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Mendel T, Steinke M, Schenk P, Migliorini F, Schütte V, Reisberg A, Kobbe P, Heinecke M. Conservative management of proximal hamstring avulsion: A clinical study. J Orthop 2024; 55:74-79. [PMID: 38665987 PMCID: PMC11039336 DOI: 10.1016/j.jor.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction The management of proximal hamstring tear (PHT) is debated and consensus regarding recommended measures and individual treatment regimens is lacking. The present investigation evaluated the efficacy of a conservative management of partial and complete PHT. Methods The present observational study was conducted following the STROBE statement. In June 2018 the medical databases of the BG Klinikum Bergmannstrost Halle, Germany were accessed. All the patients with PHT were retrieved. The outcomes of interest were to evaluate the clinical examination, PROMs, imaging, and isokinetic muscle strength at the baseline and last follow-up. Results 31 patients were enrolled in the present study. Nine patients (29 % (9 of 31) described local pain at the ischial tuberosity in sitting situations and also in manual palpation. A persistent gap in the tendon string beneath the tuberosity in manual palpation was reported in 25.8 % (8 of 31). The mean VAS at the last follow-up was 2.3 ± 2.3. The mean LEFS score was 50.9 ± 18.8.Control MRI at follow-up showed scarring restitution in the proximal tendon in all patients in the partial tear group. In the complete tear group, a persisting defect state of the proximal tendon course was found in 45 % (9 of 20). The injured side achieved 81.5 ± 22.2 % of the force of the uninjured side, measured in the flexion movement at 60°/s. At an angular velocity of 240°/s, 83.2 ± 26.3 % of the force of the uninjured side was achieved. Conclusion According to the main findings of the present study, conservative therapy of PTH tears is associated with good clinical outcomes. High-quality investigations are required to establish the proper therapeutic algorithm and advantages of conservative management compared to a surgical approach. Level of evidence Level III.
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Affiliation(s)
- Thomas Mendel
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
- University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Trauma Surgery, Halle, Germany
| | - Mark Steinke
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
| | - Philipp Schenk
- BG Hospital Bergmannstrost Halle, Research Executive Department, Halle, Germany
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100 Bolzano, Italy
| | - Vincent Schütte
- Gesundheitszentrum Halle-Neustadt, Center Orthopaedic Surgery, Halle, Germany
| | - André Reisberg
- BG Hospital Bergmannstrost Halle, Department of Radiology and Neuroradiology, Halle, Germany
| | - Philipp Kobbe
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
- University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Trauma Surgery, Halle, Germany
| | - Markus Heinecke
- Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department, Eisenberg, Germany
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Lin Y, Sahr M, Lan R, Nguyen J, Tan ET, Sneag DB. MRI findings correlate with difficult dissection during proximal hamstring repair and with postoperative sciatica. Skeletal Radiol 2024:10.1007/s00256-024-04668-6. [PMID: 38581584 DOI: 10.1007/s00256-024-04668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE This study examines the correlation between MRI findings and difficult dissection during proximal primary hamstring repair and postoperative sciatica. MATERIALS AND METHODS A 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. RESULTS On 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. CONCLUSION Preoperative 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.
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Affiliation(s)
- Yenpo Lin
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, 10021, USA
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Meghan Sahr
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, 10021, USA.
| | - Ranqing Lan
- Biostatistics Core Facility, Hospital for Special Surgery, New York, NY, USA
| | - Joe Nguyen
- Biostatistics Core Facility, Hospital for Special Surgery, New York, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, 10021, USA
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Allahabadi S, Salazar LM, Obioha OA, Fenn TW, Chahla J, Nho SJ. Hamstring Injuries: A Current Concepts Review: Evaluation, Nonoperative Treatment, and Surgical Decision Making. Am J Sports Med 2024; 52:832-844. [PMID: 37092718 DOI: 10.1177/03635465231164931] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
The purpose of this current concepts review is to highlight the evaluation and workup of hamstring injuries, nonoperative treatment options, and surgical decision-making based on patient presentation and injury patterns. Hamstring injuries, which are becoming increasingly recognized, affect professional and recreational athletes alike, commonly occurring after forceful eccentric contraction mechanisms. Injuries occur in the proximal tendon at the ischial tuberosity, in the muscle belly substance, or in the distal tendon insertion on the tibia or fibula. Patients may present with ecchymoses, pain, and weakness. Magnetic resonance imaging remains the gold standard for diagnosis and may help guide treatment. Treatment is dictated by the specific tendon(s) injured, tear location, severity, and chronicity. Many hamstring injuries can be successfully managed with nonoperative measures such as activity modification and physical therapy; adjuncts such as platelet-rich plasma injections are currently being investigated. Operative treatment of proximal hamstring injuries, including endoscopic or open approaches, is traditionally reserved for 2-tendon injuries with >2 cm of retraction, 3-tendon injuries, or injuries that do not improve with 6 months of nonoperative management. Acute surgical treatment of proximal hamstring injuries tends to be favorable. Distal hamstring injuries may initially be managed nonoperatively, although biceps femoris injuries are frequently managed surgically, and return to sport may be faster for semitendinosus injuries treated acutely with excision or tendon stripping in high-level athletes.
