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1 The place of surgical treatment in chronic muscular lesions Dr Benjamin Dessart ICOS Sport Doctor In tribute to the Dr Jean-Pierre Franceschi
2 Epidemiology Acute muscle injury = 1st cause of injury among professional football players Chronic muscle injury = rare Lower limbs +++ (90%): IJ > Add > Quad 5 times more frequent in competition 2
3 Chronic muscular lesions When facing a muscle injury: Most of the time : good evolution Chronicity = complications 2 situations: Lack of initial support Reccurent injuries with +/- past trauma Surgical management : After failure of medical treatment and proven functionnal discomfort after 3
4 Surgery à Rare Evolution of Surgery indications (Traumato Sport department of Pr Jaegger) More effec6ve medical support
5 Surgical principle No suture indication of muscle fibers = RISK OF NECROSIS Stitched muscle = Doomed muscle 5
6 Examination History of the trauma Severe muscular injury background Detail of treatments follow-up Pain every time resuming sport(same location, same gesture) Return to sport too early? 5
7 Morphology Palpation Physical examination Induration/swelling/dehiscence/indurated cord Stretching Limitation of amplitudes /pain Isometric contraction: à OFTEN NORMAL Pain/lack of strength/change of aspect
8 Imagery reviews Radiography Intra-muscular calcification Ossification of periosteal origin Ultrasound (gold standard; same = acute injury) MRI (before surgery, 3D assessment) Scintigraphy (differential diagnosis) Secondary ossification of the anterior right muscle
9 Classification Sequela lesions: EARLY: Organized hematoma Beginning Intra-muscular ossification LATE: Fibrous nodule Fibrous degeneration Cystic lesion Calcification ossification Sequela of (proximal) rupture Muscle Atrophy Fat degeneration
10 SURGICAL INDICATIONS Fiber scars ++++ Encysted hematoma +/- Ossifiying myositis++ Special case: Chronic exertional compartment syndrome (CECS)
11 Fiber scar Fibrous nodule Scar = stronger than the initial musculo tendinous junction Secondary dyskinesias with lesions around this scar Iterative pains, brief. Incomplete recovery of the sport. Examination: Pain during tightness Sometimes palpable Less marked than an acute accident
12 Fiber scar Fibrous nodule Treatment: Functional: Deep transverse massage / Shockwave therapy / Eccentric Sometimes surgery: Medical treatment failure Delay> 6 weeks Operating technique: 1. Adhesiolysis Musculo aponeurotic intermuscular 2. Excision of pathological tissues
13 Cystic lesions Encysted hematomas Intra-muscular fluid pocket with sclerotic shell Palpation: renal tumefaction Treatment: Puncture/compression under echo ++ Surgery: wide surgery with padding
14 Calcification Calcification Same clinical picture as the fibrous nodule
15 Ossification Ossification Extrinsic mechanisms ++ Contact sport/fighting sport Discovery possibly radiographic US ok if post traumatic MRI, Scintigraphy, CT-scan (differential diagnosis) 10% muscle contusion complications
16 Ossification Support: Therapeutic abstinence +++ (well tolerated) Sometimes resection surgery in case of residual pain
17 Chronic exertional compartment syndrome (CECS) Definition: muscle(s) cramped in its inextensible aponeurotic lodge by default of fluid drainage (venous or lymphatic) Epidemiology: Men, running ++ Specific sports (repeated movements, «arm pump») : motorcycle, scuba-diving, motorsport
18 Chronic exertional compartment syndrome (CECS) Physical examination: Pain during effort, at the same place, need to : î or stop the effort 1/3 case : with muscle hernia Charlopain test Dynamic intracompartmental muscle measurements: Rest: > 15 mm Hg Post-exercise: > 30 mm Hg after 1 min
19 Chronic exertional compartment syndrome (CECS) Support: Botulinum toxin (efficiency = 10 month) Surgery: fasciotomies
20 Post-operative rehabilitation Essential secondary rehabilitation support Surgery = bleeding = necrotic risk Identical to a recent and SERIOUS muscle injury (> stage 2 Rodineau and Durey) Return to sport after at least 6 weeks
21 Conclusion Chronic muscular injury: Inadequate initial support Insufficient support Ultrasound: gold standard for diagnosis and follow-up Rarely surgery or even exceptionally PREVENTION +++ (isocikinetic assessment at the beginning of the season) Immobilization =
22 Conclusion et ouverture au débat. A personnaliser
This presentation is the intellectual property of the author. Contact them for permission to reprint and/or distribute.
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