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Lefèvre N, Coughlan A, Valentin E, Sezer HB, Bohu Y, Moussa MK, Hardy A. Magnetic resonance imaging should be the first-line imaging modality for investigating suspected proximal hamstring avulsion injuries. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38769849 DOI: 10.1002/ksa.12258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/28/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE The purpose of the study was to evaluate how the initial diagnostic tool used-specifically ultrasound (US) or magnetic resonance imaging (MRI)-for diagnosing proximal hamstring avulsion injury affects the delay before surgery and, secondarily, the outcomes of these injuries. METHODS This was a retrospective analysis of prospectively collected data (2012-2020). It targeted patients primarily treated for proximal hamstring avulsion injury. It included all patients with a preoperative US and/or MRI. Patients were divided into two groups based on the initial diagnostic tool used (US-first vs. MRI-first groups). The primary outcomes measure was the time from initial injury to surgical intervention (surgical delay). The secondary outcomes were the Parisien Hamstring Avulsion Score, as well as the activity level as measured by the University of California, Los Angeles (UCLA) Activity Scale and Tegner Activity Scale. RESULTS The analysis included 392 patients with a mean age of 43.8 ± 13.6 years for the MRI-first group and 47.6 ± 12.0 years for US-first group. Patients in the MRI-first group had a significantly shorter median time from injury to surgery of 20.0 days (interquartile range [IQR]: 11.0-61.0) compared to 30 days (IQR: 18-74) in the US-first group. At the final follow-up (4.2 ± 2.2 years for the MRI-first group and 5.1 ± 1.9 years for the US-first group), the MRI-first group had significantly higher mean Tegner Activity Scale and UCLA scores than the US-first group: The Tegner Activity Scale was median 5 (IQR: 3-7) for the MRI-first group versus median 4 (IQR: 2-6) for the US-first group (p < 0.05). The UCLA scores were 7.9 ± 2.4 for the MRI-first group compared to 7.3 ± 2.4 for the US-first group (p < 0.05). This difference was more pronounced when comparing the MRI-first group with the patient-false negative initial ultrasound. No difference was found regarding the Parisien Hamstring Avulsion Score. CONCLUSION MRI as the initial diagnostic tool for proximal hamstring avulsion injury is associated with a shorter time to surgery and better postoperative outcomes in Tegner Activity Scale and UCLA scores, compared to US. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Adam Coughlan
- Clinique du sport, Paris, France
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | | | | | | | - Mohamad K Moussa
- Clinique du sport, Paris, France
- Groupe Hospitalier Sélesta-Obernai, Sélesta, France
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Li ZI, Buldo-Licciardi M, Moore M, Kanakamedala A, Burke CJ, Samim MM, Youm T. Assessment of fatty infiltration of the hamstring muscles in chronic proximal hamstring ruptures and effect on clinical outcomes after surgical repair: a novel application of the Goutallier classification. Arch Orthop Trauma Surg 2024; 144:2171-2179. [PMID: 38480556 DOI: 10.1007/s00402-024-05255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/18/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Increased time to surgery has been previously associated with poorer clinical outcomes after surgical treatment of proximal hamstring ruptures, though the etiology remains unclear. The purpose of this study was to evaluate whether degree of muscle atrophy, as assessed using the Goutallier classification system, is associated with worse outcomes following surgical treatment of chronic proximal hamstring ruptures. MATERIALS AND METHODS This was a retrospective case series of patients who underwent repair of proximal hamstring ruptures from 2012 to 2020 with minimum 2-year follow-up. Patients were included if they underwent primary repair of a proximal hamstring rupture ≥ 6 weeks after the date of injury and had accessible preoperative magnetic resonance imaging (MRI). Exclusion criteria were allograft reconstruction, endoscopic repair, or prior ipsilateral hip surgery. Patients were administered validated surveys: the modified Harris Hip Score (mHHS) and Perth Hamstring Assessment Tool (PHAT). Fatty atrophy on preoperative MRI was independently graded by two musculoskeletal radiologists using the Goutallier classification. Multivariate regression analysis was performed to evaluate associations of preoperative characteristics with muscle atrophy, as well as mHHS and PHAT scores. RESULTS Complete data sets were obtained for 27 patients. A majority of this cohort was male (63.0%), with a mean age of 51.5 ± 11.8 years and BMI of 26.3 ± 3.8. The mean follow-up time was 62.6 ± 23.1 months, and the mean time from injury-to-surgery was 20.4 ± 15.3 weeks. The Goutallier grading inter-reader weighted kappa coefficient was 0.655. Regression analysis demonstrated that atrophy was not significantly associated with PHAT (p = 0.542) or mHHS (p = 0.574) at latest follow-up. Increased age was significantly predictive of muscle atrophy (β = 0.62, p = 0.005) and was also found to be a significant predictor of poorer mHHS (β = - 0.75; p = 0.037). CONCLUSIONS The degree of atrophy was not found to be an independent predictor of clinical outcomes following repair of chronic proximal hamstring ruptures. Increasing age was significantly predictive of increased atrophy and poorer patient-reported outcomes.
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Affiliation(s)
- Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Michael Buldo-Licciardi
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | - Michael Moore
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | - Ajay Kanakamedala
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
| | | | | | - Thomas Youm
- Department of Orthopedic Surgery, NYU Langone Health, 333 E 38th St, New York, NY, 10016, USA
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Lefèvre N, Freiha K, Moussa MK, Valentin E, Bohu Y, Meyer A, Hardy A. Risk Factors for Rerupture After Proximal Hamstring Avulsion Injury Including the Optimal Timing for Surgery. Am J Sports Med 2024; 52:1173-1182. [PMID: 38482843 PMCID: PMC10986149 DOI: 10.1177/03635465241233734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/14/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND Despite the prevalence of proximal hamstring avulsion injuries (PHAIs), the understanding of rerupture risk factors and the influence of injury chronicity on these rates remain limited. PURPOSE To investigate the rerupture rate after PHAI repair and identify its associated risk factors and the optimal time to primary surgery. STUDY DESIGN Case-control study; Level of evidence, 3. METHOD This is a retrospective analysis of prospectively collected data from the French Proximal Hamstring Avulsion Surgery Cohort Study targeting patients surgically treated for PHAI between 2002 and 2022. The primary outcome measure of this study was the rerupture rate of PHAI repair. The secondary outcome measures included the assessment of the potential risk factors for rerupture as well as the investigation of the incidence rate of rerupture for 100 person-years depending on various injury-surgery delay definitions. RESULTS This study analyzed 740 patients with a mean age of 45.9 years (SD, 13.6 years) and followed up for a mean of 4.9 years (SD, 3.9 years). The rerupture rate was 4.59% (34/740). Most reruptures (75%) occurred within the first 6 months after surgery (median, 88.5 days; interquartile range, 39.5-182 days), and 74% were atraumatic. Univariate analysis identified potential risk factors: longer initial surgery delay (hazard ratio [HR], 1.03; 95% CI, 1.01-1.04; P = .04) and initial complete ruptures (HR, 4.47; 95% CI, 1.07-18.7; P = .04). Receiver operating characteristic curve analysis found the optimal injury-surgery delay cutoff predicting rerupture to be 32 days (area under the curve, 0.62; 95% CI, 0.53-0.71). The relative Youden index was calculated at 0.24, corresponding to a sensitivity of 65% and a specificity of 59%. Surpassing this cutoff showed the highest HR (2.56), narrowest 95% CI (1.27-5.17), and highest incidence of rerupture (1.42 per 100 person-years) (P = .01). In the multivariate analysis, an injury-surgery delay of >32 days (HR, 2.5; 95% CI, 1.24-5.06; P = .01) and initial complete ruptures (HR, 4.33; 95% CI, 1.04-18.08; P = .04) emerged as significant risk factors for rerupture. CONCLUSION This study found a 4.59% rerupture risk after PHAI repair. Most reruptures (75%) occurred within the first 6 months after surgery. Risk factors for rerupture included chronicity and initial complete injury. The optimal threshold for chronicity of PHAI lesions, based on rerupture rate, was marked by an injury-surgery delay of >32 days.
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Wong SE, Julian KR, Carpio JG, Zhang AL. Proximal Hamstring Repair With All-Suture Anchors and an Accelerated Rehabilitation and Bracing Protocol Demonstrates Good Outcomes at 1-Year Follow-Up. Arthrosc Sports Med Rehabil 2024; 6:100891. [PMID: 38362482 PMCID: PMC10867423 DOI: 10.1016/j.asmr.2024.100891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024] Open
Abstract
Purpose To evaluate patient-reported outcomes and risk for rerupture after surgical treatment of proximal hamstring tendon ruptures using all-suture anchors and a unique postoperative bracing strategy. Methods A retrospective review of a prospectively collected database was conducted of patients undergoing proximal hamstring repair or reconstruction from 2020 to 2022 at a tertiary, academic institution. Patients were included if they reached minimum 1-year follow-up and completed postoperative patient-reported outcomes. The surgical protocol for proximal hamstring repairs included all-suture anchors placed either in an open or endoscopic fashion in the ischial tuberosity. After surgery, all patients underwent an accelerated rehabilitation protocol, including 6 weeks touchdown weight-bearing in a hinged knee brace locked in extension for ambulation, allowing passive knee flexion to 90° while seated. Descriptive statistics were used to analyze the data. Results Twenty-one patients were included (mean age 50.4 ± 9.5 years, body mass index 24.4 ± 3.5, 66.7% female). Lower Extremity Functional Scale score achieved postoperatively was 74.2 ± 7.5 (out of 80). Patients had minimal pain (mean visual analog scale pain score of 0.9 ± 1.2). 61.9% of patients were able to return to the same level of activity after based on Tegner score by 1 year. Postoperative Single Assessment Numeric Evaluation activity of daily living was 94.3 ± 8.3, and Single Assessment Numeric Evaluation Sports was 82.3 ± 19.0. Mean Short Form Survey (SF-12) postoperative scores were 51.6 ± 6.8 for SF-12 Physical Component Score and 53.9 ± 9.7 for Mental Component Score. 95.2% (20 of 21) patients were satisfied with their outcome. There were no reruptures, infections, or reoperations. One patient of 21 (4.8%) incurred a postoperative deep venous thrombosis, which was treated with therapeutic anticoagulation for 3 months. Conclusions All-suture anchors for proximal hamstring repair with a unique accelerated postoperative rehabilitation and bracing protocol result in good outcomes and patient satisfaction with minimal risk of complications. Level of Evidence Level IV, case series, therapeutic.
