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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.
Osteitis 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.
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 and5).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 short-sheath 4-mm round burr. Care was taken to avoid 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 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 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 caudad-cephalad 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 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 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 knot-tying 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 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.
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 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.
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.
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.
This video shows the key steps in the endoscopic surgery for athletic pubalgia. Included is endoscopic pubic symphysectomy for recalcitrant osteitis pubis, inspection of adductor tendons, reattachment of avulsed prepubic aponeurotic complex using suture anchor fixation, and repair of distal rectus abdominis tear.