New Anatomical Concepts regarding Pubic-Related Groin Pain: A Dissection Study.

OBJECTIVE: Pubis-related groin pain remains a difficult topic in orthopedic and sports medicine. A better understanding of the anatomy of the adductors and the pubic ligaments is necessary. The aim of this study is to map all the musculotendinous attachments to the pubic ligaments and to investigate in detail all the possible inter-adductor fusions. METHODS: The pubic symphyses were dissected in eight male and fourteen female embalmed cadavers (mean age 85 years), focusing on the fusion between the adductors, pubic ligaments, and musculotendinous attachments at the pubic ligaments. The 95% confidence intervals for the prevalence of the different conjoint tendons and tendon attachment to ligament were calculated. RESULTS: The presence of three types of conjoint tendons was found: adductor brevis and gracilis (AB/G) 90.9 [72.2 - 97.5]%; adductor brevis and adductor longus (AB/AL) 50.0 [30.7 - 69.3]%; adductor longus and gracilis (AL/G) 50.0 [30.7 - 69.3]%. The AL, AB and G were in every cadaver attached to the anterior pubic ligament (APL). 64% of the AB and 100% of the G were attached to the inferior pubic ligament (IPL). CONCLUSION: The proximal anatomy of the adductors is more complex than initially described. This study identified three possible conjoint tendons between the proximal adductors. The AB/G conjoint tendon was significantly more present than the AB/AL or AL/G conjoint tendon. The IPL has attachments only from the AB and G. Rectus Abdominis (RA) and AL were not attached to IPL. Mapping the musculotendinous attachments on the pubic ligaments creates more clarity on the pathophysiology of lesions in this area.

Three-dimensional visualization and measurement of myopectineal orifice in non-inguinal hernia patients.

PURPOSE: The myopectineal orifice (MPO) is a weak area at lower part of the anterior abdominal wall that directly determines the mesh size required in inguinal hernia repair. However, MPO data have mainly been acquired from measurements of cadavers or anesthetized patients. Furthermore, there are very few reports on the measurement of the MPO in Chinese patients. The present study aimed to use three-dimensional visualization technology to measure the MPO in live non-anesthetized Chinese patients, and to use this information to indicate the appropriate mesh size required for inguinal hernia repair. METHODS: In this study, we used the parameters of the MPO and the pelvis that were measured in 40 patients with peripheral arterial disease of the lower limb arteries (80 inguinal regions) using Medraw software (Image Medraw Technology Co., Ltd., China). RESULTS: The result showed that the average width and height of the MPO were 5.71 ± 0.99 cm and 4.96 ± 0.69 cm, respectively (5.22 ± 0.77 cm and 5.13 ± 0.63 cm in males, and 6.20 ± 0.95 cm and 4.80 ± 0.71 cm in females). The average projected area of the MPO was 16.06 ± 4.37 cm2 on the left, and 15.61 ± 4.10 cm2 on the right (P > 0.05). CONCLUSION: Three-dimensional visualization was used to measure the area, width, and height of the MPO in living non-anesthetized Chinese patients. MPO area was correlated with age, but not with pelvic parameters.

Study of lymph node vascular relationships of the inferior epigastric veins: The solve anatomical study.

INTRODUCTION: Tissue surrounding the superficial inferior epigastric vein (SIEV) can be harvested for vascularised lymph node transfer (vLNT) for the treatment of lymphoedema. The aim of this study is to define the anatomical relationship of lymph nodes surrounding the SIEV. METHODS: Twenty-five fresh-frozen cadaveric groin specimens were harvested en bloc to the level of the deep fascia along the following anatomical boundaries, yielding quadrilateral tissue blocks: pubic tubercle (medial), anterior superior iliac spine (lateral), 5 cm superior and inferior to the inguinal ligament. The SIEV was marked at its entry point with the femoral vein. Specimens were oriented, secured and fixed in formaldehyde and analysed using longitudinal slices at 3 mm intervals. RESULTS: A total of 86 lymph nodes were identified. The average position of lymph nodes examined was 0.4 cm medial and 3.2 cm inferior to the mid-inguinal point. CLINICAL RELEVANCE: An improved understanding of the anatomical locations of lymph nodes surrounding the SIEV will allow a more purposeful harvest during vLNT, allowing a greater number of lymph nodes to be captured whilst limiting donor site morbidity.

A qualitative literature review exploring the role of the inguinal ligament in the context of inguinal disruption management.