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Affiliation(s)
- Stephanie E. Wong
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Kaitlyn R. Julian
- School of Medicine, University of California San Francisco, San Francisco, California, U.S.A
| | - Jocelyn G. Carpio
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Alan L. Zhang
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
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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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Wyatt PB, Ho TD, Hopper HM, Satalich JR, O’Neill CN, Cyrus J, Vap AR, O’Connell R. Systematic Review of Bracing After Proximal Hamstring Repair. Orthop J Sports Med 2024; 12:23259671241230045. [PMID: 38405008 PMCID: PMC10894551 DOI: 10.1177/23259671241230045] [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: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 02/27/2024] Open
Abstract
Background Traditionally, postoperative rehabilitation protocols after proximal hamstring repair (PHR) for avulsion of the proximal hamstring tendon from its ischial insertion recommend bracing the hip and/or knee to protect the fixation. However, because of the cumbersome nature of these orthoses, recent studies have investigated outcomes in patients with postoperative protocols that do not include any form of postoperative bracing. Purpose To synthesize the current body of evidence concerning bracing versus nonbracing postoperative management of PHR. Study Design Systematic review; level of evidence, 4. Methods Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a thorough search of the PubMed/Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase (OVID) databases on March 24, 2023. We analyzed complication rates, reoperation rates, patient satisfaction, return to sport, and patient-reported outcomes of studies that used postoperative bracing versus studies that used no postoperative bracing after PHR with at least 12 months of follow-up. A total of 308 articles were identified after initial search. Results In total, 25 studies were included in this review: 18 studies (905 patients) on bracing and 7 studies (291 patients) on nonbracing after PHR. The overall complication rate in the braced patients was found to be 10.9%, compared with 12.7% in nonbraced patients. The rate of reoperation due to retear of the proximal hamstring was found to be 0.05% in braced patients and 3.1% in nonbraced patients. Patient-reported outcome measures were found to be higher at the final follow-up in braced versus nonbraced patients, and patient satisfaction was found to be 94.7% in braced studies compared with 88.9% in nonbraced studies. The rate of 12-month return to sport in athletic patients was 88.4% with bracing and 82.7% without bracing. Conclusion The findings of this review demonstrated lower complication and reoperation rates, higher patient-reported outcome scores, higher patient satisfaction, and a higher rate of return to sport in braced patients compared with nonbraced patients.
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Affiliation(s)
- Phillip B. Wyatt
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Tiffany D. Ho
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Haleigh M. Hopper
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - James R. Satalich
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Conor N. O’Neill
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - John Cyrus
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Alexander R. Vap
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Robert O’Connell
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Nishimura H, Yamaura K, Stetzelberger VM, Garcia AR, Hollenbeck JFM, Brown JR, Mologne MS, Uchida S, Philippon MJ. Biomechanical Comparison of Proximal Hamstring Reconstruction Using Distal Hamstring Graft Versus Fascia Lata Graft for Treatment of Chronic Hamstring Injury. Am J Sports Med 2023; 51:3756-3763. [PMID: 37975438 DOI: 10.1177/03635465231206464] [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: 11/19/2023]
Abstract
BACKGROUND Surgical reconstruction using autografts is often required in treating chronic proximal hamstring injuries where the hamstring has retracted >5 cm. There is a paucity of evidence that evaluates reconstructive procedures using the 2 most popular autografts, distal hamstring and fascia lata. PURPOSE To (1) compare failure load and elongation at failure between the proximal hamstring tendon reconstruction with distal hamstring and fascia lata grafts and (2) compare the stiffness between these reconstructions and the native state. STUDY DESIGN Controlled laboratory study. METHODS Seven pairs of human cadaveric hemipelvises (mean age, 60.4 ± 5.0 years; 6 male, 1 female) with no evidence of previous injury or abnormality were dissected to the proximal hamstring origin. Through use of a dynamic tensile testing system, each specimen underwent preconditioning followed by a distraction test to determine the native specimen stiffness. Each pair of specimens was assigned to undergo proximal hamstring reconstruction with distal hamstring and reconstruction with fascia lata. Each specimen then underwent preconditioning followed by pull to failure. The failure load, elongation at failure, mode of failure, and stiffness were determined for each repair. RESULTS The distal hamstring group exhibited a greater failure load (mean, 334 ± 108 N; P = .031) and higher stiffness (mean, 47.6 ± 16.0 N/mm; P = .009) compared with the fascia lata group (mean, 179 ± 78 N and 23.0 ± 11.2 N/mm, respectively). Although the stiffness of the repair state in the distal hamstring group (mean, 61.4 ± 13.4 N/mm) was not significantly different from that of the native state (mean, 47.6 ± 16.0 N/mm), the stiffness of the repair state in the fascia lata group (mean, 23.0 ± 11.2 N/mm) was significantly lower than that of the native state (mean, 60.1 ± 17.7 N/mm) (P < .0001). The elongation at failure of the distal hamstring graft group (mean, 33.0 ± 6.6 mm) was not significantly different from that of the fascia lata graft group (mean, 29.2 ± 14.9 mm) (P = .58). The most common modes of failure for the distal hamstring group (29% each) were at the repair site, at the graft-muscle interface, and at the muscle, while the most common modes of failure for the fascia lata graft were at the tendon-graft interface. CONCLUSION The distal hamstring group achieved higher failure load and stiffness than the fascia lata group, and stiffness of the distal hamstring group was not significantly different from that of the native tendon. Elongation at failure was not different between repair techniques. Although distal hamstring graft failure predominantly occurred in 3 distinct locations, failure of the fascia lata repair occurred predominantly at the tendon-graft interface. These cadaveric results suggest that it may be more clinically appropriate to use distal hamstring versus fascia lata for proximal hamstring reconstruction. CLINICAL RELEVANCE Our time-zero study suggests that the proximal hamstring reconstruction with distal hamstring could be the preferred surgical treatment for chronic hamstring injury over reconstruction with fascia lata. The failure load of reconstruction with distal hamstring was inferior to that of primary suture anchor, suggesting that rehabilitation after reconstruction should not be more aggressive than the standard postoperative rehabilitation protocol for acute repair.
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Affiliation(s)
| | - Kohei Yamaura
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | | | - Justin R Brown
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Soshi Uchida
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital University of Occupational and Environmental Health, Kitakyusyu, Fukuoka, Japan
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
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Ebert JR, Breidahl W, Klinken S, Annear PT. Development and application of a proximal hamstring MRI-based scoring tool in patients undergoing proximal hamstring tendon surgical repair. J Orthop 2023; 45:61-66. [PMID: 37860177 PMCID: PMC10582688 DOI: 10.1016/j.jor.2023.10.008] [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: 07/24/2023] [Revised: 10/02/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023] Open
Abstract
Purpose An MRI-based scoring tool assessing surgical repair after proximal hamstring avulsions may provide benefit in the context of research, while serial post-operative MRI will provide insight of what to expect in the clinical context of early re-injury requiring imaging. This study developed and assessed the reliability of a Proximal Hamstring Objective Magnetic Resonance Imaging Score (PHOMRIS), further assessing MRI-based repair status and its correlation with patient-reported outcome. Methods 15 patients that underwent proximal hamstring surgical repair underwent MRI and clinical review pre-operatively and at 3-, 6- and 12-months. Clinical scores included the Lower Extremity Functional Scale (LEFS), the Perth Hamstring Assessment Tool (PHAT) and Tegner Activity Scale (TAS). The MRI-based tool assessed the conjoint (semitendinosus & biceps femoris) and semimembranosus insertion components based on bone-tendon healing, signal and retraction. Inter- and intra-observer reliability of the tool was assessed. Results Inter-observer reliability indicated a strong correlation for the semimembranosus (rho = 0.827, p < 0.0001) and conjoint (rho = 0.851, p < 0.0001) components. Intra-observer reliability indicated a strong correlation for the semimembranosus (rho = 0.852, p < 0.0001) and conjoint (rho = 0.996, p < 0.0001) components. All clinical scores and the semimembranosus hamstrings component MRI score significantly improved (p < 0.05) over time, though the conjoint component did not (p = 0.219). At 12 months, a higher LEFS was significantly associated with a better semimembranosus MRI score (r = -0.57, p = 0.042), though no other significant correlations (p > 0.05) were observed between clinical and MRI measures. Conclusions Excellent reliability was observed for the MRI-based scoring tool, which may prove useful in both a research and clinical setting.
