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Zoland et al (2018) assessed sports hernia/athletic pubalgia in women. This article is an uncontrolled, case series evaluating 18 women. Of these, 9 had an injury in combination with one or more inguinal, obturator, or femoral hernias present on imaging. The article suggests treatment success based on responses to self-questionnaires at 1 year of follow-up post-surgery. 15/17 women available for follow-up report successful surgery. Results demonstrated a mean reduction of pain from 7.82 to 1.76 on VAS score for the total study participants. The study presented with limitations, such as no control group, single center experience and a small sample size. A larger, prospective study examining surgical outcomes is needed to validate these findings.
A 2017 ERCI response for treating AP reported that the available studies (n=28 publications) provide evidence suggestive of support for the safety and effectiveness of surgery after conservative treatment failure. However, the report states the overall quality of the evidence assessing surgical treatments was low because no studies compared surgical and conservative treatment in independent groups and the studies comparing surgical procedures were not randomized. Additional larger, prospective studies with direct comparators are warranted.
In a prospective cohort study, Muschaweck and Berger (2010) examined the safety and effectiveness of the “minimal repair” technique to treat AP in both athletes and non-athletes. The authors developed this new surgical technique, which is an open-suture method to stabilize the posterior wall. The authors assert that this new “minimal repair” technique offers the following advantages: (1) no insertion of prosthetic mesh, (2) no general anesthesia, (3) less trauma, and (4) lower risk of severe complications when compared to laparoscopic methods such as TAPP and TEP. The individuals in this study (n = 128 males, 1 female) were followed for 4 weeks at the time of publication (though the study was designed for 6-month, 1-year, and 5-year follow-up). Primary outcomes were time to resuming low-level training, full training/competing, and complete relief of pain. Secondary outcomes were postoperative complications and level of post-operative pain. Of all individuals, 78.9% reported that they were completely free of pain (median of 14 days). At 4-week follow-up, there was a statistically significant difference in time to resume low-level training and full return to sport within 28 days when comparing athletes and non-athletes. However, there was no statistically significant difference in time to full return to sport (regardless of time period) and complete relief of pain when comparing athletes and non-athletes. The authors reported no post-operative complications at 30-day follow-up. There was no statistically significant difference in post-operative pain when comparing athletes and non-athletes. The authors admit that they were unable to randomize study participants into two different interventional treatment groups for ethical reasons. The study is limited by its small sample size and short follow-up period, post-hoc analyses, and lack of randomization into two intervention groups. Despite these limitations, the authors conclude that the “minimal repair” technique is “probably superior to other currently used techniques.”
Transabdominal Pre-Peritoneal (TAPP)
In a retrospective study, Ziprin et al. (2008) evaluated 17 male athletes who were treated for suspected AP by diagnostic laparoscopy followed by TAPP mesh repair. Study participants were followed for a median of 23 weeks with pain defined as the primary outcome measurement. Sixteen of the 17 individuals returned to sports at pre-injury levels within a median of 42 days. Five individuals had mild pain 3 weeks after surgery. This pain was resolved at 24 weeks of follow-up for all but 1 patient. The authors admitted that there was insufficient evidence to suggest that either TAPP or TEP was more effective and safe for the repair of groin hernias. The authors concluded that TAPP is safe and effective in the diagnosis and treatment of AP. Limitations of this study include its retrospective study design, small sample size, and lack of long-term follow-up.
In a retrospective study, Santilli et al. (2015) evaluated laparoscopic TAPP in 590 athletes with diagnosed AP, including 414 amateurs and 176 professionals. Thirty days post-procedure, the athletes were evaluated to assess pain and the degree of physical activity as a sign of functional outcome. In 573 of the athletes, ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, of which 498 coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1%) and ipsilateral defects, resulting in a total of 1006 hernias. Ultrasound had a sensitivity of 95.42% and a specificity of 100%, with positive and negative predictive values at 100% and 99.4%, respectively. No postoperative complications were reported and seven athletes suffered recurrence of pain at 30 days post-procedure. The authors concluded that AP was often associated with adductor muscle strains and other injuries of the groin. The study is limited in its retrospective study design, lack of long-term follow-up, and lack of comparison to CT.
Totally Extraperitoneal (TEP)
In a retrospective study, Srinivasan and Shuricht (2002) evaluated 15 male professional athletes who were treated for AP by laparoscopic TEP. Study participants were followed for a mean of 12.1 months by telephone survey; 3 individuals were lost to follow-up. There was no indication as to whether a pre-treatment survey was conducted. 87% of individuals (n = 13) could fully return to sports activity within 4 weeks of treatment. One study participant reported soreness 4 years after surgery; the authors claimed that they felt it was unrelated to surgery. No other adverse sequelae or recurrence of symptoms was reported. The authors admitted that there was no control group in the study. They reasoned that the study participants could not be randomized due to their need and desire to return to competitive competition quickly. The authors concluded that laparoscopic TEP should be considered as a treatment modality in athletes presenting with chronic groin pain. The study was limited as there was no comparative analysis with other surgical approaches or CT. The lack of control, small sample size, and retrospective study design were limitations as well.
