Adductor Brevis Research Articles

Is Percutaneous Adductor Tenotomy as Effective and Safe as the Open Procedure?

Percutaneous adductor longus tenotomy (PAT) is a frequently used procedure, yet no study has ever compared its effectiveness and safety with those of open adductor longus tenotomy (OAT). We conducted this prospective study to describe the effects of PAT and to compare them with those of OAT. This consisted of a cross-over randomized controlled trial including 50 consecutive hips from 27 patients with cerebral palsy scheduled for adductor tenotomy in the setting of multilevel tendon lengthening/release procedures or hip surgery (femoral or Dega osteotomy) in a university hospital. A pediatric orthopaedic surgeon conducted a PAT. Another surgeon extended the wound to explore what had been cut during the PAT, and completed the tenotomy if necessary. Hip abduction (HA) was assessed by a third surgeon immediately before PAT, after PAT, and then after OAT, using a goniometer, in a standardized reproducible manner. All 3 surgeons were blinded to the others' findings. Primary end-points included the percentage of tendon/muscle portion sectioned percutaneously, and the HA measure. Comparison between HA after PAT and OAT was done using a paired t-test with a 95% confidence interval. The influence of anatomic variants of adductor longus origin was also assessed. Mean HA (hips flexed) measured 40.36 degrees preoperatively and increased to 50.04 degrees after PAT (P<0.0001). After OAT, HA averaged 53.32 degrees with no statistical gain compared with that observed after PAT (P=0.2). The tendinous portion of adductor longus was cut to an average of 98% by PAT (completely in 46 cases and more than 75% in only 4 cases). The muscular portion of adductor longus origin was cut to an average of 83.7% (completely in only 15 cases, cut to more than 75% in 26 cases, and approximately 50% in 9 cases). The gain in HA positively correlated with the extent of the tendinous portion divided (P=0.03) but not with the extent of muscular portion divided. Results were independent of the anatomic variants of adductor longus origin. Partial section of adductor brevis after PAT was encountered in 6 cases. No major iatrogenic lesion was observed (obturator nerve, major vessels). This is the only prospective study concerning the effects of PAT. The anatomic factor associated with gain in HA seems to be the extent of the section of the tendinous portion of adductor longus origin, which was found to be cut to more than 90% in all cases after PAT. The extent of muscular portion section does not seem to influence the gain in HA. The researchers detail the technique of percutaneous adductor tenotomy and show that when done correctly, PAT is a fast and simple procedure, as reliable and effective as the open release and without any major risks. Level II therapeutic study-prospective comparative study.

Botulinum Toxin as a Solution in Voluntary Hip Dislocation After Modular Unipolar Hemiarthroplasty

This article presents a case of an 82-year-old woman with Alzheimer's disease who was treated with a modular unipolar hemiarthroplasty for a right femoral neck fracture, which she voluntarily dislocated 3 times in the first postoperative week. The hip was stable in all directions, even in 60 degrees internal rotation, 0 degrees abduction, and 90 degrees flexion. The patient was mobilized 1 day postoperatively with full weight bearing. She dislocated her hip on postoperative day 3 while lying on her bed. After the dislocation, reduction under sedation was done again followed by a botulinum toxin injection of 50 IU to her adductor muscle group (including adductor longus, brevis, and magnus). The patient was mobilized after the injection and she had no difficulty walking. During the 6 months after the injection, no dislocation occurred again. Botulinum toxin decreases muscle activity by blocking the release of acetylcholine at the neuromuscular junction, thereby rendering the muscle unable to contract for up to 3 to 4 months. This method of botulinum injection can be applied to noncompliant patients with mental problems as an alternative conservative and surgical approaches.

