Repair Of 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.

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.

Endoscopic Repair of Proximal Hamstring Insertion With Sciatic Nerve Neurolysis

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

Incidence of Symptomatic Venous Thromboembolism in Proximal Hamstring Repair: A Prospective Cohort Study.

Background:Surgical repair of proximal hamstring avulsion injuries can enable the return to preinjury levels of sporting function and minimize the risk of recurrence in both professional and recreational athletes. While venous thromboembolism (VTE) is a recognized complication of surgical repair, the incidence thereof is poorly reported in the literature.Purpose/Hypothesis:To report the incidence of symptomatic VTE after proximal hamstring avulsion repair and assess the efficacy of our thromboprophylaxis protocol. It was hypothesized that the incidence of VTE after proximal hamstring avulsion repair is low and that aspirin is an adequate choice of chemical prophylaxis.Study Design:Cohort study; Level of evidence, 2.Methods:We performed a prospective cohort study of 2 groups of patients who underwent proximal hamstring avulsion (partial and complete) repair between 2000 to 2020 with different thromboprophylaxis protocols. No patients were routinely screened for VTEs, and VTE was investigated only if clinically indicated. Prospectively collected data included demographics, the mechanism and sport that caused injury, use of bracing, and clinical diagnosis of deep vein thrombosis (DVT) or pulmonary embolism (PE). The first cohort (n = 380) was given mechanical prophylaxis in the form of compression stockings for 6 weeks postoperatively. The second cohort (n = 600) was given compression stockings and aspirin 150 mg once daily routinely, or prophylactic low–molecular weight heparin in high-risk individuals, until the 6-week follow-up. Patients in both cohorts underwent early mobilization after surgery; a hinged knee brace locked at 60° to 120° was provided if the tendon repair was under significant tension. The surgical technique and rehabilitation protocol remained consistent throughout the study.Results:The overall incidence of symptomatic VTE was 0.51%. A total of 5 patients developed symptomatic VTEs (3 DVTs, 2 PEs) in the first cohort, and no patients developed symptomatic VTEs in the second cohort (1.32% vs 0%; P = .0048).Conclusion:The incidence of symptomatic VTE after proximal hamstring avulsion repairs was extremely low. A combination of aspirin, early mobilization despite bracing, compression stockings, and good hydration was an effective thromboprophylaxis strategy.

Endoscopic Repair of the Proximal Hamstring

Background: Proximal hamstring injuries are increasingly common. While open repair with suture anchors placed in the ischial tuberosity has long been the gold standard technique for surgical management, endoscopic techniques can allow for smaller incisions, reduced wound complications, and an expedited recovery. Indications: Patients with full-thickness 3-tendon proximal hamstring tears, 2-tendon tears with retraction &gt;2 cm, or partial tears that remain symptomatic despite conservative management are considered for surgery. High-demand patients are often treated acutely, and low-demand patients may be offered surgery after a conservative management period. Technique Description: In the prone position, 2 arthroscopic portals are created in the gluteal fold. Fluoroscopy is used to verify safe portal placement, and the sciatic nerve is visualized along with the retracted tendon origin. The ischial tuberosity is identified, and the hamstring origin is debrided and decorticated. An accessory portal is created for suture anchor placement. Two double-loaded anchors are placed in the tuberosity, the sutures of which are used to repair the hamstring tendons using a horizontal mattress configuration. Patients undergo a stepwise postoperative physical therapy protocol. Results: An 85% return to sport rate can be expected following all hamstring repairs, with some studies reporting as high as 95% after endoscopic repair. Compared with nonoperative treatment, proximal hamstring repair overall results in higher patient satisfaction and return to sport. While large studies have yet to report on outcomes compared with the traditional open technique, the smaller incisions look to reduce wound complications and postoperative pain. Discussion/Conclusion: Recent advancements in endoscopic techniques have allowed for adequate visualization and robust repair of proximal hamstring avulsions. We present our endoscopic technique of the proximal hamstring, which, compared with the traditional open repair, can decrease perioperative complications and accelerate recovery.

The surgical repair of proximal hamstring avulsions.

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. 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. 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). 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.

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.

Endoscopic Approach to Proximal Hamstring Avulsion Repair.

