Complete Proximal Hamstring Avulsions Research Articles

Poster 193: Long-Term Outcomes of Partial Proximal Hamstring Avulsion Repair: Average 10-Year Follow-Up

Objectives: While a growing body of literature supports the benefit of surgical repair of complete proximal hamstring avulsions involving all 3 tendons, the optimal treatment for partial proximal hamstring avulsions remains uncertain. Initial nonoperative management of partial proximal hamstring avulsions is typically recommended, but several recent studies have shown improved pain and function at short- and mid-term follow-up. However, the durability of surgical repair at long-term follow-up is unknown. The purpose of this study was to report the long-term outcomes of partial proximal hamstring avulsion repair compared to outcomes at midterm follow-up. It was hypothesized that hamstring function and patient satisfaction would remain stable over time. Methods: All patients who underwent surgical repair of a partial proximal hamstring avulsion by a single surgeon between 2006 and 2018 with a minimum 5-year follow-up were included. Institutional review board approval was obtained prior to study initiation, and all patients signed informed consent. Exclusion criteria were complete avulsions involving all 3 hamstring tendons, retraction > 2 cm, or magnetic resonance imaging (MRI) findings of isolated tendinopathy. All patients had first attempted nonoperative treatment, including nonsteroidal anti-inflammatory drugs and physical therapy. Patient characteristics were collected including age, sex, injury, laterality, sports played, level of participation, length of time from injury to intervention, and length of follow-up. Patients completed a HIPPA-compliant online questionnaire (REDCap) containing the patient-reported outcomes scores of the Lower Extremity Functional Score (LEFS), Marx Activity Rating Scale, custom LEFS (%), and custom Marx (%). A Total Proximal Hamstring Score was calculated by averaging the custom Marx score and the custom LEFS. Patient satisfaction with surgical outcome (yes/no) was also determined. A portion of the included patients had the same outcome measures available from a previous study entailing a minimum 2-year follow-up, with an average follow-up of 6.2 years. Paired comparisons of current outcome scores with earlier scores were performed using a paired Mann-Whitney U test for continuous variables and Fisher exact test for categorical variables. Results: Fifty-three patients (57 hamstrings) with a mean age at surgery of 47.4 years were included at an average follow-up time of 10.1 years. Of the 53 patients, 4 had bilateral injuries and 4 underwent revision surgery. The right (n = 29) and left (n = 28) hamstrings were equally affected with a predominance of female patients (41 female, 16 male). Running was the most common sport at the time of injury (Table 1). Excellent functional outcomes were seen at average 10.1 years (Table 2). 91.2% of patients were satisfied with the results of surgery and were able to return to their desired sport at an average of 10.9 months after surgery. Nearly 88% of hamstrings considered their strength to be >75% strength of the contralateral side, with approximately 58% of hamstrings reporting equal (100%) strength. When comparing the 44 partial hamstring repairs with outcome scores available at both midterm (6.2 years) and long-term follow-up (10.7 years), only the Marx and custom Marx scores were found to decline with time. Scores for LEFS, custom LEFS, Total Proximal Hamstring, satisfaction, and subjective strength were unchanged between midterm and long-term follow-up (Table 3). Conclusions: Excellent patient-reported outcomes and high levels of satisfaction were found at 10-year follow-up following partial proximal hamstring avulsion repair. Notably, the LEFS and custom LEFS, which are the most common patient-reported outcome measures used to assess hamstring function following injury, remained high at midterm and long-term follow-up. The Marx (12.5 vs. 8.5) and custom Marx scores (100% vs. 94%) did achieve statistically significant differences between time points, with lower scores at long-term follow-up possibly in part due to self-determined reduction in strenuous activities with aging. Patient-reported satisfaction and subjective strength remained high at long-term follow-up. Surgical repair of partial proximal hamstring avulsions remains a successful and durable treatment strategy in active patients who have failed nonoperative measures at an average follow-up exceeding 10 years.

