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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.

Purpose The purpose of this study was to assess clinical and radiological outcome in patients after proximal hamstring tendon repair. We hypothesized that there is a significant correlation among subjective clinical outcome and interlimb asymmetries in muscle strength, fatty infiltration, and hamstring volume. Methods This retrospective monocentric case series included patients with surgical repair after proximal hamstring tendon rupture. Clinical outcome was assessed utilizing: Healthy Days Core Module (CDC HRQOL-4), numeric pain rating scale (NRS), modified Harris Hip Score (mHHS), Tegner Activity Scale (TAS), return to pre-injury activity level (RTPA), and patient satisfaction score. Postoperative hamstring strength was measured using a handheld dynamometer and radiological outcome was determined by postoperative magnetic resonance imaging (MRI). Results Twenty-seven patients with a mean age of 51.2 (± 12.6) years were available for follow-up at a mean of 41.11 (± 18.4) months. Patients state a mean of 10.6 (± 11.5) days in the unhealthy days (UHD) index and 88.9% show “good health” in the simple summary score (SSS). Mean subjective outcome scores were as follows: NRS 1.1 (± 2.4), mHHS 90.3 (± 14.8) and TAS 5.7 (± 2.2). A total of 59.3% RTPA and 88.9% state to be somewhat or very satisfied with their surgery. Mean interlimb strength ratio was 0.88 (± 0.21). MRI demonstrated a fully restored muscle–tendon unit, significantly greater fatty infiltration in the injured hamstrings ( p  = 0.009, d  = 0.558), and a mean interlimb hamstring volume ratio of 0.94 (± 0.11). With respect to the 10% benchmark, patients had no significant asymmetries in muscle strength ( p  = 0.677, d  = 0.084) or hamstring volume ( p  = 0.102, d  = − 0.34). Correlation analysis revealed moderate correlation among asymmetries in strength and volume ( p  = 0.073, r  = 0.373). In patients with the operated side inferior to the healthy side ( n  = 15), there was strong correlation among asymmetries in strength and volume ( p  = 0.002, r  = 0.725). Statistically significant correlation was found between interlimb muscle volume atrophy and increase in fatty infiltration ( p  = 0.015, r  = 0.481). Conclusion Proximal hamstring repair results in good clinical outcome with satisfactory recovery of hamstring strength and volume. Interlimb asymmetries, in terms of muscle strength, fatty infiltration, and hamstring volume do not correlate with clinical outcome. Study Type Retrospective cohort study; Level of evidence, 3.

Purpose Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique. Methods Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the “Graft” was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The “Tibial Tunnel” was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0–10. Tunnel and graft positioning were evaluated. Results At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months ( p  = 0.008) and 18-months ( p  = 0.028), the tunnel was significantly smaller ( p  < 0.05) and less enlarged at both follow-ups ( p  < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months ( p  < 0.05). The total score of the non-detached group saw a significant improvement at 4-months ( p  = 0.006) that remained stable at 18-months (n.s.). Conclusions Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient. Level of evidence IV.

ObjectiveThis study examines the correlation between MRI findings and difficult dissection during proximal primary hamstring repair and postoperative sciatica.Materials and methodsA total of 32 cases of surgically repaired hamstring tendon tears that underwent preoperative and postoperative MRI were divided into sciatica (n = 12) and control (n = 20) groups based on the presence or absence of postoperative sciatica. Cases were scored by two blinded musculoskeletal radiologists for imaging features associated with difficult surgical dissection and the development of subsequent sciatica. Intra- and interrater agreements, as well as correlation of MRI findings with symptoms (odds ratio, OR), were calculated.ResultsOn preoperative MRI, diffuse hamstring muscle edema pattern suggestive of active denervation (OR 9.4–13.6), and greater sciatic perineural scar circumference (OR 1.9–2) and length (OR 1.2–1.3) were significantly correlated with both difficult dissection and postoperative sciatica. Preoperatively, a greater number of tendons torn (OR 3.3), greater tear cross-sectional area (CSA, OR 1.03), and increased nerve T2-weighted signal (OR 3.2) and greater perineural scar thickness (OR 1.7) were also associated with difficult dissection, but not postoperative sciatica. On postoperative MRI, hamstring denervation, sciatic nerve tethering to the hamstring tendon, and development of perineural scar and greater perineural scar extent were all significantly correlated with postoperative sciatica.ConclusionPreoperative hamstring MRI demonstrates findings predictive of difficult sciatic nerve dissection; careful MRI evaluation of the nerve and for the presence and extent of perineural scar is important for preoperative planning. Preoperative and postoperative MRI both depict findings that correlate with postoperative sciatica.

