Successful results seen with repair of acute and chronic proximal hamstring ruptures

Investigators found better outcomes in patients with acute, rather than chronic, ruptures.

Issue: June 2012

Recently presented findings show high patient-reported satisfaction, strength and function following repair of acute and chronic proximal hamstring ruptures.

Perspective from Russell F. Warren, MD

“This is the first study to use subjective, validated outcome scales in patients that have undergone proximal hamstring repair,” Steven B. Cohen, MD, said during his presentation at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. “Most studies have looked at strength. One of the problems is that we do not have good studies that assess postinjury, presurgical strength testing for proximal hamstring avulsions, but rather, most studies have assessed postsurgical repair strength. The results of this study indicate successful subjective outcomes for both acute and chronic repairs. However, acute repairs had slightly higher functional and hamstring scores, and estimated hamstring strength. Certainly, from a technical standpoint, acute repairs are easier to perform.”

Cohen and colleagues administered a telephone survey to collect outcome data on 52 patients with a mean age of 48 years who underwent proximal hamstring repair. Of these patients, 40 had acute proximal hamstring ruptures and the remainder had chronic ruptures. Overall, the mechanism of injury was sports-related in 22 patients and most resulted from running and waterskiing, Cohen said.

Surgeons used a transverse approach through the gluteal fascia for each repair, “elevating the gluteus maximus and exposing the hamstring fascia,” Cohen said. “Once the proximal hamstring was found and tagged, we performed a five anchor (3.0 mm bioabsorbable) repair in an X configuration, with two proximal, one central and two distal anchors.”

Postoperatively, patients used a hip orthosis for 6 weeks to 8 weeks, followed by progression to full weightbearing at 4 weeks. Patients were able to return to sports at 5 months to 8 months. The patients had an average follow-up of 33 months.

Most survey respondents (98%) were satisfied with their outcomes. Two-thirds could perform strenuous activities postoperatively and perceived their estimated strength to be 88%. The patients achieved an average Lower Extremity Functional Scale (LEFS) score of 75.2 out of 80 points. Marx activity scores averaged 10.2 out of 16 points, and proximal hamstring questionnaire scores averaged 91 points out of 100.

“What we found was that Lower Extremity Functional Scale scores were significantly better in acute acute patients compared to chronic, but we did not find this to be statistically significant in the Marx activity or hamstring scores,” Cohen said.

The researchers found two patients had distal deep venous thromboses that resolved, five patients had numbness in their posterior thighs “consistent with femoral cutaneous nerve injury” and 20 patients reported incisional numbness typical of the surgery, Cohen said.

The researchers found no difference in subjective scores for any of the patients who sustained nerve injuries. Half of patients reported discomfort when sitting on hard surfaces, Cohen noted. – by Renee Blisard Buddle

Reference:

Cohen SB, Rangavajjula A, Vyas D, Bradley JP. Functional outcomes following proximal hamstring repair. Paper #670. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.

For more information:

Steven B. Cohen, MD, can be reached at the Rothman Institute, 925 Chestnut St., 5th Flr., Philadelphia, PA 19107; 215-267-7812; email: steven.cohen@rothmaninstitute.com.
Disclosure: Cohen has no relevant financial disclosures.

Perspective

Russell F. Warren, MD

The paper on hamstring injuries and their functional outcome by Jim Bradley and commented on by Steve Cohen is a well done, retrospective phone survey that has the usual difficulties of these types of studies. They conclude that acute repair is better than chronic from the survey. I totally agree with this conclusion as it is far easier and of less risk to the sciatic nerve. However, our study surprisingly did not show significant strength deficits in the chronic cases, but I certainly prefer repair within the first 2 weeks to 3 weeks.

From a technical point of view, we differ in that we have generally needed only two to three anchors using a pulley system to create good fixation. A transverse incision, while more cosmetic, may prove difficult in tears that are more displaced or chronic tears where the tendon is distal and requires nerve dissection. Postoperatively, I have found that most acute repairs can bear weight early using a hip orthosis to prevent flexion. They generally discontinue this at 6 weeks, but can be full weightbearing by 3 weeks to 4 weeks.

The postoperative nerve issues we have also seen, and care for the cutaneous nerve just below the fossa is important. The nerve can vary in its location over the tendon and may require retraction in placing the tendon sutures. The authors have nicely pointed out the significant issues related to proximal hamstring rupture. The issue on the degree of displacement that requires repair is still a bit grey in those tears with 2 cm to 3 cm of displacement where healing may occur, but may not be predictable.

The bow string sign of a missing tendon at the knee with flexion will indicate poor function and the need for repair.

Russell F. Warren, MD

Hospital for Special Surgery, New York

Disclosures: Warren receives royalties from Biomet and Smith & Nephew; has stock or stock options in Cayenne, Orthonet and Regen Biologics; and receives royalties from Wolters Kluwer Health and Lippincott, Williams and Wilkins.