In a prospective randomized controlled trial, Paajanen et al. (2011) examined the safety and effectiveness of TEP when compared to CT for the treatment of AP. The individuals in this study (n = 60) were mostly athletes at an elite level (9 were non-elite athletes) and were randomized 1:1 to TEP or CT. Primary outcome measurements were pre- and post-operative pain using a visual analog scale (VAS) and partial or full recovery to sports activity. Individuals had persistent groin pain for 3 to 6 months and prior to treatment randomization, had pelvic x-rays and MRIs to rule out avulsion fractures, and other musculoskeletal abnormalities except AP. TEP involved mesh placement behind the pubic symphysis. CT involved at least 2 months of active physiotherapy, including corticosteroid injections and oral anti-inflammatory analgesics. Of the 60 individuals in the study, 6 had simultaneous insertion tendonitis of the adductor magnus or longus. Open tenotomy was performed concurrent to the TEP surgery. Study participants were followed after 1, 3, 6, and 12 months; none were lost to follow-up. Patients in both treatment groups had similar characteristics and VAS pain scores. Mean pain scores during exercise decreased more rapidly in the TEP group. Full return to sports activity was achieved in 67% and 90% of athletes after 1 and 3 month follow-up respectively in the TEP group, compared to 20% and 27% in the CT group (p < 0.0001). After 6 months of follow-up, 7 of the 30 athletes in the CT group crossed-over to the TEP group due to persistent pain. After 12 months of follow-up, the authors reported that individuals in the TEP group were more satisfied with the treatment than the individuals in the CT group. The authors concluded that TEP was more effective than CT for the treatment of AP and suggested that professional athletes should receive at least 2 months of CT prior to surgery; nonprofessionals should wait 4-6 months prior to surgery. Limitations of this study include its small sample size and patient cross-over into the TEP arm of the study. Statistical analyses do not appear to take this cross-over into account, which potentially confound the statistically significant difference in patient satisfaction reported by the authors.
Athletic Pubalgia and Femoroacetabular Impingement
In a retrospective study, Larson et al. (2011) evaluated 9 female and 21 male athletes who were treated for associated FAI pathology and AP by hip arthroscopy and/or AP surgery, respectively. AP surgical procedures included laparoscopic repair, open pelvic floor repair, and mesh reinforcement repair; 13 adductor tenotomies were additionally performed. Patients were followed for a mean of 29 months. Of the 16 individuals who had AP surgery as the index procedure, 25% (n = 4) of the individuals returned to sports without limitations and 69% (n = 11) of the individuals had subsequent hip arthroscopy at a mean of 20 months after AP surgery. Of the 8 individuals who had hip arthroscopy as the index procedure, 50% (n = 4) of the individuals returned to sports without limitations, and 43% (n = 3) of the individuals had subsequent AP surgery at a mean of 6 months after hip arthroscopy. Thirteen individuals had concurrent hip arthroscopy and AP surgery. Concurrent and eventual surgical treatment of FAI and AP led to improved postoperative outcome scores (p < 0.05) and an unrestricted return to sporting activity in 89% of study participants. The authors concluded that when surgery only addresses FAI or AP individually, outcomes are suboptimal.
In a retrospective study, Hammoud et al. (2012) evaluated 38 male professional athletes who were surgically treated for AP and required subsequent surgical treatment for FAI. Specific AP surgical procedures were not clarified. Moreover, no standardized follow-up regimen was designated. Twelve individuals (32%) were unable to return to sports after isolated AP surgery, but were able to return after subsequent hip arthroscopy to treat FAI. The remaining individuals were able to return to sports with hip arthroscopy alone, though were not necessarily pain free. The mean time between hip arthroscopy and return to sports was 5.9 months. Thirty-nine percent (n = 15) of the athletes with concomitant AP and FAI had complete resolution of pain and dysfunction with hip arthroscopy alone. The authors concluded that there was a high incidence of AP symptoms in professional athletes with FAI and that athletes may manifest AP symptoms due to stresses from FAI.