Groin Pain in the Athlete: Non-Bony Pathology Including Sportsman’s Groin

Groin pain is a common complaint amongst sportsmen and women accounting for nearly 10% of all sports related injuries. This article focuses on non-bony causes of groin pain in sportsmen, particularly upon the condition commonly known as 'sportsman's hernia' or 'sportsman's groin'. It also highlights a new concept for the cause of groin pain in that the authors consider that many elite athletes with groin pain have pain arising from their inguinal ligament attachment. A new procedure known as the Lloyd Release Procedure has been specifically developed to treat this cause of groin pain. By performing a laparoscopic release of the inguinal ligament and reinforcing the groin with a mesh also placed laparoscopically, nearly all athletes are rendered pain free and most players can resume their activities within weeks. In a prospective study on over 140 elite athletes undergoing the Lloyd Release Procedure more than 90% of sportsmen returned to their normal sporting activities within four weeks of surgery. Groin pain is a common complaint amongst sportsmen and women, particularly those participating in sports involving kicking, rapid accelerations and deceleration, and sudden change of direction (1). It has been estimated that groin injuries account for between 0.5-6.2% of sports-related injuries, with the prevalence in sports such as football as high as 5-15% (2,3). Chronic groin pain can be difficult to diagnose, treat, and rehabilitate and is therefore responsible for a large proportion of time lost from sport and work in such athletes. This article focuses on non-bony causes of groin pain in athletes, particularly upon the condition commonly known as 'sportsman's hernia' or 'sportsman's groin'. The 'groin' comprises quite a large anatomical field from the lower abdomen and its muscles to the adductor muscle group insertion thereby encompassing the lower rectus abdominis muscle, the conjoined tendon, the superficial and deep inguinal rings, the tranvsversalis fascia, the inguinal and pectineal (Cooper's) ligaments, the pectineus muscle and fascia, adductor longus and brevis and even gracilis. Although many athletes are diagnosed with a so-called 'sportsman's hernia', careful clinical examination is important in these patients as most do not have a surgical 'lump' or hernia and they are more likely to have pain and tenderness of the ligamental attachments or tendinous insertions, particularly of the inguinal ligament, pectineal ligament and adductor tendon insertions. It must be remembered that all the insertions onto the pubic bone 'join together' and form an aponeurosis on the anterior aspect of the pubic bone (Fig. 1).

Ultrasound-Guided Obturator Nerve Block

For knee surgery, obturator nerve block (ONB) has been shown to enhance postoperative analgesia provided by femoral block. Current techniques for obturator block use surface landmarks or ultrasound guidance (USG) with nerve stimulation. This preliminary observational study evaluated the success of an ultrasound-guided ONB without the additional use of nerve stimulation. Thirty patients scheduled for knee surgery under general anesthesia with nerve block for postoperative analgesia had ONB performed using USG and injection of 10 mL 0.5% ropivacaine with epinephrine. Half of the ropivacaine was injected between the pectineus and adductor brevis muscles, and half between the adductor brevis and adductor magnus muscles. The strength of thigh adduction was measured at 5, 10, and 15 mins after injection, and 50% strength reduction at 15 mins indicated a successful block. All patients showed reduction of strength, and 28 of 30 or 93% met the criteria for successful block with mean strength reduction of 82.2% (SD, 21.6%) at 15 mins. Blocks were completed in 122 secs (SD, 33 secs). Obturator nerve block using USG to achieve interfascial injection without nerve stimulation had success similar to that reported in studies using nerve stimulation.

Anatomic Localization of Motor Points of Hip Adductors

To identify the precise location of the motor points of hip adductors in relation to bony landmarks. Nineteen limbs from ten adult cadavers were anatomically dissected. The motor point of each adductor muscle was determined by measuring its distance from the pubic tubercle with reference to a line joining the pubic tubercle and the medial epicondyle of the femur, and this distance was expressed as a percentage. For describing the mediolateral relationship between the motor point of each adductor and bony landmarks, its distance from the pubic tubercle was measured with reference to a line joining the pubic tubercle and the greater trochanter of the femur, and the result was expressed as a percentage. The percent distances along the longitudinal reference line distal to the pubic tubercle were as follows: adductor longus, 26.0% +/- 4.8%; adductor brevis, 21.0% +/- 4.8%; gracilis, 32.1% +/- 2.1%; and adductor magnus, 30.4% +/- 4.1%. Further, the percent distances along the horizontal reference line lateral to the pubic tubercle were as follows: adductor longus, 24.9% +/- 7.8%; adductor brevis, 24.9% +/- 7.4%; and adductor magnus, 33.6% +/- 5.9%. Identification of these motor points facilitates the efficacy and efficiency of a neural blockade and decreases undesirable complications.

