Long-standing groin pain in contact sports: a prospective case-control and MRI study.

OBJECTIVES: We aimed to prospectively evaluate the prevalence of long-standing groin pain and related MRI findings in contact sports. METHODS: This case-control study followed three male elite-level soccer, ice-hockey and bandy teams (102 players) for 2 years. All athletes with long-standing groin pain lasting >30 days and age-matched controls (1:3) from the same teams were examined clinically, using pelvic MRI and Hip and Groin Outcome Scores (HAGOS). Primary outcome measures were annual prevalence of groin pain and underlying MRI findings. RESULTS: The annual prevalence of chronic groin pain was 7.5%. Training characteristics and pain scores of athletes were similar in all teams. On MRI, there was no significant difference in the percentage of pubic bone marrow oedema (p = 0.80) between symptomatic players (8/15; 53%) versus controls (20/43; 47%), but adductor tendinopathy and degenerative changes at the pubic symphysis were twice more common among players with pain. Rectus muscle or iliopsoas pathology were seldom observed. Lower HAGOS subscales (p < 0.01) were recorded in players who experienced groin pain compared with the controls. CONCLUSION: Long-standing groin pain was observed annually in 1 of 14 athletes in contact sports. Abnormalities in the pubic symphysis were common MRI findings in both symptomatic and asymptomatic players. TRIAL REGISTRATION NUMBER: NCT02560480.

Athletic Pubalgia in Females: Predictive Value of MRI in Outcomes of Endoscopic Surgery.

BACKGROUND: Athletic pubalgia is typically associated with male athletes participating in contact sports and less frequently with females. Endoscopic surgery may fully treat the patient with athletic pubalgia. PURPOSE: To perform an outcomes analysis of magnetic resonance imaging (MRI) and endoscopic surgery in female patients with athletic pubalgia. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Fifteen physically active female patients (mean age, 37 years) with athletic pubalgia were treated surgically via placement of total extraperitoneal endoscopic polypropylene mesh behind the injured groin area. The presence of preoperative bone marrow edema (BME) at the pubic symphysis seen on MRI was graded from 0 to 3 and correlated with pain scores after surgery. The outcome measures were pre- and postoperative pain scores and recovery to daily activity between 1 and 12 months after surgery. Results were compared with previously published scores from male athletes (n = 30). RESULTS: With the exception of lower body mass index, the females with (n = 8) and without (n = 7) pubic BME had similar patient characteristics to the corresponding males. Mean inguinal pain scores (0-10) before surgical treatment were greater in females than males (during exercise, 7.8 ± 1.1 vs 6.9 ± 1.1; P = .0131). One month after surgery, mean pain scores for females were still greater compared with males (2.9 ± 1.7 vs 1.3 ± 1.6; P = .0034). Compared with female athletes with normal MRI, pubic BME was related to increased mean preoperative pain scores (8.13 ± 0.99 vs 6.43 ± 1.2; P = .0122). After 1 year, surgical outcomes were excellent or good in 47% of women. CONCLUSION: Endoscopic surgery was helpful in half of the females with athletic pubalgia in this study. The presence of pubic BME may predict slightly prolonged recovery from surgery.

Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia).

BACKGROUND: Chronic groin pain in athletes presents often a diagnostic and therapeutic challenge. Sportsman's hernia (also called "athletic pubalgia") is a deficiency of the posterior wall of the inguinal canal, which is often repaired by laparoscopic mesh placement. Endoscopic mesh repair may offer a faster recovery for athletes with sportsman's hernia than nonoperative therapy. METHODS: A randomized, prospective study was conducted on 60 patients with a diagnosis of chronic groin pain and suspected sportsman's hernia. Clinical data and MRI were collected on all patients. After 3 to 6 months of groin symptoms, the patients were randomized into an operative or a physiotherapy group (n = 30 patients in each group). Operation was performed using a totally extraperitoneal repair in which mesh was placed behind the symphysis and painful groin area. Conservative treatment included at least 2 months of active physiotherapy, including corticosteroid injections and oral anti-inflammatory analgesics. The outcome measures were pre- and postoperative pain using a visual analogue scale and partial or full recovery to sports activity at 1, 3, 6, and 12 months after randomization. RESULTS: The athletes in both treatment groups had similar characteristics and pain scores. Operative repair was more effective than nonoperative treatment to decrease chronic groin pain after 1 month and up to 12 months of follow-up (P < .001). Of the 30 athletes who underwent operation, 27 (90%) returned to sports activities after 3 months of convalescence compared to 8 (27%) of the 30 athletes in the nonoperative group (P < .0001). Of the 30 athletes in the conservatively treated group, 7 (23 %) underwent operation later because of persistent groin pain. CONCLUSION: This randomized controlled study indicated that the endoscopic placement of retropubic mesh was more efficient than conservative therapy for the treatment of sportsman's hernia (athletic pubalgia).