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Affiliation(s)
- Jay R. Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Western Australia, 6009, Australia
- HFRC Rehabilitation Clinic, 117 Stirling Highway, Nedlands, Western Australia, 6009, Australia
- Perth Orthopaedic and Sports Medicine Research Institute, West Perth, Western Australia, Australia
| | - William Breidahl
- Perth Radiological Clinic, Subiaco, Perth, Western Australia, 6008, Australia
| | - Sven Klinken
- Perth Radiological Clinic, Subiaco, Perth, Western Australia, 6008, Australia
| | - Peter T. Annear
- Perth Orthopaedic & 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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Lawson JJ, Abraham EA, Imbergamo CM, Sequeira SB, Dreese JC, Gould HP. Systematic Review of Complications Associated With Proximal Hamstring Tendon Repair. Orthop J Sports Med 2023; 11:23259671231199092. [PMID: 37781641 PMCID: PMC10536870 DOI: 10.1177/23259671231199092] [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: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 10/03/2023] Open
Abstract
Background Although several complications of proximal hamstring tendon ruptures have been reported in the literature, few studies have comprehensively analyzed the complication profile of proximal hamstring tendon repair. Purpose To identify the overall rate of complications following proximal hamstring tendon repair and to differentiate these complications into categories. Study Design Systematic review; Level of evidence, 4. Methods Included in this review were studies that examined surgical repair of proximal hamstring tendon ruptures; all studies were in English and had an evidence level of 4 or higher. No restrictions were made regarding publication date or methodological quality. Data regarding complications were extracted to calculate the overall complication rate as well as the rate of major and minor complications. A quantitative data synthesis was conducted using the chi-square test to compare the proportion of patients who experienced complications with the endoscopic versus open approach. Results A total of 43 articles including 2833 proximal hamstring tendon repairs were identified. The overall postoperative complication rate was 15.3% (n = 433). The rate of major complications was 4.6%, including a 1.7% rate of sciatic nerve injury, 0.8% rate of venous thromboembolism, 0.8% reoperation rate, 0.8% rerupture rate, and 0.4% rate of deep infection. Minor complications included a 2.4% rate of posterior femoral cutaneous nerve injury, 2.3% rate of persistent hamstring myopathy, 2.2% rate of persistent sitting pain, 1.8% rate of peri-incisional numbness, 1.1% rate of superficial infection, and 0.8% rate of hematoma/seroma. Conclusion Proximal hamstring tendon repair is associated with an overall complication rate of 15.3%, including a 4.6% rate of major complications.
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Affiliation(s)
- Jonathan J. Lawson
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Eliza A. Abraham
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Casey M. Imbergamo
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Sean B. Sequeira
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - James C. Dreese
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Heath P. Gould
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
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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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11
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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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12
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Leão RV, De Souza TRC, Helito PVP, Correa MFDP, Helito CP. Iliotibial band reconstruction with allograft fasciae latae tissue: Imaging aspects of a novel surgical technique. Radiol Case Rep 2023; 18:556-562. [DOI: 10.1016/j.radcr.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022] Open
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13
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Jokela A, Stenroos A, Kosola J, Valle X, Lempainen L. A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes. Ann Med 2022; 54:978-988. [PMID: 35416097 PMCID: PMC9009934 DOI: 10.1080/07853890.2022.2059560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hamstring injuries are among the most common muscle injuries. They have been reported in many different sports, such as running, soccer, track and field, rugby, and waterskiing. However, they are also present among the general population. Most hamstring injuries are mild strains, but also moderate and severe injuries occur. Hamstring injuries usually occur in rapid movements involving eccentric demands of the posterior thigh. Sprinting has been found to mainly affect the isolated proximal biceps femoris, whereas stretching-type injuries most often involve an isolated proximal injury of the semimembranosus muscle. The main cause of severe 2- or 3-tendon avulsion is a rapid forceful hip flexion with the ipsilateral knee extended. Most hamstring injuries are treated non-surgically with good results. However, there are also clear indications for surgical treatment, such as severe 2- or 3-tendon avulsions. In athletes, more aggressive recommendations concerning surgical treatment can be found. For a professional athlete, a proximal isolated tendon avulsion with clear retraction should be treated operatively regardless of the injured tendon. Surgical treatment has been found to have good results in severe injuries, especially if the avulsion injury is repaired in acute phase. In chronic hamstring injuries and recurring ruptures, the anatomical apposition of the retracted muscles is more difficult to be achieved. This review article analyses the outcomes of surgical treatment of hamstring ruptures. The present study confirms the previous knowledge that surgical treatment of hamstring tendon injuries causes good results with high satisfaction rates, both in complete and partial avulsions. Early surgical repair leads to better functional results with lower complication rates, especially in complete avulsions.KEY MESSAGEsSurgical treatment of hamstring tendon ruptures leads to high satisfaction and return to sport rates.Both complete and partial hamstring tendon ruptures have better results after acute surgical repair, when compared to cases treated surgically later.Athletes with hamstring tendon ruptures should be treated more aggressively with operative methods.
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Affiliation(s)
- Aleksi Jokela
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Antti Stenroos
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
| | - Jussi Kosola
- Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Xavier Valle
- Medical Department, FC Barcelona, Barcelona, Spain
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14
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Ríos Luna A, Fahandezh-Saddi Díaz H, Villanueva Martínez M, Bueno Horcajadas Á, Prado R, Anitua E, Padilla S. Reconstruction of Chronic Proximal Hamstring Tear: A Novel Surgical Technique with Semitendinosus Tendon Allograft Assisted with Autologous Plasma Rich in Growth Factors (PRGF). J Clin Med 2022; 11:jcm11185443. [PMID: 36143088 PMCID: PMC9503197 DOI: 10.3390/jcm11185443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/08/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
The reconstruction of a chronic proximal hamstring tear is a challenging pathology that posits difficulties to surgeons due to the distal retraction of the hamstring tendon stumps and the entrapment of the sciatic nerve within the scar formed around the torn hamstring tendon. We describe a novel surgical technique using a semitendinosus tendon allograft sutured in a “V inversion” manner, thereby avoiding an excess of tension and length of the new reconstructed hamstring tendons. In addition, and in order to speed up the healing process and avoid new sciatic entrapment, we assisted the surgery with liquid plasma rich in growth factors (PRGF) injected intraosseously, intratendinously and within the suture areas, as well as wrapping the sciatic nerve with a PRGF membrane. In conclusion, this novel approach offers mechanical and biological advantages to tackle the large retraction of hamstring stumps and the entrapment of the sciatic nerve within the scar.
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Affiliation(s)
- Antonio Ríos Luna
- Department of Traumatology and Orthopedic Surgery, Clínica Orthoindal, 04004 Almería, Spain
- Correspondence:
| | | | | | - Ángel Bueno Horcajadas
- Department of Radiology, Hospital Universitario Fundación Alcorcón, 28922 Alcorcón, Spain
| | - Roberto Prado
- BTI—Biotechnology Institute I MAS D, 01007 Vitoria, Spain
| | - Eduardo Anitua
- BTI—Biotechnology Institute I MAS D, 01007 Vitoria, Spain
| | - Sabino Padilla
- BTI—Biotechnology Institute I MAS D, 01007 Vitoria, Spain
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15
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Bloom DA, Gyftopoulos S, Alaia MJ, Youm T, Campbell KA, Alaia EF. Variability of MRI reporting in proximal hamstring avulsion injuries: Are musculoskeletal radiologists and orthopedic surgeons utilizing similar landmarks? Clin Imaging 2022; 93:46-51. [DOI: 10.1016/j.clinimag.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 08/27/2022] [Accepted: 09/06/2022] [Indexed: 11/30/2022]
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16
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Johnson EE, Brutico JM, Rangavajjula L, Xia Y, Paul RW, Otlans P, Arner JW, Hammoud S, Bradley JP, Cohen SB. Open Repair of Complete Proximal Hamstring Avulsions in Workers’ Compensation Patients. Orthop J Sports Med 2022; 10:23259671221119774. [PMID: 36081409 PMCID: PMC9445462 DOI: 10.1177/23259671221119774] [Citation(s) in RCA: 2] [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: 05/28/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Several studies have reported excellent results after surgical repair of proximal hamstring avulsions. However, the effect on these patients of receiving workers’ compensation has not yet been explored. Hypothesis: Workers’ compensation patients undergoing proximal hamstring repair of complete tears will have similar outcomes when compared with a matched control group of non–workers’ compensation patients. Study Design: Cohort study; Level of evidence, 3. Methods: Workers’ compensation patients who underwent complete proximal hamstring avulsion open repair between 2010 and 2019 were identified (WC group). A control group was matched by age (±3 years), sex, and body mass index (BMI; ±3). Demographics and patient-reported outcome measures were compared, including standard and custom Marx activity rating scale (MARS), standard and custom lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain. Rate and time to return to work were recorded. Results: The WC group was composed of 20 patients (8 men, 12 women) with a mean age of 52.3 years and BMI of 32.4. The 20 matched controls (8 men, 12 women) who underwent repair had a mean age of 50.6 years and a mean BMI of 31.2. There was no difference between the groups regarding age (P = .924), sex (P > .999), or BMI (P = .330). The WC group reported similar mean MARS (3.3 vs 5.4; P = .174), custom MARS (87.5 vs 97.0; P = .215), and VAS pain (3.3 vs 3.8; P = .698) scores compared with controls. However, the WC group had significantly lower standard LEFS (69.1 vs 94.1; P < .001) and custom LEFS (62.3 vs 87.9; P < .001) scores, returned to work at a lower rate (70.0% vs 94.1%; P = .039), and required more time to return to work after repair (4.3 vs 3.5 months; P = .029) compared with controls. Conclusion: Workers’ compensation patients who underwent open proximal hamstring repair for complete avulsions experienced inferior patient-reported outcomes, required more time to return to work, and returned to work at a lower rate than a matched control group.