PURPOSE: Groin injury, sportsman's groin and inguinal disruption (ID) refer to a diffuse chronic groin pain syndrome that has significant impact on athletes and is often unresponsive to conservative management. The ID aetiology is poorly understood but may involve weakness of the inguinal ligament attachments or the posterior inguinal canal wall or the tendons of adductor longus and rectus abdominis. We discuss the literature in which the inguinal ligament was directly targeted for ID management in athletic populations. Secondarily, we discuss the anatomical reclassification of the inguinal ligament to a tendon based on the above information. METHODS: This was a qualitative review of the published literature, in English, from January 2007 to February 2017. RESULTS: Five research papers, including 264 patients, were appraised. In patients with ID, tears were identified in the inguinal ligament, and to relieve pain, the surgical treatment of the ligament by tenotomy was shown to be beneficial. Techniques such as radiofrequency denervation involving the inguinal ligament and ilioinguinal nerve were also shown to relieve symptoms in athletes. CONCLUSIONS: This qualitative review has specifically focused on the literature directly targeting the inguinal ligament in ID which is a relatively unexplored management approach. When treated as a tendon, the inguinal ligament appears to be an appropriate ID therapeutic target. Integrated studies and randomised clinical trials will promote a better understanding of the role of the inguinal ligament and its tendinous properties in ID and provide a foundation for evidence-based management of chronic groin pain in athletes.

Is it possible to identify the inguinal nerves during hernioplasty? A systematic review of the literature and meta-analysis of cadaveric and surgical studies.

PURPOSE: Patients who undergo inguinal hernioplasty may suffer from persistent postoperative pain due to inguinal nerve injuries. The aim of this systematic review and meta-analysis was to provide comprehensive data on the prevalence (identification rates), anatomical characteristics, and ethnic variations of the ilioinguinal (IIN), the iliohypogastric (IHN) and the genital branch of the genitofemoral (GNF) nerves. METHODS: The systematic literature search was conducted using the PubMed, Scopus and Web of Science databases. RESULTS: A total of 26 articles (5265 half-body examinations) were included in this study. The identification rate of the IIN was 94.4% (95% CI 89.5-97.9) using a random-effects model. Unweighted multiple regression analysis showed that study sample size (ß = - 0.74, p = .036) was the only statistically significant predictor of lower prevalence. The identification rates of the IHN and GNF was 86.7% (95% CI 78.3%-93.3%) and 69.1% (95% CI 53.1%-83.0%) using a random-effects model, respectively. For those outcomes, a visual analysis of funnel and Doi plots indicated irregularity and provided evidence that larger studies tended to have lower identification rates. In terms of the synthesis of anatomical reference points, there was a large and statistically significant amount of heterogeneity for most outcomes. CONCLUSIONS: The identification rates of the inguinal nerves in our study were lower than reported in literature. The lowest was found for GNF, suggesting that this nerve was the most difficult to identify. Knowledge regarding the anatomy of the inguinal nerves can facilitate their proper identification and reduce the risk of iatrogenic injury and postoperative pain.

A general practitioner primer on groin hernias.

BACKGROUND: Patients, particularly adult males, commonly present to general practice with groin hernias. Although rarely life-threatening, groin hernias can be associated with considerable morbidity and limitation of earning capacity. General practitioners should be equipped with a sound knowledge of the relevant anatomy, clinical findings and management principles in order to facilitate all aspects of the patient journey. OBJECTIVE: Drawing on evidence from the literature and personal clinical experience, this article seeks to enhance understanding of groin hernias and provide information on what is considered current best practice. DISCUSSION: A number of key points have been generated that will serve to inform the management of patients with groin hernias in the primary care setting.

Imaging of inguinal-related groin pain in athletes.

Inguinal canal-related groin pain is common in athletes and may involve numerous structures such as the conjoint tendon and the transversalis fascia. Ultrasound is the only dynamic tool that shows the passage of preperitoneal fat at the level of the Hesselbach triangle and allows excluding true inguinal hernias. Fascia transversalis bulging and inguinal ring dilatation may also be described. MRI assesses injuries of rectus abdominis and adductor longus enthesis and osteitis symphysis but its accuracy for the diagnosis of inguinal-related groin pain remains debated.

A meta-analysis of the incidence of complications associated with groin access after the use of resuscitative endovascular balloon occlusion of the aorta in trauma patients.