Endoscopic repair of a proximal hamstring avulsion promotes precise anatomical repair and lowers the risk of neurovascular injury. Indications for proximal endoscopic repair of the proximal part of the hamstrings include acute tears of 2 tendons with >2 cm of retraction in young active patients, acute complete tears of 3 tendons with >2 cm of retraction, or failed conservative treatment of tears of ≥2 tendons with ≤2 cm of retraction. Repair of a proximal hamstring avulsion is performed using 2 portals. The medial portal is developed percutaneously under fluoroscopic guidance. The lateral portal is developed under direct visualization. The footprint of the hamstrings is identified from medial to lateral. The sciatic and posterior femoral cutaneous nerves must be carefully identified and protected. The avulsed tendons are fixed with suture anchors with the knee in flexion. Conservative treatment is commonly used to treat injuries of the musculotendinous junction (type 2), incomplete or complete avulsion with minimal retraction (≤2 cm) (type 3 or 4, respectively), and patients with limited mobility or severe comorbidities1. The initial treatments consist of RICE (rest, ice, compression, and elevation), protective ambulation, and then physical therapy. Open repair is used for incomplete or complete avulsion with >2 cm of retraction, or when conservative treatments have failed1-3. Open reconstruction is used for chronic avulsion with tendon retraction of >5 cm4-6. Endoscopic surgery is a minimally invasive procedure that offers excellent visualization of the subgluteal space without gluteus maximus muscle retraction. In open repair, the inferior border of the gluteus maximus muscle is mobilized to access the ischial tuberosity. The mean distance (and standard deviation) from the inferior border of the gluteus maximus muscle to the hamstring origin has been reported to be 6.3 ± 1.3 cm, which is close to the mean distance from the inferior border of the gluteus maximus to the inferior gluteal nerve and artery, which has been reported to be 5.0 ± 0.8 cm7. Open repair, which requires gluteus maximus retraction, poses an injury risk to the inferior gluteal nerve and artery. Open repair increases the risk of wound infection because the incision involves the perineum8. The feasibility of the endoscopic repair depends on the chronicity and amount of tendon retraction. It is feasible for a symptomatic tear of ≥2 tendons with a retraction of ≤2 cm. Mobilization of the retracted tendon is challenging in endoscopic repair. In acute injuries, the degree of retraction is not critical because the tendon is easily mobilized. Chronic injuries (>2 months) and those with far tendon retraction (>5 cm) are not suitable for endoscopy9. In chronic injuries with incomplete or complete avulsion with minimal retraction (≤2 cm) (types 3 and 4) that have failed conservative treatment, endoscopy is suitable since the tendon is not retracted1. Endoscopic repair can be converted to an open procedure in difficult endoscopic conditions.

Endoscopic Repair of Proximal Hamstring Tear With Double-Row Suture Bridge Construct

Hamstring strains account for 25% to 30% of all muscle strains and are an exceedingly common injury in the athletic population. Although proximal hamstring avulsion injuries occur less commonly than strains at the myotendinous junction, they are more severe and debilitating. Proximal hamstring avulsions do not respond well to conservative treatment and are more likely to require surgical intervention. Surgical repair of proximal hamstring avulsions is indicated when the injury fails to respond to conservative treatment, in cases of osseous avulsion with retraction, and in cases of tearing of all 3 hamstring tendons. Endoscopic repair of proximal hamstring avulsions is a promising technique to repair these injuries while reducing morbidity. We describe our technique for endoscopic proximal hamstring repair, which uses a double-row suture bridge construct to reattach the tendons to the ischial tuberosity.

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

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.

Accelerated Rehabilitation Following Repair of Proximal Hamstring Avulsion: 4 Year Outcomes

