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Mendel T, Steinke M, Schenk P, Migliorini F, Schütte V, Reisberg A, Kobbe P, Heinecke M. Conservative management of proximal hamstring avulsion: A clinical study. J Orthop 2024; 55:74-79. [PMID: 38665987 PMCID: PMC11039336 DOI: 10.1016/j.jor.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction The management of proximal hamstring tear (PHT) is debated and consensus regarding recommended measures and individual treatment regimens is lacking. The present investigation evaluated the efficacy of a conservative management of partial and complete PHT. Methods The present observational study was conducted following the STROBE statement. In June 2018 the medical databases of the BG Klinikum Bergmannstrost Halle, Germany were accessed. All the patients with PHT were retrieved. The outcomes of interest were to evaluate the clinical examination, PROMs, imaging, and isokinetic muscle strength at the baseline and last follow-up. Results 31 patients were enrolled in the present study. Nine patients (29 % (9 of 31) described local pain at the ischial tuberosity in sitting situations and also in manual palpation. A persistent gap in the tendon string beneath the tuberosity in manual palpation was reported in 25.8 % (8 of 31). The mean VAS at the last follow-up was 2.3 ± 2.3. The mean LEFS score was 50.9 ± 18.8.Control MRI at follow-up showed scarring restitution in the proximal tendon in all patients in the partial tear group. In the complete tear group, a persisting defect state of the proximal tendon course was found in 45 % (9 of 20). The injured side achieved 81.5 ± 22.2 % of the force of the uninjured side, measured in the flexion movement at 60°/s. At an angular velocity of 240°/s, 83.2 ± 26.3 % of the force of the uninjured side was achieved. Conclusion According to the main findings of the present study, conservative therapy of PTH tears is associated with good clinical outcomes. High-quality investigations are required to establish the proper therapeutic algorithm and advantages of conservative management compared to a surgical approach. Level of evidence Level III.
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Affiliation(s)
- Thomas Mendel
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
- University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Trauma Surgery, Halle, Germany
| | - Mark Steinke
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
| | - Philipp Schenk
- BG Hospital Bergmannstrost Halle, Research Executive Department, Halle, Germany
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100 Bolzano, Italy
| | - Vincent Schütte
- Gesundheitszentrum Halle-Neustadt, Center Orthopaedic Surgery, Halle, Germany
| | - André Reisberg
- BG Hospital Bergmannstrost Halle, Department of Radiology and Neuroradiology, Halle, Germany
| | - Philipp Kobbe
- BG Hospital Bergmannstrost Halle, Department of Trauma and Reconstructive Surgery, Halle, Germany
- University Hospital Halle, Martin Luther University Halle-Wittenberg, Department of Trauma Surgery, Halle, Germany
| | - Markus Heinecke
- Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department, Eisenberg, Germany
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Mauch M, Nüesch C, Bühl L, Chocholac T, Mündermann A, Stoffel K. Reconstruction of proximal hamstring ruptures restores joint biomechanics during various walking conditions. Hip Int 2024; 34:516-523. [PMID: 38372148 DOI: 10.1177/11207000241230282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
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).
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Affiliation(s)
- Marlene Mauch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Corina Nüesch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Spine Surgery, University Hospital Basel, Basel, Switzerland
| | - Linda Bühl
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Tomas Chocholac
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
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Lefèvre N, Coughlan A, Valentin E, Sezer HB, Bohu Y, Moussa MK, Hardy A. Magnetic resonance imaging should be the first-line imaging modality for investigating suspected proximal hamstring avulsion injuries. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38769849 DOI: 10.1002/ksa.12258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/28/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE The purpose of the study was to evaluate how the initial diagnostic tool used-specifically ultrasound (US) or magnetic resonance imaging (MRI)-for diagnosing proximal hamstring avulsion injury affects the delay before surgery and, secondarily, the outcomes of these injuries. METHODS This was a retrospective analysis of prospectively collected data (2012-2020). It targeted patients primarily treated for proximal hamstring avulsion injury. It included all patients with a preoperative US and/or MRI. Patients were divided into two groups based on the initial diagnostic tool used (US-first vs. MRI-first groups). The primary outcomes measure was the time from initial injury to surgical intervention (surgical delay). The secondary outcomes were the Parisien Hamstring Avulsion Score, as well as the activity level as measured by the University of California, Los Angeles (UCLA) Activity Scale and Tegner Activity Scale. RESULTS The analysis included 392 patients with a mean age of 43.8 ± 13.6 years for the MRI-first group and 47.6 ± 12.0 years for US-first group. Patients in the MRI-first group had a significantly shorter median time from injury to surgery of 20.0 days (interquartile range [IQR]: 11.0-61.0) compared to 30 days (IQR: 18-74) in the US-first group. At the final follow-up (4.2 ± 2.2 years for the MRI-first group and 5.1 ± 1.9 years for the US-first group), the MRI-first group had significantly higher mean Tegner Activity Scale and UCLA scores than the US-first group: The Tegner Activity Scale was median 5 (IQR: 3-7) for the MRI-first group versus median 4 (IQR: 2-6) for the US-first group (p < 0.05). The UCLA scores were 7.9 ± 2.4 for the MRI-first group compared to 7.3 ± 2.4 for the US-first group (p < 0.05). This difference was more pronounced when comparing the MRI-first group with the patient-false negative initial ultrasound. No difference was found regarding the Parisien Hamstring Avulsion Score. CONCLUSION MRI as the initial diagnostic tool for proximal hamstring avulsion injury is associated with a shorter time to surgery and better postoperative outcomes in Tegner Activity Scale and UCLA scores, compared to US. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Adam Coughlan
- Clinique du sport, Paris, France
- Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | | | | | | | - Mohamad K Moussa
- Clinique du sport, Paris, France
- Groupe Hospitalier Sélesta-Obernai, Sélesta, France
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Lefèvre N, Moussa MK, Valentin E, Meyer A, Bohu Y, Gerometta A, Khiami F, Grimaud O, Khalaf Z, Hardy A. Predictors of Early Return to Sport After Surgical Repair of Proximal Hamstring Complex Injuries in Professional Athletes: A Prospective Study. Am J Sports Med 2024; 52:1005-1013. [PMID: 38353018 PMCID: PMC10943609 DOI: 10.1177/03635465231225486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/04/2023] [Indexed: 03/02/2024]
Abstract
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).
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Wyatt PB, Ho TD, Hopper HM, Satalich JR, O’Neill CN, Cyrus J, Vap AR, O’Connell R. Systematic Review of Bracing After Proximal Hamstring Repair. Orthop J Sports Med 2024; 12:23259671241230045. [PMID: 38405008 PMCID: PMC10894551 DOI: 10.1177/23259671241230045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 02/27/2024] Open
Abstract
Background Traditionally, postoperative rehabilitation protocols after proximal hamstring repair (PHR) for avulsion of the proximal hamstring tendon from its ischial insertion recommend bracing the hip and/or knee to protect the fixation. However, because of the cumbersome nature of these orthoses, recent studies have investigated outcomes in patients with postoperative protocols that do not include any form of postoperative bracing. Purpose To synthesize the current body of evidence concerning bracing versus nonbracing postoperative management of PHR. Study Design Systematic review; level of evidence, 4. Methods Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a thorough search of the PubMed/Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase (OVID) databases on March 24, 2023. We analyzed complication rates, reoperation rates, patient satisfaction, return to sport, and patient-reported outcomes of studies that used postoperative bracing versus studies that used no postoperative bracing after PHR with at least 12 months of follow-up. A total of 308 articles were identified after initial search. Results In total, 25 studies were included in this review: 18 studies (905 patients) on bracing and 7 studies (291 patients) on nonbracing after PHR. The overall complication rate in the braced patients was found to be 10.9%, compared with 12.7% in nonbraced patients. The rate of reoperation due to retear of the proximal hamstring was found to be 0.05% in braced patients and 3.1% in nonbraced patients. Patient-reported outcome measures were found to be higher at the final follow-up in braced versus nonbraced patients, and patient satisfaction was found to be 94.7% in braced studies compared with 88.9% in nonbraced studies. The rate of 12-month return to sport in athletic patients was 88.4% with bracing and 82.7% without bracing. Conclusion The findings of this review demonstrated lower complication and reoperation rates, higher patient-reported outcome scores, higher patient satisfaction, and a higher rate of return to sport in braced patients compared with nonbraced patients.
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Affiliation(s)
- Phillip B. Wyatt
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Tiffany D. Ho
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Haleigh M. Hopper
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - James R. Satalich
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Conor N. O’Neill
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - John Cyrus
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Alexander R. Vap
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Robert O’Connell
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Fenn TW, Timmermann AP, Brusalis CM, Kaplan DJ, Ebersole JW, Nho SJ. Clinical Outcomes After Open and Endoscopic Repair of Proximal Hamstring Tendon Tears at a Minimum Follow-up of 5 Years. Orthop J Sports Med 2023; 11:23259671231209054. [PMID: 38021310 PMCID: PMC10668568 DOI: 10.1177/23259671231209054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 06/07/2023] [Indexed: 12/01/2023] Open
Abstract
Background Current evidence supports favorable short-term clinical outcomes with few complications after surgical management of proximal hamstring injuries; however, the durability of clinical benefits beyond approximately 2 years after surgery is unknown. Purpose To evaluate patient-reported clinical outcomes and complication rates associated with open and endoscopic repair of proximal hamstring tears at minimum 5-year follow-up. Study Design Case series; Level of evidence, 4. Methods A single-surgeon registry of patients was queried between October 1, 2014, and December 31, 2017, to identify patients who underwent open or endoscopic repair of a proximal hamstring tear. Patients who reported minimum 5-year follow-up data were included. Multiple patient-reported outcome measures, including the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales, 12-Item International Hip Outcome Tool (iHOT-12), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain domains, along with surgical complications, were analyzed. Results Among 35 eligible patients (65.7% female; mean age, 52.3 ± 8.4 years), 24 had full-thickness tears and 11 had partial-thickness tears. There were 23 open repairs and 12 endoscopic repairs. Mean duration from symptom onset to surgical intervention was 37.9 weeks (range, 1.3-306.9 weeks). At a mean follow-up of 69.0 months (range, 60.0-95.0 months), mean postoperative outcome scores were as follows: HOS-ADL, 86.8 ± 12.7; HOS-SS, 83.1 ± 19.5; iHOT-12, 86.3 ± 14.9; PROMIS-PF, 50.0 ± 11.8; and PROMIS-Pain, 50.2 ± 7.9. Regarding complications, 28.6% of patients had a complication including persistent peri-incisional numbness (11.4%), wound infection (11.4%), postoperative neuropathy (8.6%), and revision surgery (2.9%). Conclusion Both open and endoscopic surgical techniques for repair of proximal hamstring injuries produced favorable patient-reported clinical outcomes at a minimum 5-year follow-up.
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Affiliation(s)
- Thomas W. Fenn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Anne P. Timmermann
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Christopher M. Brusalis
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
- Department of Orthopaedic Surgery, Division of Sports Medicine, NYU Langone Orthopaedic Hospital, New York, NY, USA
| | - Daniel J. Kaplan
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
- Department of Orthpaedic Surgery, Division of Sports Medicine, Hospital for Special Surgery, New York, NY, USA
| | - John W. Ebersole
- Department of Diagnostic Radiology, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J. Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
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Lawson JJ, Abraham EA, Imbergamo CM, Sequeira SB, Dreese JC, Gould HP. Systematic Review of Complications Associated With Proximal Hamstring Tendon Repair. Orthop J Sports Med 2023; 11:23259671231199092. [PMID: 37781641 PMCID: PMC10536870 DOI: 10.1177/23259671231199092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 10/03/2023] Open
Abstract
Background Although several complications of proximal hamstring tendon ruptures have been reported in the literature, few studies have comprehensively analyzed the complication profile of proximal hamstring tendon repair. Purpose To identify the overall rate of complications following proximal hamstring tendon repair and to differentiate these complications into categories. Study Design Systematic review; Level of evidence, 4. Methods Included in this review were studies that examined surgical repair of proximal hamstring tendon ruptures; all studies were in English and had an evidence level of 4 or higher. No restrictions were made regarding publication date or methodological quality. Data regarding complications were extracted to calculate the overall complication rate as well as the rate of major and minor complications. A quantitative data synthesis was conducted using the chi-square test to compare the proportion of patients who experienced complications with the endoscopic versus open approach. Results A total of 43 articles including 2833 proximal hamstring tendon repairs were identified. The overall postoperative complication rate was 15.3% (n = 433). The rate of major complications was 4.6%, including a 1.7% rate of sciatic nerve injury, 0.8% rate of venous thromboembolism, 0.8% reoperation rate, 0.8% rerupture rate, and 0.4% rate of deep infection. Minor complications included a 2.4% rate of posterior femoral cutaneous nerve injury, 2.3% rate of persistent hamstring myopathy, 2.2% rate of persistent sitting pain, 1.8% rate of peri-incisional numbness, 1.1% rate of superficial infection, and 0.8% rate of hematoma/seroma. Conclusion Proximal hamstring tendon repair is associated with an overall complication rate of 15.3%, including a 4.6% rate of major complications.
