mr o j a gilmore symposium 240909.ppt - gilmore's groin ... · waterpolo kick boxing ......
TRANSCRIPT
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GROIN GROIN
DISRUPTIONDISRUPTION
MR O J A GILMORE MS FRCS MR O J A GILMORE MS FRCS
FRCS (ED)FRCS (ED)
F. INST. SPORTS MED.F. INST. SPORTS MED.
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5% ALL SPORTS INJURIES 5% ALL SPORTS INJURIES
AFFECT GROINAFFECT GROIN
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PATIENT’S REFERRED with PATIENT’S REFERRED with
GROIN PAINGROIN PAIN
1980 1980 -- 20020088
TOTALTOTAL 72737273
MALEMALE 70307030 (9(977%)%)
FEMALEFEMALE 273273 ((33%)%)
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PATIENT REFERRAL (1980 PATIENT REFERRAL (1980 -- 20020088))
INCIDENCE of OPERATIONINCIDENCE of OPERATION
CASES REFERREDCASES REFERRED 77273273
OPERATIONSOPERATIONS 42274227 (58%)(58%)
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OTHER SPORTS
Basketball Fencing
Handball Equestrian
Gaelic football Martial Arts
American Football Dancers
Hurling Gymnasts
Waterpolo Kick Boxing
Ice Hockey Skiing & Snowboarding
GROIN PAINGROIN PAIN
•• MANY CAUSESMANY CAUSES
•• ORTHOPAEDICORTHOPAEDIC
•• SOFT TISSUE INJURYSOFT TISSUE INJURY
•• COCO--EXISTENT PATHOLOGYEXISTENT PATHOLOGY
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DIRECT TRAUMADIRECT TRAUMA
FALLFALL
KICKKICK
PUNCHPUNCH
IMPACTIMPACT
SQUEESESQUEESE
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REFERRED PAINREFERRED PAIN
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GROIN DISRUPTIONGROIN DISRUPTION
SPORTSMEN GROINSPORTSMEN GROIN
GILMORE’S GROINGILMORE’S GROIN
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GILMORE’S GROIN GILMORE’S GROIN ––
TYPICAL PATIENTTYPICAL PATIENT
•• YOUNG MALEYOUNG MALE
•• ACTIVE SPORTSMENACTIVE SPORTSMEN
•• RARE OVER 45RARE OVER 45
•• RARE IN FEMALES (1%)RARE IN FEMALES (1%)
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GROIN PAIN: SITE GROIN PAIN: SITE
IMPLICATIONSIMPLICATIONS•• ABOVE INGUINAL LIGAMENTABOVE INGUINAL LIGAMENT
•• Gilmore Groin. Gilmore Groin.
•• BELOW INGUINAL LIGAMENTBELOW INGUINAL LIGAMENT
•• Mid Inguinal Point HIPMid Inguinal Point HIP
•• Adductor Insertion ADDUCTORAdductor Insertion ADDUCTOR
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GROIN DISRUPTIONGROIN DISRUPTION
•• MUSCULO MUSCULO –– TENDINOUS INJURYTENDINOUS INJURY
•• ALL LAYERS GROINALL LAYERS GROIN
•• INGUINAL REGIONINGUINAL REGION
•• “MUSCLE DISLOCATION”“MUSCLE DISLOCATION”
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CASE 1CASE 1 D.M. 27D.M. 27
FULL BACK:FULL BACK: TOTTENHAM HOTSPUR FCTOTTENHAM HOTSPUR FC
PRESENTED:PRESENTED: 28.08.8028.08.80
SYMPTOMS:SYMPTOMS: 17 WEEKS PAIN RIGHT GROIN17 WEEKS PAIN RIGHT GROIN
AFTER EVERSION INJURYAFTER EVERSION INJURY
LAST GAME:LAST GAME: 17 WEEKS17 WEEKS
PAIN INCREASED:PAIN INCREASED: SPRINTINGSPRINTING
KICKINGKICKING
TWISTING & TURNINGTWISTING & TURNING
COUGHINGCOUGHING
SNEEZINGSNEEZING
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CASE 1CASE 1 D.M.D.M.
