about 70 % improvement and return to previous sport activity [3]. On the basis of our previously published work with the first few cases operated on the purpose of this technical note
123
1596
Arch Orthop Trauma Surg (2014) 134:1595–1599
is rather to provide an elaborate description of our new surgical technique supported by a comprehensive video illustration, than to emphasize diagnostic regimen behind it.
Surgical technique Patient positioning and adductor longus tendon exposure The patient is initially placed in supine position on the operating table and general anaesthesia is induced. A thirdgeneration cephalosporine is administered. An indwelling catheter is inserted to empty the urinary bladder. Then, the patient is positioned in low lithotomy position with both hips slightly flexed (20°), abducted (30°) and externally rotated (20°) to expose the groin. The genital is covered and in male patient the genitalia are carefully retracted down between the proximal thighs. The symphyseal area and the groin on both sides are prepared and draped in an usual sterile manner. The important landmarks, which are the symphyseal cleft, the superior ramus, the femoral artery and the easily palpable adductor longus tendon, are identified. The image intensifier is positioned laterally on the opposite side, the arthroscopic tower laterally on the side of the lesion. After marking, a 6-cm obliqued skin incision is made at the groin skin fold, directly over the palpable adductor longus tendon. Several crossing veins in the subcutaneous soft tissue are coagulated or ligated. The adductor longus tendon is identified by blunt dissection. The adductor longus fascia is then split longitudinally along the tendon from musculotendinous junction to its origin at the pubic bone, where its fibres merge with the anterior symphyseal capsule complex. Adherent tissue over the anterior symphysis pubis capsule is bluntly dissected and the spermatic cord is palpated and protected by a retractor. Localization of the adductor lesion utilizing symphysographic diagnostic Thereby, adjustment of the image intensifier is of paramount importance, because for the puncture the mid-point of the pubic symphysis can only be reliably met in pelvic outlet view. The exact depths of the needle are controlled in pelvic inlet view. A precise intraoperative localization of the adductor longus tendon lesion by intraoperative arthrography of the symphysis (iopromid, UltravistÒ300, Bayer Healthcare) is performed under fluoroscopic control and marked (Fig. 1). This area is compared with the radiographic ‘‘secondary cleft sign’’, which has been already diagnosed during outpatient clinic visits, to identify the exact topography of the lesion during operation.
123
Fig. 1 Localization and consecutive marking of the exact lesion site at the adductor longus origin by intraoperative arthrography (‘‘symphysography’’)
Fig. 2 Detached adductor tendon. Black asterisk indicates physiologic orientation of the normal tendon fibres in the superficial layer, while the white asterisk shows a pathological mix of fibrous tissue in the deep tendon layer
Installation of the ‘‘suprapubic portal’’ A transverse 2-cm skin incision is made centrally and 1 cm above the symphysis pubis. Under fluoroscopy guidance in the standard pelvic inlet view, a cannula and subsequently a flexible nitinol guide wire are introduced through the centre of the superior pubic ligament into the symphyseal cleft. With the aid of a dilator (Storz, Tuttlingen, Germany), a small opening to the symphyseal joint cleft is created. Through this opening a 4.5-mm motorized shaver (Dyonics System, Smith and Nephew, Germany) is introduced in Seldinger technique under simultaneous fluoroscopic guidance in the standard pelvic inlet view. Adductor longus tendon debridement and creation of ‘‘anterior–central portal’’ Exactly at the initially marked lesion area of the adductor longus tendon, a U-shaped longitudinal incision is made, the complete 1-cm broad tendon flap detached from its
Arch Orthop Trauma Surg (2014) 134:1595–1599
Fig. 3 Arthroscopic view into the symphysis pubis before (a) and after (b) debridement of the disc. Note the narrow joint space with the shaver between the adjacent pubic rami
bony origin and the loose tendon retracted laterally. A mixture of degenerative and fibrous tissue is identified in the deep layer of the tendon and is completely selectively excised (Fig. 2). Thereby, an opening to the symphyseal joint cleft is created, and through this developing ‘‘anterior portal’’ a 2.7-mm 30° arthroscopic optic (Karl Storz, Tuttlingen, Germany) was carefully introduced. Under this sufficient arthroscopy visualization of the symphyseal joint, complete debridement of the ruptured fibrocartilaginous disc tissue and the remaining degenerated hyaline cartilage is performed gradually using the shaver, until the subchondral bone layer is opened and small punctate bleedings are obtained (Fig. 3a, b). Direct outflow of the purisole solution is guaranteed through the opened wound. In general, low fluid pump pressures under 100 mmHg are sufficient for complete arthroscopic procedure.