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Affiliation(s)
- Jonathan J. Lawson
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Eliza A. Abraham
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Casey M. Imbergamo
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Sean B. Sequeira
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - James C. Dreese
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Heath P. Gould
- MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, Maryland, USA
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deMeireles AJ, Kent RN, Bedi A, Crawford EA. Degree of Tendon Retraction and Younger Age Are Associated With Functional Decline Following Nonoperative Management of Complete Proximal Hamstring Ruptures. Arthrosc Sports Med Rehabil 2023; 5:e389-e394. [PMID: 37101885 PMCID: PMC10123420 DOI: 10.1016/j.asmr.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/04/2023] [Indexed: 02/19/2023] Open
Abstract
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.
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Affiliation(s)
- Alirio J. deMeireles
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Robert N. Kent
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Asheesh Bedi
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Eileen A. Crawford
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
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Pihl E, Skorpil M, Sköldenberg O, Hedbeck CJ, Jonsson KB. 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. J Orthop Surg Res 2023; 18:114. [PMID: 36797740 PMCID: PMC9933258 DOI: 10.1186/s13018-023-03582-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/06/2023] [Indexed: 02/18/2023] Open
Abstract
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.
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Affiliation(s)
- Elsa Pihl
- Unit of Orthopeadics, Department of Clinical Sciences at Danderyds Hospital, Karolinska Institutet, Ortopedmottagningen Danderyds Sjukhus, 182 88, Stockholm, Sweden. .,Danderyd University Hospital Corp, Stockholm, Sweden.
| | - Mikael Skorpil
- grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Olof Sköldenberg
- grid.4714.60000 0004 1937 0626Unit of Orthopeadics, Department of Clinical Sciences at Danderyds Hospital, Karolinska Institutet, Ortopedmottagningen Danderyds Sjukhus, 182 88 Stockholm, Sweden ,grid.412154.70000 0004 0636 5158Danderyd University Hospital Corp, Stockholm, Sweden
| | - Carl Johan Hedbeck
- grid.4714.60000 0004 1937 0626Unit of Orthopeadics, Department of Clinical Sciences at Danderyds Hospital, Karolinska Institutet, Ortopedmottagningen Danderyds Sjukhus, 182 88 Stockholm, Sweden ,grid.412154.70000 0004 0636 5158Danderyd University Hospital Corp, Stockholm, Sweden
| | - Kenneth B. Jonsson
- grid.412354.50000 0001 2351 3333Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Looney AM, Day HK, Comfort SM, Donaldson ST, Cohen SB. Proximal Hamstring Ruptures: Treatment, Rehabilitation, and Return to Play. Curr Rev Musculoskelet Med 2023; 16:103-113. [PMID: 36757628 PMCID: PMC9943812 DOI: 10.1007/s12178-023-09821-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/10/2023]
Abstract
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.
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Affiliation(s)
- Austin M. Looney
- The Rothman Orthopaedic Institute, Sports Medicine Division, 925 Chestnut St Fl 5, Philadelphia, PA 19107-4216 USA
| | - Hannah K. Day
- School of Medicine, Georgetown University, Washington, DC USA
| | | | | | - Steven B. Cohen
- The Rothman Orthopaedic Institute, Sports Medicine Division, 925 Chestnut St Fl 5, Philadelphia, PA 19107-4216 USA
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11
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Kanakamedala AC, Mojica ES, Hurley ET, Gonzalez-Lomas G, Jazrawi LM, Youm T. Increased time from injury to surgical repair in patients with proximal hamstring ruptures is associated with worse clinical outcomes at mid-term follow-up. Arch Orthop Trauma Surg 2023; 143:951-957. [PMID: 35316390 DOI: 10.1007/s00402-022-04421-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/10/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Prior studies of hamstring tendon tears have reported varied findings on whether increased delay from injury to surgery is associated with worse outcomes. The purpose of this study was to determine whether increased time from injury to surgical repair is associated with worse clinical outcomes in patients with proximal hamstring ruptures. MATERIALS AND METHODS Patients who underwent surgical repair of a proximal hamstring rupture from 2010 to 2019 were followed for a minimum of 24 months from surgery. A cutoff of 6 weeks from injury to the time of surgery was used to distinguish between acute and chronic ruptures. All patients completed patient-reported outcome measures (PROs) at the final follow-up. Multiple factors were analyzed for their effects on PROs including time to surgery, amount of tendon retraction, and demographics such as sex and age. RESULTS Complete data sets were obtained for 38 patients at a mean follow-up of 4.9 years. All data is reported as a mean ± standard deviation. Patients who underwent acute repair of proximal hamstring ruptures had significantly greater Perth Hamstring Assessment Tool (PHAT) scores than those who underwent chronic repair (76.9 ± 18.8 vs 60.6 ± 18.2, p = 0.01). Increased time to surgery was significantly correlated with worse PHAT scores (ρ = - 0.47, p = 0.003). There was no difference in PROs based on the amount of tendon retraction, number of tendons torn, sex, smoking status, or BMI. CONCLUSIONS This study found that acute repair performed within 6 weeks of injury appears to yield improved PROs compared to chronic repair. These data highlight the importance of timely and accurate diagnosis of proximal hamstring ruptures and early operative intervention for surgical candidates.
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Affiliation(s)
- Ajay C Kanakamedala
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States.
| | - Edward S Mojica
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
| | - Eoghan T Hurley
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
| | - Guillem Gonzalez-Lomas
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
| | - Thomas Youm
- Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th st, 14th floor, New York, NY, 10003, United States
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12
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Modified surgical anchor refixation in older patients with acute proximal hamstring rupture: clinical outcome, patient satisfaction and muscle strength. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04752-3. [PMID: 36622424 PMCID: PMC9828366 DOI: 10.1007/s00402-022-04752-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/28/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION After conventional surgical refixation of the hamstrings after proximal hamstring rupture, patients frequently experience pain while sitting and deficits in hamstring muscle strength of the operated side. To improve these outcomes, we have modified the surgical anchor placement and have carried out a thorough follow-up examination. MATERIALS AND METHODS Thirteen older patients (8 female, 5 males) with a median age of 64.2 (range, 52.1-80.4) years were surgically treated for acute proximal hamstring rupture using modified anchor placement and participated in a follow-up assessment at a median of 46.2 (11.2-75.0) months after surgery. Patients completed the Perth Hamstring Assessment Tool (PHAT), quality of life questionnaire (EQ-5D-5L) and the Lower Extremity Functional Scale (LEFS), and rated their satisfaction level on a scale from 0 to 100%. Local tenderness on the ischial tuberosity and maximum passive hip flexion were measured on both limbs. Maximum isokinetic knee flexor muscle strength was measured bilaterally using a dynamometer. RESULTS The median (range) PHAT, EQ-5D-5L and LEFS score were 78.8/100 (54.6-99.8), 0.94/1 (0.83-1) and 88.75/100 (61.25-100). The median satisfaction was 100% (90-100%). Only one patient felt discomfort when the ischial tuberosity was palpated. Neither maximum passive hip flexion nor maximum isokinetic flexor muscle strength differed between the operated and non-operated side (P > 0.58). Clinical scores did not correlate with the leg symmetry index of knee flexor muscle strength (Spearman's rho < 0.448, P > 0.125). There were no tendon re-ruptures, or postoperative sciatic radiculopathy, at the time of follow-up. CONCLUSIONS The modified extra-anatomical anchor placement resulted in good clinical and functional outcome of surgical repair of acute proximal hamstring rupture. Especially the absence of postoperative pain while sitting and the comparable muscle strength to the contralateral side is promising. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04867746, registered.
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13
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Jokela A, Stenroos A, Kosola J, Valle X, Lempainen L. A systematic review of surgical intervention in the treatment of hamstring tendon ruptures: current evidence on the impact on patient outcomes. Ann Med 2022; 54:978-988. [PMID: 35416097 PMCID: PMC9009934 DOI: 10.1080/07853890.2022.2059560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Hamstring injuries are among the most common muscle injuries. They have been reported in many different sports, such as running, soccer, track and field, rugby, and waterskiing. However, they are also present among the general population. Most hamstring injuries are mild strains, but also moderate and severe injuries occur. Hamstring injuries usually occur in rapid movements involving eccentric demands of the posterior thigh. Sprinting has been found to mainly affect the isolated proximal biceps femoris, whereas stretching-type injuries most often involve an isolated proximal injury of the semimembranosus muscle. The main cause of severe 2- or 3-tendon avulsion is a rapid forceful hip flexion with the ipsilateral knee extended. Most hamstring injuries are treated non-surgically with good results. However, there are also clear indications for surgical treatment, such as severe 2- or 3-tendon avulsions. In athletes, more aggressive recommendations concerning surgical treatment can be found. For a professional athlete, a proximal isolated tendon avulsion with clear retraction should be treated operatively regardless of the injured tendon. Surgical treatment has been found to have good results in severe injuries, especially if the avulsion injury is repaired in acute phase. In chronic hamstring injuries and recurring ruptures, the anatomical apposition of the retracted muscles is more difficult to be achieved. This review article analyses the outcomes of surgical treatment of hamstring ruptures. The present study confirms the previous knowledge that surgical treatment of hamstring tendon injuries causes good results with high satisfaction rates, both in complete and partial avulsions. Early surgical repair leads to better functional results with lower complication rates, especially in complete avulsions.KEY MESSAGEsSurgical treatment of hamstring tendon ruptures leads to high satisfaction and return to sport rates.Both complete and partial hamstring tendon ruptures have better results after acute surgical repair, when compared to cases treated surgically later.Athletes with hamstring tendon ruptures should be treated more aggressively with operative methods.
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Affiliation(s)
- Aleksi Jokela
- Faculty of Medicine, University of Turku, Turku, Finland
| | - Antti Stenroos
- Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
| | - Jussi Kosola
- Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Xavier Valle
- Medical Department, FC Barcelona, Barcelona, Spain
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Johnson EE, Brutico JM, Rangavajjula L, Xia Y, Paul RW, Otlans P, Arner JW, Hammoud S, Bradley JP, Cohen SB. Open Repair of Complete Proximal Hamstring Avulsions in Workers’ Compensation Patients. Orthop J Sports Med 2022; 10:23259671221119774. [PMID: 36081409 PMCID: PMC9445462 DOI: 10.1177/23259671221119774] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Several studies have reported excellent results after surgical repair of proximal hamstring avulsions. However, the effect on these patients of receiving workers’ compensation has not yet been explored. Hypothesis: Workers’ compensation patients undergoing proximal hamstring repair of complete tears will have similar outcomes when compared with a matched control group of non–workers’ compensation patients. Study Design: Cohort study; Level of evidence, 3. Methods: Workers’ compensation patients who underwent complete proximal hamstring avulsion open repair between 2010 and 2019 were identified (WC group). A control group was matched by age (±3 years), sex, and body mass index (BMI; ±3). Demographics and patient-reported outcome measures were compared, including standard and custom Marx activity rating scale (MARS), standard and custom lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain. Rate and time to return to work were recorded. Results: The WC group was composed of 20 patients (8 men, 12 women) with a mean age of 52.3 years and BMI of 32.4. The 20 matched controls (8 men, 12 women) who underwent repair had a mean age of 50.6 years and a mean BMI of 31.2. There was no difference between the groups regarding age (P = .924), sex (P > .999), or BMI (P = .330). The WC group reported similar mean MARS (3.3 vs 5.4; P = .174), custom MARS (87.5 vs 97.0; P = .215), and VAS pain (3.3 vs 3.8; P = .698) scores compared with controls. However, the WC group had significantly lower standard LEFS (69.1 vs 94.1; P < .001) and custom LEFS (62.3 vs 87.9; P < .001) scores, returned to work at a lower rate (70.0% vs 94.1%; P = .039), and required more time to return to work after repair (4.3 vs 3.5 months; P = .029) compared with controls. Conclusion: Workers’ compensation patients who underwent open proximal hamstring repair for complete avulsions experienced inferior patient-reported outcomes, required more time to return to work, and returned to work at a lower rate than a matched control group.
