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Lin KM, Atzmon R, Pierre KJ, Vel MS, Brinson K, Sherman SL. Common Soft Tissue Injuries About the Knee in American Football. HSS J 2023; 19:330-338. [PMID: 37435123 PMCID: PMC10331270 DOI: 10.1177/15563316231165298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/01/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Kenneth M Lin
- Division of Sports Medicine, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
| | - Ran Atzmon
- Division of Sports Medicine, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
| | - Kinsley J Pierre
- Division of Sports Medicine, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
| | - Monica S Vel
- Division of Sports Medicine, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
| | - Kenneth Brinson
- Division of Sports Medicine, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
| | - Seth L Sherman
- Division of Sports Medicine, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
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2
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Ranzoni LV, Guberovich MA, Ejnisman L, Miyahara HS, Rath E, Gurgel HMDC, Jacomo AL. Proximal endoscopic repair of the hamstring tendons: a cadaveric anatomical study of posterior hip portals. J Hip Preserv Surg 2023; 10:75-79. [PMID: 37900891 PMCID: PMC10604049 DOI: 10.1093/jhps/hnad001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/06/2022] [Accepted: 01/10/2023] [Indexed: 10/31/2023] Open
Abstract
Arthroscopy and endoscopic hip surgery have attracted increasing attention in the orthopedic field. In the case of arthroscopy, portals and their relationships with neurovascular bundle structures at risk are well established. However, studies on endoscopic portals used for the repair of hamstring tendon injuries are insufficient. Hamstring injuries are the most common muscle injury in sports medicine, and up to 12% can present as a tendon rupture. Endoscopic surgery is advantageous because it has a lower rate of bleeding and avoids excessive handling of the gluteal muscles. The objective of this study is to perform an anatomical evaluation of endoscopic portals for hamstring repair and measure their distance to neurovascular structures-mainly sciatic nerve and posterior femoral cutaneous nerve (PFCN). Fifteen hips from frozen and formalized cadavers were evaluated. Specimens that showed any modification in their anatomy were excluded. Portals were simulated using Steinmann pins, and anatomical dissection was performed. Distances from neurovascular structures were measured using a digital caliper. Four male cadaver hips (26%) and eleven female cadaver hips (74%) were included. Two dissected hips presented PFCN injury through the posterolateral portal- mean 20.28 mm (±8.14), and one through the distal accessory portal- 21.87 mm (±12.03). The injury rate for PFCN was 3/15 or 20%. None of the portals presented sciatic nerve injury. Conclusion: There is an imminent risk of nerve injury to the PFCN by performing the lateral portals for hamstring repair. To avoid this, we recommend starting the procedure through the most medial (posteromedial) portal, and the other portals must be performed under direct visualization.
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Affiliation(s)
- Lucas Verissimo Ranzoni
- Department of Pathophysiology, Faculty of Medicine, USP, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil
| | - Matheus Almeida Guberovich
- Department of Pathophysiology, Faculty of Medicine, USP, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil
| | - Leandro Ejnisman
- Orthopedics Department, Hospital Israelita Albert Einstein, Dr. Ovídio Pires de Campos Street, 333, Cerqueira Cesar, São Paulo, SP 05403-010, Brazil
| | - Helder Souza Miyahara
- Orthopedics Department, Hospital das Clínicas—FMUSP, Dr. Ovídio Pires de Campos Street, 333, Cerqueira Cesar, São Paulo, SP 05403-010 Brazil
| | - Ehud Rath
- Orthopedics Department, Tel Aviv University School of Medicine, Tel Aviv-Yafo 6997801, Israel
| | - Henrique Melo de Campos Gurgel
- Orthopedics Department, Hospital das Clínicas—FMUSP, Dr. Ovídio Pires de Campos Street, 333, Cerqueira Cesar, São Paulo, SP 05403-010 Brazil
| | - Alfredo Luiz Jacomo
- Department of Surgery, Faculty of Medicine, USP, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil
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Lawton CD, Sullivan SW, Hancock KJ, Burger JA, Nawabi DH, Kelly BT, Ranawat AS, Nwachukwu BU. Achievement of the minimal clinically important difference following open proximal hamstring repair. J Hip Preserv Surg 2021; 8:348-353. [PMID: 35505799 PMCID: PMC9052411 DOI: 10.1093/jhps/hnab068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/05/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022] Open
