Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis

Conservative management of proximal hamstring avulsion: A clinical study

Introduction

The management of proximal hamstring tear (PHT) is debated and consensus regarding recommended measures and individual treatment regimens is lacking. The present investigation evaluated the efficacy of a conservative management of partial and complete PHT.

Methods

The present observational study was conducted following the STROBE statement. In June 2018 the medical databases of the BG Klinikum Bergmannstrost Halle, Germany were accessed. All the patients with PHT were retrieved. The outcomes of interest were to evaluate the clinical examination, PROMs, imaging, and isokinetic muscle strength at the baseline and last follow-up.

Results

31 patients were enrolled in the present study. Nine patients (29 % (9 of 31) described local pain at the ischial tuberosity in sitting situations and also in manual palpation. A persistent gap in the tendon string beneath the tuberosity in manual palpation was reported in 25.8 % (8 of 31). The mean VAS at the last follow-up was 2.3 ± 2.3. The mean LEFS score was 50.9 ± 18.8.Control MRI at follow-up showed scarring restitution in the proximal tendon in all patients in the partial tear group. In the complete tear group, a persisting defect state of the proximal tendon course was found in 45 % (9 of 20). The injured side achieved 81.5 ± 22.2 % of the force of the uninjured side, measured in the flexion movement at 60°/s. At an angular velocity of 240°/s, 83.2 ± 26.3 % of the force of the uninjured side was achieved.

Conclusion

According to the main findings of the present study, conservative therapy of PTH tears is associated with good clinical outcomes. High-quality investigations are required to establish the proper therapeutic algorithm and advantages of conservative management compared to a surgical approach.

Level of evidence

Level III.

Non-surgical management of acute proximal hamstring avulsions can produce clinically acceptable results

PURPOSE

To evaluate the mid-term clinical outcomes for the non-surgical and surgical management of acute proximal hamstring avulsions.

METHODS

Sixty physically active individuals were offered surgical or non-surgical management for their proximal hamstring avulsion injuries. Distal retraction was defined as greater than 2 cm. Primary outcome measures were the Victorian Institute of sport assessment-proximal hamstring tendons (VISA-H) and functional assessment scale for acute hamstring injuries (FASH). Secondary outcome measures included palpable gap (cm), return to sport (RTS) and the ability to perform Nordic hamstring curls. Outcome variables were adjusted in regression models for gender, age, and treatment.

RESULTS

Thirty-one patients elected to undertake non-surgical management, and 29 chose surgery with a mean follow-up of 34.8 ± 8.7 and 34.9 ± 7.0 months, respectively. The mean VISA-H for the non-surgical and surgical groups were 87.3 ± 3.4 and 87.9 ± 4.1 (n.s.), respectively. The mean FASH for the non-surgical group was 89.3 ± 2.4 and 88 ± 3.6 for the surgical group (n.s.). This was consistent after adjusting for confounders. The mean gap for the non-surgical group was 4.5 ± 1.09 and 4.9 ± 1.19 cm for the surgical group (n.s.). No significant differences were found in the abilities to perform Nordic hamstring curls (n.s.). Both groups achieved comparable RTS rates (n.s.). On average, the non-surgical group achieved RTS at 5.5 ± 1.2 months post-injury, whereas the surgical group was at 5.7 ± 0.7 months (n.s.).

CONCLUSION

Physically active individuals with acute proximal hamstring avulsions and distal retraction of the tendon stump can be managed non-surgically, achieving similar functional levels and RTS compared to patients treated surgically.

LEVEL OF EVIDENCE

Level III.

Management of Proximal Hamstring Injuries: Non-operative and Operative Treatment

PURPOSE OF REVIEW

To evaluate the current evidence and literature on treatment options for proximal hamstring injuries.

RECENT FINDINGS

Patients with 3-tendon complete tears with greater than 2 cm of retraction have worse outcomes and higher complication rates compared to those with less severe injuries. Endoscopic and open proximal hamstring repair both have favorable patient reported outcomes at 5-year follow up. Proximal hamstring repair in patients who are male, with isolated semimembranosus injury, and have proximal hamstring free tendon rupture are more likely to have earlier return to sports. The Parisian Hamstring Avulsion Score (PHAS) is a validated patient-reported outcome measure to predict return to sports. Proximal hamstring injuries may occur in both elite and recreational athletes and may present with varying degrees of chronicity and severity. Injuries occur most commonly during forceful eccentric contraction of the hamstrings and often present with ischial tuberosity tenderness, ecchymosis, and hamstring weakness. Treatment decision-making is dictated by the tendons involved and chronicity. Many proximal hamstring injuries can be successfully treated with non-surgical measures. However, operative treatment of appropriately indicated proximal hamstring tendon injuries can result in significantly better functional outcomes and faster and more reliable return to sports compared to nonoperative treatment. Both endoscopic and open surgical repair techniques show high satisfaction levels and excellent patient-reported outcomes at short- and mid-term follow-up. Postoperative rehabilitation protocols vary across the literature and ongoing study is needed to clarify the optimal program, though emphasis on eccentric hamstring strengthening may be beneficial.

Reconstruction of proximal hamstring ruptures restores joint biomechanics during various walking conditions

PURPOSE

We aimed to examine the functional outcome in different walking conditions in elderly adults who underwent surgical repair after a non-contact hamstring injury. Our objective was to compare lower limb kinematics and kinetics over the entire gait cycle between the injured and contralateral leg in overground and level and uphill treadmill walking.

METHODS

12 patients (mean ± SD, age: 65 ± 9 years; body mass index: 30 ± 6 kg/m2) walked at self-selected speed in overground (0% slope) and treadmill conditions (0% and 10% slope). We measured spatiotemporal parameters, joint angles (normalised to gait cycle) and joint moments (normalised to stance phase) of the hip, knee and ankle. Data between sides were compared using paired sample t-tests (p < 0.05) and continuous 95% confidence intervals of the paired difference between trajectories.

RESULTS

Patients walked at an average speed of 1.31 ± 0.26 m/second overground and 0.92 ± 0.31 m/second on the treadmill. Spatiotemporal parameters were comparable between the injured and contralateral leg (p > 0.05). Joint kinematic and joint kinetic trajectories were comparable between sides for all walking conditions.

CONCLUSIONS

Refixation of the proximal hamstring tendons resulted in comparable ambulatory mechanics at least 1 year after surgery in the injured leg and the contralateral leg, which were all within the range of normative values reported in the literature. These results complement our previous findings on hamstring repair in terms of clinical outcomes and muscle strength and support that surgical repair achieves good functional outcomes in terms of ambulation in an elderly population.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04867746).

Operative Repair of Hamstring Injuries From the Jackling Position in Rugby

Background

The jackling position within rugby has not been previously described as a mechanism for proximal hamstring injuries.

Hypothesis

Acute surgical repair of proximal hamstring avulsion injuries sustained from the jackling contact position enables a return to a previous level of sporting activity with low risk of recurrence.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 54 professional rugby players (mean age, 26 ± 4.8 years) who underwent acute primary surgical repair of complete, proximal hamstring avulsion injuries. The mean follow-up time was 17 months (range, 12-24 months). Mean isometric hamstring strength and function testing was performed at 3 months and 1 year after repair.