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Affiliation(s)
- Emma E. Johnson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph M. Brutico
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lasya Rangavajjula
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yuwei Xia
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan W. Paul
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Peters Otlans
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Justin W. Arner
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sommer Hammoud
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James P. Bradley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Steven B. Cohen
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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15
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Green JS, Moran J, Schneble CA, Zazulak B, Li DT, Jimenez A, Medvecky MJ. Comparative Analysis of Patient-Reported Outcome Measures for Proximal Hamstring Injuries: A Systematic Review. Orthop J Sports Med 2022; 10:23259671221104758. [PMID: 35898205 PMCID: PMC9310242 DOI: 10.1177/23259671221104758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background There is controversy regarding which patient-reported outcome measures (PROMs) should be used for proximal hamstring tendon injuries. Hypothesis It was hypothesized that (1) most (>50%) of the questions on the 13 most common PROMs for proximal hamstring injuries would demonstrate extensive overlap in the health domains and question categories and (2) each of the PROMs would contain a variable distribution of questions within each health domain. Study Design Systematic review. Methods We conducted a literature review through PubMed, Scopus, and CINAHL and identified the 13 most common PROMs for proximal hamstring injuries: Lower Extremity Functional Scale (LEFS), Marx activity rating scale (MARS), 12-item Short Form Survey (SF-12), Tegner activity scale (TAS), Single Assessment Numeric Evaluation (SANE), Perth Hamstring Assessment Tool (PHAT), Proximal Hamstring Injury Questionnaire (PHIQ), modified Harris Hip Score (mHHS), University of California, Los Angeles activity score (UCLA), International Hip Outcome Tool (iHOT-12), Hip Outcome Score (HOS), Sydney Hamstring Origin Rupture Evaluation (SHORE), and Non-Arthritic Hip Score (NAHS). All PROM questions were sorted into 5 health domains (pain, symptoms, activities of daily living, sports, and mindset) and further divided into question categories if they referred to similar tasks or aspects of health. Questions in the same health domain and question category were considered overlapping, and those within a health domain that did not fit into a question category were considered unique. For each PROM, we analyzed the distribution of questions within particular health domains and question categories as well as the amount of overlapping and unique questions. Results Of the 165 questions evaluated, 116 (70.3%) were overlapping, and 49 (29.7%) were unique. The SF-12 contained the most unique questions (9/12 [75.0%]). The MARS, TAS, SANE, and UCLA had 0 unique questions. The PHIQ and iHOT-12 contained questions in all 5 health domains. The PHAT, SHORE, and NAHS contained questions in every health domain except mindset. The LEFS, MARS, SF-12, TAS, mHHS, SANE, UCLA, and HOS contained questions in ≤3 health domains. Conclusion The evaluated PROMs had a high degree of overlapping questions (≥50%) and demonstrated a statistically significant variance in the distribution of questions within each health domain.
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Affiliation(s)
- Joshua S. Green
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | - Jay Moran
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Christopher A. Schneble
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Bohdanna Zazulak
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Don T. Li
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Andrew Jimenez
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Michael J. Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
- Michael J. Medvecky, MD, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, Yale University, New Haven, CT, 06520, USA ()
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16
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Hillier-Smith R, Paton B. Outcomes following surgical management of proximal hamstring tendon avulsions. Bone Jt Open 2022; 3:415-422. [PMID: 35549447 PMCID: PMC9134830 DOI: 10.1302/2633-1462.35.bjo-2021-0196.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims Avulsion of the proximal hamstring tendon origin can result in significant functional impairment, with surgical re-attachment of the tendons becoming an increasingly recognized treatment. The aim of this study was to assess the outcomes of surgical management of proximal hamstring tendon avulsions, and to compare the results between acute and chronic repairs, as well as between partial and complete injuries. Methods PubMed, CINAHL, SPORTdiscuss, Cochrane Library, EMBASE, and Web of Science were searched. Studies were screened and quality assessed. Results In all, 35 studies (1,530 surgically-repaired hamstrings) were included. Mean age at time of repair was 44.7 years (12 to 78). A total of 846 tears were acute, and 684 were chronic, with 520 tears being defined as partial, and 916 as complete. Overall, 92.6% of patients were satisfied with the outcome of their surgery. Mean Lower Extremity Functional Score was 74.7, and was significantly higher in the partial injury group. Mean postoperative hamstring strength was 87.0% of the uninjured limb, and was higher in the partial group. The return to sport (RTS) rate was 84.5%, averaging at a return of 6.5 months. RTS was quicker in the acute group. Re-rupture rate was 1.2% overall, and was lower in the acute group. Sciatic nerve dysfunction rate was 3.5% overall, and lower in the acute group (p < 0.05 in all cases). Conclusion Surgical treatment results in high satisfaction rates, with good functional outcomes, restoration of muscle strength, and RTS. Partial injuries could expect a higher functional outcome and muscle strength return. Acute repairs result in a quicker RTS with a reduced rate of re-rupture and sciatic nerve dysfunction. Cite this article: Bone Jt Open 2022;3(5):415–422.
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Affiliation(s)
| | - Bruce Paton
- Institute of Sport Exercise and Health, University Colleage London, University College London Hospitals NHS Foundation Trust, London, UK
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17
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Green JS, Moran J, Kahan JB, McLaughlin WM, Wang A, Medvecky MJ. Acute Surgical Repair of Simultaneous Bilateral Proximal Hamstring Tendon Avulsion: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00032. [PMID: 36099532 DOI: 10.2106/jbjs.cc.22.00147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE Proximal hamstring tendon avulsions are rare injuries that can be successfully treated with surgical intervention. However, there are limited reports on the surgical and postoperative management of patients with bilateral avulsions. We report a 54-year-old male gym teacher with acute bilateral proximal hamstring 3-tendon nonbony avulsions who underwent simultaneous surgical repairs and a unique postoperative rehabilitation course. At 1-year clinical follow-up, the patient demonstrated significant improvements in activity levels and functionality, with no complications. CONCLUSION Bilateral proximal hamstring 3-tendon nonbony avulsions can be successfully treated with a simultaneous surgical repair and a modified postoperative rehabilitation course.
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Affiliation(s)
- Joshua S Green
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Jay Moran
- Yale School of Medicine, Department of Rehabilitation & Orthopaedics, New Haven, Connecticut
| | - Joseph B Kahan
- Yale School of Medicine, Department of Rehabilitation & Orthopaedics, New Haven, Connecticut
| | - William M McLaughlin
- Yale School of Medicine, Department of Rehabilitation & Orthopaedics, New Haven, Connecticut
| | - Annie Wang
- Yale School of Medicine, Department of Biomedical Imaging, New Haven, Connecticut
| | - Michael J Medvecky
- Yale School of Medicine, Department of Rehabilitation & Orthopaedics, New Haven, Connecticut
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18
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Rudisill SS, Kucharik MP, Varady NH, Martin SD. Evidence-Based Management and Factors Associated With Return to Play After Acute Hamstring Injury in Athletes: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211053833. [PMID: 34888392 PMCID: PMC8649106 DOI: 10.1177/23259671211053833] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/10/2021] [Indexed: 01/14/2023] Open
Abstract
Background: Considering the lengthy recovery and high recurrence risk after a hamstring injury, effective rehabilitation and accurate prognosis are fundamental to timely and safe return to play (RTP) for athletes. Purpose: To analyze methods of rehabilitation for acute proximal and muscular hamstring injuries and summarize prognostic factors associated with RTP. Study Design: Systematic review; Level of evidence, 4. Methods: In August 2020, MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, and SPORTDiscus were queried for studies examining management and factors affecting RTP after acute hamstring injury. Included were randomized controlled trials, cohort studies, case-control studies, and case series appraising treatment effects on RTP, reinjury rate, strength, flexibility, hamstrings-to-quadriceps ratio, or functional assessment, as well as studies associating clinical and magnetic resonance imaging factors with RTP. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool for Randomized Trials or the Methodological Index for Non-Randomized Studies (MINORS). Results: Of 1289 identified articles, 75 were included. The comparative and noncomparative studies earned MINORS scores of 18.8 ± 1.3 and 11.4 ± 3.4, respectively, and 12 of the 17 randomized controlled trials exhibited low risk of bias. Collectively, studies of muscular injury included younger patients and a greater proportion of male athletes compared with studies of proximal injury. Surgery for proximal hamstring ruptures achieved superior outcomes to nonoperative treatment, whereas physiotherapy incorporating eccentric training, progressive agility, and trunk stabilization restored function and hastened RTP after muscular injuries. Platelet-rich plasma injection for muscular injury yielded inconsistent results. The following initial clinical findings were associated with delayed RTP: greater passive knee extension of the uninjured leg, greater knee extension peak torque angle, biceps femoris injury, greater pain at injury and initial examination, “popping” sound, bruising, and pain on resisted knee flexion. Imaging factors associated with delayed RTP included magnetic resonance imaging-positive injury, longer lesion relative to patient height, greater muscle/tendon involvement, complete central tendon or myotendinous junction rupture, and greater number of muscles injured. Conclusion: Surgery enabled earlier RTP and improved strength and flexibility for proximal hamstring injuries, while muscular injuries were effectively managed nonoperatively. Rehabilitation and athlete expectations may be managed by considering several suitable prognostic factors derived from initial clinical and imaging examination.
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Affiliation(s)
- Samuel S Rudisill
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Health System, Boston, Massachusetts, USA.,Rush Medical College of Rush University, Chicago, Illinois, USA
| | - Michael P Kucharik
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Health System, Boston, Massachusetts, USA
| | - Nathan H Varady
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Health System, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Scott D Martin
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Health System, Boston, Massachusetts, USA
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19
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Abstract
Proximal hamstring tears are common among athletes, especially in sports involving eccentric lengthening during forced hip flexion and knee extension, such as hurdles or water skiing. Tears are described by timing (acute [<1 month] or chronic) and severity (partial or complete). Complete tears are easily identified with magnetic resonance imaging; however, partial tears may be subtle and potentially missed. The spectrum of pathology associated with acute injuries ranges from minor strains to complete tears or avulsions. Acute tears commonly present as pain and bruising over the posterior thigh along with weakness with active knee flexion and often a sensation of instability of the lower extremity. Chronic injuries typically present with ischial pain associated with repetitive activities, and the spectrum includes chronic tendinopathies, ischial bursitis, partial tears, and nonoperatively treated complete tears. Nonoperative treatment is recommended in the setting of low-grade partial tears and insertional tendinosis. However, failure of nonoperative treatment of partial tears may benefit from surgical debridement and repair. Further, surgical repair of complete tears with retraction is usually recommended for active patients. Historically, surgical treatment has been limited to open surgical approaches, although endoscopic management of proximal hamstring tears and chronic ischial bursitis is an option. Our endoscopic technique employs the use of two anchors, double loaded with high-strength suture, and may support a faster recovery due to decreased surgical morbidity. It is important to note that some patients may not be candidates for this endoscopic repair as a result of several factors, including prior chronic and retracted tears, as well as those with altered regional tissue planes due to prior surgical repair.
