Delayed proximal hamstring tendon repair after ischial tuberosity apophyseal fracture in a professional volleyball athlete: a case report

Background Ischial tuberosity apophyseal fractures are avulsion fractures of the anatomic footprint of the proximal hamstring tendons. Generally, these injuries are rare and frequently occur in skeletally immature, active patients due to incomplete ossification. Depending on the fragment displacement, non-operative or operative treatment approaches are used. Case presentation We report a case of a 29-year-old professional volleyball athlete who has suffered from a nonunion avulsion fracture for 14 years. Isolated suture anchor fixation was performed after open excision of a large bony fragment followed by excellent clinical and functional outcome at 1 year postoperatively. Conclusion In conclusion, avulsion fractures of the ischial tuberosity with large fragments and restrictions to activities of daily living due to pain can, in individualized cases, be treated with an open excision of the fragment followed by repair of the proximal hamstring tendons using suture anchors.

POS1278 THE PREVALENCE AND CLINICAL SIGNIFICANCE OF ULTRASONOGRAPHIC FINDINGS OF DISTAL MEDIAL HAMSTRING TENDONS IN PATIENTS WITH POSTEROMEDIAL KNEE PAIN

Background:Periarticular abnormalities are common ultrasonographic (U/S) findings in individuals with knee pain. Incidental U/S observations, including thickening of the distal hamstring tendons, require explanations for their clinical importance. Tendon thickness may be a good indicator of tendinopathy and tendon dysfunction. Also, it is uncertain whether these tendon changes are correlated with knee pain or not?Objectives:The aim of this study was to determine U/S findings of distal medial hamstring tendons in patients with posteromedial (PM) knee pain and assess the diagnostic values of tendon thickness in predicting tendinopathy.Methods:We studied distal medial hamstring tendons (semimembranosus [SM] and semitendinosus [ST]) of 104 patients (104 knees) with non-traumatic unilateral PM knee pain and 118 healthy controls (236 knees). U/S evaluations included tendon thickness, echogenicity, the presence of intrasubstance tears, calcification, and vascularity.Results:The mean age (standard deviation) of the patients and control groups were 51.7 (10.4) years and 49.8 (9.9) years, respectively. The mean visual analogue scale (VAS) for pain among patients was 5.1 and 58.6% of them located the pain at medial joint line. The studied patients had significantly higher mean SM thickness (7.17 mm vs. 5.46 mm, respectively) and ST thickness (3.93 mm vs. 3.45 mm, respectively) than the controls. U/S abnormalities among patients were hypoechogenicity (62.5%), intrasubstance tears (31.7%), loss of fibrillar pattern (23.1%), Baker cyst (20.2%), calcification (18.3%), Anserine bursitis (11.5%), and neovascularization (6.7%). We found significant correlations between tendon thickness and VAS (r=0.752, p=0.004), and pain location (r=0.680, p=0.008). SM thickness had higher accuracy to predict tendinopathy than ST thickness (80.6% vs. 68.9%, respectively).Table 1.Diagnostic values of tendon thickness in predicting tendinopathy.TendonsCutoffSensitivitySpecificity+PV-PVAccuracyAUCSM>6.670.289.885.776.880.60.835ST>3.756.779.671.167.668.90.696SM: semimembranosus, ST: semitendinosus, +PV: positive predictive value, -PV: negative predictive value, AUC: area under curve.Conclusion:U/S changes are frequently present in patients with PM knee pain. Tendon thickness is an accurate predictor of tendinopathy. These findings suggest that U/S screening of all individuals with PM knee pain is a useful tool for improving patients’ outcomes and decreasing tendon-related disability.Disclosure of Interests:None declared

A modified oblique incision in hamstring tendon graft harvesting during ACL reconstruction

Background During anterior cruciate ligament (ACL) reconstruction, different methods of harvesting hamstring tendon may lead to different degrees of injury to the inferior patellar branch of the saphenous nerve (IPBSN). Most of recent studies in the literature suggest that the classic oblique incision (COI) can reduce the incidence of IPBSN injury. We proposed a modified oblique incision (MOI) and compared it with the COI in terms of the resulting levels of injury and sensory loss and the clinical outcome. Methods Patients with ACL injury admitted to our hospital from April 2015 to July 2019 were randomly selected and included in our study. Thirty patients underwent the COI to harvest hamstring tendons, and the other 32 patients underwent the MOI. The pin prick test was performed to detect the sensation loss at 2 weeks, 6 months, and 1 year after the operation. Digital photos of the region of hypoesthesia area were taken, and then, a computer software (Adobe Photoshop CS6, 13.0.1) was used to calculate the area of the hypoesthesia. The length of the incision and knee joint functional score were also recorded. Results At the final follow-up, the incidence of IPBSN injury in COI and MOI were 33.3% and 9.4%, and the areas of paresthesia were 26.4±2.4 cm2 and 9.8±3.4 cm2 respectively. There was no significant difference in the incision length or knee functional score between the two groups. Conclusion The MOI can significantly reduce the risk of injury to the IPBSN, reduce the area of hypoesthesia, and lead to high subjective satisfaction. Therefore, compared with the COI, the MOI is a better method of harvesting hamstring tendons in ACL reconstruction.

Outcomes of one-stage reconstruction for chronic multiligament injuries of knee

Purpose This article aims to evaluate patterns of chronic multiligament injuries and outcomes of treatment with single-stage reconstruction using autografts. Methods All patients with clinicoradiologically diagnosed multiligament knee injury (MKI) were included in this prospective observational study. As the time since injury was more than 6 weeks in all of the patients, they were categorized as having chronic MKI. Patients were assessed clinically for laxity, and the diagnosis was confirmed radiologically. Ipsilateral hamstring tendons were used for medial collateral ligament (MCL) or posterolateral corner reconstruction in a patient with Schenck knee dislocation (KD) type III. In these cases, the posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) were reconstructed by using the peroneus longus and contralateral hamstring tendons respectively. Ipsilateral hamstring tendons were used for ACL reconstruction and an ipsilateral peroneus longus tendon graft was used for reconstruction of the PCL in a KD type II injury. In two cases of KD type IV injury, the lateral laxity was only grade II and was managed conservatively; the rest of the ligaments were addressed like a KD type III injury. Outcome evaluation was done using a visual analogue scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity level, preoperatively and postoperatively at 2 years’ follow-up. Results A total of 27 patients of mean age 33.48 ± 9.9 years with MKI were included in the study. The patients were classified as eight KD type II, 17 KD type III, and two KD type IV. The majority of the patients had associated meniscal (59.2%) or chondral (40.7%) injuries. At the 2 years’ follow-up visit, there were significant improvements in VAS score (p = 0.0001) IKDC score (p = 0.0001), Lysholm score (p = 0.0001), and range of motion (p = 0.001). None of the patients had residual laxity on clinical examination of the knee joint at the 2 years’ follow-up. All but two of the patients went back to their previous activity level. These two patients had progressive knee arthritis and needed knee arthroplasty. Conclusion Single-stage surgical reconstruction for chronic MKI has favourable functional outcomes. Level of evidence Level IV, case series.