Endoscopic Rectus Abdominis and Prepubic Aponeurosis Repairs for Treatment of Athletic Pubalgia Dean K. Matsuda, M.D., Nicole A. Matsuda, Rachel Head, B.S., and Tanya Tivorsak, M.D.
Abstract: Review of the English orthopaedic literature reveals no prior report of endoscopic repair of rectus abdominis tears and/or prepubic aponeurosis detachment. This technical report describes endoscopic reattachment of an avulsed prepubic aponeurosis and endoscopic repair of a vertical rectus abdominis tear immediately after endoscopic pubic symphysectomy for coexistent recalcitrant osteitis pubis as a single-stage outpatient surgery. Endoscopic rectus abdominis repair and prepubic aponeurosis repair are feasible surgeries that complement endoscopic pubic symphysectomy for patients with concurrent osteitis pubis and expand the less invasive options for patients with athletic pubalgia.
O
steitis pubis is a form of athletic pubalgia, and a recent study found a high prevalence in professional football players.1 It is associated with femoroacetabular impingement and may be caused by transfer stress from constrained range of motion in one or both hips.2 Endoscopic pubic symphysectomy has been found to be a safe and promising, less-invasive option to open pubic symphysis curettage.3 Athletic pubalgia may also involve tears of the adductor and/or rectus abdominis tendons. Although open repair has been done, to our knowledge there is no previously published case of endoscopic repairs of the rectus tendon and the prepubic aponeurosis. The purpose of this technical report is to describe the endoscopic techniques used to perform endoscopic rectus abdominis and prepubic aponeurosis repairs after concurrent endoscopic pubic symphysectomy.
From DISC Sports and Spine (D.K.M.), Marina del Rey, California; University of California (N.A.M.), Davis, California; Loyola Marymount University, Los Angeles, California (R.H.); and Mink Radiology (T.T.), Marina del Rey, California, U.S.A. The authors report the following potential conflict of interest or source of funding: D.K.M. receives consultancy fees from Zimmer Biomet and royalties for intellectual property from Zimmer Biomet and Smith & Nephew. Received July 21, 2016; accepted September 10, 2016. Address correspondence to Dean K. Matsuda, M.D., DISC Sports and Spine, Marina del Rey, CA, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16689/$36.00 http://dx.doi.org/10.1016/j.eats.2016.09.022
Technique We describe our techniques for endoscopic pubic aponeurosis reattachment and rectus abdominis repair after endoscopic pubic symphysectomy for the treatment of recalcitrant osteitis pubis and athletic pubalgia. Preoperative radiographs revealed sclerotic bony hypertrophy at the pubic symphysis and a healed right pubic stress fracture (Fig 1), and magnetic resonance imaging revealed detachment of the prepubic aponeurosis from the pubic tubercle (Fig 2) and a tear of the rectus abdominis (Fig 3). The patient was placed in a supine lithotomy position using gynecologic stirrups without traction (Figs 4 and 5). A Foley catheter was used to decompress the adjacent bladder. Endoscopic pubic symphysectomy was performed using our previously described technique,4,5 first localizing the pubic symphysis under AP pelvic fluoroscopic guidance and marking the midpoint with a 22-gauge needle. The anterior portal was established as the initial viewing portal with the 30 standard arthroscope at a low pump pressure of 40 mm Hg. The suprapubic portal was established and a switching stick was used to locate the previously placed 22-guage needle tip in the pubic symphysis (Fig 6). The overlying bursal tissue was resected with a motorized shaver and radiofrequency ablator (Arthrocare; Smith & Nephew, Andover, MA) followed by incremental resection of the pubic symphysis beginning from anterosuperior to posteroinferior. Initial resection was performed with a 5.5-mm round burr, followed by deeper resection of the fibrocartilage disc and hyaline endplates (Fig 7) with a shortsheath 4-mm round burr. Care was taken to avoid
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Fig 1. Preoperative modified Dunn lateral view of both hips showing the sclerotic bony hypertrophy at the pubic symphysis (arrows) and a healed right pubic stress fracture. Also note the bilateral cam deformities of the proximal femurs, both of which were asymptomatic.
penetration of the posterior capsule so as to avoid iatrogenic damage to the adjacent bladder. Moreover, the important inferior capsule and arcuate ligament were retained as important stabilizers of the pubic symphysis. The arthroscope and burr may be interchanged from their starting portals as needed to facilitate the surgery. Once the endoscopic pubic symphysectomy was completed, the inferior pubic region was visualized and probed with a stitching stick, ensuring there were no gaps or adductor tendon detachment. Endoscopic visualization of the superior pubic region showed a vertical tear of the conjoint tendon of the rectus abdominis and
Fig 2. Sagittal magnetic resonance imaging view demonstrating detachment of prepubic aponeurosis (arrow).
