Hip and groin injuries are common in athletes who take part in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion of the tendons attached to the symphysis pubis has previously been described: these can be managed both operatively and non-operatively. We describe an uncommon variant of this injury, namely complete avulsion of the adductor sleeve complex: this includes adductor longus, pectineus and rectus abdominis. We go on to describe a surgical technique which promotes a full return to the pre-injury level of sporting activity.

Over a period of ten years, 15 high-level athletes with an MRI-confirmed acute adductor complex avulsion injury (six to 34 days old) underwent surgical repair. The operative procedure consisted of anatomical re-attachment of the avulsed tissues in each case and mesh reinforcement of the posterior inguinal wall in seven patients. All underwent a standardised rehabilitation programme, which was then individualised to be sport-specific.

One patient developed a superficial wound infection, which was successfully treated with antibiotics. Of the 15 patients, four complained of transient local numbness which resolved in all cases. All patients (including seven elite athletes) returned to their previous level of participation in sport.

Cite this article: Bone Joint J 2015;97-B:1488–92.

Introduction

Hip and groin injuries are common in athletes participating in high level sports. Adductor muscle tendon injuries represent a small but important number of these injuries. Avulsion injuries involving tendons attaching to the symphysis pubis have previously been described and can be managed both operatively and non-operatively.

The aim is to describe a rare variant of this injury; complete avulsion of the adductor sleeve complex including adductor longus, pectineus and rectus abdominus. A surgical technique is then outlined which promotes a full return to pre-injury level of sporting activity.

Background

Adductor muscle and tendon injuries are commonly seen in sport. Complete adductor avulsions have been described and can be managed non-operatively or operatively. A rare variant of this injury is the complete avulsion of the adductor complex with the pectineus and rectus abdominus amounting to a complete sleeve avulsion from the pubis. This is a severe injury that is increasingly recognised due to improved imaging and lower diagnostic threshold.

Study design: Retrospective study of 34 patients with a massive rotator cuff tear, who were treated with an arthroscopic tuberoplasty, debridement of the degenerate cuff and biceps tenotomy.

Objectives: To evaluate the clinical outcome of a reversed decompression at the medium term follow up.

Summary of background data: Rotator cuff repair can become impossible for massive tears in the elderly. If conservative management fails, a reverse total shoulder arthroplasty (RSA) is commonly used. However, Fenlin described in 2002 a tuberoplasty for this pathology and reported good to excellent results. This procedure appears to be well tolerated as it is arthroscopic, not time consuming and not depending on intensive physiotherapy. In case of failure, a primary RSA is still possible.

Methods: 36 patients treated with a tuberoplasty between February 2002 and September 2006 were identified.

One patient deceased, one patient developed Alzheimer dementia, leaving 34 patients available for follow-up. They completed the SF-36 questionnaire and the Simple shoulder test. They were clinically reviewed and scored with the Constant-Murley score. All 34 had complete radiographic work-up (x-ray; ultrasound) preoperatively and at final follow up.

Results: Median age at operation was 71 years (range: 52,5 – 82,16). Mean follow-up was 3,1 years (SD: +/− 0,75).

Mean operating time was 35 minutes (SD: +/− 12.33). There were no surgical complications. Postoperatively, there was an uneventful recovery in all patients.

At final follow-up, two patients were revised to a RSA. One patient was revised after 9 months because of continuous pain and loss of function. The second patient developed a complete osteonecrosis and was revised after one year.

The 32 remaining patients had a preoperative Constant-Murley score adjusted for age and gender of 34,8. This improved to an average of 84 at final follow up.

The simple shoulder test improved from an average of 1,8 to 8,4.

The average decrease of subacromial space was 2,34 mm and the loss of glenohumeral joint space was 0,57. Finally, the preoperative grade of arthrosis was 0,46 compared to a postoperative average of 1,1.

At final follow-up, 85% (27/32) were either satisfied or very satisfied with the result. 12,5% (4/32) appreciated the result as only fair. 2,5% (1/32) was dissatisfied, but didn’t consider revision surgery.

Conclusion: We conclude that a tuberoplasty with rotator cuff debridement and biceps tenotomy is a reliable treatment for massive rotator cuff tears in the elderly at medium follow up. In case of failure, revision to RSA is still a valuable option.