Surgical Technique

Patients were placed supine on the operating table, and their hair was clipped before the area was prepped and draped in a typical fashion. Bony landmarks were palpated and marked. The patient’s legs were placed in the frog-leg position. A 4-cm horizontal incision was made on the injured side along the superior pubic ramus in the upper one-third of the bone. This was then carried down with scissor dissection spreading in the cephalad-to-caudad direction to protect superficial neural structures. In male patients, the spermatic cord was palpated and retracted medially for protection. The common aponeurosis of the adductor longus and rectus abdominis was identified (Figure 4). Needle-tip electrocautery was used to perform fractional lengthening and incomplete adductor longus tenotomy anteriorly (from medial to lateral) approximately 1 cm off the pubic origin, leaving a 1-cm flap of the adductor tendon at the pelvic attachment (Figure 5). This tendon flap was then folded back and turned up onto the rectus aponeurosis, and 3 nonabsorbable figure-of-8 sutures were used to join the rectus, underlying periosteum, and adductor flap (Figure 6). Early in the series, a deep drain was placed and removed at the physical therapy recheck on the first postoperative day. During the series, the change was made to placing thrombin-soaked Gelfoam (Pfizer) in the fractionated adductor site in lieu of a deep drain (Figure 7). After irrigation, the wound was closed with buried 3-0 Monocryl (Ethicon) and running 3-0 Monocryl, and island dressings were placed.

The deep investing fascial layer is exposed. A surgical marking pen has been used to outline the lateral border of the rectus abdominis and adductor longus at their common attachment points of the pubis.

Needle-tip electrocautery is utilized to perform limited adductor longus tenotomy and generate a soft tissue sleeve to turn up, repair, and reinforce the rectus abdominis to the pubis.

Nonabsorbable suture is used for repair.

Gelfoam is used for hemostasis and a void filler to facilitate reconstitution of the fractionated adductor longus tendon.

Physical therapy began on postoperative day 1. Phase 1, consisting of weeks 1 and 2, was focused on decreasing pain and inflammation by stretching, walking, and cryotherapy. Recruitment of the transversus abdominis with controlled isometrics was initiated. Week 2 comprised more active hip and core exercises including hip strengthening, mini-squats, lunges, pelvic tilts, and continued stretching. Phase 2, consisting of weeks 3 and 4, began when the patient had minimal pain, improved hip and spine range of motion, an ability to achieve a neutral spine, and recruitment of the transversus abdominis. Core activity was significantly increased in weeks 3 and 4. The single-leg stance and perturbations improved hip and core strength. More aggressive stretching was permitted, and jogging was initiated. Phase 3, the advanced exercise phase, was centered around returning to light sport activity and the ability to initiate the single-leg stance with good stabilization of the spine and pelvis. Core and hip strengthening was increased, plyometric training was initiated, and light sport activity was started but without cutting or lateral movements. Cutting, agility, pivoting, and speed training began around week 6. Return to play was allowed once certain criteria were met: full range of motion without pain, equal hip strength, sport-specific drills without pain, and satisfactory physical examination findings by the physician.