Results

Of the 54 players, 51 (94.4%) returned to their preinjury level of sporting activity. The mean time from surgical repair to full sporting activity was 7 months (range, 4-12 months). No patients had recurrence of the primary injury. At 1 year postoperatively, patients had significantly restored mean isometric hamstring muscle strength when compared with the uninjured leg at 0° (98.4% ± 2.8%), 15° (95.9% ± 2.9%), and 45° (92.9% ± 4.1%); improved Lower Extremity Functional Score (78.0 ± 2.0); and improved Marx activity rating score (14.3 ± 1.5) (P < .001 for all).

Conclusion

Acute surgical repair of proximal hamstring avulsion injuries caused by the contact jackling position produced a high return to preinjury level of sporting activity, increased muscle strength, and improved functional outcome scores, with a low risk of recurrence at short-term follow-up.

Magnetic resonance imaging should be the first-line imaging modality for investigating suspected proximal hamstring avulsion injuries

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.

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

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.

Risk Factors for Rerupture After Proximal Hamstring Avulsion Injury Including the Optimal Timing for Surgery

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.

Hamstring muscle injuries in athletics

Hamstring muscle injuries (HMI) are a common and recurrent issue in the sport of athletics, particularly in sprinting and jumping disciplines. This review summarizes the latest literature on hamstring muscle injuries in athletics from a clinical perspective. The considerable heterogeneity in injury definitions and reporting methodologies among studies still needs to be addressed for greater clarity. Expert teams have recently developed evidence-based muscle injury classification systems whose application could guide clinical decision-making; however, no system has been adopted universally in clinical practice, yet.The most common risk factor for HMI is a previously sustained injury, particularly early after return-to-sport. Other modifiable (e.g. weakness of thigh muscles, high-speed running exposure) and non-modifiable (e.g. older age) risk factors have limited evidence linking them to injury. Reducing injury may be achieved through exercise-based programs, but their specific components and their practical applicability remain unclear.Post-injury management follows similar recommendations to other soft tissue injuries, with a graded progression through stages of rehabilitation to full return to training and then competition, based on symptoms and clinical signs to guide the individual speed of the recovery journey. Evidence favoring surgical repair is conflicting and limited to specific injury sub-types (e.g. proximal avulsions). Further research is needed on specific rehabilitation components and progression criteria, where more individualized approaches could address the high rates of recurrent HMI. Prognostically, a combination of physical examination and magnetic resonance imaging (MRI) seems superior to imaging alone when predicting 'recovery duration,' particularly at the individual level.

Hamstring Injuries: A Current Concepts Review: Evaluation, Nonoperative Treatment, and Surgical Decision Making

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.

Predictors of Early Return to Sport After Surgical Repair of Proximal Hamstring Complex Injuries in Professional Athletes: A Prospective Study

BACKGROUND

Proximal hamstring complex injury (PHCI) is a common injury among professional athletes, particularly those participating in pivot contact sports. Previous studies have suggested that surgery can be effective in restoring function and allowing athletes to return to sport (RTS), but the factors influencing successful RTS have been less clear.

PURPOSE

To assess RTS capabilities after surgical treatment of PHCI in professional athletes and to identify favorable predictors of RTS.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study (2002-2022) was conducted on professional athletes who underwent surgical treatment for PHCI at a sports surgery center. The primary outcome of the study was the RTS capability, evaluated based on the rate of athletes' return to their preinjury level of competition, time delay to RTS, and quality of RTS as measured using their level of performance and progression of scores on activity scales such as the Tegner Activity Scale (TAS) and University of California, Los Angeles (UCLA), scale. "Maintained performance" was defined as athletes returning to the same preinjury activity level (per the TAS and UCLA scale) and perceiving themselves to have maintained their performance. Secondary outcomes covered the potential RTS predictors and complication rate. The study distinguished 2 types of PHCI: proximal hamstring tendon avulsion injury (proximal rupture with empty footprint, or having a "positive dropped ice cream sign") and complete proximal hamstring free tendon rupture (PHTR; proximal rupture without empty footprint, or having a "negative dropped ice cream sign").

RESULTS

The study examined 64 professional athletes (mean age, 27.3 years; 82.8% male) undergoing surgery for PHCI. The RTS rate was 98.4%, with 78.1% of the athletes returning to their preinjury level of competition at 6.2 months (SD, 2.5 months). Twelve (19%) patients had returned to sport at an inferior level of competition, and 2 (3.1%) were unable to continue in their preinjury sport. Subgroup analysis revealed variation in RTS based on sport type, with the highest rate of return to preinjury performance found in athletes in handball and sports with splits (fencing, squash, and escalade; 100%) and soccer (95.2%). In the univariate analysis, male sex (hazard ratio [HR], 4.05; 95% CI, 1.45-11.3; P = .008), higher preinjury TAS score (HR, 1.27; 95% CI, 1.06-1.52; P = .011), injury involving the semimembranosus (HR, 4.84; 95% CI, 2.31-10.2; P < .001) or conjoint tendon (HR, 3.12; 95% CI, 1.55-6.25; P = .001), and PHTR (HR, 7.77; 95% CI, 3.54-17.0; P < .001) were significantly associated with a better postoperative level of competition. Multivariate analysis identified 3 favorable predictors of RTS with HRs of 2.91 (95% CI, 1.01-8.35; P = .047) for male sex, 3.86 (95% CI, 1.78-8.37; P < .001) for isolated semimembranosus injury, and 5.18 (95% CI, 2.24-12.0; P < .001) for PHTR. The complication rate was 4.7%.

CONCLUSION

Favorable predictors of early RTS were male sex, isolated semimembranosus injury, and PHTR injuries.

REGISTRATION

NCT02906865 (ClinicalTrials.gov identifier).

Association Between Proximal Hamstring Tear Characteristics and Achievement of Clinically Significant Outcomes After Endoscopic and Open Repair at Minimum 2-Year Follow-up

BACKGROUND

The effect of preoperative tear characteristics and the relative efficacy of open versus endoscopic surgical techniques have not been elucidated for the surgical treatment of proximal hamstring tendon injuries.

PURPOSE

(1) To report on achievement rates of clinically significant outcomes at a minimum 2-year follow-up for multiple patient-reported outcomes (PROs) after surgical treatment of proximal hamstring injuries, stratified according to severity of proximal hamstring injury, and (2) to compare clinical outcomes associated with endoscopic versus open surgical repair for a subset of similarly classified tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A single-surgeon clinical registry was queried for patients who underwent surgical repair for proximal hamstring ruptures between January 2012 and March 2021. Injuries were classified by magnetic resonance imaging as follows: grade 1, incomplete tear with the involvement of 1 or 2 tendons; grade 2, complete tear with the involvement of 3 tendons and ≤2-cm retraction; and grade 3, complete tear with the involvement of 3 tendons and >2-cm retraction. The Patient Acceptable Symptom State (PASS) for multiple PROs was calculated and compared among injury grades and between surgical techniques.

RESULTS

Among 75 patients with a mean follow-up of 30.5 ± 5.1 months, 20 had grade 1 tears, 24 had grade 2 tears, and 31 had grade 3 tears. Favorable 2-year postoperative PROs were demonstrated by each grade for all measured PROs. Patients with grade 3 tears were noted to have significantly lower rates of 2-year PASS achievement for the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Specific (HOS-SS) scales (P≤ .032). Among grade 2 tears, patients treated endoscopically demonstrated significantly greater HOS-SS (endoscopic, 91.7%; open, 58.3%; P = .045) and Patient-Reported Outcomes Measurement Information System for Physical Function (endoscopic, 80.0%; open, 50.0%; P = .033) PASS achievement rates compared with those treated with the open technique. Complication rates were highest in patients with grade 3 tears (45.2%, P = .043).

