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Surgical repair effective for chronic, acute cases of complete hamstring rupture
Researcher describes a new repair technique using Achilles allograft, interference screws.
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SAN DIEGO – A novel surgical technique to repair complete hamstring ruptures allowed patients to regain strength and function and showed promising subjective results, according to investigators.
“Complete rupture of the proximal hamstring accounts for only 1.5% of all hamstring injuries,” said Gregory J. Folsom, MD, during the American Academy of Orthopaedic Surgeons 74th Annual Meeting, here. “As with other rare conditions, there are no randomized studies to guide treatment decisions. The literature is limited to case reports and small case series.”
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Folsom and lead investigator, Christopher Larson, MD, conducted a retrospective review on 26 patients with complete proximal hamstring tears. Larson performed surgery on all of these patients between 2002 and 2005. This is the largest series of patients with this injury to date, Folsom said. The new surgical technique was performed on four of the 26 patients.
Surgical technique
Patients with three-tendon tears and greater than 2 cm of retraction were surgical candidates. Larson enrolled 21 acute cases, treated within 1 month of injury, and five chronic cases with delayed presentation ranging from 4 months to 8 years, Folsom said. Patients averaged 44 years old, and included 12 men and 14 women. Water skiing was the dominant cause of injury, accounting for 65% of cases.
Mobilized tendon
Larson performed the repairs directly with suture anchors and reapproximated the torn tendons to the ischium.
“One of the difficulties in treating chronic cases is that the surgeon is often unable to fully mobilize the tendon for direct repair,” Folsom said. “Sciatic neurolysis’ typically required and repairs are performed via direct mobilization, and repair, as in acute cases, if possible. One of our cases was treated in this manner.”
Larson used an Achilles allograft when a gap remained after mobilization or when augmentation became necessary, Folsom said. “More recently we have left the bone block attached to the graft and secured it into the ischium with an interference screw … the allograft and native tissues are then sutured together.”
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Image: Folsom GJ |
Images: Larson C |
Subjective results
Postoperatively, patients wore knee braces at 90° of flexion, progressing to full extension for 4 to 6 weeks. Larson instructed patients to delay strengthening until 3 months after surgery.
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Folsom and Larson conducted patient interviews in the clinic and by phone for subjective analysis. They obtained subjective follow-up for 20 acute cases at an average 20 months, and for the five chronic cases at an average 17 months.
“Subjective results were good for both [chronic and acute] treatment groups and trends were similar,” Folsom said. “Twenty percent of patients reported pain with activity. Muscle spasms were only seen in the acute group. A sense of poor leg control or giving way was rare in both groups.”
Ninety-six percent of patients reported good leg control, he said. Most patients, including 75% of acute patients and 80% of chronic patients, returned to sports at 6 months.
One patient in the acute group reportedly would not choose to have surgery again.
Isokinetic testing
Using a Biodex dynamometer [Biodex, Corp.], Larson and Folsom performed postoperative isokinetic testing on seven acute cases at an average 1 year, and on three chronic cases at an average 17 months.
The acute group demonstrated an average hamstring deficit of 8% at 60° per second and 12% at 180° per second. Chronic patients demonstrated average deficits of 21% at 60° and 2% at 180°. “With the numbers available, there was no statistically significant difference between the two groups,” Folsom said.
Three complications – all in the acute group – included one case of deep infection, a case of complex regional pain syndrome, and a failed repair, secondary to a fall that required revision, Folsom said.
“Surgical repair or reconstruction [of the hamstring] results in fairly reliable return of strength and function with good subjective results,” Folsom said. “Athletically active patients should be considered for surgery.”
For more information:
- Folsom GJ, Larson C. Results of surgical treatment of acute vs. chronic complete proximal hamstring ruptures. #494. Presented at the American Academy of Orthopaedic Surgeons 74th Annual Meeting. Feb. 14-18, 2007. San Diego.
- Gregory J. Folsom, MD, Ortho KC, 8919 Parallel Parkway, Suite 270, Kansas City, KS 66112; 913-788-7111. He has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
- Christopher Larson, MD, Minnesota Sports Medicine, Twin Cities Orthopaedics, 775 Prairie Center Drive, Suite 250, Eden Prairie, MN 55344; 952-944-2519; clars@med.unc.edu. He receives research or institutional support and funding from Clearant and Arthrotek, and is also a consultant for the companies. He also receives funding from Smith & Nephew.