A Retrospective Review of Surgical Interventions for Sports Hernias

Thursday, September 21, 2023

3:30 PM – 3:40 PM CT

Location: Chicago Ballroom D-H, 5th Floor

Member Speaker(s)

EG

Evan G. Guay, DO, PhD

Resident
McLaren Greater Lansing/Michigan State University

Disclosure(s): No financial relationships to disclose

Slides
RF

Ryan T. Fahy, DO

General Surgeon
McLaren Bay Region

Disclosure(s): No financial relationships to disclose

Disclosure(s):

Evan G. Guay, DO, PhD: No financial relationships to disclose

Ryan T. Fahy, DO: No financial relationships to disclose

Learning Objectives:

Upon completion, participant will be able to describe the presentation and workup for sports hernias.
Upon completion, participant will be able to guide patients through understanding etiologies and ambiguities of groin pain and sports hernias.
Upon completion, participant will be able to discuss treatment options for sports hernias.
Upon completion, participant will be able to discuss further directions in the field of sports hernia research.

Introduction/Purpose: Sports hernias, also known as “athletic pubalgia” or “core muscle injury”, are entities of unclear clinical significance: commonly regarded as not true hernias, but rather laxity or tear(s) of tendon at or near the pubic bone. Along with disagreements in terminology and diagnostic criteria, debate lingers regarding whether or how to approach “repairing” this ailment. Laparoscopic mesh repair of an otherwise non-healing core muscle injury has shown clinical promise, as measured by improved pain and quicker return to activity. The theory behind the success of mesh repair is that these core muscle injuries may represent occult hernias or pelvic floor laxity that p</span>erpetuate local inflammation, thereby generating a pain signal. Surgical intervention for these ailments often consists of placing a mesh over the myopectineal orifice, thereby buttressing a weak pelvic floor and repairing any occult hernia. Despite the apparent success of surgical interventions, questions remain about the epidemiology, pathophysiology, diagnosis and operative techniques surrounding these ailments. This retrospective case series seeks to better characterize this ailment and lay the groundwork for a future, prospective study.

Methods or Case Description: This is a retrospective case series of patients taken to surgery for a diagnosis of “sports hernia.” Chart review was carried out for a single surgeon at a single institution from 2018 to 2021. Both male and female p</span>atients age greater than or equal to 18-years-old were included in the study. 99 patients were identified, and information was collected regarding age, pre-op diagnosis, pre-op imaging and physical exam, intra-operative findings including location and laterality of any hernia(s), and patient activity level. Exclusion Criteria included age < 18, hernia repairs performed for any reason other than suspected sports hernia, age less than 18, insufficiently documented operative findings, and case performed at any other hospital. Data were then compiled and analyzed. This project was evaluated by McLaren Greater Lansing IRB and Scholarly Activity Review Board.

Outcomes: 99 patients were identified to have undergone surgery for a sports hernia during the window of data collection. Of the 99 patients, 7 patients were excluded due to inguinal hernias identified on pre-op physical exam; 8 were excluded because they were under 18-years-old; and 5 were excluded because of unclear post-op diagnoses. This left 79 patients in the study. 22 patients did not undergo pre-operative imaging; all other patients had MRI pelvis +/- ultrasound +/- CT scan, with MRI being the most common imaging modality (n=51). The most common MRI finding was “athletic pubalgia,” with roughly equal occurrence on the left (n=20) as right side (n=19). Intra-operative findings led to diagnoses of true hernias in 74 of the 79 patients, with direct inguinal hernia being the most common (n=51), followed by indirect inguinal hernia (n=17) and femoral hernia (n=1), with some patients have multiple defects found during the operation (n=16). Consistent with literature, intra-operative findings showed more right-sided hernias (n=26) than left-sided hernias (n=16), with 17 patients having bilateral hernias, and 5 pantaloon defects discovered. There was a high rate of concordance between the laterality of intraoperative pathology findings and the laterality of MRI pathology findings (n=39), compared to discordance between operative and MRI findings (n=7).

Conclusion: This review suggests that “sports hernias” are predominantly occult, true, direct hernias. The most common preoperative finding, which justified taking a patient to the OR was athletic pubalgia found on MRI. Direct-space inguinal hernias were the most common pathology. Interestingly, the laterality of the MRI findings (mostly “athletic pubalgia”) and operative findings typically aligned. These findings highlight how traditional methods of hernia detection (physical exam, CT scan) are ineffective at identifying a substantial type of inguinal hernias. Furthermore, these findings suggest that athletic pubalgia and direct hernias may share a common pathophysiology that presents differently in highly active versus more sedentary populations. Further research is needed to better characterize these types of hernias, as well as to provide longer-term follow-up data on this under-recognized pathology.