1597
Fig. 4 Suture anchor placement in the pubic bone under image intensifier control
Table 1 Recommendations for the surgical procedure 1. The use of intraoperative fluoroscopic control in standard inlet and outlet projections warrants precise localization of the site of the adductor lesion as well as a correct installation of the suprapubic portal 2. Two arthroscopic portals are recommended: the suprapubic ‘‘working’’ portal and the antero-central ‘‘scope’’ portal 3. Small-size arthroscopes (2.7 mm, 30° angled optic) and shavers (maximum 4.5 mm) enable improved manoeuvrability during arthroscopic procedure 4. Arthroscopic debridement should only be performed in a sagittal direction, in order not to intrude into the cancellous bone 5. Avoidance of extensive bone resection or damaging of the symphyseal ligaments is imperative, because of potential pubic instability
Postoperative rehabilitation course Debridement of pubic origin and reattachment of adductor longus tendon After removal of the arthroscopic instruments, subsequently the bony origin of the pubic bone is debrided with pincers and a chisel, and the debrided tendon is reattached to its original contact area using two 2.8-mm suture anchors (Arthrex FastakÒ, Naples, Florida) (Fig. 4) and their correct position is verified with image intensifier control in the pelvic inlet view. Additional supporting sutures to the surrounding normal tendon tissue are made to protect this reattached tendon against traction forces which may cause detachment of this repaired area. If required, the tendon is partially released at the musculotendinous junction, if hypertension after reattachment is palpable. A drain tube is inserted and the wounds are closed by layer with non-absorbable sutures. Recommendations for this surgical procedure are summarized in Table 1. The entire surgical procedure is shown in Video 1.
Postoperatively the patient is allowed full weight-bearing immediately on the day of surgery, with limited abduction and adduction against resistance for 6 weeks. Subsequently, increased mobility and muscle strengthening exercises as well as specific stabilizing core exercises follow, as comfort allows. At the latest, after 3 months sportsspecific training exercises and if pain-free, competitive sports activities are allowed.
Discussion The primary treatment of osteitis pubis should be by conservative measures. Nevertheless, up to 10 % of all patients do not respond to nonoperative treatment [10]. Several authors have reported invasive surgical procedures either by total resection [7] or a trapezoid-shaped wedge resection [6] of the pubic symphysis to treat this group of patients. However, some of these patients required secondary
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arthrodesis of the pubic symphysis and both sacroiliac joints for debilitating pain caused by posterior instability after the surgery, and therefore cannot be recommended in high demanding athletes with an unpredictable time away from sports. Primary pubic symphysis stabilization with compression plate and bone grafting in athletes with refractory osteitis pubis was successful in 100 % of the cases [8]. Nonetheless, the reported mean time to return to sports following surgery was 6.6 months and therefore quite long. It is still debatable, if the diagnosis of osteitis pubis and instability of just more than 2 mm justifies this invasive procedure, keeping the athletes for a long period of time away from sports. The stability of symphysis pubis is maintained by a stable ligamentous envelope which is formed by four different pubic ligaments, together with the adjacent tendons of the rectus and the adductors [11]. Among these ligaments, strong anterior and inferior (arcuate) pubic ligament reinforces the symphysis pubis to resist the