Successful outcomes after surgical treatment of chronic complete proximal hamstring avulsions in female athletes older than 55 years

IntroductionProximal hamstring avulsions are a rare pathology, usually treated conservatively in elderly patients, resulting in severe functional limitation. Surgical repair can obtain a significant improvement in functionality and quality of life. MethodsProspective case series of 3 women over 55 years of age (mean age 61), amateur athletes, with complete proximal and retracted hamstring conjoint tendon avulsion, treated by open primary repair surgery in chronic period (>4 weeks). The study variables were functional scales (PHAT, LEFS, and SF-12) before the intervention and one year after surgery, and strength measurement with a dynamometer and digital voltage scale. Statistical analysis included the Wilcoxon t-test and the Mann–Whitney U test. ResultsOne year after surgery, all functional scales improved: PHAT 16 vs 83.33, LEFS 17.33 vs 68.67, P/SF-12.25.47 vs 51.14, and M/SF-12.35.42 vs 57.92. A normalization of the strength was obtained, observing a strength of 97.33% (range 72–140) and 111.67% (range 89–128) for contraction at 90° of flexion and in extension, respectively, with no differences between both legs. Digital measurement showed a strength of 99% (range 50–180). ConclusionSurgery for complete and retracted proximal avulsions of the hamstring conjoint tendon in chronic period improves functionality and quality of life in elderly women with regular sports practice, as well as normalization of muscle strength.

Variability of MRI reporting in proximal hamstring avulsion injuries: Are musculoskeletal radiologists and orthopedic surgeons utilizing similar landmarks?

BackgroundMagnetic resonance imaging (MRI) is an integral component of the treatment algorithm for proximal hamstring avulsion injuries. ObjectiveThe purpose of this study was to survey orthopedic surgeons and musculoskeletal radiologists on the reporting and analysis of proximal hamstring avulsions on MRI. MethodsTwo online surveys were developed to evaluate musculoskeletal radiologists' and orthopedic surgeons' perceptions of MRI-reporting for proximal hamstring avulsion injuries. Each survey was designed to provide information on physicians' best practices with respect to four primary questions (1) ischial tuberosity landmark determination (2) difficulties associated with measuring tendon retraction, (3) important ancillary findings, and (4) perceived clinical impact of measured retraction.Descriptive statistics were calculated for all categorical variables, which were reported as frequencies with percentages. Chi-squared test was utilized to compare rates of responses between surgeons and radiologists. Statistically significant differences were analyzed with post-hoc Fisher's exact tests; p < 0.05 considered statistically significant. Results218-Musculoskeletal radiologists and 33-orthopedic surgeons responded to their respective surveys. There were statistically significant differences with responses to two of the questions asked in both surveys; (1) in cases of complete hamstring avulsion (avulsion of both the semimembranosus and conjoint tendon), which arrow represents the tendon gap measurement used for planning surgery? p = 0.028; (2) in cases of avulsion of only the conjoint tendon, which arrow represents the tendon gap measurement used for planning surgery? p = 0.013. Post-hoc testing demonstrated that for either partial or complete hamstring avulsions, more surgeons use the conjoint tendon origin to measure tendon retraction than radiologists (p < 0.05 for both). Significantly more radiologists use the semimembranosus origin to measure hamstring retraction for partial or complete hamstring tears (p < 0.05 for both). However, for each of these questions, both radiologists and surgeons most frequently stated that the conjoint tendon landmark should be used for surgical planning. ConclusionMusculoskeletal radiologists and orthopedists frequently utilize the conjoint tendon origin as an anatomic landmark for measuring complete and partial proximal hamstring avulsion injuries; though, orthopedists are more likely to utilize this landmark. Additionally, the broad surface area of the ischial tuberosity may lead to variability in measurement. Clinical impactStandard landmarks at the ischial tuberosity and/or detailed descriptions of tendon retractions would improve communication between radiologists and surgeons for proximal hamstring avulsions.

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

Background:Several studies have reported excellent results after surgical repair of proximal hamstring avulsions. However, the effect on these patients of receiving workers’ compensation has not yet been explored.Hypothesis:Workers’ compensation patients undergoing proximal hamstring repair of complete tears will have similar outcomes when compared with a matched control group of non–workers’ compensation patients.Study Design:Cohort study; Level of evidence, 3.Methods:Workers’ compensation patients who underwent complete proximal hamstring avulsion open repair between 2010 and 2019 were identified (WC group). A control group was matched by age (±3 years), sex, and body mass index (BMI; ±3). Demographics and patient-reported outcome measures were compared, including standard and custom Marx activity rating scale (MARS), standard and custom lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain. Rate and time to return to work were recorded.Results:The WC group was composed of 20 patients (8 men, 12 women) with a mean age of 52.3 years and BMI of 32.4. The 20 matched controls (8 men, 12 women) who underwent repair had a mean age of 50.6 years and a mean BMI of 31.2. There was no difference between the groups regarding age (P = .924), sex (P > .999), or BMI (P = .330). The WC group reported similar mean MARS (3.3 vs 5.4; P = .174), custom MARS (87.5 vs 97.0; P = .215), and VAS pain (3.3 vs 3.8; P = .698) scores compared with controls. However, the WC group had significantly lower standard LEFS (69.1 vs 94.1; P < .001) and custom LEFS (62.3 vs 87.9; P < .001) scores, returned to work at a lower rate (70.0% vs 94.1%; P = .039), and required more time to return to work after repair (4.3 vs 3.5 months; P = .029) compared with controls.Conclusion:Workers’ compensation patients who underwent open proximal hamstring repair for complete avulsions experienced inferior patient-reported outcomes, required more time to return to work, and returned to work at a lower rate than a matched control group.

