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Vadhera AS, Lee JS, Sivasundaram L, Ogle M, Westrick JC, Kunze KN, Gursoy S, Chahla J. Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis. J Pediatr Orthop B 2023; 32:268-277. [PMID: 36445382 DOI: 10.1097/bpb.0000000000001029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.
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Affiliation(s)
- Amar S Vadhera
- Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Jonathan S Lee
- Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Lakshmanan Sivasundaram
- Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Miranda Ogle
- Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Jennifer C Westrick
- Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Kyle N Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Safa Gursoy
- Department of Orthopaedic Surgery, Faculty of Medicine, Acibadem University, Istanbul, Turkey
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
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Di Maria F, Testa G, Sammartino F, Sorrentino M, Petrantoni V, Pavone V. Treatment of avulsion fractures of the pelvis in adolescent athletes: A scoping literature review. Front Pediatr 2022; 10:947463. [PMID: 36210934 PMCID: PMC9537814 DOI: 10.3389/fped.2022.947463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Avulsion fractures of the pelvis and hip region are typical injuries in adolescent athletes. Avulsion sites include the muscle tendon origin or insertion, and treating these injuries surgically or conservatively remains a debated issue. The main goals of this review were to assess and summarize injury types and sites, treatment-related clinical outcomes, and return to sport for adolescent patients with a pelvis avulsion fracture and to provide support for making treatment decisions. The PubMed database was searched in November 2021 to identify all published articles from 2000 to 2021 that reported the outcome and return to sport after conservative or surgical treatment. Eighteen studies with 453 patients were included in this review. The age range was 13.6-16.8 years. The most common injury site the was anterior superior iliac spine (37%), followed by the anterior inferior iliac spine (31%), ischial tuberosity (14%), lesser trochanter (9%), iliac crest (8%), and superior corner of the pubic symphysis (1%). Overall complications were lower in the surgical group compared to the conservative group. The rate of return to pre-injury activity level was greater in patients who underwent surgical treatment (p < 0.05). In conclusion, surgery is preferred for major dislocation and fragment size, providing a better return-to-sport rate and decreasing the risk of complications.
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Affiliation(s)
- Fabrizio Di Maria
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico "Rodolico-San Marco", University of Catania, Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico "Rodolico-San Marco", University of Catania, Catania, Italy
| | - Fabio Sammartino
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico "Rodolico-San Marco", University of Catania, Catania, Italy
| | - Marco Sorrentino
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico "Rodolico-San Marco", University of Catania, Catania, Italy
| | - Vincenzo Petrantoni
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico "Rodolico-San Marco", University of Catania, Catania, Italy
| | - Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico "Rodolico-San Marco", University of Catania, Catania, Italy
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Cai W, Xie Y, Su Y. Comparison of non-surgical and surgical treatment using absorbable screws in anterior-superior iliac spine avulsion fractures with over 1.5cm displacement. Orthop Traumatol Surg Res 2020; 106:1299-1304. [PMID: 32409270 DOI: 10.1016/j.otsr.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION There is some debate over the best treatment for anterior-superior iliac spine (ASIS) avulsion fractures, although non-surgical treatment can achieve the same results as open surgery. HYPOTHESIS Absorbable screws can be safely used for ASIS avulsion fractures in children and adolescents. AIM OF THE STUDY Here, we compared patients on whom no surgery was performed with those who underwent open surgery and investigated the feasibility of using absorbable screws as a new fixation material for treating ASIS avulsion fractures in children and adolescents. PATIENTS AND METHODS We retrospectively analyzed the data of 59 patients diagnosed with ASIS avulsion fractures in our hospital between January 2009 and December 2016. Based on the clinical data, these patients were assigned into group A (non-surgical group) and group B (absorbable screws group). After the inclusion and exclusion criteria were applied, patients' clinical records, including radiographs, were analyzed. All patients were assessed for range of motion (ROM) and by X-ray as they returned to activity. Evaluation of hip function was done by calculating the American Academy of Orthopedic Surgeons (AAOS) lower limb and hip scores. RESULTS According to AAOS scores, there were significant differences between the two groups at the first and third months postoperatively (p=0.003), but by the sixth and twelfth months, there was no significant difference (p=0.42). Significant differences were also observed between both groups regarding callus growth on radiographs, time to resume sporting activities, and occurrence of complications such as meralgia paresthetica. All complications resolved by 6 months follow-up. CONCLUSION Our study agrees with previous reports, absorbable screws can be safely used for ASIS avulsion fractures with greater than 1.5cm displacement in children and adolescents. In comparison with non-surgical therapy, our results indicate that absorbable screws are associated with shorter recovery time and lesser early complications. LEVEL OF EVIDENCE IV, retrospective study with control group.
