**9. Suture versus immobilization**

reconstruction of the anterior cruciate ligament, so in theory it is an "expendable" tendon. Indeed it has been shown that athletes who have had removed their semitendinosus tendon were able to return to the previous level of activity without the harvest causing an important deficit in the competitive performance [42]. A traumatic injury of this region, however, can result in a partial or total lesion that causes pain, and interferes with the physical activity of the patient. Also in this case few articles are available in literature and it is not clear when it is advisable to choose conservative treatment and when to opt for surgical treatment. From our literature search we found 25 cases described [40, 41, 43, 44], 14 patients had been treated conservatively and 11 surgically. The surgery in all cases was a tenotomy with eventual release of adhesions, in no case was a suture performed to restore the damaged anatomical structure. In 5 of the 14 cases (35%) treated conservatively there was a treatment failure and the patient needed surgery that subsequently gave good results. Of the 11 patients treated surgically al

The study with the largest case series [40] emphasized that early surgical treatment (within 4 weeks from injury) leads to a much earlier return to sports: with conservative treatment (7 cases) return to sport occurs at an average of 18.4 weeks, with surgery (5 cases) at 6.8 weeks, while if conservative treatment fails and surgery is needed (5 cases), return to the field is much later, at 29.6 weeks on average. Unfortunately, however, the results are not statistically

A lesion at the proximal end of the abductor complex is not a common injury. There are few articles in literature about it, and those few are of a low level of evidence and with a few selected cases. An eccentric contraction during a movement of forced abduction of the lower limb may cause this type of acute injury. The most common mechanism is bilateral abduction of the lower limbs with a hip flexion and internal rotation of the other hip [45]. Usually the acute injury is preceded by painful symptoms previous to the accident that express an acute injury on a chronic disease in the area. In fact, histological studies [46, 47] have shown that in the area near the lesion there are degenerative tissue alterations. For this reason the first therapeutic approach to acute injuries of proximal abductor insertion was based on the results of treatment of the chronic lesion. Tenotomy, often used for chronic pain resistant to conservative therapies, had not guaranteed excellent results: 40% of patients were unable to return to competitive activity after surgery and the strength of the adductors reported a significant decrease at the isokinetic test [48]. These results led to the surgical reconstruction of the injured tendon / muscle to prevent the loss of strength and try to increase the percentage of athletes who could

It was later shown that about 60% of the athletes complained of an aspecific symptom, especially abdominal or inguinal pain in the period prior to the injury [49]. However, the importance of the integrity of these anatomical structures has decreased. Studies on the conservative treatment of these lesions have shown that the anatomical continuity of these

returned to their previous level of athletic activities.

significant because of the small sample number.

return to their previous level of competitive activity [46].

**8. Adductor muscle**

230 Muscle Injuries in Sport Medicine

Few studies in the literature have compared muscle suture and immobilization. Animal studies, usually in the Sprague-Dawley rat, have shown that lesions performed for experi‐ mental purposes heal better if sutured. Almekinders [52] has shown that the benefits obtained by suturing muscles are significant at one week after injury, while at two weeks surgical treatment or treatment with simple immobilization bring the same results in terms of maxi‐ mum failure load, active force generation as well as from the histological point of view. Menetrey [3] instead found significant improvements with suturing muscle in respect to not suturing and immobilization; in fact one month after the injury the sutured muscle produced 81% of the tetanus strength misured in the intact muscle, while the non sutured muscle produced 35% and the immobilized muscle 18%. It is evident how the overabundance of connective tissue in the scar tissue inhibits the formation of myofibers at 12 weeks [1] whereas the suture prevents the formation of scar tissue in depth; it restricts the formation of hematoma by decreasing the gap of the lesion and the infiltration of mononuclear cells is limited to the surface region only. Desmin's detection has proved that the greatest number of regenerating myofibers is in the sutured muscle already at 2 days after injury, this is not because it limits the inflammatory phase or cellular necrosis (that occurs anyway) but probably because it produces a microenvironment favorable to repair, keeping the muscle stumps together [3].

Clearly the results of the animal tests should be interpreted with caution for several reasons: the lesion that is created is a surgical one, metabolism and healing of the lesion are different between humans and rats. In humans, the only studies comparing surgery and conservative treatment are about lesions of the biceps brachii [25, 53] where the best results are had in patients treated with the myorrhaphy. However, these articles have a poor methodology and take into account only a small number of patients; obviously future larger and better conducted studies are required in order to determine more specifically which type of treatment is most suitable in humans. It remains clear, however, that surgical treatment is rarely necessary, only for certain types of injuries, and only with a specific indication. We perform surgery only when strictly necessary.

muscles of human cadaver, Kessler stitch was the least resistant and tore the muscle with an average load of 1.65 kg; the strongest suture, as was observed in other studies, was the combined suture, Mason-Allen plus perimeter stitch, that withstood a weight of 6.4 kg on average. It was also observed that the simple sutures tend to tear the tissue and the epimysium longitudinally, whereas the more complex sutures failure involves more the transversal tissue. In fact, the epimysium is the key to a robust suture, it is more robust in the tissue where the suture can adhere firmly, the complex sutures involve a greater surface area than the simple

Surgical Treatment

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http://dx.doi.org/10.5772/56736

It should also be noted that the simple sutures close the epimysium flaps but in the deep layers, fibers are free and when subsequent contraction of the muscle flaps occur, although held together at the extremity by the suture, deep below the surface tend to form a gap that favors the formation of hematomas, prolong the period of healing and promote excessive fibrosis which may in turn lead to exuberant scar tissue. Hence, the complex suture allows the surgeon to pull together the edges of the tear both at the extremes and deep in the muscle enhancing a

The muscle tissue, due to its physical characteristics, does not offer a solid anchor for sutures which, if positioned improperly, tend to tear the fibers and are pulled from the muscle. When the suturing encompasses multiple points on the injured muscle and the correct technique is used, it can sustain heavy loads and prevent further injuries and ineffective sutures. In theory a stronger suture and one that is less damaging to the muscle tissue should allow earlier mobilization without the risk of failure; therefore improving the healing, shortening the period

These in vitro tests demonstrate how to make the most of myorrhaphy. In vivo, however, there are no significant differences between the stitches used Even when comparing a Kessler stitch with a simple suture in a tendon graft, Chien et al. [57] found no difference in terms of muscle

Some authors have proposed the use of grafts to reinforce the suture, but It is still unclear whether the use of an augmentation graft suture, as performed by Botte et al. [59] on a case series of 58 patients, is useful to make improvements in clinical and functional outcomes.

The indication for surgical treatment applies to a small number of muscle lacerations. The tearing of the muscle belly is a common occurrence in athletes and nowadays are difficult to predict or prevent. There is no clear indication for surgical suture for these lesions and there is no real guide line to follow. The majority of the authors in literature consider performing surgery when the lesion affects more than 50% of the total of muscle fibers. Such an extensive injury would provoke a massive scar reaction making it difficult to achieve efficient and functional tissue leading to an excess of collagen and fibrotic tissue which would change the muscle mechanics and facilitate the onset of new lesions. It has also been evaluated and

ones.

greater biological performance [58].

healing in rabbits.

**11. Conclusions**

of immobility and in turn decreasing muscle atrophy.
