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Prof. dr. C.H.J. van Eijck Afd. Heelkunde Sportershernia/plaatsen matje.

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Presentation on theme: "Prof. dr. C.H.J. van Eijck Afd. Heelkunde Sportershernia/plaatsen matje."— Presentation transcript:

1 Prof. dr. C.H.J. van Eijck Afd. Heelkunde Sportershernia/plaatsen matje

2 Chirurg

3 Clubarts

4

5 Sportsmans hernia

6

7 Chronic groin painChronic groin pain –Incidence: 6% –60% during active soccer carier –50% > 20 weeks complaints Differential diagnosisDifferential diagnosis

8 Differential diagnosis Groin injury Muscle and tendon injuryMuscle and tendon injury –Tendon-bone or tendon-muscle –Avulsion fracture Adductor longus, rectus femoris or abdominisAdductor longus, rectus femoris or abdominis X-Pelvis, bone scan, ultrasound or MRIX-Pelvis, bone scan, ultrasound or MRI

9 Differential diagnosis Groin injury Osteïtis pubisOsteïtis pubis –Painfull symfysis and adductor- tenoperiostitis –Direct trauma –Pelvic instability/Sacroiliacal abnormalities 25% Radiologic abnormalities25% Radiologic abnormalities X-Pelvis,, ultrasound or MRIX-Pelvis, bone scan, ultrasound or MRI

10 Osteïtis pubis

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12 Differential diagnosis Groin injury StressfractureStressfracture –Ramus inferior os pubis (5%) –Collum femoris avascular necrosis Femur head X-Pelvis, bone scan, (MRI)X-Pelvis, bone scan, (MRI)

13 Differential diagnosis Groin injury Urologic diseaeUrologic diseae –Prostatitis –Epididymitis –Urethritis –Hydrocèle testis –Non-descending testicle Rectal toucher, bact. culture, ultrasoundRectal toucher, bact. culture, ultrasound

14 Differential diagnosis Groin injury Hip en Spine diseaseHip en Spine disease –Osteochondritis lumbal verterbra –M. Scheuermann –Discus pathology., L 1 en L 2 –Cam type femoroacetabular impingement –Congenital hipdysplasia –Epifysiolysis femur headkop –Avascular necrosis femur head X-LWK (+3/4), X-femur (Faux-profile), bone scan and CT-scan (arthography)X-LWK (+3/4), X-femur (Faux-profile), bone scan and CT-scan (arthography)

15 Differential diagnosis Groin injury Nerve entrapment/previous surgeryNerve entrapment/previous surgery –N. ilio-inguinalis (symfysis) –N. genitofemoralis (testicle)

16 Differential diagnosis Groin injury Nerve entrapment/previous surgeryNerve entrapment/previous surgery –N. ilio-inguinalis (symfysis) –N. genitofemoralis (testicle) –N. obturatorius (med. thigh and adductor weakness) Proof blockade and/or EMGProof blockade and/or EMG

17 N. obturatorius (med. thigh and adductor weakness) Nerve entrapment N. obturatorius (med. thigh and adductor weakness)

18 Physical examination Groin injury Renee Dannenburg

19 Physical examination Groin injury Lower back, SI Joint and hipLower back, SI Joint and hip Abdominal musclesAbdominal muscles Muscles of the upper legsMuscles of the upper legs Rectal toucherRectal toucher Palp funiculus and testiclesPalp funiculus and testicles

20 Physical examination Groin injury Lower back, SI Joint and hipLower back, SI Joint and hip Abdominal musclesAbdominal muscles Muscles of the upper legsMuscles of the upper legs Rectal exam., palp funiculus and testiclesRectal exam., palp funiculus and testicles Painfull int. and ext. annulus with elevated intra-abdominal pressurePainfull int. and ext. annulus with elevated intra-abdominal pressure Painfull int. and ext. annulus with elevated intra-abdominal pressure

21 Sportsmans hernia Weakness of the post. inguinal wallWeakness of the post. inguinal wall Symptomatic non-palpable herniaSymptomatic non-palpable hernia Disruption of the ext. obl. aponeurosisDisruption of the ext. obl. aponeurosis PubalgyPubalgy

