Adults Ischium Age Estimation Based on Deep Learning and 3D CT Reconstruction.

OBJECTIVES: To develop a deep learning model for automated age estimation based on 3D CT reconstructed images of Han population in western China, and evaluate its feasibility and reliability. METHODS: The retrospective pelvic CT imaging data of 1 200 samples (600 males and 600 females) aged 20.0 to 80.0 years in western China were collected and reconstructed into 3D virtual bone models. The images of the ischial tuberosity feature region were extracted to create sex-specific and left/right site-specific sample libraries. Using the ResNet34 model, 500 samples of different sexes were randomly selected as training and verification set, the remaining samples were used as testing set. Initialization and transfer learning were used to train images that distinguish sex and left/right site. Mean absolute error (MAE) and root mean square error (RMSE) were used as primary indicators to evaluate the model. RESULTS: Prediction results varied between sexes, with bilateral models outperformed left/right unilateral ones, and transfer learning models showed superior performance over initial models. In the prediction results of bilateral transfer learning models, the male MAE was 7.74 years and RMSE was 9.73 years, the female MAE was 6.27 years and RMSE was 7.82 years, and the mixed sexes MAE was 6.64 years and RMSE was 8.43 years. CONCLUSIONS: The skeletal age estimation model, utilizing ischial tuberosity images of Han population in western China and employing the ResNet34 combined with transfer learning, can effectively estimate adult ischium age.

Ischial Tuberosity Avulsion Fracture Mimicking Calcified Mass on Plain Films: A Case Report.

Ischial tuberosity avulsion fractures are overall uncommon but are known injuries in the adolescent population. They are the result of sudden, forceful contraction of the hamstring muscle groups. The characteristic radiographic appearance of an ischial tuberosity avulsion fracture is of an irregular ischial margin and a nearby avulsed bone fragment. Callous formation may ensue and appears as a calcific density in the region of injury. Awareness of the spectrum of radiographic presentations can help ensure correct diagnosis and minimize concern for alternative underlying diagnoses. This case report describes a 14-year-old boy with a chronic ischial tuberosity avulsion fracture which demonstrated an unusual presentation on radiographs and required MRI to confirm the diagnosis and rule out other potentially ominous pathology.

Assessment in location of sciatic nerve between the ischial tuberosity and the greater trochanter of the femur: A cadaveric study.

Background: The location description of the sciatic nerve (SN) of adult between the ischial tuberosity (IT) and the greater trochanter of the femur (GT) is inconsistent in publications, this impels us to investigate and measure the distance relationship with SN between IT and GT. Methods: Thirty-one adult cadavers were dissected to investigate the distance relationship of SN with the posterior prominent position of the ischial tuberosity (ppIT), the medial edge of IT (mIT) and the lateral prominent position of GT (lGT). Results: SN passed through the point of the junction of medial one-third and middle one-third of a length from ppIT to lGT, and the midpoint of a length from mIT to lGT from the average data of the total studied cadavers. From average data of female and male, the left SN passed through the point of the junction of the medial two-fifths and the lateral three-fifths of the length between mIT and lGT. Between ppIT and lGT, SN located in a range of proportions from 0.1 to 0.6 from medial to lateral. Between mIT and lGT, SN located in a range of proportions from 0.2 to 0.7 from medial to lateral and all SN passed through the middle third of the length. Conclusions: Different bony landmarks draw different location descriptions of anatomic structure. In anatomic study and clinical practice, the utilized bony landmark should be clearly and accurately identified the reference point, inaccurate bony landmark can result in erroneous localization of the interested anatomic structure and lead to operation failure or iatrogenic injury.

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.

The Transverse Mechanical Axis of the Pelvis for Post-Operative Evaluation of Total Hip Arthroplasty.

Currently, orthopedic surgeons mainly use the inter-teardrop line (IT-line) as the transverse mechanical axis of the pelvis (TAP) for postoperative evaluation of total hip arthroplasty (THA). However, the teardrop is often unclear in the pelvis anteroposterior (AP) radiographs, which makes postoperative evaluation of THA difficult. In this study, we attempted to identify other clear and accurate axes for postoperative evaluation of THA. We calculated the mean and standard deviation of these angles and tested the significance of these angles using t-tests. The inter-teardrops line (IT line) and the upper rim of the obturator foramen (UOF) had smaller angles with the IFH line. The bi-ischial line (BI line) was relatively inaccurate in measurements. We recommend using the IT line as the TAP when the lower boundary of the teardrops is clear and the shapes of the teardrops on both sides of the pelvis are symmetrical. When there is no deformation of the obturator foramen on pelvic AP radiographs, the UOF is also a good choice for the TAP. We do not recommend the BI line as the TAP.

