Outcomes following adolescent athlete proximal hamstring apophyseal avulsion bone fragment excision and direct tendon-ischial tuberosity reattachment

Abstract

Apophyseal proximal hamstring bone avulsion is uncommon, occurring in adolescents following sudden forceful contraction of the musculotendinous unit. It can be severely disabling, preventing return to sport. This study assessed outcome following avulsed bone excision and direct hamstring tendon-ischial tuberosity reattachment using bone anchors. Validated hamstring-specific Sydney hamstring orthopaedic research evaluation PROMs were prospectively collected from consecutively treated athletes (7 elite and 11 recreational) by a single surgeon over 13 years.Outcomes at 1-year and final follow-up for primary acute surgery at less than 3 months after injury (group 1), primary chronic surgery at more than 3 months after established nonunion (group 2) and revision following failed screw fixation (group 3) were analyzed with sport participation and level at 1 year. Sixteen primary and two revision procedures were analyzed. Mean injury age was 14.6 years (SD, 1.8). Combined primary mean injury scores improved from 11.89 (SD, 7.32) to 33.31 (SD, 2.30) and showed mean 1 year and final follow-up scores within 0.3-6.1% of preinjury values. Pronounced improvement occurred from injured scores for groups 1 versus 2, respectively at 1 year by 247.7% versus 59.0% and at final follow-up by 251.0% versus 64.1%, for groups 1 versus 2, respectively. Final outcome scores of group 3 were high. All cases returned to preinjury sport level by 1 year and indicated satisfaction to repeat treatment. No significant complications occurred. As the largest series to assess outcomes following this surgical technique, success is highlighted by high score improvements close to preinjury values and return to preinjury sport level.

Systematic Review of Bracing After Proximal Hamstring Repair

“…Of the 26 included articles, 7 studies 4 , 18 , 25 , 26 , 31 , 38 , 41 (n = 291 patients) reported on nonbracing postoperatively, and 19 studies ‖ (n = 985 patients) reported on some form of postoperative bracing. Five of the studies on bracing used hip bracing to limit excessive hip flexion postoperatively, 3 , 12 , 36 , 39 , 45 11 of the studies used a knee brace to limit excessive knee extension, 1 , 2 , 6 , 8 , 9 , 19 - 22 , 24 , 34 and 2 of the studies 29 , 37 used combined hip and knee bracing to limit both excessive knee extension and hip flexion.…”

“…The mean SANE score (93.6%) in the single braced study 8 that used the SANE tool was higher. In terms of general patient satisfaction, 96 of the 108 (88.9%) nonbraced patients in 4 studies 18 , 26 , 31 , 41 reported they were satisfied with their surgical outcome at the final follow-up. In the 12 braced studies ** that assessed patient satisfaction, 407 of 430 (94.7%) patients reported that they were satisfied with their surgical outcome.…”

“…Of the 4 nonbraced studies 18 , 26 , 31 , 38 that assessed successful return to sport, 86 of the 104 (82.7%) patients returned to their prior sport of choice within 12 months of surgery. Ten braced studies 1 , 3 , 8 , 12 , 20 - 22 , 24 , 37 , 45 assessed return-to-sport rates within the first year postoperatively.…”

“…Of the 4 nonbraced studies 18,26,31,38 that assessed successful return to sport, 86 of the 104 (82.7%) patients returned to their prior sport of choice within 12 months of surgery.…”

“…The PHAT, which is measured on a scale of 0 to 100, was used in 1 nonbraced study, 4 in which the mean score was 76 at the final follow-up. In the 3 braced studies 2,9,19 that used PHAT, the mean score at the final follow-up was Nerve injury in sciatic distribution (n = 90) 3,6,12,19,21,22,29,36,45,46 Wound infection (n = 7) 1,6,19,20,45 Rerupture (n = 5) 1,19,45 DVT (n = 2) 19,36,45 Hematoma (n = 2) 29,45 Chronic draining sinus tract (n = 1) 19 CRPS (n = 1) 20 Nerve injury in sciatic distribution (n = 12) 25,26,31,38,41 Wound infection (n = 10) 4,18,26,38,41 Rerupture (n = 9) 25,26,38 DVT (n = 2) 25,38 Osteomyelitis (n = 1) 25 Partial wound dehiscence (n = 1) 38 Seroma (n = 1) 38 Hypertrophic scarring (n = 1) 26 Overall reoperation rate c 0.05% 3.1% a Data are reported as mean (range), n, or percent. CRPS, chronic regional pain syndrome; DVT, dee...…”