Biomechanical Evaluation of Proximal Hamstring Repair: All-Suture Anchor Versus Titanium Suture Anchor.

Background:Proximal hamstring avulsions are severe tendon injuries and are commonly sports-related. Open and endoscopic techniques as well as different anchor configurations have already been described for proximal hamstring repair. Novel all-suture anchors have been developed to provide decreased bone loss during placement and reduced occupied bone volume when compared with titanium suture anchors.Hypothesis:Complete proximal hamstring avulsions repaired with all-suture anchors will demonstrate equal load to failure and comparable displacement under cyclic loading when compared with titanium suture anchors.Study Design:Controlled laboratory study.Methods:Complete proximal hamstring avulsions were created in 18 paired cadaveric specimens (mean ± SD age, 63.0 ± 10.4 years). Either all-suture anchors or titanium suture anchors were used for repair. Cyclic loading from 10 to 125 N at 1 Hz was performed for 1500 cycles with a material testing machine. Displacement was assessed along anterior and posterior aspects of the tendon repair with optical tracking. Specimens were loaded to failure at a rate of 120 mm/min. Displacement, load to failure, and repair construct stiffness were compared between matched pairs with the Wilcoxon signed-rank test. Correlations were determined by Spearman rho analysis.Results:The all-suture anchors showed significantly higher load-to-failure values when compared with the titanium anchor repairs (799.64 ± 257.1 vs 573.27 ± 89.9 N; P = .008). There was no significant difference in displacement between all-suture anchors and titanium suture anchors at the anterior aspect (6.60 ± 2.2 vs 5.49 ± 1.1 mm; P = .26) or posterior aspect (5.87 ± 2.08 vs 5.23 ± 1.37 mm; P = .678) of the repaired hamstring tendons.Conclusion:All-suture anchors demonstrated similar displacement and superior load to failure when compared with titanium suture anchors.Clinical Relevance:The results of this study suggest that all-suture anchors are an equivalent alternative to titanium suture anchors for proximal hamstring avulsion repair.

Proximal hamstring tendon avulsion injuries occur predominately in middle-aged patients with distinct gender differences: epidemiologic analysis of 263 surgically treated cases.

Epidemiologic data of proximal hamstring avulsions have mainly been reported in relatively small patient cohorts. Detailed information on patient demographics, injury mechanism, and injury patterns is lacking in the literature. Since these injuries are rare and frequently misdiagnosed, a better understanding may help to increase awareness and to improve diagnosis of proximal hamstring avulsions. A chart review was performed to identify all patients who had undergone surgical repair for complete proximal hamstring avulsions between 01/2006 and 02/2019 at the authors' institution. The following demographic and injury-specific data were obtained: Sex, age, body mass index (BMI), cause of injury (sports, activities of daily living, and others), presence of neurologic symptoms referable to the sciatic nerve, time to surgery, injury pattern (affected tendons), tendon retraction, and type of injury according to Wood et al.`s classification (Type 1: osseous avulsions, Type 2: tear at the musculotendinous junction, Type 3: incomplete avulsion from bone, Type 4: complete avulsion with only minimal retraction, and Type 5: complete avulsion with retraction > 2cm). Data were analyzed for the entire study population and group comparison was performed with regard to sex, cause of injury, and the type of injury. A total of 263 patients were included (53% male). The mean age was 49 ± 13years with most patients (56%) aged between 45-59years. Most injuries occurred while participating in sports (52%) and injury type 5 was most commonly diagnosed (66%). Five percent of patients had sensory deficits referable to the sciatic nerve. Gender comparison showed that female patients were significantly older, predominantly represented in the age group 45-59years, and most commonly injured during activities of daily living, whereas male patients were significantly more often represented in younger age groups, and the most common cause of injury was sports. Compared to Type 4 and 5 injuries, patients with a Type 1 injury were significantly younger and had a significantly longer time to surgery. Proximal hamstring avulsion occurs predominately in the middle-aged patient and only rarely in patients under the age of 30years. No gender dominance exists. Female patients are typically older and get injured during activities of daily living, whereas male patients are younger and get injured more often during sports. These epidemiologic data may help physicians to make an accurate and early diagnosis. IV.