Perineal approach to vascular anatomy during transobturator cystocele repair

To evaluate the risk of vascular injury during transobturator approach of cystocele repair. Dissection of the obturator area by perineal approach was performed after placement of mesh needles used for cystocele mesh repair. Surgery school of Paris. Twenty obturator regions in ten fresh female cadavers. Transperineal dissection of the obturator area was conducted in ten fresh female anatomic subjects after inserting anterior Prolift needles. The vascular anatomy of the obturator region was mapped. Distances between needles and vascular structures of the obturator area were measured three times and averaged for each side. The anterior cannula-equipped needle perforated the gracilis and the adductor brevis muscles. The mean (SD) distance to the anterior obturator vessels was 21.2 (1.6) mm on the right side and 20.4 (1.5) mm on the left. The posterior needle perforated the adductor magnus. Its distance to the posterior division of the obturator vessels was 1.8 (1.0) mm on the right side and 1.1 (0.9) mm on the left. During mesh cystocele repair by transobturator approach, the posterior obturator vessels division seems at risk of injury during the posterior needle insertion.

Open reduction by means of a medial approach: an alternative for congenital hip dislocation

Introduction Open reduction by means of a medial approach (adductors) is used in non-ambulating patients under 13 months, diagnosed with hip dislocation and managed with early closed reduction in unstable non concentric hips. Material and method The present retrospective study includes a series of cases that illustrate the authors’ experience. The results of 548 hips (367 patients) operated over a period of 12 years (1995-2007) are reported. Results Complications occurred in 62 hips. The most frequent were epiphysitis (2.9%), partial or total necrosis of the femoral head (6.3%) and redislocation (2%). Conclusions We describe a modification to the surgical technique originally reported by Ludloff, whereby the adductor brevis is not split; instead, the latter is detached and the pectineus muscle is pushed distally. In this way, the surgeon has a good view of the circumflex vessels, which protects them from injury. Also, the tension generated between the pectineus and the psoas by the abduction maneuvers is relaxed.

Reducción abierta por vía interna: una opción para la luxación congénita de cadera

Introduction Open reduction by means of a medial approach (adductors) is used in non-ambulating patients under 13 months, diagnosed with hip dislocation and manager with early closed reduction in unstable non concentric hips. Material and method The present retrospective study includes a series of cases that illustrate the authors’ experience. The results of 548 hips (367 patients) operated over a period of 12 years (1995–2007) are reported. Results Complications occurred in 62 hips. The most frequent were epiphysitis (2.9%), partial or total necrosis of the femoral head (6.3%) and redislocation (2%). Conclusions We describe a modification to the surgical technique originally reported by Ludloff, whereby the adductor brevis is not split; instead, the latter is detached and the pectineus muscle is pushed distally. In this way, the surgeon has a good view of the circumflex vessels, which protects them from injury. Also, the tension generated between the pectineus and the psoas by the abduction maneuvers is relaxed.

Anatomic Variations of the Obturator Nerve in the Inguinal Region

This study was conducted to provide a thorough description of the variability in the obturator nerve branching pattern in the inguinal region. The anatomic variability of obturator nerve branching among 84 dissected embalmed cadavers was investigated. Ultrasound examination of the inguinal region was undertaken in 20 cases and the location of the obturator nerve was identified. The point of division for the obturator nerve into the anterior and posterior branches was intrapelvic (23.22%), within the obturator canal (51.78%), or in the thigh (25%). Most commonly, the anterior branch was divided among 3 major muscular branches (66.66%) that innervated the adductor longus, adductor brevis, and gracilis muscles. Four, and 2 subdivisions of the anterior branches were observed, in 4.76% and 28.57% of cases, respectively. The posterior branch predominantly separated into 2 divisions (60.11%), which provided innervation to the adductor brevis and adductor magnus muscles. In addition, either 1 (13.69%), 3 (19.04%), or 4 (7.14%) muscular divisions of the posterior branch were observed. The articular branch of the obturator nerve showed 9 different branching patterns, which most frequently arose from the common obturator nerve. The fascias medial to the femoral vessels and deep to the pectineus muscle were clearly visualized (100%) by ultrasound imaging. This region was used as an "imaging" landmark for localization (success rate of 80%) of the common obturator nerve. High anatomic variability in the obturator nerve's divisions and subdivisions does exist, and explains the difficulty frequently encountered in the application of regional anesthetic techniques.