CONCLUSION

Surgical repair of proximal hamstring tendon tears with varying extents of tendon retraction resulted in high rates of achieving PASS at the 2-year follow-up. Among complete tears with <2 cm of retraction, endoscopic repairs exhibited equal or higher rates of achieving PASS compared with open repairs across multiple PROs at 2 years postoperatively. However, patients with complete tears and retraction >2 cm achieved lower rates of PASS on the HOS-ADL and HOS-SS scales and had a higher rate of complications.

Systematic Review of Bracing After Proximal Hamstring Repair

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.

Repair of Retracted Hamstring Tears with Hamstring Pulley Technique and Inferomedial Portal

Endoscopic repair of hamstring tears is well described in the literature, but endoscopic management for significantly retracted hamstring tears is not well described. Currently, repairing a hamstring tendon that has retracted 8 cm or more from the footprint on the ischial tuberosity is performed as an open procedure. The technique described here details endoscopic repair of retracted hamstring tears using a suture pulley mechanism and an inferomedial portal.

Biomechanical Comparison of Proximal Hamstring Reconstruction Using Distal Hamstring Graft Versus Fascia Lata Graft for Treatment of Chronic Hamstring Injury

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.

Development and application of a proximal hamstring MRI-based scoring tool in patients undergoing proximal hamstring tendon surgical repair

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.

Clinical Outcomes After Open and Endoscopic Repair of Proximal Hamstring Tendon Tears at a Minimum Follow-up of 5 Years

Background

Current evidence supports favorable short-term clinical outcomes with few complications after surgical management of proximal hamstring injuries; however, the durability of clinical benefits beyond approximately 2 years after surgery is unknown.

Purpose

To evaluate patient-reported clinical outcomes and complication rates associated with open and endoscopic repair of proximal hamstring tears at minimum 5-year follow-up.

Study Design

Case series; Level of evidence, 4.

Methods

A single-surgeon registry of patients was queried between October 1, 2014, and December 31, 2017, to identify patients who underwent open or endoscopic repair of a proximal hamstring tear. Patients who reported minimum 5-year follow-up data were included. Multiple patient-reported outcome measures, including the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, 12-Item International Hip Outcome Tool (iHOT-12), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain domains, along with surgical complications, were analyzed.

Results

Among 35 eligible patients (65.7% female; mean age, 52.3 ± 8.4 years), 24 had full-thickness tears and 11 had partial-thickness tears. There were 23 open repairs and 12 endoscopic repairs. Mean duration from symptom onset to surgical intervention was 37.9 weeks (range, 1.3-306.9 weeks). At a mean follow-up of 69.0 months (range, 60.0-95.0 months), mean postoperative outcome scores were as follows: HOS-ADL, 86.8 ± 12.7; HOS-SS, 83.1 ± 19.5; iHOT-12, 86.3 ± 14.9; PROMIS-PF, 50.0 ± 11.8; and PROMIS-Pain, 50.2 ± 7.9. Regarding complications, 28.6% of patients had a complication including persistent peri-incisional numbness (11.4%), wound infection (11.4%), postoperative neuropathy (8.6%), and revision surgery (2.9%).

Conclusion

Both open and endoscopic surgical techniques for repair of proximal hamstring injuries produced favorable patient-reported clinical outcomes at a minimum 5-year follow-up.

Endoscopic Proximal Hamstring Tendon Repair With Knotless Suture-Bridge Technique

Symptomatic proximal hamstring tendon tears are typically repaired surgically, with open incision and knot-tying technique. An endoscopic, knotless, suture-bridge repair technique is presented. Potential advantages include knotless simplicity, compression over a broad zone to improve tendon-bone healing, and decreased pain secondary to elimination of knots and the open incision and approach.

Surgical treatment of high-grade acute intramuscular hamstring tendon injuries in athletes leads to predictable return to sports and no re-injuries

PURPOSE

The purpose of this study was to assess the post-operative return to sport and re-injury rates following surgical repair of acute, first-time, high-grade intramuscular hamstring tendon injuries in high level athletes.

METHODS

Patients were identified using the databases of two sports surgeons. Once patients were identified their clinical notes and imaging were reviewed to confirm that all patients had injuries to the intramuscular portion of the distal aspect of the proximal biceps femoris tendon. All imaging was reviewed by an experienced musculoskeletal radiologist to confirm diagnosis. Surgery for such injuries was indicated in high-level athletes presenting with acute hamstring injuries. All patients were operated on within 4 weeks. Outcomes included Tegner scores, return to sport, Lower Extremity Functional Score (LEFS), current hamstring symptoms and complications including re-injury.

RESULTS

Eleven injuries (10 patients) were included in the study. All patients were male and Australian Rules Football players. Six patients were professional athletes and 4 semi-professional athletes. Median age was 24.5 (range 21-29) and median follow-up period was 33.7 months (range; 16-65). 91% were British Athletic Muscle Injury Classification (BAMIC) 3c and 9% were BAMIC 4c. 91% were classed as MR2 and 9% as MR3 on the simplified four-grade injury classification. Athletes achieved return to play (RTP) at an average of 3.1 months (SD 1.0) post repair. All but one patient achieved a Tegner score equal to pre-injury levels. Maximum LEFS was achieved by all patients. Minor pain scores (all with VAS < 1/10) on sciatic and functional stretch were recorded in 36% and 27% of patients respectively, with subtle neural symptoms (9%) and subjective tightness (36%) also noted. There were no surgical complications in our patient cohort. No patients had a re-injury or re-operation.

CONCLUSIONS

Surgical repair of high-grade intramuscular tendon injuries of the biceps femoris hamstring muscle in athletes resulted in high levels of return to pre-injury sporting levels and no re-injuries. The intra-muscular tendon should be scrutinized when assessing hamstring injuries in elite sport and offer surgery in high-grade cases.

LEVEL OF EVIDENCE

IV.

Sciatic Nerve Compression after a Chronic Proximal Hamstring Tear: A Report of Two Cases and a Narrative Review of the Literature

Proximal hamstring tears are among the most common injuries afflicting athletes and middle-aged individuals. Sciatic nerve compression after a proximal hamstring injury, which can occur due to scar formation and subsequent irritation or compression of the nerve, is an infrequent but severe complication with few cases documented in the literature. No evidence is available about the optimal treatment for sciatic nerve symptoms after proximal hamstring injuries. In this case report, we present two cases involving patients primarily treated conservatively at another institution after suffering from a proximal hamstring injury and developing sciatic nerve symptoms over the course of a few months. Both were treated with open neurolysis at our institution without reattachment of the ruptured muscles to the ischial tuberosity due to the chronicity of the injuries. Both patients exhibited neurological symptoms over two years, which recovered after surgery. These two cases show that neurolysis of the sciatic nerve without reattachment of the proximal hamstring muscles is an applicable option for the treatment of chronic proximal hamstring tears with sciatic nerve compression. Further studies will be needed to validate this hypothesis.

Increasing incidence of surgically treated hamstring injuries: a nationwide registry study in Sweden between 2001 and 2020

BACKGROUND AND PURPOSE

Data on incidence and on trends in treatment of hamstring injuries, including proximal hamstring tendon avulsions (PHA), is limited. We aimed to investigate the incidence, trends in operative treatment, age, and sex distribution of hamstring injuries in Sweden between 2001 and 2020.

