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Lefèvre N, Moussa MK, Chahal A, Meyer A, Grimaud O, Khalaf ZM, Alayane A, Bohu Y, Hardy A. The Cobra sign: A marker for overestimation of tendon retraction in proximal semimembranosus tendon avulsion. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39171445 DOI: 10.1002/ksa.12437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 08/02/2024] [Accepted: 08/05/2024] [Indexed: 08/23/2024]
Abstract
PURPOSE To introduce a new magnetic resonance imaging (MRI) sign, termed the Cobra sign, and identify its diagnostic metrics. The secondary aim was to demonstrate that this sign can be a source of false evaluation of tendon retraction in patients with proximal hamstring avulsion injury. METHOD This retrospective cohort study targeted patients surgically treated for proximal hamstring avulsion injury from January 2019 to June 2023. The MRI Cobra sign was defined as a wavy curved T2-hypointense band with the free end folding distally over itself, resembling a cobra head. The primary outcome measure was the characterization of the Cobra sign in patients with proximal hamstring avulsion injury. The secondary outcome was the association of this sign with tendon retraction. The study included 81 proximal hamstring avulsion injury patients (mean age of 45.7, SD = 13.9), with 41 (50.6%) complete avulsions, 33 semimembranosus, and 7 conjoint tendons. RESULTS The MRI Cobra sign was found in 25 patients (17 semimembranosus and 8 complete). It was confirmed surgically only in semimembranosus cases. It demonstrated 51.5% sensitivity and 83.3% specificity for isolated semimembranosus avulsions, with a significant positive likelihood ratio of 3.0. MRI retraction was 10.05 cm (±3.0), reducing to 7.9 cm (±2.5) on surgical measurement (mean difference = 2.0 cm, p < 0.001). The regression analysis confirmed MRI retraction's influence on the Cobra sign, with a 1.4 odds increase per unit (p < 0.001). In linear regression analysis, each unit increase in MRI retraction corresponded to a 79% increase in surgical retraction (coefficient 0.7, t = 11.1, p < 0.001). CONCLUSION The Cobra sign demonstrated acceptable diagnostic accuracy for isolated semimembranosus avulsion, with a high specificity of 83.3%, a low sensitivity of 51.5%, and a positive likelihood ratio of 3.0. The presence of the Cobra sign indicates an overestimated MRI retraction by approximately 21%. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Mohamad K Moussa
- Department of Orthopedic Surgery, Group Hospitalier Sélestat Obernai, Séléstat, Alsace, France
| | - Ahmad Chahal
- Department of Radiology, Hôpital Saint Camille, Bry-sur-Marne, France
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Li ZI, Buldo-Licciardi M, Moore M, Kanakamedala A, Burke CJ, Samim MM, Youm T. Assessment of fatty infiltration of the hamstring muscles in chronic proximal hamstring ruptures and effect on clinical outcomes after surgical repair: a novel application of the Goutallier classification. Arch Orthop Trauma Surg 2024; 144:2171-2179. [PMID: 38480556 DOI: 10.1007/s00402-024-05255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/18/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Increased time to surgery has been previously associated with poorer clinical outcomes after surgical treatment of proximal hamstring ruptures, though the etiology remains unclear. The purpose of this study was to evaluate whether degree of muscle atrophy, as assessed using the Goutallier classification system, is associated with worse outcomes following surgical treatment of chronic proximal hamstring ruptures. MATERIALS AND METHODS This was a retrospective case series of patients who underwent repair of proximal hamstring ruptures from 2012 to 2020 with minimum 2-year follow-up. Patients were included if they underwent primary repair of a proximal hamstring rupture ≥ 6 weeks after the date of injury and had accessible preoperative magnetic resonance imaging (MRI). Exclusion criteria were allograft reconstruction, endoscopic repair, or prior ipsilateral hip surgery. Patients were administered validated surveys: the modified Harris Hip Score (mHHS) and Perth Hamstring Assessment Tool (PHAT). Fatty atrophy on preoperative MRI was independently graded by two musculoskeletal radiologists using the Goutallier classification. Multivariate regression analysis was performed to evaluate associations of preoperative characteristics with muscle atrophy, as well as mHHS and PHAT scores. RESULTS Complete data sets were obtained for 27 patients. A majority of this cohort was male (63.0%), with a mean age of 51.5 ± 11.8 years and BMI of 26.3 ± 3.8. The mean follow-up time was 62.6 ± 23.1 months, and the mean time from injury-to-surgery was 20.4 ± 15.3 weeks. The Goutallier grading inter-reader weighted kappa coefficient was 0.655. Regression analysis demonstrated that atrophy was not significantly associated with PHAT (p = 0.542) or mHHS (p = 0.574) at latest follow-up. Increased age was significantly predictive of muscle atrophy (β = 0.62, p = 0.005) and was also found to be a significant predictor of poorer mHHS (β = - 0.75; p = 0.037). CONCLUSIONS The degree of atrophy was not found to be an independent predictor of clinical outcomes following repair of chronic proximal hamstring ruptures. Increasing age was significantly predictive of increased atrophy and poorer patient-reported outcomes.