Abstract
There is a paucity of literature on patient-reported outcome measures (PROMs) following proximal hamstring repair beyond return to play, patient satisfaction and pain improvement. The minimal clinically important difference (MCID) defines the minimum degree of quantifiable improvement that a patient can perceive, but the MCID and predictors of this measure have not been defined for this patient population. This study aimed to define the MCID and determine the efficacy of open proximal hamstring repair through achievement of MCID and identify characteristics predictive of achieving MCID. A retrospective cohort review of an institutional hip registry was conducted, analyzing the modified Harris Hip Score (mHHS) and International Hip Outcome Tool (iHOT-33). MCID was calculated using a distribution-based method. Demographic and clinical variables predictive of achieving MCID were analyzed using univariable and multivariate logistic regression analyses. Thirty-nine patients who underwent open proximal hamstring repair were included. The mean patient age was 48.5 ± 12.4 years, with a mean follow-up of 37.1 ± 28 months. The MCID was determined for each PROM (mHHS—11.8; iHOT-33—12.6). A high percentage of patients achieved MCID for both PROMs (mHHS—85.7%; iHOT-33—91.4%). Univariate logistical regression demonstrated increased age (P = 0.163), increased body mass index (BMI; P = 0.072), requirement for inpatient admission (P = 0.088) and pre-operative iHOT-33 (P = 0.104) trended towards clinically significant predictors of not achieving MCID. A high percentage of patients achieved MCID while age, BMI, inpatient admission and pre-operative iHOT-33 appear to influence the achievement of clinically significant outcome in patients undergoing open proximal hamstring repair.
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Affiliation(s)
- Cort D Lawton
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Spencer W Sullivan
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Kyle J Hancock
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Joost A Burger
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Danyal H Nawabi
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
- Weill Cornell Medical College, New York, NY 10021, USA
| | - Bryan T Kelly
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
- Weill Cornell Medical College, New York, NY 10021, USA
| | - Anil S Ranawat
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
- Weill Cornell Medical College, New York, NY 10021, USA
| | - Benedict U Nwachukwu
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
- Weill Cornell Medical College, New York, NY 10021, USA
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4
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Partenheimer A, Lill H. [Avulsion of the hamstring muscles]. Unfallchirurg 2021; 124:536-541. [PMID: 34143257 DOI: 10.1007/s00113-021-01026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Avulsion injuries of the proximal hamstring muscles are rare but very severe injuries to the dorsal thigh musculature. OBJECTIVE Due to improved diagnostics and experience in treatment, the decision for surgical treatment is becoming more and more frequent. Presentation of the surgical method, follow-up treatment and outcome. MATERIAL AND METHODS Description of the anatomy, origin, diagnostics and treatment of avulsions of the hamstring musculature. RESULTS Due to improvement of knowledge and diagnostics, avulsion injuries of the hamstring muscles are identified more frequently. The rapid expansion of the diagnostics, including magnetic resonance imaging (MRI) is decisive for a better identification of the extent and severity of the injury. Even if the differences in long-term results between surgical and conservative treatment are not significant in the literature, there is a clear improvement in function and resilience after surgical treatment of avulsion injuries of the hamstring muscles. CONCLUSION In view of the poor results of nonsurgical treatment and the clearly positive reports of surgical success, open refixation is recommended for recent proximal hamstring ruptures.
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Affiliation(s)
- Axel Partenheimer
- Praxis Spine & Sport, Herrenhäuser Kirchweg 38, 30167, Hannover, Deutschland. .,Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland.