Patient-reported outcomes after surgical and non-surgical treatment of proximal hamstring avulsions in middle-aged patients

ObjectivesIn 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 Injuries: Review of Operative and Nonoperative Management

AbstractWhile uncommon, proximal hamstring injuries can result in significant pain and dysfunction, while also posing considerable treatment dilemmas due to the spectrum of injury that exists. Recent literature suggests that outcomes are improved with acute surgical repair of complete proximal hamstring avulsions, highlighting the importance of timely management of these unique injuries. While chronic repair or reconstruction can result in predictable improvements in pain and function postoperatively, the results are less predictable than acute surgical repair. Nonoperative management should be considered as the initial treatment strategy for patients with proximal hamstring tendinopathy or partial tears, as delayed surgical intervention in this setting has not been shown to significantly affect outcomes. Although current evidence is limited, evolving therapeutic techniques, including biologic injections and endoscopic repair techniques, need to be carefully evaluated to determine their role moving forward. This review aims to provide updated information on the relevant anatomy, mechanism of injury, diagnosis, and management of proximal hamstring injuries, with a specific focus on surgical indications, techniques, and outcomes.

Twenty-three-year Follow-up in a Patient with a Surgically Repaired Complete Proximal Hamstring Avulsion

Twenty-three-year Follow-up in a Patient with a Surgically Repaired Complete Proximal Hamstring Avulsion

Timing of Surgery for Complete Proximal Hamstring Avulsion Injuries

Background: Avulsion of the proximal hamstring origin is well documented, and surgical treatment is advocated for complete avulsions. Purpose: To compare the return to preinjury level of sport and the complexity of surgery in athletes undergoing surgical intervention for complete proximal hamstring avulsions within 6 weeks, 6 months, and after 6 months of injury. Study Design: Case series; Level of evidence, 4. Methods: This was the largest case series from a tertiary referral center reported in the literature. A total of 112 athletes were included, with complete proximal avulsion injuries confirmed on MRI scans; 63 patients (56.3%) were high-level athletes. Patients were divided into subgroups depending on the timing of surgical intervention: “early” was defined within 6 weeks, “delayed” within 6 weeks to 6 months, and “late” after 6 months. All patients were surgically explored and repaired with the aim of comparing the timing between each group and the return to preinjury sport. All patients underwent an individualized rehabilitation protocol. There was no loss to follow-up. The primary outcome measure was the return to preinjury level sports activity. Results: A total of 108 patients (96.4%) returned to sport. In the early intervention group, the average time of return to play was 16 weeks, 9 weeks faster than the delayed group and 13 weeks faster than the late group. There were 2 partial reruptures in those with delayed intervention—both athletes retired from competitive sport but were recreationally active. Two other athletes recovered well but retired from playing at all levels. Twelve athletes (2 in the early intervention group, 5 in the delayed, 5 in the late) were delayed by local nerve symptoms. Only 2 cases required further exploration. Conclusion: Early surgical intervention was associated with good clinical outcomes and a quicker return to sport; however, delaying the diagnosis can lead to prolonged morbidity and an increased likelihood of complications.

Complete Avulsion of the Proximal Hamstring Insertion: Functional Outcomes After Nonsurgical Treatment.

Complete proximal hamstring avulsions are an uncommon injury. The purpose of this study was to determine the functional and subjective outcomes following nonsurgical management of complete proximal hamstring avulsions. We retrospectively identified nineteen patients (mean age, fifty-nine years; range, forty-four to seventy-three years) at one institution who presented with complete avulsions of the proximal hamstring insertion, confirmed on magnetic resonance imaging, and had nonsurgical treatment. Results on the Lower Extremity Functional Scale (LEFS) and Short Form-12 version 2 (SF-12v2) questionnaires as well as functional and isometric testing (with a handheld dynamometer) were collected. Seventeen patients completed the questionnaires. Ten patients underwent functional testing. The average follow-up period was thirty-one months (range, eight to 156 months). The mean score on the LEFS was 70.2 of a maximum of 80 points. The mean SF-12v2 physical and mental component summary scores were 52.5 and 54.1, respectively. Hamstring strength at 45° and 90° of flexion was an average of 62% (p = 0.09) and 66% (p = 0.07), respectively, of that of the uninvolved limb. The single-leg hop test revealed an average decline of 2.2% (p = 0.93) compared with the uninvolved limb. Twelve of the seventeen patients were able to return to their previous sporting activities. Nonsurgical management after a complete proximal hamstring avulsion yields noticeable subjective and strength deficits. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Proximal hamstring avulsion in a professional soccer player