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Affiliation(s)
- Emma E. Johnson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph M. Brutico
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lasya Rangavajjula
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yuwei Xia
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan W. Paul
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Peters Otlans
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Justin W. Arner
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sommer Hammoud
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James P. Bradley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Steven B. Cohen
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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17
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Hillier-Smith R, Paton B. Outcomes following surgical management of proximal hamstring tendon avulsions. Bone Jt Open 2022; 3:415-422. [PMID: 35549447 PMCID: PMC9134830 DOI: 10.1302/2633-1462.35.bjo-2021-0196.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims Avulsion of the proximal hamstring tendon origin can result in significant functional impairment, with surgical re-attachment of the tendons becoming an increasingly recognized treatment. The aim of this study was to assess the outcomes of surgical management of proximal hamstring tendon avulsions, and to compare the results between acute and chronic repairs, as well as between partial and complete injuries. Methods PubMed, CINAHL, SPORTdiscuss, Cochrane Library, EMBASE, and Web of Science were searched. Studies were screened and quality assessed. Results In all, 35 studies (1,530 surgically-repaired hamstrings) were included. Mean age at time of repair was 44.7 years (12 to 78). A total of 846 tears were acute, and 684 were chronic, with 520 tears being defined as partial, and 916 as complete. Overall, 92.6% of patients were satisfied with the outcome of their surgery. Mean Lower Extremity Functional Score was 74.7, and was significantly higher in the partial injury group. Mean postoperative hamstring strength was 87.0% of the uninjured limb, and was higher in the partial group. The return to sport (RTS) rate was 84.5%, averaging at a return of 6.5 months. RTS was quicker in the acute group. Re-rupture rate was 1.2% overall, and was lower in the acute group. Sciatic nerve dysfunction rate was 3.5% overall, and lower in the acute group (p < 0.05 in all cases). Conclusion Surgical treatment results in high satisfaction rates, with good functional outcomes, restoration of muscle strength, and RTS. Partial injuries could expect a higher functional outcome and muscle strength return. Acute repairs result in a quicker RTS with a reduced rate of re-rupture and sciatic nerve dysfunction. Cite this article: Bone Jt Open 2022;3(5):415–422.
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Affiliation(s)
| | - Bruce Paton
- Institute of Sport Exercise and Health, University Colleage London, University College London Hospitals NHS Foundation Trust, London, UK
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18
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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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Best R, Meister A, Meier M, Huth J, Becker U. Predictive Factors Influencing Functional Results After Proximal Hamstring Tendon Avulsion Surgery: A Patient-Reported Outcome Study After 227 Operations From a Single Center. Orthop J Sports Med 2021; 9:23259671211043097. [PMID: 34734098 PMCID: PMC8558812 DOI: 10.1177/23259671211043097] [Citation(s) in RCA: 4] [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: 05/18/2021] [Accepted: 05/27/2021] [Indexed: 01/10/2023] Open
Abstract
Background Although debilitating, proximal hamstring tendon avulsion injuries are rare and often overlooked or misdiagnosed. Consequently, delayed diagnosis and surgical treatment may result in poor outcomes. Studies investigating a correlation between postoperative functional outcomes and this delay in surgical treatment or other concomitant factors in large cohorts have not yet been performed to our knowledge. Purpose/Hypothesis The purpose of this study was to conduct an investigation in a large patient group regarding factors that could influence a patient's functional outcome after hamstring surgery. We hypothesized that this outcome would significantly correlate to the time between trauma and surgery. Study Design Case series; Level of evidence, 4. Methods Patients who received surgical treatment of proximal hamstring tendon avulsion injuries in our institution between the years 2010 and 2020 were asked to complete a validated, injury-specific outcome measurement, the Perth Hamstring Assessment Tool (PHAT; 0-100 points). In addition to calculating these outcomes, we evaluated the association of the obtained results with possible predictive factors such as age, sex, stump retraction shown on magnetic resonance imaging (MRI), and timing and duration of surgery. Results A total of 226 patients (227 operations) were eligible for the study, and 204 cases of hamstring tendon avulsion injury met our inclusion criteria. The return rate for the PHAT questionnaire was 85.3%. The mean PHAT score revealed good results (79.8 ± 19.1). Irrespective of concomitant factors, the scores of male patients were significantly higher compared with those of female patients (83.8 ± 16.9 vs 75.8 ± 20.6 respectively; P = .004). The mean time to surgery was 5.7 weeks after trauma, and more delayed surgery correlated significantly with lower PHAT scores (P = .003; r = -0.228). The mean degree of stump retraction on MRI (5 cm) did not significantly influence PHAT scores (P = .525; r = -0.06). Conclusion Delay of surgery and female sex were disadvantageous in terms of a good functional outcome measure (PHAT score) after hamstring tendon refixation surgery. By contrast, patient age as well as the retraction of the tendon stump on preoperative MRI did not influence PHAT scores in the present study.
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Affiliation(s)
- Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany.,Department of Sports Medicine, University of Tuebingen, Tuebingen, Germany
| | - Anorte Meister
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany
| | - Malin Meier
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany
| | - Jochen Huth
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany
| | - Ulrich Becker
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart GmbH, Stuttgart, Germany
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20
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Fletcher AN, Pereira GF, Lau BC, Mather RC. Endoscopic Proximal Hamstring Repair Is Safe and Efficacious With High Patient Satisfaction at a Minimum of 2-Year Follow-Up. Arthroscopy 2021; 37:3275-3285. [PMID: 33887414 DOI: 10.1016/j.arthro.2021.03.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 03/27/2021] [Accepted: 03/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the short-term outcomes of endoscopic proximal hamstring repair including clinical outcomes, patient-reported outcomes, and complications. METHODS A retrospective analysis was performed on consecutive patients who underwent endoscopic proximal hamstring repair from 2013-2018 by a senior sports medicine orthopaedic surgeon. Demographic, operative, clinical data, complications, and patient-reported outcomes were collected and analyzed including the International Hip Outcome Tool-12 (iHOT-12), Single Assessment Numeric Evaluation (SANE), modified Harris Hip Score (mHHS), and the Hip Outcome Score activities of daily living scale (HOS-ADL). RESULTS Thirty patients were included with a minimum 24.0- and average 44.0-month follow-up. The average age was 52.0 years (standard deviation [SD], 14.2), and 80.0% (n = 24) were women. Most patients presented with a history of refractory insertional tendinosis (83.3%, n = 25) and an average of 34.0 months of symptoms prior to surgical intervention. Two-year patient-reported outcomes were clinically acceptable with a postoperative iHOT-12 of 81.9 (SD, 21.1), SANE 78.8% (SD, 20.0), mHHS 89.6 (SD 13.4), and HOS-ADLs 87.2% function (SD, 15.9). Nine patients (30%) had available preoperative iHOT-12 scores. Among these patients, the mean increase in iHOT-12 was 46.3 (P = .0005; n = 9). Eighty percent (n = 24) of patients achieved the iHOT-12 patient acceptability symptomatic state. Complications (3%) included 1 atraumatic rerupture. Four patients participated in an organized sport and 18 in recreational sport with a return to play of 100% and 72.2%, respectively. All patients returned to work. Some 76.7% (n = 23) of patients reported return to their baseline level of physical activity, and 73.3% (n=22) of patients reported complete resolution of pain at last follow-up. There was a 90.0% (n=27) satisfaction rate. CONCLUSIONS Short-term follow-up for endoscopic proximal hamstring repair shows high patient satisfaction (90.0%) and clinically significant patient-reported outcomes with minimal residual pain and a low complication rate (3%). LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Amanda N Fletcher
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A..
| | - Gregory F Pereira
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Brian C Lau
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
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21
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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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22
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[Clinical results after refixation of proximal hamstring tendon ruptures comparing different anchor systems]. Unfallchirurg 2021; 124:560-567. [PMID: 34143256 DOI: 10.1007/s00113-021-01020-8] [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: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Injuries to the hamstring muscles and tendon complex are among the most frequent muscular injuries with proximal hamstring tendon avulsion being a particularly severe form. The surgical treatment of these injuries is superior to conservative management with respect to patient satisfaction, recovery of muscle strength and function as well as return to sport rates. It is therefore the method of choice. OBJECTIVE Presentation and comparison of the surgical results after treatment with titanium, polyether ether ketone (PEEK) and all suture anchors. MATERIAL AND METHODS A systematic search was carried out in the PubMed medical database and the results are summarized. RESULTS All systems exhibit comparable biomechanical properties regarding elongation and ultimate failure load. Tendon repair with these anchors results in good to excellent clinical outcomes and shows high return to sport and low complication rates. Patient satisfaction after hamstring tendon repair is reported to be over 90% and return to sport rate is 80-100%. The muscle strength recovers to 80-90% in comparison to the contralateral side. CONCLUSION All available anchors systems provide good to excellent clinical outcomes and an explicit advantage for one anchor system could so far not be shown.
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23
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Reza T, Hinkle AJ, Perez-Chaumont A, Brown SM, Mulcahey MK. Systematic Review of Outcome Measures Used After Proximal Hamstring Repair. Orthop J Sports Med 2021; 9:23259671211005101. [PMID: 33997081 PMCID: PMC8113800 DOI: 10.1177/23259671211005101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Patient-reported outcome measures are important to determine outcomes after
orthopaedic procedures. There is currently no standard for outcome measures
in the evaluation of patient outcomes after proximal hamstring repair. Purpose: To identify and evaluate outcome measures used after proximal hamstring
repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed to identify all English-language articles
assessing outcomes after proximal hamstring repair in PubMed, Embase, CINAHL
via EBSCOhost, MEDLINE via OvidSP, and Web of Science between 2000 and 2019.
