Chronic Ischial Avulsion Fracture Excision With Primary Proximal Hamstring Repair: A Technique

Abstract

Ischial avulsion fractures classically occur in the pediatric population and are relatively uncommon. These injuries are treated conservatively; however, in cases where there is greater than 2 cm of displacement, surgical intervention is recommended. In some cases, displaced fractures are either misdiagnosed or proper treatment is neglected, and patients who transition into adulthood are left with chronic nonunions that can become a source of pain and disability. Here we present a surgical technique for a chronic ischial avulsion fracture nonunion that is excised, and the hamstring tendons are then primarily repaired to the ischium using suture anchors.

Technique Video

Video 1

This is a video for the surgical intervention for a patient with a chronic right sided ischial avulsion fracture. The patient is placed in the prone position with all bony prominences padded. After a standard sterile prep and drape of the right lower extremity, an 8 to 10 cm incision is made in the gluteal crease, overlying the right-sided ischium. Electrocautery is used to reveal the underlying gluteal fascia. The gluteal fascia is incised using dissecting scissors. A Schnitt is used to open the interval inferior to the gluteus maximus muscle, and a large retractor is placed. A sciatic neurolysis is performed. The chronic avulsion fracture is revealed using electrocautery. A combination of electrocautery and a cobb elevator is used to free the bony fragment. After removal, the eburnated surface of the ischium is revealed. A combination of curettes and osteotomes are used to create a bleeding bone bed on the native ischium. Next, two 2.8 mm Q-fix (Smith and Nephew, Andover, MA) double-loaded all-suture anchors are placed into the native ischium. From each anchor, 1 suture limb from 1 pair is passed through the hamstring tendon in a locking fashion while the other is left free. From the other suture pair from the same anchor, one limb is passed in a modified Mason-Allen technique, and the other limb is left free. This is repeated for the other anchor. Using the free limbs of the anchors, the tendon is delivered to the ischium. The corresponding suture limbs are tied, and the free ends are cut with a knife. After copious irrigation a multilayer closure is performed. Dermabond is placed on the skin and a dry sterile dressing. After surgery the patient is made flat foot weightbearing in a hip orthosis and is started on chemical anticoagulation. At the first postoperative visit the wound is evaluated, and an X-ray film is obtained. (Soundtrack: Morning Routine by Ghostrifter Official | https://soundcloud.com/ghostrifter-official Music promoted by https://www.chosic.com/free-music/all/Creative Commons CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0/)