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20
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Lawton CD, Sullivan SW, Hancock KJ, Burger JA, Nawabi DH, Kelly BT, Ranawat AS, Nwachukwu BU. Achievement of the minimal clinically important difference following open proximal hamstring repair. J Hip Preserv Surg 2021; 8:348-353. [PMID: 35505799 PMCID: PMC9052411 DOI: 10.1093/jhps/hnab068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/05/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022] Open
Abstract
There is a paucity of literature on patient-reported outcome measures (PROMs) following proximal hamstring repair beyond return to play, patient satisfaction and pain improvement. The minimal clinically important difference (MCID) defines the minimum degree of quantifiable improvement that a patient can perceive, but the MCID and predictors of this measure have not been defined for this patient population. This study aimed to define the MCID and determine the efficacy of open proximal hamstring repair through achievement of MCID and identify characteristics predictive of achieving MCID. A retrospective cohort review of an institutional hip registry was conducted, analyzing the modified Harris Hip Score (mHHS) and International Hip Outcome Tool (iHOT-33). MCID was calculated using a distribution-based method. Demographic and clinical variables predictive of achieving MCID were analyzed using univariable and multivariate logistic regression analyses. Thirty-nine patients who underwent open proximal hamstring repair were included. The mean patient age was 48.5 ± 12.4 years, with a mean follow-up of 37.1 ± 28 months. The MCID was determined for each PROM (mHHS—11.8; iHOT-33—12.6). A high percentage of patients achieved MCID for both PROMs (mHHS—85.7%; iHOT-33—91.4%). Univariate logistical regression demonstrated increased age (P = 0.163), increased body mass index (BMI; P = 0.072), requirement for inpatient admission (P = 0.088) and pre-operative iHOT-33 (P = 0.104) trended towards clinically significant predictors of not achieving MCID. A high percentage of patients achieved MCID while age, BMI, inpatient admission and pre-operative iHOT-33 appear to influence the achievement of clinically significant outcome in patients undergoing open proximal hamstring repair.
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Affiliation(s)
- Cort D Lawton
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Spencer W Sullivan
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Kyle J Hancock
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Joost A Burger
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Danyal H Nawabi
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
- Weill Cornell Medical College, New York, NY 10021, USA
| | - Bryan T Kelly
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
- Weill Cornell Medical College, New York, NY 10021, USA
| | - Anil S Ranawat
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
- Weill Cornell Medical College, New York, NY 10021, USA
| | - Benedict U Nwachukwu
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY 10021, USA
- Weill Cornell Medical College, New York, NY 10021, USA
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21
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[Clinical results after refixation of proximal hamstring tendon ruptures comparing different anchor systems]. Unfallchirurg 2021; 124:560-567. [PMID: 34143256 DOI: 10.1007/s00113-021-01020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Injuries to the hamstring muscles and tendon complex are among the most frequent muscular injuries with proximal hamstring tendon avulsion being a particularly severe form. The surgical treatment of these injuries is superior to conservative management with respect to patient satisfaction, recovery of muscle strength and function as well as return to sport rates. It is therefore the method of choice. OBJECTIVE Presentation and comparison of the surgical results after treatment with titanium, polyether ether ketone (PEEK) and all suture anchors. MATERIAL AND METHODS A systematic search was carried out in the PubMed medical database and the results are summarized. RESULTS All systems exhibit comparable biomechanical properties regarding elongation and ultimate failure load. Tendon repair with these anchors results in good to excellent clinical outcomes and shows high return to sport and low complication rates. Patient satisfaction after hamstring tendon repair is reported to be over 90% and return to sport rate is 80-100%. The muscle strength recovers to 80-90% in comparison to the contralateral side. CONCLUSION All available anchors systems provide good to excellent clinical outcomes and an explicit advantage for one anchor system could so far not be shown.
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22
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Ahearn N, Wood DG. Distal avulsion of reconstituted hamstring tendons. Knee Surg Sports Traumatol Arthrosc 2021; 29:1722-1727. [PMID: 32767079 DOI: 10.1007/s00167-020-06202-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/31/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Hamstring tendon autograft (semitendinosus and gracilis) is the most commonly used graft in anterior cruciate ligament (ACL) reconstruction. Distal hamstring tendons avulsion is a rare condition, and this paper describes a previously unreported injury, local management of this rare injury pattern, and the existing literature regarding treatment options. METHODS Two cases are presented of distal hamstring avulsion from the tibia of reconstituted tendons, together with additional 12 cases of distal hamstrings tendon avulsion. Functional outcomes following treatment of this injury are presented, together with a literature review of management options. RESULTS Early surgical reattachment using suture anchor fixation was performed and excellent results were achieved in 93% of cases (13 out of 14 patients). Patient-reported outcome measures demonstrated a median Marx score 14.5 (IQR 4) and median SHORE score 34.5 (IQR 4). The mean time to surgery was 22 days (range 5-60), with mean time to return to sport at pre-injury level 5.5 months (range 2.5-12). CONCLUSIONS Distal hamstring tendon avulsion is a rare condition, with no consensus regarding optimal management options. Acute surgical repair leads to excellent results, with a return to pre-injury level of sporting activity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Nathanael Ahearn
- North Sydney Orthopaedic and Sports Medicine Centre, Mater Clinic, Wollstonecraft, NSW, 2065, Australia.
| | - David G Wood
- North Sydney Orthopaedic and Sports Medicine Centre, Mater Clinic, Wollstonecraft, NSW, 2065, Australia
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23
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Pihl E, Jonsson KB, Berglöf M, Brodin N, Sköldenberg O, Hedbeck CJ. Exploring the Perth Hamstring Assessment Tool and Lower Extremity Functional Scale in a Proximal Hamstring Avulsion Cohort: A Cross-sectional Study. Am J Sports Med 2021; 49:1732-1740. [PMID: 33909488 DOI: 10.1177/03635465211008568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The goal of treatment for a proximal hamstring avulsion (PHA) is an objectively restored muscle and a subjectively satisfied, pain-free patient at follow-up. Different self-reported and performance-based outcome measures have been used to evaluate recovery, but their validity is poorly investigated. PURPOSE To investigate (1) the correlation between the commonly used self-reported outcome measurements, the Perth Hamstring Assessment Tool (PHAT) and the Lower Extremity Functional Scale (LEFS); (2) to what extent these scores can be explained by physical dysfunction as measured by performance-based tests; (3) whether performance-based tests can discriminate between the injured and uninjured extremity; and (4) which activity limitations are perceived by patients several years after the injury. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 3. METHODS We included a consecutive series of patients treated for or diagnosed with PHA in our department between 2007 and 2016 having at least 2 tendons avulsed from the ischial tuberosity. Participants attended 2 study visits, answered questionnaires (PHAT, LEFS, and Patient-Specific Functional Scale [PSFS]), and performed physical performance-based tests (single-leg hop tests, single-step down test, and isometric and isokinetic strength tests). RESULTS A total of 50 patients were included (26 men [52%], 24 women [48%]; mean age, 50.9 years [SD, 9.8 years]). The mean follow-up time was 5.5 years (SD, 2.7 years), and 74% had been surgically treated. The correlation between PHAT and LEFS was strong (r = 0.832) and statistically significant (P < .001). Seven of the performance-based tests exhibited a statistically significant but weak correlation with LEFS (0.340-0.488) and 3 of the tests to PHAT (-0.304 to 0.406). However, only peak torque could significantly discriminate between the extremities. The activity limitation most commonly mentioned in PSFS was running (16 patients [32%]). CONCLUSION Although PHAT and LEFS correlated strongly, the correlations between functional tests and the patient-reported outcome scores were weak, and most functional tests failed to discriminate between the injured and uninjured lower extremity in patients with PHA 5 years after injury. In general, patients alleged few activity limitations, but running difficulty was a common sequela after PHA.
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Affiliation(s)
- Elsa Pihl
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Orthopaedics, Stockholm, Sweden.,Danderyd University Hospital Corp, Department of Orthopaedics, Stockholm, Sweden
| | - Kenneth B Jonsson
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Mida Berglöf
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.,Södersjukhuset, Department of Hand Surgery, Stockholm, Sweden
| | - Nina Brodin
- Danderyd University Hospital Corp, Department of Orthopaedics, Stockholm, Sweden.,Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Stockholm, Sweden
| | - Olof Sköldenberg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Orthopaedics, Stockholm, Sweden.,Danderyd University Hospital Corp, Department of Orthopaedics, Stockholm, Sweden
| | - Carl Johan Hedbeck
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Orthopaedics, Stockholm, Sweden.,Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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24
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Reza T, Hinkle AJ, Perez-Chaumont A, Brown SM, Mulcahey MK. Systematic Review of Outcome Measures Used After Proximal Hamstring Repair. Orthop J Sports Med 2021; 9:23259671211005101. [PMID: 33997081 PMCID: PMC8113800 DOI: 10.1177/23259671211005101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Patient-reported outcome measures are important to determine outcomes after
orthopaedic procedures. There is currently no standard for outcome measures
in the evaluation of patient outcomes after proximal hamstring repair. Purpose: To identify and evaluate outcome measures used after proximal hamstring
repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed to identify all English-language articles
assessing outcomes after proximal hamstring repair in PubMed, Embase, CINAHL
via EBSCOhost, MEDLINE via OvidSP, and Web of Science between 2000 and 2019.
After duplicates were removed, studies were selected using eligibility
criteria established by the authors. Image reviews, anatomic/histology
studies, literature reviews, surgical technique reports, systematic reviews,
narrative reviews, case studies, and studies with <5 patients were
excluded. Extraction, synthesis, and analysis of outcome measure data were
performed using Microsoft Excel. Quality assessment of included studies was
performed using Methodological Index for Non-Randomized Studies
criteria. Results: After duplicate articles were removed, a total of 304 unique articles were
identified and 27 met the inclusion criteria. The mean number of patients
with proximal hamstring repairs per study was 40. The most frequently
reported outcome measures were return to sport (14/27; 51.9%), custom
survey/questionnaire (13/27; 48.1%), and isokinetic hamstring strength
testing (13/27; 48.1%). Six of the 10 most commonly used outcome measures
were validated and included Lower Extremity Functional Scale, 12-Item Short
Form Health Survey, visual analog scale for pain, Perth Hamstring Assessment
Tool (PHAT), Single Assessment Numeric Evaluation, and Tegner Activity
Scale. Of those, PHAT was the only validated outcome measure designed for
proximal hamstring repair. Conclusion: There is currently no consensus on the best outcome measurements for the
evaluation of patients after proximal hamstring repair. We recommend an
increased commitment to the use of return to sport, isokinetic strength
testing, Lower Extremity Functional Scale, and PHAT when assessing such
injuries. Future studies should aim to define the most reliable methods of
outcome measurement in this patient population through consistent use of
tools that are clinically relevant and important to patients and can easily
be employed in a variety of clinical scenarios.
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Affiliation(s)
- Tara Reza
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Andrew J Hinkle
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | | | - Symone M Brown
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
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25
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Hamula MJ, Cady A, Yousefzadeh K, Banffy M. Endoscopic Implantation of Bioinductive Patch for Chronic Partial Retearing After Hamstring Repair. Arthrosc Tech 2021; 10:e311-e316. [PMID: 33680761 PMCID: PMC7917025 DOI: 10.1016/j.eats.2020.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/08/2020] [Indexed: 02/03/2023] Open
Abstract
Proximal hamstring tendon avulsions are a relatively rare type of hamstring injury associated with persistent morbidity, including pain, weakness, and functional limitations. Open or endoscopic surgical repair is the standard treatment for complete tendon avulsions or partial tears that remain symptomatic despite conservative management in relatively young, healthy, and active patients. However, complications known to occur include retearing of the hamstring, infection, nerve injury, inability to return to work or sport, subjective persistent weakness, and subjective persistent pain. In the case of persistent pain where the repair is partially retorn, a careful history, physical examination, and scrutiny of radiologic studies can help guide management. We describe a technique for using revision endoscopy and augmentation with a bovine bioinductive patch in a case of chronic persistently painful partial retear after a proximal hamstring repair.
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Affiliation(s)
- Mathew J. Hamula
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, U.S.A
| | - Adam Cady
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, U.S.A
| | - Keon Yousefzadeh
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, U.S.A
| | - Michael Banffy
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, U.S.A
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26
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Bertiche P, Mohtadi N, Chan D, Hölmich P. Proximal hamstring tendon avulsion: state of the art. J ISAKOS 2020; 6:237-246. [PMID: 34272300 DOI: 10.1136/jisakos-2019-000420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 09/17/2020] [Accepted: 09/24/2020] [Indexed: 11/04/2022]
Abstract
Complete proximal hamstring tendon avulsions from the ischial tuberosity, though infrequent, are the most severe type of hamstring muscle injury in the field of sport medicine. These serious injuries are commonly associated with a delayed or even misdiagnosis, despite obvious clinical findings. The published literature favours surgical repair even though the studies represent lower levels of evidence. Non-surgical treatment is a viable option for lower physical demand patients. This state-of-the-art article reviews the relevant anatomy, the clinical assessment including specific physical examination signs and diagnostic testing in patients suspected of a proximal hamstring avulsion. Up-to-date evidence is reviewed to address surgical and non-surgical treatment options and outcome assessment. The authors provide a detailed description of what would be considered the current worldwide standard of care; an open, suture-anchor-based repair of the avulsed tendon complex (semitendinosus, long head of biceps femoris and semimembranosus) securely to the ischial tuberosity. Also included are surgical tips and tricks, with advice on postsurgical management and rehabilitation. Future perspectives should involve higher quality, prospective research to better define the indications for surgery, evaluate the emerging role of endoscopic repair and disclose complications along with measuring patient-reported outcomes.
