Chronic Ischial Apophyseal Avulsion. Surgical Treatment with Achilles Allograft Volume 53- Issue 5

Santos Ledo Ciro¹ and Rebeca García Barcenilla^2*

• ¹Sierrallana Hospital, Torrelavega, Spain
• ²Marqués de Valdecilla University Hospital, Santander, Spain

Received: October 30, 2023; Published: November 22, 2023

*Corresponding author: Rebeca García Barcenilla, Marqués de Valdecilla University Hospital, Santander, Spain

DOI: 10.26717/BJSTR.2023.53.008465

Abstract PDF

Hamstring injuries are among the most common injuries in sports. The majority of them happen at the myotendinous junction but a low percentage are avulsions at the proximal insertion. Even though most of them usually respond fairly to a conservative management, some of them will experience chronic debilitating pain and weakness [1,3].

We present the case of a 25 years-old male who was diagnosed with a muscle strain of the hamstring as a young athlete.

A 25-years-old male is referred complaining about functional impairment and inability to perform recreational sports, radicular pain along the sciatic nerve and buttock pain while sitting. He has a history of a pubity muscle strain to the hamstring while practicing sports that was never studied appropriately, Physical exploration demonstrated a palpable painful mass around the ischiatic tuberosity as well as knee flexion weakness on prone position. Patient had a positive Tinel sign around the proximal sciatic nerve but presented no sensory or motor deficit. MRI, CT and simple radiograph study of the pelvis was obtained and the patient was diagnosed with a chronic avulsion of the ischial tuberosity and secondary hypertrophic ossification as shown on (Figure 1). With the diagnosis of a Type 1 (David G. Wood classification) lesion [1] and failure of conservative treatment decision was made for a surgical repair. Under general anesthesia and with the patient on prone position and “L-shaped” incision was performed on the posterior aspect of the thigh. Direct identification of the sciatic nerve, neurolysis and removal of the scar tissue around was performed; identification with a vessel loop and protection through the rest of the procedure [2] (Figure 2). Attention was paid later to identification of the hypertrophic ossification and avulsion of the hamstring tendons. Removal of the ossification and mobilization of the tendons was performed [4] but a persistent gap remained so decision was made to perform a reconstruction with Achilles allograft.

Figure 1

Figure 2

The ischial tuberosity was first debrided and then the allograft (Figure 3) was secured with a 4.5 mm bioabsorbable implant (Figure 4) [1,2]; afterwards the allograft was sutured to the remains of the proximal hamstring insertion after testing the correct tension (Figure 5). Patient was placed on a pelvic-thigh-hip orthosis on post operative day and was kept on it for 6 weeks, after which progressive movement was allowed. Rehabilitation was started at week 8 with progressive hip and knee motion and strengthening programs. Patient experienced hypoesthesia with a positive Tinel sign on the posterior femorocutaneous nerve [1] since postoperative day 1. At 1 year follow-up patient referred no symptoms of radicular pain or pain while sitting and has been able to return to sports with minimal pain. Although Tinel of the posterior femorocutaneous nerve resolved, persistent discomfort and hypoesthesia remained around the scar. Post operative X-Ray at follow-up show mild heterotopic ossification around the Achilles reconstruction (Figure 6). Most hamstring injuries consist of mild strains of the muscles or myotendinous junction that perform well with conservative management [1]. Apophyseal injuries represent an uncommon form of hamstring injuries that happen on skeletally immature patients [1-3] that deserve particular attention as they can produce chronic impairment due to secondary displacement, hypertrophic ossification and symptoms of radicular irritation [1,4].

Figure 3

Figure 4

Figure 5

Figure 6

1. Wood DG, Packham I, Trikha SP, Linklater J (2008) Avulsion of the proximal hamstring origin. J. Bone Jt. Surg. Am. 90 (11): 2365-2374.
2. Ali AM, Lewis A, Sarraf KM (2020) Surgical treatment of an ischial tuberosity avulsion fracture with delayed presentation. J Clin Orthop Trauma 11 (Suppl 1): S4-S6.
3. Gidwani S, Bircher MD (2007) Avulsion injuries of the hamstring origin - a series of 12 patients and management algorithm. Ann R Coll Surg Engl 89 (4):394-399.
4. Sikka RS, Fetzer GB, Fischer DA (2013) Ischial apophyseal avulsions: proximal hamstring repair with bony fragment excision. J Pediatr Orthop 33(8): e72-6.