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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...
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Purpose
To ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after arthroscopic posterior shoulder stabilization.
Methods
Medline, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies o...
Citations
... Along with the low-level evidence of the included papers a comparison of the intervention-based outcome remains challenging. Conversely, for hamstring [33,[86][87][88] and Anterior Cruciate Ligament (ACL) [89][90][91][92] injuries extensive research has been done regarding surgical and conservative intervention with detailed rehabilitation plans. The relatively long RTS time of RF injuries warrant similar attention. ...
Rectus femoris (RF) injury is a concern in sports. The management RF strains/tears and avulsion injuries need to be clearly outlined. A systematic review of literature on current management strategies for RF injuries, and to ascertain the efficacy thereof by the return to sport (RTS) time and re-injury rates. Literature search using Medline via PubMed, WorldCat, EMBASE, SPORTDiscus. Eligible studies were reviewed. Thirty-eight studies involving hundred and fifty-two participants were included. Majority (n = 138; 91%) were males, 80% (n = 121) sustained RF injury from kicking and 20% (n = 31) during sprinting. The myotendinous (MT), (n = 27); free tendon (FT), (n = 34), and anterior-inferior iliac spine (AIIS), (n = 91) were involved. Treatment was conservative (n = 115) or surgical (n = 37) across the subgroups. 73% (n = 27) of surgical treatments followed failed conservative treatment. The mean RTS was shorter with successful conservative treatment (MT: 1, FT: 4, AIIS avulsion: 2.9 months). Surgical RTS ranged from 2-9 months and 18 months with labral involvement. With either group, there was no re-injury within 24 months follow-up. With low certainty of evidence RF injury occurs mostly from kicking, resulting in a tear or avulsion at the FT and AIIS regions with or without a labral tear. With low certainty, findings suggest that successful conservative treatment provides a shortened RTS. Surgical treatment remains an option for failed conservative treatment of RF injuries across all subgroups. High-level studies are recommended to improve the evidence base for the treatment of this significant injury.
... Or, même si l'impact fonctionnel de ces désinsertions est peu important chez les patients les moins actifs, 5 chez les patients sportifs, elles peuvent engendrer un handicap avec une absence prolongée avant le retour au sport. 6 Dès le diagnostic posé, une prise en charge médicale et/ou chirurgicale précoce est donc nécessaire. ...
Proximal hamstring tendon proximal lesion is the most severe of hamstring muscles injuries. These serious injuries are commonly associated with a delayed or even misdiagnosis, despite of obvious clinical findings. MRI is essential to confirm diagnosis and to plan the surgery. The published literature suggests surgical repair for active patients. This surgery should be proceeded as soon as possible for better results. This article reviews the relevant anatomy, epidemiology, clinical assessment including specific physical examination signs, imagery, rehabilitation 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 mean RTS rate of 83.7% and the mean time taken to RTS of 6.5 months should give medical professionals and patients an idea of how likely and how soon they might RTS. These results are similar to those reported in a review by Coughlin et al, 50 who found a RTS rate of 87.0% at a mean time of 5.8 months after surgical management. Overall, the RTS rate in this analysis is high for both acute (88.3%) and chronic (87.3%) injuries, but acute repairs resulted in a quicker RTS (4.5 months) compared to chronic injuries (5.5 months). ...
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.
... On the other hand, van der Made et al. [12] reported minimal to no differences in outcome of acute and delayed repairs with similar results in satisfaction, pain, functional scale scores and strength/flexibility. Belk et al. [36] found that the early repair group had the quickest time to return to sports and the highest rate of return to sports, but statistical significance was not reached in neither of these outcomes. Coughlin et al. [37] concluded that no major differences were found in return to sports between acute and chronic groups, discussing that the definition of chronicity varied between studies, which may have influenced the results. In this study, we found acute repair resulting statistically significantly better outcomes in satisfaction (p < .001), ...
... Therefore, the chronicity of partial injuries may cause confounding bias in the analyses of these injuries. Belk et al. [36] concluded in a systematic review that patients with partial and complete hamstring tears can be expected to return to sports at a similar rate after operative repair (partial 96.8% and complete 93.0%, p¼.18), which was similar finding with the systematic review authored by Coughlin et al. [37]. In this study, most of the patients were satisfied in both groups (complete 92% vs. partial 87%). ...
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 MESSAGEs
Surgical 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.
... 1 Proximal injuries such as avulsion or avulsion fractures are rare, 6 but these injuries often require surgical fixation. 7,8 Sports related to proximal hamstring injury mechanism are skiing, dancing, sprinting, and those that require explosive acceleration, as well as sports that combine this with kicking, like soccer. 1,6 All the aforementioned activities require hip flexion with the following hamstring eccentric contraction and injury. ...
... 17,18 Early surgery has been linked with better results and a faster return to sports. 8,17 Specific surgical indications have been established to surgically repair these tears. 6,76,7 The literature recommends surgical repair when 2 or more tendons are involved, a complete tear with 2 cm of retraction, and in patients who have not responded to 3 to 6 months of conservative management. ...
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.
... Similarly, there is a publication bias in that most publications relate to surgical treatment and involve highly active patients. [2][3][4][5] The largest and most recent series represents 263 patients over a 13-year period. The majority occurred during sporting activities, with soccer being the most common followed by tennis in this series. ...
... They concluded that there is a 'paucity of high-quality studies' and that acute surgically treated patients essentially have better outcomes. 9 Coughlin (2018) 3 and Belk (2019) 19 addressed the issue of returning to sport in their systematic reviews. Coughlin included 21 publications and performed both a quality assessment and meta-analysis of the available data. ...
... Their main outcome was a return to sport, which was achieved in the majority of patients treated surgically. 3 Belk (2019) 19 included 16 studies and had similar conclusions with a return to sport in greater than 90% of the patients having a hamstring repair. ...
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.
... 46 (49%) patients returned to their pre-injury level, whereas another 35 (37%) could return at a reduced sport activity level. The numbers were comparable to previous reports, which showed a RTS rate of 80-100%, while the number of patients achieving their pre-injury level was smaller (50-70%) [5,7,9,10,13,15,29,32,34]. Delayed surgery was not only seen to reduce RTS rate but was also associated with a longer rehabilitation period before returning back to sports [5,32]. ...
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.
... Multiple studies have shown success with open repair techniques and, more recently, endoscopic techniques. [2][3][4][5][6][7][8] However, little attention has been given to the potential risk factors for the development of PHI. ...
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.
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.