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Affiliation(s)
- Pablo Bertiche
- Department of Sport Medicine and Arthroscopic Surgery, Sanatorio Allende, Cordoba, Argentina
| | - Nicholas Mohtadi
- University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada
| | - Denise Chan
- University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada
| | - Per Hölmich
- Sports Orthopedic Research Center, Copenhagen, Denmark.,Department of Orthopedic Surgery, Arthroscopic Center Hvidovre, Hvidovre, Denmark
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27
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Return to Sport After Surgical Management of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Clin J Sport Med 2020; 30:598-611. [PMID: 30444732 DOI: 10.1097/jsm.0000000000000688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the rates and timing of return to sport for the surgical management of proximal hamstring avulsions (PHAs). METHODS Three databases, PubMed, MEDLINE, and EMBASE, were searched from database inception until October 7, 2017, by 2 reviewers independently and in duplicate. The inclusion criteria were studies reporting return to sport outcomes for surgical management of acute, chronic, complete, and partial PHA. The rate of return to sports was combined in a meta-analysis of proportions using a random-effects model. RESULTS Overall, 21 studies with a total of 846 patients met the inclusion criteria, with a mean age of 41.4 years (range, 14-71 years) and a mean follow-up of 37.8 months (range, 6-76 months). Two studies were of prospective comparative design (level II), 2 were retrospective comparative (level III), 8 were prospective case series (level IV), and 9 were retrospective case series (level IV). The overall mean time to return to sport was 5.8 months (range, 1-36 months). The pooled rate of return to any sport participation was 87% [95% confidence interval (CI), 77%-95%]. The pooled rate of return to preinjury level of sport was 77% (95% CI, 66%-86%). CONCLUSIONS Pooled results suggest a high rate of return to sport after surgical management of PHA; however, this was associated with a lower preinjury level of sport. No major differences in return to sport were found between partial versus complete and acute versus chronic PHA.
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28
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Abstract
Aims Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically. Methods This is a prospective series of 156 proximal hamstring surgical repairs, with a mean age of 48.9 years (21.5 to 78). Functional outcomes were assessed preinjury, preoperatively, and postoperatively (six months and minimum three years) using the Sydney Hamstring Origin Rupture Evaluation (SHORE) score. Operating time was recorded for every patient. Results Overall, significant improvements in SHORE scores were seen at both six months and mid-term follow-up. Preoperatively, acute patients (median score 27.1 (interquartile range (IQR) 22.9)) reported significantly poorer SHORE scores than chronic patients (median score 42.9 (IQR 22.1); p < 0.001). However, this difference was not maintained postoperatively. For partial tears, acutely repaired patients reported significantly lower preoperative SHORE scores compared to chronically reapired partial tears (median score 24.3 (IQR 15.7) vs median score 40.0 (IQR 25.0); p < 0.001) but also significantly higher SHORE scores at six-month follow-up compared to chronically repaired partial tears (median score 92.9 (IQR 10.7) vs. median score 82.9 (IQR 14.3); p < 0.001). For complete tears, there was only a difference in preoperative SHORE scores between acute and chronic groups. Overall, acute repairs had a significantly shorter operating time (mean 64.67 minutes (standard deviation (SD) 12.99)) compared to chronic repairs (mean 74.71 minutes (SD = 12.0); t = 5.12, p < 0.001). Conclusion Surgical repair of proximal hamstring avulsions successfully improves patient reported functional outcomes in the majority of patients, irrespective of the timing of their surgery or injury classification. However, reducing the time from injury to surgery is associated with greater improvement in patient outcomes and an increased likelihood of returning to preinjury functional status. Acute repair appears to be a technically less complex procedure, as indicated by reduced operating times, postoperative neurological symptoms and number of patients requiring bracing. Acute repair is therefore a preference among many surgeons. Cite this article: Bone Joint J 2020;102-B(10):1419–1427.
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Affiliation(s)
- David Wood
- North Sydney Orthopaedics and Sports Medicine Centre, Sydney, Australia
| | - Sofie R. French
- Australian Institute of Musculoskeletal Research, Sydney, Australia
| | - Selin Munir
- Australian Institute of Musculoskeletal Research, Sydney, Australia
| | - Rajiv Kaila
- North Sydney Orthopaedics and Sports Medicine Centre, Sydney, Australia
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29
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Hinckel BB, Baumann CA, Ejnisman L, Cavinatto LM, Martusiewicz A, Tanaka MJ, Tompkins M, Sherman SL, Chahla JA, Frank R, Yamamoto GL, Bicos J, Arendt L, Fithian D, Farr J. Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00083. [PMID: 33986224 PMCID: PMC7537824 DOI: 10.5435/jaaosglobal-d-20-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.
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Affiliation(s)
- Betina B Hinckel
- From the Oakland University, Rochester (Dr. Hinckel, and Dr. Cavinatto); Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak (Dr. Hinckel, Dr. Cavinatto), MI; the University of Missouri-School of Medicine, Columbia, MO (Mr. Baumann); the Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR (Dr. Ejnisman); the Shoulder and Elbow Surgery, Beaumont Orthopaedic Associates, Beaumont Health (Dr. Martusiewicz); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Tanaka); the Department of Orthopedic Surgery, TRIA Orthopedic Center, University of Minnesota, Gillette Children's Specialty Healthcare, MN (Dr. Tompkins); the Department of Orthopedic Surgery, Stanford University, CA (Dr. Sherman); the Rush University Medical Center, Chicago, IL (Dr. Chahla); the Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, Aurora, CO (Dr. Frank); the Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Yamamoto); CEGH-CEL, Instituto de Biociências, Universidade de São Paulo (Dr. Yamamoto); DASA Laboratories, Sao Paulo, Brazil (Dr. Yamamoto); the Michigan Orthopedic Surgeons, Fellowship Director William Beaumont Sports Medicine Fellowship, Assistant Professor Oakland University William Beaumont School of Medicine, MI (Dr. Bicos); the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Arendt); the Southern California Permanente Medical Group and Torrey Pines Orthopaedic Medical Group, San Diego, CA (Dr. Fithian); and the Knee Preservation, Cartilage Regeneration and OrthoBiologics, Department of Orthopedic Surgery, Indiana University School of Medicine, OrthoIndy and OrthoIndy Hospital, Greenwood and Indianapolis, IN (Dr. Farr)
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30
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Shambaugh BC, Wuerz TH, Miller SL. Does Time From Injury to Surgery Affect Outcomes After Surgical Repair of Partial and Complete Proximal Hamstring Ruptures? Orthop J Sports Med 2020; 8:2325967120946317. [PMID: 32923506 PMCID: PMC7457414 DOI: 10.1177/2325967120946317] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/13/2020] [Indexed: 11/15/2022] Open
Abstract
Background No previous study has compared the outcomes of repair for partial and complete proximal hamstring ruptures at various intervals after the injury. Purpose The primary aim was to determine whether time from injury to surgery affected outcomes after primary repair of partial and complete proximal hamstring ruptures. The secondary aim was to assess patients' experiences from initial evaluation to finding a treating surgeon. Study Design Cohort study; Level of evidence, 3. Methods Records from 2007 to 2016 from a single surgeon's practice were reviewed. A total of 124 proximal hamstring repair procedures in 121 patients were identified. There were 92 patients who completed questionnaires: a custom survey, the standard Lower Extremity Functional Scale (LEFS), a custom LEFS, the standard Marx activity scale, a custom Marx activity scale, and the University of California Los Angeles (UCLA) activity score. Results were analyzed for partial and complete repair procedures performed at ≤3 weeks, ≤6 weeks, and >6 weeks after the injury. Results The mean follow-up was 43 months (median, 38 months). Of 93 repair procedures reviewed, 51% (9/28 partial; 38/65 complete), 79% (16/28 partial; 57/65 complete), and 22% (12/28 partial; 8/65 complete) were performed at ≤3 weeks, ≤6 weeks, and >6 weeks, respectively. At those various intervals, no statistical difference was found in standard LEFS, custom LEFS, standard Marx, custom Marx, or UCLA scores. Female sex, older age, and body mass index >30 kg/m2 were negative predictors of outcome measures. When repaired >6 weeks after the injury, a greater percentage of patients reported weakness of the operative leg compared with the contralateral side (partial tears: 6.3% vs 25%, respectively; complete tears: 24.6% vs 50%, respectively) in addition to greater sitting intolerance (partial tears: 0% vs 25%, respectively; complete tears: 7.1% vs 12.5%, respectively). Patients repaired >6 weeks after the injury visited, on average, 2.6 practitioners before an evaluation by the treating surgeon compared with 1.6 treated surgically at ≤6 weeks (P = .008). Conclusion Patients with proximal hamstring repair performed in the acute and chronic settings can expect successful outcomes but may experience more subjective weakness and difficulty with prolonged sitting when the repair is performed >6 weeks after the injury. Patients faced challenges in receiving the correct diagnosis and referral to an appropriate treating surgeon, emphasizing the need for an increased awareness of the injury.
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Affiliation(s)
| | - Thomas H Wuerz
- Boston Sports & Shoulder Center, Waltham, Massachusetts, USA
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31
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Kurowicki J, Novack TA, Simone ES, Mease SJ, Festa A, McInerney VK, Scillia AJ. Short-Term Outcomes Following Endoscopic Proximal Hamstring Repair. Arthroscopy 2020; 36:1301-1307. [PMID: 31830518 DOI: 10.1016/j.arthro.2019.11.126] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the outcomes of endoscopic proximal hamstring repair (ePHR), specifically: (1) functional and subjective outcomes, (2) effectiveness of treatment (preoperative-to-postoperative change), (3) complications, (4) acute versus chronic tears, and (5) partial versus complete tears. METHODS A retrospective case series of a single-surgeon database for all patients who underwent ePHR between November 2014 and January 2019 with a minimum 1-year follow-up (range, 12 to 48 months) was performed. Charts were analyzed for preoperative and postoperative passive range of motion (PROM), strength, VAS pain, UCLA activity, and modified Harris Hip Score (mHHS). Manual muscle strength testing based on standard grading scale of 0 to 5 was performed. Complications including re-tear of the repair site, infection, iatrogenic nerve injury, inability to return to work/sport at the same level as preinjury, persistent hamstring weakness, pain with sitting, and subsequent surgery were recorded. RESULTS We identified 20 ePHR (6 males, 14 females) with a mean age of 46 years (range, 18 to 63 years). At most recent follow-up, mean VAS pain was 1.85 (SD 2), UCLA activity was 8 (SD 2), mHHS was 90.6 (SD 10.5), and PROM hip flexion of 121.7° (SD 14.5°). Effectiveness of treatment demonstrated significant improvement in objective hamstring strength, hip flexion PROM by 17.3°, UCLA activity by 3, and VAS pain by 3 points. Subjective hamstring weakness was reported in 8 (42.1%) and persistent pain with sitting in 3 (15.8%). Return to work and sport were 100% and 95%, respectively. mHHS was significantly higher postoperatively in patients with complete versus partial tears (95.5 versus 85.7). CONCLUSION Endoscopic proximal hamstring repair is an effective approach that provides patients significant improvement in pain and function. LEVEL OF EVIDENCE IV, Case Series.
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Affiliation(s)
- Jennifer Kurowicki
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, Paterson, New Jersey, U.S.A
| | - Thomas A Novack
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, Paterson, New Jersey, U.S.A
| | - Erica S Simone
- New Jersey Orthopaedic Institute, Wayne, New Jersey, U.S.A
| | - Samuel J Mease
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, Paterson, New Jersey, U.S.A
| | - Anthony Festa
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, Paterson, New Jersey, U.S.A.; Hackensack Meridian School of Medicine at Seton Hall University, Department of Orthopaedic Surgery, Nutley, New Jersey, U.S.A
| | - Vincent K McInerney
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, Paterson, New Jersey, U.S.A.; Hackensack Meridian School of Medicine at Seton Hall University, Department of Orthopaedic Surgery, Nutley, New Jersey, U.S.A
| | - Anthony J Scillia
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, Paterson, New Jersey, U.S.A.; Hackensack Meridian School of Medicine at Seton Hall University, Department of Orthopaedic Surgery, Nutley, New Jersey, U.S.A..
