Hamstring Injury: When to Consider Surgical Treatment

Prof. dr. Gino Kerkhoffs

Johannes Tol

www.acesamsterdam.nlOrthopaedic Surgery

‘Typical hamstring injury’ or candidate for surgery?

When to consider surgery?

Free tendon

Intramuscular tendon

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.

Operative Nonoperative P<0.05

Satisfaction (%) 91 53 √

Return to Sports (%) 80 71

Strength (% of other leg) 85 64 √

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?

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) √

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.

Opinion based indications’ for surgery

Top 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 (accepted ISAKOS)

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.

van der Made AD et al. The hamstring muscle complex. Knee Surg Sports Traumatol Arthrosc. 2015 Jul;23(7):2115-22.

Minimal retraction / ‘free’ sciatic nerve

Retraction / ‘trapped’ sciatic nerve

Identification & mobilisation of tendon stump(s)

– Release of adhesions to obtain adequate length

– Reapproximate in knee flexion

Preparation of ischial tuberosity

– Debridement of ischial tuberosity

– Drilling & suture anchor placement

Fixation of tendon stump(s)

– Sutures are secured thoroughly to the tendon stump(s)

– Tendon stump(s) are tightened to the ischial tuberosity

Fixation of tendon stump(s)

– Assessment of tension on repair

– Post-operative bracing/casting

Adolescent athlete

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.

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

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.

Intramuscular tendon injuries

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?

Absent <50% or 50-99% 100%

Intramuscular tendon disruption

Waviness

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.

van der Made AD et al. Intramuscular tendon injury is not associated with an increased hamstring reinjury rate within 12 months after return to play. Br J Sports Med. 2018 Apr 13.

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)

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 (?)