PREVIOUS INVESTIGATIONS:PREVIOUS INVESTIGATIONS:
3 ORTHOPAEDIC OPINIONS3 ORTHOPAEDIC OPINIONS
XX--RAYRAY
CT SCAN: IRREGULARITY CT SCAN: IRREGULARITY -- NO INSTABILITYNO INSTABILITY
U/S SCANU/S SCAN
PREVIOUS TREATMENT:PREVIOUS TREATMENT:
COMPLETE RESTCOMPLETE REST
PHYSIOTHERAPYPHYSIOTHERAPY
MANIPULATIONMANIPULATION
LOCAL STEROIDSLOCAL STEROIDS
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CASE 1 D.M. PHYSICAL SIGNSCASE 1 D.M. PHYSICAL SIGNS
INSPECTION:INSPECTION: N.A.D.N.A.D.
PALPATION:PALPATION: N.A.D.N.A.D.
PALPATION VIA SCROTUM:PALPATION VIA SCROTUM:
-- RIGHT SUPERFICIAL INGUINAL RIGHT SUPERFICIAL INGUINAL RING DILATEDRING DILATED
-- COUGH IMPULSECOUGH IMPULSE
-- TENDERTENDER
INSERTION OF FINGER INSERTION OF FINGER �� PAIN COMPARED TO OPPOSITE SIDEPAIN COMPARED TO OPPOSITE SIDE
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GROIN DISRUPTION: PATHOLOGYGROIN DISRUPTION: PATHOLOGY
Found at OperationFound at Operation
TORN EXTERNAL OBLIQUE TORN EXTERNAL OBLIQUE �� DILATED SUPERFICIAL DILATED SUPERFICIAL
INGUINAL RINGINGUINAL RING
TORN CONJOINED TENDONTORN CONJOINED TENDON
CONJOINED TENDONCONJOINED TENDON
}} DEHISCENCEDEHISCENCE
INGUINAL LIGAMENTINGUINAL LIGAMENT
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GROIN DISRUPTIONGROIN DISRUPTION(GILMORE’S GROIN)(GILMORE’S GROIN)
2299 YEARSYEARS
1980 1980 -- 20020088
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PATIENT REFERRAL RELATED TO SPORTPATIENT REFERRAL RELATED TO SPORT
1980 1980 -- 20020088
CASESCASES %%
ASSOCIATION FOOTBALLASSOCIATION FOOTBALL 41244124 5577
RUGBY UNION & LEAGUERUGBY UNION & LEAGUE 700700 1100
RACQUET GAMESRACQUET GAMES 275275 44
ATHLETESATHLETES 317317 44
CRICKETCRICKET 116262 22
HOCKEYHOCKEY 114400 22
OTHER SPORTS/GENERAL FITNESSOTHER SPORTS/GENERAL FITNESS 15551555 2121
______________________________________________________________________________________________________________
TOTALTOTAL 72737273
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OPERATIONSOPERATIONS
1980 1980 -- 20020088
TOTAL TOTAL 42274227
MALEMALE 41854185 (99%)(99%)
FEMALEFEMALE 4422 (1%)(1%)
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INCIDENCE OF OPERATION INCIDENCE OF OPERATION
RELATED TO SPORTRELATED TO SPORT
1980 1980 -- 20020088
CASESCASES OPNOPN %%
ASSOCIATION FOOTBALLASSOCIATION FOOTBALL 41244124 22842842 6969
RUGBY UNION + LEAGUERUGBY UNION + LEAGUE 700700 447447 64 64
RACQUET GAMESRACQUET GAMES 275275 9393 3434
ATHLETESATHLETES 317317 126126 4040
CRICKETCRICKET 162162 111212 6969
HOCKEYHOCKEY 114400 8181 5588
OTHER SPORTS/GENERAL FITNESSOTHER SPORTS/GENERAL FITNESS 11555555 525266 3434
____________________________________________________________________________________________________________________
TOTALTOTAL 72737273 4227 4227 5858
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INCIDENCE OF OPERATIONS INCIDENCE OF OPERATIONS
ASSOCIATION FOOTBALL 1980 ASSOCIATION FOOTBALL 1980 -- 20020088
TOTALTOTAL OPNOPN %%
PROFESSIONALPROFESSIONAL 15115155 12124646 8282
SEMI PRO.SEMI PRO. 773355 525211 7171
AMATEURAMATEUR 18187474 10107575 5757
______________________________________________________________________________________________
TOTALTOTAL 41244124 22842842 6969
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PROFESSIONAL FOOTBALLERSPROFESSIONAL FOOTBALLERS
1980 1980 -- 20020088
CASES CASES 15115155
OPERATIONSOPERATIONS 12124646 (82%)(82%)
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ENGLISH FOOTBALL LEAGUEENGLISH FOOTBALL LEAGUE
CLUBSCLUBS
(92 CLUBS)(92 CLUBS)
PATIENTS REFERRED BY 87 CLUBSPATIENTS REFERRED BY 87 CLUBS
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AETIOLOGY:MUSCLE IMBALANCEAETIOLOGY:MUSCLE IMBALANCE
1. 1. STRONG HIP FLEXORS STRONG HIP FLEXORS PULL PELVIS DOWNPULL PELVIS DOWN
(QUADS)(QUADS)
2.2. TILTED PELVISTILTED PELVIS STRETCH ABDO MUSCLESSTRETCH ABDO MUSCLES
3. STRETCHED ABDO MUSCLES 3. STRETCHED ABDO MUSCLES BECOME WEAKBECOME WEAK
(OBLIQUES)(OBLIQUES) FAIL TO STABILIZE PELVISFAIL TO STABILIZE PELVIS
44. . OVERUSEOVERUSE RECURRENT TEARSRECURRENT TEARS
GROIN DISRUPTIONGROIN DISRUPTION
5. MALE > FEMALE (99%) 5. MALE > FEMALE (99%)
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ARSENAL F.C.: GILMORE’S GROINARSENAL F.C.: GILMORE’S GROIN
OPERATIONOPERATION P.A.P.A.
