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

Abstract

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.

Hamstring muscle injuries in athletics

“…Given such lack of evidence, the multidisciplinary panel of experts of the "London consensus" on HMI highlighted the agreed indications for surgical reconstruction of HMI which were in line with the available literature recommendations [57]. For example, injuries with anatomic gaps, loss of tension, and those that are not healing after a rehabilitation period are good candidates for operational management, as well as proximal bony avulsions [57]. Any decision-making, however, should be guided by the athlete's personal demands and the odds of a full functional recovery with rehabilitation only [57].…”

“…Higher grade injuries, especially proximal avulsions, are potentially an indication for surgical treatment [85], with equivocal and weak evidence showing either superior [95] or similar [96] outcomes compared to non-operative management, but evidence from randomised controlled trials is lacking [85]. Given such lack of evidence, the multidisciplinary panel of experts of the "London consensus" on HMI highlighted the agreed indications for surgical reconstruction of HMI which were in line with the available literature recommendations [57]. For example, injuries with anatomic gaps, loss of tension, and those that are not healing after a rehabilitation period are good candidates for operational management, as well as proximal bony avulsions [57].…”

“…In 2020, a Delphi study comprised of 2 online surveys of 35 and 99 experts on diagnosing and/or managing HMI interspersed by a face-to-face meeting for 15 of them that took place in London, recently published its results [56][57][58]. Regarding current classification systems, most clinicians preferred the BAMIC system (58%), followed by the "Munich classification" (12%), although they agreed that no single system is entirely adequate to guide clinical decisionmaking and further development should incorporate details on the exact muscle injured, injury mechanism and patient-related outcomes [56].…”

“…For example, injuries with anatomic gaps, loss of tension, and those that are not healing after a rehabilitation period are good candidates for operational management, as well as proximal bony avulsions [57]. Any decision-making, however, should be guided by the athlete's personal demands and the odds of a full functional recovery with rehabilitation only [57]. However, particularly for track-andfield athletes, non-operational management still seems to be preferred even for high-grade injuries [9,22].…”

Revisiting the hamstring injury prevention and rehabilitation literature: filling the gaps!

“…Hamstring injuries receive widespread attention in sports science and medicine due to their impact on athlete performance, health and time loss burden. On the topic of hamstring injury prevention and rehabilitation, ~30 reviews have been published since 2011, alongside clinical practice guidelines (comprehensive list in online supplemental material) and a recent consensus 1–3. The aim of this editorial is to offer a perspective on the existing hamstring injury prevention and rehabilitation literature, highlighting current limitations that could benefit from different research paths in the future.SP110.1136/bjsports-2023-106878.supp1…”