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Pihl E, Laszlo S, Rosenlund AM, Kristoffersen MH, Schilcher J, Hedbeck CJ, Skorpil M, Micoli C, Eklund M, Sköldenberg O, Frihagen F, Jonsson KB. Operative versus Nonoperative Treatment of Proximal Hamstring Avulsions. NEJM EVIDENCE 2024; 3:EVIDoa2400056. [PMID: 39023393 DOI: 10.1056/evidoa2400056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Operative treatment is widely used for acute proximal hamstring avulsions, but its effectiveness compared with that of nonoperative treatment has not been shown in randomized trials. METHODS In this noninferiority trial at 10 centers in Sweden and Norway, we enrolled patients 30 to 70 years of age with a proximal hamstring avulsion in a randomized trial and a parallel observational cohort. Treatments were operative reinsertion of the tendons or nonoperative management. The primary end point was the Perth Hamstring Assessment Tool (PHAT) at 2 years of follow-up. Secondary outcomes included scores on the Lower Extremity Functional Scale (LEFS). RESULTS A total of 119 patients were enrolled in the randomized trial and 97 patients in the observational cohort. In the per-protocol analysis of the randomized trial, the mean (±standard deviation) PHAT scores were 79.9±19.5 and 78.5±19.4 in the operative and nonoperative groups, respectively (PHAT scores range from 0 to 100, with higher scores indicating higher function). The prespecified noninferiority limit of 10 points was not crossed (mean difference, -1.2; 95% confidence interval [CI], -8.6 to 6.2; P=0.009 for noninferiority). Analyses of secondary outcomes, including a mean difference in the LEFS score of -1.6 (95% CI, -5.2 to 2.0), aligned with the primary outcome. The observed numbers of adverse events in the randomized trial were nine in the operative group versus three in the nonoperative group (odds ratio, 0.3; 95% CI, 0.1 to 1.2). In the analysis of the observational cohort, the mean PHAT score difference between the nonoperative and operative treatment groups was -2.6 (95% CI, -9.9 to 4.6). CONCLUSIONS In patients 30 to 70 years of age with proximal hamstring avulsions, nonoperative treatment was noninferior to operative treatment. (Funded by Afa Försäkring and others; ClinicalTrials.gov number, NCT03311997.).
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Affiliation(s)
- Elsa Pihl
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm
- Department of Orthopedics, Danderyds Hospital, Stockholm
| | - Sofia Laszlo
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Anne-Mari Rosenlund
- Institute of Clinical Medicine, University of Oslo, Oslo
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo
| | | | - Jörg Schilcher
- Department of Orthopedic Surgery and Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Wallenberg Centre for Molecular Medicine, Linköping University, Linköping, Sweden
| | - Carl Johan Hedbeck
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm
- Department of Orthopedics, Danderyds Hospital, Stockholm
| | - Mikael Skorpil
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm
| | - Chiara Micoli
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm
| | - Martin Eklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm
| | - Olof Sköldenberg
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm
- Department of Orthopedics, Danderyds Hospital, Stockholm
| | - Frede Frihagen
- Institute of Clinical Medicine, University of Oslo, Oslo
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Kenneth B Jonsson
- Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
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Green JS, Moran J, Schneble CA, Zazulak B, Li DT, Jimenez A, Medvecky MJ. Comparative Analysis of Patient-Reported Outcome Measures for Proximal Hamstring Injuries: A Systematic Review. Orthop J Sports Med 2022; 10:23259671221104758. [PMID: 35898205 PMCID: PMC9310242 DOI: 10.1177/23259671221104758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background There is controversy regarding which patient-reported outcome measures (PROMs) should be used for proximal hamstring tendon injuries. Hypothesis It was hypothesized that (1) most (>50%) of the questions on the 13 most common PROMs for proximal hamstring injuries would demonstrate extensive overlap in the health domains and question categories and (2) each of the PROMs would contain a variable distribution of questions within each health domain. Study Design Systematic review. Methods We conducted a literature review through PubMed, Scopus, and CINAHL and identified the 13 most common PROMs for proximal hamstring injuries: Lower Extremity Functional Scale (LEFS), Marx activity rating scale (MARS), 12-item Short Form Survey (SF-12), Tegner activity scale (TAS), Single Assessment Numeric Evaluation (SANE), Perth Hamstring Assessment Tool (PHAT), Proximal Hamstring Injury Questionnaire (PHIQ), modified Harris Hip Score (mHHS), University of California, Los Angeles activity score (UCLA), International Hip Outcome Tool (iHOT-12), Hip Outcome Score (HOS), Sydney Hamstring Origin Rupture Evaluation (SHORE), and Non-Arthritic Hip Score (NAHS). All PROM questions were sorted into 5 health domains (pain, symptoms, activities of daily living, sports, and mindset) and further divided into question categories if they referred to similar tasks or aspects of health. Questions in the same health domain and question category were considered overlapping, and those within a health domain that did not fit into a question category were considered unique. For each PROM, we analyzed the distribution of questions within particular health domains and question categories as well as the amount of overlapping and unique questions. Results Of the 165 questions evaluated, 116 (70.3%) were overlapping, and 49 (29.7%) were unique. The SF-12 contained the most unique questions (9/12 [75.0%]). The MARS, TAS, SANE, and UCLA had 0 unique questions. The PHIQ and iHOT-12 contained questions in all 5 health domains. The PHAT, SHORE, and NAHS contained questions in every health domain except mindset. The LEFS, MARS, SF-12, TAS, mHHS, SANE, UCLA, and HOS contained questions in ≤3 health domains. Conclusion The evaluated PROMs had a high degree of overlapping questions (≥50%) and demonstrated a statistically significant variance in the distribution of questions within each health domain.
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Affiliation(s)
- Joshua S. Green
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | - Jay Moran
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Christopher A. Schneble
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Bohdanna Zazulak
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Don T. Li
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Andrew Jimenez
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Michael J. Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
- Michael J. Medvecky, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, 06520, USA ()
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Best R, Meister A, Meier M, Huth J, Becker U. Predictive Factors Influencing Functional Results After Proximal Hamstring Tendon Avulsion Surgery: A Patient-Reported Outcome Study After 227 Operations From a Single Center. Orthop J Sports Med 2021; 9:23259671211043097. [PMID: 34734098 PMCID: PMC8558812 DOI: 10.1177/23259671211043097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/27/2021] [Indexed: 01/10/2023] Open
Abstract
Background Although debilitating, proximal hamstring tendon avulsion injuries are rare and often overlooked or misdiagnosed. Consequently, delayed diagnosis and surgical treatment may result in poor outcomes. Studies investigating a correlation between postoperative functional outcomes and this delay in surgical treatment or other concomitant factors in large cohorts have not yet been performed to our knowledge. Purpose/Hypothesis The purpose of this study was to conduct an investigation in a large patient group regarding factors that could influence a patient's functional outcome after hamstring surgery. We hypothesized that this outcome would significantly correlate to the time between trauma and surgery. Study Design Case series; Level of evidence, 4. Methods Patients who received surgical treatment of proximal hamstring tendon avulsion injuries in our institution between the years 2010 and 2020 were asked to complete a validated, injury-specific outcome measurement, the Perth Hamstring Assessment Tool (PHAT; 0-100 points). In addition to calculating these outcomes, we evaluated the association of the obtained results with possible predictive factors such as age, sex, stump retraction shown on magnetic resonance imaging (MRI), and timing and duration of surgery. Results A total of 226 patients (227 operations) were eligible for the study, and 204 cases of hamstring tendon avulsion injury met our inclusion criteria. The return rate for the PHAT questionnaire was 85.3%. The mean PHAT score revealed good results (79.8 ± 19.1). Irrespective of concomitant factors, the scores of male patients were significantly higher compared with those of female patients (83.8 ± 16.9 vs 75.8 ± 20.6 respectively; P = .004). The mean time to surgery was 5.7 weeks after trauma, and more delayed surgery correlated significantly with lower PHAT scores (P = .003; r = -0.228). The mean degree of stump retraction on MRI (5 cm) did not significantly influence PHAT scores (P = .525; r = -0.06). Conclusion Delay of surgery and female sex were disadvantageous in terms of a good functional outcome measure (PHAT score) after hamstring tendon refixation surgery. By contrast, patient age as well as the retraction of the tendon stump on preoperative MRI did not influence PHAT scores in the present study.