Effect of heavy training in contact sports on MRI findings in the pubic region of asymptomatic competitive athletes compared with non-athlete controls.

OBJECTIVE: Bone marrow edema (BME) at the pubic symphysis on magnetic resonance imaging (MRI) is usually associated with groin pain and stress injury of the pubic bone. Little is known of the pubic MR imaging findings of asymptomatic heavy training athletes in contact sports. MATERIALS AND METHODS: Pelvic MRI of male asymptomatic soccer (n=10), ice hockey (n=10), bandy (n=10) and female floor-ball players (n=10) were compared with non-athlete controls (10 males, 10 females) without groin pain to analyse the presence of BME (on a four-point scale). To study the possible changes of BME directly following heavy physical activity, 10 bandy players underwent MRI before and immediately after a 2-h training session. RESULTS: Magnetic resonance imaging showed minimal BME (grade 1) at the pubic symphysis in 19 of the 40 athletes (48%). Two soccer and 2 ice hockey players (20%) had moderate grade 2 pubic edema, but severe grade 3 BME findings were not found. Also 10 out of 20 (50%) of controls had grade 1 BME. The extent of increased signal was equally distributed in the asymptomatic athletes of different contact sports and controls. A heavy 2-h training session did not cause any enhanced signal at the pubic symphysis. CONCLUSIONS: This study indicates that the presence of grade 1 pubic BME was a frequent finding in contact sports and comparable to that in non-athletes. Grade 2 BME was found only in asymptomatic athletes undergoing heavy training.

Does preoperative core needle biopsy increase surgical site infections in breast cancer surgery? Randomized study of antibiotic prophylaxis.

BACKGROUND: Preoperative core needle biopsies may increase the risk of surgical site infection (SSI) in breast cancer surgery. The purpose of this randomized trial was to determine whether a prophylactic antibiotic would prevent SSI under these conditions. METHODS: Imaging-guided multiple core needle biopsies were performed one to two weeks prior to surgery to obtain confirmation of the presence of breast cancer. Then the patients were randomized to receive either a single intravenous dose of 1.0 g of dicloxacillin (n = 144) or placebo infusion of saline (n = 148) 30 min prior to operation. After breast surgery, incisional morbidity was monitored for 30 days. The number of SSIs was compared with that in 672 patients treated before the implementation of core needle biopsies. RESULTS: The patient characteristics and risk factors for SSI were similar in the antibiotic prophylaxis and placebo groups. The incidence of SSI was 7.2% (21/292) in the prospective trial compared with 6.8% (46/672) in the retrospective cohort (p = 0.890). The incidence of postoperative SSIs was 5.6% (8/144) in the dicloxacillin group and 8.8% (13/148) in the placebo group (p = 0.371). For the first two weeks, there was a non-significant trend to fewer SSIs in the antibiotic group (n = 1) than the placebo group (n = 4). Body mass index, smoking, or previous illness did not affect the likelihood of SSI. CONCLUSIONS: Core needle biopsy did not increase the incidence of SSI. Antibiotic prophylaxis did not prevent SSI, probably because so few infections occurred.

Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training.

