Proximal Hamstring Avulsions

guest ed itor:
Peter I. Sallay, MD
Proximal Hamstring Avulsions
OperativeTechniques
in
Sports Medicine
ELSEYI ER
Management of Chronic Proximal
Hamstring
Ruptures: Surgical Treatment
,
Christopher
M. Larson, MD
Proximal hamstring ruptures are often associated with a delay in diagnosis. Patients with
continued disability for months or even years after this injury, present the surgeon with
unique treatment dilemmas. Several studies have shown inferior results with primary repair
or tenodesis of chronic ruptures when compared with acute surgical intervention. Reports
after distal fractional lengthening with proximal repair and allograft reconstruction of
chronic ruptures have shown improved outcomes, approaching those seen after acute
repair. The current article describes the typical presentation, treatment options, and
outcomes after surgical management of chronic proximal hamstring ruptures. In addition, a
specific technique for Achilles allograft reconstruction is outlined in detail.
Oper Tech Sports Med 17:210-214 © 2009 Elsevier Inc. All rights reserved.
tendon rupture, sports medicine, hamstring injury, chronic injury
KEYWORDS
There
ment
have
several hamstnng
studies reponing
surgicalSurgIcal
treatfor been
proXImal
ruptures.I-I6
treatment
ruptures
ability
is generally
in active
associated
recommended
individuals
with this injury.
awareness
of this injury,
frequently
go undiagnosed
uncommon
to have
for acute
to avoid
proximal
Despite
presenting
dis-
the increasing
hamstring
ruptures
early on. As a result,
patients
complete
the potential
still
it is not
months
or even
years after injury with continued
disability.
Management
of patients presenting with symptomatic
chronic proximal
hamstring
ruptures can be challenging
with respect to surgical treatment.
Primary repair with or without fractional
lengthening,
tenodesis,
allograft
augmentation,
and allo-
graft reconstruction
have all been described
for this injury2.5-9.12,15.16 The current article presents the typical presentation,
surgical
and outcomes
string
ruptures.
treatment,
postoperative
after management
In addition,
graft reconstruction,
which
is described in detail.
of chronic
a specific
rehabilitation,
proximal
technique
has been previously
hamof allo-
reponed,
History
Proximal hamstring ruptures can occur in multiple settings,
but are most frequently reported because of water-skiing accidents.I.8.IO,II,14.15 These injuries can also be sustained because of a sporting injury or less frequently from simply an
awkward fall. Lower energy injuries may be associated with a
greater degree of pre-existing proximal hamstring partial tear
and tendinopathy.
The typical mechanism involves an injury
with the affected hip flexed and the knee extended, Many
patients will note an audible pop with extreme pain in the
proximal thigh and buttock region, These injuries can be
quite disabling, and bruising often results over 24-48 hours.
When eliciting a history for a patient with a remote history of
injury to the posterior, proximal thigh, the above findings are
highly suggestive for a previous complete proximal hamstring rupture.
Most patients will improve
over several weeks to months.
with respect to daily activities
Generally, the more active the
patient, the more pronounced
the eventual disability because
of an untreated complete proximal hamstring injury. Patients
presenting late after injury will typically note poor leg control
through the eccentric hamstring phase of gait with running
Minnesota Orthopedic Sports Medicine Institute (MOSMI). Twin Cities Orthopedics. Eden Prairie, MN.
Address reprint requests to Christopher
M. Larson, MD, Minnesota Or-
thopedic Sports Medicine Institute (MOSMI), Twin Cities Orthopedics, 775 Prairie Center Dr, Suite 250, Eden Prairie, MN 55344.
E-mail: clars@med.unc.edu
210
1060-1872/09/$-see front matter © 2009 Elsevier Inc. All rights rcsen'ed.
doi:10. 1053/j.otsm.2009. I 1.001
and brisk walking2.5-8,12,14,15 In addition, patients may note
posterior thigh cramping, subjective weakness, feelings of
"giving way," and sciatica or radicular type symptoms. One
study reponed a mean of 61 % hamstring strength deficit and
an inability to return to sporting activities in 5 patients with
chronic proximal hamstring ruptures, 14A unique situation is
the history of injury of adolescents
with an apophyseal
avul-
211
Chronic proximal hamstring ruptures
Magnetic resonance images of the left thigh and pelvis at the time of injury reveals a complete proximal
hamstring rupture (solid arrow) and the ischial tuberosity (dashed arrow) with approximately 6 cm of distal retraction
in a 45-year-old femalewho sustained a water-skiing injury 2 'years ago.
Figure 1
sion. Although most of these do well with conservative management, significant retraction can lead to the same symptoms noted earlier in the text, in addition to significant
discomfort with sitting secondary to the retracted bony fragment.
Physical Examination
The physical examination of a patient with a chronic proximal hamstring rupture is less dramatic on first inspection
than an acute rupture. Examination is begun in the prone
position. With the knee in 90° of flexion, resisted hamstring
strength is tested and compared with the contralateral side.