PATIENTS AND METHODS

We obtained data recorded in the National Patient Register between 2001 and 2020 on patients between 18 and 90 years of age, with the ICD-10 code S76.3, to calculate the incidence of patients treated operatively for hamstring injuries in Sweden. Patients with the NOMESCO classification NFL49 were considered as having been treated operatively. Data on quadriceps and Achilles tendon injuries were obtained for comparison. To calculate incidences, adult population data for every year were obtained from the Statistics Sweden website.

RESULTS

The incidence of patients diagnosed with hamstring injuries increased from 2.2 to 7.3 per 100,000 person-years. There was a rising trend of surgical treatment per diagnosed case from 3.0% to 14.2%. Patients diagnosed in units with the highest experience of surgical treatment of hamstring injuries tended to be operated on more often (22.2%) than patients diagnosed in units with limited experience (5.1%), although the fraction of operated patients was increasing in both groups.

CONCLUSION

Between 2001 and 2020 there was an increase in the proportion of operatively treated hamstring injuries.

Endoscopic Partial Proximal Hamstring Repair

The contemporary treatment of hamstring avulsions has been evolving, as more patients are being identified as having persistently symptomatic partial hamstring tears recalcitrant to nonoperative treatment. The endoscopic hamstring repair allows surgeons improved visualization of the footprint, as well as safe dissection of the sciatic nerve. The present technique article provides a step-by-step technical note to allow for safe and effective surgical treatment of partial hamstring tears.

Outcomes following adolescent athlete proximal hamstring apophyseal avulsion bone fragment excision and direct tendon-ischial tuberosity reattachment

Apophyseal proximal hamstring bone avulsion is uncommon, occurring in adolescents following sudden forceful contraction of the musculotendinous unit. It can be severely disabling, preventing return to sport. This study assessed outcome following avulsed bone excision and direct hamstring tendon-ischial tuberosity reattachment using bone anchors. Validated hamstring-specific Sydney hamstring orthopaedic research evaluation PROMs were prospectively collected from consecutively treated athletes (7 elite and 11 recreational) by a single surgeon over 13 years. Outcomes at 1-year and final follow-up for primary acute surgery at less than 3 months after injury (group 1), primary chronic surgery at more than 3 months after established nonunion (group 2) and revision following failed screw fixation (group 3) were analyzed with sport participation and level at 1 year. Sixteen primary and two revision procedures were analyzed. Mean injury age was 14.6 years (SD, 1.8). Combined primary mean injury scores improved from 11.89 (SD, 7.32) to 33.31 (SD, 2.30) and showed mean 1 year and final follow-up scores within 0.3-6.1% of preinjury values. Pronounced improvement occurred from injured scores for groups 1 versus 2, respectively at 1 year by 247.7% versus 59.0% and at final follow-up by 251.0% versus 64.1%, for groups 1 versus 2, respectively. Final outcome scores of group 3 were high. All cases returned to preinjury sport level by 1 year and indicated satisfaction to repeat treatment. No significant complications occurred. As the largest series to assess outcomes following this surgical technique, success is highlighted by high score improvements close to preinjury values and return to preinjury sport level.

No difference in clinical outcomes between operative and nonoperative management of minimally retracted proximal hamstring ruptures

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.

Recurrence of Hamstring Injuries and Risk Factors for Partial and Complete Tears in the National Football League: An Analysis From 2009-2020

PURPOSE

To (1) characterize hamstring injury (HSI) recurrence rates across the 2009-2010 to 2019-2020 NFL seasons and (2) to identify HSI recurrence risk factors among positions and determine the weekly return to play (RTP) recurrence risk. We hypothesized that older players, skill position players, and players returning to play faster were most at risk.

METHODS

Public data from the 2009-2010 to 2019-2020 seasons were reviewed to identify HSIs. Player characteristics were collected before and two seasons following injury. A week-by-week analysis of recurrence risk was evaluated with linear and logarithmic trendlines of the best fit.

RESULTS

A total of 2075 HSI were identified with a mean age of 26.2 years (20.0-43.0), BMI of 29.6 (22.7-43.5), and 3.4 seasons of experience (0-17), with 1826 strains (88.0%), 236 partial tears (11.3%), and 13 complete tears (0.63%). Of the 2075 injuries, 796 (38.4%) were recurrent, with 247 (11.9%) being a same-season reinjury. Logistic regression found that fewer weeks before RTP, in-game injury, and lower BMI were risk factors for same-season recurrence. For any recurrence, logistic regression identified more recent year of injury, lower BMI, and longer playing experience as significant risk factors. Wide receivers were found to be at risk for same-season recurrence. For any-season recurrence, defensive backs, linebackers, running backs, tight ends, and wide receivers were at risk. Week-by-week recurrence analysis determined the greatest risk to be when players returned within 2 weeks (13.4%).

CONCLUSIONS

There is a high rate of HSI recurrence in the NFL. Risk factors for same-season injury include shorter time to RTP, in-game injury, lower BMI, and playing wide receiver. Risk factors for any-season recurrence were more recent year of injury, lower BMI, longer playing experience, and playing defensive back, linebacker, running back, tight end, or wide receiver. The greatest risk factor for HSI recurrence was RTP within 2 weeks.

Degree of Tendon Retraction and Younger Age Are Associated With Functional Decline Following Nonoperative Management of Complete Proximal Hamstring Ruptures

Purpose

To characterize functional outcomes of patients with complete proximal hamstring tendon ruptures who were treated nonoperatively and determine whether there are patient characteristics associated with unfavorable outcomes.

Methods

We retrospectively identified patients aged 18-80 (treated 1/2000-12/2019) who received nonoperative management of complete rupture of the hamstring tendon origin. Participants completed the Lower Extremity Functional Scale (LEFS), as well as Tegner Activity Scale (TAS), and a chart review was conducted to obtain demographic and medical information. Preinjury and postinjury TAS scores were compared, and additional models quantified associations between LEFS scores or changes in TAS scores (ΔTAS) and patient characteristics.

Results

Twenty-eight subjects (mean age: 61.5 ± 1.5 years; 10 male) were included. The mean follow-up time was 5.8 ± 0.8 years (range: 2-22 years). Mean preinjury and postinjury TAS scores were 5.3 ± 0.4 and 3.7 ± 0.4, respectively, with a change of 1.5 ± 0.3 (P = .0002). Degree of tendon retraction showed a negative correlation with LEFS score (P = .003) and ΔTAS (P = .005). Increased follow-up time (P = .015) and body mass index (P = .018) were associated with lower LEFS scores. Moreover, increased follow-up time (P = .002) and younger age at injury (P = .035) were associated with more negative ΔTAS. Patients classified with an American Society of Anesthesiologists (ASA) score of 2 had a median LEFS score that was 20 points (95% CI: 6.9-33.6) lower than those classified as ASA 1 (P = .015).

Conclusions

In this study, we found that increased degree of tendon retraction, increased follow-up time, and younger age at initial injury were associated with significantly worse self-reported functional outcomes.

Level of Evidence

Level IV, prognostic case series.

