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WHY GILMORE’S GROIN IS NOT A HERNIA 16.06.2011.

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Presentation on theme: "WHY GILMORE’S GROIN IS NOT A HERNIA 16.06.2011."— Presentation transcript:

1 WHY GILMORE’S GROIN IS NOT A HERNIA 16.06.2011

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3 GILMORE’S GROIN SPORTSMEN GROIN GROIN DISRUPTION ATHLETIC PUBALGIA (Sportsmen hernia NO!)

4 CASE 1D.M. 27 FULL BACK: TOTTENHAM HOTSPUR FC PRESENTED: 28.08.80 SYMPTOMS: 17 WEEKS GROIN PAIN AFTER EVERSION INJURY LAST GAME: 17 WEEKS PAIN INCREASED: SPRINTING KICKING TWISTING & TURNING COUGHINGSNEEZING

5 CASE 1D.M. PREVIOUS INVESTIGATIONS: 3 ORTHOPAEDIC OPINIONS X-RAY CT SCAN U/S SCAN PREVIOUS TREATMENT: COMPLETE REST PHYSIOTHERAPYMANIPULATION LOCAL STEROIDS

6 CASE 1 D.M. PHYSICAL SIGNS INSPECTION:N.A.D. –NO SWELLING PALPATION:N.A.D. – NO LUMP PALPATION VIA SCROTUM: -RIGHT SUPERFICIAL INGUINAL RING DILATED -COUGH IMPULSE -TENDER INSERTION OF FINGER  PAIN COMPARED TO OPPOSITE SIDE

7 Presented 16.03.81 (Eversion / Overstretching Injury) 15 wks Groin Pain but No Lump Prevented Training /Play Post Op: Training with Aberdeen 3 wks In Scotland Squad 7 wks

8 GROIN DISRUPTION TYPICAL PATIENT YOUNG MALEYOUNG MALE ACTIVE SPORTSMENACTIVE SPORTSMEN RARE OVER 45RARE OVER 45 RARE IN FEMALES (1%)RARE IN FEMALES (1%)

9 GROIN DISRUPTION MUSCULO – TENDINOUS INJURYMUSCULO – TENDINOUS INJURY ALL LAYERS GROINALL LAYERS GROIN INGUINAL + (ADDUCTOR 40%)INGUINAL + (ADDUCTOR 40%) “MUSCLE DISLOCATION”“MUSCLE DISLOCATION”

10 ONSET OF SYMPTOMS INSIDIOUS72% SPECIFIC INJURY28% OVERSTRETCHING OVERSTRETCHING MISKICKING MISKICKING ABDUCTION ABDUCTION EVERSION EVERSION

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12 PATIENT’S REFERRED with GROIN PAIN 1980 - 2010 TOTAL7738 MALE7479(97%) FEMALE259(3%)

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14 INCIDENCE OF OPERATION 1980 - 2010 Referred 7738 pts Ops 4466 pts 58%

15 C 1980-2010 Over 31 years 7479 Sporsmen referred with “Groin Pain” Many have returned with other complaints including Haemorrhoids and skin lesions But ONLY 1 with HERNIA

16 INTERNATIONALS 1980-2010 SOCCER 257 RUGBY UNION 44 ATHLETES24 CRICKET22 RUGBY LEAGUE17 HOCKEY15 HANDBALL 4 RACQUET GAMES 4 SKIING2 BASKETBALL 2 FENCING 2 LACROSSE 2 MARTIAL ARTS 3 ICE HOCKEY2 GYMNASTICS 1 WATERPOLO 1 ROWING1 "STRONGMAN" 1 WEIGHT LIFTING 1 _______________________ TOTAL407

17 SYMPTOMS DURING EXERCISE PAIN IN GROIN INCREASES WITH RUNNINGSTRIDINGSPRINTING SUDDEN MOVEMENT TWISTING & TURNING SIDE STEPPING JUMPING DEAD BALL KICKING LONG BALL KICKING (BUT NO SWELLING)

18 SYMPTOMS AFTER EXERCISE PAIN IN GROIN INCREASES WITH TURNING IN BED GETTING OUT OF BED GETTING OUT OF CAR SIT UPS COUGHINGSNEEZING SUDDEN MOVEMENT STIFF & SORE

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20 MRI in Groin Disruption MRI Poor in Abdomen Resolution insufficient for subtle changes But Inguinal ligament – clearly visible Hernia Hernia Gross Scar Tissue Defects / Gaps Significant Disruption MRI Good in Pelvis & Thigh Adductor Tear Osteitis pubis HIP Pathology Also visible clearly seen David Connell 2009

21 Ultrasound in Groin Disruption State of Art Ultrasound Equipment – required Subtle changes in Inguinal ligament Conjoined Tendon Conjoined Tendon Dynamic assessment – Essential Abdominal straining Sonopalpation Tender over Inguinal Canal Bulging Post. Wall Bulging Post. Wall HERNIA: Shows Clearly as Peritoneal Sac or Protrusion maybe seen David Connell 2009

22 31 Years No Groin Patient Complained of Swelling

23 INDICATIONS FOR SURGERY Groin Disruption PROFESSIONALANDAMATEUR FAILED CONSERVATIVE TREATMENT

24 INDICATION FOR SURGERY: PROFESSIONALS GAME INHIBITED TRAINING INHIBITED  LOSS OF SPEED  LOSS OF SPEED LOSS OF FITNESS

25 INDICATION FOR SURGERY: AMATEURS SYMPTOMS AFFECT EVERYDAY LIFE LOSS OF SPORT AFFECTS QUALITY OF LIFE

26 GROIN DISRUPTION: PATHOLOGY Found at Operation TORN EXTERNAL OBLIQUE ====DILATED SUPERFICIAL INGUINAL RING TORN CONJOINED TENDON CONJOINED TENDON } DEHISCENCE } DEHISCENCE INGUINAL LIGAMENT ( 40% also have Adductor Pathology)

27 Groin Disruption Surgery Groin Reconstruction Normal Anatomy - RestoredNormal Anatomy - Restored Each layer – RepairedEach layer – Repaired Each Injury- RepairedEach Injury- Repaired Permanent Suture – EssentialPermanent Suture – Essential Nylon Darn / Ethilon DarnNylon Darn / Ethilon Darn Preferable to Absorbable Sutures (Don’t Last)Preferable to Absorbable Sutures (Don’t Last) Preferable to Mesh (May Restrict Mobility)Preferable to Mesh (May Restrict Mobility)

28 CONJOINED TENDON REPAIR TRASVERSALIS FASCIA PLICATED with O Vicryl

29 TENSION FREE NYLON DARN (CONJ. TENDON to ING. LIG)

30 EXT OBLIQUE REPAIR (NEW S.I.R)

31 GROIN DISRUPTION & ADDUCTOR TEAR PRESENT IN 40% HALF REQUIRE ADDUCTOR TENOTOMY

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33 D No evidence of increased incidence of Hernia in Sportsmen Groin Disruption/Gilmore’s Groin Groin Disruption/Gilmore’s Groin Neither Hernia or Pre Hernia Terminology HERNIA: Incorrect HERNIA IN SPORTSMEN

34 B QUOTE “Jerry I had your “Groin” in 74, As did my colleague Alan Mullery We both had to rest for months There was no other treatment then” Terry Venables 2006

35 E A Protrusion of a Viscus beyond it’s normal confines HERNIA

36 HERNIA (2% MALES IN UK) INGUINAL 73% FEMORAL 17% (Bailey & Love ) (Bailey & Love )

37 INGUINAL – DIRECT INDIRECT INDIRECTFEMORALOBTURATOR GROIN HERNIA

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39 G INDIRECT INGUINAL HERNIA Congenital Peritoneal Sac In the Inguinal Canal Passing through DIR Out through the SIR Usually no other abnormality

40 H INDIRECT INGUINAL HERNIA PRESENTATION Usually young males Swelling only occurs with standing/straining Swelling can be difficult to reduce If swelling persists - Pain

41 Swelling which when present causes pain or discomfort Irreducible swelling Strangulation HERNIA: INDICATION FOR SURGERY

42 INDIRECT INGUINAL HERNIA OPERATION Herniotomy (Excise Indirect Sac) Reconstitute Inguinal canal (Repair only necessary if post wall defect)

43 I DIRECT INGUINAL HERNIA Protrusion of Viscus through Post Inguinal Canal Wall Due to defect in Post Wall

44 J Swelling readily appears with Coughing or Standing Swelling reduces when lying down Patient often complains of discomfort with Standing e.g. cocktail parties or window shopping (Sport rarely Restricted) DIRECT INGUINAL HERNIA PRESENTATION

45 K

46 Reduce Peritoneal Sac Insert Mesh Close Ext Oblique & Skin DIRECT INGUINAL HERNIA OPERATION

47 Protrusion through Femoral Canal Swelling: Below and lateral to pubic tubercle i.e. Upper thigh i.e. Upper thigh FEMORAL HERNIA

48 Reduce Sac contents Excise Sac Suture Lacunar to Inguinal ligament FEMORAL HERNIA OPERATION

49 Groin Disruption/Gilmore’s Groin Significantly different to Hernia Inguinal InguinalFemoralObturator Only similarity: SITE SYMPTOMS & PATHOLOGY

50 DEPENDS ON DEPENDS ON ACCURATE DIAGNOSIS OfPATHOLOGY CORRECT SURGICAL TREATMENT ALWAYS

51 Groin Disruption/Gilmore’s Groin Significantly different to Hernia REPAIR using Hernia Mesh Technique Open or Laparoscopic Open or Laparoscopic Usually FAILS Usually FAILS PATHOLOGY in PATHOLOGY in

52 F “I have had the mesh repair But I can still feel a tear behind the mesh My symptoms have not improved” P.W Patient 2009 8% our Operations in Patients with Previous Groin Repair

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54 A “General Surgeons in this area either do not recognise Gilmore’s Groin or They treat it as a Hernia with mesh repair, which fails” Johnny Morris Sports Medicine Physician Hampshire 2011 QUOTE

55 F DOES NOT CURE DOES NOT CURE OFTEN COMPLICATES SIGNIFICANT DELAY in RECOVERY or or RESULTS IN FAILURE Conclusion:Wrong Diagnosis Resulting in Wrong Operation

56 Patients with Groin Problems Deserve a GROIN SURGEON Patients with Groin Problems Deserve a GROIN SURGEON 16.06.2011

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