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Affiliation(s)
- Wenquan Cai
- Department II of Orthopaedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders, the Children's Hospital of Chongqing Medical University, Yuzhong District Zhongshan 2road 136#, 400014 Chongqing, China
| | - Yan Xie
- Clinical Laboratory Department, Maternal and Child Health Care Hospital of Chongqing Yubei District, Chongqing, China
| | - Yuxi Su
- Department II of Orthopaedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders, the Children's Hospital of Chongqing Medical University, Yuzhong District Zhongshan 2road 136#, 400014 Chongqing, China.
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Klasan A, Neri T, Putnis SE, Dworschak P, Schüttler KF, Fuchs-Winkelmann S, Schofer MD, Heyse TJ. The prevalence of a prominent anterior inferior iliac spine. Arch Orthop Trauma Surg 2019; 139:1045-1049. [PMID: 30770995 DOI: 10.1007/s00402-019-03146-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Impingement of the prominent anterior inferior iliac spine (AIIS) against the femoral neck has recently been described as another type of impingement. The purpose of this study is to provide a distribution of AIIS types using the classification proposed by Hetsroni and thus report on the prevalence of prominent types. MATERIALS AND METHODS A total of 400 patients were included in the study with an average age 27.3 ± 6.9 years (range 18-40). All patients received a whole-body polytrauma computer tomography (CT) scan in the emergency room (ER) upon arrival. The classification of AIIS proposed by Hetsroni et al., which describes three morphological types, was used. Type II and III were grouped as prominent types. The measurements were performed in all three planes by two examiners. RESULTS Male to female ratio was 71:29. Type I was observed in 367 (91.7%) patients. Type II was observed in 31 (7.8%) patients and type III was observed in 2 (0.5%) patients, unilaterally. Prominent types were much more prevalent in men (10.5%) than in women (2.6%). The CT assessment demonstrated excellent intra- and interreliability (overall: 0.926, I/II: 0.906, III: 1.000). CONCLUSION A young population demonstrates a prevalence of a prominent AIIS of 11.5%. Prominent AIIS is more common in men than in women.
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Affiliation(s)
- Antonio Klasan
- Center for Orthopedics and Traumatology, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - Thomas Neri
- Department of Orthopaedic Surgery, University Hospital St Etienne, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France
| | - Sven Edward Putnis
- The Gallery, Sydney Orthopaedic Research Institute, Level 1, 445 Victoria Avenue, Chatswood, NSW, 2067, Australia
| | - Philipp Dworschak
- Center for Orthopedics and Traumatology, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Karl Friedrich Schüttler
- Center for Orthopedics and Traumatology, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Susanne Fuchs-Winkelmann
- Center for Orthopedics and Traumatology, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Markus D Schofer
- Orthomedic Frankfurt Offenbach, Herrnstraße 57, 63065, Offenbach, Germany
| | - Thomas J Heyse
- Orthomedic Frankfurt Offenbach, Herrnstraße 57, 63065, Offenbach, Germany
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Otto A, Banke IJ, Mehl J, Beitzel K, Imhoff AB, Scheiderer B. Retrograde fixation of the lesser trochanter in the adolescent: new surgical technique and clinical results of two cases. Arch Orthop Trauma Surg 2019; 139:537-545. [PMID: 30535582 DOI: 10.1007/s00402-018-3091-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Avulsions of the lesser femoral trochanter are rare injuries in the adolescent population. An acute avulsion causes severe functional impairment with compromised hip flexion. Recent literature reports the superiority of surgical treatment for apophyseal avulsion fractures of the pelvis in adolescents. Unfortunately, there are no guidelines for an evidence-based treatment of lesser trochanter avulsions established. We present the cases of two adolescent athletes treated operatively. MATERIALS AND METHODS Two adolescent males, 12 and 16 years old, suffered an avulsion of the lesser trochanter during soccer. They reported immobilizing groin pain with subjective impairment in daily activities and inability to perform sports. Surgical treatment with a new retrograde technique by applying an adapted mini-open anterior approach was performed. Intraoperatively, both cases showed an intact musculo-tendinous unit attached to the avulsed fragment. RESULTS Both patients showed excellent postoperative results and were satisfied with the clinical outcome. In the postoperative follow-up an adequate consolidation of the lesser trochanter was visible. No complications were postoperatively reported at final follow-up. CONCLUSIONS The retrograde fixation technique has led to an excellent outcome without complications in two adolescents with acute lesser trochanter apophyseal avulsions. Further clinical use may support the value of this new surgical technique.
