Apophyseal avulsion fractures of the pelvis. A review

Surgical treatment of an old avulsion fracture of the ischial tuberosity and ischial ramus: A case report

BACKGROUND

Avulsion fracture of the ischial tuberosity is a relatively clinically rare type of trauma that is mainly incurred by adolescents during competitive sports activities. According to previous literature, the most commonly involved sports are soccer, sprinting, and gymnastics, in descending order. Dance-induced avulsion fracture of the ischial tuberosity and ischial ramus is extremely clinically rare.

CASE SUMMARY

A case of a neglected avulsion fracture of the ischial tuberosity and ischial ramus was diagnosed in a young female dancer who complained of pain and restricted movement of her right hip. She stated that she had suffered the injury while performing a split leap during a dance performance 9 mo prior. Eventually, she underwent surgery and obtained satisfactory treatment results.

CONCLUSION

Early diagnosis of these fractures is important to ensuring early proper treatment towards a quicker recovery. For old fractures with nonunion and chronic buttock pain, surgery is a preferred therapeutic choice with good treatment outcomes.

Bilateral Sleeve Fracture of the Patella in a Healthy 11-Year-Old Male: A Case Report

Bilateral sleeve fracture of the patella (SFP) in skeletally immature children is a rare injury. We report the case of a healthy 11-year-old male who suffered bilateral SFP while playing tag. The avulsed fragments of his left patella were highly comminuted. Open reduction and internal fixation (ORIF) were performed using suture anchors, and the knees were immobilized using a cylinder cast for three weeks. At the one-year follow-up assessment, both knees were found to have regained full strength with no extension lag. However, we observed malunion due to lateral shift of the avulsed fragment, cystic lesions, and clicking in the patella, and the patient experienced residual pain in the left knee. Based on this, we conclude that the sleeve fracture of the patella with comminuted cartilaginous fragments was difficult to treat and might have led to poor clinical results if anatomical reduction and fixation had not been performed.

Surgical management of paediatric pelvic fractures: a prospective case series and early experience from a level one Egyptian trauma centre

PURPOSE

We aimed to report our early experience treating paediatric pelvic fractures (PPF) surgically, reporting on indications, outcomes, and complications.

METHODS

Patients aged 0-15 with PPF treated surgically at a level I trauma centre were included prospectively between 2016 and 2018. Fractures were classified according to AO/OTA classification system. Functional evaluation was performed using a modification of the Majeed functional scoring system. Radiological evaluation of vertical and posterior displacement was performed according to Matta and Tornetta criteria and the method described by Keshishyan et al. for assessing pelvic rotational asymmetry.

RESULTS

We included 45 patients (77.8% males and 22.2% females), with a mean age of 9.53 ± 3.63 and 19.87 ± 8.84 months of mean follow-up. The functional outcome was excellent in 42 (93.3%) patients, good in two (4.4%), and fair in one (2.2%). Radiologically, the vertical displacement improved from 5.91 ± 4.64 to 3.72 ± 2.87 mm (p-value 0.065), the posterior displacement improved from 7.87 ± 8.18 to 5.33 ± 13.4 mm (p-value 0.031), and the symphyseal diastasis improved from 9.88 ± 7.51 mm to 7.68 ± 3.18 mm (p-value 0.071). Residual pelvic asymmetry improved from 1.2 ± 0.61 to 0.8 ± 0.7 (p-value 0.001). Complications occurred in 21 (46.7%) patients, 11 (24.4%) pin tract infection, six (13.3%) limb length discrepancy, two (4.4%) prominent metals, one (2.2%) subcutaneous haematoma, one (2.2%) infected ISS.

CONCLUSIONS

We achieved acceptable functional and radiological outcomes after surgically treating a group of patients with PPF, which was relatively safe with minimal complications. The proper approach and fracture fixation tool should be tailored according to the fracture classification and the presence of associated injuries.

Apophyseal Avulsion of the Rectus Femoris Tendon Origin in Adolescent Soccer Players

Apophyseal avulsions of the rectus femorus tendon (RFT) at the anterior inferior iliac spine (AIIS) can occur in adolescents, often while performing soccer. Patient-reported outcomes (PROMs) and time to return to sport of these patients are relatively unknown. Therefore, the aim of this study was to assess the PROMs and return to sports of patients with AIIS avulsions and compare the results with those reported in the literature. This is a case series of seven consecutive patients presenting at our hospital between 2018 and 2020 with an apophyseal avulsion of the RFT from the AIIS. The patients were assessed with use of the WOMAC and Tegner scores and return to sports was evaluated. All patients were male soccer players (median age 13 years; range, 12–17). They were all initially treated non-operatively. One of the patients subsequently needed excision surgery of a heterotopic ossification because of non-transient hip impingement. All other patients recovered after a period of relative rest. Median time to return to sports was 2.5 months (range, 2–3). At a median follow-up of 33 months (range, 18–45), the WOMAC (median, 100; range, 91–100) and Tegner scores (median, 9; range, 5–9) were high. In accordance with the existing literature, most patients with apophyseal avulsions of the AIIS recover well with non-operative treatment. However, the avulsion can lead to hip impingement due to heterotopic ossifications possibly needing surgical excision. Sport resumption is achievable after 2–3 months, and patient-reported outcomes are highly satisfactory in the long term.