After duplicates were removed, studies were selected using eligibility
criteria established by the authors. Image reviews, anatomic/histology
studies, literature reviews, surgical technique reports, systematic reviews,
narrative reviews, case studies, and studies with <5 patients were
excluded. Extraction, synthesis, and analysis of outcome measure data were
performed using Microsoft Excel. Quality assessment of included studies was
performed using Methodological Index for Non-Randomized Studies
criteria. Results: After duplicate articles were removed, a total of 304 unique articles were
identified and 27 met the inclusion criteria. The mean number of patients
with proximal hamstring repairs per study was 40. The most frequently
reported outcome measures were return to sport (14/27; 51.9%), custom
survey/questionnaire (13/27; 48.1%), and isokinetic hamstring strength
testing (13/27; 48.1%). Six of the 10 most commonly used outcome measures
were validated and included Lower Extremity Functional Scale, 12-Item Short
Form Health Survey, visual analog scale for pain, Perth Hamstring Assessment
Tool (PHAT), Single Assessment Numeric Evaluation, and Tegner Activity
Scale. Of those, PHAT was the only validated outcome measure designed for
proximal hamstring repair. Conclusion: There is currently no consensus on the best outcome measurements for the
evaluation of patients after proximal hamstring repair. We recommend an
increased commitment to the use of return to sport, isokinetic strength
testing, Lower Extremity Functional Scale, and PHAT when assessing such
injuries. Future studies should aim to define the most reliable methods of
outcome measurement in this patient population through consistent use of
tools that are clinically relevant and important to patients and can easily
be employed in a variety of clinical scenarios.
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Affiliation(s)
- Tara Reza
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Andrew J Hinkle
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | | | - Symone M Brown
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
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24
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Grasso M, O’Neill C, Constantinescu D, Moatshe G, Vap A. Reconstruction of Chronic Proximal Hamstring Tear: Description of a Surgical Technique. Arthrosc Tech 2021; 10:e1307-e1313. [PMID: 34141546 PMCID: PMC8185645 DOI: 10.1016/j.eats.2021.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/29/2021] [Indexed: 02/03/2023] Open
Abstract
While proximal hamstring tears at the myotendinous junction are common sports-related injuries that are often successfully treated nonoperatively, complete avulsions from the origin on the ischial tuberosity are less common and better treated with surgical repair to prevent significant functional limitations and ongoing weakness. The diagnosis can be easily missed, leading patients to present several months after the initial injury. In addition, some patients decide on nonoperative management initially but later present requesting surgical intervention. The delayed cases are challenging due to often significant tendon retraction, making direct repair difficult if not impossible. Techniques using allograft and autograft reconstruction have been described for this clinical situation. This Technical Note describes the use of 2 Achilles tendon allografts fixed via 5 suture anchors to reconstruct a chronic complete avulsion injury of the proximal hamstring with >5-cm retraction.
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Affiliation(s)
- Mackenzie Grasso
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia,Address correspondence to Mackenzie Grasso, M.D., Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA.
| | - Conor O’Neill
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia
| | - David Constantinescu
- Department of Orthopaedic Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida, U.S.A
| | - Gilbert Moatshe
- Division of Orthopaedic Surgery, Oslo University Hospital,Norwegian School of Sports Science, Oslo Sport Trauma Research Center, Oslo, Norway
| | - Alexander Vap
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia
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25
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Maldonado DR, Annin S, Lall AC, Krych AJ, Athey AG, Spinner RJ, Hartigan DE, Emblom BA, Ryan MK, Domb BG. Outcomes of Open and Endoscopic Repairs of Chronic Partial- and Full-Thickness Proximal Hamstring Tendon Tears: A Multicenter Study With Minimum 2-Year Follow-up. Am J Sports Med 2021; 49:721-728. [PMID: 33449797 DOI: 10.1177/0363546520981767] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The preponderance of literature on the repair of proximal hamstring tendon tears focuses on the acute phase (<4 weeks). As such, there is a paucity of data reporting on the outcomes of chronic proximal hamstring tears. PURPOSE To report minimum 2-year postoperative patient-reported outcome (PRO) scores, visual analog scale (VAS) for pain, and patient satisfaction from patients who underwent open or endoscopic repair of partial- and full-thickness chronic proximal hamstring tendon tears. STUDY DESIGN Case series study; Level of evidence, 4. METHODS Between April 2002 and May 2017, prospectively collected data from 3 tertiary care institutions were retrospectively reviewed for patients who underwent open and endoscopic repair of partial- and full-thickness chronic proximal hamstring tendon tears. Patients were included only if they had a chronic proximal hamstring tear (defined as ≥4 weeks from symptom onset to surgery). Patients were excluded if they had a tear treated <4 weeks after injury, underwent hamstring reconstruction, or claimed workers' compensation. Patients who reported minimum 2-year follow-up for VAS, patient satisfaction, and the following PROs had their outcomes analyzed: the modified Hip Harris Score, Non-arthritic Hip Score, iHOT-12 (International Hip Outcome Tool), and Hip Outcome Score-Sports Specific Subscale. RESULTS Fifty patients (34 females and 16 males) were included in this study. There were 19 endoscopic repairs and 31 open repairs. Within the cohort, 52.0% had a full-thickness tendon tear on magnetic resonance imaging, and 48.0% had a partial tear. Average follow-up time was 58.07 ± 37.27 months (mean ± SD; range, 24-220 months). The mean age and body mass index of the group were 46.13 ± 13 years and 25.43 ± 5.14. The average time from injury to surgery was 66.73 weeks (range, 5.14-215.14 weeks). Average postoperative PROs were as follows: modified Hip Harris Score, 91.94 ± 9.96; Non-arthritic Hip Score, 91.33 ± 9.99; iHOT-12, 87.17 ± 17.54; Hip Outcome Score-Sports Specific Subscale, 87.15 ± 18.10; and VAS, 1.16 ± 1.92. Patient satisfaction was 8.22 ± 1.20. CONCLUSION Patients who underwent open and endoscopic repairs for chronic partial- and full-thickness proximal hamstring tendon tears reported high PROs and satisfaction at a minimum 2-year follow-up with low rates of complications.
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Affiliation(s)
| | - Shawn Annin
- American Hip Institute Research Foundation, Chicago, Illinois, USA
| | - Ajay C Lall
- American Hip Institute, Chicago, Illinois, USA.,AMITA Health St Alexius Medical Center, Hoffman Estates, Illinois, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander G Athey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert J Spinner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David E Hartigan
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Benton A Emblom
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - Michael K Ryan
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois, USA.,AMITA Health St Alexius Medical Center, Hoffman Estates, Illinois, USA
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26
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Longo UG, Stelitano G, Berton A, Candela V, Barneschi G, Marescalchi M, Grasso A, Papalia R, Denaro V. 2019 Marathon of Rome. Hamstring injuries in long distance runners: influence of age, gender, weight, height, numbers of marathon and impact profile. J Sports Med Phys Fitness 2021; 61:1653-1660. [PMID: 33586934 DOI: 10.23736/s0022-4707.21.12027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hamstring diseases are one of the most widespread diseases in athletes, especially in runners, sprinters, and endurance athletes. Notwithstanding the importance of the problem, risk factors are still marginally known. This transversal study analyzes the correlation between Hamstring tendinopathy and hamstring strains and age, gender, weight, height, number of marathons, and impact profile in athletes who took part in the 2019 Rome Marathon. METHODS At the 2019 Marathon of Rome, 700 runners (484 males and 216 females; mean age: 43.6 years, range 17-80 years) filled the VISA-H and FASH questionnaires. An adequately skilled orthopedic surgeon made a diagnosis of Hamstring tendinopathy and Hamstring strain injuries in line with clinical criteria. RESULTS A diagnosis of Hamstring tendinopathy was made in 537 participants while in 624 of hamstring strains. There was evidence of a positive correlation statistically significant between age, weight and impact profile with Hamstring strain injuries, while there was no association between sex and number of marathons and the Hamstring strains. No statistically significant positive correlation was found between all of the parameters analyzed and VISA-H. The association between VISA-H score and FASH score has resulted statistically significant. CONCLUSIONS In marathon athletes, there was not found evidence of a statistically significant correlation between gender, weight, height, number of marathons, impact profile and Hamstring tendinopathy. Nonetheless, age, weight and impact profile were associated with Hamstring strains, while sex and number of marathons had not shown statistically significant positive association with Hamstring strain injuries.
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Affiliation(s)
- Umile G Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy -
| | - Giovanna Stelitano
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Alessandra Berton
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Candela
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Gianfilippo Barneschi
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Marina Marescalchi
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | | | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
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27
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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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28
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Validation and defining the minimal clinically important difference of the Japanese version of the IKDC Subjective Knee Form. J Orthop Sci 2021; 26:149-155. [PMID: 32340786 DOI: 10.1016/j.jos.2020.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/03/2020] [Accepted: 02/07/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study aimed to validate and determine the minimal clinically important difference (MCID) in the Japanese version of the International Knee Documentation Committee Subjective Knee Form (Japanese IKDC-SKF) for patients with anterior cruciate ligament (ACL) injuries. METHODS This prospective study was performed using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guideline to assess the measurement properties of reliability, responsiveness, validity, and interpretability of the Japanese IKDC-SKF. RESULTS A total of 152 patients were enrolled in the study. The Japanese IKDC-SKF had excellent internal consistency [Cronbach's alpha (95% confidence interval, CI) was 0.90 (0.88-0.92), and the test-retest reliability [intraclass correlation coefficient, ICC2,1 (95% CI)] was 0.97 (0.94-0.98). The content validity (r), which was interpretable between the Japanese IKDC-SKF and the Japanese Anterior Cruciate Ligament questionnaire 25 was -0.87 (P < 0.001). The construct validity for the IKDC-SKF was 86% (six of seven hypotheses were consistent with the results), also indicating high validity. Responsiveness of the Japanese IKDC-SKF was confirmed, with an acceptable area under the curve of 0.81 and a large effect size (Cohen's d of 0.8). There were no floor or ceiling effects. The MCID for the Japanese IKDC-SKF for ACL injury was 10.7. CONCLUSIONS Our results indicate that the Japanese version of the IKDC-SKF is a reliable, valid, and responsive measurement instrument with which to evaluate the physical function of patients with ACL injuries.
