Open Repair of Complete Proximal Hamstring Avulsions in Workers’ Compensation Patients

Hamstring Injuries in Athletes: Anatomy, Pathology, and Treatment

Hamstring injuries are common in athletes and result in missed time from sport and activities. Recurrent injury is a persistent issue. Injury location and severity dictate treatment. Complete acute proximal hamstring avulsions are typically treated successfully with open or endoscopic surgery, while partial avulsions commonly are initially treated nonsurgically. If required, surgical repair results in high patient-reported outcomes, satisfaction, and return to activities. Chronic complete proximal avulsions have less predictable outcomes. Myotendinous injuries are typically treated nonsurgically; however, lost time and reinjury are common. Distal myotendinous injuries can lead to greater delay in return to sport and higher reinjury rate than their proximal or midsubstance counterparts. Owing to this, there has been a recent interest in surgical repair, but historically nonsurgical treatment has been the standard. Distal hamstring avulsions require a thorough knee evaluation for isolated hamstring and/or concomitant injuries, with surgical treatment being determined based on injury pattern, including location and severity. Return to sport and activities require a graduated physical therapy program focused on restoring tissue length without excessive strain. Hamstring injury prevention programs are efficacious, but implementation and compliance are variable. The purpose of this study was to describe the current understanding of the anatomy, pathology, and treatment of hamstring injuries in athletes.

Association Between Proximal Hamstring Tear Characteristics and Achievement of Clinically Significant Outcomes After Endoscopic and Open Repair at Minimum 2-Year Follow-up

BACKGROUND

The effect of preoperative tear characteristics and the relative efficacy of open versus endoscopic surgical techniques have not been elucidated for the surgical treatment of proximal hamstring tendon injuries.

PURPOSE

(1) To report on achievement rates of clinically significant outcomes at a minimum 2-year follow-up for multiple patient-reported outcomes (PROs) after surgical treatment of proximal hamstring injuries, stratified according to severity of proximal hamstring injury, and (2) to compare clinical outcomes associated with endoscopic versus open surgical repair for a subset of similarly classified tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A single-surgeon clinical registry was queried for patients who underwent surgical repair for proximal hamstring ruptures between January 2012 and March 2021. Injuries were classified by magnetic resonance imaging as follows: grade 1, incomplete tear with the involvement of 1 or 2 tendons; grade 2, complete tear with the involvement of 3 tendons and ≤2-cm retraction; and grade 3, complete tear with the involvement of 3 tendons and >2-cm retraction. The Patient Acceptable Symptom State (PASS) for multiple PROs was calculated and compared among injury grades and between surgical techniques.

RESULTS

Among 75 patients with a mean follow-up of 30.5 ± 5.1 months, 20 had grade 1 tears, 24 had grade 2 tears, and 31 had grade 3 tears. Favorable 2-year postoperative PROs were demonstrated by each grade for all measured PROs. Patients with grade 3 tears were noted to have significantly lower rates of 2-year PASS achievement for the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Specific (HOS-SS) scales (P≤ .032). Among grade 2 tears, patients treated endoscopically demonstrated significantly greater HOS-SS (endoscopic, 91.7%; open, 58.3%; P = .045) and Patient-Reported Outcomes Measurement Information System for Physical Function (endoscopic, 80.0%; open, 50.0%; P = .033) PASS achievement rates compared with those treated with the open technique. Complication rates were highest in patients with grade 3 tears (45.2%, P = .043).

CONCLUSION

Surgical repair of proximal hamstring tendon tears with varying extents of tendon retraction resulted in high rates of achieving PASS at the 2-year follow-up. Among complete tears with <2 cm of retraction, endoscopic repairs exhibited equal or higher rates of achieving PASS compared with open repairs across multiple PROs at 2 years postoperatively. However, patients with complete tears and retraction >2 cm achieved lower rates of PASS on the HOS-ADL and HOS-SS scales and had a higher rate of complications.

Systematic Review of Complications Associated With Proximal Hamstring Tendon Repair

Background

Although several complications of proximal hamstring tendon ruptures have been reported in the literature, few studies have comprehensively analyzed the complication profile of proximal hamstring tendon repair.

Purpose

To identify the overall rate of complications following proximal hamstring tendon repair and to differentiate these complications into categories.

Study Design

Systematic review; Level of evidence, 4.

Methods

Included in this review were studies that examined surgical repair of proximal hamstring tendon ruptures; all studies were in English and had an evidence level of 4 or higher. No restrictions were made regarding publication date or methodological quality. Data regarding complications were extracted to calculate the overall complication rate as well as the rate of major and minor complications. A quantitative data synthesis was conducted using the chi-square test to compare the proportion of patients who experienced complications with the endoscopic versus open approach.

Results

A total of 43 articles including 2833 proximal hamstring tendon repairs were identified. The overall postoperative complication rate was 15.3% (n = 433). The rate of major complications was 4.6%, including a 1.7% rate of sciatic nerve injury, 0.8% rate of venous thromboembolism, 0.8% reoperation rate, 0.8% rerupture rate, and 0.4% rate of deep infection. Minor complications included a 2.4% rate of posterior femoral cutaneous nerve injury, 2.3% rate of persistent hamstring myopathy, 2.2% rate of persistent sitting pain, 1.8% rate of peri-incisional numbness, 1.1% rate of superficial infection, and 0.8% rate of hematoma/seroma.

Conclusion

Proximal hamstring tendon repair is associated with an overall complication rate of 15.3%, including a 4.6% rate of major complications.