The evidence supporting the surgical treatments of AP is limited for a number of reasons. There is a lack of consensus regarding the diagnostic criteria. Due to this uncertainty, studies have suggested that surgical treatment be limited to a select group of high-performance athletes. Additionally, based on an established consensus meeting of the British Hernia Society, Sheen et al. (2014) recommended that initial treatment should consist of a multidisciplinary approach with tailored physiotherapy. Among those that advocate surgical treatment, some believe that laparoscopic TEP or TAPP may be superior in terms of post-operative pain, rehabilitation, and time to return to sports. However, others suggest that laparoscopic surgery is often inconsistent and requires a steep learning curve. In fact, Meyers et al. (2002) maintain that they have performed open procedures on many athletes who had previous laparoscopic or ‘incorrect’ open procedures. They believe that a laparoscopic approach cannot address causative pathology and though available published peer-reviewed literature suggests successful results, this may be attributed to general fibrosis that may act to stabilize the anterior pelvis. Among those that advocate an open approach, there is no general consensus as to the best surgical procedure. Muschaweck et al. (2010) assert that an open-suture “minimal repair” technique without prosthetic mesh placement offers successful outcomes. Meyers et al. (2008) primarily advocate an open pelvic floor repair, though admit that there are up to 26 different procedures and 121 different combinations of procedures to treat AP.
There are limited studies that are appropriately designed to compare the effectiveness of any particular surgical approach to conservative treatment. Bringman et al. (2003) describe a randomized controlled trial that compares the effectiveness of laparoscopic TEP to open mesh-plug and to Lichtenstein hernia repair. They reported that a laparoscopic approach offered shorter recovery times and that there were no statistically significant differences in recurrence or post-operative complications between the three treatment groups. However, these results cannot necessarily be generalizable to individuals with AP because the patient population was diagnosed with unilateral inguinal hernias. Furthermore, the patient population was not athlete-dense, and there was no comparison to CT.
Additionally, there is one prospective cohort study evaluating “minimal repair” surgery to treat AP. However, the comparison groups are not appropriate to examine the safety and/or effectiveness of “minimal repair” surgery to other surgical approaches or CT. Muschaweck et al. (2010) compared the outcomes between athletes and non-athletes and did not assess the “minimal repair” technique vs. CT. The study was also limited in its small sample size (n = 87). To date, there is one randomized controlled trial that compares the effectiveness of laparoscopic TEP to CT. However, this study is limited in its small sample size (n = 60) and there are issues with patient cross-over, which were not fully detailed in the statistical analysis comparing the two treatment methods. Once the cross-over is taken into account, the statistically significant difference between the two treatment groups reported by the authors may be called into question. Moreover, as with many of the studies that evaluate AP surgery, there are issues with outcome measurements.
Most studies attribute AP surgical success to time to return to sports activity. This outcome is subjective and has potentially limited validity. Particularly in a patient population of professional athletes, where time to return to sports activity is of pressing concern, this outcome measurement may not necessarily indicate the complete resolution of symptoms. Athletes may feel the need to return to sports activity despite persistent pain. Furthermore, studies that utilize pain scores as an outcome measurement have presented with inconsistent survey techniques. To measure these outcomes, Bringman et al. (2003) utilized a self-administered questionnaire (SAQ), which is subject to reporting and recall bias when compared to questionnaires administered by trained clinicians. Moreover, there is a lack of consistency because these measurements were not collected at regular intervals; lack of participation is also a concern. Objective and effective outcome measurements should include standardized diagnostic inclusion criteria, recurrence of AP symptoms, and VAS pain scores prior to surgery and at standardized follow-up intervals with appropriate length. In addition, the literature and clinical guidance suggests that potential surgical treatment of AP be limited to elite athletes. The aforementioned outcome measurements should be conducted when these individuals have returned to sports. Oftentimes, individuals with suspected AP symptoms have pain during sports activity, but may otherwise be fine during non-sports activity.
Studies have suggested a possible association between FAI and AP. Hammoud et al. (2012) were able to conclude that athletes may manifest AP symptoms due to stresses from FAI. The authors found that 32% of the treated individuals were unable to return to sports after isolated AP surgery, but were able to return after subsequent hip arthroscopy to treat FAI. The remaining study participants were able to return to sports activity with hip arthroscopy alone. Studies have also suggested that FAI is a possible precursor to AP. This may indicate the need to consider FAI before AP, especially when there is no general consensus concerning the actual existence of AP and its etiology is debatable.
In summary, although there have been studies that suggest that either an open or laparoscopic surgical approach to treat AP may provide successful outcomes, these studies are of low quality. There exist very few randomized controlled trials that appropriately compare the effectiveness of AP surgery to CT. Moreover, heterogeneity of patient populations and study designs indicate a need for further longer-term, randomized prospective controlled trials comparing the effectiveness of the various surgical approaches with CT. Issues with subjective outcome measurements and a lack of consensus regarding the etiology, diagnosis, and treatment of AP warrant the need for further research.
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