Fig 3. Coronal magnetic resonance imaging view showing the distal rectus abdominis tear (arrow).
some torn muscle fibers. The vertical tear extended 4 cm above the superior margin of the pubic symphysis. The prepubic aponeurosis was visualized and probed, revealing detachment from the anterior pubis adjacent to the pubic symphysis (Fig 8). Endoscopic prepubic aponeurosis repair was performed before rectus abdominis repair to optimize visualization of the former procedure. Endoscopic repair of the prepubic aponeurotic detachment was performed after initial soft tissue removal with the radiofrequency ablator at the anterosuperior pubic bones adjacent to the area of prior endoscopic pubic symphysectomy and gentle decortication with a motorized burr to stimulate healing of tendinous
Fig 4. Supine lithotomy patient positioning and setup. Note adjacent positioning of arthroscopy and fluoroscopy monitors at head of bed location.
ENDOSCOPIC SURGERY FOR ATHLETIC PUBALGIA
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Fig 7. Supine endoscopic view with 30 arthroscope from the anterior portal of endoscopic pubic symphysectomy to address recalcitrant osteitis pubis. Note the unhooded burr (from the suprapubic portal) and the hyaline endplates of the pubic symphysis (*).
aponeurosis to bone. Via a short 8.5-mm arthroscopic cannula (Smith & Nephew) in the suprapubic portal, the right prepubic aponeurotic tissue was reapproximated to the prepared bony bed using endoscopically placed horizontal mattress stitch (no. 2 Ultrabraid; Smith & Nephew). The vertical mattress was intentionally placed at the level of desired attachment and no attempt was made for distal advancement as the aponeurosis appeared otherwise intact with the more
distal adductor attachments and in neutral caudadcephalad alignment. The knotless suture anchor (Swivelock 4.75-mm PEEK [polyether ether ketone]; Arthrex, Naples, FL) was placed after initial anchor site preparation with the appropriate tap, but the sclerotic bone made advancement difficult. The tap was removed and the 4.5-mm drill was used to a depth of 20 mm, with endoscopic visualization confirming no violation into the area of pubic symphysectomy. Moreover, the anterosuperior to posteroinferior and medial to lateral vectors encouraged from the suprapubic portal facilitated desired intra-osseous anchor placement aligned with the pubic orientation and
Fig 6. Anterior (arrowhead) and suprapubic (arrow) portals. A 30 arthroscope is used in the anterior portal. A plastic arthroscopic cannula is later used in the suprapubic portal to aid with suture management and suture anchor fixation.
Fig 8. Supine endoscopic view, with 30 arthroscope, of the detached prepubic aponeurosis complex. Note the bare pubic crests (*).
Fig 5. Position of the surgeon between the patient legs while performing endoscopic surgery with seamless monitoring of the arthroscopic and fluoroscopic monitors.
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Fig 9. Supine endoscopic view showing reattachment of the detached prepubic aponeurosis using knotless anchor in the pubic crest adjacent to area of previous endoscopic pubic symphysectomy (*).
aimed away from the underlying bladder in case of inadvertent penetration of the far cortex. The sutures were tensioned before seating the knotless anchors with confirmed secure reattachment of the prepubic aponeurosis (Fig 9). The process was repeated for the left prepubic aponeurosis repair. Endoscopic repair of the vertical tear of the rectus abdominis tendon (Fig 10) was performed under endoscopic guidance with the 30 arthroscope in the anterior portal. Working proximal to distalward toward the arthroscope, side-to-side suture repair using nonabsorbale no. 2 sutures (Ultrabraid; Smith & Nephew) was performed through the plastic cannula in the suprapubic portal with a birdbeak suture passer first through the right tendon margin, passing the suture material into the recently excavated trough of the pubic
Fig 10. Supine endoscopic view of the distal vertical tear of the rectus abdominis tendon (arrows).
