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Proximal Hamstring Tendon Avulsions: A Survey of Orthopaedic Surgeons’ Current Practices in the Nordic Countries. SPORTS MEDICINE - OPEN 2022; 8:49. [PMID: 35403955 PMCID: PMC9001781 DOI: 10.1186/s40798-022-00439-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 03/22/2022] [Indexed: 12/03/2022]
Abstract
Background and purpose Evidence guiding the decision on whether to treat proximal hamstring tendon avulsions (PHA) operatively or non-operatively is very limited. The aim of this study was to identify the current practices and the rationale behind PHA treatment decisions in the Nordic countries. Methods A survey was sent to orthopaedic surgeons in Sweden, Norway, Finland and Denmark. The study population consisted of responding surgeons with exposure to surgical treatment of PHA (n = 125). The questions covered surgeon and unit characteristics, and surgeons’ understanding of the evidence for treatment, and they explored which patient and injury factors influence treatment allocation. Results Although some surgeons indicated a preference for one of the treatments, 84% stated that the treatment decision was based on patient and injury-related factors. Severe obesity, drug abuse, a sedentary lifestyle, age > 60 years and delayed diagnosis (> 6 weeks) were considered contraindications to surgical treatment. Also, there was agreement that patients expressing a preference for non-operative treatment should not be operated. Complete avulsions with tendon dislocation ≥ 2–3 cm on MRI were relative indications for surgical treatment. The majority of surgeons did not believe that operatively treated patients did better than non-operatively treated patients and experienced that patients, generally, were satisfied with the treatment result, regardless of the type of treatment. Most surgeons had experienced significant complications to operative treatment. Conclusion Current practices varied among different units, and despite the lack of evidence for their prognostic value, several factors were inconsistently being used as decision modifiers when selecting patients for surgical treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s40798-022-00439-6.
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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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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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Six WR, Buckens CF, Tol JL, Smithuis FF, Maas M, Kerkhoffs GM, van der Made AD. Reliability of MRI in Acute Full-thickness Proximal Hamstring Tendon Avulsion in Clinical Practice. Int J Sports Med 2020; 42:537-543. [PMID: 33321521 DOI: 10.1055/a-1306-0618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In clinically suspected acute full-thickness proximal hamstring tendon avulsions, MRI is the gold standard for evaluating the extent of the injury. MRI variables such as full-thickness free tendon discontinuity, extent of tendon retraction (>20 mm), and continuity of the sacrotuberous ligament with the conjoint tendon (STL-CT) are used in treatment decision-making. The objective was to assess the intra- and inter-rater reliability of these relevant MRI variables after acute full-thickness proximal hamstring tendon avulsion. Three musculoskeletal radiologists assessed MRIs of 40 patients with an acute full-thickness proximal hamstring tendon avulsion. MRI variables included assessment of free tendon discontinuity and continuity of the STL-CT and extent of tendon retraction. Absolute and relative intra- and inter-rater reliability were calculated. Intra- and inter-rater reliability for the assessment of tendon discontinuity was substantial (Kappa [ĸ]=0.78;0.77). For the retraction measurement of the conjoint and semimembranosus tendons, intra-rater reliability was moderate and poor (Intraclass correlation coefficient (ICC)=0.74;0.45), inter-rater reliability was moderate (ICC=0.73;0.57). Intra- and inter-rater reliability of the STL-CT continuity assessment was substantial and fair (ĸ=0.74;0.31). In conclusion, MRI assessment for full-thickness free tendon discontinuity is reliable. However, assessment of extent of tendon retraction and STL-CT continuity is not reliable enough to guide the treatment decision-making process.
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Affiliation(s)
- Willem R Six
- Department of Orthopaedic Surgery, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Constantinus F Buckens
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Department of Radiology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Johannes L Tol
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Frank F Smithuis
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Department of Radiology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Mario Maas
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Department of Radiology, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Gino M Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Anne D van der Made
- Department of Orthopaedic Surgery, Amsterdam UMC - Locatie AMC, 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 - Locatie AMC, Amsterdam, The Netherlands.,Academic Center for Evidence-based Sports medicine (ACES), Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
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Bertiche P, Mohtadi N, Chan D, Hölmich P. Proximal hamstring tendon avulsion: state of the art. J ISAKOS 2020; 6:237-246. [PMID: 34272300 DOI: 10.1136/jisakos-2019-000420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 09/17/2020] [Accepted: 09/24/2020] [Indexed: 11/04/2022]
Abstract
Complete proximal hamstring tendon avulsions from the ischial tuberosity, though infrequent, are the most severe type of hamstring muscle injury in the field of sport medicine. These serious injuries are commonly associated with a delayed or even misdiagnosis, despite obvious clinical findings. The published literature favours surgical repair even though the studies represent lower levels of evidence. Non-surgical treatment is a viable option for lower physical demand patients. This state-of-the-art article reviews the relevant anatomy, the clinical assessment including specific physical examination signs and diagnostic testing in patients suspected of a proximal hamstring avulsion. Up-to-date evidence is reviewed to address surgical and non-surgical treatment options and outcome assessment. The authors provide a detailed description of what would be considered the current worldwide standard of care; an open, suture-anchor-based repair of the avulsed tendon complex (semitendinosus, long head of biceps femoris and semimembranosus) securely to the ischial tuberosity. Also included are surgical tips and tricks, with advice on postsurgical management and rehabilitation. Future perspectives should involve higher quality, prospective research to better define the indications for surgery, evaluate the emerging role of endoscopic repair and disclose complications along with measuring patient-reported outcomes.
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Affiliation(s)
- Pablo Bertiche
- Department of Sport Medicine and Arthroscopic Surgery, Sanatorio Allende, Cordoba, Argentina
| | - Nicholas Mohtadi
- University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada
| | - Denise Chan
- University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada
| | - Per Hölmich
- Sports Orthopedic Research Center, Copenhagen, Denmark.,Department of Orthopedic Surgery, Arthroscopic Center Hvidovre, Hvidovre, Denmark
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