Anatomy of the motor nerve to the gracilis muscle and its implications in a one-stage microneurovascular gracilis transfer for facial reanimation

The present study was conducted to investigate the anatomy of the motor nerve to the gracilis muscle (MNG) to provide the anatomical basis for harvesting a one-stage gracilis transfer with a long nerve for re-animation of the paralysed face. An anatomical study was performed on 24 lower-limb specimens (from the pelvis down to the knee) from 12 embalmed cadavers. The MNG was dissected from the surface of the muscle to the obturator foramen. Two anatomical regions were defined in the course of the nerve. The first region includes the part of the nerve that can easily be reached through a standard incision in the medial aspect of the thigh, that is, from the surface of the muscle to the posterior border of the adductor brevis muscle and the second region from there to the obturator foramen. Measurements of both anatomical regions and the maximum length of the nerve were taken with a calliper. The anatomical relations of the nerve were also noted and photo-documented. The median maximum length of the MNG from the surface of gracilis to the posterior border of adductor brevis ('first anatomical region') was 7.7 cm (Range 6.3-10.5 cm); from there to the obturator foramen ('second anatomical region') the length was 3.7 cm (Range 2-6 cm), giving a median length of dissection of the nerve as 11.5 cm (Range 9.9-13.6 cm). Intraneural dissection of the MNG has to be performed proximally in the course of the nerve (the part corresponding to the second anatomical region), just where it runs inside the fascia over the obturator externus muscle. Over 10-cm length of the MNG can be obtained when dissected along the course of the nerve up to the obturator foramen. To achieve the maximum length, intraneural dissection must normally be performed after the nerve passes the posterior border of the adductor brevis. An endoscopic approach or extended proximal incision is recommended to easily reach the proximal part of the nerve as far as the obturator foramen.

Chronic Groin Pain Presenting As Osteitis Pubis

HISTORY: 23-year-old college football receiver who felt a pop in his right groin followed by pain during drills 18 months ago. Initially diagnosed with adductor strain and referred to P.T. Continued pain with drills and running. Rest, NSAIDs, P.T., prednisone, and 3 pubic symphysis steroid injections provided no long term relief. Experienced complete but temporary relief with symphysis injections. Since feeling pop 6 weeks ago now notes left groin pain. Pain worse with lateral movements. History of right inguinal hernia repair 8 y/a. Previous interventions: Pelvis MRI 2/06: Signal abnormality at right inferior rami Pelvis MRI 6/06: Secondary cleft sign at symphysis Symphysis pubis injection 2/07: Secondary cleft at insertion of right adductor longus Bone scan 4/07: Negative Pelvis MRI 5/07: Increased signal at insertion of left adductor Pelvic US 6/07: Negative for hernia bilaterally Symphysis injection 6/07: Same result Symphysis injection 7/07: Bilateral secondary cleft sign Left hip arthrogram 8/07: Normal hip. Cystic changes within symphysis. Bilateral cleft sign, partial tears of adductor brevis and obturator externus muscles bilaterally. Partial tear of adductor longus muscle. PHYSICAL EXAMINATION: FROM of lower back without pain. FROM of hips with mild pain on left hip internal rotation. Mild tenderness over left adductor tendon and pain with resisted adduction. No tenderness over pubic body or symphysis. Tender over inferior lateral rectus abdominis (L>R). Pain with valsalva. Negative straight leg raise and Patrick's sign. No inguinal hernia. 5/5 strength lower extremities. DIFFERENTIAL DIAGNOSIS: Adductor strain Distal rectus abdominus strain Inguinal hernia Osteitis pubis Sports hernia TEST AND RESULTS: Pelvis Radiograph 8/07: cystic changes within symphysis. Reevaluation of MRI suspicious for sports hernia FINAL WORKING DIAGNOSIS: Sports hernia with concurrent osteitis pubis TREATMENT AND OUTCOMES: Referred for surgical consideration. Underwent bilateral pelvic floor repair and adductor releases. Patient running pain free and pleased with results. We feel this case represents delay in diagnosis of a sports hernia due to concurrent osteitis pubis and improvement with therapeutic interventions (e.g. symphysis pubis injection) that are not necessarily specific to a single diagnosis.