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29
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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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30
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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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31
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Return to Sport After Surgical Management of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Clin J Sport Med 2020; 30:598-611. [PMID: 30444732 DOI: 10.1097/jsm.0000000000000688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the rates and timing of return to sport for the surgical management of proximal hamstring avulsions (PHAs). METHODS Three databases, PubMed, MEDLINE, and EMBASE, were searched from database inception until October 7, 2017, by 2 reviewers independently and in duplicate. The inclusion criteria were studies reporting return to sport outcomes for surgical management of acute, chronic, complete, and partial PHA. The rate of return to sports was combined in a meta-analysis of proportions using a random-effects model. RESULTS Overall, 21 studies with a total of 846 patients met the inclusion criteria, with a mean age of 41.4 years (range, 14-71 years) and a mean follow-up of 37.8 months (range, 6-76 months). Two studies were of prospective comparative design (level II), 2 were retrospective comparative (level III), 8 were prospective case series (level IV), and 9 were retrospective case series (level IV). The overall mean time to return to sport was 5.8 months (range, 1-36 months). The pooled rate of return to any sport participation was 87% [95% confidence interval (CI), 77%-95%]. The pooled rate of return to preinjury level of sport was 77% (95% CI, 66%-86%). CONCLUSIONS Pooled results suggest a high rate of return to sport after surgical management of PHA; however, this was associated with a lower preinjury level of sport. No major differences in return to sport were found between partial versus complete and acute versus chronic PHA.
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32
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Abstract
Aims Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically. Methods This is a prospective series of 156 proximal hamstring surgical repairs, with a mean age of 48.9 years (21.5 to 78). Functional outcomes were assessed preinjury, preoperatively, and postoperatively (six months and minimum three years) using the Sydney Hamstring Origin Rupture Evaluation (SHORE) score. Operating time was recorded for every patient. Results Overall, significant improvements in SHORE scores were seen at both six months and mid-term follow-up. Preoperatively, acute patients (median score 27.1 (interquartile range (IQR) 22.9)) reported significantly poorer SHORE scores than chronic patients (median score 42.9 (IQR 22.1); p < 0.001). However, this difference was not maintained postoperatively. For partial tears, acutely repaired patients reported significantly lower preoperative SHORE scores compared to chronically reapired partial tears (median score 24.3 (IQR 15.7) vs median score 40.0 (IQR 25.0); p < 0.001) but also significantly higher SHORE scores at six-month follow-up compared to chronically repaired partial tears (median score 92.9 (IQR 10.7) vs. median score 82.9 (IQR 14.3); p < 0.001). For complete tears, there was only a difference in preoperative SHORE scores between acute and chronic groups. Overall, acute repairs had a significantly shorter operating time (mean 64.67 minutes (standard deviation (SD) 12.99)) compared to chronic repairs (mean 74.71 minutes (SD = 12.0); t = 5.12, p < 0.001). Conclusion Surgical repair of proximal hamstring avulsions successfully improves patient reported functional outcomes in the majority of patients, irrespective of the timing of their surgery or injury classification. However, reducing the time from injury to surgery is associated with greater improvement in patient outcomes and an increased likelihood of returning to preinjury functional status. Acute repair appears to be a technically less complex procedure, as indicated by reduced operating times, postoperative neurological symptoms and number of patients requiring bracing. Acute repair is therefore a preference among many surgeons. Cite this article: Bone Joint J 2020;102-B(10):1419–1427.
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Affiliation(s)
- David Wood
- North Sydney Orthopaedics and Sports Medicine Centre, Sydney, Australia
| | - Sofie R. French
- Australian Institute of Musculoskeletal Research, Sydney, Australia
| | - Selin Munir
- Australian Institute of Musculoskeletal Research, Sydney, Australia
| | - Rajiv Kaila
- North Sydney Orthopaedics and Sports Medicine Centre, Sydney, Australia
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33
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Shambaugh BC, Wuerz TH, Miller SL. Does Time From Injury to Surgery Affect Outcomes After Surgical Repair of Partial and Complete Proximal Hamstring Ruptures? Orthop J Sports Med 2020; 8:2325967120946317. [PMID: 32923506 PMCID: PMC7457414 DOI: 10.1177/2325967120946317] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/13/2020] [Indexed: 11/15/2022] Open
Abstract
Background No previous study has compared the outcomes of repair for partial and complete proximal hamstring ruptures at various intervals after the injury. Purpose The primary aim was to determine whether time from injury to surgery affected outcomes after primary repair of partial and complete proximal hamstring ruptures. The secondary aim was to assess patients' experiences from initial evaluation to finding a treating surgeon. Study Design Cohort study; Level of evidence, 3. Methods Records from 2007 to 2016 from a single surgeon's practice were reviewed. A total of 124 proximal hamstring repair procedures in 121 patients were identified. There were 92 patients who completed questionnaires: a custom survey, the standard Lower Extremity Functional Scale (LEFS), a custom LEFS, the standard Marx activity scale, a custom Marx activity scale, and the University of California Los Angeles (UCLA) activity score. Results were analyzed for partial and complete repair procedures performed at ≤3 weeks, ≤6 weeks, and >6 weeks after the injury. Results The mean follow-up was 43 months (median, 38 months). Of 93 repair procedures reviewed, 51% (9/28 partial; 38/65 complete), 79% (16/28 partial; 57/65 complete), and 22% (12/28 partial; 8/65 complete) were performed at ≤3 weeks, ≤6 weeks, and >6 weeks, respectively. At those various intervals, no statistical difference was found in standard LEFS, custom LEFS, standard Marx, custom Marx, or UCLA scores. Female sex, older age, and body mass index >30 kg/m2 were negative predictors of outcome measures. When repaired >6 weeks after the injury, a greater percentage of patients reported weakness of the operative leg compared with the contralateral side (partial tears: 6.3% vs 25%, respectively; complete tears: 24.6% vs 50%, respectively) in addition to greater sitting intolerance (partial tears: 0% vs 25%, respectively; complete tears: 7.1% vs 12.5%, respectively). Patients repaired >6 weeks after the injury visited, on average, 2.6 practitioners before an evaluation by the treating surgeon compared with 1.6 treated surgically at ≤6 weeks (P = .008). Conclusion Patients with proximal hamstring repair performed in the acute and chronic settings can expect successful outcomes but may experience more subjective weakness and difficulty with prolonged sitting when the repair is performed >6 weeks after the injury. Patients faced challenges in receiving the correct diagnosis and referral to an appropriate treating surgeon, emphasizing the need for an increased awareness of the injury.
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Affiliation(s)
| | - Thomas H Wuerz
- Boston Sports & Shoulder Center, Waltham, Massachusetts, 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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Excellent clinical outcome and low complication rate after proximal hamstring tendon repair at mid-term follow up. Knee Surg Sports Traumatol Arthrosc 2020; 28:1230-1235. [PMID: 31650312 DOI: 10.1007/s00167-019-05748-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 10/09/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Proximal hamstring tendon avulsions lead to a significant loss of strength and a functional deficit of the respective lower limb and surgery is the recommended treatment. Only little is known about the clinical outcomes and complications when comparing acute and chronic management as well as partial and complete tears. Therefore, the purpose of this study was to investigate the clinical results and the complication rate of patients after surgical treatment of proximal hamstring tendon injuries. It was hypothesized that surgical treatment of an acute proximal hamstring avulsion would lead to a superior clinical outcome with a low complication rate and high return to sports rate compared to chronic cases and partial avulsions. METHODS Patients who underwent proximal hamstring tendon repair between 2008 and 2015 were retrospectively evaluated with a minimum follow up of 2 years. Outcome measurements were obtained by means of Lysholm score, Harris Hip Score, Visual Analog Scale, and Tegner Activity Scale. Return to sports (RTS) rate was determined. Postoperative adverse events were recorded and complications reported. Patients' outcomes were compared between acute/chronic repair and partial/complete injury patterns. RESULTS Ninety-four of 120 (78.3%) were available for final assessment at a mean follow-up of 56.2 ± 27.2 months. Clinical outcome measures were excellent and did not differ between the treatment groups or between the different injury patterns. RTS was achieved by 86.2% of the patients and was significantly superior after acute treatment (p < 0.05). The overall complication rate was 8.5% and significantly higher in complete tears compared to partial tears and in delay compared to acute surgery (p < 0.05). CONCLUSION Surgical treatment of proximal hamstring tendon avulsions results in excellent clinical outcome scores and a high RTS rate. Open surgical treatment has shown to be a safe procedure with a low complication rate. Surgical timing is important, as early surgical intervention provides a higher RTS rate and a lower complication rate than delayed surgery and should therefore be preferred in clinical practice. Repair of partial and complete tears lead to similar clinical outcome, but a higher complication rate in complete avulsions. LEVEL OF EVIDENCE Level IV.