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Affiliation(s)
- Sachin Allahabadi
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Luis M Salazar
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Obianuju A Obioha
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas W Fenn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
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Fenn TW, Brusalis CM, Allahabadi S, Alvero AB, Ebersole JW, Nho SJ. Association Between Proximal Hamstring Tear Characteristics and Achievement of Clinically Significant Outcomes After Endoscopic and Open Repair at Minimum 2-Year Follow-up. Am J Sports Med 2024; 52:390-400. [PMID: 38179612 DOI: 10.1177/03635465231216118] [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] [Indexed: 01/06/2024]
Abstract
BACKGROUND The effect of preoperative tear characteristics and the relative efficacy of open versus endoscopic surgical techniques have not been elucidated for the surgical treatment of proximal hamstring tendon injuries. PURPOSE (1) To report on achievement rates of clinically significant outcomes at a minimum 2-year follow-up for multiple patient-reported outcomes (PROs) after surgical treatment of proximal hamstring injuries, stratified according to severity of proximal hamstring injury, and (2) to compare clinical outcomes associated with endoscopic versus open surgical repair for a subset of similarly classified tears. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A single-surgeon clinical registry was queried for patients who underwent surgical repair for proximal hamstring ruptures between January 2012 and March 2021. Injuries were classified by magnetic resonance imaging as follows: grade 1, incomplete tear with the involvement of 1 or 2 tendons; grade 2, complete tear with the involvement of 3 tendons and ≤2-cm retraction; and grade 3, complete tear with the involvement of 3 tendons and >2-cm retraction. The Patient Acceptable Symptom State (PASS) for multiple PROs was calculated and compared among injury grades and between surgical techniques. RESULTS Among 75 patients with a mean follow-up of 30.5 ± 5.1 months, 20 had grade 1 tears, 24 had grade 2 tears, and 31 had grade 3 tears. Favorable 2-year postoperative PROs were demonstrated by each grade for all measured PROs. Patients with grade 3 tears were noted to have significantly lower rates of 2-year PASS achievement for the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Specific (HOS-SS) scales (P≤ .032). Among grade 2 tears, patients treated endoscopically demonstrated significantly greater HOS-SS (endoscopic, 91.7%; open, 58.3%; P = .045) and Patient-Reported Outcomes Measurement Information System for Physical Function (endoscopic, 80.0%; open, 50.0%; P = .033) PASS achievement rates compared with those treated with the open technique. Complication rates were highest in patients with grade 3 tears (45.2%, P = .043). CONCLUSION Surgical repair of proximal hamstring tendon tears with varying extents of tendon retraction resulted in high rates of achieving PASS at the 2-year follow-up. Among complete tears with <2 cm of retraction, endoscopic repairs exhibited equal or higher rates of achieving PASS compared with open repairs across multiple PROs at 2 years postoperatively. However, patients with complete tears and retraction >2 cm achieved lower rates of PASS on the HOS-ADL and HOS-SS scales and had a higher rate of complications.
