Hi, I'm Dean Matsuda from Marina del Rey, California, and I've been asked to present endoscopic core muscle injury repair and pubic symphysis excision. These are my disclosures, none of which I believe are relevant to this talk. Patients often present to us with classic groin pain from labral tears and femoral acetabular impingement, but less commonly, but not uncommon, patients can have central pubic pain, either in isolation or more commonly combined with groin pain. This often is secondary to a condition called core muscle injury or athletic pubalgia. The central pubic pain in the blue on this diagram often can be secondary to osteitis pubis, which can be recalcitrant, especially in the athlete with FAI. The more proximal yellow areas could be inguinal canal problems, which we'll touch on. The red is the classic groin pain, often from hip pathology, often flexion-induced, and the green represents the adductors that can also cause core muscle injury pain. In general, but with exception, these tend to be athletes that have athletic pubalgia or core muscle injuries. Conservative treatment often does work, but it's often prolonged, and about 7-9% will fail regardless of prolonged conservative management, which could keep them out of play for a significant length of time. Oftentimes these athletes have a violent eccentric contraction of the adductors and or the distal rectus abdominis musculature causing these injuries. Aside from athletic osteitis pubis, adductor tendinopathies or tears, even avulsion tears, distal rectus abdominis injuries, there can be inguinal wall deficiencies, especially posteriorly, as well as some nerve entrapment syndromes and other conditions under the core muscle injury heading. Oftentimes the exam will focus on tenderness in response to injections in the pubic symphysis if osteitis pubis is suspected, a flamingo view, which we'll talk about later, and the adductors can be tested with resisted adduction in different positions, including straight adduction and butterfly position, and also the distal rectus abdominis can be sometimes detected on palpation as well as abdominal contraction against resistance. One of the key emerging pathomechanisms is a transfer stress from constrained motion of one or both hips with FAI, and this stress gets transferred to the pubic symphysis area as well as uneven forces are exerted on the adductor longus and the rectus abdominis. Nerve entrapment via the ilioinguinal or genitofemoral nerve are much less common, but do occur. The confluence of the rectus abdominis above and the adductor longus below forms a pubic plate of fibrous tissue anterior to the pubic symphysis and adjacent to it, and this may be a key pathologic finding in many patients with core muscle injury or athletic pubalgia. Besides the rectus abdominis and adductors, the pectineus, conjoint tendon, and inguinal ligament all have fibers in this area, and when the pubic plate detaches, often from a violent imbalanced injury between the muscles above and below, then patients can suffer significant pain from core muscle injury. The association of FAI with athletic pubalgia is quite high with reportedly as much as a 94% prevalence of FAI in patients with sports hernia and groin disruptions. As we know, association does not mean causation necessarily, but a few studies by Varel have shown that the bone marrow edema in this central pubic area occurs in Australian rules football players correlated with their groin pain, and that the decreased hip range of motion from FAI correlates with pubic bone stress injury. More recently, I worked with a group in Japan with Dr. Uchida that showed a resolution on MRI of central pubic bone marrow edema in soccer players that underwent corrective hip arthroscopy for FAI. This often cited study by Chris Larson from 2011 showed management of both FAI and central pubic injury or core muscle injury concurrently led to improved outcomes and a high return to sport on the level of 89% of athletes. Also significantly, though, 50% of patients improved and returned to sport even if they had FAI surgery alone. AP flamingo fuse standing on alternating right and then left legs can detect vertical instability of the pubic symphysis. If it's more than two millimeters, those are patients I would not recommend endoscopic pubic symphysectomy, but probably an arthrodesis type procedure for recalcitrant osteitis pubis generated pain. Open curatage of the pubic symphysis has been described as a procedure for chronic osteitis pubis, and we developed and published endoscopic pubic symphysectomy in 2010. Here we're removing a posterior superior bone spur at the tip of the burr demarcated by the red arrow, and then you can see an outline of where the pubic symphysis is, which we'll resect in a following video. We perform endoscopic pubic symphysectomy through a supine lithotomy position with the surgeon between the legs using the anterior and suprapubic portals and a 30 degree arthroscope. We're able to visualize the pubic symphysis, remove the highland end plates, posteriorly, posteriorly, superiorly, and inferiorly while retaining the important arcuate ligament for stability. We published encouraging two-year minimum outcomes in 2015. We spoke a bit about the pubic plate or prepubic aponeurotic complex. On the MRI view, sagittal, you can see a fluid layer and disruption of the pubic plate from the pubic body and pubic symphysis. On the upper right, you can see the arthroscopic view in the supine lithotomy position, and after suture repair with an anchor. On occasion, patients will have disruption of the rectus abdominis tendon as it inserts into the pubic plate region, and this is seen on the coronal MRI, and this is before and after side-to-side endoscopic repair. Here is a patient with a distal rectus tear. You can see the area of the prior pubic symphysectomy that was done all as one surgery. We are taking the leaf of the detached pubic plate and reattaching it to the freshened surface of its bony origin adjacent to the pubic symphysis with a knotless anchor. We are also repairing the vertical split in the distal part of the rectus abdominis with a side-to-side repair. This is a male soccer player who had been suffering with central pubic as well as left perisymphysial pain, worse on adduction against resistance. He was unable to play soccer. We performed an outpatient supine endoscopic pubic symphysectomy, and on the left, you can see a bone density near the left peripubic area, which is where the adductor longus had a bulge off, and we resected this endoscopically on this patient who then was able to return to sport. The indications for repair of adductor avulsion injuries is not well defined, and patients that have a major retraction and functional deficit and pain, I still consider potential candidates for repair, which historically have been done open. This is a patient we recently treated with endoscopic repair of the avulsion of the adductor longus. The G is the gracilis that's intact. The asterisk is the area where the pubic symphysis is, and the small area shows the freshened area of the origin of the adductor longus. The endoscopic repair of the cuff of avulsed tendon was tight in the supine lathotomy position, but when we put the hip into neutral extension, neutral abduction, we were able to get a nice repair of the cuff to the prepared footprint, and this patient was placed in a post-operative hip brace as well as two crutches. Regardless of whether you incorporate core muscle injury surgery to your practice, it's very important to take away the connection of FAI to core muscle injuries, especially when you see patients with more central pubic pain. May there be a continued healthy collaboration between orthopedic and general surgeons in the management of core muscle injuries, all for the ultimate benefit of our patients. Thank you for your attention to this presentation.

endoscopic core muscle injury repair

pubic symphysis excision

groin pain

labral tears

femoral acetabular impingement