Purpose The purpose of this study was to evaluate the differences in the patient-reported functional outcomes, and graft failure in revision ACL reconstruction using quadriceps tendon (QT), Hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts. Methods Between 2010 and 2020, 97 patients who underwent revision ACL reconstruction (40 patients received a QT, 26 an HT and 31 a BPTB graft) met the inclusion criteria. Pre-injury and at 2-year postoperatively patients were evaluated for patient-reported functional outcomes; Lysholm knee score, Tegner activity level and VAS (visual analogue scale) for pain; and graft failure. Patient-reported outcomes and graft failure were compared between the QT, HT and BPTB groups. The patients with graft failure were not included for outcome analysis at 2-years of follow-up. Results All three revision groups with QT, HT and BPTB autograft did not differ significantly in terms of age, sex, time from injury to surgery, concomitant injuries and single-stage or double-stage procedures (n.s.). No significant difference was found in the pre-injury patient-reported outcome; Lysholm knee score, Tegner activity and VAS for pain (n.s.) between the three groups. At the 2-year follow-up functional outcomes improved in all three groups and all the patients returned to pre-injury activity level; however, no significant difference was found in functional outcomes at the 2-year follow-up between the three groups (n.s.). Graft failure occurred in 4 (10%), 5 (19%) and 3 (10%) patients of QT, HT and BPTB groups, respectively. However, the rate of failure did not differ significantly between groups. Conclusion All three autografts (QT, HT and BPTB) demonstrated satisfactory patient-reported outcomes in revision ACL reconstruction. Compared with QT and BPTB grafts, HT graft showed a higher tendency for failure rates. With the increasing incidence of revision ACL reconstruction, surgeons should be aware of all the available graft options. The findings of this study will assist the surgeons in the graft selection for revision ACL reconstruction. Level of evidence Level III.

ObjectiveTo prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions.MethodsPatients with an MRI-confirmed proximal hamstring tendon avulsion were included. Operative or non-operative treatment was selected by a shared decision-making process. The primary outcome was the Perth Hamstring Assessment Tool (PHAT) score. Secondary outcome scores were Proximal Hamstring Injury Questionnaire, EQ-5D-3L, Tegner Activity Scale, return to sports, hamstring flexibility, isometric hamstring strength and MRI findings including proximal continuity.ResultsTwenty-six operative and 33 non-operative patients with a median age of 51 (IQR: 37–57) and 49 (IQR: 45–56) years were included. Median time between injury and initial visit was 12 (IQR 6–19) days for operative and 21 (IQR 12–48) days for non-operative patients (p=0.004). Baseline PHAT scores were significantly lower in the operative group (32±16 vs 45±17, p=0.003). There was no difference in mean PHAT score between groups at 1 year follow-up (80±19 vs 80±17, p=0.97). Mean PHAT score improved by 47 (95% CI 39 to 55, p<0.001) after operative and 34 (95% CI 27 to 41, p<0.001) after non-operative treatment. There were no relevant differences in secondary clinical outcome measures. Proximal continuity on MRI was present in 20 (95%, 1 recurrence) operative and 14 (52%, no recurrences) non-operative patients (p=0.008).ConclusionIn a shared decision-making model of care, both operative and non-operative treatment of proximal hamstring tendon avulsions resulted in comparable clinical outcome at 1-year follow-up. Operative patients had lower pretreatment PHAT scores but improved substantially to reach comparable PHAT scores as non-operative patients. We recommend using this shared decision model of care until evidence-based indications in favour of either treatment option are available from high-level clinical trials.

Introduction Anterior cruciate ligament (ACL) reconstruction is one of the most common surgical procedures worldwide. However, the ideal graft source is still debatable. This study compared hamstring (HT) and bone-free quadriceps (QT) tendon autografts in terms of muscle strength and patient-reported outcomes. Methods Between June 2018 and December 2019, 46 patients were enrolled in the study and randomly assigned to one of two groups for the ACL reconstruction surgery—the HT autograft group or the QT autograft group. An experienced examiner performed preoperative and postoperative examinations. The HUMAC NORM isokinetic machine (Computer Sports Medicine International-CSMI, 2004) was used to assess flexor and extensor thigh muscle strength. Both groups received the same surgical technique and fixation method. All patients were examined after three, six, nine, and 12 months. The final evaluations were performed at the 24-month follow-up. Patients’ scores on the International Knee Documentation Committee (IKDC) evaluation form and the Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. The two groups were also compared in terms of postoperative complications and activity levels. Results The difference between preoperative and postoperative knee flexor peak torques (FPT) was lower in the QT group than in the HT group. The average difference between preoperative and postoperative knee extensor peak torque (EPT) was higher in the QT group than in the HT group. As a result, the HT group had a lower postoperative H/Q ratio (flexor strength normalized to body mass divided by extensor strength normalized to body mass) than the QT group ( p  < 0.001). The mean IKDC scores for the HT and QT groups were 90.13 ± 6.99 and 87.12 ± 6.61, respectively. The scores of the two groups postoperatively were close, and both groups showed significant improvement. The average graft size in the QT group was significantly greater than that in the HT group. Saphenous nerve palsy was the most common complication in the HT group (22%). Thigh hematomas were observed in two patients in the QT group and required urgent intervention (12%). Conclusion After ACL reconstruction, we found a significant decrease in strength at the donor sites in both techniques, with similar patient-reported measures and stability outcomes. The H/Q strength ratio was higher in the QT group postoperatively, which may have a protective effect on the reconstructed ligament. Level of Evidence I It is a randomized controlled trial.