| | - Helmut Lill
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland
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5
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Suppauksorn S, Nwachukwu BU, Beck EC, Okoroha KR, Nho SJ. Endoscopic Approach to Proximal Hamstring Avulsion Repair. JBJS Essent Surg Tech 2020; 10:ST-D-19-00037. [PMID: 34055472 DOI: 10.2106/jbjs.st.19.00037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Endoscopic repair of a proximal hamstring avulsion promotes precise anatomical repair and lowers the risk of neurovascular injury. Description Indications for proximal endoscopic repair of the proximal part of the hamstrings include acute tears of 2 tendons with >2 cm of retraction in young active patients, acute complete tears of 3 tendons with >2 cm of retraction, or failed conservative treatment of tears of ≥2 tendons with ≤2 cm of retraction. Repair of a proximal hamstring avulsion is performed using 2 portals. The medial portal is developed percutaneously under fluoroscopic guidance. The lateral portal is developed under direct visualization. The footprint of the hamstrings is identified from medial to lateral. The sciatic and posterior femoral cutaneous nerves must be carefully identified and protected. The avulsed tendons are fixed with suture anchors with the knee in flexion. Alternatives Conservative treatment is commonly used to treat injuries of the musculotendinous junction (type 2), incomplete or complete avulsion with minimal retraction (≤2 cm) (type 3 or 4, respectively), and patients with limited mobility or severe comorbidities1. The initial treatments consist of RICE (rest, ice, compression, and elevation), protective ambulation, and then physical therapy. Open repair is used for incomplete or complete avulsion with >2 cm of retraction, or when conservative treatments have failed1-3. Open reconstruction is used for chronic avulsion with tendon retraction of >5 cm4-6. Rationale Endoscopic surgery is a minimally invasive procedure that offers excellent visualization of the subgluteal space without gluteus maximus muscle retraction. In open repair, the inferior border of the gluteus maximus muscle is mobilized to access the ischial tuberosity. The mean distance (and standard deviation) from the inferior border of the gluteus maximus muscle to the hamstring origin has been reported to be 6.3 ± 1.3 cm, which is close to the mean distance from the inferior border of the gluteus maximus to the inferior gluteal nerve and artery, which has been reported to be 5.0 ± 0.8 cm7. Open repair, which requires gluteus maximus retraction, poses an injury risk to the inferior gluteal nerve and artery. Open repair increases the risk of wound infection because the incision involves the perineum8. The feasibility of the endoscopic repair depends on the chronicity and amount of tendon retraction. It is feasible for a symptomatic tear of ≥2 tendons with a retraction of ≤2 cm. Mobilization of the retracted tendon is challenging in endoscopic repair. In acute injuries, the degree of retraction is not critical because the tendon is easily mobilized. Chronic injuries (>2 months) and those with far tendon retraction (>5 cm) are not suitable for endoscopy9. In chronic injuries with incomplete or complete avulsion with minimal retraction (≤2 cm) (types 3 and 4) that have failed conservative treatment, endoscopy is suitable since the tendon is not retracted1. Endoscopic repair can be converted to an open procedure in difficult endoscopic conditions.
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Affiliation(s)
| | - Benedict U Nwachukwu
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Kelechi R Okoroha
- Division of Sports Medicine, Department of Orthopedic Surgery, Henry Ford Macomb Hospital, Detroit, Michigan
| | - Shane J Nho
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
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6
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Bataillie F, Bataillie S, van Beek N, Corten K. Portal placement for endoscopic surgery in the deep gluteal area: a cadaveric study. J Hip Preserv Surg 2020; 7:147-152. [PMID: 32382442 PMCID: PMC7195941 DOI: 10.1093/jhps/hnaa008] [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: 07/03/2019] [Accepted: 01/09/2020] [Indexed: 12/03/2022] Open
Abstract
Partial or complete avulsion of the insertion of the proximal hamstrings at the level of the ischial tuberosity is most often treated by open exploration and reinsertion. However, endoscopic reinsertion could be considered to minimize the soft tissue damage. In this study, we aimed to determine the most optimal location of four endoscopic portals that allow for a safe exploration of the proximal hamstring insertion site. The reference points for the portals run vertically through the center of the sciatic tuberosity and through a horizontal line which lies on the inferior edge of the tuberosity. The distance and relationship between the sciatic, the inferior gluteal and posterior femoral cutaneous nerves and the four proposed endoscopic portals was documented. Our results showed that it was best to start with the inferior portal followed by the medial and lateral portal. The inferior portal allowed for a clear visualization of the sciatic nerve and was along with the medial portal at a distance of >5 cm from any of the surrounding nerves. Care must be taken with the lateral portal, as the distance to the surrounding nerves varied between specimens. A fourth portal could be used as a viewing portal when necessary. Our study showed that the sequence and position of the proposed endoscopic portals provide a safe approach to the proximal part of the hamstrings and the ischial tuberosity. These findings can be helpful for endoscopic procedures to the ischium and the sciatic nerve in the gluteal region.