Fig 11. Supine endoscopic view during repair of a vertical rectus abdominis tear. Note the suture from the right margin of the torn tendon in the trough made by previous endoscopic pubic symphysectomy being grasped by suture grasper that has passed through the left margin of the tendon to aid safe suture passage.
symphysis (Fig 11) (with care taken not to plunge into the bladder), then similarly passing the unloaded birdbeak through the left tendon margin, retrieving the suture from the pubic symphyseal trough, and completing the repair using standard arthroscopic knottying technique. Once the third, distal, and final suture was tied, endoscopic visualization confirmed secure reapproximation of the rectus abdominis tear (Fig 12). All instruments were atraumatically removed and the portals were closed with no. 2 nylon sutures followed by injection into the pubic symphyseal trough with 0.5% Marcaine and 10 mg Duromorph. A compression “jock strap” garment was applied as the patient had some scrotal swelling commonly observed in male patients after endoscopic pubic symphysectomy.5
Fig 12. Supine endoscopic view after completion of side-toside rectus abdominis repair with 3 sets of sutures.
ENDOSCOPIC SURGERY FOR ATHLETIC PUBALGIA
Fig 13. Postoperative detail of the anterior-posterior pelvic view showing the widened gap of the pubic symphysis without vertical displacement and the absence of cortical endplates, which were resected during endoscopic pubic symphysectomy. Note the entry sites for suture anchor fixation of the right and left prepubic aponeurotic complex (arrows).
A postoperative radiograph is shown (Fig 13). An accompanying video (Video 1, see supplemental material) shows key surgical steps. Technical pearls and pitfalls are highlighted in Table 1.
Discussion Although we have previously reported the technique4,5 and outcomes of endoscopic pubic symphysectomy for recalcitrant osteitis pubis,3 review of the English orthopaedic literature could find no previous case or cases of endoscopic repair of either the rectus abdominis and/or the prepubic aponeurosis. Hopp presented outcomes for arthroscopic pubic symphyseal curettage and open adductor repairs6 whereas Tansey reported successful outcomes in athletes with open repair of adductor sleeve avulsions that also included the rectus abdominis.7 We have introduced a completely endoscopic athletic pubalgia surgery to treat recalcitrant osteitis pubis, prepubic aponeurosis avulsion, and rectus abdominis tear. The muscular layer of the anterolateral abdominal wall is made up of 4 flat muscles, namely, the external oblique, internal oblique, transverse abdominis, and the rectus abominis. The recti are paired straplike muscles, separated at the midline by the linea alba. Each muscle has 2 tendinous origins; a medial head arising from the anterior surface of the pubic symphysis, and a larger lateral portion from the upper border of the pubic crest, which together insert onto the fifth, sixth and seventh costal cartilages. The aponeuroses of the internal and external obliques and transverse abdominis fuse to
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form the linea alba, a strong midline fibrous structure firmly attached to the xiphoid process above, and the pubic symphysis and pubic crest below.8 The 6 lower thoracic nerves innervate the rectus abdominis. Anatomically, the anterior aspect of the pubis acts as a common origin for important musculotendinous, aponeurotic, and ligamentous structures around the symphysis pubis. This prepubic soft-tissue complex is known as the prepubic aponeurotic complex (P-PAC) and includes interconnections between the adductor tendons, rectus abdominis, inguinal musculoaponeurotic structures, articular disc, and pubic ligaments of the symphysis pubis.9 Partial or complete avulsion injuries to this prepubic aponeurosis may cause athletic pubalgia.8 The rectus abdominis functions primarily to flex the spine and compress the abdominal and pelvic cavities. Secondarily, it assists in respiration by pulling the chest downward and depressing the lower ribs. The diagnosis of a rectus abdominis tear is usually straightforward. An indirect muscle injury mechanism involving eccentric-concentric action is the most prevalent. Acute direct blows to the abdominal wall are extremely rare, and intra-abdominal illnesses are usually not difficult to differentiate from abdominal wall sport-related injuries.8 Physical examination shows tenderness of the affected rectus abdominis, usually below the umbilicus. A functional examination of the entire abdominal musculature during isometric, concentric, eccentric, and plyometric contraction is warranted. On magnetic resonance imaging, a muscle tear shows focal high-intensity signal areas with muscle disruption, whereas scar tissue generates a low-intensity signal on all pulse sequences. Magnetic resonance imaging is considered the modality of choice for diagnosis of rectus abdominis and prepubic aponeurosis injury. Interestingly, the feasibility of performing completely endoscopic midline rectus abdominis repair as described in this technical report may have utility in performing abdominoplasty in an endoscopic manner. Abdominoplasty, also known as the tummy tuck procedure, is currently performed as a mini-open cosmetic surgery to yield a flat abdominal contour, often due to midline separation or diastasis of the rectus abdominis. Table 1. Technical Pearls and Pitfalls Perform endoscopic pubic symphysectomy (if indicated) before repairs of adductor tendon(s), prepubic aponeurosis, and/or rectus tendon. Pubic symphyseal trough facilitates suture passage and establishes medial margins for suture anchor placement. Drill and seat suture anchors in anterosuperior to posteroinferior direction for reattachment of prepubic aponeurosis. Maximizes bony engagement of suture anchor while minimizing risk of bladder damage should inadvertent far cortex penetration occur. Use low pump pressures combined with hypotensive anesthesia or even dry arthroscopy. Minimizes fluid extravasation while may cause scrotal swelling.