forces applied to the joint during physiologic gait [12]. Therefore, any surgery performed at the symphysis pubis has potential risk to damage any of these ‘‘joint stabilisers’’, resulting in an increased pathologic motion in the anterior pelvic ring, possibly leading to overall instability of the whole pelvis [6, 7]. Any aggressive ligament and bone resection should be avoided to prevent these complications. Disc curettage without excessive bone and ligament resection which is less invasive surgery was introduced [3, 9]. Radic et al. reported 16 of 23 athletes with ‘‘osteitis pubis’’ treated by open curettage, returned to full activity. Although no significant complication occurred, a total of 30 % of all patients did not return to their previous activity level or were still suffering pain and four patients, who were diagnosed to have additional concurrent partial tears of the adductor tendon by MRI scan, were not addressed with the sole curettage [3]. Hechtman et al. [9] presented a recent case series of four athletes suffering from isolated degenerative osteitis pubis in which a minimal-invasive curettage was successfully performed and tendon involvement was ruled out by MRI diagnostics preoperatively. In our arthroscopic debridement technique, the stability of important symphysis pubis capsule and ligaments is preserved. Installation of these portals, especially the suprapubic portal is performed properly with careful attention given to the topographical anatomy of the symphysis pubis under adequate image intensifier guidance and only small part of the superior ligament is breached. Recent radiologic investigations on osteitis pubis in athletes described the secondary cleft sign which is an extension of symphyseal cleft to the adductor tendon enthesis and is thought to reflect a microtear at this area [4, 5]. It was speculated that the adductor dysfunction and microtear preceded the development of osteitis pubis and
123
Arch Orthop Trauma Surg (2014) 134:1595–1599
concluded that both diseases often coexist [5]. Therefore, we describe a novel surgical procedure to address osteitis pubis with concomitant adductor longus tendinopathy simultaneously. After debridement of damaged tendon, the remaining tendon is reattached to its origin at the pubic body to maintain the balance environment between the force of adductor and rectus tendon. In any circumstances, any palpable tension of the adductor tendon is partially released at the musculotendineous junction to prevent further microtear of the enthesis. The use of diagnostic arthrography in the operative field is also helpful to precisely localize the distinct chronic lesion of the adductor longus tendon, thereby limiting the magnitude of anterior ligament incision for anterior portal, tendon detachment and debridement. With this arthroscopic debridement technique, arthrographic localization and reattachment of the adductor tendon, the symphysis pubis ‘‘joint stabiliser’’ is preserved; therefore, we presumed that the risk of causing instability to symphysis pubis is reduced to almost nil. In a previous study, Hopp et al. [13] presented an elaborate preoperative protocol to diagnose these diseases clinically. Diligent preoperative evaluation of the underlying pathology with the suggested diagnostic is of paramount importance. It was emphasized that a positive clinical provocation test is a prerequisite to confirm the diagnosis and surgery is only indicated when the symptoms reappeared. In conclusion, through this ligament-sparing arthroscopic surgery, we can presume that the risk of iatrogenic instability was decreased to almost nil. This therapeutic option has the benefit of being straight-forward and first of all tailored to the specific lesions presented. Conflict of interest
No conflicts of interest at all.