Objectives:Proximal hamstring tears are relatively uncommon injuries, but can lead to persistent pain and disability. Previous literature has described avulsion of all three proximal tendons, avulsion of two tendons with retraction of over 2 cm, and tendon avulsions with failure of non-operative management as indications for operative repair. Most previous studies have utilized post-operative protocols that include some form of brace immobilisation to restrict hip flexion and knee extension and/or a limited weight-bearing period. We hypothesize that proximal hamstring repair utilizing an accelerated rehabilitation protocol that allows full weight-bearing without immobilization immediately post-operative will result in similar outcomes to published series and that better results will be noted in acute repairs (surgery within 4 weeks of injury).Methods:Retrospective chart review identified 47 proximal hamstring tendon repairs in 43 patients performed at our institution between 2008 and 2015. Proximal hamstring tendon repair was carried out with suture anchors by a single sports medicine fellowship-trained orthopaedic surgeon. Post-operative rehabilitation included no immobilization or limited weightbearing. Patients were only instructed to avoid rapid walking for 6 weeks post-operative. Clinical history, radiographic findings, and surgical details were obtained from chart data. Patients were then contacted to by phone to assess outcomes following surgery utilizing the lower extremity functional score (LEFS), the single assessment numeric evaluation (SANE), and Marx activity scale. Complications and repair failures were also noted. Overall patient-reported scores were calculated and results of acute and chronic repairs were compared.Results:Thirty-four patients who underwent a total of 38 proximal hamstring repairs (80.8%) were available for follow-up via phone interview at a mean of 4.1 ± 2.0 years following proximal hamstring repair. There were two re-tears: one rupture at 5 weeks post-op and one partial rupture at 10 weeks post-op. Overall, patients reported high satisfaction with the procedure, with a mean LEFS score of 87± 21%, a mean SANE score of 88.1 ± 11.6, and a Median Marx activity score of 5. The acute repair group was noted to have a higher mean LEFS score (93.7 ± 11.1%) than the chronic repair group (79.8 ± 28.8%), p = 0.046. The average SANE score in the acute group (91.3 ± 8.3) was also significantly higher than in the chronic group (83.8 ± 14.3), p = 0.047. The median Marx Activity scale was similar in the acute (median = 5.5) and chronic (median = 5.0) groups (p = 0.88).Conclusion:Proximal hamstring tendon repair followed by post-operative rehabilitation that included no immobilization or limited weight bearing resulted in patient-reported outcomes scores and repair failure risk that were similar to previously published series that utilized more limiting post-operative protocols. Better patient-reported outcomes were noted in repairs performed within 4 weeks of injury.

Outcome After Surgical Repair of Proximal Hamstring Avulsions

Background: At the present time, no systematic review, including a quality assessment, has been published about the outcome after proximal hamstring avulsion repair. Purpose: To determine the outcome after surgical repair of proximal hamstring avulsions, to compare the outcome after acute (≤4 weeks) and delayed repairs (>4 weeks), and to compare the outcome after different surgical techniques. Study Design: Systematic review and best-evidence synthesis. Methods: PubMed, CINAHL, SPORTdiscus, Cochrane library, EMBASE, and Web of Science were searched (up to December 2013) for eligible studies. Two authors screened the search results separately, while quality assessment was performed by 2 authors independently using the Physiotherapy Evidence Database (PEDro) scale. A best-evidence synthesis was subsequently used. Results: Thirteen studies (387 participants) were included in this review. There were no studies with control groups of nonoperatively treated proximal hamstring avulsions. All studies had a low methodological quality. After surgical repair of proximal hamstring avulsion, 76% to 100% returned to sports, 55% to 100% returned to preinjury activity level, and 88% to 100% were satisfied with surgery. Mean hamstring strength varied between reporting studies (78%-101%), and hamstring endurance and flexibility were fully restored compared with the unaffected side. Symptoms of residual pain were reported by 8% to 61%, and reported risk of major complications was low (3% rerupture rate). No to minimal difference in outcome was found between acute and delayed repair in terms of return to sports, patient satisfaction, hamstring strength, and pain. Achilles allograft reconstruction and primary repair with suture anchors led to comparable results. Conclusion: The quality of studies included is low. Surgical repair of proximal hamstring avulsions appears to result in a subjective highly satisfying outcome. However, decreased strength, residual pain, and decreased activity level were reported by a relevant number of patients. Minimal to no differences in outcome of acute and delayed repairs were found. Limited evidence suggests that an Achilles allograft reconstruction yields results comparable with primary repair in delayed cases where primary repair is not possible. High-level studies are required to confirm these findings.

