hamstring injury: when to consider surgical treatment · 2018-10-15 · • at the proximal...
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Hamstring Injury: When to Consider Surgical Treatment
Prof. dr. Gino Kerkhoffs
www.acesamsterdam.nlOrthopaedic Surgery
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Gino Kerkhoffs Hans Tol Guus Reurink Mario Maas Pau Golanó
Rolf Peters Claire VerheulVincent GouttebargeMaarten Moen Anne van der Made
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‘Typical hamstring injury’ or candidate for surgery?
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When to consider surgery?
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Free tendon
Intramuscular tendon
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Mechanism• Typically forced hip flexion + knee extension
– Alternatively: with hip abduction (sideways split)
van der Made et al. Abduction in Proximal Hamstring Tendon Avulsion Injury Mechanism
-A Report on 3 Athletes. Clin J Sport Med. 2017 Dec 1.
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Operative Nonoperative P<0.05
Satisfaction (%) 91 53 √
Return to Sports (%) 80 71
Strength (% of other leg) 85 64 √
Single-legged hop test (cm) 119 57 √
Lower Extr. Functional Scale 73 70 √
SF-12 (QoL) 53 53
Bodendorfer et al. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions:
A Systematic Review and Meta-analysis. Am J Sports Med. 2017 Oct 1.
Operate or not?
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Operative Nonoperative P<0.05
Satisfaction (%) 91 (n=300) 53 (n=17) √
Return to Sports (%) 80 (n=553) 71 (n=17)
Strength (% of other leg) 85 (n=376) 64 (n=10) √
Single-legged hop test (cm) 119 (n=14) 57 (n=21) √
Lower Extr. Functional Scale 73 (n=58) 70 (n=28) √
SF-12 (QoL) 53 (n=72) 53 (n=17)
Quality assessment indicated low methodological quality of included studies
Operate or not?
Bodendorfer et al. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions:
A Systematic Review and Meta-analysis. Am J Sports Med. 2017 Oct 1.
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‘Indications’ for surgeryTop 3 ‘decision modifiers’:
1. Extent of retraction
Median 2 cm (IQR: 2-3 cm)
2. Function
Inability to perform activities of daily life / participate in sports
3. Involved tendons
Combined conjoint & semimembranosus tendon rupture
Expert opinion survey (prepared for submission)
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Ischial tuberosity
3. Vertical ridge
Divides upper region into:
4. Lateral facet
→ Semimembranosus (SM)
5. Medial facet
→Biceps Femoris (BF)
→Semitendinosus (ST)
van der Made AD et al. The hamstring muscle complex. Knee Surg Sports Traumatol Arthrosc. 2015 Jul;23(7):2115-22.
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van der Made AD et al. The hamstring muscle complex. Knee Surg Sports Traumatol Arthrosc. 2015 Jul;23(7):2115-22.
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Incision based on pre-operative planning
– Horizontal (gluteal crease)
– Longitudinal (medial of midline)
– Combined incision
– ! Beware of PFCN
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Minimal retraction / ‘free’ sciatic nerve
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Retraction / ‘trapped’ sciatic nerve
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Exposure
– Retractor on ischial tuberosity for gluteus maximus
– ! Beware of proximal nerves
– Opening of fascia and exploration of hematoma
– Identification & protection of sciatic nerve
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Identification & mobilisation of tendon stump(s)
– Release of adhesions to obtain adequate length
– Reapproximate in knee flexion
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Preparation of ischial tuberosity
– Debridement of ischial tuberosity
– Drilling & suture anchor placement
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Fixation of tendon stump(s)
– Sutures are secured thoroughly to the tendon stump(s)
– Tendon stump(s) are tightened to the ischial tuberosity
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Fixation of tendon stump(s)
– Assessment of tension on repair
– Post-operative bracing/casting
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Fixation of tendon stump(s)
– Assessment of tension on repair
– Post-operative bracing/casting
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Metzmaker & Pappas. Avulsion fractures of the pelvis. Am J Sports Med. 1985 Sep-Oct;13(5):349-58.Webber & Barr. Age- and gender-dependent values of skeletal muscle mass in healthy children and adolescents. J Cachexia Sarcopenia Muscle. 2012 Mar;3(1):25-9.
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Overall Surgical Nonoperative P<0.05
‘Excellent outcome’ 88% 79%
RTS (pre-injury level)
92% (µ:12.6 wks)
80% (µ:17.0 wks)
√
Pelvic avulsion fractures
Eberbach et al. Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskelet Disord. 2017 Apr 19;18(1):162.
• N=596. Mean follow-up: 12.4±11.7 months
• 90% treated nonoperatively
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Overall Surgical Nonoperative P<0.05
‘Excellent outcome’ 88% 79%
RTS (pre-injury level)
92% (µ:12.6 wks)
80% (µ:17.0 wks)
√
>15mm displacement
Surgical Nonoperative P<0.05
‘Excellent outcome’ 84% 50% √
Pelvic avulsion fractures
Eberbach et al. Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskelet Disord. 2017 Apr 19;18(1):162.
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Do these injuries require surgery?
Following a rehabilitation program only:
1. Is intramuscular tendon injury associated with delayed RTP ?
2. Does intramuscular tendon injury confer an increased re-injury rate?
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Absent <50% or 50-99% 100%
Intramuscular tendon disruption
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Waviness
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32 days*24 days 25 days22 days*23 days* 30 days*
van der Made AD et al. Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury. Br J Sports Med. 2018 Jan;52(2):83-88.
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And with surgery?
• 8 athletes with intramuscular tendon injury– 2 acute, 6 recurrent
• Excision of scar tissue and suturing of ruptured tendon– Additional suture anchor used for very proximal lesions
• RTP: 2.5-4.5 months
Lempainen et al. Central Tendon Injuries of Hamstring Muscles: Case Series of Operative Treatment. Orthop J Sports Med. 2018 Feb 15;6(2)
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Heterotopic ossification• Non-neoplastic extraskeletal bone formation
• Hereditary, non-traumatic or traumatic
• Traumatic:
– erroneous healing response in inflammatory environment
– Typically following direct injury with hematoma formation (contusion)
– Areas prone to direct impact (e.g. anterior thigh)
– Sporadically following (repeated) indirect injury
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Kaplan et al. Heterotopic ossification. J Am Acad Orthop Surg. 2004 Mar-Apr;12(2):116-25.
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Surgical intervention• Persisting complaints restricting ADL or sports activities ≥ 6 months
• Intramuscular lesion (myositis ossificans)– N=32, isolated excision
– 81% returned to pre-injury activity level with no to minimal residual symptoms
• At the proximal hamstring tendons (following bony/tendinous avulsion)– N=11, excision and suture fixation of debrided tendon
– 64% returned to pre-injury activity level with no to minimal residual symptoms
Orava et al. Surgical excision of symptomatic mature posttraumatic myositis ossificans: characteristics and outcomes in 32 athletes. Knee Surg Sports Traumatol Arthrosc. 2017 Dec;25(12):3961-3968.Orava et al. Surgical excision of posttraumatic ossifications at the proximal hamstrings in young athletes: technique and outcomes.Am J Sports Med. 2015 Jun;43(6):1331-6.
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When to consider surgery?
• Acute injuries:– Full-thickness free tendon avulsion/rupture (retracted 3-hamstring avulsions)
– Displaced apophyseal avulsion/avulsion fracture
• Chronic/recurrent injuries:– Chronic full-thickness free tendon avulsion
– Chronic avulsion fracture (i.e. non-union)
– Persistent/recurrent intramuscular tendon injury
– Persistent symptomatic heterotopic ossification