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Many patients with athletic pubalgia may have concurrent (and likely causative) femoroacetabular impingement.1 Constrained hip range of motion may cause transfer stress to the pubic region (and the lumbar spine and sacroiliac joints).2 Most athletes that we have treated for osteitis pubis and/or athletic pubalgia have undergone concurrent outpatient surgery for symptomatic femoroacetabular impingement.3 Endoscopic reattachment of the prepubic aponeurosis and/or rectus abdominis repair, often along with endoscopic pubic symphysectomy, for athletic pubalgia harnesses the advantages of minimally invasive surgery, including outpatient surgery with relatively rapid recovery and rehabilitation, minimal blood loss, and high cosmesis. It complements arthroscopic surgery for athletes with femoroacetabular impingement, and endoscopy enables magnified visualization of anatomic structures and associated pathology. Disadvantages include the potential for iatrogenic damage to the bladder and, in male patients, scrotal swelling, which may occur as a transient and minor complication after endoscopic pubic symphysectomy.3 Although unknown if scrotal swelling would occur with isolated endoscopic rectus abdominis repair and/or prepubic aponeurosis reattachment, it seems prudent to inform male patients of this possibility prior to surgery, use dry endoscopy when able, and low arthroscopic pump pressures when not. Endoscopic rectus abdominis repair and prepubic aponeurosis repair are feasible surgeries that complement endoscopic pubic symphysectomy for patients with concurrent osteitis pubis and expand the less invasive options for patients with athletic pubalgia.
References 1. Larson CM, Sikka RS, Sardelli MC, et al. Increasing alpha angle is predictive of athletic-related “hip” and “groin” pain in collegiate National Football League prospects. Arthroscopy 2013;29:405-410. 2. Verrall GM, Hamilton IA, Slavotinek JP, et al. Hip joint range of motion reduction in sports-related chronic groin injury diagnosis as pubic bone stress injury. J Sci Med Sport 2005;8:77-84. 3. Matsuda DK, Ribas M, Matsuda NA, Domb BG. Multicenter outcomes of endoscopic pubic symphysectomy for osteitis pubis associated with femoroacetabular impingement. Arthroscopy 2015;31:1255-1260. 4. Matsuda DK. Endoscopic pubic symphysectomy for recalcitrant osteitis pubis associated with bilateral femoroacetabular impingement. Orthopedics 2010;33:199-203. 5. Matsuda DK, Sehgal B, Matsuda NA. Endoscopic pubic symphysectomy for athletic osteitis pubis. Arthrosc Tech 2015;4:e251-e254. 6. Hopp SJ, Culemann U, Kelm J, Pohlemann T, Pizanis A. Osteitis pubis and adductor tendinopathy in athletes: A novel arthroscopic pubic symphysis curettage and adductor reattachment. Arch Orthop Trauma Surg 2013;133:1003-1009. 7. Tansey RJ, Benjamin-Laing H, Jassim S, Liekens K, Shankar A, Haddad FS. Successful return to high-level sports following early surgical repair of combined adductor complex and rectus abdominis avulsion. Bone Joint J 2015;97-B:1488-1492. 8. Mercouris P. Sports hernia: A pictorial review. S Afr J Rad 2014;18(2). http://www.sajr.org.za/index.php/sajr/article/ view/670. 9. MacMahon PJ, Hogan BA, Shelley MJ, Eustace SJ, Kavanagh EC. Imaging of groin pain. Magn Reson Imaging Clin N Am 2009;17:655-666.
