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. Purpose. We describe the surgical management of twelve athletes with this severe injury. Study design. Prospective case series - Level of evidence, 4. Methods. All the injuries were prospectively collected onto our institutional pelvic sports injury database. This series summarises the outcome in twelve consecutive cases where surgery was undertaken after presentation with an acute avulsion (6–34 days) in athletes. The procedure comprised anatomical reattachment of the avulsed tissues with mesh reinforcement of the inguinal wall in seven patients. An independent physiotherapist reviewed all patients. Results. One patient developed a superficial wound infection treated with antibiotics. Transient complaints of local numbness were common but all twelve sportsmen returned to high-level sport (five elite) at an average of thirteen weeks (10–21 weeks). Conclusion. Awareness of the possibility of this complex injury is important and there should be a low threshold for investigation. In elite athletes operative intervention is associated with good clinical outcomes and successful return to sport

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. Patients/Materials & Methods. Fifteen high level athletes with an MRI confirmed acute adductor complex avulsion injury (6–34 days) were identified from the institution's sports injury database over a 10 year period. All underwent surgical repair. The operative procedure comprised anatomical attachment of the avulsed tissues in all cases (plus mesh reinforcement of the inguinal wall in 7 patients). All underwent a standard format of rehabilitation which was then individualised to be sport specific. Results. One patient developed a superficial wound infection which was successfully treated with antibiotics. 12 out of 15 patients complained of transient local numbness which resolved in all cases. All patients (including 7 elite athletes) returned to their previous level of participation in sport. Discussion. Injury to the triad of adductor longus, pectineus and rectus abdominus should be considered in athletes presenting with groin pain following forced adduction. All athletes underwent early surgical exploration, previous studies have shown prolonged symptoms in early conservative management. Adductor tenotomy has shown previously acceptable results but may be less suitable in elite athletes with higher functional demands when operative repair has been shown to be successful. Conclusion. Operative repair of acute sleeve avulsion of the adductor complex in high level athletes, followed by sport specific rehabilitation promotes return to previous level of participation in sport

The aim of the study is to investigate the biomechanical effects on the pelvis of the anterolateral and posterolateral approaches at the time of hip arthroplasty. In particular the study investigates the change in stress distribution, and the change in muscle recruitment pattern following surgery. The study uses an advanced finite element model of the pelvis, in which the role of muscles and ligaments in determining the stress distribution in the pelvis is included. The model is altered for the posterolateral approach by excision of the external rotators. Different levels of gluteal damage for the anterolateral approach are modelled by excising in turn the anterior third, half, and two-thirds of the gluteus medius and minimus. Although attempt is generally made to repair gluteal damage at the time of surgery, it is clear the muscle volume will be compromised immediately after surgery. In support of previous clinical studies indicating an increased risk of limp, and pelvic tilt following the anterolateral approach, significant differences were found in the muscle recruitment pattern following the anterolateral, compared to the posterolateral approach. During single leg stance and walking force transfer to the iliacus and pectineus was observed. Required levels of muscle force, to maintain coronal balance, following the anterolateral approach were found to be close to maximum sustainable levels. In addition significant alteration to the pelvic stress distribution was found following the anterolateral approach. The effects of increasing gluteal damage for the anterolateral approach were progressive, and became more pronounced when more than fifty percent of the gluteus medius and minimus were damaged. Increases in stresses around the acetabulum were observed for the posterolateral, compared to the anterolateral approach. Thus, based on a biomechanical evaluation, the anterolateral approach presents increased risk of limp, and pelvic tilt, in comparison to the posterolateral approach

Purpose of the study: Transadductor approaches to the hip joint have been described in the spastic child. Ludl-off as well as Ferguson pass behind the short adductor and the pectineus, a narrow route with a risk of injuring the obturator nerve. We describe a simple minimally invasive approach. Material and method: The incision is made with the hip in the flexion, external rotation, abduction, from the pubic insertion of the long adductor following along the mass of the muscle for 6 to 8 cm. The aponeurosis of the long adductor is cut just deep enough to see the muscle fibres. Careful finger dissection of the muscle sheath common to the three anterior adductor muscles leads directly to the lesser trochanter. Two forceps are inserted on either side of the lesser trochanter, exposing the lesser trochanter and the tendon of the iliopsoas muscle. Dissection of the iliopsoas muscle held aside (follow the tendon on its lateral aspect leading to the vessels). An angled spreader is positioned between the anterior aspect of the capsule and the medial border of the tendon, displacing the tendon laterally and exposing the capsule. Extra-articular exposure of the capsule with a rugine to displace the posterior medial circumflex pedicle. Longitudinal incision of the capsule continued along the inter-trochanteric line to the peri-acetabular region. The medial as well as the anterior aspect of the neck can be visualized by rotating the hip. The inferior and anterior portion of the head is visible: the iliopubic branch and the entire superior and medial wall of the acetabulum can be exposed. Results: We performed 29 medial approaches. Nine for periprostheic pain, four for fresh fracture of the femoral head during posterior dislocation, four for old fractures of the femoral head during posterior dislocation, three for chondromatosis, three for tumours of the femoral head or the acetabulum, six for retractile periarthritis without arthroplasty. Hip arthroplasty (7) or not (6), median pain could be induced by the presence of retractile periarthritis with presence of synovial adherences to the femoral neck penetrating into the joint space; release relieved pain in 11/13. Conclusion: The medial approach to the hip joint is a useful orthopaedic technique with a rapid learning curve