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32
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Excellent clinical outcome and low complication rate after proximal hamstring tendon repair at mid-term follow up. Knee Surg Sports Traumatol Arthrosc 2020; 28:1230-1235. [PMID: 31650312 DOI: 10.1007/s00167-019-05748-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 10/09/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Proximal hamstring tendon avulsions lead to a significant loss of strength and a functional deficit of the respective lower limb and surgery is the recommended treatment. Only little is known about the clinical outcomes and complications when comparing acute and chronic management as well as partial and complete tears. Therefore, the purpose of this study was to investigate the clinical results and the complication rate of patients after surgical treatment of proximal hamstring tendon injuries. It was hypothesized that surgical treatment of an acute proximal hamstring avulsion would lead to a superior clinical outcome with a low complication rate and high return to sports rate compared to chronic cases and partial avulsions. METHODS Patients who underwent proximal hamstring tendon repair between 2008 and 2015 were retrospectively evaluated with a minimum follow up of 2 years. Outcome measurements were obtained by means of Lysholm score, Harris Hip Score, Visual Analog Scale, and Tegner Activity Scale. Return to sports (RTS) rate was determined. Postoperative adverse events were recorded and complications reported. Patients' outcomes were compared between acute/chronic repair and partial/complete injury patterns. RESULTS Ninety-four of 120 (78.3%) were available for final assessment at a mean follow-up of 56.2 ± 27.2 months. Clinical outcome measures were excellent and did not differ between the treatment groups or between the different injury patterns. RTS was achieved by 86.2% of the patients and was significantly superior after acute treatment (p < 0.05). The overall complication rate was 8.5% and significantly higher in complete tears compared to partial tears and in delay compared to acute surgery (p < 0.05). CONCLUSION Surgical treatment of proximal hamstring tendon avulsions results in excellent clinical outcome scores and a high RTS rate. Open surgical treatment has shown to be a safe procedure with a low complication rate. Surgical timing is important, as early surgical intervention provides a higher RTS rate and a lower complication rate than delayed surgery and should therefore be preferred in clinical practice. Repair of partial and complete tears lead to similar clinical outcome, but a higher complication rate in complete avulsions. LEVEL OF EVIDENCE Level IV.
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Abstract
AIMS To validate the Sydney Hamstring Origin Rupture Evaluation (SHORE), a hamstring-specific clinical assessment tool to evaluate patient outcomes following surgical treatment. METHODS A prospective study of 70 unilateral hamstring surgical repairs, with a mean age of 47.3 years (15 to 73). Patients completed the SHORE preoperatively and at six months post-surgery, and then completed both the SHORE and Perth Hamstring Assessment Tool (PHAT) at three years post-surgery. The SHORE questionnaire was validated through the evaluation of its psychometric properties, including; internal consistency, reproducibility, reliability, sensitivity to change, and ceiling effect. Construct validity was assessed using Pearson's correlation analysis to examine the strength of association between the SHORE and the PHAT. RESULTS The SHORE demonstrated an excellent completion rate (100%), high internal consistency (Cronbach's alpha 0.78), and good reproducibility (intraclass correlation coefficient (ICC) 0.82). The SHORE had a high correlation with the validated PHAT score. It was more sensitive in detecting clinical change compared to the PHAT. A ceiling effect was not present in the SHORE at six months; however, a ceiling effect was identified in both scores at three years post-surgery. CONCLUSION This study has validated the SHORE patient reported outcome measure (PROM) as a short, practical, reliable, valid, and responsive tool that can be used to assess symptom and function following hamstring injury and surgical repair. Cite this article: Bone Joint J 2020;102-B(3):388-393.
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Affiliation(s)
- Sofie R French
- Australian Institute of Musculoskeletal Research, Sydney, Australia
| | - Rajiv Kaila
- North Sydney Orthopaedic & Sports Medicine Centre, Sydney, Australia
| | - Selin Munir
- Australian Institute of Musculoskeletal Research, Sydney, Australia
| | - David G Wood
- North Sydney Orthopaedic & Sports Medicine Centre, Sydney, Australia
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Bataillie F, Bataillie S, van Beek N, Corten K. Portal placement for endoscopic surgery in the deep gluteal area: a cadaveric study. J Hip Preserv Surg 2020; 7:147-152. [PMID: 32382442 PMCID: PMC7195941 DOI: 10.1093/jhps/hnaa008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 01/09/2020] [Indexed: 12/03/2022] Open
Abstract
Partial or complete avulsion of the insertion of the proximal hamstrings at the level of the ischial tuberosity is most often treated by open exploration and reinsertion. However, endoscopic reinsertion could be considered to minimize the soft tissue damage. In this study, we aimed to determine the most optimal location of four endoscopic portals that allow for a safe exploration of the proximal hamstring insertion site. The reference points for the portals run vertically through the center of the sciatic tuberosity and through a horizontal line which lies on the inferior edge of the tuberosity. The distance and relationship between the sciatic, the inferior gluteal and posterior femoral cutaneous nerves and the four proposed endoscopic portals was documented. Our results showed that it was best to start with the inferior portal followed by the medial and lateral portal. The inferior portal allowed for a clear visualization of the sciatic nerve and was along with the medial portal at a distance of >5 cm from any of the surrounding nerves. Care must be taken with the lateral portal, as the distance to the surrounding nerves varied between specimens. A fourth portal could be used as a viewing portal when necessary. Our study showed that the sequence and position of the proposed endoscopic portals provide a safe approach to the proximal part of the hamstrings and the ischial tuberosity. These findings can be helpful for endoscopic procedures to the ischium and the sciatic nerve in the gluteal region.
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Affiliation(s)
- F Bataillie
- Department of Orthopedic Surgery, AZ Hospital, Herentals, Belgium
| | - S Bataillie
- Department of Ophthalmology, UZLeuven, Leuven, Belgium
| | - N van Beek
- Department of Orthopedic Surgery, AZ Hospital, Herentals, Belgium
| | - K Corten
- Hip Unit, Orthopaedic Department, Ziekenhuis Oost-Limburg, Genk, Belgium
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Fouasson-Chailloux A, Menu P, Mesland O, Dauty M. Strength assessment after proximal hamstring rupture: A critical review and analysis. Clin Biomech (Bristol, Avon) 2020; 72:44-51. [PMID: 31812036 DOI: 10.1016/j.clinbiomech.2019.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/26/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Muscular strength should be one of the main parameters to assess the interest or not of surgery after proximal hamstring rupture. Yet, this parameter is difficult to compare between the different studies because of the heterogeneous assessment methods. METHODS We realized a critical review of strength assessment methods used to evaluate treatments performed after proximal hamstring rupture. The studies were selected from several medical databases with the keywords: "proximal hamstring rupture" OR "proximal hamstring avulsion" AND "strength" OR "isokinetic". FINDINGS 24 articles evaluated muscular strength after proximal hamstring rupture. 7 have been excluded because the method was not described. 6 types of dynamometric evaluation were used: 2 with an isometric method, 3 with a pneumatic isotonic method and 13 with an isokinetic method. Muscular strengths after non-surgical treatment could not be compared because of the low number of studies and different methods of assessment. After surgery, only isokinetic results measured at the angular speed of 60°/s could have been weighted. A 15% strength deficit was shown at >12 months after surgery. INTERPRETATION Muscular strength assessment methods currently used to evaluate the strength after proximal hamstring rupture are too disparate to clearly define the strength deficit after rupture and surgery. Strength evaluation should be more rigorous in order to prove the real interest of the surgical management.
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Affiliation(s)
- Alban Fouasson-Chailloux
- CHU Nantes, Physical Medicine and Rehabilitation Department, Hôpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes Cedex 03, France; CHU Nantes, Sports Medicine Department, Hôpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes Cedex 03, France; Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes F-44042, France.
| | - Pierre Menu
- CHU Nantes, Physical Medicine and Rehabilitation Department, Hôpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes Cedex 03, France; CHU Nantes, Sports Medicine Department, Hôpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes Cedex 03, France; Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes F-44042, France
| | - Olivier Mesland
- CHU Nantes, Physical Medicine and Rehabilitation Department, Hôpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes Cedex 03, France; CHU Nantes, Sports Medicine Department, Hôpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes Cedex 03, France
| | - Marc Dauty
- CHU Nantes, Physical Medicine and Rehabilitation Department, Hôpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes Cedex 03, France; CHU Nantes, Sports Medicine Department, Hôpital Saint Jacques, 85 rue Saint Jacques, 44093 Nantes Cedex 03, France; Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes F-44042, France
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Engler ID, Bragg JT, Miller SL. Incidence of Deep Venous Thrombosis Associated With Proximal Hamstring Rupture. Orthop J Sports Med 2019; 7:2325967119888486. [PMID: 31903398 PMCID: PMC6927196 DOI: 10.1177/2325967119888486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Rates of deep venous thrombosis (DVT) have been studied for most common orthopaedic injuries. However, rates and risk factors have not been published for proximal hamstring injuries. Purpose: To determine the incidence of symptomatic DVT associated with proximal hamstring rupture and associations with prophylactic anticoagulation. Study Design: Case series; Level of evidence, 4. Methods: Inclusion criteria included all complete and, in a separate cohort, partial proximal hamstring ruptures treated by the senior author from 2007 through 2018 with at least 8 weeks of follow-up. Tendinopathy without tear was excluded. No DVT screening was performed. Charts of patients with symptomatic DVT were reviewed for the treatment method, the presence of imaging-confirmed DVT or pulmonary embolism, and risk factors for DVT. No patients received postinjury DVT prophylaxis. Surgical patients were routinely instructed to take aspirin (325 mg bid) or apixaban (2.5 mg bid) for 4 weeks. Patients with risk factors for DVT received enoxaparin (40 mg daily) for 2 weeks followed by aspirin (325 mg bid) for 2 weeks. Results: A total of 144 complete proximal hamstring ruptures were included: 132 treated operatively and 12 treated nonoperatively. There were 10 DVTs associated with the injury, for an overall rate of 6.9%. Five of the DVTs were diagnosed preoperatively in patients who had not received DVT prophylaxis; the other 5 were diagnosed postoperatively in patients on DVT prophylaxis. Six of the 10 DVTs had identifiable risk factors. All patients with postoperatively diagnosed DVTs were on prophylactic aspirin or enoxaparin. In the partial proximal hamstring rupture cohort of 114 ruptures, there were no DVTs. Conclusion: There is a high incidence of DVT associated with complete proximal hamstring ruptures (6.9%) despite many patients receiving DVT prophylaxis. This is substantially higher than that in other lower extremity injuries. Clinicians should have a high index of suspicion for DVT after these injuries, and postinjury DVT prophylaxis may be warranted.
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Affiliation(s)
- Ian D Engler
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jack T Bragg
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Suzanne L Miller
- Boston Sports and Shoulder Center, Waltham, Massachusetts, USA.,New England Baptist Hospital, Boston, Massachusetts, USA
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van der Made AD, Peters RW, Verheul C, Maas M, Kerkhoffs GM. Abduction in Proximal Hamstring Tendon Avulsion Injury Mechanism: A Report on 3 Athletes. Clin J Sport Med 2019; 29:e76-e79. [PMID: 31688186 DOI: 10.1097/jsm.0000000000000543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Proximal hamstring tendon avulsions are typically sustained during forced hip hyperflexion combined with knee extension. We present 3 cases of athletes with a proximal hamstring tendon avulsion caused by an alternative injury mechanism that also involves a considerable hip abduction component (flexion-abduction injury mechanism). All cases had at least one concurrent injury of the medial thigh muscles, either on the ipsilateral or contralateral side. The 2 elite athletes with this injury mechanism returned to sport at preinjury level relatively quickly. A history of the flexion-abduction mechanism should raise suspicion of a hamstring tendon avulsion with concomitant injury of the medial thigh muscles. The magnetic resonance imaging (MRI) protocol should include both legs, and any concurrent injury may need to be addressed as well. In future studies, it would be interesting to investigate whether injury mechanism holds prognostic value in proximal hamstring tendon avulsions.