BACKGROUND: Serious complications related to groin access have been reported with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). We performed a systematic review and meta-analysis to estimate the incidence of complications related to groin access from the use of REBOA in adult trauma patients. METHODS: We identified articles in MEDLINE and EMBASE. We reviewed all studies that involved adult trauma patients who underwent the placement of a REBOA and included only those that reported the incidence of complications related to groin access. A meta-analysis of proportions was performed. RESULTS: We identified 13 studies with a total of 424 patients. REBOA was inserted most commonly by trauma surgeons or emergency room physicians. Information regarding puncture technique was reported in 12 studies and was available for a total of 414 patients. Percutaneous access and surgical cutdown were performed in 304 (73.4%) and 110 (26.5%) patients, respectively. Overall, complications related to groin access occurred in 5.6% of patients (n = 24/424). Lower limb amputation was required in 2.1% of patients (9/424), of which three cases (3/424 [0.7%]) were directly related to the vascular puncture from the REBOA insertion. A meta-analysis that used the logit transformation showed a 5% (95% CI 3%-9%) incidence of complications without significant heterogeneity (LR test: χ = 0.73, p = 0.2, Tau-square = 0.2). In a second meta-analysis, we used the Freeman-Tukey double arcsine transformation and found an incidence of complications of 4% (95% CI 2%-7%) with low heterogeneity (I = 16.3%). CONCLUSION: We found that the incidence of complications related to groin access was of 4-5% based on a meta-analysis of 13 studies published worldwide. Currently, there are no benchmarks or quality measures as a reference to compare, and thus, further work is required to identify these benchmarks and improve the practice of REBOA in trauma surgery. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

Isolated Common Femoral Artery Injury Resulting from Blunt Military Trauma.

The incidence of an isolated femoral vessel injury in the absence of fractures or other organ injury is extremely rare. A 20-yr-old male Korean soldier was taken to the hospital with a common femoral artery (CFA) obstruction. Injured CFA segment was resected and replaced by using 7-mm PTFE (polytetrafluoroethylene) graft. Two months after the surgical treatment, the patient discharged from the hospital without any complaints or postoperative complications. We report an unusual case of isolated femoral artery injury due to blunt trauma during military service with following review of literature.

Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging Features.

CONTEXT: Evaluation of groin pain in athletes may be challenging as pain is typically poorly localized and the pubic symphyseal region comprises closely approximated tendons and muscles. As such, magnetic resonance imaging (MRI) and ultrasound (US) may help determine the etiology of groin pain. EVIDENCE ACQUISITION: A PubMed search was performed using the following search terms: ultrasound, magnetic resonance imaging, sports hernia, athletic pubalgia, and groin pain. Date restrictions were not placed on the literature search. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: MRI is sensitive in diagnosing pathology in groin pain. Not only can MRI be used to image rectus abdominis/adductor longus aponeurosis and pubic bone pathology, but it can also evaluate other pathology within the hip and pelvis. MRI is especially helpful when groin pain is poorly localized. Real-time capability makes ultrasound useful in evaluating the pubic symphyseal region, as it can be used for evaluation and treatment. CONCLUSION: MRI and US are valuable in diagnosing pathology in athletes with groin pain, with the added utility of treatment using US-guided intervention. Strength-of Recommendation Taxonomy: C.

Hiperpigmentación reticulada en pliegues / Reticulate hyperpigmentation of the flexures

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Placas ulceradas en ingle en paciente inmunodeprimida / Ulcerated Plaques on the Groin of an Immunosuppressed Woman

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Groin Injuries (Athletic Pubalgia) and Return to Play.

CONTEXT: Groin pain is a common entity in athletes involved in sports that require acute cutting, pivoting, or kicking such as soccer and ice hockey. Athletic pubalgia is increasingly recognized as a common cause of chronic groin and adductor pain in athletes. It is considered an overuse injury predisposing to disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall without a clinically detectable hernia. These patients often require surgical therapy after failure of nonoperative measures. A variety of surgical options have been used, and most patients improve and return to high-level competition. EVIDENCE ACQUISITION: PubMed databases were searched to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms groin pain, sports hernia, athletic pubalgia, adductor strain, osteitis pubis, stress fractures, femoroacetabular impingement, and labral tears. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS AND CONCLUSION: Athletic pubalgia is an overuse injury involving a weakness in the rectus abdominis insertion or posterior inguinal wall of the lower abdomen caused by acute or repetitive injury of the structure. A variety of surgical options have been reported with successful outcomes, with high rates of return to the sport in the majority of cases.

TEP and Lichtenstein anatomy: does simulation accelerate acquisition among interns?