London International Consensus and Delphi study on hamstring injuries part 1: classification

Muscle injury classification systems for hamstring injuries have evolved to use anatomy and imaging information to aid management and prognosis. However, classification systems lack reliability and validity data and are not specific to individual hamstring muscles, potentially missing parameters vital for sport-specific and activity-specific decision making. A narrative evidence review was conducted followed by a modified Delphi study to build an international consensus on best-practice decision-making for the classification of hamstring injuries. This comprised a digital information gathering survey to a cohort of 46 international hamstring experts (sports medicine physicians, physiotherapists, surgeons, trainers and sports scientists) who were also invited to a face-to-face consensus group meeting in London . Fifteen of these expert clinicians attended to synthesise and refine statements around the management of hamstring injury. A second digital survey was sent to a wider group of 112 international experts. Acceptance was set at 70% agreement. Rounds 1 and 2 survey response rates were 35/46 (76%) and 99/112 (88.4%) of experts responding. Most commonly, experts used the British Athletics Muscle Injury Classification (BAMIC) (58%), Munich (12%) and Barcelona (6%) classification systems for hamstring injury. Issues identified to advance imaging classifications systems include: detailing individual hamstring muscles, establishing optimal use of imaging in diagnosis and classification, and testing the validity and reliability of classification systems. The most used hamstring injury classification system is the BAMIC. This consensus panel recommends hamstring injury classification systems evolve to integrate imaging and clinical parameters around: individual muscles, injury mechanism, sporting demand, functional criteria and patient-reported outcome measures. More research is needed on surgical referral and effectiveness criteria, and validity and reliability of classification systems to guide management.

Effectiveness of Conservative Interventions After Acute Hamstrings Injuries in Athletes: A Living Systematic Review

BACKGROUND

Hamstrings injuries are common in sports and the reinjury risk is high. Despite the extensive literature on hamstrings injuries, the effectiveness of the different conservative (i.e., non-surgical) interventions (i.e., modalities and doses) for the rehabilitation of athletes with acute hamstrings injuries is unclear.

OBJECTIVE

We aimed to compare the effects of different conservative interventions in time to return to sport (TRTS) and/or time to return to full training (TRFT) and reinjury-related outcomes after acute hamstrings injuries in athletes.

DATA SOURCES

We searched CINAHL, Cochrane Library, EMBASE, PubMed, Scopus, SPORTDiscus, and Web of Science databases up to 1 January, 2022, complemented with manual searches, prospective citation tracking, and consultation of external experts.

ELIGIBILITY CRITERIA

The eligibility criteria were multi-arm studies (randomized and non-randomized) that compared conservative treatments of acute hamstrings injuries in athletes.

DATA ANALYSIS

We summarized the characteristics of included studies and conservative interventions and analyzed data for main outcomes (TRTS, TRFT, and rate of reinjuries). The risk of bias was judged using the Cochrane tools. Quality and completeness of reporting of therapeutic exercise programs were appraised with the i-CONTENT tool and the certainty of evidence was judged using the GRADE framework. TRTS and TRFT were analyzed using mean differences and the risk of reinjury with relative risks.

RESULTS

Fourteen studies (12 randomized and two non-randomized) comprising 730 athletes (mostly men with ages between 14 and 49 years) from different sports were included. Nine randomized studies were judged at high risk and three at low risk of bias, and the two non-randomized studies were judged at critical risk of bias. Seven randomized studies compared exercise-based interventions (e.g., L-protocol vs C-protocol), one randomized study compared the use of low-level laser therapy, and three randomized and two non-randomized studies compared injections of platelet-rich plasma to placebo or no injection. These low-level laser therapy and platelet-rich plasma studies complemented their interventions with an exercise program. Only three studies were judged at low overall risk of ineffectiveness (i-CONTENT). No single intervention or combination of interventions proved superior in achieving a faster TRTS/TRFT or reducing the risk of reinjury. Only eccentric lengthening exercises showed limited evidence in allowing a shorter TRFT. The platelet-rich plasma treatment did not consistently reduce the TRFT or have any effect on the risk of new hamstrings injuries. The certainty of evidence was very low for all outcomes and comparisons.

CONCLUSIONS

Available evidence precludes the prioritization of a particular exercise-based intervention for athletes with acute hamstrings injuries, as different exercise-based interventions showed comparable effects on TRTS/TRFT and the risk of reinjuries. Available evidence also does not support the use of platelet-rich plasma or low-level laser therapy in clinical practice. The currently available literature is limited because of the risk of bias, risk of ineffectiveness of exercise protocols (as assessed with the i-CONTENT), and the lack of comparability across existing studies.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42021268499 and OSF ( https://osf.io/3k4u2/ ).

London International Consensus and Delphi study on hamstring injuries part 2: operative management

The key indications for surgical repair of hamstring injuries (HSIs) remain unclear in the literature due to a lack of high-level evidence and expert knowledge. The 2020 London International Hamstring Consensus meeting aimed to highlight clear surgical indications and to create a foundation for future research. A literature review was conducted followed by a modified Delphi process, with an international expert panel. Purposive sampling was used with two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering (round 1) questionnaire was sent to 46 international experts, which comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n=15) comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion of each domain, a series of consensus statements were prepared, debated and refined. A round 2 questionnaire was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. The consensus threshold was set a priori at 70% agreement. Rounds 1 and 2 survey respondents were 35/46 (76%) and 99/112 (88.4%), respectively. The consensus group agreed that the indications for operative intervention included: gapping at the zone of tendinous injury (87.2% agreement) and loss of tension (70.7%); symptomatic displaced bony avulsions (72.8%); and proximal free tendon injuries with functional compromise refractory to non-operative treatment (72.2%). Other important considerations for operative intervention included: the demands of the athlete/patient and the expected functional outcome (87.1%) based on the anatomy of the injury; the risk of functional loss/performance deficit with non-operative management (72.2%); and the capacity to restore anatomy and function (87.1%). Further research is needed to determine whether surgery can reduce the risk of reinjury as consensus was not reached within the whole group (48.2%) but was agreed by surgeons (70%) in the cohort. The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence. These guidelines will help standardise treatment of HSIs, specifically the indications and decision-making for surgical intervention.

Open Proximal Hamstring Repair

Background:

Proximal hamstring ruptures meeting operative criteria may be treated through endoscopic, open, or combined techniques. Open techniques allow for facilitated tendon visualization and mobilization with ease of suture passage.

Indications:

Proximal hamstring repairs are indicated for complete 3 tendon avulsions; partial avulsions with 2 or more tendons involved with more than 2 cm of retraction in young, active patients; and partial avulsion injuries or chronic tears that remain refractory to conservative treatment.

Technique Description:

Through an incision along the gluteal crease, the tendon stump is identified and mobilized. Anchors are placed in the prepped ischium and sutures are passed through the tendon in a running fashion. The tendon is secured to its origin in a docking technique.

Results:

Patients undergoing hamstring repair have high satisfaction rates and patient-reported outcome scores. Competitive and elite athletes have demonstrated reliable return-to-sport rates at presurgical levels.

Discussion:

Open proximal hamstring repairs produce reliable results. The open technique is advantageous for its ease of tendon mobilization, direct visualization, and suture passage.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

At mid- to long-term follow-up after proximal hamstring tendon avulsion; there was greater fatty infiltration, muscle atrophy and strength deficit in the hamstring muscles of the injured leg than in the uninjured leg

BACKGROUND

Proximal hamstring tendon avulsions (PHAs) may be treated nonoperatively or operatively. Little is known about the result of the injury, and its treatment, on the quality and function of the hamstring muscle after healing and rehabilitation. We hypothesized that the injured leg would have greater fatty infiltration and atrophy than the uninjured leg at follow-up and that these findings would correlate to muscle weakness.

METHODS

In a cross-sectional cohort study, 48 patients treated for PHA, either operatively or nonoperatively, were re-examined 2-11 years post-treatment. We measured muscle strength with isokinetic strength tests, and muscle volume and fatty infiltration with MRI. Primary outcomes were hamstring muscle quality, quantified by outlining the cross-sectional area slice-by-slice, and the degree of fatty infiltration estimated using the Goutallier grading method. Secondary outcome was concentric isokinetic hamstring muscle strength measured using BioDex at 60°/sec and tendon attachment assessed on MRI. Comparisons with the outcomes of the uninjured leg were made.