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Irger M, Willinger L, Lacheta L, Pogorzelski J, Imhoff AB, Feucht MJ. Proximal hamstring tendon avulsion injuries occur predominately in middle-aged patients with distinct gender differences: epidemiologic analysis of 263 surgically treated cases. Knee Surg Sports Traumatol Arthrosc 2020; 28:1221-1229. [PMID: 31541291 DOI: 10.1007/s00167-019-05717-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/11/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Epidemiologic data of proximal hamstring avulsions have mainly been reported in relatively small patient cohorts. Detailed information on patient demographics, injury mechanism, and injury patterns is lacking in the literature. Since these injuries are rare and frequently misdiagnosed, a better understanding may help to increase awareness and to improve diagnosis of proximal hamstring avulsions. METHODS A chart review was performed to identify all patients who had undergone surgical repair for complete proximal hamstring avulsions between 01/2006 and 02/2019 at the authors' institution. The following demographic and injury-specific data were obtained: Sex, age, body mass index (BMI), cause of injury (sports, activities of daily living, and others), presence of neurologic symptoms referable to the sciatic nerve, time to surgery, injury pattern (affected tendons), tendon retraction, and type of injury according to Wood et al.`s classification (Type 1: osseous avulsions, Type 2: tear at the musculotendinous junction, Type 3: incomplete avulsion from bone, Type 4: complete avulsion with only minimal retraction, and Type 5: complete avulsion with retraction > 2 cm). Data were analyzed for the entire study population and group comparison was performed with regard to sex, cause of injury, and the type of injury. RESULTS A total of 263 patients were included (53% male). The mean age was 49 ± 13 years with most patients (56%) aged between 45-59 years. Most injuries occurred while participating in sports (52%) and injury type 5 was most commonly diagnosed (66%). Five percent of patients had sensory deficits referable to the sciatic nerve. Gender comparison showed that female patients were significantly older, predominantly represented in the age group 45-59 years, and most commonly injured during activities of daily living, whereas male patients were significantly more often represented in younger age groups, and the most common cause of injury was sports. Compared to Type 4 and 5 injuries, patients with a Type 1 injury were significantly younger and had a significantly longer time to surgery. CONCLUSION Proximal hamstring avulsion occurs predominately in the middle-aged patient and only rarely in patients under the age of 30 years. No gender dominance exists. Female patients are typically older and get injured during activities of daily living, whereas male patients are younger and get injured more often during sports. These epidemiologic data may help physicians to make an accurate and early diagnosis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Markus Irger
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Lukas Willinger
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Lucca Lacheta
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jonas Pogorzelski
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Matthias J Feucht
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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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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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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Beckmann JT, Havrilak EE, Millis MB, Wylie JD. Functional Outcome Assessment in Hip Preservation Surgery. JBJS Rev 2019; 6:e6. [PMID: 30020118 DOI: 10.2106/jbjs.rvw.17.00188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- James T Beckmann
- Department of Orthopedics, St. Luke's Health System, St. Luke's Boise Medical Center, Boise, Idaho
| | - Eren E Havrilak
- Department of Orthopedics, St. Luke's Health System, St. Luke's Boise Medical Center, Boise, Idaho
| | - Michael B Millis
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - James D Wylie
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts
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van der Made AD, Peters RW, Verheul C, Maas M, Kerkhoffs GM. Abduction in Proximal Hamstring Tendon Avulsion Injury Mechanism: A Report on 3 Athletes. Clin J Sport Med 2019; 29:e76-e79. [PMID: 31688186 DOI: 10.1097/jsm.0000000000000543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Proximal hamstring tendon avulsions are typically sustained during forced hip hyperflexion combined with knee extension. We present 3 cases of athletes with a proximal hamstring tendon avulsion caused by an alternative injury mechanism that also involves a considerable hip abduction component (flexion-abduction injury mechanism). All cases had at least one concurrent injury of the medial thigh muscles, either on the ipsilateral or contralateral side. The 2 elite athletes with this injury mechanism returned to sport at preinjury level relatively quickly. A history of the flexion-abduction mechanism should raise suspicion of a hamstring tendon avulsion with concomitant injury of the medial thigh muscles. The magnetic resonance imaging (MRI) protocol should include both legs, and any concurrent injury may need to be addressed as well. In future studies, it would be interesting to investigate whether injury mechanism holds prognostic value in proximal hamstring tendon avulsions.
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Affiliation(s)
- Anne D van der Made
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, 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), Academic Medical Center, Amsterdam, the Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
- Department of Trauma Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Claire Verheul
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, Amsterdam, the Netherlands
- ManualFysion, Amsterdam, the Netherlands
| | - Mario Maas
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, Amsterdam, the Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Gino M Kerkhoffs
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, Amsterdam, the Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
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Léger-St-Jean B, Gorica Z, Magnussen RA, Vasileff WK, Kaeding CC. Accelerated rehabilitation results in good outcomes following acute repair of proximal hamstring ruptures. Knee Surg Sports Traumatol Arthrosc 2019; 27:3121-3124. [PMID: 29725745 DOI: 10.1007/s00167-018-4964-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/23/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess outcomes of patients who underwent proximal hamstring repair utilizing an accelerated rehabilitation protocol with immediate weight bearing as tolerated and no bracing. METHODS Retrospective chart review identified 47 proximal hamstring tendon repairs with suture anchors in 43 patients performed during 2008-2015. Rehabilitation included no immobilization or limited weightbearing. Patients were contacted by phone to assess outcomes utilizing the lower extremity functional score (LEFS), single-assessment numeric evaluation (SANE), and Marx activity scale. Overall patient-reported scores were calculated and results of acute and chronic repairs compared. RESULTS Thirty-four patients (38 repairs, 80.8%) were available for follow-up at mean of 4.1 ± 2.0 years following repair. There were two re-tears: one complete rupture 5 weeks postoperative and one partial rupture 10 weeks postoperative in the chronic group. Patients in general reported low pain and good function with a mean LEFS score of 87 ± 21%, a mean SANE score of 88.1 ± 11.6, and a mean numeric pain score of 8.5 ± 15.3 in the last week and 12.2 ± 21.1 with activity. The acute repair group was noted to have a higher mean LEFS score (93.7 versus 79.8%, p = 0.004) and SANE score (91.3 versus 83.8, p = 0.047), and lower pain with activity (21.7 versus 4.8, p < 0.001) as compared to the chronic group. CONCLUSIONS Repair of acute proximal hamstring ruptures results in good function and pain relief with the use of a rehabilitation protocol that does not require weight-bearing restrictions or bracing. LEVEL OF EVIDENCE III, therapeutic.
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Affiliation(s)
- Benjamin Léger-St-Jean
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Zylyftar Gorica
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Robert A Magnussen
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA. .,OSU Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA.
| | - W Kelton Vasileff
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA.,OSU Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
| | - Christopher C Kaeding
- Department of Orthopaedics, College of Medicine, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA.,OSU Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Dr, Columbus, OH, 43202, USA
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Ryan MK, Beason DP, Fleisig GS, Emblom BA. Portal Placement and Biomechanical Performance of Endoscopic Proximal Hamstring Repair. Am J Sports Med 2019; 47:2985-2992. [PMID: 31412206 DOI: 10.1177/0363546519866453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Proximal hamstring tendon avulsions are debilitating and commonly cause pain, weakness, and functional limitations. Open surgical repair has been the standard, but improved endoscopic techniques have enabled proximal hamstring fixation with decreased risk of infection and numbness, without the morbidity of a large incision. PURPOSE/HYPOTHESIS The purpose was to (1) describe pertinent anatomy surrounding the proximal hamstring origin in relation to 4 endoscopic portal sites and (2) test for biomechanical differences between open and endoscopic repair. It was hypothesized that (1) endoscopic proximal hamstring repair is efficacious with respect to commonly used portals and (2) there is no biomechanical difference between open and endoscopic techniques. STUDY DESIGN Descriptive and controlled laboratory study. METHODS Proximal hamstring ruptures were simulated endoscopically in 10 fresh-frozen human cadaveric pelvis specimens. Endoscopic repair was then completed on 1 limb from each specimen through 4 portals. After repair, each specimen was dissected in layers and measurements from portal tracts to pertinent anatomy were obtained. Open repair was performed on all contralateral limbs, followed by cyclical biomechanical tensile testing to failure of both the open and endoscopically repaired hamstring tendons to assess failure load and local tissue strain. RESULTS On average, no portal tract was closer than 2.0 cm to the sciatic nerve or inferior gluteal neurovascular bundle. Anatomic landmarks were identified that could improve the reproducibility and safety of the procedure. Biomechanical testing revealed no differences between the open and endoscopic repair techniques for any measured parameter. CONCLUSION This study supports the safety and efficacy of endoscopic proximal hamstring repair through anatomic and biomechanical analyses and helps establish reproducible and recognizable landmarks that define a safe working zone. CLINICAL RELEVANCE This study maps the anatomic landscape of the proximal hamstring as encountered endoscopically and demonstrates equivalent biomechanical strength of endoscopic proximal hamstring repair, supporting this technique's safety and efficacy.
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Affiliation(s)
- Michael K Ryan
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - David P Beason
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Glenn S Fleisig
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Benton A Emblom
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
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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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van der Made AD, Hölmich P, Kerkhoffs GMMJ, Gouttebarge V, D’Hooghe P, Tol JL. Proximal hamstring tendon avulsion treatment choice depends on a combination of clinical and imaging-related factors: a worldwide survey on current clinical practice and decision-making. J ISAKOS 2019. [DOI: 10.1136/jisakos-2019-000292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ObjectivesTo evaluate current practice in the treatment of proximal hamstring tendon avulsions and identify decision-making preferences.MethodsAn invitation to an anonymous e-survey containing 32 questions was sent to 3475 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) and the European College of Sports and Exercise Physicians (ECOSEP).ResultsWe received 403 (12%) unique responses with a completion rate of 79%. Participants were orthopaedic/trauma surgeons (90%), sports medicine physicians (7%) or physical therapists (2%). For 83% of the participants, the preferred treatment (ie, surgical or non-operative) depends on the individual case. Participants base their decision-making process on patient- and injury-related factors (decision modifiers). The five most frequently selected decision modifiers that support the choice for surgical treatment were diminished function (84%), neurological symptoms (74%), involved tendons (82%), tendon retraction on MRI (84%) and patient preference for surgery (78%). The majority prefer early surgical repair (<2 weeks after injury) to achieve highest functional outcome (63%) and ensure a low complication risk (61%). Suture anchors are used by 93% of the participants for tendon reattachment. Estimated recovery duration (ie, time to return to sports) was a median 12 weeks (IQR: 12–20) for non-operative treatment and 17 weeks (IQR: 12–24) for surgical treatment. Estimated reinjury risk was a median 25% (IQR: 10–31.5) and 10% (IQR: 5–20), respectively.ConclusionThis survey among experienced medical professionals has summarised current practice and identified treatment decision-making preferences. The typical surgical patient has a retracted (>2 cm) two-tendon avulsion (ie, common tendon and semimembranosus tendon), is unable to engage in sports or activities of daily life, reports sciatic symptoms and prefers surgical treatment. Surgery is thought to prolong recovery and decrease reinjury risk compared with non-operative treatment and is preferably performed early.Level of evidenceLevel V.