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Affiliation(s)
- A Otto
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, CT, USA.
| | - I J Banke
- Clinic of Orthopaedics and Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - J Mehl
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, CT, USA
| | - K Beitzel
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - A B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - B Scheiderer
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Calderazzi F, Nosenzo A, Galavotti C, Menozzi M, Pogliacomi F, Ceccarelli F. Apophyseal avulsion fractures of the pelvis. A review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:470-476. [PMID: 30657114 PMCID: PMC6502104 DOI: 10.23750/abm.v89i4.7632] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 09/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM OF THE WORK Fractures of the pelvis classically occur in adolescent during sports activities with forceful and repetitive contractions or passive lengthening acting on not yet ossified growth plates. Their misdiagnosis lead to disability, chronic pain and decrease of performances. Evidence based treatment guidelines do not exist; aim of this paper is to point out clinical outcomes, return to sport rates and complications of surgical and conservative approach. METHODS A systematic search based on MEDLINE database was performed in August 2017 to identify all published articles from 2010 to 2017 reporting outcomes, return to sport and complications rates after surgical and non-operative treatment of avulsion fractures of the pelvis. RESULTS Mean age was 14,5 years with anterior inferior iliac spine avulsion representing the most common injury (46%), followed by anterior superior iliac spine avulsion (32%), ischial tuberosity avulsion (12%) and iliac crest avulsion (11%). Rates of excellent outcome and return to sports at pre-injury levels were higher after surgical treatment; surgery has a higher risk of heterotopic ossification (9%) compared to conservative treatment (1,8%), whereas the risk of non-unions is lower (0% versus 2,5%). CONCLUSIONS Surgery is preferred for major dislocations and fragment sizes, providing a faster return to pre-injury level of activity, decreasing the risk of pseudoarthrosis. Conservative treatment is advisable for minimally displaced fractures when a rapid recovery is not required; patient and his family should be informed on the risk of non-unions and the eventuality of a delayed surgical approach.
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Affiliation(s)
- Filippo Calderazzi
- Dipartimento Scienze Chirurgiche Ospedale Maggiore Parma, U.O. Clinica Ortopedica.
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Anduaga I, Seijas R, Pérez-Bellmunt A, Casasayas O, Alvarez P. Anterior Iliac Spine Avulsion Fracture Treatment Options in Young Athletes. J INVEST SURG 2018; 33:159-163. [PMID: 30212230 DOI: 10.1080/08941939.2018.1483447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: The aim of this research is to perform a literature review of the treatments available for the anterior iliac spines avulsion fracture on the young subjects. Material and Methods: We performed a systematic literature search for studies on spines avulsion fractures in young subjects from January 1, 2013, to February 2018; abstracts were screened by a single reviewer. For those studies meeting the eligibility criteria, full-text articles were obtained. Results: From 112 studies found only six articles were included in this systematic review. All the studies belonged to level IV of scientific evidence. 64 patients suffered an anterior inferior iliac spine fracture while patients 36% patients suffered an anterior superior iliac spine fracture. 93.2% underwent conservative treatment and 6.8% underwent surgery. Conclusions: The anterior iliac spine avulsions fractures are rare injuries that occur in young male athletes and the conservative option is the most selected treatment modality.
