Complete proximal hamstring avulsions: is there a role for conservative management? A systematic review of acute repairs and non-operative management

Buckwalter, Joseph A.; Westermann, Robert W.; Amendola, Annunziato

doi:10.1136/jisakos-2016-000105

Cited by 11 publications

(14 citation statements)

References 31 publications

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“…It is unclear whether between-group differences in PHAT increase can be attributed to a treatment effect. Based on the adjusted analysis, differences in outcomes between operative and non-operative treatment may be more subtle than assumed to date 2 3 5 22. While this cannot be strongly stated because treatment was not randomly allocated, our findings indicate that further comparative studies are necessary and justified.…”

Section: Discussionmentioning

confidence: 72%

“…To facilitate up-to-date shared decision-making, the information provided during the option talk was continuously updated based on annual quantitative interim analyses and emerging evidence. The latter included systematic reviews2 3 and worldwide surveys that evaluated current practice and preferences regarding the decision-making process 9 10. During the study period, decision-making was initially generally operative-minded and non-operative treatment was reserved for middle-aged patients with lower functional demand.…”

Section: Methodsmentioning

confidence: 99%

“…Proximal hamstring tendon avulsion injuries have a substantial burden, compromising sports participation and the more physical aspects of daily life 1–5. Systematic reviews report superior outcome after operative treatment in terms of satisfaction, patient-reported outcome measures, return to sports (RTS) and strength 2–4. Yet, they highlight the risk of bias as most studies are retrospective, and there is a lack of data on non-operative outcome.…”

Section: Introductionmentioning

confidence: 99%

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Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model

et al. 2022

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ObjectiveTo prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions.MethodsPatients with an MRI-confirmed proximal hamstring tendon avulsion were included. Operative or non-operative treatment was selected by a shared decision-making process. The primary outcome was the Perth Hamstring Assessment Tool (PHAT) score. Secondary outcome scores were Proximal Hamstring Injury Questionnaire, EQ-5D-3L, Tegner Activity Scale, return to sports, hamstring flexibility, isometric hamstring strength and MRI findings including proximal continuity.ResultsTwenty-six operative and 33 non-operative patients with a median age of 51 (IQR: 37–57) and 49 (IQR: 45–56) years were included. Median time between injury and initial visit was 12 (IQR 6–19) days for operative and 21 (IQR 12–48) days for non-operative patients (p=0.004). Baseline PHAT scores were significantly lower in the operative group (32±16 vs 45±17, p=0.003). There was no difference in mean PHAT score between groups at 1 year follow-up (80±19 vs 80±17, p=0.97). Mean PHAT score improved by 47 (95% CI 39 to 55, p<0.001) after operative and 34 (95% CI 27 to 41, p<0.001) after non-operative treatment. There were no relevant differences in secondary clinical outcome measures. Proximal continuity on MRI was present in 20 (95%, 1 recurrence) operative and 14 (52%, no recurrences) non-operative patients (p=0.008).ConclusionIn a shared decision-making model of care, both operative and non-operative treatment of proximal hamstring tendon avulsions resulted in comparable clinical outcome at 1-year follow-up. Operative patients had lower pretreatment PHAT scores but improved substantially to reach comparable PHAT scores as non-operative patients. We recommend using this shared decision model of care until evidence-based indications in favour of either treatment option are available from high-level clinical trials.

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Section: Discussionmentioning

confidence: 72%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model

et al. 2022

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“…Since then, many case series have followed and a recent meta-analysis by Bodendorfer et al reviewed 795 high-grade proximal HSI and found that operative treatment had significantly higher patient satisfaction (90.8% vs 52.9%) and hamstring strength (85.0% vs 64.0%) compared with non-operative treatment 7. A further systematic review showed similar improved outcomes with the addition of higher return to sport in surgical repair (94.5%) versus non-operative cases (54.2%) 16. The 2 largest non-operative case series9 17 included in the review had only 24 patients together with an average age of 58.9 (32.5–76.5) and 50.8 years.…”

Section: Surgical Repair Of Proximal Hamstring Avulsionsmentioning

confidence: 99%

“…The timing of surgical repair can significantly influence patient outcomes, with acute intervention reducing return to sport timing and complication rates 7 16 26. A meta-analysis undertaken by Bodendorfer et al found that surgical intervention for proximal hamstring tears within 8 weeks of injury was associated with reduced sciatic nerve complication rates compared with surgery after 8 weeks of injury (3.09% vs 6.61%) 7.…”

Section: Timing Of Surgical Repairmentioning

confidence: 99%

London International Consensus and Delphi study on hamstring injuries part 2: operative management

et al. 2023

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The key indications for surgical repair of hamstring injuries (HSIs) remain unclear in the literature due to a lack of high-level evidence and expert knowledge. The 2020 London International Hamstring Consensus meeting aimed to highlight clear surgical indications and to create a foundation for future research. A literature review was conducted followed by a modified Delphi process, with an international expert panel. Purposive sampling was used with two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering (round 1) questionnaire was sent to 46 international experts, which comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n=15) comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion of each domain, a series of consensus statements were prepared, debated and refined. A round 2 questionnaire was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. The consensus threshold was set a priori at 70% agreement. Rounds 1 and 2 survey respondents were 35/46 (76%) and 99/112 (88.4%), respectively. The consensus group agreed that the indications for operative intervention included: gapping at the zone of tendinous injury (87.2% agreement) and loss of tension (70.7%); symptomatic displaced bony avulsions (72.8%); and proximal free tendon injuries with functional compromise refractory to non-operative treatment (72.2%). Other important considerations for operative intervention included: the demands of the athlete/patient and the expected functional outcome (87.1%) based on the anatomy of the injury; the risk of functional loss/performance deficit with non-operative management (72.2%); and the capacity to restore anatomy and function (87.1%). Further research is needed to determine whether surgery can reduce the risk of reinjury as consensus was not reached within the whole group (48.2%) but was agreed by surgeons (70%) in the cohort. The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence. These guidelines will help standardise treatment of HSIs, specifically the indications and decision-making for surgical intervention.

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Rehabilitation of Hamstring Injuries

Wangensteen

Askling

Hickey

et al. 2020

Prevention and Rehabilitation of Hamstring Injuries

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Complete proximal hamstring avulsions: is there a role for conservative management? A systematic review of acute repairs and non-operative management

Cited by 11 publications

References 31 publications

Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model

Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model

London International Consensus and Delphi study on hamstring injuries part 2: operative management

Rehabilitation of Hamstring Injuries

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