Abstract: Review of the English orthopaedic literature reveals no prior report of endoscopic repair of rectus abdominis tears and/or prepubic aponeurosis detachment. This technical report describes endoscopic reattachment of an avulsed prepubic aponeurosis and endoscopic repair of a vertical rectus abdominis tear immediately after endoscopic pubic symphysectomy for coexistent recalcitrant osteitis pubis as a single-stage outpatient surgery. Endoscopic rectus abdominis repair and prepubic aponeurosis repair are feasible surgeries that complement endoscopic pubic symphysectomy for patients with concurrent osteitis pubis and expand the less invasive options for patients with athletic pubalgia.
O
steitis pubis is a form of athletic pubalgia, and a recent study found a high prevalence in professional football players.1 It is associated with femoroacetabular impingement and may be caused by transfer stress from constrained range of motion in one or both hips.2 Endoscopic pubic symphysectomy has been found to be a safe and promising, less-invasive option to open pubic symphysis curettage.3 Athletic pubalgia may also involve tears of the adductor and/or rectus abdominis tendons. Although open repair has been done, to our knowledge there is no previously published case of endoscopic repairs of the rectus tendon and the prepubic aponeurosis. The purpose of this technical report is to describe the endoscopic techniques used to perform endoscopic rectus abdominis and prepubic aponeurosis repairs after concurrent endoscopic pubic symphysectomy.
From DISC Sports and Spine (D.K.M.), Marina del Rey, California; University of California (N.A.M.), Davis, California; Loyola Marymount University, Los Angeles, California (R.H.); and Mink Radiology (T.T.), Marina del Rey, California, U.S.A. The authors report the following potential conflict of interest or source of funding: D.K.M. receives consultancy fees from Zimmer Biomet and royalties for intellectual property from Zimmer Biomet and Smith & Nephew. Received July 21, 2016; accepted September 10, 2016. Address correspondence to Dean K. Matsuda, M.D., DISC Sports and Spine, Marina del Rey, CA, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16689/$36.00 http://dx.doi.org/10.1016/j.eats.2016.09.022
Technique We describe our techniques for endoscopic pubic aponeurosis reattachment and rectus abdominis repair after endoscopic pubic symphysectomy for the treatment of recalcitrant osteitis pubis and athletic pubalgia. Preoperative radiographs revealed sclerotic bony hypertrophy at the pubic symphysis and a healed right pubic stress fracture (Fig 1), and magnetic resonance imaging revealed detachment of the prepubic aponeurosis from the pubic tubercle (Fig 2) and a tear of the rectus abdominis (Fig 3). The patient was placed in a supine lithotomy position using gynecologic stirrups without traction (Figs 4 and 5). A Foley catheter was used to decompress the adjacent bladder. Endoscopic pubic symphysectomy was performed using our previously described technique,4,5 first localizing the pubic symphysis under AP pelvic fluoroscopic guidance and marking the midpoint with a 22-gauge needle. The anterior portal was established as the initial viewing portal with the 30 standard arthroscope at a low pump pressure of 40 mm Hg. The suprapubic portal was established and a switching stick was used to locate the previously placed 22-guage needle tip in the pubic symphysis (Fig 6). The overlying bursal tissue was resected with a motorized shaver and radiofrequency ablator (Arthrocare; Smith & Nephew, Andover, MA) followed by incremental resection of the pubic symphysis beginning from anterosuperior to posteroinferior. Initial resection was performed with a 5.5-mm round burr, followed by deeper resection of the fibrocartilage disc and hyaline endplates (Fig 7) with a shortsheath 4-mm round burr. Care was taken to avoid
Arthroscopy Techniques, Vol 6, No 1 (February), 2017: pp e183-e188
e183
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D. K. MATSUDA ET AL.
Fig 1. Preoperative modified Dunn lateral view of both hips showing the sclerotic bony hypertrophy at the pubic symphysis (arrows) and a healed right pubic stress fracture. Also note the bilateral cam deformities of the proximal femurs, both of which were asymptomatic.
penetration of the posterior capsule so as to avoid iatrogenic damage to the adjacent bladder. Moreover, the important inferior capsule and arcuate ligament were retained as important stabilizers of the pubic symphysis. The arthroscope and burr may be interchanged from their starting portals as needed to facilitate the surgery. Once the endoscopic pubic symphysectomy was completed, the inferior pubic region was visualized and probed with a stitching stick, ensuring there were no gaps or adductor tendon detachment. Endoscopic visualization of the superior pubic region showed a vertical tear of the conjoint tendon of the rectus abdominis and
Fig 2. Sagittal magnetic resonance imaging view demonstrating detachment of prepubic aponeurosis (arrow).