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Affiliation(s)
- F Bataillie
- Department of Orthopedic Surgery, AZ Hospital, Herentals, Belgium
| | - S Bataillie
- Department of Ophthalmology, UZLeuven, Leuven, Belgium
| | - N van Beek
- Department of Orthopedic Surgery, AZ Hospital, Herentals, Belgium
| | - K Corten
- Hip Unit, Orthopaedic Department, Ziekenhuis Oost-Limburg, Genk, Belgium
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7
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Abstract
Objective: Proximal ischial hamstring avulsion injuries are relatively uncommon. As such, the management of these injuries is often highly variable. Consensus agreement is lacking for the indications for repair, along with the operative technique, and post-operative rehabilitation. The purpose of this study was to survey surgeons who treat proximal hamstring avulsion injuries to identify current trends in the management of this injury.Methods: After IRB approval, a 46-question cross-sectional survey was distributed using a secure electronic survey portal. The survey sought to determine surgeon experience, diagnostic preferences, treatment patterns, surgical indications/technique, perceived patient outcomes, surgical complications, as well as post-operative management and rehab protocols. Surveys were completed electronically and anonymously, with invitations distributed to members of the American Orthopedic Society for Sports Medicine (AOSSM) and Arthroscopy Association of Canada (AAC).Results: A total of 108 surgeons who manage proximal hamstring injuries completed the survey. Most respondents (77%) treat one to five of these injuries per year. MRI was the preferred imaging modality to confirm diagnosis. Despite 98% of respondents indicating that there was a role for surgical management of proximal hamstring avulsions, operative treatment was reportedly undertaken in only 50% of cases seen by each respondent. The top three reported surgical indications were: number of tendons involved (most important factor = 42%, second most = 26%, third most = 13%), amount of tendon retraction (28%, 41%, 16%), and patient activity level (16%, 18%, 24%).Conclusion: Based on the practice patterns of the surgeons who completed the survey, there is continued disparity in the management of proximal hamstring avulsions. A lack of agreement exists with regards to surgical indications, operative technique, and post-operative protocols. Most striking is the rate of non-operative treatment and perceived rate of poor outcomes within this cohort. Future research should focus on objective evaluation of non-operative management, and additional variables involved in surgical treatment and post-operative rehabilitation.
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Affiliation(s)
- Nicholas Pasic
- Department of Surgery, Schulich School of Medicine and Dentistry, London, ON, Canada.,Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada
| | - J Robert Giffin
- Department of Surgery, Schulich School of Medicine and Dentistry, London, ON, Canada.,Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada
| | - Ryan M Degen
- Department of Surgery, Schulich School of Medicine and Dentistry, London, ON, Canada.,Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada
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8
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Otto A, DiCosmo AM, Baldino JB, Mehl J, Obopilwe E, Cote MP, Imhoff AB, Beitzel K, Mazzocca AD, Coyner K. Biomechanical Evaluation of Proximal Hamstring Repair: All-Suture Anchor Versus Titanium Suture Anchor. Orthop J Sports Med 2020; 8:2325967119892925. [PMID: 31921936 PMCID: PMC6940602 DOI: 10.1177/2325967119892925] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/25/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Proximal hamstring avulsions are severe tendon injuries and are commonly
sports-related. Open and endoscopic techniques as well as different anchor
configurations have already been described for proximal hamstring repair.
Novel all-suture anchors have been developed to provide decreased bone loss
during placement and reduced occupied bone volume when compared with
titanium suture anchors. Hypothesis: Complete proximal hamstring avulsions repaired with all-suture anchors will
demonstrate equal load to failure and comparable displacement under cyclic
loading when compared with titanium suture anchors. Study Design: Controlled laboratory study. Methods: Complete proximal hamstring avulsions were created in 18 paired cadaveric
specimens (mean ± SD age, 63.0 ± 10.4 years). Either all-suture anchors or
titanium suture anchors were used for repair. Cyclic loading from 10 to 125
N at 1 Hz was performed for 1500 cycles with a material testing machine.
Displacement was assessed along anterior and posterior aspects of the tendon
repair with optical tracking. Specimens were loaded to failure at a rate of
120 mm/min. Displacement, load to failure, and repair construct stiffness
were compared between matched pairs with the Wilcoxon signed-rank test.
