Hamstring Injury: When to Consider Surgical Treatment

Prof. dr. Gino Kerkhoffs

www.acesamsterdam.nlOrthopaedic Surgery

Gino Kerkhoffs Hans Tol Guus Reurink Mario Maas Pau Golanó

Rolf Peters Claire VerheulVincent GouttebargeMaarten Moen Anne van der Made

‘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 √

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?

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.

‘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)

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.

Incision based on pre-operative planning

– Horizontal (gluteal crease)

– Longitudinal (medial of midline)

– Combined incision

– ! Beware of PFCN

Minimal retraction / ‘free’ sciatic nerve

Retraction / ‘trapped’ sciatic nerve

Exposure

– Retractor on ischial tuberosity for gluteus maximus

– ! Beware of proximal nerves

– Opening of fascia and exploration of hematoma

– Identification & protection of 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

Fixation of tendon stump(s)

– Assessment of tension on repair

– Post-operative bracing/casting

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.

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.

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)

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

Kaplan et al. Heterotopic ossification. J Am Acad Orthop Surg. 2004 Mar-Apr;12(2):116-25.

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.

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