Fig 3. Coronal magnetic resonance imaging view showing the distal rectus abdominis tear (arrow).
some torn muscle fibers. The vertical tear extended 4 cm above the superior margin of the pubic symphysis. The prepubic aponeurosis was visualized and probed, revealing detachment from the anterior pubis adjacent to the pubic symphysis (Fig 8). Endoscopic prepubic aponeurosis repair was performed before rectus abdominis repair to optimize visualization of the former procedure. Endoscopic repair of the prepubic aponeurotic detachment was performed after initial soft tissue removal with the radiofrequency ablator at the anterosuperior pubic bones adjacent to the area of prior endoscopic pubic symphysectomy and gentle decortication with a motorized burr to stimulate healing of tendinous
Fig 4. Supine lithotomy patient positioning and setup. Note adjacent positioning of arthroscopy and fluoroscopy monitors at head of bed location.
ENDOSCOPIC SURGERY FOR ATHLETIC PUBALGIA
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Fig 7. Supine endoscopic view with 30 arthroscope from the anterior portal of endoscopic pubic symphysectomy to address recalcitrant osteitis pubis. Note the unhooded burr (from the suprapubic portal) and the hyaline endplates of the pubic symphysis (*).
aponeurosis to bone. Via a short 8.5-mm arthroscopic cannula (Smith & Nephew) in the suprapubic portal, the right prepubic aponeurotic tissue was reapproximated to the prepared bony bed using endoscopically placed horizontal mattress stitch (no. 2 Ultrabraid; Smith & Nephew). The vertical mattress was intentionally placed at the level of desired attachment and no attempt was made for distal advancement as the aponeurosis appeared otherwise intact with the more
distal adductor attachments and in neutral caudadcephalad alignment. The knotless suture anchor (Swivelock 4.75-mm PEEK [polyether ether ketone]; Arthrex, Naples, FL) was placed after initial anchor site preparation with the appropriate tap, but the sclerotic bone made advancement difficult. The tap was removed and the 4.5-mm drill was used to a depth of 20 mm, with endoscopic visualization confirming no violation into the area of pubic symphysectomy. Moreover, the anterosuperior to posteroinferior and medial to lateral vectors encouraged from the suprapubic portal facilitated desired intra-osseous anchor placement aligned with the pubic orientation and
Fig 6. Anterior (arrowhead) and suprapubic (arrow) portals. A 30 arthroscope is used in the anterior portal. A plastic arthroscopic cannula is later used in the suprapubic portal to aid with suture management and suture anchor fixation.
Fig 8. Supine endoscopic view, with 30 arthroscope, of the detached prepubic aponeurosis complex. Note the bare pubic crests (*).
Fig 5. Position of the surgeon between the patient legs while performing endoscopic surgery with seamless monitoring of the arthroscopic and fluoroscopic monitors.
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Fig 9. Supine endoscopic view showing reattachment of the detached prepubic aponeurosis using knotless anchor in the pubic crest adjacent to area of previous endoscopic pubic symphysectomy (*).
aimed away from the underlying bladder in case of inadvertent penetration of the far cortex. The sutures were tensioned before seating the knotless anchors with confirmed secure reattachment of the prepubic aponeurosis (Fig 9). The process was repeated for the left prepubic aponeurosis repair. Endoscopic repair of the vertical tear of the rectus abdominis tendon (Fig 10) was performed under endoscopic guidance with the 30 arthroscope in the anterior portal. Working proximal to distalward toward the arthroscope, side-to-side suture repair using nonabsorbale no. 2 sutures (Ultrabraid; Smith & Nephew) was performed through the plastic cannula in the suprapubic portal with a birdbeak suture passer first through the right tendon margin, passing the suture material into the recently excavated trough of the pubic
Fig 10. Supine endoscopic view of the distal vertical tear of the rectus abdominis tendon (arrows).