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Affiliation(s)
- Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany.,Department of Sports Medicine, University of Tuebingen, Tuebingen, Germany
| | - Anorte Meister
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany
| | - Malin Meier
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany
| | - Jochen Huth
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany
| | - Ulrich Becker
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany
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Afonso J, Rocha-Rodrigues S, Clemente FM, Aquino M, Nikolaidis PT, Sarmento H, Fílter A, Olivares-Jabalera J, Ramirez-Campillo R. The Hamstrings: Anatomic and Physiologic Variations and Their Potential Relationships With Injury Risk. Front Physiol 2021; 12:694604. [PMID: 34305648 PMCID: PMC8294189 DOI: 10.3389/fphys.2021.694604] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/16/2021] [Indexed: 01/11/2023] Open
Abstract
The incidence and recurrence of hamstrings injuries are very high in sports, posing elevated performance and financial-related costs. Attempts to identify the risk factors involved in predicting vulnerability to hamstrings injury is important for designing exercise-based programs that aim to mitigate the rate and severity of hamstrings injuries and improve rehabilitation strategies. However, research has shown that non-modifiable risk factors may play a greater role than modifiable risk factors. Recognizing non-modifiable risk factors and understanding their implications will afford the prescription of better suited exercise programs, i.e., that are more respectful of the individual characteristics. In a nutshell, non-modifiable risk factors can still be acted upon, even if indirectly. In this context, an underexplored topic is how intra and inter- individual anatomic and physiologic variations in hamstrings (e.g., muscle bellies, fiber types, tendon length, aponeurosis width, attachment sites, sex- and age-related differences) concur to alter hamstrings injuries risk. Some anatomic and physiologic variations may be modifiable through exercise interventions (e.g., cross-sectional area), while others may not (e.g., supernumerary muscle bellies). This apparent dichotomy may hide a greater complexity, i.e., there may be risk factors that are partially modifiable. Therefore, we explored the available information on the anatomic variations of the hamstrings, providing a deeper insight into the individual risk factors for hamstrings injuries and contributing with better knowledge and potential applications toward a more individualized exercise prescription.
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Affiliation(s)
- José Afonso
- Centre for Research, Education, Innovation and Intervention in Sport, Faculty of Sport of the University of Porto, Porto, Portugal
| | - Sílvia Rocha-Rodrigues
- Escola Superior de Desporto e Lazer, Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal
- Research Centre in Sports Sciences, Health Sciences and Human Development, Vila Real, Portugal
- Tumor & Microenvironment Interactions Group, Instituto de Investigação e Inovação em Saúde, Porto, Portugal
| | - Filipe M. Clemente
- Escola Superior de Desporto e Lazer, Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal
- Instituto de Telecomunicações, Delegação da Covilhã, Covilhã, Portugal
| | - Michele Aquino
- Department of Health and Sport Sciences, Adelphi University, New York, NY, United States
| | | | - Hugo Sarmento
- Research Unit for Sport and Physical Activity, Faculty of Sport Sciences and Physical Education, University of Coimbra, Coimbra, Portugal
| | - Alberto Fílter
- FSI Sport Research Lab, Football Science Institute, Granada, Spain
- Research Group Physical Activity, Health and Sport CTS-948, University of Pablo de Olavide, Seville, Spain
| | - Jesús Olivares-Jabalera
- FSI Sport Research Lab, Football Science Institute, Granada, Spain
- Sport and Health University Research Institute, Department of Physical and Sports Education, University of Granada, Granada, Spain
| | - Rodrigo Ramirez-Campillo
- Department of Physical Activity Sciences, Universidad de Los Lagos, Santiago, Chile
- Centro de Investigación en Fisiología del Ejercicio, Facultad de Ciencias, Universidad Mayor, Santiago, Chile
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Factor S, Khoury A, Atzmon R, Vidra M, Amar E, Rath E. Combined endoscopic and mini-open repair of chronic complete proximal hamstring tendon avulsion: a novel approach and short-term outcomes. J Hip Preserv Surg 2021; 7:721-727. [PMID: 34377515 PMCID: PMC8349587 DOI: 10.1093/jhps/hnab006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/05/2021] [Accepted: 01/13/2021] [Indexed: 11/13/2022] Open
Abstract
To evaluate the outcome of a novel, combined endoscopic and mini-open repair (CEMR) of a chronic complete retracted proximal hamstring tendon avulsion (PHA). A retrospective case series of a single-surgeon database for all patients, with a minimum of 1-year follow-up, who underwent CEMR between July 2015 and September 2019 was performed. Patients were evaluated for their functional outcome using the Perth Hamstring Assessment Tool (PHAT). At the latest follow-up, patients were evaluated for their muscle strength, subjective satisfaction and post-operative complications. Twelve patients who underwent endoscopic surgery for chronic PHA were identified, of which seven patients underwent CEMR. After exclusion of one patient from the study due to an open claim for health insurance, six patients (five males) with a mean age of 48 years (range 20-61 years) were evaluated. The mean time from injury to surgery was 12 months (range 2-43 months). At a mean follow-up of 28 months (range 12-55 months), the average PHAT score was 73 (range 70-80). The mean subjective activity level percentage improved from 34 (range 20-50) pre-surgery to 81 (range 75-90) post-surgery. The mean strength of the quadriceps, hamstring at 30°, and hamstring at 90° of the operated leg compared to the uninjured leg did not differ significantly. One patient underwent adhesiolysis 1 year after the index procedure for treatment of subcutaneous adhesions. CEMR is a viable and safe option for the treatment of chronic complete proximal hamstring tears, with good to excellent short-term functional outcome. Level of evidence: IV.