BACKGROUND: Osteitis pubis is characterized by diffuse pain, inflammation, and bony changes in the pubic symphysis. Bone marrow edema in magnetic resonance imaging is associated with stress injury and osteitis of the pubic bone. HYPOTHESIS: Laparoscopic mesh repair decreases inflammation and pain in the pubic periosteum. The presence of extensive bone marrow edema may correlate with the severity of symptoms and may guide the surgical treatment of osteitis pubis. STUDY DESIGN: Case control study; Level of evidence, 4. METHODS: Surgery (n = 8) was performed by placement of totally extraperitoneal endoscopic mesh behind the symphysis. Nonoperative treatment (n = 8) included physical therapy and corticosteroids. Preoperative and postoperative pain was measured by the visual analog scale. Athletes were followed up from 1 to 6 years (mean, 2.7 years). All magnetic resonance imaging scans were analyzed blindly by 2 radiologists. Twenty asymptomatic ice hockey or soccer players served as controls in magnetic resonance imaging. RESULTS: The patients treated surgically had higher preoperative pain scores than did the patients treated conservatively. Seven of 8 athletes (88%) treated surgically returned to sport activities after 2 months of convalescence. No complications were associated with surgery. In the nonoperative group, 4 patients (50%) still had disabling symptoms after 1 year of follow-up, and they stopped their elite sports during 3 years of follow-up. The presence of bone marrow edema was distributed in the surgical (100%), nonoperative (88%), and asymptomatic athletes (65%) with no statistical difference between the groups. CONCLUSION: This study indicated that the placement of retropubic mesh was an efficient method for the treatment of severe pubic enthesopathy in athletes. Abnormal magnetic resonance imaging findings were also common in asymptomatic athletes, which decreases the value of magnetic resonance imaging in surgical decision-making.

Disc degeneration in low back pain: a 17-year follow-up study using magnetic resonance imaging.

STUDY DESIGN: A prospective, cohort clinical and magnetic resonance imaging (MRI) study of patients with low back pain. OBJECTIVE: To study if lumbar disc degeneration (DD), diagnosed in young patients with low back pain by using MRI will predict chronic pain, disc herniation, or functional disability after a 17-year follow-up. SUMMARY OF BACKGROUND DATA: In 1987, 75 male Finnish conscripts aged 20 years, with low back pain hindering their military service, were studied using MRI at 0.02 T. METHODS: In 2003, 32 patients were reexamined with MRI at 1.0 T. The history of low back illness during the follow-up and current functional outcome were recorded. RESULTS: In 1987, 69% of the 32-patient cohort had DD in one or more lumbar discs. In 2003, all subjects had DD in MRI. The mean number of degenerated discs in each subject increased from 1.1 to 3.0. A total of 76% of discs degenerated in 1987 were herniated in 2003, whereas only 29% of well-hydrated discs in 1987 were herniated at the time of follow-up (P = 0.0002). During 17 years of follow-up, 3 patients had undergone spinal surgery. CONCLUSIONS: Early DD in adolescent patients with low back pain predicted the evolution of enhanced DD and herniation in adulthood, but it was not associated with severe low back pain or increased frequency of spinal surgery.

Long-term pain and recurrence after repair of ventral incisional hernias by open mesh: clinical and MRI study.

BACKGROUND AND AIMS: Polypropylene mesh repair of large incisional ventral hernias has become increasingly popular. Long-term effects of the mesh on pain and abdominal muscles are not known. PATIENTS/METHODS: Retromuscular pre-peritoneal polypropylene mesh was placed by open technique in 84 consecutive patients with large ventral hernias (mean defect size 130 cm(2)). We re-examined the patients after a mean follow-up time of 3 years to find out the frequency of recurrence and chronic pain. We measured the thickness of abdominal muscles of eight patients preoperatively, and postoperatively after 1 year, using magnetic resonance imaging (MRI). RESULTS: Recurrent hernias had appeared in four patients (5%) at follow-up. Nine patients (13%) needed occasional pain-relieving drugs, but only three (4%) suffered persistent, severe, pain from the mesh. Some limitation during leisure-time physical activities was found in 10% of patients. Only ten patients (12%) were re-operated on because of wound complications or recurrence. MRI study indicated that abdominal muscles were postoperatively well preserved. Although wound infections (6%) and seroma (9%) were frequent complications, there was no need for meshes to be removed in the follow-up. CONCLUSION: Open ventral herniorrhaphy with mesh is safe, effective and inexpensive. Small, recurrent hernias were infrequent and easy to re-operated on. Severe pain from the mesh was not common. Postoperative MRI study indicated no obvious damage of abdominal muscles after mesh placement.