1986 – 1996 (GRAHAM) 33 3
1997 – 2007 (WENGER) 10 1
Gary Lewin 2007
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ONSET OF SYMPTOMSONSET OF SYMPTOMS
INSIDIOUSINSIDIOUS 72%72%
SPECIFIC INJURYSPECIFIC INJURY 28%28%
OVERSTRETCHINGOVERSTRETCHING
MISKICKINGMISKICKING
ABDUCTIONABDUCTION
EVERSION EVERSION
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SYMPTOMS DURING EXERCISESYMPTOMS DURING EXERCISE
PAIN IN GROIN INCREASES WITHPAIN IN GROIN INCREASES WITH
RUNNINGRUNNING
STRIDINGSTRIDING
SPRINTINGSPRINTING
SUDDEN MOVEMENTSUDDEN MOVEMENT
TWISTING & TURNINGTWISTING & TURNING
SIDE STEPPINGSIDE STEPPING
JUMPINGJUMPING
DEAD BALL KICKINGDEAD BALL KICKING
LONG BALL KICKINGLONG BALL KICKING
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SYMPTOMS AFTER EXERCISESYMPTOMS AFTER EXERCISE
PAIN IN GROIN INCREASES WITHPAIN IN GROIN INCREASES WITH
TURNING IN BEDTURNING IN BED
GETTING OUT OF BEDGETTING OUT OF BED
GETTING OUT OF CARGETTING OUT OF CAR
SIT UPSSIT UPS
COUGHINGCOUGHING
SNEEZINGSNEEZING
SUDDEN MOVEMENTSUDDEN MOVEMENT
STIFF & SORE
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EXAMINATIONEXAMINATION
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GROIN DISRUPTION: GROIN DISRUPTION:
PHYSICAL SIGNSPHYSICAL SIGNS
(ALL ELICITED VIA SCROTUM)(ALL ELICITED VIA SCROTUM)
S.I.R:S.I.R: DILATED (+/DILATED (+/--))
COUGH IMPULSECOUGH IMPULSE
TENDERTENDER
(PALPABLE TEAR)(PALPABLE TEAR)
TENDERNESS:TENDERNESS: MAY BE EXQUISITEMAY BE EXQUISITE
DIMINISHES WITH RESTDIMINISHES WITH REST
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INDICATION FOR SURGERY: INDICATION FOR SURGERY:
PROFESSIONALSPROFESSIONALS
GAME INHIBITEDGAME INHIBITED
TRAINING INHIBITEDTRAINING INHIBITED
�� LOSS OF SPEEDLOSS OF SPEED
LOSS OF FITNESSLOSS OF FITNESS
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INDICATION FOR SURGERY: INDICATION FOR SURGERY:
AMATEURSAMATEURS
SYMPTOMS AFFECT EVERYDAY LIFESYMPTOMS AFFECT EVERYDAY LIFE
LOSS OF SPORT AFFECTS QUALITY OF LOSS OF SPORT AFFECTS QUALITY OF
LIFELIFE
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Groin Disruption:
Pathology
found at operation
• Torn external oblique
• Dilated superficial inguinal ring
• Torn conjoined tendon
• Conjoined tendon
} Dehiscence
• Inguinal ligament
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Operation (1)
Restore Normal Anatomy
REPAIR EACH ELEMENT OF DISRUPTION
• Conjoined tendon repair ( 0 vicryl)
• Transversalis fascia plicated (0 vicryl)
• Rectus abdominis (if torn) repair (No.1 ethilon)
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Operation (2)
• Conjoined tendon reattached to pubic tubercle
with No.1 ethilon (Anchor Stitch)
• TENSION FREE NYLON DARN between ING LIG &•
CONJ. TENDON
• External oblique repair (0 vicryl)
• Scarpa’s fascia closed (0 vicryl)
• Subcuticular skin closure (3/0 vicryl rapide)
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RESULT RESULT -- OPERATION SUCCESSFULOPERATION SUCCESSFUL
97%97%
AVERAGE RETURN TO PROFESSIONAL AVERAGE RETURN TO PROFESSIONAL FOOTBALL 5 WEEKSFOOTBALL 5 WEEKS