IntroductionComparable data of functional outcomes of anterior cruciate ligament reconstruction using either hamstring- or quadriceps tendon grafts is controversial. This prospective, randomized controlled trial aims to provide data comparing both grafts regarding the functional outcome.Materials and methodsA two centre trial involving symptomatic patients 18 years of age or older with an anterior cruciate ligament tear was conducted. We randomly assigned 27 patients to quadruple hamstring tendon reconstruction and 24 to quadriceps tendon reconstruction. The patients were evaluated preoperatively, at 3, 6, 12 and 24 months post-surgery. The primary outcome parameter was the side-to-side knee laxity measured with an arthrometer. Secondary outcomes included results in the International Knee Documentation Committee (IKDC) and Lysholm Scores and isokinetic testing of strength in knee extension and flexion.ResultsForty-four patients (86%) completed the 2-year follow-up. There was significantly improved knee stability at all time intervals with no difference between the two study groups. The manual side-to-side displacement improved by 4.7 ± 3.0 mm in patients with hamstring tendon reconstruction and 5.5 ± 2.9 mm in patients with quadriceps tendon reconstruction. In addition, muscle strength and outcome scores (IKDC and Lysholm Score) did not show any differences between the hamstring tendon group and the quadriceps tendon group. Patients in the hamstring tendon group returned to their pre-injury activity level after 95.2 ± 45.5 days while patients in the quadriceps tendon group needed 82.1 ± 45.6 days.ConclusionQuadriceps and hamstring tendon autografts yield comparably good results in primary anterior cruciate ligament reconstruction.

Aims This study presents clinical outcomes, functional results, and return to sports after anterior cruciate ligament (ACL) reconstruction using quadruple hamstring tendon autograft or peroneus longus tendon autograft in a randomized controlled trial. Patients and methods Between February 2018 and July 2019, patients who underwent ACL reconstruction were randomly assigned to two groups: hamstring and peroneus longus. Patient related outcome measurements and pain intensity were evaluated using IKDC, Lysholm, and visual analog scores at 3 and 6 months, 1, 2, and 5 years after the surgery. At the 5 year follow-up, anterior stability was tested using the 3D printable Knee Arthrometer. In addition, in the peroneus longus group, ankle functional assessment was performed using the American foot and ankle score. Additionally, data on the return to sports/activities was collected for both groups at the last follow-up. Results Sixty patients, with 30 in the hamstring group and 30 in the peroneus group, were included in the study. Patients were predominately male and with low activity demands. After five years of follow-up, there was no significant difference in functional assessment scores (IKDC and Lysholm) between the two groups (P n.s ). The median graft diameter was 7.9 ± 0.4 mm in the hamstring tendon group and 8.9 ± 0.2 mm in the PL group (P < 0.001). The improvement in Arthrometer testing measurements (AMT) for the operated knees in the hamstring and peroneus longus groups were similar. In the peroneus longus group, the mean postoperative foot and ankle score was 98.6 ± 3.9 (range = 85–100). Conclusion Using Peroneus longus tendon autograft for arthroscopic ACL reconstruction is a feasible alternative as studied in this cohort of predominately male patients with low activity demands. The graft diameter in this study was sufficient, and the results regarding laxity and patient related outcome measurements were similar to those achieved with hamstring tendon autografts. Level of evidence Level I Trial registration ChiCTR2000036989

Purpose The quadriceps tendon (QT) has recently gained interest as an anterior cruciate ligament reconstruction (ACLR) autograft. There is a paucity of data from large cohort studies on failures and revision rates after ACLR using the QT graft. The purpose of the present study is to use the Danish Knee Ligament Reconstruction Registry (DKRR) to compare revision rates, objective knee stability and subjective clinical outcomes in patients who have undergone ACLR with QT, hamstring tendon (HT), and patellar tendon (PT) as a graft for ACLR. It was hypothesized that QT autografts would result in similar objective knee stability and revision rates as HT and PT autografts. Methods Data on primary ACLRs in the DKRR from 2005 through 2017 were analyzed. Knee injury and Osteoarthritis Outcome Scores (KOOS), Tegner activity scale scores, sagittal knee laxity, pivot-shift tests at 1-year follow-up and revision rates at 2-year follow-up were compared for the three autograft cohorts. Results A total of 531 QT, 14,213 HT and 1835 PT ACLR were registered in the DKLR between 2005 and 2017. QT autograft was associated with statistically significant increased laxity (1.8 mm) compared to HT autograft (1.5 mm) ( p  < 0.001) and more positive pivot shift. There was a significant higher revision rate for QT (4.7%), compared to PT (1.5%) and HT (2.3%) autografts at 2-year follow-up ( p  < 0.002). Conclusion Quadriceps tendon autografts for ACLR was associated with higher revision rates than HT and PT grafts. QT graft was also associated with small increased objective knee laxity and more positive pivot shift than HT and PT grafts. Level of evidence III