Delayed Recovery after Nonoperative Treatment of an Avulsion Fracture of the Ischial Tuberosity in an Adolescent Gymnast with a History of Growth Hormone Deficiency: A Case Report.

Introduction: Avulsion fracture of the ischial tuberosity is uncommon. Patients typically present with symptoms consistent with hamstring strain. The purpose of this case report is to describe an avulsion fracture of the ischial tuberosity and subsequent recovery in an athlete with an endocrine disorder. Case Description: A 15-year-old United States of America Gymnastics level 9 gymnast presented with right hamstring pain after regular practice. She had been diagnosed with isolated growth hormone deficiency at age 4 and was treated with growth hormone replacement therapy until age 14. Six months before presentation, she experienced the insidious onset of dull, aching pain in her right hamstring, near the junction of the thigh and buttocks, that was believed to be the result of a chronic hamstring strain. The pain increased gradually over a year and was relieved with rest, massage, and dry needling. Two days before presentation, she felt a "snap" and pain while performing a switch leap during regular practice. She had sharp localized pain in the proximal hamstring with walking and sitting. She was diagnosed with a minimally displaced avulsion fracture of the ischial tuberosity. Outcome: With nonoperative treatment, the fracture healed at three months, which is longer than the expected six weeks. Although return to sports is expected three months after this injury, it did not occur until six months in this patient. She was unable to participate in competitive level 9 gymnastics until 12 months after injury. Discussion: This case highlights that delayed recovery can occur after avulsion fracture of the ischial tuberosity in adolescent athletes with a history of growth hormone deficiency and treatment using growth hormone. Level of Evidence: 5.

CO2 Laser Debridement and Negative Pressure Wound Therapy With Endoscopic Support for Treatment of Sinus Wound at the Ischial Tuberosity: Case Report.

The sinus tract of the ischial tuberosity is often caused by pressure injury. It has the characteristics of difficult treatment and high cost, which increases the anxiety of patients and reduces the quality of life of patients. This case report is to describe an effective method to treat sinus wound at the ischial tuberosity. A 53-year-old male suffered pressure ulcer with sinus wound at the left ischial tuberosity due to inadequate walking and sedentary activity. On the basis of pressure relief and immobilization, the patient was treated with CO2 laser debridement and negative pressure wound therapy under endoscope support 3 times, the deep of the sinus wound was completely closed, and then the residual superficial wound was treated by skin grafting. Follow-up of 1 year after healing showed no recurrence of wound.

An Uncommon Ischial Tuberosity Tuberculosis Infection.

Introduction: Ischium is one of the rare sites to be involved by mycobacterium tuberculosis. The incidence is generally not more than 0.2% in any of the large series. We report an unusual case of extrapulmonary tuberculosis of the ischial tuberosity presenting with chronic gluteal pain of 6 months duration. Case Report: A 35-year-old male patient presented with chronic dull aching gluteal pain of 6 months duration, for which lifestyle modifications and rest were advised initially. Antituberculosis chemotherapy was administered (for a period of 1 year) following histopathological confirmation of tuberculosis. At 1 year post antitubercular therapy, the patient had no pain and was symptom free. Furthermore, radiographs showed healed right ischial tuberosity osteomyelitis. Conclusion: Tuberculosis involving the ischial tuberosity is rare. The early diagnosis is mandatory for good results, and with a worldwide resurgence of the disease, a high index of suspicion is necessary. Prompt diagnosis and treatment resulted in a good clinical outcome in this patient.

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.

Surgical repair techniques, functional outcome, and return to sports after apophyseal avulsion fractures of the ischial tuberosity in adolescents.