Correlations were determined by Spearman rho analysis. Results: The all-suture anchors showed significantly higher load-to-failure values
when compared with the titanium anchor repairs (799.64 ± 257.1 vs 573.27 ±
89.9 N; P = .008). There was no significant difference in
displacement between all-suture anchors and titanium suture anchors at the
anterior aspect (6.60 ± 2.2 vs 5.49 ± 1.1 mm; P = .26) or
posterior aspect (5.87 ± 2.08 vs 5.23 ± 1.37 mm; P = .678)
of the repaired hamstring tendons. Conclusion: All-suture anchors demonstrated similar displacement and superior load to
failure when compared with titanium suture anchors. Clinical Relevance: The results of this study suggest that all-suture anchors are an equivalent
alternative to titanium suture anchors for proximal hamstring avulsion
repair.
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Affiliation(s)
- Alexander Otto
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Augsburg, Germany
| | - Alyssa M DiCosmo
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut, USA
| | - Joshua B Baldino
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut, USA
| | - Julian Mehl
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut, USA
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Knut Beitzel
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,ATOS Orthoparc Klinik Köln, Cologne, Germany
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut, USA
| | - Katherine Coyner
- Department of Orthopaedic Surgery, UConn Musculoskeletal Institute, University of Connecticut, Farmington, Connecticut, USA
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Papastergiou S, Grammatikopoulou D, Iosifidou E, Manika C, Metaxiotis D, Romanidis R, Tsitouridis K. Apophysitis of the Ischial Tuberosity: A Case Report. J Orthop Case Rep 2020; 10. [PMID: 32547986 PMCID: PMC7276574 DOI: 10.13107/jocr.2020.v10.i01.1648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Sports-related recurrent injuries (microtrauma and trauma) of the apophyses are common in children and adolescents and could result in specific pathologies. One of them is the apophysitis or apophysiolysis of ischial tuberosity (Valtancoli or Kremser's disease) due to contraction of hamstrings, in sports with sudden accelerations and decelerations. CASE REPORT We present the case of a male athlete who complained of pain in the left buttock and difficulty walking after a 3months old reported trauma with pain and hematoma in his left thigh, during a kick with his contralateral leg. Due to a radiographic finding of a suspicious lesion near his left ischial tuberosity, an extensive investigation that included computed tomography, magnetic resonance imaging, bone scintigraphic scan, and blood analysis followed the diagnosis of apophysitis of the ischial tuberosity was determined and the proposed non-surgical treatment had satisfactory results. CONCLUSION The diagnosis of apophysitis of ischial tuberosity is usually delayed but has a good response to the appropriate treatment.
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Affiliation(s)
- S Papastergiou
- Department of Orthopaedic, General Hospital of Thessaloniki “Agios Pavlos,” Thessaloniki, Greece
| | - D Grammatikopoulou
- Department of Orthopaedic, General Hospital of Thessaloniki “Agios Pavlos,” Thessaloniki, Greece,Address of Correspondence: Dr. D Grammatikopoulou, Department of Orthopaedic, General Hospital of Thessaloniki “Agios Pavlos,” Thessaloniki, Greece. E-mail:
| | - E Iosifidou
- Department of Radiology, General Hospital of Thessaloniki “Agios Pavlos,” Thessaloniki, Greece
| | - C Manika
- Department of Orthopaedic, General Hospital of Thessaloniki “Papageorgiou” and Elepap, Thessaloniki, Greece
| | - D Metaxiotis
- Department of Radiology, General Hospital of Thessaloniki “Agios Pavlos,” Thessaloniki, Greece
| | - R Romanidis
- Department of Radiology, General Hospital of Thessaloniki “Agios Pavlos,” Thessaloniki, Greece
| | - K Tsitouridis
- Department of Radiology, General Hospital of Thessaloniki “Agios Pavlos,” Thessaloniki, Greece
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Ebert JR, Gormack N, Annear PT. Reconstruction of chronic proximal hamstring avulsion injuries using ipsilateral distal hamstring tendons results in good clinical outcomes and patient satisfaction. Knee Surg Sports Traumatol Arthrosc 2019; 27:2958-2966. [PMID: 30470850 DOI: 10.1007/s00167-018-5310-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/20/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To report outcomes following proximal hamstring reconstruction employing an ipsilateral distal hamstring tendon autograft, in patients with chronic proximal ruptures. METHODS Six patients presenting with a chronic proximal hamstring avulsion and a medial time from