RESULTS

The total hamstring muscle volume was on average reduced by 9% (SD ± 11%, p < 0.001) compared to that of the uninjured leg. Fatty infiltration was significantly more severe in the injured hamstrings than in the uninjured hamstrings (p < 0.001). This was also true when only analyzing operatively treated patients. The reduction in muscle volume and increase in fatty infiltration correlated significantly (r = 0.357, p = 0.013), and there was also a statistically significant correlation with muscle atrophy and reduction in isokinetic strength (r = 494, p < 0.001).

CONCLUSION

PHA injuries result in fatty infiltration and muscle atrophy and the muscle quality impairment correlates with residual muscle weakness.

Proximal Hamstring Ruptures: Treatment, Rehabilitation, and Return to Play

PURPOSE OF REVIEW

To assess the current literature surrounding the treatment and rehabilitation strategies surrounding proximal hamstring rupture injuries, along with comparative return to sport and patient-reported outcomes.

RECENT FINDINGS

A high degree of variability exists in protective and rehabilitation strategies after both operative and non-operative proximal hamstring rupture management. Acceptable outcomes after both operative and non-operative management have been observed but may vary greatly with injury chronicity, severity, and surgical technique. The high complication rates observed after surgical treatment, along with poor functional outcomes that may occur in the setting of non-operative treatment or delayed surgery, highlight the importance of early injury evaluation and careful patient selection. Further high-quality research elucidating clearer indications for early operative management and an optimized and standardized rehabilitation protocols may improve outcomes and return to sport experience and metrics for individuals sustaining proximal hamstring ruptures.

Increased time from injury to surgical repair in patients with proximal hamstring ruptures is associated with worse clinical outcomes at mid-term follow-up

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.

Modified surgical anchor refixation in older patients with acute proximal hamstring rupture: clinical outcome, patient satisfaction and muscle strength

INTRODUCTION

After conventional surgical refixation of the hamstrings after proximal hamstring rupture, patients frequently experience pain while sitting and deficits in hamstring muscle strength of the operated side. To improve these outcomes, we have modified the surgical anchor placement and have carried out a thorough follow-up examination.

MATERIALS AND METHODS

Thirteen older patients (8 female, 5 males) with a median age of 64.2 (range, 52.1-80.4) years were surgically treated for acute proximal hamstring rupture using modified anchor placement and participated in a follow-up assessment at a median of 46.2 (11.2-75.0) months after surgery. Patients completed the Perth Hamstring Assessment Tool (PHAT), quality of life questionnaire (EQ-5D-5L) and the Lower Extremity Functional Scale (LEFS), and rated their satisfaction level on a scale from 0 to 100%. Local tenderness on the ischial tuberosity and maximum passive hip flexion were measured on both limbs. Maximum isokinetic knee flexor muscle strength was measured bilaterally using a dynamometer.

RESULTS

The median (range) PHAT, EQ-5D-5L and LEFS score were 78.8/100 (54.6-99.8), 0.94/1 (0.83-1) and 88.75/100 (61.25-100). The median satisfaction was 100% (90-100%). Only one patient felt discomfort when the ischial tuberosity was palpated. Neither maximum passive hip flexion nor maximum isokinetic flexor muscle strength differed between the operated and non-operated side (P > 0.58). Clinical scores did not correlate with the leg symmetry index of knee flexor muscle strength (Spearman's rho < 0.448, P > 0.125). There were no tendon re-ruptures, or postoperative sciatic radiculopathy, at the time of follow-up.

CONCLUSIONS

The modified extra-anatomical anchor placement resulted in good clinical and functional outcome of surgical repair of acute proximal hamstring rupture. Especially the absence of postoperative pain while sitting and the comparable muscle strength to the contralateral side is promising.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04867746, registered.

A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes

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.

Pudendal Neurapraxia After Proximal Hamstring Repair: A Case Report

CASE

The pudendal nerve lies near the origin of the hamstring muscles, placing it at increased risk of injury during proximal hamstring tendon repair. In this study, we report on a 56-year old man who experienced intermittent unilateral testicular pain after a proximal hamstring tendon repair presumably due to pudendal nerve neurapraxia. At the 1-year follow-up, he continued to experience discomfort in the pudendal nerve distribution but reported significant improvement in symptoms and complete resolution of hamstring pain.

CONCLUSION

Although the risk of pudendal nerve injury during proximal hamstring tendon repair is rare, surgeons should be aware of this potential complication.

Open Repair of Complete Proximal Hamstring Avulsions in Workers’ Compensation Patients

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.

Influence of Fatty Infiltration on Hip Abductor Repair Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Increasing evidence supports surgical intervention for hip abductor tears; however, the influence of fatty infiltration (FI) on outcomes after repair remains uncertain and has been addressed only in small case series.

PURPOSE

To clarify the relationship between FI and surgical outcomes for hip abductor tears.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. FI severity was assessed by Goutallier-Fuchs (G-F) grade. The relationship between FI and improvement in Harris Hip Score (HHS)/modified Harris Hip Score (mHHS) and visual analog scale (VAS) score for pain was examined with mixed-effects metaregression. Outcomes with open and endoscopic techniques were also compared.

RESULTS

A total of 4 studies (206 repairs in 201 patients) were eligible. High-grade FI was associated with significantly less improvement in HHS/mHHS than both no FI (6.761 less; 95% CI, 3.983-11.570; P = .002) and low-grade FI (7.776 less; 95% CI, 2.460-11.062; P < .001) but did not significantly influence VAS score (P > .05). Controlling for FI severity, we found no significant difference in HHS/mHHS improvement between open versus endoscopic repair (P > .05 at each level), but open repair resulted in significantly greater improvement in VAS score for every G-F grade (all P < .005).

CONCLUSION

Surgical intervention for symptomatic hip abductor tendon tears improved outcomes as reflected by change in HHS/mHHS; however, the presence of high-grade FI resulted in less improvement. FI severity did not influence VAS scores for pain. Although no differences were found between open and endoscopic repairs in terms of FI-adjusted improvement in HHS/mHHS, open repairs resulted in significantly greater pain relief at each FI level.

Comparative Analysis of Patient-Reported Outcome Measures for Proximal Hamstring Injuries: A Systematic Review

Background

There is controversy regarding which patient-reported outcome measures (PROMs) should be used for proximal hamstring tendon injuries.

Hypothesis

It was hypothesized that (1) most (>50%) of the questions on the 13 most common PROMs for proximal hamstring injuries would demonstrate extensive overlap in the health domains and question categories and (2) each of the PROMs would contain a variable distribution of questions within each health domain.

Study Design

Systematic review.

Methods

We conducted a literature review through PubMed, Scopus, and CINAHL and identified the 13 most common PROMs for proximal hamstring injuries: Lower Extremity Functional Scale (LEFS), Marx activity rating scale (MARS), 12-item Short Form Survey (SF-12), Tegner activity scale (TAS), Single Assessment Numeric Evaluation (SANE), Perth Hamstring Assessment Tool (PHAT), Proximal Hamstring Injury Questionnaire (PHIQ), modified Harris Hip Score (mHHS), University of California, Los Angeles activity score (UCLA), International Hip Outcome Tool (iHOT-12), Hip Outcome Score (HOS), Sydney Hamstring Origin Rupture Evaluation (SHORE), and Non-Arthritic Hip Score (NAHS). All PROM questions were sorted into 5 health domains (pain, symptoms, activities of daily living, sports, and mindset) and further divided into question categories if they referred to similar tasks or aspects of health. Questions in the same health domain and question category were considered overlapping, and those within a health domain that did not fit into a question category were considered unique. For each PROM, we analyzed the distribution of questions within particular health domains and question categories as well as the amount of overlapping and unique questions.