PURPOSE: Among juvenile apophyseal avulsion injuries of the pelvis in adolescents, fractures of the ischial tuberosity are rare but sustainably debilitating. Also because informations on surgical repair options are very sparse and so far limited to general reviews, reports of individual cases or heterogeous small case series, practitioners, patients and their parental environment still feel a comprehensible hesitation regarding operative treatment. Therefore we intended to investigate patient related outcome measurements and return to sports rates after different types of surgical intervention in an own case series, so far unprecendented in its size. METHODS: Patient data of adolescents that underwent surgical intervention for a displaced apophyseal avulsion fracture of the ischial tuberosity between 01/2015 and 12/2019 in our institution were gathered. Patients were then evaluated using the hamstring injury specific Perth Hamstring Assessment Tool (PHAT). Furthermore the return to sports level in comparison to the particular pre-injury level was rated. RESULTS: Eleven adolescents with an acute or chronic mean fragment dislocation of 3.3 cm (SD ± 1.7) underwent surgical intervention in the assigned period. The mean post-operative PHAT score was 86.9 (0-100, SD ± 11.9) and thus good to excellent. The majority of adolescents (10/11) was able to return to their pre-injury sports, whereas 63.6% achieved full or nearly full level. CONCLUSIONS: Surgical refixation or restoration of aphoyseal avulsion fractures of the ischial tuberosity result in good to excellent outcomes and return to sport rates, irrespective of the type of intervention. Here prompt diagnosis with a timely intervention seems more promising than delayed interventions in chronic cases. Beyond 1.5 cm of fragment displacement affected patients should be counselled for surgical intervention.

Avulsion fracture of the ischial tuberosity: A surgical dilemma.

The clinician should make the treatment choice considering the patient's requirements. Thus, surgical treatment can successfully achieve long-lasting satisfactory results and provide the best chance for a rapid return to sports.

Chemoprotection with botulinum toxin following proximal hamstring-Ischial tuberosity avulsion fracture repair: Running title: Chemoprotection for hamstring avulsion fractures.

INTRODUCTION: Surgical treatment for avulsion injuries of the proximal hamstrings has gained increasing popularity over the past decade. Despite good outcomes, early failures have been noted and have been attributed to slipping and falling, postoperative muscle spasm, or early mobilization. In a recent review of hamstring repair rehabilitation protocols, it was shown that there is marked variability in post-operative management. Post-operative bracing with limiting knee extension and hip flexion is the standard of care in most early rehabilitation protocols. Braces with limitation of hip flexion and knee locked in 900 flexion can be awkward, cumbersome and create fall risk.Chemoprotection has more recently been proposed to be an alternative approach to prevent tendon repair failure and controlled mobilization which has been shown to be superior to complete immobilization. We present the first case series of the use of botulinum toxin for chemo-protection of the proximal hamstring ischial avulsion repair, demonstrating its safety and efficacy. METHODS: Retrospective case series at a tertiary children's hospital which included patients <18 years of age who underwent interventional treatment for proximal hamstring avulsion injuries of the ischium utilizing botulinum toxin as a chemoprotective agent. Data collected included demographic data, injury and treatment details, imaging, post-operative rehabilitation and return to activity. Descriptive statistical analysis was conducted. RESULTS: Five male patients with mean age 14 years (12-17) were included in the study. All were sports related non-contact injuries. Radiographs showed displaced avulsion fractures in all 5 patients. All patients had failed conservative management initially; mean time to surgery from initial injury was 34.4 weeks. 4 patients underwent open reduction and internal fixation (ORIF), 1 patient with less displacement had bone marrow aspirate (BMA) injection; all had chemoprotection using botulinum toxin injected in the hamstrings. No patient required hip immobilization or knee immobilization locked to 90°. We elected to use a brace locked at 20° knee flexion in 2/5 patients. All patients underwent supervised physical therapy and achieved symmetric knee range of motion (ROM). Post-operative radiographs confirmed healing of the avulsion fracture in all 5 patients and they all returned to previous level of activity at mean 32 weeks (21-43) from surgery. None of the patients had a hamstring re-injury at mean follow up of 27 months (11-42). CONCLUSION: Our case series is the first in literature that shows the safety and efficacy of chemoprotection with botulinum toxin for the post-operative management of avulsion injuries of proximal hamstrings, by minimizing the need for cumbersome bracing and allowing controlled motion during physical therapy.

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.

Evaluation of the sciatic nerve location regarding its relationship to the piriformis muscle.