injury of 11.0 months (range 7-18), confirmed via magnetic resonance imaging, underwent proximal hamstring repair using a free graft harvested from the ipsilateral distal hamstrings. Patients were evaluated at 6, 12 and 24 months post-surgery, via the Perth Hamstring Assessment Tool, the Short Form Health Survey, the Lower Extremity Functional Scale, a Patient Satisfaction Questionnaire, the Active Knee Extension and 6 min walk tests, the single and triple hop tests for distance, and isokinetic knee extensor and flexor strength. Knee strength was assessed at 180° and 240°/s (total work, peak and average torque), and both mean absolute scores and limb symmetry indices (LSIs) comparing the operated and non-operated limbs were presented. RESULTS Patients demonstrated good clinical improvement throughout the post-operative timeline in all subjective and objective outcomes. Mean knee extensor LSIs had recovered by 12 and 24 months. At 24 months post-surgery, while mean LSIs for knee flexor peak and average torque were at (or above) 90%, a significant difference still existed between the operated and non-operated limbs in knee flexor total work. At 24 months, five patients (83%) were satisfied with the results of the surgery, as well as their ability to return to recreational and sporting activities. There were two adverse events including an early deep vein thrombosis and a secondary surgery to remove a loosened staple. CONCLUSIONS While isokinetic hamstring strength had not fully recovered by 24 months, this surgical technique demonstrated a high level of patient satisfaction and return to function, in patients with chronic proximal hamstring ruptures. As the clinical relevance, this surgical technique provides a viable option with good post-operative outcomes for patients with chronic proximal hamstring tears that cannot be approximated back to the ischium. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jay R Ebert
- The School of Human Sciences (Exercise and Sport Science), The University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia.
- Perth Orthopaedic and Sports Medicine Research Institute, West Perth, Western Australia, Australia.
| | - Nicholas Gormack
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, 6005, Australia
| | - Peter T Annear
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, 6005, Australia
- Perth Orthopaedic and Sports Medicine Research Institute, West Perth, Western Australia, Australia
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11
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Anatomy of proximal attachment, course, and innervation of hamstring muscles: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 2019; 27:673-684. [PMID: 30374579 DOI: 10.1007/s00167-018-5265-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/23/2018] [Indexed: 01/12/2023]
Abstract
Hamstring injuries are very common in sports medicine. Knowing their anatomy, morphology, innervation, and function is important to provide a proper diagnosis, treatment as well as appropriate prevention strategies. In this pictorial essay, based on anatomical dissection, the detailed anatomy of muscle-tendon complex is reviewed, including their proximal attachment, muscle course, and innervation. To illustrate hamstrings' role in the rotational control of the tibia, the essay also includes the analysis of their biomechanical function.Level of evidence V (expert opinion based on laboratory study).
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12
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Abstract
PURPOSE OF REVIEW To outline the typical presentation, physical examination, diagnostic imaging, and therapeutic treatment options for proximal hamstring injuries to improve awareness, expedient diagnosis, and definitive management. RECENT FINDINGS Proximal hamstring tendinopathy and partial-thickness tears can often successfully be managed with a combination of non-operative modalities, including physiotherapy focused on eccentric strengthening, extracorporeal shock wave therapy, or peri-tendinous injections. Surgery is reserved for refractory cases, but can yield good outcomes. Contrastingly, non-operative treatment often leads to unsatisfactory outcomes in complete ruptures, with residual weakness and reduced function with poor return-to-sport rates. Instead, surgical repair can provide satisfactory outcomes, with good-to-excellent functional outcomes and strength, with acute treatment preferred over delayed, chronic repair. Hamstring tendinopathy and partial-thickness tears can be successfully treated non-operatively with good functional outcomes, with surgical repair reserved for refractory cases. Complete tears are best managed with surgical repair, allowing improved strength and functional outcomes.