References 1. Batt ME, McShane JM, Dillingham MF (1995) Osteitis pubis in collegiate football players. Med Sci Sports Exerc 27:629–633 2. Hiti CJ, Stevens KJ, Jamati MK, Garza D, Matheson GO (2011) Athletic Osteitis Pubis. Sports Med 41(5):361–376 3. Radic R, Annear P (2008) Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes. Am J Sports Med 36:122–128 ´ Connell MJ, Ryan M, Cunningham P, Taylor D, 4. Brennan D, O ´ Neill P, Eustace S (2005) Secondary cleft sign as a Cronin C, O marker on injury in athletes with groin pain: MR image appearance and interpretation. Radiology 235:162–167 ´ Connell M, MacMahon P, O ´ Neill 5. Cunningham PM, Brennan D, O P, Eustace S (2007) Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR 188:291–296 6. Grace JN, Sim FH, Shives TC, Coventry MB (1989) Wedge resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Jt Surg Am 71:358–364
Arch Orthop Trauma Surg (2014) 134:1595–1599 7. Moore RS Jr, Stover MD, Matta JM (1998) Late posterior instability of the pelvis after resection of the symphysis pubis for the treatment of osteitis pubis. A report of two cases. J Bone Jt Surg Am 80:1043–1048 8. Williams PR, Thomas DP, Downes EM (2000) Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail. Am J Sports Med 28:350–355 9. Hechtman KS, Zvijac JE, Popkin CA, Zych GA, Botto-van Bemden A (2010) A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes. Orthopedics 2:210–215 ´ Brien P, Blachut P (2006) 17. Can J Surg 10. Mehin R, Meek R, O 49(3):170
1599 11. Robinson P, Salehi F, Grainger A, Clemence M, Schilders E, ´ Connor P, Agut A (2007) Cadaveric and MRI Study of the O musculotendinous contributions to the capsule of the symphysis pubis. Am J Rad 188:440–445 12. Becker I, Woodley SJ, Stringer MD (2010) The adult human pubic symphysis: a systematic review. J Anat 217:475–487 13. Hopp S, Culemann U, Kelm J, Pohlemann T, Pizanis A (2013) Osteitis pubis and adductor tendinopathy in athletes—a novel arthroscopic pubic symphysis curettage and adductor reattachment. Arch Orthop Trauma Surg 133(7):1003–1009
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ARTHROSCOPY AND SPORTS MEDICINE
Arthroscopic pubic symphysis debridement and adductor enthesis repair in athletes with athletic pubalgia: technical note and video illustration Sascha Hopp • Masjudin Tumin • Peter Wilhelm Tim Pohlemann • Jens Kelm
•
Received: 8 March 2014 / Published online: 24 July 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract We elaborately describe our novel arthroscopic technique of the symphysis pubis in athletes with osteitis pubis and concomitant adductor enthesopathy who fail to conservative treatment modalities. The symphysis pubis is debrided arthroscopically and the degenerated origin of adductor tendon (enthesis) is excised and reattached. With our surgical procedure the stability of the symphysis pubis is successfully preserved and the adductor longus enthesopathy simultaneously addressed in the same setting. Keywords Arthroscopy Pubic symphysis Osteitis pubis Debridement Adductor enthesopathy Athletes
Introduction Osteitis pubis in athletes still presents a diagnostic and therapeutic challenge. Although it is described as a noninfectious, inflammatory condition to the symphysis pubis
Electronic supplementary material The online version of this article (doi:10.1007/s00402-014-2065-x) contains supplementary material, which is available to authorized users. S. Hopp (&) P. Wilhelm T. Pohlemann Department of Trauma, Hand and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg/ Saar, Germany e-mail: [email protected] M. Tumin Department of Orthopaedic and Trauma Surgery, Sultanah Aminah Hospital, 80100 Johor Bahru, Johor, Malaysia J. Kelm Center of general and Orthopedic Surgery, Illingen, Germany
and its supporting structures [1], the actual aetiology and pathogenesis remain obscure. It is postulated that increased biomechanical stress during sports activities with stop and go movements, sharp sprints as well as pivoting manoeuvres leads to an overuse injury at the symphysis pubis and the stabilizing ligaments with subsequent degeneration of the fibrocartilaginous disc tissue, resulting in anterior pelvic instability in the end stage [2]. The most favourite sports associated with these activities include soccer, Australian-rules football and to a lesser degree, distance running [1–3]. Athletes with osteitis pubis commonly present with anterior and medial groin pain and, in some cases, may have pain centred directly over the pubic symphysis. Pain may also be felt in the adductor region, lower abdominal muscles, perineal region, inguinal region or scrotum [2]. Furthermore, recent radiological investigations speculated that the adjacent adductor tendinopathy is also implicated in the aetiology of osteitis pubis and both often coexist [4, 5]. Usually the majority of the cases with osteitis pubis respond well to conservative programs of rest, physiotherapy with core muscle strengthening, oral medication or local injection therapy with corticoids; however, they may often take a considerable period of time to heal [1, 3]. However, a small number of athletes may be refractory to these conservative measures and need surgical intervention. A variety of surgical procedures with varying efficacies have been reported in the literature, such as wedge resection [6], total resection [7], pubic symphysis stabilization with compression plate and bone grafting [8] and also the least violating surgery which is symphysis pubis curettage [3, 9]. However, sole pubic symphysis curettage only resulted in about 70 % improvement and return to previous sport activity [3]. On the basis of our previously published work with the first few cases operated on the purpose of this technical note
123
1596
Arch Orthop Trauma Surg (2014) 134:1595–1599
is rather to provide an elaborate description of our new surgical technique supported by a comprehensive video illustration, than to emphasize diagnostic regimen behind it.