Fig 11. Supine endoscopic view during repair of a vertical rectus abdominis tear. Note the suture from the right margin of the torn tendon in the trough made by previous endoscopic pubic symphysectomy being grasped by suture grasper that has passed through the left margin of the tendon to aid safe suture passage.
symphysis (Fig 11) (with care taken not to plunge into the bladder), then similarly passing the unloaded birdbeak through the left tendon margin, retrieving the suture from the pubic symphyseal trough, and completing the repair using standard arthroscopic knottying technique. Once the third, distal, and final suture was tied, endoscopic visualization confirmed secure reapproximation of the rectus abdominis tear (Fig 12). All instruments were atraumatically removed and the portals were closed with no. 2 nylon sutures followed by injection into the pubic symphyseal trough with 0.5% Marcaine and 10 mg Duromorph. A compression “jock strap” garment was applied as the patient had some scrotal swelling commonly observed in male patients after endoscopic pubic symphysectomy.5
Fig 12. Supine endoscopic view after completion of side-toside rectus abdominis repair with 3 sets of sutures.
ENDOSCOPIC SURGERY FOR ATHLETIC PUBALGIA
Fig 13. Postoperative detail of the anterior-posterior pelvic view showing the widened gap of the pubic symphysis without vertical displacement and the absence of cortical endplates, which were resected during endoscopic pubic symphysectomy. Note the entry sites for suture anchor fixation of the right and left prepubic aponeurotic complex (arrows).
A postoperative radiograph is shown (Fig 13). An accompanying video (Video 1, see supplemental material) shows key surgical steps. Technical pearls and pitfalls are highlighted in Table 1.
Discussion Although we have previously reported the technique4,5 and outcomes of endoscopic pubic symphysectomy for recalcitrant osteitis pubis,3 review of the English orthopaedic literature could find no previous case or cases of endoscopic repair of either the rectus abdominis and/or the prepubic aponeurosis. Hopp presented outcomes for arthroscopic pubic symphyseal curettage and open adductor repairs6 whereas Tansey reported successful outcomes in athletes with open repair of adductor sleeve avulsions that also included the rectus abdominis.7 We have introduced a completely endoscopic athletic pubalgia surgery to treat recalcitrant osteitis pubis, prepubic aponeurosis avulsion, and rectus abdominis tear. The muscular layer of the anterolateral abdominal wall is made up of 4 flat muscles, namely, the external oblique, internal oblique, transverse abdominis, and the rectus abominis. The recti are paired straplike muscles, separated at the midline by the linea alba. Each muscle has 2 tendinous origins; a medial head arising from the anterior surface of the pubic symphysis, and a larger lateral portion from the upper border of the pubic crest, which together insert onto the fifth, sixth and seventh costal cartilages. The aponeuroses of the internal and external obliques and transverse abdominis fuse to
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form the linea alba, a strong midline fibrous structure firmly attached to the xiphoid process above, and the pubic symphysis and pubic crest below.8 The 6 lower thoracic nerves innervate the rectus abdominis. Anatomically, the anterior aspect of the pubis acts as a common origin for important musculotendinous, aponeurotic, and ligamentous structures around the symphysis pubis. This prepubic soft-tissue complex is known as the prepubic aponeurotic complex (P-PAC) and includes interconnections between the adductor tendons, rectus abdominis, inguinal musculoaponeurotic structures, articular disc, and pubic ligaments of the symphysis pubis.9 Partial or complete avulsion injuries to this prepubic aponeurosis may cause athletic pubalgia.8 The rectus abdominis functions primarily to flex the spine and compress the abdominal and pelvic cavities. Secondarily, it assists in respiration by pulling the chest downward and depressing the lower ribs. The diagnosis of a rectus abdominis tear is usually straightforward. An indirect muscle injury mechanism involving eccentric-concentric action is the most prevalent. Acute direct blows to the abdominal wall are extremely rare, and intra-abdominal illnesses are usually not difficult to differentiate from abdominal wall sport-related injuries.8 Physical examination shows tenderness of the affected rectus abdominis, usually below the umbilicus. A functional examination of the entire abdominal musculature during isometric, concentric, eccentric, and plyometric contraction is warranted. On magnetic resonance imaging, a muscle tear shows focal high-intensity signal areas with muscle disruption, whereas scar tissue generates a low-intensity signal on all pulse sequences. Magnetic resonance imaging is considered the modality of choice for diagnosis of rectus abdominis and prepubic aponeurosis injury. Interestingly, the feasibility of performing completely endoscopic midline rectus abdominis repair as described in this technical report may have utility in performing abdominoplasty in an endoscopic manner. Abdominoplasty, also known as the tummy tuck procedure, is currently performed as a mini-open cosmetic surgery to yield a flat abdominal contour, often due to midline separation or diastasis of the rectus abdominis. Table 1. Technical Pearls and Pitfalls Perform endoscopic pubic symphysectomy (if indicated) before repairs of adductor tendon(s), prepubic aponeurosis, and/or rectus tendon. Pubic symphyseal trough facilitates suture passage and establishes medial margins for suture anchor placement. Drill and seat suture anchors in anterosuperior to posteroinferior direction for reattachment of prepubic aponeurosis. Maximizes bony engagement of suture anchor while minimizing risk of bladder damage should inadvertent far cortex penetration occur. Use low pump pressures combined with hypotensive anesthesia or even dry arthroscopy. Minimizes fluid extravasation while may cause scrotal swelling.
