Avulsion fracture of the ischial tuberosity: Is the current evidence sufficient to resolve the challenges of treatment selection?

Table 1 Thresholds for surgical intervention of avulsion fracture of the ischial tuberosity suggested in the literature

Threshold for surgery	Ref.	Cohort size and fragment displacement	Treatment methods; duration between trauma and surgery; internal fixation	Rehabilitation methods	Follow-up duration; outcome measures	Reported results
20 mm	Schuett et al[6], 2015	25; 9.5 ± 11.6 mm	Conservative treatment	Protected weight-bearing for 4 weeks to 6 weeks, followed by physical therapy	Mean 151 days of radiographic follow-up; mean 292 days of clinical follow-up	1 with fracture displacement of 6 mm developed a symptomatic nonunion, 3 with displacement over 20 mm resulting in an asymptomatic nonunion
20 mm	Biedert[9], 2015	3; > 20 mm	Surgical treatment; 2-22 weeks; biodegradable suture anchors	Patients fitted with harness device to hold the knee at 90 degrees of flexion for 4-6 weeks; specific postoperative rehabilitation regime	12-24 months; subjective and objective functional results	Good subjective and objective functional results obtained in 3 patients, with all returning to their preinjury sports activities, although one patient underwent a reoperation due to suture loosening
15 mm	Ferlic et al[10], 2014	13; 4 cases < 15 mm and 9 cases > 15 mm	Conservative treatment in 8 patients and surgical treatment in 5 patients; duration not specified; cannulated compression screws	Partial weight-bearing for 6 weeks followed by physical therapy and then eccentric and concentric training for conservative management of patients; partial weight-bearing with light training for 6 weeks in surgically treated patients followed by sports activities	At least 24 months; clinical assessment including strength testing of the hamstring and adductor muscles, range of motion, neurologic examinations, subjective complaints, modified Harris Hip Score, surgical complication, and radiological assessment	4 cases with < 15 mm displacement exhibited excellent outcomes with conservative treatment, 4 cases > 15 mm displacement achieved excellent outcomes with surgical treatment, but 2/4 cases > 15 mm displacement developed pseudoarthrosis with conservative treatment, and another patient who developed pseudoarthrosis following initial conservative treatment obtained good results with surgical intervention but stopped playing soccer
15 mm	Best et al[12], 2021	11; 3.3 cm (mean)	Surgical treatment; mean 14.8 weeks and median within 3 weeks; screws or anchors, excision of bony fragment and suture anchor repair of the tendons, or suture of the tendinous scary bridge	Standardized rehabilitation program	Mean 18.2 months; Hamstring injury-specific Perth Hamstring Assessment Tool, return to sports	Surgery led to very good functional results, with a Perth Hamstring Assessment Tool score mean of 86.9 and high return to sports (10/11)
10 mm	Gidwani and Bircher[13], 2007	6; 1 case no displacement, 1 case 2 cm, 3 cases ≥ 3 cm, 1 case 3 cm chronic avulsion	2 cases non-operative management and 4 cases operative management; 3-month delay in 1 case and ≥ 30 months delay in 3 cases, unknown delay duration in 2 cases; reconstructive plate with or without bone graft	Not specified	Not specified	All patients obtained good outcomes