Surgical technique Patient positioning and adductor longus tendon exposure The patient is initially placed in supine position on the operating table and general anaesthesia is induced. A thirdgeneration cephalosporine is administered. An indwelling catheter is inserted to empty the urinary bladder. Then, the patient is positioned in low lithotomy position with both hips slightly flexed (20°), abducted (30°) and externally rotated (20°) to expose the groin. The genital is covered and in male patient the genitalia are carefully retracted down between the proximal thighs. The symphyseal area and the groin on both sides are prepared and draped in an usual sterile manner. The important landmarks, which are the symphyseal cleft, the superior ramus, the femoral artery and the easily palpable adductor longus tendon, are identified. The image intensifier is positioned laterally on the opposite side, the arthroscopic tower laterally on the side of the lesion. After marking, a 6-cm obliqued skin incision is made at the groin skin fold, directly over the palpable adductor longus tendon. Several crossing veins in the subcutaneous soft tissue are coagulated or ligated. The adductor longus tendon is identified by blunt dissection. The adductor longus fascia is then split longitudinally along the tendon from musculotendinous junction to its origin at the pubic bone, where its fibres merge with the anterior symphyseal capsule complex. Adherent tissue over the anterior symphysis pubis capsule is bluntly dissected and the spermatic cord is palpated and protected by a retractor. Localization of the adductor lesion utilizing symphysographic diagnostic Thereby, adjustment of the image intensifier is of paramount importance, because for the puncture the mid-point of the pubic symphysis can only be reliably met in pelvic outlet view. The exact depths of the needle are controlled in pelvic inlet view. A precise intraoperative localization of the adductor longus tendon lesion by intraoperative arthrography of the symphysis (iopromid, UltravistÒ300, Bayer Healthcare) is performed under fluoroscopic control and marked (Fig. 1). This area is compared with the radiographic ‘‘secondary cleft sign’’, which has been already diagnosed during outpatient clinic visits, to identify the exact topography of the lesion during operation.
123
Fig. 1 Localization and consecutive marking of the exact lesion site at the adductor longus origin by intraoperative arthrography (‘‘symphysography’’)
Fig. 2 Detached adductor tendon. Black asterisk indicates physiologic orientation of the normal tendon fibres in the superficial layer, while the white asterisk shows a pathological mix of fibrous tissue in the deep tendon layer
Installation of the ‘‘suprapubic portal’’ A transverse 2-cm skin incision is made centrally and 1 cm above the symphysis pubis. Under fluoroscopy guidance in the standard pelvic inlet view, a cannula and subsequently a flexible nitinol guide wire are introduced through the centre of the superior pubic ligament into the symphyseal cleft. With the aid of a dilator (Storz, Tuttlingen, Germany), a small opening to the symphyseal joint cleft is created. Through this opening a 4.5-mm motorized shaver (Dyonics System, Smith and Nephew, Germany) is introduced in Seldinger technique under simultaneous fluoroscopic guidance in the standard pelvic inlet view. Adductor longus tendon debridement and creation of ‘‘anterior–central portal’’ Exactly at the initially marked lesion area of the adductor longus tendon, a U-shaped longitudinal incision is made, the complete 1-cm broad tendon flap detached from its
Arch Orthop Trauma Surg (2014) 134:1595–1599
Fig. 3 Arthroscopic view into the symphysis pubis before (a) and after (b) debridement of the disc. Note the narrow joint space with the shaver between the adjacent pubic rami
bony origin and the loose tendon retracted laterally. A mixture of degenerative and fibrous tissue is identified in the deep layer of the tendon and is completely selectively excised (Fig. 2). Thereby, an opening to the symphyseal joint cleft is created, and through this developing ‘‘anterior portal’’ a 2.7-mm 30° arthroscopic optic (Karl Storz, Tuttlingen, Germany) was carefully introduced. Under this sufficient arthroscopy visualization of the symphyseal joint, complete debridement of the ruptured fibrocartilaginous disc tissue and the remaining degenerated hyaline cartilage is performed gradually using the shaver, until the subchondral bone layer is opened and small punctate bleedings are obtained (Fig. 3a, b). Direct outflow of the purisole solution is guaranteed through the opened wound. In general, low fluid pump pressures under 100 mmHg are sufficient for complete arthroscopic procedure.