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Affiliation(s)
- Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
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Papastergiou S, Grammatikopoulou D, Iosifidou E, Manika C, Metaxiotis D, Romanidis R, Tsitouridis K. Apophysitis of the Ischial Tuberosity: A Case Report. J Orthop Case Rep 2019; 10:82-85. [PMID: 32547986 DOI: 10.13107/jocr.2019.v10.i01.1648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Sports-related recurrent injuries (microtrauma and trauma) of the apophyses are common in children and adolescents and could result in specific pathologies. One of them is the apophysitis or apophysiolysis of ischial tuberosity (Valtancoli or Kremser's disease) due to contraction of hamstrings, in sports with sudden accelerations and decelerations. Case Report We present the case of a male athlete who complained of pain in the left buttock and difficulty walking after a 3months old reported trauma with pain and hematoma in his left thigh, during a kick with his contralateral leg. Due to a radiographic finding of a suspicious lesion near his left ischial tuberosity, an extensive investigation that included computed tomography, magnetic resonance imaging, bone scintigraphic scan, and blood analysis followed the diagnosis of apophysitis of the ischial tuberosity was determined and the proposed non-surgical treatment had satisfactory results. Conclusion The diagnosis of apophysitis of ischial tuberosity is usually delayed but has a good response to the appropriate treatment.
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Affiliation(s)
- S Papastergiou
- Department of Orthopaedic, General Hospital of Thessaloniki "Agios Pavlos," Thessaloniki, Greece
| | - D Grammatikopoulou
- Department of Orthopaedic, General Hospital of Thessaloniki "Agios Pavlos," Thessaloniki, Greece
| | - E Iosifidou
- Department of Radiology, General Hospital of Thessaloniki "Agios Pavlos," Thessaloniki, Greece
| | - C Manika
- Department of Orthopaedic, General Hospital of Thessaloniki "Papageorgiou" and Elepap, Thessaloniki, Greece
| | - D Metaxiotis
- Department of Radiology, General Hospital of Thessaloniki "Agios Pavlos," Thessaloniki, Greece
| | - R Romanidis
- Department of Radiology, General Hospital of Thessaloniki "Agios Pavlos," Thessaloniki, Greece
| | - K Tsitouridis
- Department of Radiology, General Hospital of Thessaloniki "Agios Pavlos," Thessaloniki, Greece
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Schröder JH, Gesslein M, Schütz M, Perka C, Krüger DR. [Minimally invasive proximal hamstring insertion repair]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 30:419-434. [PMID: 30443745 DOI: 10.1007/s00064-018-0575-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/19/2018] [Accepted: 08/22/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Minimally invasive endoscopic reconstruction of avulsion injuries of the proximal hamstring insertion to prevent persistent weakness and pain. INDICATIONS Fresh retracted 2‑ and 3‑tendon avulsion injuries of the proximal hamstring insertion. Unsuccessful conservative therapy of less retracted injuries. Painful chronic partial lesions of the proximal hamstring insertion. CONTRAINDICATIONS Major comorbidities with an increased surgical risk, older patients with low functional demands. Chronic injuries without functional deficits. SURGICAL TECHNIQUE Endoscopic refixation using suture anchors after freshening the footprint on the tuber ischiadicum. Visualization of the sciatic nerve to ensure its protection. POSTOPERATIVE MANAGEMENT Partial loading with a knee brace for strict prevention of combined knee extension and hip flexion for 4-6 weeks. Start of active exercise and stretching 8 weeks postoperatively. RESULTS From 2014-2016, 12 patients were treated with an endoscopic reconstruction of the proximal hamstring insertion. After a mean follow-up of 25 months (range 16-34 months), an average visual analog scale (VAS) of 0 (range 0-2) and an average subjective assessment of function (Subjective Hip Value) of 94% (range 80-100%) were found. No neurovascular complications were seen in our collective, in particular no evidence of hypesthesia in the area of the posterior femoral cutaneous nerve. All patients were able to return to their original level of activity (Tegner Activity Scale 5.2 preoperatively vs. 5.2 postoperatively), while the average time until return to sport was 6.5 months (range 3-12 months). All patients were able to return to their original occupation.
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Affiliation(s)
- J H Schröder
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - M Gesslein
- Klinik für Orthopädie und Unfallchirurgie, Paracelsus Medizinische Privatuniversität Nürnberg, Nürnberg, Deutschland
| | - M Schütz
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - C Perka
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - D R Krüger
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
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Abstract
Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient's hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.
