Medial Thigh Pain Research Articles

Comparative Analysis of the Efficacy of Different Surgical Modalities for the Treatment of Female Stress Urinary Incontinence: A Multicenter Retrospective Study.

To compare the efficacy of autologous fascial retropubic midurethral sling, anterior vaginal wall epithelial flap midurethral suspension, tension-free vaginal tape-obturator and adjustable urethral suspension with a single incision for the treatment of female stress urinary incontinence. A total of 243 SUI patients who were admitted to Minda Hospital of Hubei Minzu University, were chosen and split into four groups based on various surgical techniques: the AFS group (59 cases), TVT-O group (61 cases), epithelial flap group (62 cases) and ASIS group (61 cases). A comparison of four patient groups' quality-of-life scores, urodynamic indices, urethral structure-related indices before and a year after treatment, complication rates and perioperative-related indices. There was no discernible difference in the treatment outcomes among the four groups(P>0.05). However, the ASIS group exhibited significantly reduced intraoperative hemorrhage, hospitalization duration and operative time compared to the mucosal flap and TVT-O groups(P<0.05). Both the TVT-O and ASIS groups demonstrated significantly higher hospitalization expenditures than the mucosal flap and AFS groups (P<0.05). No significant differences were observed in postoperative indwelling catheterization, IIQ-7 and I-QOL ratings, urodynamic indices or urethral structure-related indexes across the four patient groups(P>0.05). The TVT-O group showed a significantly higher incidence of postoperative medial thigh pain compared to the AFS, mucosal flap, and ASIS groups(P<0.05). Similarly, the AFS group had a significantly greater incidence of postoperative urine retention compared to the mucosal flap, TVT-O, and ASIS groups(P<0.05). While all four surgical techniques demonstrated good efficacy and improved patients' quality of life, our study suggests that TVT-O had a significantly higher incidence of post-treatment medial thigh pain and ASIS may be a safer and less problematic surgical approach for the treatment of female SUI. This has important therapeutic implications.

Small Bowel Obstruction Caused by Obturator Hernia.

Teaching point: In an elderly patient with a history of atypical, intermittent medial thigh pain presenting with signs of intestinal obstruction, entrapment of bowel loops in an obturator hernia should be included in the differential diagnosis and should be further elaborated by computed tomography (CT).

ID:16316 PNS for Chronic Ilioinguinal and Genitofemoral Neuralgia: A Light at the End of the Tunnel

A 40 year old female who came to the pain clinic for evaluation of long standing right lower abdominal, hip, groin, and medial thigh pain. Her discomfort was debilitating, and affected several aspects of her everyday life including standing, bending, and even mild physical activity and exercise. Over the course of fifteen years, she had tried several treatment modalities including acupuncture, physical therapy, occupational therapy, massage, medications, and steroid injections to no avail. She underwent radiofrequency ablation of the right ilioinguinal and genitofemoral nerves which did provide her relief for almost one year, but she was in search of a more permanent solution to her pain as she found repeat procedures quite uncomfortable.

Open Ischiofemoral Impingement Decompression

Ischiofemoral impingement is a relatively rare cause of posterior hip pain associated with narrowing of the space between the lateral aspect of the ischium and the lesser trochanter. Symptoms typically consist of lower buttock, groin, and/or medial thigh pain, which is commonly exacerbated by adduction, extension, and external rotation of the hip. This condition can be treated nonoperatively in many circumstances; however, recalcitrant cases may require surgical intervention. Whereas described operative treatment options for this pathology range from endoscopic to open procedures, this Technical Note describes a safe and reliable technique for open ischiofemoral decompression with sciatic nerve neurolysis through a posterior approach for treatment of ischiofemoral impingement refractory to conservative treatment.

Novel wrapping surgery for symptomatic sacral perineural cysts.

