![Page 1: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/1.jpg)
Dr. Ulrike Muschaweck
The Sportsmen´s Groin – Diagnostics & Therapy
The Minimal Repair Technique
![Page 2: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/2.jpg)
Financial Disclosures
nothing to declare
![Page 3: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/3.jpg)
Expert-Panel
6 experts 6 definitions 6 diagnoses 6 therapies
What are we talking about?
?Causes of groin pain in athletes are numerous
![Page 4: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/4.jpg)
Sport hernia is one of the least understood poorly defined and under-researched maladies to affect the human body. The media has popularized the use of this diagnostic term, but the actual injury characteristics are poorly defined. Sports hernia reflects a compilation of diagnosis grouped together with a wide range of other pathologies that need to be excluded before this should be considered a diagnosis. (Nam A; Brody F. Management and therapy of sports hernia. AmCollSurg 2008)diagnosis of exclusion!?
diagnosis of exclusion!?
Sports hernia has been described as a common diagnosis in otherwise unexplained chronic groin pain (Farber AJ. Wilckens JH. Sports hernia: Diagnosis and therapeutic approach. J Am Acad Surg 2007)
attempted explanation…
![Page 5: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/5.jpg)
Consensus summaryInguinal Disruption is a condition recognised by groin pain and is commonly seen in very active sports persons. It can be defined as pain in the inguinal region near the pubic tubercle, which may have an insidious or acute onset and where no obvious other pathology exists to explain the symptoms.
Br J Sports Med 2013
preferred terminology should be
Inguinal Disruption (ID)
diagnosis of exclusion?
![Page 6: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/6.jpg)
Inguinal Disruption??
![Page 7: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/7.jpg)
Pathology
What is a sportsmen‘s groin?
Weakness of the posterior wall of the inguinal canal (transversal fascia)
causes localized bulging
compresses an afferent nerve (genital branch of the genito-femoral nerve)
„Blue Line“ - thegenital branch ofthe genito-femoralnerve
Weakness of the posterior wall
It is not a hernia!
![Page 8: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/8.jpg)
Pathology
Morphological findings of the genital branch
![Page 9: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/9.jpg)
PathologyMorphological findings
![Page 10: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/10.jpg)
Pathology
Cranial and medial displacement of the rectus abdominis muscle
Increasing tension at the pubic bone (Os pubis)
Pubalgia
![Page 11: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/11.jpg)
Diagnosis
• Dull, sharp or burning pain • Radiation into inner upper thigh
(adductors), scrotum and/or lower back and pubic bone
Typical sign of a nerve irritation (genital branch of the genito-femoral nerve)
We need to listen to our patients!
![Page 12: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/12.jpg)
Diagnosis
Clinical Examination
• A palpable bulge of the posterior wall of the inguinal canal and a dilatation of the internal inguinal ring (peritoneal protrusion) can be detected during “Valsalva-Maneuver” “Valsalva-Maneuver” by a skilled examiner.
• painful when exerting pressure on the posterior wall (transversal fascia)
We need to examine our patients!
![Page 13: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/13.jpg)
Diagnosis
Imaging• Static and dynamic Ultrasound with a high-
frequency transducer 5-13 MHz- a distinct protrusion of the transverse fascia
during “Valsalva-Maneuver” “Valsalva-Maneuver” can be detected with experience- the size of the circumscribed weakness in
the area of the posterior wall can be measured
• MRI not significant (recumbent position)
We need verifiable parameters!
![Page 14: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/14.jpg)
Diagnosis (Ultrasound)
Weakness of the posterior wall of the inguinal canal
![Page 15: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/15.jpg)
Diagnosis (Dynamic US)
![Page 16: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/16.jpg)
Treatment consideration
Primum nihil nocere - above all do not harm
![Page 17: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/17.jpg)
Conservative Treatment
High dosages of NSAIDs (combined with B vitamins)
However: following diagnosis only a 4-6 week time frame remains for conservative treatment:
Otherwise there is an increased risk of subsequent chronic inguinal pain
![Page 18: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/18.jpg)
Surgical Options
Mesh-free techniques
Gilmore TechniqueBassiniShouldiceMinimal Repair
Mesh techniques
LichtensteinTIPPPlug&PatchUHS/PHSMIC (TAPP/TEP)Combination with
- inguinal ligament tenotomy- adductor release tenotomy- ligament shaving
![Page 19: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/19.jpg)
Surgical Results
Open mesh free (n = 226) 89 daysOpen mesh (n = 42) 100 days
TAPP/TEP (n = 472) 92 days
Return to normal activity:
![Page 20: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/20.jpg)
What can happen.. after UHS
• Professional Goal keeper with groin pain• UHS-Repair 8/2011• „no lateral hernia sac detected during operation“• Post-operative chronic pain syndrome• Surgical revision and thermic denervation of N. ilioinguinalis and R.femoralis
11/2011 without any effect
![Page 21: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/21.jpg)
What can happen….. after TAPP
• Professional football striker with groin pain • Minimal invasive surgery with TAPP and large pore mesh 2012• Persisting pain after operation
![Page 22: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/22.jpg)
What can happen….. after Lichtenstein
• Professional football player with groin pain • Open repair with Lichtenstein and large pore mesh 2013• Persisting pain directly after surgery• Conservative pain treatment for 6 month
![Page 23: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/23.jpg)
Is mesh repair the solution?
![Page 24: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/24.jpg)
3D-MRI-Reconstruction
![Page 25: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/25.jpg)
What does the patient want
no recurrence no pain no foreign material (if possible) no sick leave no general anaesthesia no hospital stay no negative long term effects no complications … and if, please treatable!
![Page 26: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/26.jpg)
Selection of the Method
Criteria: - no hernia sack - but: distinct protrusion (bulge) of the
transverse fascia during “Valsalva-Maneuver”
- compression of an afferent nerve
Search for a procedure without the risk of mesh induced complications taking the
pathology of sportsmen`s groin into account
![Page 27: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/27.jpg)
Hernia Centre Munich London
Surgery in local anaesthesia Admission in the morning/ Discharge in the
evening of the day of surgery
Development of a new technique for professional athletes -“Minimal Repair”- in 2002
![Page 28: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/28.jpg)
Surgical Goals:
• Goal 1: Reducing pain quickly
• Goal 2: Retaining the slide bearing function of the abdominal wall
• Goal 3: Rapid return of exercise tolerance and peak performance for top athletes
Minimal Repair
![Page 29: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/29.jpg)
Local Anaesthesia
1. Initial block ventral/cranial of the anterior iliac spine
2. Ropivacain 7,5 mg/ml 20–30 ml
3. Injection in the area of planned incision with Ropivacain 7,5 mg/ml 10ml
4. Intraoperative re-injection in the ilio-inguinal nerve and the genital branch of the genito-femoral nerve
![Page 30: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/30.jpg)
• Only the defect is opened (sound tissue remains intact)
• Contains only preperitoneal fat, no hernia sack
• If necessary resection of the genital branch of the genito-femoral nerve
Surgical Steps
![Page 31: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/31.jpg)
• Stabilizing the posterior wall
• Reducing the tension of the rectus abdominis muscle
• Suture line over the pubic bone
Surgical Steps
![Page 32: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/32.jpg)
• Creating a muscular
collar to protect the
preserved nerve and
the plexus
pampiniformis
Surgical Steps
![Page 33: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/33.jpg)
Postoperative Training Ability
• Weight lifting directly after surgery• Training (running, biking) is resumed as early as
post-operative day (POD) 2
• Beginning of training POD 3 - 4• Complete training possible for athletes, including
kicking and sprinting on POD 5 • Peak performance achieved between POD 10
and 14
„DO WHAT YOU WANT TO DO!!!!“
![Page 34: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/34.jpg)
With the Minimal Repair technique, we observed neither minor nor major complications during a follow-up of 30 days.In 87 professional athletes repairs the time to return to pre-injury sports activity levels amounted to 14 days
This study shows that the Minimal Repair technique allows an excellent relief of groin pain with fast recovery to full sporting activities.
early results
![Page 35: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/35.jpg)
Long-term results5 year follow–up after Minimal Repair in professional atheletes
Questionnaire and/or telephone interview
- still active athelete?
- did any symptoms return?
- pain score (NAS)
- pain quality/ intensity/ character?
- any need for medication for groin pain?
- limitation of performance?
- sensitivity of the groin/ numbness?
- was another operation performed?
- overall satisfaction?
![Page 36: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/36.jpg)
Long-term results5 year follow–up after Minimal Repair in professional athelets
n = 65 hernia-repairs = 75% follow-up ratemedian age: 29 years (range 27-33y)median follow-up: 5.5 y
95,4%
4.6%
Nerve resection-R.genitalis 28%
preliminary results
![Page 37: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/37.jpg)
Conclusion
Pathologies in the groin can be multifarious!
Sportmen`s groin is a entity of its own! Not a diagnosis by exclusion!
We need to listen and investigate our patients carefully!
![Page 38: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/38.jpg)
Necessity for Surgery?
YES!
• Only if diagnosis shows weakness of the posterior wall with bulging (by a skilled examiner)
• If the pain is severe• If the athlete is handicapped• Failed conservative treatment
To avoid chronic pain syndrome
![Page 39: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/39.jpg)
Overtreatment?
NO!
• Only the defect is repaired• No sound or intact structures are
destroyed• The cause of the pain is removed• Preservation of the slide bearing of the
abdominal wall • No loss of elasticity due to mesh
implantation• No risk of mesh induced complications
Minimal procedure with maximal effect
![Page 40: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/40.jpg)
Is there any prevention???
![Page 41: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/41.jpg)
NO!
![Page 42: La hernie du sportif : diagnostic et traitement, technique mini-ainvasive -Dr Ulrike MUSCHAWECK -1ère Journée Européenne de la Pubalgie - Clinique du Sport Bordeaux Mérignac](https://reader033.vdocuments.site/reader033/viewer/2022042607/5593fe8d1a28aba77f8b4689/html5/thumbnails/42.jpg)
Thank you very much!
www.herniacenter.eu