Osseous avulsion of adductor longus presenting as incarcerated inguinal hernia

Abstract

An acute rupture of adductor longus tendon is a rare injury[1]. In most cases, distal insertion of the tendon is involved[2]. The rupture of proximal attachment of the tendon iseven rarer [3].There has been only handful of cases reportedin the literature [4, 5]. Treatment of this ranges from non-operative to complete excision of the muscle [1]. A typicalmechanism of injury is eccentric overload when forcedabduction of the leg occurs during contraction of the adduc-tor muscle group.We describe a case report where an acute onset ofgroin swelling presenting as an incarcerated inguinalhernia was surgically explored by the general surgeons.During the operation, an avulsion of the adductor lon-gus muscle was diagnosed and an immediate repair wasperformed by the orthopaedic surgeons. Informed con-sent was obtained from the patient for the publication ofthis case report.Case reportA 33-year-old male with groin swelling and pain around thegroin presented to general surgeons. This was acute in onsetand was sustained while playing football. The time to pre-sentation from the time of injury was 48 h. There were nogastrointestinal symptoms on presentation. On examination,there was a tender lump around the groin. The lump wasbelow the pubic tubercle. There was no visible bruising. Thelump was irreducible, non-pulsatile and there was no coughimpulse. The surgical team suspected an incarcerated ingui-nal hernia. An ultrasound scan was performed which wasinconclusive for hernia.A surgical exploration of his groin was performed by thegeneral surgeons. At operation, a 3×3-cm mass was found4 cm inferior to the pubic tubercle. Superior to the mass, acavity extended up to the pubis which could easily bepalpated. An avulsion of the attachment of adductor longustendon from the pubis was suspected. They asked for thehelp from orthopaedic team.The bikini line incision in the groin was extended forbetter exposure. Osseous avulsion of adductor longus wasconfirmed. The edge of the tendon was debrided back to ahealthy margin. Soft tissues were elevated form the sym-physis. The periosteum was elevated and a small burr usedto create a bleeding cancellous surface. Two 3.5 bioabsorb-able suture anchors were inserted into the pubis. The sutureswere then passed through the tendon edge and secured (seeFig. 1). The leg was abducted postoperatively to check therepair. Washout of the wound was done and wound wasclosed with interrupted non-absorbable ethilon.Postoperatively, partial weight bearing was allowed for2 weeks followed by weight bearing as tolerated. No abduc-tion beyond neutral was advised for initial 3 weeks followedby strengthening exercises at 6 weeks. He returned to fullactivity with no pain after 3 months.DiscussionThe adductor longus muscle arises from the superior pubicramus and inserts onto the middle part of the linea aspera.The muscle is narrow proximally and expands for a broadinsertion on the femur. The adductor longus is innervated bythe obturator nerve and is involved in the adduction of thehip. Acute tears of the proximal attachment are very rare,and best treatment for these is still debatable. Managementoptions include conservative, surgical excision of the entiremuscle and repair. The recent trend is towards surgical