Cadaveric and MRI Study of the Musculotendinous Contributions to the Capsule of the Symphysis Pubis

The purpose of this article is to define the relations of the symphysis pubis and capsular tissues to the adductor and rectus abdominis soft-tissue attachments on cadaver dissection and correlate with MRI of the anterior pelvis. Seventeen cadavers (8 males and 9 females; mean age, 80 years) were dissected bilaterally. Rectus abdominis and adductor muscles were traced to the pubis and further attachments to the pubic symphysis were defined. Ten asymptomatic (mean age, 17; age range, 16.5-29 years) male athletes underwent 1.5-T MRI of the anterior pelvis with two surface microcoils (each 42 mm in diameter). An axial T2-weighted turbo spin-echo (TSE) sequence (TR/TE, 2,609/106; voxel size, 0.4 mm) was obtained. Axial and sagittal 3D T1-weighted fast-field echo (FFE) sequences (25/4.9; voxel size, 0.3 mm) were obtained. Sequences were repeated incorporating fat suppression and i.v. gadolinium. The relation of the symphysis pubis, disk, and capsular tissues to the insertions of the rectus abdominis, adductor muscles, and gracilis were independently evaluated by two experienced radiologists blinded to all clinical details. In all 17 cadaver specimens, the adductor longus and rectus abdominis attached to the capsule and disk of the symphysis pubis, whereas the adductor brevis had an attachment to the capsule in seven specimens and the gracilis in one. All adductor tendons attached to the pubis. In all 10 athletes, the adductor longus and rectus abdominis bilaterally contributed to the capsular tissues and disk. This was only the case for the adductor brevis in four athletes. No other tendons involved the capsular tissues. Cadaver and MRI findings show an intimate relationship between the adductor longus; rectus abdominis; and symphyseal cartilage, disk, and capsular tissues.

Sonographic Imaging of the Obturator Nerve for Regional Block

Today, there is a growing appreciation of the importance of the obturator nerve in clinical anesthesia. The aim of this study is to describe the ultrasound appearance of the obturator nerve for potential utility in guiding these nerve blocks. We scanned left and right inguinal regions of 20 volunteers lateral and distal to the pubic tubercle (PT) and assessed visibility, size and shape, and depth from the skin of common obturator nerves and their associated divisions. In addition to the volunteer study, we retrospectively reviewed a clinical series of obturator nerve blocks performed with ultrasound guidance and nerve stimulation. The obturator nerve can be sonographically visualized by scanning along the known course of the nerve; the anterior division characteristically converges toward the posterior division along the lateral border of the adductor brevis muscle to form the common obturator nerve more proximally. In the set of 20 volunteers, 25% (10/40) of common, 85% (34/40) of anterior, and 87.5% (35/40) of posterior obturator nerves were sonographically identified. The common obturator nerve was visualized 1.3 +/- 1.5 cm distal and 2.3 +/- 1.2 cm lateral to the PT. Divisions were visualized 2.1 +/- 2.0 cm distal and 2.1 +/- 1.2 cm lateral to the PT. The nerves (common, anterior, and posterior) averaged 2.7 +/- 1.2 mm, 1.4 +/- 0.6 mm, and 1.7 +/- 0.6 mm in anterior-posterior dimension and 9.0 +/- 4.3 mm, 9.6 +/- 3.9 mm, and 10.9 +/- 4.1 mm in medial-lateral dimension and were 25.9 +/- 7.6 mm, 15.5 +/- 3.9 mm, and 29.3 +/- 7.9 mm below the skin surface. The common obturator nerve and its anterior and posterior divisions are all relatively flat nerves with average anterior-posterior/medial-lateral dimension ratios of 0.32, 0.18, and 0.18, respectively. In the clinical series, nerve identification was confirmed with nerve stimulation (n = 6 block procedures, mean threshold stimulating current for evoked adductor contraction = 0.70 +/- 0.14 mA). The obturator nerve and its divisions are the flattest peripheral nerves yet described with ultrasound imaging. Knowledge of the obturator nerve's ultrasound appearance facilitates localization of this nerve for regional block and may increase success of such procedures.