BACKGROUND: The localisation of sciatic nerve (SN) is essential for the achievement of several procedures performed in the gluteal region. This study proposed to investigate the location of SN regarding its relationship to the piriformis (PM) by the line joining the posterior superior iliac spine (PSIS), ischial tuberosity (IT) and greater trochanter (GT). MATERIALS AND METHODS: SN-PM relationship was examined in 204 specimens from 102 embalmed cadavers (55 males, 47 females). Distances between PSIS, IT and GT were measured. Midpoints of SN at the lower edge of PM (S1) and IT-GT line (S2) were marked. Perpendicular line from S1 to PSIS-GT (S1-R) and to PSIS-IT (S1-Q), were created and measured. Distances of PSIS-R, PSIS-Q (S1) and IT-S2 were measured and calculated into percentage of PSIS-GT, PSIS-IT and IT-GT lengths, respectively. RESULTS: Regarding the classification of Beaton and Anson, three types of SN-PM relationship (a, b and c) were obtained. The percentage of type a, b and c was 74.02, 22.55 and 3.43, respectively. Symmetrical SN-PM relationship was found in 75.49%. The mean length of PSIS-IT, PSIS-GT and IT-GT in all types was 129.63 ± 11.89 mm, 151.34 ± 14.78 mm and 73.02 ± 10.20 mm, respectively. A statistically significant difference was found between types a and b (p = 0.013) in PSIS-IT length, whereas mean length of IT-GT and PSIS-GT showed no statistically significant difference between SN-PM types. PSIS-IT line passed SN at the lower edge of PM (S1) in 112 specimens (54.90%). In these cases, S1 and Q were the same point. A statistically significant difference was also found between types a and b (p = 0.023) in PSIS-Q (S1) length. The mean lengths of PSIS-Q (S1), PSIS-R and IT-S2 in term of percentage of PSIS-IT, PSIS-GT and IT-GT line in all types were 60.06 ± 5.90%, 54.19 ± 6.10%, and 37.87 ± 8.27%, respectively. The mean lengths of S1-R and S1-Q were 30.07 ± 8.30 mm and 6.54 ± 7.99 mm. Therefore, SN at S1 could be located at the point of 54.19 ± 6.10% of PSIS-GT length (R) with a distance of 30.07 ± 8.30 mm perpendicular to PSIS-GT line (S1-R). Since the PSIS-IT line did not pass SN at S1 in every case, it might not be suitable for localizing SN at S1. SN at S2 could be located at the point of 37.87 ± 8.27% of IT-GT line. No significant difference was found between types. CONCLUSIONS: Sciatic nerve can be localised by PSIS-GT and IT-GT lines without statistically significant difference between types (a, b, and c) of SN-PM relationship.

Surgical treatment of an ischial tuberosity avulsion fracture with delayed presentation.

Avulsion fractures of the ischial tuberosity usually occur in skeletally immature athletes following eccentric contraction of the hamstrings. When displaced fractures are left untreated, subsequent non-union and proximal hamstring fibrosis may lead to chronic pain and reduced activity. However, the indications for and outcomes of operative fixation when presentation is delayed remain unclear. We report the case of a 14 year old male athlete who presented to our institution 6 weeks after sustaining a displaced ischial tuberosity avulsion fracture. He underwent open reduction and internal fixation using a cannulated screw system via a posterior approach, with excellent results at 18 months follow-up. We report our surgical findings in detail as well as a novel method for post-operatively assessing functional screw head prominence-the seated radiograph.

The relationship between pressure offloading and ischial tissue health in individuals with spinal cord injury: An exploratory study.

Objectives: To compare thickness and texture measures of tissue overlying the ischial region in able-bodied (AB) individuals vs. individuals with spinal cord injury (SCI) and to determine if there is a relationship between pressure offloading of the ischial tuberosities (IT) and tissue health in individuals with SCI. Design: Exploratory cross-sectional study. Setting: University setting and rehabilitation hospital. Outcome Measures: Thickness and texture measurements from ultrasound images of tissues overlying the IT were obtained from AB individuals (n = 10) and individuals with complete or incomplete traumatic and non-traumatic SCI American Spinal Injury Association Impairment Scale (AIS) classification A-D (n = 15). Pressure offloading was measured in individuals with SCI and correlated with tissue health measurements. Results: The area overlying the IT occupied by the muscle was significantly greater in the SCI when compared with AB cohort. The area occupied by the muscle in individuals with SCI appeared to lose the striated appearance and was more echogenic than nearby skin and subcutaneous tissue (ST). There was no correlation between offloading times and thickness, echogenicity and contrast measurements of skin, ST and muscle in individuals with SCI. Conclusion: Changes in soft tissues overlying the ischial tuberosity occur following SCI corresponding to the loss of striated appearance of muscle and increased thickness of the area occupied by the muscle. Further studies using a larger sample size are recommended to establish if thickness and tissue texture differ between individuals with SCI who sustain pressure injuries vs. those who do not.