Results

Of the 165 questions evaluated, 116 (70.3%) were overlapping, and 49 (29.7%) were unique. The SF-12 contained the most unique questions (9/12 [75.0%]). The MARS, TAS, SANE, and UCLA had 0 unique questions. The PHIQ and iHOT-12 contained questions in all 5 health domains. The PHAT, SHORE, and NAHS contained questions in every health domain except mindset. The LEFS, MARS, SF-12, TAS, mHHS, SANE, UCLA, and HOS contained questions in ≤3 health domains.

Conclusion

The evaluated PROMs had a high degree of overlapping questions (≥50%) and demonstrated a statistically significant variance in the distribution of questions within each health domain.

No Difference in Complications Between Elbow Ulnar Collateral Ligament Reconstruction With the Docking and Modified Jobe Techniques: A Systematic Review and Meta-analysis

BACKGROUND

The most commonly used techniques for elbow ulnar collateral ligament reconstruction (UCLR) are the docking and modified Jobe figure-of-8 techniques. Previous literature has suggested that UCLR with the docking technique is associated with fewer complications; however, these studies included results from the original classic Jobe technique without controlling for the effects of flexor pronator mass (FPM) detachment and routine submuscular ulnar nerve transposition (UNT).

PURPOSE/HYPOTHESIS

This study sought to compare the rates of complications and subsequent unplanned surgical procedures between the docking and figure-of-8 techniques. We hypothesized that there would be no significant difference in the rates of complications or subsequent unplanned surgical procedures between the techniques when the FPM was preserved and no routine submuscular UNT was performed.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A series of mixed-effects multivariate metaregression models were implemented using the restricted maximum likelihood method. Complications and subsequent unplanned surgical procedures were modeled as Freeman-Tukey transformed incidence rates for variance stabilization, and nerve-specific complications were assessed as the Freeman-Tukey transformed proportion of cases, with back-transformation to estimate summary effects.

RESULTS

There were 19 studies eligible for qualitative analysis, consisting of 1788 cases of UCLR (303 docking, 1485 figure-of-8), 18 of which were suitable for quantitative analysis (1769 cases; 291 docking, 1478 figure-of-8). A total of 338 complications were reported (17 for docking, 321 for figure-of-8), the majority of which were nerve related. Additionally, a total of 75 subsequent unplanned surgical procedures were related to the index UCLR procedure. There was no significant difference in the rate of complications (P = .146) or proportion of cases with nerve-specific complications (P = .127) between the docking and figure-of-8 techniques when controlling for FPM preservation versus detachment with submuscular UNT. FPM detachment with submuscular UNT was independently associated with a significantly higher proportion of postoperative nerve-related complications (P = .004). There was also no significant difference in the rates of subsequent unplanned surgical procedures between the docking and figure-of-8 techniques (P = .961), although FPM detachment with routine submuscular UNT was independently associated with a significantly higher incidence of subsequent unplanned surgical procedures.

CONCLUSION

The results of this study demonstrate no significant difference in the rates of complications or subsequent unplanned surgical procedures between the figure-of-8 and docking techniques for UCLR when controlling for FPM preservation versus detachment with submuscular UNT. With modern muscle-sparing approaches and avoiding submuscular UNT, the modified Jobe technique does not differ significantly from the docking technique in terms of complication rates, proportions of cases with nerve-specific complications, or rates of subsequent unplanned surgical procedures.

Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review

BACKGROUND

Latissimus dorsi transfer (LDT) and pectoralis major transfer (PMT) were developed to treat an irreparable subscapularis tendon tear (ISScT); however, the difference in their outcomes remains unclear.

PURPOSE

To systematically review and compare the outcomes of LDT and PMT for ISScT.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed through a comprehensive search of Embase, PubMed, and the Cochrane Library. Studies of LDT or PMT were included according to the inclusion and exclusion criteria. The primary outcome was the Constant-Murley score (CMS) at the final follow-up. Secondary outcomes included the subjective shoulder value (SSV), visual analog scale (VAS) score for pain, active shoulder range of motion, and the belly-press and lift-off tests. Postoperative failure and complication rates were the safety outcome measures. Outcomes were summarized into the LDT and PMT groups, and results were compared statistically (P < .05).

RESULTS

Twelve studies were included in this review: 184 shoulders from 9 studies for the PMT group and 85 shoulders from 3 studies for the LDT group. For the PMT and LDT groups, the mean ages were 58.9 and 55.1 years, respectively, and the mean follow-up was 66.9 and 17.4 months, respectively. Overall, the LDT and PMT groups improved in the primary outcome (CMS) and secondary outcomes (SSV, VAS, ROM, and belly-press and lift-off tests), with low rates of failure and complication. When compared with the PMT group, the LDT group showed more significant improvements in CMS (35.2 vs 24.7; P < .001), active forward flexion (44.3° vs 14.7°; P < .001), abduction (35.0° vs 17.6°; P < .002), and positive belly-press test rate (45% vs 27%; P < .001). No statistically significant difference was seen between the groups in postoperative failure rate, complication rate, mean improvement of active internal rotation, VAS, or SSV.

CONCLUSION

In general, LDT showed significantly better clinical outcomes postoperatively than did PMT. The available fair-quality evidence suggested that LDT might be a better choice for ISScT. Further evaluations on the relative benefits of the 2 surgical approaches are required, with more high-quality randomized controlled studies.

Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial.

PURPOSE/HYPOTHESIS

We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms "hip,""arthroscopy,""capsule,""capsular,""repair," and "closure" were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living (ADL), and HOS-Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes.

RESULTS

Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033).

CONCLUSION

This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.

Outcomes following surgical management of proximal hamstring tendon avulsions

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.

Endoscopic Repair of Proximal Hamstring Insertion With Sciatic Nerve Neurolysis

Open surgical repair of proximal hamstring avulsions has been the standard of care for a long time, when surgery is needed. Endoscopic repair is a relatively new surgery, and its popularity increased in the last 10 years. This technique allows the surgeon an anatomic repair and a safe sciatic nerve exploration with small incisions and dissection. As a new technique, it has its limitations, mostly in chronic retracted tears, and long follow-up series are needed to assess long-term outcomes. We present an endoscopic repair of a right proximal hamstring avulsion performed along with a sciatic nerve neurolysis.

Acute Proximal Hamstring Tears Can be Defined Using an Imaged-Based Classification

Purpose

To develop a clinically meaningful proximal hamstring tear classification system and to present outcome data for defined subtypes.

Methods

Retrospective review was undertaken of patients diagnosed with proximal hamstring tears at a single institution from 2012 to 2019. Images were reviewed by an orthopedic surgeon and musculoskeletal radiologist. Tears were classified as Type 1: partial with subtypes (1A, 1 cm or mild complete tear; 1B, 1-2 cm or full tear with <2 cm retraction), Type 2: complete single-tendon tears with subtypes (2c conjoint tendon only; 2s semimembranosus tendon only); or Type 3: complete tears with >2 cm retraction. Demographics, patient-reported outcome measures including Hip Outcome Score, Activities of Daily Living Subscore (HOS-ADL) and patient satisfaction were evaluated. A poor outcome was defined as HOS-ADL < 80%, and the patient acceptable symptom state (PASS) was defined as HOS-ADL 89.7%.