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Belk JW, Kraeutler MJ, Mei-Dan O, Houck DA, McCarty EC, Mulcahey MK. Return to Sport After Proximal Hamstring Tendon Repair: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119853218. [PMID: 31259189 PMCID: PMC6591667 DOI: 10.1177/2325967119853218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Previous studies have evaluated functional outcomes and return-to-sport rates
after proximal hamstring tendon (HT) repair. Purpose: To systematically review the literature in an effort to evaluate
return-to-sport rates after proximal HT repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed by searching PubMed, the Cochrane Library,
and Embase to identify studies that evaluated postoperative lower extremity
function and return-to-sport rates in patients after proximal HT repair.
Search terms used were “hamstring,” “repair,” “return to sport,” and “return
to play.” Patients were assessed based on return to sport, return to
preinjury activity level, type of HT tear (complete or partial), and
interval from injury to surgery. Patients were also divided into subgroups
depending on timing of the surgical intervention: early, <1 month;
delayed, 1 to 6 months; and late, >6 months from the time of injury. Results: Sixteen studies (one level 2, five level 3, ten level 4) met the inclusion
criteria, including 374 patients with a complete proximal HT tear (CT group)
and 93 patients with a partial proximal HT tear (PT group), with a mean
follow-up of 2.9 years. Overall, 93.8% of patients (438/467) returned to
sport, including 93.0% (348/374) in the CT group and 96.8% (90/93) in the PT
group (P = .18). The mean time to return to sport was 5.7
months, and 83.5% of patients (330/395) returned to their preinjury activity
level. The early group demonstrated the greatest rate of return to sport at
94.4% (186/197) as well as the quickest time to return at a mean of 4.8
months, although this was not found to be statistically significant. Conclusion: Over 90% of patients undergoing repair of a complete or partial proximal HT
tear can be expected to return to sport regardless of the tear type. Early
surgical interventions of these injuries may be associated with a quicker
return to sport, although the rate of return to sport does not differ based
on timing of the surgical intervention.
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Affiliation(s)
- John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Omer Mei-Dan
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Darby A Houck
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mary K Mulcahey
- Department of Orthopaedics, Tulane University School of Medicine, New Orleans, Louisiana, USA
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46
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Functional impairment after successful surgical reconstruction for proximal hamstring avulsion. INTERNATIONAL ORTHOPAEDICS 2018; 43:2341-2347. [DOI: 10.1007/s00264-018-4263-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
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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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Bodendorfer BM, Curley AJ, Kotler JA, Ryan JM, Jejurikar NS, Kumar A, Postma WF. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Am J Sports Med 2018; 46:2798-2808. [PMID: 29016194 DOI: 10.1177/0363546517732526] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND No meta-analysis has compared outcomes of operative and nonoperative proximal hamstring avulsion treatment. PURPOSE To compare outcomes of operative and nonoperative proximal hamstring avulsion treatment, including acute, chronic, partial, and complete repairs. STUDY DESIGN Meta-analysis. METHODS PubMed, CINAHL, SPORTdiscus, Cochrane Library, EMBASE, and Web of Science were searched up to July 2016. Three authors screened the studies and performed quality assessment using criteria from the Methodologic Index for Nonrandomized Studies. A best evidence synthesis was subsequently used. RESULTS Twenty-four studies (795 proximal hamstring avulsions) were included. Twenty-two studies included proximal hamstring avulsion repairs; 1 study had proximal hamstring avulsion repairs and a control group of nonoperatively treated proximal hamstring avulsions; and 1 study had solely nonoperatively treated proximal hamstring avulsions. The majority of studies were of low methodological quality. Overall, repairs had significantly higher patient satisfaction (90.81% vs 52.94%), hamstring strength (85.01% vs 63.95%), Lower Extremity Functional Scale scores (72.77 vs 69.53), and single-legged hop test results (119.1 vs 56.62 cm) (all P < .001); complications occurred in 23.17% of cases. Compared with chronic repairs, acute avulsion repairs had greater patient satisfaction (95.48% vs 83.79%), less pain (1.07 vs 3.71), and greater strength (85.2% vs 82.8%), as well as better scores for the Lower Extremity Functional Scale (75.64 vs 71.5), UCLA activity scale (University of California, Los Angeles; 8.57 vs 8.10), and Single Assessment Numeric Evaluation (93.36 vs 86.50) (all P < .001). Compared with partial avulsion repairs, complete avulsion repairs had higher patient satisfaction (89.64% vs 81.35%, P < .001), less pain (1.87 vs 4.60, P < .001), and higher return to sport or preinjury activity level, but this was insignificant (81.43% vs 73.83%, P = .082). Partial avulsion repairs had better hamstring strength (86.04% vs 83.71%, P < .001) and endurance (107.13% vs 100.17%, P < .001). Complete repairs had significantly higher complication rates (29.38% vs 11.27%, P = .001). CONCLUSION Proximal hamstring avulsion repair resulted in superior outcomes as compared with nonoperative treatment, although the complication rate was 23.17%. The nonoperative group was quite small, making a true comparison difficult. Acute repairs have better outcomes than do chronic repairs. Complete avulsion repairs had higher patient satisfaction, less pain, and a higher complication rate than partial avulsion repairs, although partial avulsion repairs had better hamstring strength and endurance. Studies of high methodological quality are lacking in terms of investigating the outcomes of proximal hamstring avulsion repairs.
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Affiliation(s)
- Blake M Bodendorfer
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Andrew J Curley
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Joshua A Kotler
- Bone & Joint/Sports Medicine Institute, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - James M Ryan
- School of Medicine, Georgetown University, Washington, DC, USA
| | | | - Anagha Kumar
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - William F Postma
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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49
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Pietrzak JRT, Kayani B, Tahmassebi J, Haddad FS. Proximal hamstring tendinopathy: pathophysiology, diagnosis and treatment. Br J Hosp Med (Lond) 2018; 79:389-394. [DOI: 10.12968/hmed.2018.79.7.389] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jurek RT Pietrzak
- Senior Clinical Fellow, Department of Trauma and Orthopaedics, University College Hospital, London
| | - Babar Kayani
- Specialist Orthopaedic Registrar, Department of Trauma and Orthopaedics, University College Hospital, London NW1 2BU
| | - Jenni Tahmassebi
- Research Physiotherapist, Department of Trauma and Orthopaedics, University College Hospital, London
| | - Fares S Haddad
- Professor of Orthopaedic and Sports Surgery, Department of Trauma and Orthopaedics, University College Hospital, London
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50
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Cvetanovich GL, Saltzman BM, Ukwuani G, Frank RM, Verma NN, Bush-Joseph CA, Nho SJ. Anatomy of the Pudendal Nerve and Other Neural Structures Around the Proximal Hamstring Origin in Males. Arthroscopy 2018; 34:2105-2110. [PMID: 29606539 DOI: 10.1016/j.arthro.2018.02.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To define the anatomy of the pudendal nerve in relationship to the proximal hamstring and other nearby neurological structures during proximal hamstring repair. METHODS Six fresh-frozen human cadaveric hemi-pelvises from male patients ages 64.0 ± 4.1 years were dissected in prone position with hips in 10° flexion to identify the relationship of proximal hamstring origin to surrounding neurologic structures including the pudendal nerve, sciatic nerve, and posterior femoral cutaneous nerve. Two independent observers used digital calipers to measure distances. RESULTS The pudendal nerve emerged at the inferior border of the piriformis muscle 6.3 ± 1.4 cm from the superior aspect of the proximal hamstring origin. It passed the superior border of the sacrotuberous ligament 3.0 ± 0.6 cm from the superior aspect and 3.9 ± 0.7 cm from the medial aspect of the hamstring origin. It crossed the inferior border of the sacrotuberous ligament 3.0 ± 0.4 cm from the superior aspect and 2.7 ± 0.7 cm from the medial aspect of the proximal hamstring origin. The shortest distance from the hamstring origin to the pudendal nerve was 2.6 ± 0.5 cm from the superior aspect and 2.3 ± 0.8 cm from the medial aspect. The shortest distance from the hamstring origin to the pudendal nerve was located deep to the sacrotuberous ligament in all cadavers. The sciatic nerve was an average of 1.1 ± 0.1 cm lateral to the lateral aspect of the proximal hamstring origin. The posterior femoral cutaneous nerve was located between the hamstring origin and the sciatic nerve, 0.7 ± 0.2 cm lateral to the lateral aspect of the proximal hamstring origin. CONCLUSIONS The proximal hamstring origin lies in close proximity to surrounding nerves, including the pudendal, sciatic, and posterior femoral cutaneous nerves. CLINICAL RELEVANCE Knowledge that the pudendal nerve lies 2 to 3 cm superior and medial to the proximal hamstring origin may help to prevent iatrogenic damage during surgical dissection and retraction when performing proximal hamstring repair or deep gluteal space endoscopy.
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Affiliation(s)
- Gregory L Cvetanovich
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
| | - Bryan M Saltzman
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Gift Ukwuani
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Rachel M Frank
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Charles A Bush-Joseph
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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