Adductor brevis myositis following transobturator tape procedure: a case report and review of the literature

The tension-free vaginal tape (TVT) procedure has long been considered the gold standard for female stress incontinence. Since its introduction in 1995, several other tapes and other minimally invasive treatments have arisen. The transobturator tape (TOT) procedure reproduces the natural suspension of the urethra through the obturator and puborectalis muscles. The TOT procedure was reportedly developed in an effort to prevent bladder perforation associated with the TVT and is generally considered to be a procedure with low morbidity. At our institution, we report the first case of infected mesh with subsequent myositis of adductor muscles after a TOT procedure. To our knowledge, this is the first case reporting this complication, citing specifically that the anatomical structures traversed by the tape, including both muscle and fascia, can be at risk for infection and ultimately require removal of the sling material. We performed a MEDLINE literature search using key words such as "transobturator tape," "tension free vaginal tape," and "adductor and obturator complications" to ascertain any reported adductor or obturator muscle complications after placement of TOT. Further, we reviewed the literature to elucidate the consequences of using different mesh materials, specifically their effects on erosion. We reported our case of a 43-year-old woman who presented with right-leg cellulitis and vaginal discharge after having a TOT placed for stress incontinence. Inflammation of the adductor muscles was demonstrated on computed tomography (CT) scan and ultrasound. On physical exam, the mesh had visibly eroded through the vaginal wall. Our patient underwent excision of the mesh material. She ultimately had an uneventful postoperative course and was discharged home in good condition on the postoperative day 2. The mesh material removed was ObTape. We believe our study is the first case report to discuss the complication of infected adductor muscles and erosion of the tape during post-TOT procedure. After a careful review of the literature, there is no mention of myositis of adductor muscles as a possible complication after the TOT procedure. In fact, the literature has deemed this minimally invasive treatment as a safe and effective procedure with minimal complications including only de novo urgency or urinary retention. The site of infection is of particular interest and can be explained by the course through the anatomical structures that are unique to this particular procedure. Ultimately, the treatment for this procedure was the removal of the mesh along with broad-spectrum antibiotics. In conclusion, the burden falls upon the surgeons to report in a timely fashion both successes and complication for the TOT procedure given their relatively limited experience. This is paramount in determining patients' risks.

Critical sites of entrapment of the posterior division of the obturator nerve

Methods: This study was carried out on 28 cadavers of both sexes and of different ages using the traditional anatomical macro- and micro-dissection. Summary of results: In the current anatomic study special attention was given to the relationship of the posterior division of the obturator nerve with respect to surrounding structures that may, in certain conditions, constitute critical sites of entrapment. These entrapment sites are as follows: The obturator canal, where the posterior division is surrounded by the obturator vessels, nerve to obturator externus muscle, anterior division of the obturator nerve, and adipose tissue. The fibro-muscular canal formed by the obturator membrane and the posterior surface of the obturator externus muscle. The muscular tunnel where the posterior division perforates the obturator externus muscle. The distinct fascial plane situated deep to the pectineus and adductor brevis muscles and superficial to the obturator externus and proximal one third of the adductor magnus muscles. Conclusion: Knowledge of the sites of entrapment of the posterior division of the obturator nerve can aid in the diagnosis of peripheral neuropathies, and contribute to safe and more effective surgical procedures. No external support.

Obstructive Lymphoedema of the Extremity due to Tumor Compression: Is It Reversible?-A Case Report

The lymphoedema of extremities is very disabling to the patients. Most physicians and gynecologists always think that the patients should tolerate the miserable condition because it is ”untreatable' and ”incurable”. A concept prevalent among the surgeons is that the result of surgery for lymphoedema is always poor and is not worthwhile trying for these patients. However, in the recent decade, there is a great deal of improvement in anesthesiology, plastic surgery and physiotherapy so that the result can be totally different in selected patients. There are two kinds of patients in whom surgical intervention should be encouraged. The first category is those patients with the condition of lymphoedema before compartment formation. The second is short-term lymphoedema due to obstruction by the tumor compressed which can be removed. An example is demonstrated. The case had a liposarcoma at his right medial thigh and resulted in lymphoedema at his right lower limb. Then we performed wide excision of the sarcoma as well as the adductor brevis and longus muscles where the tumor was located. The lymphoedema of the right lower limb gradually subsided with softening of the skin after operation. There was no more attacks of cellulitis. However, prolonged physiotherapy was necessary to bring back the lower limb functions due to resection of a major muscle where the tumor was located. We make a conclusion that when there is severe chronic fibrosis causing compartment formation, the lymphoedema is irreversible. Before the development of fibrosis the lymphoedema can be solved after removal of the obstructing tumor.