Osteochondritis Lesions of the Ischiopubic Area in Young Adolescents

Osteochondritis of the ischiopubic area is a rare disease of children that presents with hip pain and limping. Careful examination and appropriate investigations are essential to establish a definite diagnosis. We report a case series of four children, ages 10–14-year-old, with osteochondritis of the ischiopubic area. Plain X-ray examination showed an area of diffuse irregular calcification of the ischium in two of the children, while in the other two there was an asymmetrical enlargement of the ischiopubic synchondrosis. MRI investigation was the most helpful examination. Bone edema was found in all four children. A calcified mass separated from the host ischium was found in the first two children. The cortex was normal, without irregular destruction. Bone edema of both the ischium and pubic alongside the synchondrosis was found in the following two children, with intact cortices and asymmetrical enlargement. Osteochondritis lesions of the ischium and the ischiopubic area have radiological findings similar to several severe diseases. Bone edema on MRI investigation in children must be properly evaluated. Appropriate radiological examination enabled us to confirm the diagnosis of the osteochondritis and to avoid unnecessary procedures. We want to draw attention to the rare diagnosis of osteochondritis of the ischiopubic area, and the clinical significance, as a cause of hip pain and limping in children.

Avulsion Fracture of the Anterior Superior Iliac Spine in a Young Athlete Detected by Point-Of-Care Ultrasound

Pelvic avulsion fractures (PAFs) are common in adolescents. X-ray is commonly used to diagnose PAF, but the use of point-of-care ultrasound (POCUS) for this purpose in pediatric emergency departments has yet to be published. We reported herein a pediatric case of anterior superior iliac spine (ASIS) avulsion fracture detected by POCUS. A 14-year-old male patient visited our emergency department for groin pain he experienced during a game of baseball. POCUS of the right ilium demonstrated a hyperechoic structure anterolaterally displaced towards the ASIS, suggesting an ASIS avulsion fracture. X-ray of the pelvis confirmed the findings and led to the diagnosis of ASIS avulsion fracture.

[Apophyseal avulsion in the pelvic region in childhood and adolescence]

BACKGROUND

The importance of the apophyseal plates during growth is often underestimated. They act as a muscular insertion and influence the joint mechanics by the load-dependent change in shape.

PATHOMECHANISMS

An anatomically functional adaptation occurs as protection from overloading. In special kinds of sports with highly dynamic movements, sudden changes of direction and eccentric/concentric muscle activities the resulting stress may exceed the strength of the apophyseal plate. In adolescence this results in a total or partial tearing of the apophysis in the sense of an avulsion injury. In the pelvic region the ischial tuberosity, the anterior superior and inferior iliac spine are mainly affected.

DIAGNOSTICS

The medical history and clinical diagnostics are supplemented by conventional radiographic imaging. Sectional imaging diagnostics are usually unnecessary.

TREATMENT

Conservative management by reduced (partial) weight bearing and physiotherapy represents the gold standard in treatment. In cases with a fragment displacement >1.5-2.0 cm and in competitive athletes an open reduction should be considered.

Satisfactory clinical outcome of operative and non-operative treatment of avulsion fracture of the hamstring origin with treatment selection based on extent of displacement: a systematic review

PURPOSE

To compare outcome of operative and non-operative treatment of avulsion fractures of the hamstring origin, with minor (< 1.5 cm) and major (≥ 1.5 cm) displacement, and early (≤ 4 weeks) and delayed (> 4 weeks) surgery.

METHODS

A systematic literature search was performed using PubMed, Cochrane, Embase, CINAHL and SPORTDiscus. A quality assessment was performed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Eight studies with 90 patients (mean age: 16 years) were included. All studies had low methodological quality (PEDro score ≤ 5). Operative treatment yielded a return to preinjury activity rate (RTPA) of 87% (95% CI: 68-95), return to sports (RTS) rate of 100% (95% CI: 82-100), Harris hip score (HHS) of 99 (range 96-100) and a University of California Los Angeles activity scale (UCLA) score of 100%. Non-operative treatment yielded a RTPA rate of 100% (95% CI:68-100), RTS rate of 86% (95% CI: 69-94), HHS score of 99 (range 96-100), and non-union rate of 18% (95% CI: 9-34). All patients with minor displacement were treated non-operatively (RTPA: 100% [95% CI: 21-100], RTS: 100% [95% CI: 51-100]). For major displacement, operative treatment led to RTPA and RTS rates of 86% (95% CI: 65-95) and 100% (95% CI: 84-100), and 0% (0/1, 95% CI: 0-79) and 100% (95% CI: 51-100) for non-operative treatment. Early surgery yielded RTPA and RTS rates of 100% (95% CI: 34-100 & 57-100) compared to 100 (95% CI: 72-100) and 90% (95% CI: 60-98) for delayed repair.