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D. K. MATSUDA ET AL.
Many patients with athletic pubalgia may have concurrent (and likely causative) femoroacetabular impingement.1 Constrained hip range of motion may cause transfer stress to the pubic region (and the lumbar spine and sacroiliac joints).2 Most athletes that we have treated for osteitis pubis and/or athletic pubalgia have undergone concurrent outpatient surgery for symptomatic femoroacetabular impingement.3 Endoscopic reattachment of the prepubic aponeurosis and/or rectus abdominis repair, often along with endoscopic pubic symphysectomy, for athletic pubalgia harnesses the advantages of minimally invasive surgery, including outpatient surgery with relatively rapid recovery and rehabilitation, minimal blood loss, and high cosmesis. It complements arthroscopic surgery for athletes with femoroacetabular impingement, and endoscopy enables magnified visualization of anatomic structures and associated pathology. Disadvantages include the potential for iatrogenic damage to the bladder and, in male patients, scrotal swelling, which may occur as a transient and minor complication after endoscopic pubic symphysectomy.3 Although unknown if scrotal swelling would occur with isolated endoscopic rectus abdominis repair and/or prepubic aponeurosis reattachment, it seems prudent to inform male patients of this possibility prior to surgery, use dry endoscopy when able, and low arthroscopic pump pressures when not. Endoscopic rectus abdominis repair and prepubic aponeurosis repair are feasible surgeries that complement endoscopic pubic symphysectomy for patients with concurrent osteitis pubis and expand the less invasive options for patients with athletic pubalgia.
References 1. Larson CM, Sikka RS, Sardelli MC, et al. Increasing alpha angle is predictive of athletic-related “hip” and “groin” pain in collegiate National Football League prospects. Arthroscopy 2013;29:405-410. 2. Verrall GM, Hamilton IA, Slavotinek JP, et al. Hip joint range of motion reduction in sports-related chronic groin injury diagnosis as pubic bone stress injury. J Sci Med Sport 2005;8:77-84. 3. Matsuda DK, Ribas M, Matsuda NA, Domb BG. Multicenter outcomes of endoscopic pubic symphysectomy for osteitis pubis associated with femoroacetabular impingement. Arthroscopy 2015;31:1255-1260. 4. Matsuda DK. Endoscopic pubic symphysectomy for recalcitrant osteitis pubis associated with bilateral femoroacetabular impingement. Orthopedics 2010;33:199-203. 5. Matsuda DK, Sehgal B, Matsuda NA. Endoscopic pubic symphysectomy for athletic osteitis pubis. Arthrosc Tech 2015;4:e251-e254. 6. Hopp SJ, Culemann U, Kelm J, Pohlemann T, Pizanis A. Osteitis pubis and adductor tendinopathy in athletes: A novel arthroscopic pubic symphysis curettage and adductor reattachment. Arch Orthop Trauma Surg 2013;133:1003-1009. 7. Tansey RJ, Benjamin-Laing H, Jassim S, Liekens K, Shankar A, Haddad FS. Successful return to high-level sports following early surgical repair of combined adductor complex and rectus abdominis avulsion. Bone Joint J 2015;97-B:1488-1492. 8. Mercouris P. Sports hernia: A pictorial review. S Afr J Rad 2014;18(2). http://www.sajr.org.za/index.php/sajr/article/ view/670. 9. MacMahon PJ, Hogan BA, Shelley MJ, Eustace SJ, Kavanagh EC. Imaging of groin pain. Magn Reson Imaging Clin N Am 2009;17:655-666.