1209 1209 OUT OFOUT OF 1246 1246 PLAYERSPLAYERS
RANGERANGE 3 3 –– 9 9 WEEKSWEEKS
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INTERNATIONAL SOCCER INTERNATIONAL SOCCER
FOOTBALLERSFOOTBALLERS
1980 1980 -- 20020088
ENGLANDENGLAND 6161
SCOTLANDSCOTLAND 3434
NORTHERN IRELANDNORTHERN IRELAND 1188
EIREEIRE 1166
WALESWALES 1515
OTHERSOTHERS 101077______
251251
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INTERNATIONALS 1980INTERNATIONALS 1980--20020088SOCCER SOCCER 251251
RUGBY UNION RUGBY UNION 4343
ATHLETESATHLETES 2244
CRICKETCRICKET 2211
RUGBY LEAGUERUGBY LEAGUE 1616
HOCKEYHOCKEY 1414
HANDBALLHANDBALL 44
RACQUET GAMESRACQUET GAMES 33
SKIINGSKIING 22
BASKETBALLBASKETBALL 22
FENCING FENCING 22
LACROSSELACROSSE 22
MARTIAL ARTS MARTIAL ARTS 22
SQUASH SQUASH 11
GYMNASTICSGYMNASTICS 11
WATERPOLOWATERPOLO 11
ROWINGROWING 11
VOLLEYBALLVOLLEYBALL 11
"STRONGMAN" "STRONGMAN" 11
WEIGHT LIFTING WEIGHT LIFTING 11
ICE HOCKEYICE HOCKEY 11______________________________________________
TOTALTOTAL 393911
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Ulrike MuschaweckUlrike Muschaweck
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D.N. Act 24. English International
•Jan 2008 Right Minimally Invasive Groin Repair –
• Ulrike Mushaweck
•2 weeks: Playing
•3 1/2 weeks: Pain recurred
•Struggled for the rest of the season
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DN
– Ulrike Mushaweck: TECHNIQUE
According to operation report:
“Just the defect of the transverse fascia is opened
reverse doubling fascia is made, achieving a tension
free defect closure “
No mention of sutures used.
No mention of ilio-inguinal nerve division
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D.N. ( Repair in Jan 2008 )D.N. ( Repair in Jan 2008 )
•: Increasing problems same groin:Next Season
•Early Oct 08: Right Groin Pain – Severe
•Not played: 3 weeks
•Referred to: OJAG
•Symptoms & Signs: Typical GG
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D.N
•7 Oct 2008: Re-Exploration Right Groin by
OJAG
•Findings: Dense Scar Tissue
No permanent sutures seen
Dehiscence between Inguinal
ligament and conjoined tendon
Spermatic Cord bent in Inguinal
canal
•Standard GG Repair with Nylon Darn
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D.N
•Post op review: At 3 weeks
•Running, sprinting: 90% capacity
•Patient comment “This Repair feels
completely different , it feels more sound and
more solid”
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D.N
•Missed no games following re-exploration &
repair right groin with nylon darn
•Until developed Left Gilmores Groin
•10 June 09 Left standard GG Repair with nylon
darn
•9July 09 Full involvement in pre-season training
•No problems either side since
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CONCLUSION
• Reliable: Solid Repair
Each Layer
+
Non Absorbable
Nylon Darn
• Preferable to: Dissolvable Sutures
+
Division of Ilio inguinal nerve
Allowing early pain free return
but often recurrent symptoms
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THANK THANK
YOUYOU