Acute iliopsoas and adductor brevis abscesses presenting with proximal leg muscle weakness

Pyomyositis is a bacterial infection of skeletal muscle. We describe the clinical case of a 77-year-old woman affected by gait disturbance, repetitive falls, low back pain and left thigh and groin pain, but without symptoms of systemic infection. Computed tomography and magnetic resonance imaging of the abdomen and pelvis showed abscesses in the left psoas and adductor brevis muscles. Investigations of urogenital tract and gastrointestinal system were normal. Systemic antibiotic treatment alone was not efficient, while surgical drainage improved the clinical picture. The aetiological organism, isolated from the abscess, was Staphylococcus aureus. We suggest that this patient had a primary pyomyositis rather than a secondary form. This is the first report of concomitant abscesses of psoas and adductor brevis muscles with early neurological involvement.

A functional model to describe the action of the adductor muscles at the hip in the transverse plane

Anatomical texts agree on most muscle actions, with a notable exception being the action of the adductors of the hip in the transverse plane. Some texts list an action of the adductor brevis (AB), adductor longus (AL), and/or adductor magnus (AM) as internal rotation, whereas others list an action of external rotation. The purpose of this article is to present a functional model in support of the action of external rotation. Transverse plane motion of the femur at the hip during normal gait is driven by subtalar joint motion during the loading response, terminal stance, and preswing phases. During the loading response, the subtalar joint pronates, and the talus adducts. This talar adduction results in the lower leg, and subsequently the femur, internally rotating. During terminal stance and preswing, the opposite occurs; the subtalar joint supinates as the talus abducts in response to forces generated from the lower extremity and in the forefoot. Electromyographic (EMG) studies indicate varied activity in the AB, AL, and AM during the loading response, terminal stance, and preswing phases of the gait cycle. A careful analysis of EMG activity and kinematics during gait suggests that, in the transverse plane, the adductors may be eccentrically controlling internal rotation of the femur at the hip during the loading response, rather than the previously reported role as concentric internal rotators. In addition, these muscles may also concentrically produce external rotation of the femur at the hip during terminal stance and preswing. Physical therapists should consider this important function of the hip adductors during gait when evaluating a patient and designing an intervention program. Anatomical texts should consider listing the concentric action of external rotation of the femur at the hip as one action of the AB, AL, and AM, particularly when starting from the anatomic position.

Acute calcific tendonitis of the adductor brevis tendon of the foot

A case report of a case of acute calcific tendonitis of the adductor hallucis insertion in a 56-year-old male is presented and the clinical features, treatment and outcome discussed. A review of the literature concerning foot and ankle calcific tendonitis is also presented. The original presentation of this was one of acute pain with local tenderness but minimal radiological support for a diagnosis. Subsequently the appearance of a well defined local swelling prompted further treatment. Though rare in this site, the diagnosis should be considered in patients with persistent pain occurring in the first web space.

Motor Points for Neuromuscular Blockade of the Adductor Muscle Group

We sought to identify the motor nerve points for the adductor muscle group, relate them to specific surface anatomy markings, and define the points in terms of percentage distances along an anatomic reference line. We dissected four muscles in each of 20 legs from 15 skeletally mature, formalin-preserved cadavers. Multiple motor branches occurred in 21 of the 80 muscles dissected, but in only four limbs were they observed for more than one muscle in the group. Motor points (defined as the entry point of the motor branch into the muscle) were identified for each muscle along a reference line from the symphysis pubis to the medial joint line at the distal extent of the medial femoral condyle. The mean motor points and 95% confidence limits were as follows: adductor longus, 31% +/- 1.1%; adductor brevis, 22% +/- 1.8%; adductor magnus, 38% +/- 2.5%; and gracilis, 44% +/- 3.1%. Identification of these motor points facilitates accurate placement of neuromuscular blocking agents, such as botulinum toxin, and may lead to increased clinical efficacy of the block with a reduction in local or systemic side effects.