Successful Clinical Outcomes Of Proximal Hamstring Avulsion Repair In Athletes Presenting Within 6 Weeks, 6 Months And After 6 Months Of Injury

Successful Clinical Outcomes Of Proximal Hamstring Avulsion Repair In Athletes Presenting Within 6 Weeks, 6 Months And After 6 Months Of Injury

Successful Clinical Outcomes Of Proximal Hamstring Avulsion Repair In Athletes Presenting Within 6 Weeks, 6 Months And After 6 Months Of Injury

Successful Clinical Outcomes Of Proximal Hamstring Avulsion Repair In Athletes Presenting Within 6 Weeks, 6 Months And After 6 Months Of Injury

Self-Reported and Performance-Based Functional Outcomes After Surgical Repair of Proximal Hamstring Avulsions

Background: Because a proximal hamstring avulsion results in residual loss of function, surgical repair is recommended. Few studies have investigated postoperative function with validated outcomes. Purpose: To examine lower extremity function after surgical repair of proximal hamstring avulsions using validated self-reported and performance-based functional outcomes. Study Design: Case series; Level of evidence, 4. Methods: Operative records from 2006 to 2010 were retrospectively reviewed in 3 hospitals. A total of 39 patients who had undergone surgical repair of a proximal hamstring avulsion were identified, and 36 met the inclusion criteria. Thirty-one patients completed questionnaires with demographic background data and quality of life–related questions: the Lower Extremity Functional Scale (LEFS) and the Proximal Hamstring Injury Questionnaire (PHIQ). Thirty patients were evaluated using a Biodex dynamometer for isokinetic quadriceps and hamstring strength measurements at a velocity of 60 deg/s, and 27 patients performed 4 single-legged hop tests. Results: Twenty-eight repairs were acute (<4 weeks), and 3 were chronic. There were complete ruptures of all 3 tendons in 17 (55%) cases. The mean follow-up was 30 months. Most patients experienced little or no pain or limitations during activities of daily living. The mean LEFS score was 89%, and 29 (94%) of the 31 patients were satisfied with the result after surgery. Eighteen (58%) of the 31 patients had returned to their preinjury activity level. Significant differences in the mean hamstring strength (peak torque) (P < .001) and single-legged hop test (P = .01) between the uninvolved and involved leg were found. Twenty-two (71%) of the 31 patients did not fully trust their operated leg during physical activities and feared sustaining a hamstring injury. Return to activity significantly correlated with the single-legged hop test, the LEFS score, and the questions regarding trust and fear. Conclusion: In this study, using both validated self-reported and performance-based outcome measures after surgical repair of proximal hamstring avulsions, minor pain and limitations to activities of daily living were seen. Isokinetic hamstring strength in the operated leg was significantly lower compared with the nonoperated leg, and a majority of the patients did not trust the operated leg completely during physical activity.

Endoscopic Repair of Proximal Hamstring Avulsion

Hamstring muscle injuries are common in athletes and mostly consist of sprains at the myotendinous junction, which often respond well to conservative treatment. Proximal hamstring avulsion injuries, though less common, can be severely debilitating. This injury is often seen in water skiers but has been described in many other sports and in middle-aged patients. Complete avulsions in young and active individuals do not respond well to conservative treatment and may require surgical repair. In contrast, many partial tears may be treated nonoperatively. However, when symptoms continue despite a trial of extensive therapy, surgery may be warranted. Traditional surgery for proximal hamstring repair is performed with the patient in the prone position with an incision made longitudinally or along the gluteal fold, followed by identification of the torn tendons and fixation to the ischial tuberosity. We describe a novel surgical technique for endoscopic repair of proximal hamstring avulsion injuries.