Perineural cysts, also called Tarlov cysts, are dilatations of the nerve root sleeves commonly found in the sacrum. The majority of the cysts are asymptomatic and found incidentally on routine spine imaging. Symptomatic sacral perineural cysts (SPCs) that induce intractable low-back pain, radicular symptoms, and bladder/bowel dysfunction require surgery. However, the surgical strategy for symptomatic SPCs remains controversial. The authors hypothesized that the symptoms were caused by an irritation of the adjacent nerve roots caused by SPCs, and developed a wrapping surgery to treat these cysts. Seven patients with severe unilateral medial thigh pain and ipsilateral SPCs were included. Preoperative MRI showed that the cysts were severely compressing the adjacent nerve roots in all patients. After a partial laminectomy of the sacrum, the SPCs were punctured and CSF was aspirated to reduce their size, followed by dissection of the adjacent nerve roots from the SPCs. The SPCs were then wrapped with a Gore-Tex membrane to avoid reexpansion. All 7 patients experienced substantial relief of their symptoms. The average numeric rating scale pain score was reduced from an average preoperative value of 7.9 to 0.6 postoperatively. Postoperative MRI showed that all cysts were reduced in size and the adjacent nerve roots were decompressed. Regrowth of the treated cysts or recurrence of the symptoms did not occur during the entire follow-up period, which ranged from 39 to 90 months. No complications were noted. The authors' new wrapping technique was effective in relieving radicular symptoms for patients with symptomatic SPCs. The results suggested that the symptoms stemmed from compression of the adjacent nerve roots caused by the SPCs, and not from the nerve roots in the cysts.

Obturator hernia: a case report

BackgroundObturator hernia is rare and accounts for less than 1% of all abdominal wall hernias. It represents a diagnostic challenge due to its nonspecific signs and symptoms.Case presentationWe present a case of an 89-year-old caucasian female with a 12-hour history of right medial thigh pain. Computed tomography scan revealed a right obturator hernia with small bowel obstruction. The hernia was successfully repaired laparoscopically without any need for small bowel resection. She was discharged on postoperative day 2 with an uneventful recovery and zero complications.ConclusionThis case report highlights the importance of rapid diagnosis and repair of obturator hernia even in the setting of an improving clinical picture. It also demonstrates the safety of laparoscopic repair in this setting.

Perineural dextrose injections in the treatment of lower urinary tract symptoms and dyspareunia induced by obturator neuralgia

Obturator neuralgia is commonly diagnosed and treated in orthopedics. It produces groin pain, sensory alteration in the medial thigh (dysesthesia, sensory loss, or pain), adductor muscle weakness and pain/restriction of hip movements. Basically, the clinical diagnosis of obturator neuralgia is made by producing pain during internal rotation of the hip against resistance (“obturator sign”) or by extension and lateral leg movements. We postulate obturator neuralgia can induce lower urinary tract symptoms and dyspareunia and be diagnosed by using three clinical signs characterizing neuralgia everywhere on the body: painful nerve trunk (at the entrance of the obturator canal; by vaginal or rectal examination), abnormal sensibility and painful skin rolling test in its cutaneous innervation territory (inferomedial skin of the thigh). To support our assumptions, three female patients with longstanding lower urinary tract symptoms and/or dyspareunia and a clinical examination suggestive of obturator neuralgia (three clinical signs positive) were treated by perineural injections of dextrose 5% in sterile water (D5W). The three patients were clinically improved or cured after the treatment with two of them being cured after a single injection. While waiting for confirmation of these findings by randomized controlled trials, we suggest that obturator neuralgia should be sought in every patient with lower urinary tract symptoms and/or dyspareunia and that obturator perineural D5W injections be tried to relieve these patients.