The proximal thigh is inspected and palpated for an obvious
"popeye" deformity and lack of proximal tendon contraction
near the ischium with resisted new flexion. Passive hamstring
tension is then evaluated by passively extending the knee
from a position of 90° hip and knee flexion in the supine
position. t5 Markedly decreased tension in the medial greater
than lateral distal hamstrings is consistent with a chronic
proximal hamstring rupture.
Imaging
Plain radiographs are typically unremarkable with the exception of the chronic apophyseal avulsion in adolescents. Magnetic resonance imaging is the study of choice and can accurately reveal the degree of retraction and changes with the
musculature, such as fatty atrophy (Fig. 1). It is helpful to
accurately define the location of the sciatic nerve with respect
to the retracted hamstring tendon as well as the specific
length of tendon retraction. We have found that a chronic
tendon retraction of more than 5 or 6 cm may limit the ability
to primarily repair the chronic rupture and ultimately require
other procedures, such as distal fractional lengthening or
allograft augmentation/reconstruction.
Surgical Indications
The indications for surgery in the setting of a chronic
complete proximal hamstring rupture include continued
weakness that limits activity, poor leg control through the
eccentric phase of gait, recurrent spasm or cramping, and
occasionally associated sciatica. Weakness and poor leg
control are the author's primary indications for surgery. We
have not found that particular lengths of time from injury or
degree of muscle atrophy and tendon retraction are strict
contraindications for surgery. We have performed surgery in
the presence of severe tendon retraction, significant magnetic
resonance imaging evidence of muscle atrophy, and up to 8
years postinjury with significant improvements still noted
postoperatively in a limited number of patients. Despite these
promising outcomes, we remain very careful to realize expectations with patients when considering surgical management
in the chronic setting.
Surgical Technique
for Chronic Ruptures
The patient is placed prone on the operating room table. We
typically use a laminectomy frame. Other frames or alternatively 2 large rolls, 1 under the chest and 1 under the pelvis,
can be used, thus providing approximately 20° of hip flexion.
The entire leg from the posterior pelvis to the fo'ot is prepped
and draped. The foot is prepped and not covered to better
assess sciatic nerve function intraoperatively.
For chronic ruptures, a longitudinal incision starting at the
gluteal crease is made with the length based on the degree of
hamstring retraction (Fig. 2). Sharp dissection is carried
through the skin, subcutaneous tissues, and down to the
hamstring fascia. At this point, the sciatic nerve is identified
and a neurolysis is performed to protect the nerve proximally
and distally. A nerve stimulator is used to further identify the
C.M. Larson
212
1
Intraoperative photo of the left leg of the patient in prone
position. A marker has been used to draw a longitudinal incision
beginning at the gluteal crease and centered over the ischial lUberosity and hamstring tendon.
Figure Z
nerve and differentiate from the surrounding scar tissue (Fig. 3).
The retracted hamstring
tendon is then dissected out and
mobilized (Fig. 4). The ischial tuberosity is identified, and if
the tendon does not reach the ischial tuberosity, an Achilles
allograft is prepared, leaving an 8 X 20 mm bone plug attached (Fig. 5). The ischial tuberosity is cleared of soft tissue
and a guidewire for an 8-mm reamer is placed in the ischial
tuberosity (Fig. 6). It is helpful to verify that at least 20 mm of
the guide pin is within the tuberosity before reaming to verify
that the entire Achilles bone plug and interference screw will
fit within the tunnel and not be prominent. The bone plug of
the Achilles allograft is then placed within the tunnel in the
tuberosity and secured with a 7 or 8 X 20 mm interference
screw (Fig. 7). With the hip flexed 20° on the laminectomy
frame, the knee is then flexed up to 45°, and tension is placed
distally on the Achilles tendon
string tendon.
Under tension,
and proximally
absorbable
sutures
on the hamare used to
Figure 4 The sciatic nerve has been identified (solid black arrow),
and the retracted proximal hamstring stump is mobilized (dashed
arrow).
secure the Achilles
tension is evaluated.
jective. [n general, the allograft hamstring tendon complex
should be taught in 45° of knee flexion but allow for further
knee extension to at least 10° short of full knee extension. If
too little or excessive tension is noted, the previous step is
repeated until appropriate
tension is achieved. Nonabsorbable sutures are then used to secure the final construct in a
locking type manner (Figs. 8 and 9). The wound is copiously
irrigated, and routine skin closure is performed. A hinged
knee brace locked at 90° of knee flexion is then applied at the
conclusion of the case.
For the less common
symptomatic
chronic
proximal
ap-
ophyseal injury with significant retraction, continued weakness, ancIJor difficulty sitting, we use the same exposure as
that noted earlier in the text. Typically, the bony avulsion is
easily identified and mobilized. We have not performed open
reduction and internal fixation of these apophyseal injuries in
the chronic
Figure 3 Intraoperative photo after the initial skin incision is made
with the sciatic nerve identified (arrows) and a nerve stimulator
used during the neurolysis.
allograft to the hamstring
tendon and
Evaluation of tension is somewhat sub-
selling
as the bony
fragment
is typically
over-
Figure 5 Intraoperative image of the prepared Achilles allograft with
an 8 X 20 mm bone plug left attached.