Functional Results and Outcomes After Repair of Proximal Hamstring Avulsions

Background: The purpose of this study was to assess postsurgical outcomes in active patients after primary repair of acute and chronic proximal hamstring tears. Hypothesis: Surgical treatment of both acute and chronic proximal hamstring avulsion injuries would result in improved patient outcomes using validated outcome scores and a hamstring-specific questionnaire, and operative repair of these injuries results in excellent outcomes with a high level of patient satisfaction, pain relief, and return to function. Study Design: Case series; Level of evidence, 4. Methods: Fifty-two patients who underwent proximal hamstring repair (26 male and 26 female; average age, 47.7 years) completed the Lower Extremity Functional Scale (LEFS), a custom LEFS, the Marx Activity Scale, a custom Marx scale, a proximal hamstring score (which combines the sum of the custom LEFS and Marx), and a proximal hamstring questionnaire with subjective questions. Forty patients were characterized as having acute repairs, and 12 patients had chronic repairs. All patients underwent surgical repair with 5 suture anchors on the ischial tuberosity through a transverse incision. The rehabilitation protocol was also similar with the use of a hip orthosis for 6 to 8 weeks, allowing progressive weightbearing and range of motion. Results: The mean follow-up in our study was 33 months (range, 12-76 months). The mechanism of injury in 28 patients was eccentric hip flexion and knee extension in the ipsilateral knee typically caused by a slip and fall accident. One patient’s injury was caused by trauma to the proximal hamstring. In 23 patients, hamstring injuries were sports related. Overall, 51 (98%) were satisfied with their outcome after surgery. The LEFS, Marx, custom LEFS, custom Marx, and proximal hamstring scores for patients with acute injuries were 76.2, 10.0, 71.4, 20, and 91.7, respectively. For those with chronic injury, the scores were 71.5, 10.4, 70.8, 18.7, and 89.8, respectively. The scores were not statistically different for LEFS, Marx, custom LEFS, and proximal hamstring scores (P = .22, P = .6, P = .72, and P = .6, respectively). Patients with acute injury did have a greater custom Marx score (P = .001). Postoperatively, 5 patients (9.6%) had burning pain or numbness in the posterior thigh or foot, and 25 (48%) had at least some discomfort sitting. Thirty-five patients (67%) reported they could participate in strenuous activities at their latest follow-up. All patients estimated their strength recovery at ≥75%. Conclusion: Results of this study indicate successful outcomes for both acute and chronic repairs, although patients with the acute repairs had higher functional and hamstring scores, and estimated hamstring strength.

Functional Outcome After Repair of Proximal Hamstring Avulsions

Rupture of the proximal origin of the hamstrings leads to pain, weakness, and a debilitating decrease in physical activity. Repair of these injuries should be based on the expectation that these deficits can be addressed. The goal of this study was to objectively evaluate the efficacy of repair of proximal hamstring avulsions. Thirty-four patients were identified retrospectively to have a complete rupture of the proximal origin of the hamstrings based on the presence of a bowstring sign and the results of magnetic resonance imaging (MRI).Patients were contacted for follow-up evaluation to fill out a subjective questionnaire, to undergo functional testing, and to undergo isokinetic testing on a Cybex dynamometer. Twenty-three patients were evaluated. There were nine acute and fourteen chronic repairs, and the average period of follow-up was 43.3 months. Twenty-one of twenty-three patients reported returning to activity at an average of 95% of their pre-injury activity level at an average of 9.8 months. Eighteen patients reported excellent results; four, good results; and one, fair results. Hamstring strength was an average of 93% and 90% of that in the uninvolved limb at 240° per second and 180° per second, respectively. The hamstrings-to-quadriceps ratio was 56% for 240° per second and 48% at 180° per second. Hamstring endurance was an average of 81% and 91% of the nonoperative limb at 240° per second and 180° per second, respectively. Postoperative quadriceps strength and endurance were positively correlated with return to pre-injury level of activity (r = 0.6, p < 0.05; and r = 0.6, p < 0.05) and negatively correlated with time to return to sport (r = -0.5, p < 0.05; and r = -0.5, p < 0.05). There was no significant effect associated with age or time from injury. Repair of a symptomatic and displaced ruptured proximal hamstring tendon yields good subjective and objective functional results with minimal complications. Overall, patients are satisfied with surgical repair and experience return of functional activity with minimal postoperative weakness.

Proximal Hamstring Avulsion Injuries: A Technique Note on Surgical Repairs

Proximal hamstring avulsions from the ischium are becoming more frequently recognized, secondary to their disability when treated nonoperatively. The acute repair of these injuries is becoming prevalent given the improved outcomes reported in the literature. Anatomic studies have recently been conducted on the proximal hamstring origin; however, there are few reports on surgical techniques for repair in the setting of injury. The present article describes the technique for proximal hamstring avulsion repair, as performed by the senior author. More than 30 cases have been performed based on this technique, with excellent results.