Evaluation of clinical results and complications of internal fixation of intertrochanteric femur fracture with proximal femoral nail antirotation

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The purpose of the present study was to evaluate the theoretical advantages of the proximal femoral nail antirotation in cases of intertrochanteric fractures and also whether it actually alters the eventual functional outcome of the patient.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The present study includes a total 30 patients with intertrochanteric femur fractures managed with proximal femoral nail antirotation between December 2014 to November 2016. In all patients similar standard physical rehabilitation therapy were followed. All complications including intra and postoperative were assessed and recorded. The patients were followed up for over 24 months. Functional outcome was assessed using the Harris hip score.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; All of 30 cases of intertrochanteric fracture got united with good anatomical position and average time of fracture union was 14 weeks. Postoperative complications included 2 degree varus deformity (n=1, 3%), calcification at tip of greater trochanter (n=4, 13%), sensitivity over TFL (n=2, 7%), medial thigh pain (n=3, 10%). 10 patients developed femoral shortness (mean=0.22 cm, range from 0-1 cm). Average harris hip score at the end of study showed mean value of 87, ranged from 65 to 94 with almost 22 (73%) patients showing excellent or good outcome.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Proximal femoral nail antirotation (PFNA) represents a significant treatment option in management of intertrochanteric fractures with low complication rate.&lt;/p&gt;

The Role of Medial Femoral Condyle Free Vascularized Bone Graft for the Treatment of Failed Scaphoid Nonunion Surgery associated with Proximal Pole Avascular Necrosis

There is no financial information to disclose. Revision surgery for scaphoid nonunions with proximal pole avascular necrosis is a challenge. We hypothesize that the use of free-vascularized medial femoral condyle bone grafts can heal the bone, revascularize the proximal pole, and restore scaphoid architecture, resulting in acceptable functional outcomes. We retrospectively reviewed patients who had failed prior operative treatment for a scaphoid nonunion and proximal pole avascular necrosis. Between May of 2005 and September of 2016, 49 patients were identified with this preoperative diagnosis and subsequent treatment with a medial femoral condylar free vascularized bone flap. Mean time from injury to revision surgery was 24 months, and a mean 15 months following the initial surgery. Of the 49 patients, 36 had a prior bone graft procedure and 6 patients had two previous surgeries. Initial internal fixation was with a scaphoid screw in 43 patients and K-wires alone in 3. All patients had documented avascular necrosis of the proximal pole at the time of our surgery, defined by complete absence of punctate bleeding of the proximal pole with the tourniquet deflated. Carpal indices, time to union, functional outcomes and complications were recorded. Forty-one of 49 previously operated on scaphoid nonunions healed (84%) at a mean of 16 weeks (range, 9 to 31 weeks) based upon CT scan imaging. Radiographs demonstrated significant improvement in carpal alignment following surgery, as determined by the lateral scaphoid angle, scapholunate angle, radiolunate angle, scaphoid height to length ratio and carpal height ratio. There was a trend towards improved grip strength and no significant change in total wrist range of motion pre- and postoperatively. Twenty-nine patients underwent 21 subsequent planned procedures (removal of buried K wires). There were two superficial postoperative donor site infections, however no patients complained of medial thigh pain at final follow-up. Age, smoking status, BMI, time to surgery, or preoperative radiographic findings were not found to be statistically significant predictors of failure. •We present the largest series to date of patients who have undergone revision scaphoid nonunion surgery with documented avascular necrosis of the proximal pole.•84% of patients who had failed prior scaphoid nonunion surgery healed at a mean of 16 weeks after treatment with free-vascularized medial femoral condyle grafts.

Pelvic Osteomyelitis Presenting as Groin and Medial Thigh Pain: A Resident's Case Problem

Resident's case problem. Groin pain represents a diagnostic challenge and requires a diagnostic process that rules out life-threatening illness or disease processes. Osteomyelitis is a potential fatal disease process that requires accurate diagnosis and medical management. Osteomyelitis presents a problem for the outpatient physical therapist, as the described physical findings for the diagnosis of osteomyelitis are nonspecific. A 67-year-old man with groin and bilateral medial thigh pain was referred for physical therapy care to address right adductor weakness and generalized deconditioning. He had undergone extensive treatment for bladder cancer, with a recent radical cystoprostatectomy and cutaneous urinary diversion with an Indiana pouch. Postsurgical magnetic resonance imaging indicated normal findings, and the patient was currently being managed by an orthopaedic surgeon, who diagnosed the patient as having obturator nerve palsy. The physical therapist's examination produced findings inconsistent with this diagnosis. Subsequently, nuclear medicine studies revealed pubic symphysitis/osteomyelitis with secondary myositis, predominantly affecting the right adductor muscles. Osteomyelitis represents a difficult problem for the outpatient physical therapist. Careful consideration of red-flag symptoms and inconclusive physical testing indicate the need for further medical work-up. In this case, appropriate medical management led to improvement in patient function, highlighting the need for early diagnosis. Differential diagnosis, level 4.