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Affiliation(s)
- Shai Factor
- Department of Orthopedic Surgery, Affiliated with the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo 6423906, Israel
| | - Amal Khoury
- Department of Orthopedic Surgery, Affiliated with the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo 6423906, Israel
| | - Ran Atzmon
- Department of Orthopedic Surgery, Affiliated with the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo 6423906, Israel
| | - Matias Vidra
- Department of Orthopedic Surgery, Affiliated with the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo 6423906, Israel
| | - Eyal Amar
- Department of Orthopedic Surgery, Affiliated with the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo 6423906, Israel
| | - Ehud Rath
- Department of Orthopedic Surgery, Affiliated with the Sackler Faculty of Medicine, Tel Aviv Medical Center, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo 6423906, Israel
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Reza T, Hinkle AJ, Perez-Chaumont A, Brown SM, Mulcahey MK. Systematic Review of Outcome Measures Used After Proximal Hamstring Repair. Orthop J Sports Med 2021; 9:23259671211005101. [PMID: 33997081 PMCID: PMC8113800 DOI: 10.1177/23259671211005101] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Patient-reported outcome measures are important to determine outcomes after
orthopaedic procedures. There is currently no standard for outcome measures
in the evaluation of patient outcomes after proximal hamstring repair. Purpose: To identify and evaluate outcome measures used after proximal hamstring
repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed to identify all English-language articles
assessing outcomes after proximal hamstring repair in PubMed, Embase, CINAHL
via EBSCOhost, MEDLINE via OvidSP, and Web of Science between 2000 and 2019.
After duplicates were removed, studies were selected using eligibility
criteria established by the authors. Image reviews, anatomic/histology
studies, literature reviews, surgical technique reports, systematic reviews,
narrative reviews, case studies, and studies with <5 patients were
excluded. Extraction, synthesis, and analysis of outcome measure data were
performed using Microsoft Excel. Quality assessment of included studies was
performed using Methodological Index for Non-Randomized Studies
criteria. Results: After duplicate articles were removed, a total of 304 unique articles were
identified and 27 met the inclusion criteria. The mean number of patients
with proximal hamstring repairs per study was 40. The most frequently
reported outcome measures were return to sport (14/27; 51.9%), custom
survey/questionnaire (13/27; 48.1%), and isokinetic hamstring strength
testing (13/27; 48.1%). Six of the 10 most commonly used outcome measures
were validated and included Lower Extremity Functional Scale, 12-Item Short
Form Health Survey, visual analog scale for pain, Perth Hamstring Assessment
Tool (PHAT), Single Assessment Numeric Evaluation, and Tegner Activity
Scale. Of those, PHAT was the only validated outcome measure designed for
proximal hamstring repair. Conclusion: There is currently no consensus on the best outcome measurements for the
evaluation of patients after proximal hamstring repair. We recommend an
increased commitment to the use of return to sport, isokinetic strength
testing, Lower Extremity Functional Scale, and PHAT when assessing such
injuries. Future studies should aim to define the most reliable methods of
outcome measurement in this patient population through consistent use of
tools that are clinically relevant and important to patients and can easily
be employed in a variety of clinical scenarios.
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Affiliation(s)
- Tara Reza
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Andrew J Hinkle
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | | | - Symone M Brown
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
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