Acute hamstring strains are a common athletic injury, which may be treated non-operatively with a satisfactory outcome. A complete proximal hamstring avulsion is a rare and potentially career ending injury to an elite athlete. For these high demand patients, surgical reattachment should be immediately undertaken to shorten return to sport and to improve functional outcome. This report describes the occurrence of a complete avulsion of the proximal hamstrings in a professional footballer during an international match. We highlight the clinical presentation, the appropriate diagnostic investigations, the surgical technique and the rehabilitation protocol for this injury. The successful surgical reattachment of the common hamstring tendon was confirmed by magnetic resonance imaging done 5 months after repair and allowed the player a full return to competition at 6 months after surgery. Hamstrings isokinetic peak torque was 80% at 6 months and 106% at 11 months after repair comparing with the uninjured side.

Clinical and Magnetic Resonance Imaging Outcomes After Surgical Repair of Complete Proximal Hamstring Ruptures

Background: The use of validated outcome questionnaires and magnetic resonance imaging (MRI) when assessing outcomes after surgical treatment of proximal hamstring avulsions has been limited. Purpose: To comprehensively evaluate clinical, functional, and radiological outcomes in patients treated with surgical repair for complete proximal hamstring avulsions. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of 15 consecutive patients was performed. Outcome measures included the Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, Proximal Hamstring Injury Questionnaire, Lower Extremity Functional Scale (LEFS), Harris Hip Score (HHS), and Tegner Activity Scale (TAS). Physical examination was performed by an independent sports medicine fellow. Magnetic resonance imaging of the lower extremity was used to assess tendon healing and muscle quality after repair. Results: Thirteen of 15 (87%) eligible patients were available for follow-up at a mean 36.9 months (range, 27-63 months), including 8 men and 6 left-sided injuries. The average age was 44.6 years (range, 26-58 years). Twelve of 13 patients underwent surgical repair within 60 days of injury. Mean (± standard deviation) postoperative functional outcome scores were as follows: LEFS, 74.9 ± 7.8 (range, 59-80); HHS, 90.7 ± 13.9 (range, 67-100); SANE, 93.6 ± 7.5 (range, 75-100); VAS for pain, 1.3 ± 1.9 (range, 0-5); and TAS, 4.6 ± 2.3 (range, 1-7). All 11 patients who participated in sports before surgery were able to return to sport, but 45% reported a decrease in their current level of activity. Isokinetic muscle testing demonstrated that injured hamstring strength recovered up to 78% ± 6.1% (range, 74%-88%) of the contralateral side. The MRI examinations revealed that 100% of patients had a healed proximal hamstring repair, with signs of tendinopathy and mild atrophy in 3 of 12 patients. Conclusion: The current findings indicate that surgical repair of complete hamstring ruptures provides reliable pain relief, good functional outcomes, high satisfaction rates, and excellent healing rates (MRI) but does not fully restore hamstring function and sports activity to preinjury levels.

Avulsion of the Hamstring Muscle Group: A Follow‐Up of 6 Adult Non‐Athletes with Early Operative Treatment: A Brief Report

Complete proximal avulsions of the hamstring muscle group may cause significant morbidity and loss of function. These pelvis-near musculoskeletal injuries are mostly acquired during sports activities in a hip flexion and knee extension. Here we present a study group of 6 middle-aged to elderly patients suffering a complete proximal hamstring avulsion and following early surgical refixation. Early surgical refixation leads to complete resumption of the activities of daily life without loss of function. The 6 patients (3 men and 3 women) included in this study had an average age of 59.07 +/- 4.47 years at the time of injury. All of them suffered a complete avulsion of the hamstring muscle group. Surgical refixation was accomplished with the corkscrew anchor refixation system (Arthrex Manufacturing, Inc., Naples, FL). The cases were retrospectively analyzed using a hip joint evaluation system, the Harris Hip Score, and radiological follow-up by magnetic resonance imaging (MRI). Data are given as mean +/- SEM. Student's t-test was used for normal distribution of the data. The mean follow-up time was 31.83 +/- 18.9 months (range: 10-118 months). All patients were rated not to have a significant difference in function compared with the uninjured side. None of the patients suffered any handicaps resulting from surgery or the injury. A complete consolidation in all patients was observed in the follow-up MRI. Early surgical intervention and subsequent therapy in a complete hamstring avulsion injury may prevent loss of hip-joint stability and prevent the sequelae of degradative hip or vertebral events.