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Affiliation(s)
- Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Michael Buldo-Licciardi
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | - Michael Moore
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | - Ajay Kanakamedala
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | | | | | - Thomas Youm
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, 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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van der Made AD, Smithuis FF, Buckens CF, Tol JL, Six WR, Lauf K, Peters RW, Kerkhoffs GM, Maas M. Good Interrater Reliability for Standardized MRI Assessment of Tendon Discontinuity and Tendon Retraction in Acute Proximal Full-Thickness Hamstring Tendon Injury. Am J Sports Med 2021; 49:2475-2481. [PMID: 34166119 PMCID: PMC8283186 DOI: 10.1177/03635465211021612] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Proximal full-thickness free hamstring tendon injury (ie, tendon avulsion or rupture) is a severe injury. Treatment decision making relies on clinical factors and magnetic resonance imaging (MRI) variables; it specifically relies on which tendons are injured as well as the extent of tendon retraction. According to a worldwide evaluation of current practice, discontinuity of both proximal tendons and retraction of >2 cm are used as surgical indications. However, both the diagnosis and the use of MRI variables in decision making may be fraught with uncertainty in clinical practice. A reliable standardized MRI assessment is required. PURPOSE To propose an MRI assessment for acute proximal full-thickness free hamstring tendon injury and to evaluate its interater reliability. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS We included 40 MRI scans of patients with acute (≤4 weeks of injury) proximal full-thickness free hamstring tendon injury. Three musculoskeletal radiologists assessed proximal full-thickness free hamstring tendon discontinuity using the novel "dropped ice cream sign" and tendon retraction (in mm). Quantification of tendon retraction (in mm) was performed using 2 different methods: (1) a direct (ie, shortest distance between the center of the hamstring origin and the tendon stump) method and (2) a combined craniocaudal/mediolateral measurement method. Absolute and relative interrater reliability were calculated. RESULTS We found an almost perfect interrater agreement (kappa = 0.87) for assessment of full-thickness tendon discontinuity using the dropped ice cream sign. Interrater agreement for the direct and craniocaudal retraction measurements was good for both the conjoint (intraclass correlation coefficient [ICC], 0.88 and 0.83) and the semimembranosus tendons (ICC, 0.81 and 0.79). The mediolateral retraction measurement yielded only moderate to poor reliability for the conjoint (ICC, 0.53) and semimembranosus tendons (ICC, 0.41). CONCLUSION The standardized MRI assessment to identify proximal hamstring tendon discontinuity and quantify tendon retraction is reliable. We recommend using the novel dropped ice cream sign and the direct retraction measurement in clinical practice and research.
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Affiliation(s)
- Anne D. van der Made
- Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands,Academic Center for Evidence-based Sports Medicine, Amsterdam UMC, Amsterdam, the Netherlands,Amsterdam Collaboration for Health and Safety in Sports, AMC/VUmc IOC Research Center, Amsterdam, the Netherlands,Anne D. van der Made, MD, Department of Orthopedic Surgery, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands () (Twitter: @AvanderMade)
| | - Frank F. Smithuis
- Academic Center for Evidence-based Sports Medicine, Amsterdam UMC, Amsterdam, the Netherlands,Amsterdam Collaboration for Health and Safety in Sports, AMC/VUmc IOC Research Center, Amsterdam, the Netherlands,Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Constantinus F. Buckens
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Johannes L. Tol
- Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands,Academic Center for Evidence-based Sports Medicine, Amsterdam UMC, Amsterdam, the Netherlands,Amsterdam Collaboration for Health and Safety in Sports, AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
| | - Willem R. Six
- Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands,Academic Center for Evidence-based Sports Medicine, Amsterdam UMC, Amsterdam, the Netherlands,Amsterdam Collaboration for Health and Safety in Sports, AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
| | - Kenny Lauf
- Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands,Academic Center for Evidence-based Sports Medicine, Amsterdam UMC, Amsterdam, the Netherlands,Amsterdam Collaboration for Health and Safety in Sports, AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
| | - Rolf W. Peters
- Academic Center for Evidence-based Sports Medicine, Amsterdam UMC, Amsterdam, the Netherlands,Amsterdam Collaboration for Health and Safety in Sports, AMC/VUmc IOC Research Center, Amsterdam, the Netherlands,Department of Trauma Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Gino M. Kerkhoffs
- Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands,Academic Center for Evidence-based Sports Medicine, Amsterdam UMC, Amsterdam, the Netherlands,Amsterdam Collaboration for Health and Safety in Sports, AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
| | - Mario Maas
- Academic Center for Evidence-based Sports Medicine, Amsterdam UMC, Amsterdam, the Netherlands,Amsterdam Collaboration for Health and Safety in Sports, AMC/VUmc IOC Research Center, Amsterdam, the Netherlands,Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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