Results

At a mean follow-up of 38.6 (range: 12-94) months for 114 patients, distributions were as follows: 18.4% Type 1A, 19.2% Type 1B, 7.8% Type 2c, 3.5% Type 2s, and 50.9% Type 3. Intra-observer and inter-observer reliability had a mean Kappa of 0.985 (95% CI: .956, 1.01) and .905 (95% CI: .895 .915). 66 patients underwent surgery, with 68.97% of them being Type 3. The mean HOS-ADL and PASS rate were higher for operatively treated patients (95%, 93.4%) than for nonoperatively treated patients (81.86%, 44.7%). There were significantly more patients satisfied in the surgery group in both Type 1 and Type 3 tears (P = .046 and P = .049). Body mass index was a significant predictor of a poor outcome in Type 3 tears (P = .039). History of corticosteroid or PRP injection, smoking, and diabetes were not significant predictors of a poor outcome.

Conclusion

We present an MRI-based classification system for proximal hamstring injuries with both excellent intra-observer and inter-observer reliability. Outcome measures were improved in patients who underwent surgery.

Level of Evidence

IV, cohort study: diagnostic case series.

Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis

BACKGROUND AND HYPOTHESIS

Ruptures of the distal biceps tendon are most commonly due to traumatic eccentric loading in the middle-aged male population and can result in functional deficits. Although surgical repair has been demonstrated to result in excellent outcomes, there are few comparative studies that show clear functional benefits over nonoperative management. The aim of this systematic review and meta-analysis is to compare the functional outcomes of operative and nonoperative management for these injuries. We hypothesized that operative treatment would be associated with significantly superior outcomes.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed using MEDLINE, SPORTDiscus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Registry of Controlled Trials), Embase, and Web of Science databases. Outcomes of interest included range of motion (ROM), strength, endurance, and patient-reported outcomes including Disabilities of the Arm, Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) for pain scores. Summary effect estimates of the mean difference between operative and nonoperative management for each outcome were estimated in mixed effects models.

RESULTS

Of an initially identified 6478 studies, 62 reported outcomes for a total of 2481 cases (2402 operative, 79 nonoperative), with an overall average age of 47.4 years (47.3 for operative, 50.3 for nonoperative). There were 2273 (98.5%) males and 35 (1.5%) females among operative cases, whereas all 79 (100%) nonoperative cases were males. Operative management was associated with a significantly higher flexion strength (mean difference, 25.67%; P < .0001), supination strength (mean difference, 27.56%; P < .0001), flexion endurance (mean difference, 11.12%; P = .0268), and supination endurance (mean difference, 33.86%; P < .0001). Patient-reported DASH and MEPS were also significantly superior in patients who underwent surgical repair, with mean differences of -7.81 (P < .0001) and 7.41 (P = .0224), respectively. Comparative analyses for ROM and pain VAS were not performed because of limited reporting in the literature for nonoperative management.

CONCLUSION

This study represents the first systematic review and meta-analysis to compare functional and clinical outcomes following operative and nonoperative treatment of distal biceps tendon ruptures. Operative treatment resulted in superior elbow and forearm strength and endurance, as well as superior DASH and MEPS.

Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model

OBJECTIVE

To prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions.

METHODS

Patients with an MRI-confirmed proximal hamstring tendon avulsion were included. Operative or non-operative treatment was selected by a shared decision-making process. The primary outcome was the Perth Hamstring Assessment Tool (PHAT) score. Secondary outcome scores were Proximal Hamstring Injury Questionnaire, EQ-5D-3L, Tegner Activity Scale, return to sports, hamstring flexibility, isometric hamstring strength and MRI findings including proximal continuity.

RESULTS

Twenty-six operative and 33 non-operative patients with a median age of 51 (IQR: 37-57) and 49 (IQR: 45-56) years were included. Median time between injury and initial visit was 12 (IQR 6-19) days for operative and 21 (IQR 12-48) days for non-operative patients (p=0.004). Baseline PHAT scores were significantly lower in the operative group (32±16 vs 45±17, p=0.003). There was no difference in mean PHAT score between groups at 1 year follow-up (80±19 vs 80±17, p=0.97). Mean PHAT score improved by 47 (95% CI 39 to 55, p<0.001) after operative and 34 (95% CI 27 to 41, p<0.001) after non-operative treatment. There were no relevant differences in secondary clinical outcome measures. Proximal continuity on MRI was present in 20 (95%, 1 recurrence) operative and 14 (52%, no recurrences) non-operative patients (p=0.008).

CONCLUSION

In a shared decision-making model of care, both operative and non-operative treatment of proximal hamstring tendon avulsions resulted in comparable clinical outcome at 1-year follow-up. Operative patients had lower pretreatment PHAT scores but improved substantially to reach comparable PHAT scores as non-operative patients. We recommend using this shared decision model of care until evidence-based indications in favour of either treatment option are available from high-level clinical trials.

Routine diagnostic arthroscopy with elbow ulnar collateral ligament reconstruction does not reduce the need for future valgus extension overload-related surgeries: a systematic review and meta-analysis

BACKGROUND

Valgus extension overload syndrome (VEOS) most commonly affects overhead athletes and consists of a constellation of conditions involving the medial, posterior, and lateral elbow, with the most widely discussed being ulnar collateral ligament (UCL) injuries. Many athletes with UCL tears also have findings consistent with other VEOS conditions, though these are not consistently symptomatic. Given the high rate of concomitant pathology, many authors have recommended performing arthroscopy at the time of UCL reconstruction (UCLR) to diagnose and address concomitant VEOS pathology; however, it is not known if this practice actually leads to a reduction in subsequent surgeries for VEOS conditions following index UCLR. The purpose of this systematic review and meta-analysis was to determine if performing routine diagnostic arthroscopy (RDA) in patients undergoing UCLR was associated with a lower incidence of future VEOS-related surgery.

METHODS

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with the primary outcome of interest being the likelihood of needing future surgery to address VEOS conditions with or without RDA at the time of index UCLR. The proportion and incidence rate of subsequent VEOS-related surgeries following UCLR with and without RDA were compared in mixed effects models.

RESULTS

There were 25 eligible studies from an initial 1335 systematically identified articles, with results for 2118 UCLR cases. Among these, there were a total of 94 reported VEOS-related surgeries. The proportion of subsequent VEOS-related surgeries was lower when UCLR was performed with RDA (0.40%, 95% CI 0.00%-3.51%) than without (1.16%, 95% CI 0.03%-3.25%), but the difference was not significant (P = .584). The incidence rate of VEOS-related surgeries was 0.16 (95% CI 0.00-0.95) per 100 person-years with RDA and 0.14 (95% CI 0.00-0.55) per 100 person-years without RDA (P = .942).

CONCLUSION

RDA preceding UCLR does not significantly reduce the proportion or rate of subsequent surgery for other VEOS conditions. There has been a decrease in RDA utilization with UCLR over time for athletes with torn/incompetent UCLs but otherwise no known symptomatic VEOS conditions, and this trend appears to be justified based on these findings.

Predictive Factors Influencing Functional Results After Proximal Hamstring Tendon Avulsion Surgery: A Patient-Reported Outcome Study After 227 Operations From a Single Center

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.

Endoscopic Proximal Hamstring Repair Is Safe and Efficacious With High Patient Satisfaction at a Minimum of 2-Year Follow-Up

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.