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Affiliation(s)
- Thomas W Fenn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Christopher M Brusalis
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
- Department of Orthopedic Surgery, Division of Sports Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Sachin Allahabadi
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
- Department of Orthopaedic Surgery, Division of Sports Medicine, Houston Methodist, Houston, Texas, USA
| | - Alexander B Alvero
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - John W Ebersole
- Department of Musculoskeletal Radiology, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
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Fenn TW, Timmermann AP, Brusalis CM, Kaplan DJ, Ebersole JW, Nho SJ. Clinical Outcomes After Open and Endoscopic Repair of Proximal Hamstring Tendon Tears at a Minimum Follow-up of 5 Years. Orthop J Sports Med 2023; 11:23259671231209054. [PMID: 38021310 PMCID: PMC10668568 DOI: 10.1177/23259671231209054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 06/07/2023] [Indexed: 12/01/2023] Open
Abstract
Background Current evidence supports favorable short-term clinical outcomes with few complications after surgical management of proximal hamstring injuries; however, the durability of clinical benefits beyond approximately 2 years after surgery is unknown. Purpose To evaluate patient-reported clinical outcomes and complication rates associated with open and endoscopic repair of proximal hamstring tears at minimum 5-year follow-up. Study Design Case series; Level of evidence, 4. Methods A single-surgeon registry of patients was queried between October 1, 2014, and December 31, 2017, to identify patients who underwent open or endoscopic repair of a proximal hamstring tear. Patients who reported minimum 5-year follow-up data were included. Multiple patient-reported outcome measures, including the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, 12-Item International Hip Outcome Tool (iHOT-12), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain domains, along with surgical complications, were analyzed. Results Among 35 eligible patients (65.7% female; mean age, 52.3 ± 8.4 years), 24 had full-thickness tears and 11 had partial-thickness tears. There were 23 open repairs and 12 endoscopic repairs. Mean duration from symptom onset to surgical intervention was 37.9 weeks (range, 1.3-306.9 weeks). At a mean follow-up of 69.0 months (range, 60.0-95.0 months), mean postoperative outcome scores were as follows: HOS-ADL, 86.8 ± 12.7; HOS-SS, 83.1 ± 19.5; iHOT-12, 86.3 ± 14.9; PROMIS-PF, 50.0 ± 11.8; and PROMIS-Pain, 50.2 ± 7.9. Regarding complications, 28.6% of patients had a complication including persistent peri-incisional numbness (11.4%), wound infection (11.4%), postoperative neuropathy (8.6%), and revision surgery (2.9%). Conclusion Both open and endoscopic surgical techniques for repair of proximal hamstring injuries produced favorable patient-reported clinical outcomes at a minimum 5-year follow-up.
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Affiliation(s)
- Thomas W. Fenn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Anne P. Timmermann
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Christopher M. Brusalis
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
- Department of Orthopaedic Surgery, Division of Sports Medicine, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Daniel J. Kaplan
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
- Department of Orthpaedic Surgery, Division of Sports Medicine, Hospital for Special Surgery, New York, NY, USA
| | - John W. Ebersole
- Department of Diagnostic Radiology, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J. Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
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Laszlo S, Jonsson KB. Increasing incidence of surgically treated hamstring injuries: a nationwide registry study in Sweden between 2001 and 2020. Acta Orthop 2023; 94:336-341. [PMID: 37417907 PMCID: PMC10327580 DOI: 10.2340/17453674.2023.13650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/21/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Data on incidence and on trends in treatment of hamstring injuries, including proximal hamstring tendon avulsions (PHA), is limited. We aimed to investigate the incidence, trends in operative treatment, age, and sex distribution of hamstring injuries in Sweden between 2001 and 2020. PATIENTS AND METHODS We obtained data recorded in the National Patient Register between 2001 and 2020 on patients between 18 and 90 years of age, with the ICD-10 code S76.3, to calculate the incidence of patients treated operatively for hamstring injuries in Sweden. Patients with the NOMESCO classification NFL49 were considered as having been treated operatively. Data on quadriceps and Achilles tendon injuries were obtained for comparison. To calculate incidences, adult population data for every year were obtained from the Statistics Sweden website. RESULTS The incidence of patients diagnosed with hamstring injuries increased from 2.2 to 7.3 per 100,000 person-years. There was a rising trend of surgical treatment per diagnosed case from 3.0% to 14.2%. Patients diagnosed in units with the highest experience of surgical treatment of hamstring injuries tended to be operated on more often (22.2%) than patients diagnosed in units with limited experience (5.1%), although the fraction of operated patients was increasing in both groups. CONCLUSION Between 2001 and 2020 there was an increase in the proportion of operatively treated hamstring injuries.
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Affiliation(s)
- Sofia Laszlo
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Kenneth B Jonsson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Capurro B, Fenn TW, Kaplan DJ, Larson JH, Nho SJ. Endoscopic Partial Proximal Hamstring Repair. Arthrosc Tech 2023; 12:e1075-e1081. [PMID: 37533921 PMCID: PMC10390821 DOI: 10.1016/j.eats.2023.02.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/21/2023] [Indexed: 08/04/2023] Open
Abstract
The contemporary treatment of hamstring avulsions has been evolving, as more patients are being identified as having persistently symptomatic partial hamstring tears recalcitrant to nonoperative treatment. The endoscopic hamstring repair allows surgeons improved visualization of the footprint, as well as safe dissection of the sciatic nerve. The present technique article provides a step-by-step technical note to allow for safe and effective surgical treatment of partial hamstring tears.