1597
Fig. 4 Suture anchor placement in the pubic bone under image intensifier control
Table 1 Recommendations for the surgical procedure 1. The use of intraoperative fluoroscopic control in standard inlet and outlet projections warrants precise localization of the site of the adductor lesion as well as a correct installation of the suprapubic portal 2. Two arthroscopic portals are recommended: the suprapubic ‘‘working’’ portal and the antero-central ‘‘scope’’ portal 3. Small-size arthroscopes (2.7 mm, 30° angled optic) and shavers (maximum 4.5 mm) enable improved manoeuvrability during arthroscopic procedure 4. Arthroscopic debridement should only be performed in a sagittal direction, in order not to intrude into the cancellous bone 5. Avoidance of extensive bone resection or damaging of the symphyseal ligaments is imperative, because of potential pubic instability
Postoperative rehabilitation course Debridement of pubic origin and reattachment of adductor longus tendon After removal of the arthroscopic instruments, subsequently the bony origin of the pubic bone is debrided with pincers and a chisel, and the debrided tendon is reattached to its original contact area using two 2.8-mm suture anchors (Arthrex FastakÒ, Naples, Florida) (Fig. 4) and their correct position is verified with image intensifier control in the pelvic inlet view. Additional supporting sutures to the surrounding normal tendon tissue are made to protect this reattached tendon against traction forces which may cause detachment of this repaired area. If required, the tendon is partially released at the musculotendinous junction, if hypertension after reattachment is palpable. A drain tube is inserted and the wounds are closed by layer with non-absorbable sutures. Recommendations for this surgical procedure are summarized in Table 1. The entire surgical procedure is shown in Video 1.
Postoperatively the patient is allowed full weight-bearing immediately on the day of surgery, with limited abduction and adduction against resistance for 6 weeks. Subsequently, increased mobility and muscle strengthening exercises as well as specific stabilizing core exercises follow, as comfort allows. At the latest, after 3 months sportsspecific training exercises and if pain-free, competitive sports activities are allowed.
Discussion The primary treatment of osteitis pubis should be by conservative measures. Nevertheless, up to 10 % of all patients do not respond to nonoperative treatment [10]. Several authors have reported invasive surgical procedures either by total resection [7] or a trapezoid-shaped wedge resection [6] of the pubic symphysis to treat this group of patients. However, some of these patients required secondary
123
1598
arthrodesis of the pubic symphysis and both sacroiliac joints for debilitating pain caused by posterior instability after the surgery, and therefore cannot be recommended in high demanding athletes with an unpredictable time away from sports. Primary pubic symphysis stabilization with compression plate and bone grafting in athletes with refractory osteitis pubis was successful in 100 % of the cases [8]. Nonetheless, the reported mean time to return to sports following surgery was 6.6 months and therefore quite long. It is still debatable, if the diagnosis of osteitis pubis and instability of just more than 2 mm justifies this invasive procedure, keeping the athletes for a long period of time away from sports. The stability of symphysis pubis is maintained by a stable ligamentous envelope which is formed by four different pubic ligaments, together with the adjacent tendons of the rectus and the adductors [11]. Among these ligaments, strong anterior and inferior (arcuate) pubic ligament reinforces the symphysis pubis to resist the forces applied to the joint during physiologic gait [12]. Therefore, any surgery performed at the symphysis pubis has potential risk to damage any of these ‘‘joint stabilisers’’, resulting in an increased pathologic motion in the anterior pelvic ring, possibly leading to overall instability of the whole pelvis [6, 7]. Any aggressive ligament and bone resection should be avoided to prevent these complications. Disc curettage without excessive bone and ligament resection which is less