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Affiliation(s)
- Anne D van der Made
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, Amsterdam, the Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
| | - Rolf W Peters
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, Amsterdam, the Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
- Department of Trauma Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Claire Verheul
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, Amsterdam, the Netherlands
- ManualFysion, Amsterdam, the Netherlands
| | - Mario Maas
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, Amsterdam, the Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Gino M Kerkhoffs
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Academic Center for Evidence-based Sports Medicine (ACES), Academic Medical Center, Amsterdam, the Netherlands
- Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, the Netherlands
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Ryan MK, Beason DP, Fleisig GS, Emblom BA. Portal Placement and Biomechanical Performance of Endoscopic Proximal Hamstring Repair. Am J Sports Med 2019; 47:2985-2992. [PMID: 31412206 DOI: 10.1177/0363546519866453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Proximal hamstring tendon avulsions are debilitating and commonly cause pain, weakness, and functional limitations. Open surgical repair has been the standard, but improved endoscopic techniques have enabled proximal hamstring fixation with decreased risk of infection and numbness, without the morbidity of a large incision. PURPOSE/HYPOTHESIS The purpose was to (1) describe pertinent anatomy surrounding the proximal hamstring origin in relation to 4 endoscopic portal sites and (2) test for biomechanical differences between open and endoscopic repair. It was hypothesized that (1) endoscopic proximal hamstring repair is efficacious with respect to commonly used portals and (2) there is no biomechanical difference between open and endoscopic techniques. STUDY DESIGN Descriptive and controlled laboratory study. METHODS Proximal hamstring ruptures were simulated endoscopically in 10 fresh-frozen human cadaveric pelvis specimens. Endoscopic repair was then completed on 1 limb from each specimen through 4 portals. After repair, each specimen was dissected in layers and measurements from portal tracts to pertinent anatomy were obtained. Open repair was performed on all contralateral limbs, followed by cyclical biomechanical tensile testing to failure of both the open and endoscopically repaired hamstring tendons to assess failure load and local tissue strain. RESULTS On average, no portal tract was closer than 2.0 cm to the sciatic nerve or inferior gluteal neurovascular bundle. Anatomic landmarks were identified that could improve the reproducibility and safety of the procedure. Biomechanical testing revealed no differences between the open and endoscopic repair techniques for any measured parameter. CONCLUSION This study supports the safety and efficacy of endoscopic proximal hamstring repair through anatomic and biomechanical analyses and helps establish reproducible and recognizable landmarks that define a safe working zone. CLINICAL RELEVANCE This study maps the anatomic landscape of the proximal hamstring as encountered endoscopically and demonstrates equivalent biomechanical strength of endoscopic proximal hamstring repair, supporting this technique's safety and efficacy.
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Affiliation(s)
- Michael K Ryan
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - David P Beason
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Glenn S Fleisig
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Benton A Emblom
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
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Ebert JR, Gormack N, Annear PT. Reconstruction of chronic proximal hamstring avulsion injuries using ipsilateral distal hamstring tendons results in good clinical outcomes and patient satisfaction. Knee Surg Sports Traumatol Arthrosc 2019; 27:2958-2966. [PMID: 30470850 DOI: 10.1007/s00167-018-5310-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/20/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To report outcomes following proximal hamstring reconstruction employing an ipsilateral distal hamstring tendon autograft, in patients with chronic proximal ruptures. METHODS Six patients presenting with a chronic proximal hamstring avulsion and a medial time from injury of 11.0 months (range 7-18), confirmed via magnetic resonance imaging, underwent proximal hamstring repair using a free graft harvested from the ipsilateral distal hamstrings. Patients were evaluated at 6, 12 and 24 months post-surgery, via the Perth Hamstring Assessment Tool, the Short Form Health Survey, the Lower Extremity Functional Scale, a Patient Satisfaction Questionnaire, the Active Knee Extension and 6 min walk tests, the single and triple hop tests for distance, and isokinetic knee extensor and flexor strength. Knee strength was assessed at 180° and 240°/s (total work, peak and average torque), and both mean absolute scores and limb symmetry indices (LSIs) comparing the operated and non-operated limbs were presented. RESULTS Patients demonstrated good clinical improvement throughout the post-operative timeline in all subjective and objective outcomes. Mean knee extensor LSIs had recovered by 12 and 24 months. At 24 months post-surgery, while mean LSIs for knee flexor peak and average torque were at (or above) 90%, a significant difference still existed between the operated and non-operated limbs in knee flexor total work. At 24 months, five patients (83%) were satisfied with the results of the surgery, as well as their ability to return to recreational and sporting activities. There were two adverse events including an early deep vein thrombosis and a secondary surgery to remove a loosened staple. CONCLUSIONS While isokinetic hamstring strength had not fully recovered by 24 months, this surgical technique demonstrated a high level of patient satisfaction and return to function, in patients with chronic proximal hamstring ruptures. As the clinical relevance, this surgical technique provides a viable option with good post-operative outcomes for patients with chronic proximal hamstring tears that cannot be approximated back to the ischium. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jay R Ebert
- The School of Human Sciences (Exercise and Sport Science), The University of Western Australia, 35 Stirling Highway, Crawley, Western Australia, 6009, Australia.
- Perth Orthopaedic and Sports Medicine Research Institute, West Perth, Western Australia, Australia.
| | - Nicholas Gormack
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, 6005, Australia
| | - Peter T Annear
- Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, 6005, Australia
- Perth Orthopaedic and Sports Medicine Research Institute, West Perth, Western Australia, Australia
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van der Made AD, Hölmich P, Kerkhoffs GMMJ, Gouttebarge V, D’Hooghe P, Tol JL. Proximal hamstring tendon avulsion treatment choice depends on a combination of clinical and imaging-related factors: a worldwide survey on current clinical practice and decision-making. J ISAKOS 2019. [DOI: 10.1136/jisakos-2019-000292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ObjectivesTo evaluate current practice in the treatment of proximal hamstring tendon avulsions and identify decision-making preferences.MethodsAn invitation to an anonymous e-survey containing 32 questions was sent to 3475 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) and the European College of Sports and Exercise Physicians (ECOSEP).ResultsWe received 403 (12%) unique responses with a completion rate of 79%. Participants were orthopaedic/trauma surgeons (90%), sports medicine physicians (7%) or physical therapists (2%). For 83% of the participants, the preferred treatment (ie, surgical or non-operative) depends on the individual case. Participants base their decision-making process on patient- and injury-related factors (decision modifiers). The five most frequently selected decision modifiers that support the choice for surgical treatment were diminished function (84%), neurological symptoms (74%), involved tendons (82%), tendon retraction on MRI (84%) and patient preference for surgery (78%). The majority prefer early surgical repair (<2 weeks after injury) to achieve highest functional outcome (63%) and ensure a low complication risk (61%). Suture anchors are used by 93% of the participants for tendon reattachment. Estimated recovery duration (ie, time to return to sports) was a median 12 weeks (IQR: 12–20) for non-operative treatment and 17 weeks (IQR: 12–24) for surgical treatment. Estimated reinjury risk was a median 25% (IQR: 10–31.5) and 10% (IQR: 5–20), respectively.ConclusionThis survey among experienced medical professionals has summarised current practice and identified treatment decision-making preferences. The typical surgical patient has a retracted (>2 cm) two-tendon avulsion (ie, common tendon and semimembranosus tendon), is unable to engage in sports or activities of daily life, reports sciatic symptoms and prefers surgical treatment. Surgery is thought to prolong recovery and decrease reinjury risk compared with non-operative treatment and is preferably performed early.Level of evidenceLevel V.
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Surgical Approach Impacts Posterior Femoral Cutaneous Nerve Outcomes After Proximal Hamstring Repair. Clin J Sport Med 2019; 29:281-284. [PMID: 31241529 DOI: 10.1097/jsm.0000000000000514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The goal of this study was to characterize the risk of intraoperative injury to the posterior femoral cutaneous nerve and to evaluate potential risk factors for injury during surgical repair of proximal hamstring injuries. DESIGN Retrospective cohort study. SETTING Single tertiary referral center. PATIENTS The cohort consisted of all patients presenting to a single institution with a proximal hamstring avulsion injury who were managed with surgical repair between January 1, 2000 and August 1, 2016. A total of 67 patients were included in the cohort. INDEPENDENT VARIABLES Variables assessed for their association with postoperative numbness in the distribution of the posterior femoral cutaneous nerve included age, sex, body mass index, mechanism of injury, time to surgical repair, and incision used. MAIN OUTCOME MEASURES The primary outcome of interest was neurologic symptoms referable to the posterior femoral cutaneous nerve. RESULTS Postoperatively, 13 patients (19%) developed new numbness in the distribution of the posterior femoral cutaneous nerve. One patient reported neuropathic pain and paresthesias associated with the numbness. The use of a gluteal crease incision was the only predictive factor for postoperative numbness in the posterior femoral cutaneous nerve distribution (odds ratio 8.67; 95% confidence interval, 2.30-42.80; P = 0.001). CONCLUSIONS The current study provides data that can be used in discussing the risks and benefits of surgical repair with patients and when weighing the pros and cons of using a gluteal crease versus longitudinal incision.
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Belk JW, Kraeutler MJ, Mei-Dan O, Houck DA, McCarty EC, Mulcahey MK. Return to Sport After Proximal Hamstring Tendon Repair: A Systematic Review. Orthop J Sports Med 2019; 7:2325967119853218. [PMID: 31259189 PMCID: PMC6591667 DOI: 10.1177/2325967119853218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Previous studies have evaluated functional outcomes and return-to-sport rates
after proximal hamstring tendon (HT) repair. Purpose: To systematically review the literature in an effort to evaluate
return-to-sport rates after proximal HT repair. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed by searching PubMed, the Cochrane Library,
and Embase to identify studies that evaluated postoperative lower extremity
function and return-to-sport rates in patients after proximal HT repair.
Search terms used were “hamstring,” “repair,” “return to sport,” and “return
to play.” Patients were assessed based on return to sport, return to
preinjury activity level, type of HT tear (complete or partial), and
interval from injury to surgery. Patients were also divided into subgroups
depending on timing of the surgical intervention: early, <1 month;
delayed, 1 to 6 months; and late, >6 months from the time of injury. Results: Sixteen studies (one level 2, five level 3, ten level 4) met the inclusion
criteria, including 374 patients with a complete proximal HT tear (CT group)
and 93 patients with a partial proximal HT tear (PT group), with a mean
follow-up of 2.9 years. Overall, 93.8% of patients (438/467) returned to
sport, including 93.0% (348/374) in the CT group and 96.8% (90/93) in the PT
group (P = .18). The mean time to return to sport was 5.7
months, and 83.5% of patients (330/395) returned to their preinjury activity
level. The early group demonstrated the greatest rate of return to sport at
94.4% (186/197) as well as the quickest time to return at a mean of 4.8
months, although this was not found to be statistically significant. Conclusion: Over 90% of patients undergoing repair of a complete or partial proximal HT
tear can be expected to return to sport regardless of the tear type. Early
surgical interventions of these injuries may be associated with a quicker
return to sport, although the rate of return to sport does not differ based
on timing of the surgical intervention.
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Affiliation(s)
- John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Omer Mei-Dan
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Darby A Houck
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mary K Mulcahey
- Department of Orthopaedics, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Pihl E, Skoldenberg O, Nasell H, Jonhagen S, Kelly Pettersson P, Hedbeck CJ. Patient-reported outcomes after surgical and non-surgical treatment of proximal hamstring avulsions in middle-aged patients. BMJ Open Sport Exerc Med 2019; 5:e000511. [PMID: 31191968 PMCID: PMC6539150 DOI: 10.1136/bmjsem-2019-000511] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2019] [Indexed: 11/03/2022] Open
Abstract
Objectives In the literature on proximal hamstring avulsions, only two studies report the outcomes of non-surgically treated patients. Our objective was to compare subjective recovery after surgical and non-surgical treatment of proximal hamstring avulsions in a middle-aged cohort. Methods We included 47 patients (33 surgically and 14 non-surgically treated) with a mean (SD) age of 51 (±9) years in a retrospective cohort study. Follow-up time mean (SD) of 3.9 (±1.4) years. The outcome variables were the Lower Extremity Functional Scale (LEFS) and questions from the Proximal Hamstring Injury Questionnaire. Outcome variables were adjusted in regression models for gender, age, American Society of Anestesiologits (ASA) classification and MRI findings at diagnosis. Results The baseline characteristics showed no differences except for the MRI result, in which the surgically treated group had a larger proportion of tendons retracted ≥ 2 cm. The mean LEFS score was 74 (SD±12) in the surgically treated cohort and 72 (SD±16) in the non-surgically treated cohort. This was also true after adjusting for confounders. The only difference in outcome at follow-up was the total hours performing physical activity per week, p=0.02; surgically treated patients reported 2.5 hours or more (5.2 vs 2.7). Conclusion This study on middle-aged patients with proximal hamstring avulsions was unable to identify any difference in patient-reported outcome measures between surgically and non-surgically treated patients. The vast majority of patients treated surgically had complete proximal hamstring avulsions with ≥ 2 cm of retraction. We conclude that to obtain an evidence-based treatment algorithm for proximal hamstring avulsions studies of higher scientific level are needed.