22 Complaints Long existing groin painLong existing groin pain Pain around the external annulusPain around the external annulus Combination with adductor-tendopathyCombination with adductor-tendopathy Good reaction on NSAIDsGood reaction on NSAIDs Increased pain with elevated intra- abdominal pressureIncreased pain with elevated intra- abdominal pressure

23 Pathofysiology Sportsmans hernia Post wall inguinal canal: fascia transversalis No striated muscle fibers Funiculus through the int. annulus

24 Pathofysiology Sportsmans hernia

25 Post wall inguinal canal: fascia transversalis No striated muscle fibers Funiculus through the int. annulus Weakness post. wall Lat. Hernia Tension peritoneum Nerve entrapment

26 Treatment Sportsmans hernia ConservativeConservative –Rest, Fysiotherapy and NSAIDs Renee Dannenburg

27 Treatment Sportsmans hernia ConservativeConservative –Rest, Fysiotherapy and NSAIDs OperativeOperative –Strengthening of the post. Wall of the inguinal canal –Conventional (Lichtenstein- plastiek) –Laparoscopic

28 Patients Sportsmans hernia Since 1998 till present: n=240Since 1998 till present: n=240 (4 women)(Semi)professional n=98 (4 women) 76 soccer, 4 atletics, 3 tennis, 4 cycling, 11 misc.76 soccer, 4 atletics, 3 tennis, 4 cycling, 11 misc. (3 women)Amateur n=142 (3 women) 127 soccer, 15 misc.127 soccer, 15 misc.

29 Mean Age: 25 ± 4.5 year (17-36)Mean Age: 25 ± 4.5 year (17-36) Time complaints: 3 months till >2 yearsTime complaints: 3 months till >2 years Patients Sportsmans hernia

30 Diagnostics Sportsmans hernia Herniografie (n=7) –High false-negative percentage Ultrasonography (n=167) X-pelvic and femur (n=68) Bone scan (n=53) CT-scan (n=22) MRI (n=57) Laparoscopy (n=1)

31 Indirect H.inguinalis 1 2

32 Open Lichtenstein n=3Open Lichtenstein n=3 Laparoscopic TEP n=237Laparoscopic TEP n=237 Tenotomy n=12Tenotomy n=12 Left n=86Left n=86 Right n=89Right n=89 Both n=65Both n=65 Patients Sportsmans hernia

33 Total Extra Perinoneal (TEP)

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36 Laparoscopy TEP right

37 Total Extra Perinoneal (TEP)

38 Laparoscopy

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41 Total Extra Perinoneal (TEP)

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44 (Min.) lateral hernia n=65(Min.) lateral hernia n=65 (Min.) medial hernia n=24(Min.) medial hernia n=24 Preperitoneal lipoma n=39Preperitoneal lipoma n=39 Enlarged lymph nodes n=32Enlarged lymph nodes n=32 No abnormallities n=80No abnormallities n=80 Peroperative findings Sportsmans hernia

45 Sup. woundinfection (S.aureus) (n=4)Sup. woundinfection (S.aureus) (n=4) Adductor longus tendinopathy (n=14)Adductor longus tendinopathy (n=14) tenotomie (n=4) tenotomie (n=4) Mesh irritation/seroma (Prolene ® ) (n=12)Mesh irritation/seroma (Prolene ® ) (n=12) Mesh displacement ( n=4)Mesh displacement ( n=4) Giant cell tumor re prox. femur (n=1)Giant cell tumor re prox. femur (n=1) Sports recoverySports recovery Complications Sportsmans hernia

46 Sportsmans hernia Time Revalidation Week Renee Dannenburg Week Week Week Week 6

47 Sportsmans hernia TimePurposeTherapy Week 0 - 1Wound recovery Pain management Walking 5 km/h Week 1 - 2Optimizing scar tissue Preventing muscle atrophia Aqua training Power walking Cycle ergometer Isometric training Rect. Abd. Steps Week 2 - 3Dynamic training Rect. Abd. Functional exercise Sit-ups Running Lunges Week 3 - 5Sport specific trainingWeight training Normal training Week 6Normal training

48 Sportsmans hernia

49 RecoveryRecovery –Without tenotomy: 4-8 weeks –With tenotomy: weeks

50 Conclusion The TEP is an efficient method for the treatment of patients with a Sportsmans hernia

51 Dank voor jullie aandacht en veel succes verder


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