Obturator canal lymph node metastasis from rectal carcinoid tumor.

440 Background: The optimal treatment option for rectal carcinoid tumor remains unsettled. Trans-anal excision has been accepted for small tumors (&lt; 1-2 cm in size) without lymph node involvement. Larger tumors, and those with lymph node metastasis, however, are usually treated via low anterior resection (LAR) with total mesorectal excision (TME). Midgut carcinoid tumors have been found to have the tendency to obstruct lymphatic flow and create a detour in lymphatic passage. We hypothesize that rectal carcinoid may have similar potential to develop alternative lymphatic pathways outside of the mesorectal envelope, thus escaping surgical removal with traditional TME. Methods: A retrospective chart review of rectal carcinoid patients who underwent radical LAR with TME between 2006 and 2011 was conducted to determine if any extra-mesorectal metastasis had occurred. Results: 19 patients who underwent LAR with TME for rectal carcinoid were identified. 14 patients had radio-guided surgery (RGS). 12 of which, were injected with TC-99 intra-operatively and 2 had a preoperative injection of In-111 for octreotide scan. 6 of the 19 patients (31.5%) were found to have obturator canal lymph node metastasis, confirmed by final pathologic review. 5 of these 6 patients had the nodal metastasis to the right obturator canal. Of note, 4 of the 6 patients complained of debilitating foot and medial thigh pain on the affected side, with complete symptom resolution after surgical excision. Conclusions: Up to 31.5% of rectal carcinoid patients can have extra-mesorectal lymph node metastasis that could easily be missed by the traditional TME. Preoperative octreotide scanning with In-111 injection or intra-operative Tc-99 peri-tumor injection, with concomitant RGS can easily identify and remove such metastasis. Symptomatic improvement can be accomplished with its removal. The effect of such extra-mesorectal metastasis on patients’ long term or disease free survival is yet to be determined.

Isolated Tears of the Gracilis Muscle

Background: Although posterior thigh muscle strains are common in athletes, there are no reports regarding isolated gracilis muscle injuries. The authors present a case series of 7 elite athletes with isolated gracilis muscle ruptures. Purpose: To present the injury pattern, clinical presentation, diagnosis, and outcome of gracilis muscle ruptures. Study Design: Case series; Level of evidence, 4. Methods: This is a retrospective review of 7 elite athletes with posterior thigh pain (3 dancers, 2 soccer players, 1 tae kwon do player, 1 tennis player). In all athletes, the injury occurred during thigh adduction with the hip internally rotated, as clearly evident at ultrasound scans performed 1 to 20 days after the injury. Management included an initial rest period, followed by physiotherapy and gradual return to sports activities. Results: According to the ultrasound scans, the lesions were in the proximal-middle third junction of the thigh, at the muscle-tendon junction. The lesions were classified as grade 2 (partial discontinuity). The muscle injury area was, on average, 17.1 × 23.7 mm (range, 10-31 × 9-46 mm). The average length of the lesions was 40.14 mm (range, 20-52 mm). All athletes recovered and returned to full performance within 6 weeks of the injury (average, 35.6 days). Conclusion: Medial thigh pain after eccentric contraction during hip adduction should raise suspicion of a gracilis muscle tear. Ultrasound is useful, and full recovery occurs within 6 weeks from the injury.