CONCLUSION

All included studies have high risk of bias. There is only low level of evidence with a limited number of included patients to compare outcome of operative and non-operative treatment. Overall outcome was satisfactory. There is a treatment selection phenomenon based on displacement, with acceptable outcome in both groups. There is insufficient data to draw conclusions regarding timing of surgery.

LEVEL OF EVIDENCE

IV.

Capsular management in the arthroscopic treatment of the femoro-acetabular impingement in athletes: our experience

Background and aim of the work:

In the last decade, thanks to the improvement of the surgical techniques, arthroscopic treatment of hip diseases has significantly spread and evolved and currently it represents the gold standard for the treatment of femoral-acetabular impingement. In the recent years, the function of the joint capsule (and therefore the results of an arthroscopic capsulotomy) has been better understood, opening a heated debate. The Literature is still torn about a proper capsular management and the need for a capsular suture, but latest studies are more oriented to its execution at the end of the surgical procedure. According to these recent studies, the joint capsule performs an essential function on primary stability, so a conservative capsulotomy and its final closure are therefore reccomended to restore the native anatomy and physiology. Although capsular management remains a controversial topic, in recent years we have developed a new conservative capsulotomy technique associated with a final capsular suture. The aim of the present retrospective study is to assess the influence of different capsulotomy techniques and a possible capsular suture role on the patient’s functional outcome in a cohort of patients with femoral-acetabular impingement arthroscopically treated.

Hypothesis:

Our hypothesis is that a conservative “longitudinal” capsulotomy with a proper capsular suture positively influences the patient’s functional outcome in athletes.

Methods:

36 patients (competitive athletes) treated with hip arthroscopy for femoral-acetabular impingement have been retrospectively enrolled at the Orthopaedic Clinic of Academic Hospital of Udine during a period of two years (2016-2018); collected data have been analyzed and compared with a retrospective model. Patients have been divided into three equivalent groups, 12 without a suitable capsular management (T-Capsulotomy technique), 12 performing a Longitudinal Capsulotomy but without a final suture and 12 treated with a conservative Longitudinal Capsulotomy and a capsular suture. Patient’s post-operative functional outcome has been analysed using the modified Harris Hip Score (mHHS), the Hip Outcome Score-Activity of Daily Living (HOS-ADL) and the Hip Outcome Score-Sport Scale (HOS-SS). Return to sport.

Results:

In our series there was no statistically significant difference in functional scores, however longitudinal capsulotomy seems to be associated with a higher percentage of return to sports activity (91,6% vs 75%).

Conclusions:

The new longitudinal shape capsulotomy technique and a capsular suture with a single side-to-side stitch at the end of the procedure in athletes can positively influence the patient’s functional outcome. (www.actabiomedica.it)

Efficacy and safety of viscosupplementation with hyaluronic acid for hip osteoarthritis: results from a cross-sectional study with a minimum follow-up of 4 years

Background and aim of the work:

Osteoarthritis is the most common cause of disability in elderly. Hip osteoarthritis is the second most frequent form affecting a large joint and the social and economic impact on society of its related disability is expected to increase. The purpose of this study was to verify the efficacy and safety of ultrasound-guided viscosupplementation with high weight hyaluronic acid in hip osteoarthritis.

Methods:

183 patients with painful hip OA (Kellgren-Lawrence 1-2-3) were treated from January 2014 to December 2016 with viscosupplementation. Patients were evaluated before injection (T0) and after 1,2,3,4 (T1-T2-T3-T4) years through the VAS scale and Harris Hip Score (HHS). Patients who underwent to subsequent injections were followed and assessed. Subjects who underwent prosthesis were analyzed for a minimum of 6 months in order to detect any early postoperative complication.

Results:

The mean improvement of HHS and VAS between T0 and T1 was statistically significant. Patients who underwent subsequent injections showed a higher improvement even if statistical significance was not observed. Results showed that patients with grade 2 of osteoarthritis had the higher change in the scores. No adverse effects were registered. No early complications were reported in those patients who needed prosthesis.

Discussion and Conclusions:

Results observed confirm that ultrasound-guided viscosupplementation with high weight hyaluronic acid could be a possibility in the treatment of hip osteoarthritis, especially in patients with Kellgren-Lawrence grade 2 of disease. Subsequent injections are not characterized by similar positive effects. Outcomes of prosthetic surgery are not influenced by viscosupplementation.