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Adult thigh muscle injuries-from diagnosis to treatment: what the radiologist should know. Skeletal Radiol 2018; 47:1087-1098. [PMID: 29564488 DOI: 10.1007/s00256-018-2929-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 03/10/2018] [Accepted: 03/11/2018] [Indexed: 02/02/2023]
Abstract
Muscle injuries are one of the major problems facing elite athletes, representing a significant source of time lost from competition, with substantial consequences for teams and athletes. There are considerable pressures for a rapid return, but players who return to competition too soon have an increased risk of recurrent muscle injuries, which are associated with longer lay-offs. Imaging plays a key role in achieving the correct diagnosis, and magnetic resonance imaging (MRI) has emerged as the method of choice for skeletal muscle imaging. Several authors have reported prognostic MRI features, but it is difficult to predict the exact length of time to return to full training afterwards due to considerable discrepancy and overlap between different injuries. Therefore, development of a universally applicable classification and grading system is challenging. This paper aims to: (a) review the contemporary role of imaging in the setting of muscle injuries, with special focus on thigh muscles; (b) list the most accepted terminology used to describe muscle injuries;
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Multimodal Care in the Management of a Patient With Chronic Tendinopathy of the Biceps Femoris: A Case Report. J Chiropr Med 2017; 16:156-162. [PMID: 28559756 DOI: 10.1016/j.jcm.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/09/2017] [Accepted: 01/24/2017] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The purpose of this case report was to describe the use of dry needling in conjunction with auricular acupuncture, core exercises, and light aerobic activity for treating chronic tendinopathy of the biceps femoris. CLINICAL FEATURES A 30-year-old white female presented with chronic biceps femoris tendinopathy. The injury had occurred 18 months prior while training for a triathlon. Active stretching of her right biceps femoris while standing with her feet 6 inches apart aggravated the pain at the origin in the right tendon of the biceps femoris at 0 degrees of movement. INTERVENTION/OUTCOME The combination of dry needling and auricular acupuncture with core rehabilitation exercises and light activity was employed. Alleviation of pain with full range of motion was achieved during hip extension, knee flexion, and standing biceps femoris stretch at the 11th, 16th, and 18th treatments. In addition, the patient also reported improvement in her symptoms, including night sweats, insomnia, anxiety, tension, and constipation. CONCLUSIONS This patient's symptoms and function improved after 18 treatments of multimodal care. Dry needling employed simultaneously with auricular acupuncture, core exercises, and light activity could be considered a possible strategy for treating chronic tendinopathy.
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Moatshe G, Chahla J, Vap AR, Ferrari M, Sanchez G, Mitchell JJ, LaPrade RF. Repair of Proximal Hamstring Tears: A Surgical Technique. Arthrosc Tech 2017; 6:e311-e317. [PMID: 28580247 PMCID: PMC5442402 DOI: 10.1016/j.eats.2016.10.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/04/2016] [Indexed: 02/03/2023] Open
Abstract
Proximal hamstring tears are among the most common sports-related injuries. These injuries often occur as strains or partial tears at the proximal muscle belly or the musculotendinous junction, with avulsion injuries of the proximal attachment occurring less frequently. Regardless of the mechanism, they produce functional impairment and negatively affect an athlete's performance. Various classifications for these injuries are reported in the literature. Early surgical treatment is recommended for patients with either a 2-tendon tear/avulsion with more than 2 cm retraction or those with complete 3-tendon tears. Surgery can be performed in the chronic phase but it is technically demanding because of scar formation and tendon retraction. This Technical Note describes a biomechanically validated surgical technique for repair of the proximal hamstring tears.
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Affiliation(s)
- Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway,OSTRC, Norwegian School of Sports Sciences, Oslo, Norway
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Marcio Ferrari
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - George Sanchez
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Robert F. LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Robert F. LaPrade, M.D., Ph.D., Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, Colorado 81657, U.S.A.Steadman Philippon Research Institute181 West Meadow DriveSuite 1000VailColorado81657U.S.A.
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Ischiofemoral Impingement and Hamstring Syndrome as Causes of Posterior Hip Pain: Where Do We Go Next? Clin Sports Med 2016; 35:469-486. [PMID: 27343397 DOI: 10.1016/j.csm.2016.02.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent advances in understanding hip joint anatomy and biomechanics have contributed to improvement of diagnosis and treatment decisions for distal causes of deep gluteal syndrome (DGS). Ischiofemoral impingement and hamstrings syndrome are sources of posterior hip pain that can simulate symptoms of DGS. The combination of a comprehensive history and physical examination with imaging and ancillary testing are critical for diagnosis. Six key physical examination tests are described to differentiate distal versus proximal sources of extrapelvic posterior hip pain. Outcomes depend on patient compliance and the understanding of the entire anatomy, biomechanics, clinical presentation, and open versus endoscopic treatment options.
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