Medial thigh pain: An unusual presentation of giant calculi in sigmoid neobladder

Calculi in a neobladder usually present with irritative lower urinary tract symptoms, flank pain, and haematuria. We report a case of giant stones in a sigmoid neobladder, who presented with medial thigh pain.

Ultrasound-guided Nerve Blocks for Post-hernia Repair Pain

Ultrasound-guided Nerve Blocks for Post-hernia Repair Pain

Long-term outcome following ilioinguinal neurectomy for chronic pain

Ilioinguinal neuralgia is one cause of chronic groin pain following inguinal hernia repair, and it affects approximately 10% of patients. Selective ilioinguinal neurectomy is one proposed treatment option for carefully selected patients. The goal of this study was to determine the long-term outcome of patients who underwent selective ilioinguinal neurectomy for chronic post-hernia pain. The authors retrospectively reviewed the clinical assessment, surgical treatment, and long-term outcome in 26 patients with ilioinguinal neuralgia who underwent selective ilioinguinal neurectomy performed by the senior author (K.J.B.) at Oregon Health & Science University between 1998 and 2008. Data were collected from patient charts and a follow-up telephone questionnaire. Twenty-six patients (14 men and 12 women) had a clinical diagnosis of ilioinguinal neuralgia based on a history of radiating neuropathic groin, medial thigh, and genitalia pain. One patient had bilateral disease (therefore there were 27 surgical cases). A selective nerve block was performed in 21 (81%) of 26 patients and was positive in 20 (77%) of the 26. In all but 2 patients, pain onset followed abdominal surgery (for hernia repair in 18 patients), and was immediate in 16 (67%) of 24 patients. The mean patient age was 48.7 years, and the mean duration of pain prior to neurosurgical consultation was 3.9 years. Surgery was performed after induction of local or general anesthesia in 17 and 10 cases, respectively. The ilioinguinal nerve was identified in 25 cases, and the genitofemoral nerve in 2, either entrapped in mesh, scar, or with obvious neuroma (22 of 27 cases). The identified nerve was doubly ligated, cut, and buried in muscle at its most proximal point. At the 2-week follow-up evaluations, 14 (74%) of 19 patients noted definite pain improvement. Nineteen (73%) of the 26 patients were contacted by telephone and agreed to participate in completing long-term follow-up questionnaires. The mean follow-up duration was 34.78 months. Return of pain was reported by 13 (68%) of 19 patients. Using a verbal numerical rating scale (0-10), pain was completely relieved in 27.8%, better in 38.9%, no better in 16.7%, and worse in 16.7% of patients. Ilioinguinal neurectomy is an effective and appropriate treatment for selected patients with iatrogenic ilioinguinal neuralgia following abdominal surgery. Although a high proportion of patients reported some long-term recurrence of pain, complete or partial pain relief was achieved in 66.7% of the patients observed.

Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures

We evaluated the radiographic and functional results of the proximal femoral nail antirotation (PFNA) system in patients with unstable intertrochanteric femoral fractures. The study included 45 patients (25 women, 20 men; mean age 72 years; range 27 to 97 years) who underwent osteosynthesis using the PFNA for unstable intertrochanteric femoral fractures. The fractures were in the right hip in 25 patients, and in the left hip in 20 patients. The fractures were classified according to the AO system. One patient had an open fracture due to firearm injury (Gustilo-Anderson 3A). The patients underwent surgery within a mean of eight days (range 2 to 21 days) from injury. The mean hospital stay was 13.5 days (range 4 to 25 days). Closed reduction was achieved in all the patients. The results were assessed clinically and radiographically. The neck-shaft angle of the femur (collodiaphysial angle) and the tip-apex distance were measured. The position of the helical screw within the femoral head was determined using the method of Cleveland and Bosworth. Clinical evaluation was made using the Harris hip score. Perioperative and postoperative complications were recorded. The mean follow-up period was 17.3 months (range 6 to 23 months). The mean operation time was 37.8 min (range 22 to 118 min) and the mean blood loss was 225 ml (range 150 to 450 ml). During surgery, femoral shaft fracture occurred in three patients, and greater trochanter fracture occurred in nine patients. Union was obtained in all the patients. Reduction was poor in four patients (8.9%), acceptable in seven patients (15.6%), and good in 34 patients (75.6%). The mean collodiaphysial angle was 136.7 degrees (range 125 degrees to 148 degrees). The tip-apex distance was <25 mm in 36 patients (80%), and =or>25 mm in nine patients (20%). The position of the helical screw in the femoral head was appropriate in 38 patients (84.4%). Postoperative complications included secondary varus (n=2, 4.4%), calcification at the tip of the greater trochanter (n=7, 15.5%), sensitivity over the fascia lata (n=7), medial thigh pain (n=11, 24.4%), and screw cut-out (n=1, 2.2%). Nine patients developed femoral shortness (mean 9.4 mm; range 8 to 13 mm). Screws showed lateral displacement in five patients (11.1%), which was less than 5 mm in four patients. Secondary surgery was required in four patients (8.9%). The mean Harris hip score was 77.8. Harris hip scores were very good in 11 patients (24.4%), good in 19 patients (42.2%), moderate in nine patients (20%), and poor in six patients (13.3%). Due to advantages of high union rate, early postoperative mobilization, and short operation time, PFNA osteosynthesis is the method of choice for surgical treatment of unstable intertrochanteric femoral fractures..

Orthopaedic · Radiology · Pathology Conference: Thigh Pain in a 53-year-Old Woman

A 53-year-old woman presented with 3 months of progressively worsening right medial thigh pain. She reported having constant severe pain and a burning sensation in the upper thigh. Her pain was worse at night, often awakening her from sleep. Initially, she experienced some relief with aspirin, ibuprofen, and naproxen; however, these no longer provided relief. She obtained partial pain relief with acetaminophen. She had a history of mild, blunt trauma to the left torso approximately 1 month before presentation, but no history of trauma to the affected limb. She denied any back pain, fever, chills, night sweats, or weight loss. Physical examination revealed a well-developed woman with no obvious deformity. Right antalgic gait was noted. There was no edema, erythema, skin warmth, or palpable mass on examination of the right thigh. Deep palpation did not change her symptoms. There was full and painless active and passive range of motion of the right hip and knee. Neurovascular examination, strength, and tone were normal. Magnetic resonance images of the right hip and thigh (Fig. 1), CT scans of the right proximal femur (Fig. 2), and a total body bone scan (Fig. 3) were available from the referring physician. Plain radiographs had not been performed at the time of the initial evaluation. Based on the history, physical examination, and the imaging studies, what is the differential diagnosis?

Obturator neuropathy

Obturator neuropathy is a difficult clinical problem to evaluate. One possible cause of pain is due to fascial entrapment of the nerve. Symptoms include medial thigh or groin pain, weakness with leg adduction, and sensory loss in the medial thigh of the affected side. Radiographic imaging provides limited diagnostic help. MRI may detect atrophy in the adductors of the leg. However, it is unable to detect any abnormality of the nerve or in the fibro-osseus tunnel. The best test for diagnosis is by electromyography (EMG) and can be confirmed by a local nerve block. Pharmacologic management of pain and physical therapy can be helpful in the acute phase of injury. Surgical decompression of the nerve should be considered for lesions documented by EMG or local nerve block, for those with predisposing risk factors (prior surgery, pelvic trauma, or hematoma) and with prolonged or severe lesions.

Removal of Transobturator Midurethral Sling for Refractory Thigh Pain

Polypropylene midurethral slings have become the most common surgical procedure for the treatment of stress urinary incontinence. The efficacy has been well established through prospective and systematic evaluation. Transobturator midurethral slings have demonstrated comparable efficacy relative to the retropubic approach with the potential to minimize the morbidity associated with retropubic needle passage. We present a case of recalcitrant medial thigh pain after transobturator midurethral sling placement that ultimately required medial thigh/transobturator exploration and sling excision.

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain