Endoscopic surgery treats athletes with osteitis pubis and core muscle injury
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Treatment of co-afflicted athletes with femoroacetabular impingement and osteitis pubis or core muscle injury has been a challenging dilemma. Recent developments in peripubic endoscopic surgery may provide a long-awaited solution.
Osteitis pubis may afflict athletic patients and is often associated with femoroacetabular impingement (FAI). Up to 8% of athletes, in general, and 18% of soccer athletes with this condition are sidelined and often experience a lengthy rehabilitation period that averages 9.6 months in elite male soccer players with a failure rate of 9% and a recurrence rate of 25%. Core muscle injury (CMI), which was previously called athletic pubalgia or sports hernia, is a closely related condition with recent evidence implicating disruption of the prepubic aponeurotic complex (PPAC), also called the pubic plate or rectus aponeurosis, as a key stabilizing anchor point for the rectus abdominis above and the adductor muscles below. FAI has been reported in as much as 94% of patients with CMI. The constrained hip range of motion of FAI causes pathologic transfer stress to the pubic region. Surgical options have included open pubic symphysis (PS) debridement and reparative procedures involving peripubic structures. A higher return to play rate is reported in co-afflicted patients who undergo either concurrent or staged surgeries that address FAI and osteitis pubis/CMI vs. procedures that treat only one condition or the other.
Source: Dean K. Matsuda, MD, FAAOS, FAANA
We developed endoscopic pubic symphysectomy in 2008, which was performed as an outpatient procedure in a patient who underwent concurrent simultaneous bilateral hip arthroscopy for FAI syndrome. A multicenter outcome study with 3 years average follow-up, including some professional soccer players, demonstrated a mean preoperative VAS pain score of 6.7 improved to a mean postoperative VAS score of 1.5 (P = .03). The mean preoperative nonarthritic hip score (NAHS) of 50.2 points in these patients improved to a mean postoperative NAHS of 84.7 points (P = .03) and the mean patient satisfaction rating was 8.3 of a maximum of 10. In 2016, we introduced endoscopic repairs of an avulsed PPAC and torn distal rectus abdominis tendon. In 2021, we performed endoscopic repair of a retracted grade 3 fibrocartilaginous avulsion of the adductor longus. This article aims to introduce the surgical techniques used to successfully accomplish these minimally invasive procedures.
Endoscopic debridement
Patients with recalcitrant osteitis pubis who have had at least one confirmatory pubic symphyseal injection and have no vertical instability on flamingo views may be surgical candidates. The patient is placed in the supine lithotomy position with a Foley catheter for bladder decompression and a vertical C-arm is positioned for intermittent fluoroscopic guidance (Figure 1). An anterior PS portal (APP) and suprapubic portal (SP) are developed. The APP is the initial viewing portal, and the SP is the initial working portal. Anterior bursal tissue is resected using a motorized shaver and the Ambient HipVac 50 (Smith & Nephew) radiofrequency ablator under endoscopic visualization with a 30° arthroscope using arthroscopic pump pressures less than or equal to 40 mm Hg to minimize peripubic soft tissue extravasation.
Once the anterior PS and midline fibrocartilage are visualized, resection of the latter is performed using the same instruments. Endoscopic resection of both hyaline endplates is then performed beginning with a 5.5-mm burr. We aim to have a gap of 8 mm to 10 mm between the resected margins. Care is taken to avoid penetration of the posterior capsule to prevent inadvertent bladder damage (Figure 2) and injury to the inferior arcuate ligament, which is the primary stabilizer of the PS (Figure 3). Deeper resection is aided by using a 4-mm burr with a short sheath. Posteroinferior endplate resection may be facilitated by switching portals. As these procedures are often performed with concurrent hip arthroscopy for FAI syndrome, we prefer that the latter precedes the former. However, both conditions are treated with concurrent outpatient minimally invasive surgery (Figure 4).
Source: Dean K. Matsuda, MD FAAOS, FAANA
Source: Dean K. Matsuda, MD, FAAOS, FAANA
Source: Dean K. Matsuda, MD, FAAOS, FAANA
Endoscopic CMI repair
The PPAC is a key anatomic anchor point adjacent to the PS that links the rectus abdominis above with the adductors below. Using the aforementioned supine lithotomy position and setup, endoscopic repair is performed, typically after endoscopic pubic symphysectomy. The right and/or left PPAC avulsion is identified and the underlying footprint is gently decorticated (Figure 5).
Source: Dean K. Matsuda, MD, FAAOS, FAANA
Nonabsorbable #2 suture is passed through the avulsed PPAC tissue and retrieved from the space created by the endoscopic pubic symphysectomy. Secure suture anchor repair to the pubic footprint is then performed (Figure 6). Endoscopic repair of a vertical tear involving the distal rectus abdominis tendon (Figure 7) is performed in a side-to-side manner (Figure 8).
Source: Elsevier. Reprinted with permission of Elsevier
Source: Elsevier. Reprinted with permission of Elsevier
Source: Elsevier. Reprinted with permission of Elsevier
Adductor longus avulsion repair
In the supine lithotomy position, the soft tissue defect can be palpated relative to contralateral intact tendon. An APP is made, followed by an ipsilateral anteromedial adductor portal 2 cm distal to the palpated proximal end of the retracted adductor longus tendon. A 30° arthroscope in the APP visualizes triangulation of a switching stick placed through the adductor portal, followed by debridement of overlying bursal tissue and adhesions with a motorized shaver and radiofrequency ablation wand. Diagnostic endoscopy enables identification of the PS, ipsilateral PPAC, distal rectus abdominis tendon, inguinal ligament insertion at pubic tubercle, the pubic body with area of avulsed adductor footprint, gracilis, pectineus, adductor brevis and the retracted proximal free end of the adductor longus tendon. The pubic footprint is gently decorticated with a 5.5-mm motorized burr. Once adhesions and hematoma are resected, the proximal adductor cuff is freshened with a shaver and #2 suture tape is passed via a First Pass suture passer (Smith & Nephew) in a cinch stitch or luggage tag configuration, which is achieved by passing the two free suture tape ends under the initial horizontal suture tape (Figure 9). Secure purchase is confirmed via longitudinal traction of the suture tape via the APP. The ipsilateral lower extremity is taken out of the lithotomy position into neutral hip extension and 20° abduction to facilitate approximation of the tendon cuff to the footprint.
Source: Dean K. Matsuda, MD, FAAOS, FAANA
Knotless suture anchor fixation is performed using a Healicoil skeletonized suture anchor (Smith & Nephew) to encourage local exudation of bone marrow elements (Figure 10). Small horizontal cuts of the epimysium may be indicated to enable tendon-to-footprint approximation; however, we have no experience with this.
Source: Dean K. Matsuda, MD, FAAOS, FAANA
Portal incisions are closed and sterile dressings are applied with removal of the Foley catheter. A hip brace that maintains 20° abduction and limits hip hyperextension is applied prior to reversal of general anesthesia.
Complications
Transient peripubic fluid extravasation may occur and can manifest as labial or scrotal swelling. This typically resolves spontaneously within 1 week, without sequelae. Theoretical complications may include iatrogenic anterior bladder wall injury and PS instability, the latter of which could contribute to late posterior pelvic ring instability. These possible complications should be discussed with the patient during preoperative counseling. Judicious use of arthroscopic pump pressures not exceeding 40 mm Hg, prophylactic Foley catheterization and retained integrity of the posterior capsuloligamentous layer and arcuate ligament can minimize the risk for complications.
Athletes with osteitis pubis and CMI may undergo a single outpatient endoscopic surgery that may seamlessly be combined with arthroscopic treatment of FAI syndrome in co-afflicted patients.
- References:
- Larson CM, et al. Arthroscopy. 2011;doi:10.1016/j.arthro.2011.01.018.
- Matsuda DK. Arthrosc Tech. 2021;doi:10.1016/j.eats.2021.02.024.
- Matsuda DK, et al. Arthroscopy. 2015;doi:10.1016/j.arthro.2015.02.005.
- Matsuda DK, et al. Arthrosc Tech. 2015;doi:10.1016/j.eats.2015.02.004.
- Matsuda DK, et al. Arthrosc Tech. 2017;doi:10.1016/j.eats.2016.09.022.
- Matsuda DK. Orthopedics. 2010;doi:10.3928/01477447-20100129-31.
- Saito M, et al. Am J Sports Med. 2019;doi:10.1177/0363546518819099.
- Verrall GM, et al. J Sci Med Sport. 2007;doi:10.1016/j.jsams.2006.11.006.
- For more information:
- Dean K. Matsuda, MD, FAAOS, FAANA, a member of the Orthopedics Today Editorial Board, is CEO of Premier Hip Arthroscopy in Marina Del Ray and Manhattan Beach, California. He can be reached at 13160 Mindanao Way, #300, Marina Del Rey, CA 90292; email: dmatsuda@laspineortho.com.
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