Complete Proximal Hamstring Avulsions: A Series of 41 Patients With Operative Treatment

Complete Proximal Hamstring Avulsions: A Series of 41 Patients With Operative Treatment

Surgical and Therapeutic Management of a Complete Proximal Hamstring Avulsion After a Failed Conservative Approach

Case report. After 2 attempts at conservative care for a diagnosis of hamstring strain, the patient had a surgical hamstring allograft reconstruction. The purpose of this report is to describe the physical therapy approach to postoperative management of a hamstring reconstruction. A 24-year-old female coach who sustained a complete avulsion of the proximal hamstring tendon while playing softball had a surgical hamstring reconstruction using an Achilles tendon allograft. Precautions concerning range of motion and stretching, weight-bearing status, and brace were followed to protect the surgical graft. Treatment incorporated cardiovascular, strength and proprioception exercises, and progressed with the focus on correct movement patterns and eccentric muscle control during functional movements. The patient attended 25 physical therapy sessions over 7 months. Muscle strength improved from 4/5 to 5/5. Straight-leg raise range of motion decreased from 145 degrees to 90 degrees . Lower Extremity Functional Scale (LEFS) scores improved from 15/80 to 70/80. A complete avulsion of the proximal insertion is rare. Conservative management of hamstring tears has traditionally focused on end-range passive stretching, modalities, and direct hamstring strengthening. New evidence recommends a program that is more protective of the injured tissue and includes exercises such as core stabilization; indirect hamstring strengthening may be beneficial in the treatment of hamstring injuries. This concept was taken into account when considering the rehabilitation protocol and progression for this patient. Therapy, level 4.

Allograft reconstruction for symptomatic chronic complete proximal hamstring tendon avulsion

Complete proximal hamstring tendon avulsion is an uncommon injury that can cause significant disability in young, athletic individuals. Surgical reattachment is recommended and can be performed on a delayed basis if the tissue is sufficiently mobile. We report 2-year follow up for two cases where interpositional allograft tissue was used for reconstruction because the tendon was too retracted for primary repair. Two 30-year-old patients with complete proximal hamstring avulsion at least 2 years earlier reported severe hamstring weakness and restrictions with respect to sport and recreational activities. Proximal hamstring tendon reconstruction with Achilles tendon allograft was performed for both patients. They were immobilized for 8 weeks with the hip in extension and the knee in flexion using a custom orthosis, followed by physical therapy and weight bearing as tolerated. The patients were followed for over 2 years after the surgery and were evaluated with physical examination, isokinetic strength testing and detailed questions about their function. Following the procedure, both patients returned to a more active lifestyle that was greatly improved with respect to participation in sport and function. This procedure should be considered as a salvage operation as the patients did not return to completely normal function and demonstrated hamstring weakness on the operated side.

Complete Proximal Hamstring Avulsions

Background Complete proximal hamstring avulsions can cause considerable morbidity and are often associated with significant functional loss. Hypothesis Early surgical treatment leads to better results than does surgery in the chronic phase. Study Design Case series; Level of evidence, 4. Methods Forty-one patients (21 men and 20 women) with a complete proximal hamstring avulsion were included. The cases were retrospectively analyzed, and a 4-category rating system was used to evaluate the overall result of the surgical treatment. Results The mean follow-up was 37 months (range, 12–72 months). Nineteen patients were rated as having an excellent result and 10 patients a good result. In 5 patients, the result was classified as moderate and in 7 patients poor. In the patients with an excellent or good result, the delay from the injury to surgery averaged 2.4 months, whereas in patients with a moderate or poor result, the delay averaged 11.7 months. The difference was statistically significant (P < .001). Conclusion Excellent or good results can often be expected with surgery, and considerable improvement of symptoms may be achieved even in chronic cases. According to the results, early operative treatment in complete proximal avulsions of the hamstring muscles gives better results than does late surgery and is therefore recommended.