213
Chronic proximal hamstring ruptures
Intraoperative image after exposure of the ischial tuberosity
(white arrow) and placement of a guidewire into the tuberosity
before reaming the tunnel for graft placement.
Figure 6
grown and deformed. In this situation, we simply excise the
bony fragment from the tendon stump, taking care to protect
the sciatic nerve. These injuries are rarely retracted more than
4-6 cm, and a primary repair to the ischium is usually possible after removal of the bony fragment.
Postoperative Rehabilitation
Postoperatively, we have found that a hinged knee brace
allows for adequate protection for allograft reconstruction of
chronic proximal hamstring ruptures. We have not found
that a hip or knee orthosis is necessary in this situation with
secure fixation. The brace is typically worn for 6 weeks, with
the knee locked at 90° of flexion for 2 weeks, 60° of flexion
for 2 weeks, and 30° of flexion for the final 2 weeks. The
brace is kept on at all times with the exception of showering.
A drop-lock type brace can be used to allow for an extension
stop and free passive flexion for ease of sitting and standing.
This intraoperative image shows the Achilles allograft
(black arrows) after the Achilles bone plug has been secured into the
ischial tuberosity with a metal interference screw.
Figure 7
Intraoperative image of the final Achilles tendon/proximal
hamstring construct (solid arrows) secured with nonabsorbable sutures in a locking-type fashion. The sciatic nerve is also shown
(dashed arrows).
Figure B
We do not use physical therapy in the first 6 weeks after
surgery. At 6 weeks postoperatively, the brace is discontinued and crutches are weaned.
We begin physical therapy with gentle range of motion and
core strengthening at 6-8 weeks postoperatively, and implement resisted hamstring strengthening at around 10 weeks.
Although riding a stationary cycle is permitted without toeclips at 6-8 weeks postoperatively, we generally avoid functional sports until 4-6 months after surgery. Most patients are
able to return to jogging and other sporting activities by 6
months and continue to improve for at least a year with
respect to strength and function.
Postoperative anteroposterior radiograph demonstrates the
interference screw (black arrow) in the ischial tuberosity with the
Achilles tendon bone plug placed lateral to the graft.
Figure 9
214
Outcomes
Although there has been an increase in the number of studies
regarding surgical treatment of proximal hamstring ruptures,
the results after treatment of chronic ruptures are limited to
case repons and small series2.5-9.12.15.16
There are even fewer
repons comparing the outcomes between acute and chronic
surgical repair of proximal hamstring ruptures2.5-9,l5.16
Cross et al12 evaluated 9 patients who underwent direct
repair of chronic proximal hamstring ruptures at a mean 36
months after injury. The repairs were only possible after Oexing the knee to nearly 90° and immobilization in this position
of Oexion for 8 weeks postoperatively. This technique resulted in a 40% strength deficit at most recent follow-up. In
another study, 4 chronic proximal hamstring ruptures were
treated with direct repair or tenodesis, with poor results
noted in 75%6 Sarimo et a]l6 reponed on 41 proximal hamstring ruptures that were surgically repaired. Twenty-two
patients underwent repair within 3 months, whereas 19 underwent repair with greater than 3-month delay. The risk for
a poor outcome was 28 times greater for patients with a delay
in surgery greater than 6 months in comparison with those
undergoing surgery within 3 months. All but one of the
chronic cases, however, was treated with primary repair.
Klingele and Sallay5reponed a series of 11 patients who underwent proximal hamstring repair. Seven cases were acute repairs and in 4 chronic cases a distal fractional lengthening was
performed before direct primary repair. Excellent outcomes
were reported for both groups, and isokinetic strength was reported to be 83% and 89% of the contralateral side for acute and
chronic ruptures, respectively. We reported our results in 26
patients who underwent surgical treatment of proximal hamstring ruptures8 Twenty-one patients underwent acute primary
repair and 5 chronic cases underwent either a direct primary
repair,l Achilles allograft reconstruction with suture anchors,2
or Achilles allograft reconstruction with interference screw fixation2 At a mean follow-up of 20 months, outcomes were improved with a specific functional questionnaire in all but 1 patient. The mean isokinetic strength was 92 % vs 79% at 60° per
second and 88% vs 98% at 180° per second compared with the
contralateral leg for the acute vs chronic groups, respectively.
We have now performed 36 acute repairs and 8 chronic surgeries (6 Achilles allograft reconstructions). We believe that the use
of an Achilles allograft reconstruction for chronic tears has the
advantage of secure fixation, ease of tensioning the repair, avoids
excessive tension or tethering of the sciatic nerve, and allows for
postoperative mobilization of the leg similar to that for acute
proximal hamstring repairs.
Conclusions
Untreated complete proximal hamstring ruptures can lead to
significant disability in active patients. A detailed history and
C.M. Larson
physical examination can make the diagnosis in most cases.
Although primary repair and tenodesis for chronic injuries
have resulted in suboptimal outcomes, both fractional
lengthening in addition to primary repair and allograft reconstruction have lead to improved outcomes approaching those
seen after acute repair. Allograft reconstruction may simplify
the procedure in comparison with distal fractional lengthening, and with the small numbers available the outcomes have
been rewarding.
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