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Affiliation(s)
- Bruno Capurro
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery and Traumatology, Instituto Musculoesquelético Europeo, IMSKE, Valencia, Spain
| | - Thomas W. Fenn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Daniel J. Kaplan
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jordan H. Larson
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J. Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
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Kanakamedala AC, Rynecki ND, Mojica ES, Markus DH, Song MY, Gonzalez-Lomas G, Strauss EJ, Youm T, Jazrawi LM. No difference in clinical outcomes between operative and nonoperative management of minimally retracted proximal hamstring ruptures. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07400-4. [PMID: 37022392 DOI: 10.1007/s00167-023-07400-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE The indications for surgical treatment of proximal hamstring ruptures are continuing to be refined. The purpose of this study was to compare patient-reported outcomes (PROs) between patients who underwent operative or nonoperative management of proximal hamstring ruptures. METHODS A retrospective review of the electronic medical record identified all patients who were treated for a proximal hamstring rupture at our institution from 2013 to 2020. Patients were stratified into two groups, nonoperative or operative management, which were matched in a 2:1 ratio based on demographics (age, gender, and body mass index), chronicity of the injury, tendon retraction, and number of tendons torn. All patients completed a series of PROs including the Perth Hamstring Assessment Tool (PHAT), Visual Analogue Scale for pain (VAS), and the Tegner Activity Scale. Statistical analysis was performed using multi-variable linear regression and Mann-Whitney testing to compare nonparametric groups. RESULTS Fifty-four patients (mean age = 49.6 ± 12.9 years; median: 49.1; range: 19-73) with proximal hamstring ruptures treated nonoperatively were successfully matched 2:1 to 27 patients who had underwent primary surgical repair. There were no differences in PROs between the nonoperative and operative cohorts (n.s.). Chronicity of the injury and older age correlated with significantly worse PROs across the entire cohort (p < 0.05). CONCLUSIONS In this cohort of primarily middle-aged patients with proximal hamstring ruptures with less than three centimeters of tendon retraction, there was no difference in patient-reported outcome scores between matched cohorts of operatively and nonoperatively managed injuries. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ajay C Kanakamedala
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA.
| | - Nicole D Rynecki
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA
| | - Edward S Mojica
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA
| | - Danielle H Markus
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA
| | - Melissa Y Song
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA
| | - Guillem Gonzalez-Lomas
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA
| | - Eric J Strauss
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA
| | - Thomas Youm
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA
| | - Laith M Jazrawi
- Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Health, 333 E 38th, New York, NY, 10015, USA
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Kanakamedala AC, Mojica ES, Hurley ET, Gonzalez-Lomas G, Jazrawi LM, Youm T. Increased time from injury to surgical repair in patients with proximal hamstring ruptures is associated with worse clinical outcomes at mid-term follow-up. Arch Orthop Trauma Surg 2023; 143:951-957. [PMID: 35316390 DOI: 10.1007/s00402-022-04421-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/10/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Prior studies of hamstring tendon tears have reported varied findings on whether increased delay from injury to surgery is associated with worse outcomes. The purpose of this study was to determine whether increased time from injury to surgical repair is associated with worse clinical outcomes in patients with proximal hamstring ruptures. MATERIALS AND METHODS Patients who underwent surgical repair of a proximal hamstring rupture from 2010 to 2019 were followed for a minimum of 24 months from surgery. A cutoff of 6 weeks from injury to the time of surgery was used to distinguish between acute and chronic ruptures. All patients completed patient-reported outcome measures (PROs) at the final follow-up. Multiple factors were analyzed for their effects on PROs including time to surgery, amount of tendon retraction, and demographics such as sex and age. RESULTS Complete data sets were obtained for 38 patients at a mean follow-up of 4.9 years. All data is reported as a mean ± standard deviation. Patients who underwent acute repair of proximal hamstring ruptures had significantly greater Perth Hamstring Assessment Tool (PHAT) scores than those who underwent chronic repair (76.9 ± 18.8 vs 60.6 ± 18.2, p = 0.01). Increased time to surgery was significantly correlated with worse PHAT scores (ρ = - 0.47, p = 0.003). There was no difference in PROs based on the amount of tendon retraction, number of tendons torn, sex, smoking status, or BMI. CONCLUSIONS This study found that acute repair performed within 6 weeks of injury appears to yield improved PROs compared to chronic repair. These data highlight the importance of timely and accurate diagnosis of proximal hamstring ruptures and early operative intervention for surgical candidates.