invasive surgery was introduced [3, 9]. Radic et al. reported 16 of 23 athletes with ‘‘osteitis pubis’’ treated by open curettage, returned to full activity. Although no significant complication occurred, a total of 30 % of all patients did not return to their previous activity level or were still suffering pain and four patients, who were diagnosed to have additional concurrent partial tears of the adductor tendon by MRI scan, were not addressed with the sole curettage [3]. Hechtman et al. [9] presented a recent case series of four athletes suffering from isolated degenerative osteitis pubis in which a minimal-invasive curettage was successfully performed and tendon involvement was ruled out by MRI diagnostics preoperatively. In our arthroscopic debridement technique, the stability of important symphysis pubis capsule and ligaments is preserved. Installation of these portals, especially the suprapubic portal is performed properly with careful attention given to the topographical anatomy of the symphysis pubis under adequate image intensifier guidance and only small part of the superior ligament is breached. Recent radiologic investigations on osteitis pubis in athletes described the secondary cleft sign which is an extension of symphyseal cleft to the adductor tendon enthesis and is thought to reflect a microtear at this area [4, 5]. It was speculated that the adductor dysfunction and microtear preceded the development of osteitis pubis and
123
Arch Orthop Trauma Surg (2014) 134:1595–1599
concluded that both diseases often coexist [5]. Therefore, we describe a novel surgical procedure to address osteitis pubis with concomitant adductor longus tendinopathy simultaneously. After debridement of damaged tendon, the remaining tendon is reattached to its origin at the pubic body to maintain the balance environment between the force of adductor and rectus tendon. In any circumstances, any palpable tension of the adductor tendon is partially released at the musculotendineous junction to prevent further microtear of the enthesis. The use of diagnostic arthrography in the operative field is also helpful to precisely localize the distinct chronic lesion of the adductor longus tendon, thereby limiting the magnitude of anterior ligament incision for anterior portal, tendon detachment and debridement. With this arthroscopic debridement technique, arthrographic localization and reattachment of the adductor tendon, the symphysis pubis ‘‘joint stabiliser’’ is preserved; therefore, we presumed that the risk of causing instability to symphysis pubis is reduced to almost nil. In a previous study, Hopp et al. [13] presented an elaborate preoperative protocol to diagnose these diseases clinically. Diligent preoperative evaluation of the underlying pathology with the suggested diagnostic is of paramount importance. It was emphasized that a positive clinical provocation test is a prerequisite to confirm the diagnosis and surgery is only indicated when the symptoms reappeared. In conclusion, through this ligament-sparing arthroscopic surgery, we can presume that the risk of iatrogenic instability was decreased to almost nil. This therapeutic option has the benefit of being straight-forward and first of all tailored to the specific lesions presented. Conflict of interest
No conflicts of interest at all.
References 1. Batt ME, McShane JM, Dillingham MF (1995) Osteitis pubis in collegiate football players. Med Sci Sports Exerc 27:629–633 2. Hiti CJ, Stevens KJ, Jamati MK, Garza D, Matheson GO (2011) Athletic Osteitis Pubis. Sports Med 41(5):361–376 3. Radic R, Annear P (2008) Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes. Am J Sports Med 36:122–128 ´ Connell MJ, Ryan M, Cunningham P, Taylor D, 4. Brennan D, O ´ Neill P, Eustace S (2005) Secondary cleft sign as a Cronin C, O marker on injury in athletes with groin pain: MR image appearance and interpretation. Radiology 235:162–167 ´ Connell M, MacMahon P, O ´ Neill 5. Cunningham PM, Brennan D, O P, Eustace S (2007) Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR 188:291–296 6. Grace JN, Sim FH, Shives TC, Coventry MB (1989) Wedge resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Jt Surg Am 71:358–364
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