Osteochondroma formation after avulsion fracture of anterior inferior iliac spine: A case report

BACKGROUND

Hip avulsion fractures occur mostly during adolescence when actions such as kicking or running cause forceful contraction of attached muscle. Osteochondroma is benign tumor that mostly occurs at the metaphysis of a long bone, being usually asymptomatic.

CASE SUMMARY

A 15-year-old patient experienced feeling and sound of a break while kicking a ball in soccer game three years prior to his visit to our hospital. A simple X-ray revealed an avulsion fracture of the apophysis of the anterior inferior iliac spine (AIIS). Later in the follow-up X-ray, a palpable mass was found and demonstrated by magnetic resonance imaging to be a pedunculated osteochondroma in the superolateral aspect of the AIIS. For surgical treatment, we performed osteotomy for surgical excision and excisional biopsy. A mass with smooth surface and an unclear superolateral AIIS border was found intraoperatively. Pathologic exam showed definite diagnosis of osteochondroma. Postoperatively, discomfort during hip flexion was improved, and the hip joint range of motion during walking was recovered at the last follow-up, which was three weeks after the surgery.

CONCLUSION

This is a rare case to demonstrate relevant previous trauma history prior to the formation of osteochondroma.

Pelvic ring fractures: what about timing?

BACKGROUND AND AIM

Pelvic ring fractures represent a challenge for orthopaedic surgeon. Their management depends on patient's condition, pattern of fracture and associated injuries. Optimal timing for synthesis is not yet clear. The aim of this study was to define if surgical timing influenced clinic and radiographic outcomes following open reduction and internal fixation for Tile B and C fractures.

MATERIALS AND METHODS

38 patients were included. Patients underwent a clinical examination with the Majeed Score, Iowa Pelvic Score and Orlando Pelvic Score. The radiographic assessment was performed according to Matta Pelvic Score. A statistical analysis of the data compared patients who were operated within 3 weeks (group 1) and those operated later (group 2).

RESULTS

Both clinical and radiological outcomes were influenced by timing of surgery.

CONCLUSION

Pelvic ring fractures interest many polytrauma patients and, therefore, their surgical orthopedic approach is frequently delayed as consequence of the severity of the associated clinical conditions. An early surgery of pelvic rong fractures allows a better quality of reduction and osteosynthesis.

Rectus femoris myotendinous lesion treated with PRP: a case report

BACKGROUND AND AIM OF WORK

Musculoskeletal injuries are the most common cause of severe, chronic pain and physical disability for the majority of all sport-related injuries. Platelet-rich plasma is being used more frequently to promote healing of muscle injuries. We report a case of 39 years old non professional soccer player who came to our attention for a quadriceps muscle pain onset after kicking the ball during a match.

METHODS

Clinical and instrumental evaluation revealed a myotendinous junction rupture of the rectus femoris with retraction of 1.5 cm from the anterior inferior iliac spine. We decided to treat the patient with PRP ultrasound guided injections and a specific rehabilitation protocol.

RESULTS

Clinical evaluation 45 days following the end of the treatment showed the resolution of the pain and the full recovery of strength and range of motion. Muscle healing was documented by magnetic resonance imaging.

CONCLUSIONS

Even if the role of PRP in muscle injury is not still clear, the result observed confirms that it could be used in the treatment of muscle lesions.

Surgical or conservative treatment in ARGP syndrome? A systematic review

Background and aim of the work: The rectus-adductor syndrome is a common cause of groin pain. In literature the adductor longus is reported as the most frequent site of injury so that the syndrome can be fitted into the adductor related groin pain (ARGP) group. The aim of this study was to define what is the best treatment between surgical and conservative in athletes affected by ARGP in terms of healing and return to play (RTP) time. Methods: A systematic review was performed searching for articles describing studies on RTP time for surgical or conservative interventions for ARGP. A qualitative synthesis was performed. Only 10 out 7607 articles were included in this systematic review. An exploratory meta-analysis was carried out. Due to high heterogeneity of the included studies, raw means of surgery and conservative treatment groups were pooled separately. A random effects model was used. Results: The results showed quicker RTP time for surgery when pooled raw means were compared to conservative treatments: 11,23 weeks (CI 95%, 8.18,14.28, p<0.0001, I^2=99%) vs 14,9 weeks (CI 95%, 13.05,16.76, p<0.0001, I^2 = 77%). The pooled results showed high statistical heterogeneity (I^2), especially in the surgical group. Conclusions: Surgical interventions are associated with quicker RTP time in athletes affected by ARGP, but due to the high heterogeneity of the available studies and the lack of dedicated RCTs this topic needs to be investigated with dedicated high quality RCT studies. (www.actabiomedica.it)