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Affiliation(s)
- Ajay C Kanakamedala
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States.
| | - Edward S Mojica
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
| | - Eoghan T Hurley
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
| | - Guillem Gonzalez-Lomas
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
| | - Thomas Youm
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
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10
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Modified surgical anchor refixation in older patients with acute proximal hamstring rupture: clinical outcome, patient satisfaction and muscle strength. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04752-3. [PMID: 36622424 PMCID: PMC9828366 DOI: 10.1007/s00402-022-04752-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION After conventional surgical refixation of the hamstrings after proximal hamstring rupture, patients frequently experience pain while sitting and deficits in hamstring muscle strength of the operated side. To improve these outcomes, we have modified the surgical anchor placement and have carried out a thorough follow-up examination. MATERIALS AND METHODS Thirteen older patients (8 female, 5 males) with a median age of 64.2 (range, 52.1-80.4) years were surgically treated for acute proximal hamstring rupture using modified anchor placement and participated in a follow-up assessment at a median of 46.2 (11.2-75.0) months after surgery. Patients completed the Perth Hamstring Assessment Tool (PHAT), quality of life questionnaire (EQ-5D-5L) and the Lower Extremity Functional Scale (LEFS), and rated their satisfaction level on a scale from 0 to 100%. Local tenderness on the ischial tuberosity and maximum passive hip flexion were measured on both limbs. Maximum isokinetic knee flexor muscle strength was measured bilaterally using a dynamometer. RESULTS The median (range) PHAT, EQ-5D-5L and LEFS score were 78.8/100 (54.6-99.8), 0.94/1 (0.83-1) and 88.75/100 (61.25-100). The median satisfaction was 100% (90-100%). Only one patient felt discomfort when the ischial tuberosity was palpated. Neither maximum passive hip flexion nor maximum isokinetic flexor muscle strength differed between the operated and non-operated side (P > 0.58). Clinical scores did not correlate with the leg symmetry index of knee flexor muscle strength (Spearman's rho < 0.448, P > 0.125). There were no tendon re-ruptures, or postoperative sciatic radiculopathy, at the time of follow-up. CONCLUSIONS The modified extra-anatomical anchor placement resulted in good clinical and functional outcome of surgical repair of acute proximal hamstring rupture. Especially the absence of postoperative pain while sitting and the comparable muscle strength to the contralateral side is promising. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04867746, registered.
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11
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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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12
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Green JS, Moran J, Kahan JB, McLaughlin WM, Wang A, Medvecky MJ. Acute Surgical Repair of Simultaneous Bilateral Proximal Hamstring Tendon Avulsion: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00032. [PMID: 36099532 DOI: 10.2106/jbjs.cc.22.00147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE Proximal hamstring tendon avulsions are rare injuries that can be successfully treated with surgical intervention. However, there are limited reports on the surgical and postoperative management of patients with bilateral avulsions. We report a 54-year-old male gym teacher with acute bilateral proximal hamstring 3-tendon nonbony avulsions who underwent simultaneous surgical repairs and a unique postoperative rehabilitation course. At 1-year clinical follow-up, the patient demonstrated significant improvements in activity levels and functionality, with no complications. CONCLUSION Bilateral proximal hamstring 3-tendon nonbony avulsions can be successfully treated with a simultaneous surgical repair and a modified postoperative rehabilitation course.
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Affiliation(s)
- Joshua S Green
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Jay Moran
- Yale School of Medicine, Department of Rehabilitation & Orthopaedics, New Haven, Connecticut
| | - Joseph B Kahan
- Yale School of Medicine, Department of Rehabilitation & Orthopaedics, New Haven, Connecticut
| | - William M McLaughlin
- Yale School of Medicine, Department of Rehabilitation & Orthopaedics, New Haven, Connecticut
| | - Annie Wang
- Yale School of Medicine, Department of Biomedical Imaging, New Haven, Connecticut
| | - Michael J Medvecky
- Yale School of Medicine, Department of Rehabilitation & Orthopaedics, New Haven, Connecticut
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13
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van der Made AD, Peters RW, Verheul C, Smithuis FF, Reurink G, Moen MH, Tol JL, Kerkhoffs GMMJ. Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model. Br J Sports Med 2022; 56:340-348. [PMID: 34996751 DOI: 10.1136/bjsports-2021-104588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions. METHODS Patients 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. RESULTS Twenty-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). CONCLUSION In 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.