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Affiliation(s)
- Elsa Pihl
- Ortopedkliniken Danderyds sjukhus, Karolinska Institutet Department of Clinical Sciences Danderyd Hospital, Danderyd, Sweden
| | - Olof Skoldenberg
- Ortopedkliniken Danderyds sjukhus, Karolinska Institutet Department of Clinical Sciences Danderyd Hospital, Danderyd, Sweden
| | - Hans Nasell
- Ortopedkliniken Danderyds sjukhus, Karolinska Institutet Department of Clinical Sciences Danderyd Hospital, Danderyd, Sweden
| | - Sven Jonhagen
- Ortopedkliniken Danderyds sjukhus, Karolinska Institutet Department of Clinical Sciences Danderyd Hospital, Danderyd, Sweden
| | - Paula Kelly Pettersson
- Ortopedkliniken Danderyds sjukhus, Karolinska Institutet Department of Clinical Sciences Danderyd Hospital, Danderyd, Sweden
| | - Carl Johan Hedbeck
- Ortopedkliniken Danderyds sjukhus, Karolinska Institutet Department of Clinical Sciences Danderyd Hospital, Danderyd, Sweden
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44
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Gerhardt M. Editorial Commentary: Proximal Hamstring Injuries-Is the Hip to Blame? Arthroscopy 2019; 35:1403-1405. [PMID: 31054719 DOI: 10.1016/j.arthro.2019.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 02/02/2023]
Abstract
There is a growing understanding of the relation between femoroacetabular impingement (FAI) and injury to adjacent structures. Patients with proximal hamstring pathology appear to have a high prevalence of underlying FAI. The kinetic chain phenomenon is a potential explanation of the high correlation between proximal hamstring injury and underlying FAI of the hip.
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Abstract
PURPOSE OF REVIEW To outline the typical presentation, physical examination, diagnostic imaging, and therapeutic treatment options for proximal hamstring injuries to improve awareness, expedient diagnosis, and definitive management. RECENT FINDINGS Proximal hamstring tendinopathy and partial-thickness tears can often successfully be managed with a combination of non-operative modalities, including physiotherapy focused on eccentric strengthening, extracorporeal shock wave therapy, or peri-tendinous injections. Surgery is reserved for refractory cases, but can yield good outcomes. Contrastingly, non-operative treatment often leads to unsatisfactory outcomes in complete ruptures, with residual weakness and reduced function with poor return-to-sport rates. Instead, surgical repair can provide satisfactory outcomes, with good-to-excellent functional outcomes and strength, with acute treatment preferred over delayed, chronic repair. Hamstring tendinopathy and partial-thickness tears can be successfully treated non-operatively with good functional outcomes, with surgical repair reserved for refractory cases. Complete tears are best managed with surgical repair, allowing improved strength and functional outcomes.
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Affiliation(s)
- Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
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46
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Bowman EN, Marshall NE, Gerhardt MB, Banffy MB. Predictors of Clinical Outcomes After Proximal Hamstring Repair. Orthop J Sports Med 2019; 7:2325967118823712. [PMID: 30800686 PMCID: PMC6378442 DOI: 10.1177/2325967118823712] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Proximal hamstring avulsions cause considerable morbidity. Operative repair results in improved pain, function, and patient satisfaction; however, outcomes remain variable. Purpose To evaluate the predictors of clinical outcomes after proximal hamstring repair. Study Design Case series; Level of evidence, 4. Methods We retrospectively reviewed proximal hamstring avulsions repaired between January 2014 and June 2017 with at least 1-year follow-up. Independent variables included patient demographics, medical comorbidities, tear characteristics, and repair technique. Primary outcome measures were the Single Assessment Numerical Evaluation (SANE), International Hip Outcome Tool-12 (iHOT-12), and Kerlan-Jobe Orthopaedic Clinic (KJOC) Athletic Hip score. Secondary outcome measures included satisfaction, visual analog scale for pain, Tegner score, and timing of return to sports. Results Of 102 proximal hamstring repairs, 86 were eligible, 58 were enrolled and analyzed (67%), and patient-reported outcomes were available for 45 (52%), with a mean 29-month follow-up. The mean patient age was 51 years, and 57% were female. Acute tears accounted for 66%; 78% were complete avulsions. Open repair was performed on 90%. Overall satisfaction was 94%, although runners were less satisfied compared with other athletes (P = .029). A majority of patients (88%) returned to sports by 7.6 months, on average, with 72% returning at the same level. Runners returned at 6.3 months, on average, but to the same level 50% of the time and at a decreased number of miles per week compared to nonrunners (15.7 vs 7.8, respectively; P < .001). Postoperatively, 78% had good/excellent SANE Activity scores, but the mean Tegner score decreased (from 5.5 to 5.1). Acute tears had higher SANE Activity scores. The mean iHOT-12 and KJOC scores were 99 and 77, respectively. Endoscopic repairs had equivalent outcome scores to open repairs, although conclusions were limited given the small number of patients in the endoscopic group. Greater satisfaction was noted in patients older than 50 years (P = .024), although they were less likely to return to running (P = .010). Conclusion Overall, patient satisfaction and functionality were high. With the numbers available, we were unable to detect any significant differences in functional outcome scores based on patient age, sex, body mass index, smoking status, medical comorbidities, tear grade, activity level, or open versus endoscopic technique. Acute tears had better SANE Activity scores. Runners should be cautioned that they may be unable to return to the same preinjury activity level after proximal hamstring repair. Clinical Relevance When counseling patients with proximal hamstring tears, runners and those with chronic tears should set appropriate expectations.
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Affiliation(s)
- Eric N Bowman
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Michael B Banffy
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
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47
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Abstract
Hip adduction is accomplished through coordinated effort of the adductor magnus, brevis, and longus and the obturator externus and pectineus muscles. Each of these muscles may be injured at its proximal or distal insertion or in its midsubstance. The incidence of injuries to the adductor complex is difficult to determine in sport because of players' underreporting and playing through minor strains. The most commonly injured adductor muscle is the adductor longus muscle. The injury most frequently occurs at the proximal or distal musculotendinous junction, but several case reports of origin and insertional ruptures of the adductor longus exist in the literature. Successful outcomes have been obtained with both operative and nonoperative approaches in these cases. Reports of isolated proximal avulsion of the adductor magnus are less common. This article describes our surgical technique for management of a rare acute proximal adductor magnus avulsion.
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48
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Functional impairment after successful surgical reconstruction for proximal hamstring avulsion. INTERNATIONAL ORTHOPAEDICS 2018; 43:2341-2347. [DOI: 10.1007/s00264-018-4263-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
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49
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Schröder JH, Gesslein M, Schütz M, Perka C, Krüger DR. [Minimally invasive proximal hamstring insertion repair]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 30:419-434. [PMID: 30443745 DOI: 10.1007/s00064-018-0575-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/19/2018] [Accepted: 08/22/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Minimally invasive endoscopic reconstruction of avulsion injuries of the proximal hamstring insertion to prevent persistent weakness and pain. INDICATIONS Fresh retracted 2‑ and 3‑tendon avulsion injuries of the proximal hamstring insertion. Unsuccessful conservative therapy of less retracted injuries. Painful chronic partial lesions of the proximal hamstring insertion. CONTRAINDICATIONS Major comorbidities with an increased surgical risk, older patients with low functional demands. Chronic injuries without functional deficits. SURGICAL TECHNIQUE Endoscopic refixation using suture anchors after freshening the footprint on the tuber ischiadicum. Visualization of the sciatic nerve to ensure its protection. POSTOPERATIVE MANAGEMENT Partial loading with a knee brace for strict prevention of combined knee extension and hip flexion for 4-6 weeks. Start of active exercise and stretching 8 weeks postoperatively. RESULTS From 2014-2016, 12 patients were treated with an endoscopic reconstruction of the proximal hamstring insertion. After a mean follow-up of 25 months (range 16-34 months), an average visual analog scale (VAS) of 0 (range 0-2) and an average subjective assessment of function (Subjective Hip Value) of 94% (range 80-100%) were found. No neurovascular complications were seen in our collective, in particular no evidence of hypesthesia in the area of the posterior femoral cutaneous nerve. All patients were able to return to their original level of activity (Tegner Activity Scale 5.2 preoperatively vs. 5.2 postoperatively), while the average time until return to sport was 6.5 months (range 3-12 months). All patients were able to return to their original occupation.
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Affiliation(s)
- J H Schröder
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - M Gesslein
- Klinik für Orthopädie und Unfallchirurgie, Paracelsus Medizinische Privatuniversität Nürnberg, Nürnberg, Deutschland
| | - M Schütz
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - C Perka
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
| | - D R Krüger
- Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
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50
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Bodendorfer BM, Curley AJ, Kotler JA, Ryan JM, Jejurikar NS, Kumar A, Postma WF. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Am J Sports Med 2018; 46:2798-2808. [PMID: 29016194 DOI: 10.1177/0363546517732526] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND No meta-analysis has compared outcomes of operative and nonoperative proximal hamstring avulsion treatment. PURPOSE To compare outcomes of operative and nonoperative proximal hamstring avulsion treatment, including acute, chronic, partial, and complete repairs. STUDY DESIGN Meta-analysis. METHODS PubMed, CINAHL, SPORTdiscus, Cochrane Library, EMBASE, and Web of Science were searched up to July 2016. Three authors screened the studies and performed quality assessment using criteria from the Methodologic Index for Nonrandomized Studies. A best evidence synthesis was subsequently used. RESULTS Twenty-four studies (795 proximal hamstring avulsions) were included. Twenty-two studies included proximal hamstring avulsion repairs; 1 study had proximal hamstring avulsion repairs and a control group of nonoperatively treated proximal hamstring avulsions; and 1 study had solely nonoperatively treated proximal hamstring avulsions. The majority of studies were of low methodological quality. Overall, repairs had significantly higher patient satisfaction (90.81% vs 52.94%), hamstring strength (85.01% vs 63.95%), Lower Extremity Functional Scale scores (72.77 vs 69.53), and single-legged hop test results (119.1 vs 56.62 cm) (all P < .001); complications occurred in 23.17% of cases. Compared with chronic repairs, acute avulsion repairs had greater patient satisfaction (95.48% vs 83.79%), less pain (1.07 vs 3.71), and greater strength (85.2% vs 82.8%), as well as better scores for the Lower Extremity Functional Scale (75.64 vs 71.5), UCLA activity scale (University of California, Los Angeles; 8.57 vs 8.10), and Single Assessment Numeric Evaluation (93.36 vs 86.50) (all P < .001). Compared with partial avulsion repairs, complete avulsion repairs had higher patient satisfaction (89.64% vs 81.35%, P < .001), less pain (1.87 vs 4.60, P < .001), and higher return to sport or preinjury activity level, but this was insignificant (81.43% vs 73.83%, P = .082). Partial avulsion repairs had better hamstring strength (86.04% vs 83.71%, P < .001) and endurance (107.13% vs 100.17%, P < .001). Complete repairs had significantly higher complication rates (29.38% vs 11.27%, P = .001). CONCLUSION Proximal hamstring avulsion repair resulted in superior outcomes as compared with nonoperative treatment, although the complication rate was 23.17%. The nonoperative group was quite small, making a true comparison difficult. Acute repairs have better outcomes than do chronic repairs. Complete avulsion repairs had higher patient satisfaction, less pain, and a higher complication rate than partial avulsion repairs, although partial avulsion repairs had better hamstring strength and endurance. Studies of high methodological quality are lacking in terms of investigating the outcomes of proximal hamstring avulsion repairs.
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Affiliation(s)
- Blake M Bodendorfer
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Andrew J Curley
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Joshua A Kotler
- Bone & Joint/Sports Medicine Institute, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - James M Ryan
- School of Medicine, Georgetown University, Washington, DC, USA
| | | | - Anagha Kumar
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - William F Postma
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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