Proximal hamstring avulsions

 

Proximal hamstring tearProx Hs MRIPelvis

 

Epidemiology

 

Irger et al KSSTA 2020

- 263 cases

- most aged 45 - 69

- 53% male

- 50% occurred during sport

- 66% avulsions displaced > 2cm

- 5% had sciatic nerve symptoms

 

Etiology

 

Violent contraction

- forced hip flexion with knee extended

 

Sporting injury

- water skiing

 

Anatomy

 

PH anatomy 2PH anatomy 1Pelvis

 

Hamstring by definition originate from the (lateral aspect of) the ischial tuberosity

 

Conjoint tendon

- biceps femoris and semitendinosus

- posterolateral aspect of the ischial tuberosity

 

Semimembranosus

- separate attachment

- anterolateral aspect of the ischial tuberosity

 

Symptoms

 

Sudden onset pain

 

Chronic tears

- weakness

- difficulty sprinting

 

Signs

 

Large haematoma / bruise down back of leg

Palpable defect

Distal retraction of muscle into thigh with contraction

 

Proximal Hamstring Rupture BruiseProximal hamstring tear

 

Xray

 

Exclude bony avulsion

 

MRI

 

Complete / retracted tears

 

Proximal Hamstring Avulsion MRI CoronalProx hs tear MRI

Proximal hamstring tear on right (red circle), normal insertion on tuberosity on left (blue circle)

 

Prox Hs MRIProx HS MRI

Proximal hamstring avulsion on right - red circle is retracted hamstring tendon, blue circle is normal insertion on left

 

Prox HS MRIProx HS MRI 2

Proximal hamstring tear on right (red circle), normal insertion on left (blue circle)

 

HS 3HS 1HS 2

Proximal hamstring avulsion, with tendon floating in hematoma / seroma

 

Incomplete tears

 

MRI partial tearPartial tear

High grade partial tear proximal hamstring

 

Classification

 

Type 1:  Osseous avulsions

Type 2:  Tear at the musculotendinous junction

Type 3:  Incomplete avulsion from bone

Type 4:  Complete avulsion with only minimal retraction

Type 5:  Complete avulsion with retraction > 2 cm

 

Management

 

Operative versus non operative management

 

Bodendorfer et al AJSM 2018

- systematic review of 24 studies and 800 proximal hamstring avulsions

- satisfaction: operative 90% versus nonoperative 53%

- strength: operative 85%% versus nonoperative 64%

- functional score: operative 73% versus nonoperative 70%

 

Non operative

 

Indications

- single tendon tears

- partial tears

- minimally retracted tears

- chronic tears

- low function individuals

 

Operative

 

Outcomes

 

Function

 

Hillier-Smith et al Bone J Open 2022

- 35 studies and 1500 surgically repaired cases

- 93% satisfaction

- mean functional outcome score 74

- mean strength 87% compared to other leg

- return to sport 85%

- rerupture rate 1.2%

- sciatic nerve dysfunction 3.5%

- better outcomes with acute repair or partial tears

 

Timing / chronicity

 

Shambaugh et al Orthop J Sports Med 2020

- 93 proximal hamstring repairs

- no difference in outcome < 3 weeks versus < 6 weeks

- increased weakness with repairs > 6 weeks compared < 6 weeks

 

Best et al Orthop J Sports Med 2021

- 204 cases proximal hamstring repairs

- worse outcomes with repair > 6 weeks

 

Partial tears

 

Kayani et al Am J Sports Med 2020

- 41 patients with incomplete chronic partial tears

- excellent outcomes with operative repair

 

Complications

 

Lawson et al Orthop J Sports Med 2023

- 43 articles and 2800 surgically repaired proximal hamstring avulsions

- major complication rate 4.6%

- 1.7% sciatic nerve injury

- 1% seroma / 1% superficial infection, 0.4% deep infection

- 0.8% of DVT / PE

- 2.4% posterior femoral cutaneous nerve numbness

- 0.8% rerupture

 

InfectionProx hs infectioninfeciton

Postoperative infection

 

Surgical Technique

 

Vumedi/proximal hamstring repair

 

Vumedi/chronic proximal hamstring repair

 

Vumedi/high grade avulsions proximal hamstrings

 

Position

- patient prone with knee slightly flexed

 

Incision

- longitudinal incision - better for retracted or chronic injury, find and protect sciatic nerve distally

- horizontal incisions - can use in more acute setting

 

Prox hs incision

 

Superficial dissection

- divide fascia in line with incision

- preserve posterior femoral cutaneous nerve

- identify and elevate inferior edge of gluteus maximus

 

Deep dissection

- identify and preserve sciatic nerve (lateral to hamstring)

 

Hamstring Repair Sciatic NerveHamstring nerveHamstring Repair Sciatic Nerve 2

Hamstring (*) with sciatic nerve lateral to hamstring (blue vessiloop)

 

Identify and release proximal hamstring tendon

 

Proximal Hamstring TendonHamstringProximal Hamstring Tendon

Stump of the conjoint tendon (*)

 

Expose ischial tuberosity

- superior retractor on ischial tuberosity

- medial and lateral retractors, care with sciatic nerve

- use osteotomes to create bleeding

- 2 - 3 suture anchors, double loaded

 

Ischial tuberosityIschial tuberosity

Exposing ischial tuberosity (*) with Cobb retractor

 

Post suture repairProximal hamstring xray

Post suture anchor repair

 

Post operative rehabilitation

- splint with knee flexed

- prevent hip flexion / knee extension

- crutches

 

Proximal Hamstring BraceProx hs brace

 

 

 

Proximal Hamstring Reconstruction

 

Indication

 

Weakness / difficulty running

 

Technique

 

Identify and release sciatic nerve

 

Release hamstring

- see if hamstring will reach

 

Chronic Hamstring Tear 2Sciatic Nerve Release

Sciatic nerve with blue vessiloops

 

Prepare allograft

- tendo achilles

- 9 x 20 mm bone block

- drill to 10 x 25 mm tunnel using ACL instruments

- ensure that beath pin does not advance

- secure with 7 x 20 mm screw, bone typically very strong

 

Drill hole ischial tuberositySecure allograft bone plug with screw 2Post Proximal Hamstring Reconstruction

Ischial tuberosity exposed, then achilles bone block secured with screw

 

Pulvetaft weave tendon through the strongest, thickest part of the stump

 

HS allograftHS recon