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Affiliation(s)
- Iñigo Anduaga
- Anatomy Unit, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Roberto Seijas
- Anatomy Unit, Universitat Internacional de Catalunya, Barcelona, Spain.,Fundación García-Cugat, Barcelona, Spain.,Artroscopia GC, Hospital Quirón, Barcelona, Spain
| | | | - Oriol Casasayas
- Anatomy Unit, Universitat Internacional de Catalunya, Barcelona, Spain.,Bruguera Tennis Academy, Barcelona, Spain
| | - Pedro Alvarez
- Anatomy Unit, Universitat Internacional de Catalunya, Barcelona, Spain.,Fundación García-Cugat, Barcelona, Spain.,Artroscopia GC, Hospital Quirón, Barcelona, Spain.,Mutualidad Catalana de Futbolistas, Federación Española de Fútbol, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW Provide the reader with an evidence-based update on the importance of accurate diagnosis of commonly missed avulsion fractures of pelvis apophyses, the necessary imaging studies, the feared complications and the recent treatment recommendations. RECENT FINDINGS Accurate diagnosis of avulsion fractures of pelvis apophyses is high yield as misdiagnosis leads to improper treatment. They should be differentiated from muscle strain and apophysitis. These fractures are usually associated with good outcomes; however, missed diagnosis can lead to further displacement, nonunion, functional limitation, femoroacetabular impingement and infection. A/P and frog lateral pelvis radiograph show the fracture and its displacement in the majority of cases. Conservative treatment, consisting of a short period of rest and immobilization followed by passive stretching then progressive resisted activity before return to sports, is recommended in minimally displaced avulsions. Surgical treatment is favored in displaced fractures (>15 mm), as it is associated with quicker return to sports. SUMMARY Treating physicians should keep a high index of suspicion in pediatric and adolescent patients presenting with typical clinical exam findings. Pelvic Anteroposterior and frog leg radiographs are often diagnostic. Missed diagnosis can aggravate the prognosis of a usually benign condition. Adequate medical or surgical treatment should then be administered.
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Sinikumpu JJ, Hetsroni I, Schilders E, Lempainen L, Serlo W, Orava S. Operative treatment of pelvic apophyseal avulsions in adolescent and young adult athletes: a follow-up study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:423-429. [PMID: 29159479 DOI: 10.1007/s00590-017-2074-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/01/2017] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pelvic apophyseal avulsion can limit young athletes' performance for months and may result in permanent disability. Nonoperative treatment is most commonly preferred, while surgical management with reduction and fixation is reserved for selected cases. Our aim was to evaluate outcomes of operative management of pelvic apophyseal avulsions in a series of adolescents and young adult athletes. MATERIALS AND METHODS Operative room registries and medical records were reviewed to identify patients who received surgical treatment for pelvic apophyseal avulsions who were younger than 24 years and with a minimum of 12 month follow-up. RESULTS Thirty-two patients (16.8 years ± 2.6) were identified. The most common avulsion sites were anterior inferior iliac spine (34.4%, N = 11) and ischial tuberosity (34.4%, N = 11). Other avulsions were five cases (15.6%) of the pubic apophysis, four cases (12.5%) of the anterior superior iliac spine apophysis and one case of the iliac crest apophysis. Seventeen cases (53.1%) underwent surgery early, i.e., during the first 3 months after the acute injury. Twenty-two cases (68.8%) involved reduction with internal fixation, and six cases (18.8%) involved resection of the fragment. Twenty-six athletes (81.3%, N = 26) reported good outcomes and were able to return to preinjury sports level. Six patients (18.8%) had moderate outcome and reported activity limitations during high-level sports. Large displacement (> 20 mm) or delayed (> 3 months) surgery was not associated with inferior outcomes (P = 0.690 and P = 0.392, respectively). Injury side (P = 0.61) or gender (P = 0.345) did not affect outcomes. CONCLUSIONS Operative management of pelvic apophyseal avulsion results in return to the preinjury sports level in more than 80% of the cases. However, while both acute surgery for large displacement and delayed intervention for failed nonoperative treatment are generally successful in improving sports function in these cases, comparative studies are required to refine criteria for surgery. LEVEL OF EVIDENCE Case series, IV.
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Affiliation(s)
- Juha-Jaakko Sinikumpu
- Department of Pediatric Surgery and Orthopedics, Oulu University Hospital, POB 23, 90029 OYS, Oulu, Finland. .,Pedego Research Group, Medical Research Center Oulu, Oulu University, Oulu, Finland. .,Mehiläinen Sports Clinic, Oulu, Finland.
| | - Iftach Hetsroni
- Department of Orthopedic Surgery, Meir General Hospital, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ernest Schilders
- Fortius Clinic, FIFA Medical Centre of Excellence, London, UK.,Leeds Beckett University, Leeds, UK
| | | | - Willy Serlo
- Department of Pediatric Surgery and Orthopedics, Oulu University Hospital, POB 23, 90029 OYS, Oulu, Finland.,Pedego Research Group, Medical Research Center Oulu, Oulu University, Oulu, Finland
| | - Sakari Orava
- Sports Injury Research Center, Hospital NEO, Turku, Finland
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