PURPOSE: The anatomy of the inguinal region is notoriously challenging to master. We sought to teach open inguinal hernia (OIH) and totally extraperitoneal (TEP) anatomy with simulation models among general surgery (GS) interns. METHODS: Low-fidelity OIH and TEP models were constructed out of cardboard, plastic bins, fabric, and yarn. GS interns (n = 30) participated in a 3-h hernia session including a pretest, anatomy lecture, simulated OIH and TEP hernia repair, and posttest. Pre- and posttest scores were based on a difficult 30-point exam which included didactic questions (10 points), drawing relevant TEP (10 points), and OIH (10 points) anatomy. Participants were surveyed following the session. RESULTS: Median pretest scores were 13 % (range 0-60 %). Median posttest scores improved to 47 % (range 20-93 %, p < 0.001). Median number of structures drawn in the TEP image improved from 2 (range 0-14) to 11 (range 1-21, p < 0.001). Median number of structures drawn in the OIH image improved from 3 (range 0-15) to 7 (range 1-19, p < 0.001). 67 % (12/18) demonstrated improvement in knowledge of abdominal wall layers. 23 % (7/30) knew the triangles of pain/doom on the pretest vs. 77 % (23/30) on the posttest. Mean Likert scores favored session enjoyability (4.5), not a waste of training time (4.4), and improved understanding of OIH and TEP anatomy (4.4, 4.2). CONCLUSIONS: Low-fidelity simulators can be used to teach and assess knowledge of TEP and OIH anatomy. While enjoyable and useful, one 3-h session does not create master hernia surgeons or expert anatomists out of novice trainees.

Lymphatic anatomy of the inguinal region in aid of vascularized lymph node flap harvesting.

BACKGROUND: Vascularized lymph node transfer (VLNT) has shown promise as a treatment for breast cancer-related lymphedema, a common and debilitating condition among breast cancer survivors. In VLNT, the most popular lymph node flap donor site is the inguinal region; however, concerns about the possibility of iatrogenic lymphedema hamper the widespread adoption of VLNT. A better understanding of the anatomy of the lymphatic system in the inguinal region is essential to preserving lymph drainage in the leg and avoiding iatrogenic lymphedema. METHODS: Five human cadaver hind-quarter specimens were used for this study. First, the specimens were scanned with indocyanine green fluorescence lymphography to map the lymphatic vessels. A dual injection technique using different radiocontrast media was then applied to delineate arteries and lymphatic vessels on radiographs. Finally, radiological analysis and meticulous dissection were used to investigate relationships between the arteries and lymphatic vessels. RESULTS: By chasing the lymphatic vessels retrogradely from their corresponding lymph nodes, we were able to divide the superficial inguinal lymph nodes into three subgroups: the abdominal, medial thigh, and lateral thigh nodes. We found no connections between the superficial and deep lymphatic system in the inguinal region. The dominant lymph nodes draining the leg were in the lower part of the inguinal triangle, and their efferent lymphatic vessels ran medial to the common femoral artery. CONCLUSIONS: Preserving the sentinel nodes of the lower leg in the medial thigh and their efferent lymphatic vessels is crucial to avoid iatrogenic lymphedema in limbs with donor sites for VLNT.

The distribution of lymph nodes and their nutrient vessels in the groin region: an anatomic study for design of the lymph node flap.

BACKGROUND: The groin lymph node flap transfer has been used for treatment of extremity lymphedema. The design of this flap is based on the superficial circumflex iliac artery/vein (SCIA/V), or superficial inferior epigastric artery/vein (SIEA/V). The purpose of this study is to delineate the distribution of lymph nodes in the groin area and their relationship to inguinal vessels by the use of multidirector-row CT angiography (MDCTA). METHODS: MDCTA was performed in 52 patients who underwent the deep inferior epigastric perforator (DIEP) flap or transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction. The MDCTA data were used to analyze the locations of lymph nodes and their adjacent vascular vessels. The groin region was divided into the superior lateral (I), superior medial (II), inferior lateral (III), and inferior medial (IV) quadrants based on the point where SCIV joined into great saphenous vein. The number of lymph nodes in each of the four quadrants was counted and the dominant vessels were observed. RESULTS: The mean number of lymph nodes in quadrants I-IV were 3.3 ± 1.6, 2.0 ± 1.2, 1.5 ± 1.3, and 1.9 ± 1.4, respectively. The difference between the four quadrants was statistically significant (P < 0.001). In quadrant I, the appearance rate of SCIA was 100% while SIEA was 6.6%. In quadrant II, no SCIA was observed but the appearance rate of SIEA was 78.0%. There were neither SCIA nor SIEA observed in quadrants III and IV. CONCLUSIONS: The superior lateral quadrant of the groin region was found to have the most lymph nodes. The superficial circumflex iliac vessels are the major sources for blood supply to this region. The findings from this study provide evidence for the clinical design of the lymph node flap from the groin area.