Ultrasound imaging of tissue overlying the ischial tuberosity: Does patient position matter?

BACKGROUND: Deep Tissue Pressure Injury (DTI) occurs in the tissues underlying the skin that may not have visible signs of skin breakdown and may be detected by ultrasound. The optimal position for ischial region ultrasound image acquisition to facilitate assessment of the tissue proximal to the ischias not been determined. OBJECTIVE: To evaluate the mean difference in geometric and grey scale measures of tissues overlying the ischial tuberosity (IT) acquired from ultrasound images in supine and lateral recumbent simulated sitting positions from adults with spinal cord impairment (SCI). METHODS: Nine individuals (3 acute and 6 chronic) with SCI or disease with neurological level of injury C4-T12 and AIS A-D and who used a wheelchair for mobility were recruited and underwent ultrasound acquisition in the supine and lateral recumbent positions. One participant was imaged twice on a separate day. Three images from the left (n = 8) and right (n = 2) IT were scanned using a 6 - 18 MHz linear ultrasound probe (Acuson S2000) with participants' hips and knees flexed to 90° in both the supine and lateral recumbent positions using a single rater protocol. MATLAB Image Processing Toolbox with a customized script was used to obtain mean and maximal thickness, echogenicity and contrast of skin, subcutaneous tissue and muscle. Wilcoxon Signed Rank Test and Bland Altman analysis was used to determine if there were differences between the two image acquisition positions and to construct limits of agreement. RESULTS: Thickness and contrast measures were similar in the supine and lateral recumbent positions (p > 0.05). Muscle echogenicity was lower in the supine position (p = 0.04). CONCLUSION: There is agreement in geometric and grey scale measures of tissues over the IT between the supine and lateral recumbent positions with the exception of muscle echogenicity, which was lower in the supine position. Since DTI is thought to originate in the muscle and echogenicity plays in a role in abnormal tissue imaging diagnosis, further studies are recommended to determine the impact of body position on muscle echogenicity prior to being used in prospective studies.

Chronic ischial tuberosity avulsion nonunion fracture treated with a platelet-rich plasma injection as a bone graft.

We present a case of an 18-year-old with a 2-year history of buttock pain who failed extensive treatment for a perceived hamstring strain. Upon evaluation, he was diagnosed with an ischial tuberosity nonunion avulsion fracture. The patient underwent bone grafting via an ultrasound guided leukocyte rich platelet-rich plasma injection followed by the use of a bone stimulator to enhance the bone healing. At 3 months, he was asymptomatic and had radiographic evidence of excellent bone healing. He remained asymptomatic at 1 year and had resumed full activities. This case report is the first in the literature to describe the treatment of a chronic ischial tuberosity nonunion avulsion fracture with the use of platelet-rich plasma as a bone graft.

Ischial tuberosity avulsion fracture nonunions in the adolescent population treated with a posterior column screw: A case series of two patients.

Various surgical techniques exist to approach an ischial tuberosity avulsion fracture, including open reduction and internal fixation with screws and suture anchors, augmentation with allograft tendon, and excision of the fragment. However, the majority of these techniques approached acute fractures, and nonunions were not addressed nor studied. This case series describes two adolescent patients treated for ischial tuberosity nonunions with a posterior column screw through a subgluteal approach. Both patients demonstrated radiographic healing of their nonunion sites at 6 months' follow-up. Each patient reported no pain during activity, had symmetric hamstring strength, and were able to return to pre-injury level of activity by final follow-up. In conclusion, the authors utilized a muscle-sparing approach to the ischial tuberosity nonunion site through a cosmetically appealing incision and introduced a novel approach to nonunion fixation without the use of bone graft, resulting in excellent clinical outcomes.