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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 (ACES), Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
| | - Rolf W Peters
- Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Department of Trauma surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Claire Verheul
- Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Fysiokliniek Amsterdam, Amsterdam, The Netherlands
| | - Frank F Smithuis
- Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Gustaaf Reurink
- Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,The Sports Physicians Group, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Maarten H Moen
- The Sports Physicians Group, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Johannes L Tol
- Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Gino M M J Kerkhoffs
- Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands .,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
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14
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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: 1] [Impact Index Per Article: 0.3] [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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15
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Abstract
Proximal hamstring injuries can present as chronic tendinosis, acute strain, partial tendinous avulsions, or complete 3-tendon rupture. Nonoperative management for chronic insertional tendinosis and low-grade tears includes activity modification, anti-inflammatories, and physical therapy. Platelet-rich plasma injections, corticosteroid injections, dry needling, and shock wave therapy are newer therapies that also may provide benefit. Surgical indications include complete, proximal avulsions; partial avulsions with least 2 tendons injured with more than 2 cm of retraction in young, active patients; and partial avulsion injuries or chronic tendinosis that have failed nonoperative management. Surgical management entails open primary repair, endoscopic primary repair, or augmentation/reconstruction.
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Affiliation(s)
- Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, 311 Trent Drive, Durham, NC 27710, USA
| | - Jonathan W Cheah
- Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, 751 South Bascom Avenue, San Jose, CA 95128, USA
| | - Shane J Nho
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Orthopedic Building Suite 400, Chicago, IL 60612, USA
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Duke Sports Science Institute, 3475 Erwin Road, Durham, NC 27705, USA.
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Shilt J, McHorse G, Moisiuc A, Kushare I. Chemoprotection with botulinum toxin following proximal hamstring-Ischial tuberosity avulsion fracture repair: Running title: Chemoprotection for hamstring avulsion fractures. J Clin Orthop Trauma 2021; 12:172-176. [PMID: 33716443 PMCID: PMC7920335 DOI: 10.1016/j.jcot.2020.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/27/2020] [Accepted: 06/19/2020] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Jeffrey Shilt
- Department of Orthopedic Surgery, Texas Children’s Hospital, 17580 Interstate 45 South, The Woodlands, TX, 77384, USA,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Grant McHorse
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Alexis Moisiuc
- Department of Orthopedic Surgery, Texas Children’s Hospital, 17580 Interstate 45 South, The Woodlands, TX, 77384, USA
| | - Indranil Kushare
- Department of Orthopedic Surgery, Texas Children’s Hospital, 17580 Interstate 45 South, The Woodlands, TX, 77384, USA,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA,Corresponding author. D 17580 Interstate 45 South, The Woodlands, TX, 77384, USA.
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Leininger A, Duerr RA, Chauhan A, McGovern RP, Christoforetti JJ. Endoscopic-Assisted Anatomic Reconstruction of Chronic Proximal Hamstring Avulsion With Achilles Allograft. Arthrosc Tech 2020; 9:e1133-e1139. [PMID: 32874893 PMCID: PMC7451431 DOI: 10.1016/j.eats.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/12/2020] [Indexed: 02/03/2023] Open
Abstract
Hamstring injuries commonly occur at the musculotendinous junction; however, they can occur as proximal avulsion injuries. A lack of recognition can lead to proximal hamstring injuries being frequently misdiagnosed, resulting in delayed treatment. Chronic proximal hamstring tears are often retracted and scarred to the surrounding soft tissues. Owing to the poor quality of tissue at the torn ends of the tendon, an augmented reconstruction using an allograft may be required. In cases with poor visualization of the ischial tuberosity and proximal hamstring footprint, an Achilles tendon allograft can be secured directly to the tuberosity with suture anchors. However, visualization of the footprint can be optimized using an arthroscope. This report describes a technique for endoscopic-assisted anatomic reconstruction using an Achilles allograft with both knotless and knotted suture anchors for chronic complete avulsions of the proximal hamstring.
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Affiliation(s)
| | | | | | - Ryan P. McGovern
- Address correspondence to Ryan P. McGovern, Ph.D., A.T.C., Texas Health Sports Medicine, 1120 Raintree Cir, Ste 280, Allen, TX 75013, U.S.A.
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