What Is Repair Option On Origin
Br J Sports Med. 2006 Aug; 40(viii): 688–691.
Surgical handling of partial tears of the proximal origin of the hamstring muscles
Abstruse
Background
Hamstring injuries are common especially in athletes. Partial and complete tears of the proximal origin may cause pain and functional loss.
Objective
To evaluate the results of surgical treatment for fractional proximal hamstring tears.
Methods
Between 1994 and 2005, 47 athletes (48 cases, 1 bilateral) with partial proximal hamstring tears were operated on. The cases were retrospectively analysed. Before surgery, 42 of the patients had undergone conservative treatment with unsatisfactory results, whereas in five patients the operation was performed inside 4 weeks of the injury.
Results
The mean length of the follow upward was 36 months (range 6–72). The result of the operation was rated excellent in 33 cases, practiced in nine, fair in 4, and poor in two. Forty one patients were able to return to their one-time level of sport after an average of five months (range 1–12).
Decision
In most cases, fantabulous or proficient results can exist expected after surgical repair of partial proximal hamstring tears even after conservative handling has failed.
Keywords: hamstring, muscle, partial tear, surgical treatment, injury
Hamstring muscle strain is ane of the near common injuries in sports that involve running and jumping with rapid dispatch and deceleration.1 These injuries have been reported in various sports, such as soccer, Australian football game, runway and field, and rugby.two ,3 ,4 ,five ,6
The hamstring musculus group consists of the biceps femoris (long and short head), the semimembranosus, and the semitendinosus muscles. They are the major flexors of the human knee and also aid in hip extension. These muscles adhere proximally to the ischial tuberosity, except for the short caput of the biceps femoris, which originates from the linea aspera and the lateral supracondylar ridge of the femur.7 The semitendinosus and the long caput of the biceps femoris accept a conjoint origin from the posteromedial attribute of the ischial tuberosity.eight The semimembranosus arises from a long apartment tendon at the posterolateral aspect of the ischial tuberosity, lateral to the conjoint tendon of the biceps femoris and semitendinosus.viii
Near injuries associated with hamstring muscles are strains and are treated past conservative ways.ane ,9 ,x The virtually serious injury is a complete rupture of the hamstring muscles. Despite the severity and potentially devastating event of this injury, the results of surgical treatment tin oftentimes exist practiced.11 ,12 ,13
In this report we nowadays a series of 48 cases of partial proximal hamstring tear and the results of surgical treatment. To our noesis this is the largest reported serial of this particular injury.
The study protocol was approved by the local hospital ethics committee of Satakunta Central Infirmary, Pori, Finland.
Materials and methods
In this written report, 47 consecutive athletes (48 cases, 1 bilateral) with surgically treated partial proximal hamstring tears were retrospectively analysed. Only partial proximal hamstring tears in athletes were included. There were 13 professional athletes (international level), 15 competitive level athletes, and 19 recreational athletes (tabular array one ). Many of the athletes were referred from other centres later failed bourgeois handling.
Table ane Sports activities of the 28 professional person and competitive level athletes with a partial proximal hamstring musculus tear
| Activeness | Professional | Competitive level |
|---|---|---|
| Soccer | 7 | five |
| Sprinting | – | 3 |
| Basketball | 1 | 1 |
| Water ice hockey | 1 | 1 |
| Aerobics | 1 | – |
| Ballet | – | ane |
| Effigy skating | – | ane |
| Finnish baseball | – | i |
| Judo | 1 | – |
| Karate | 1 | – |
| Middle altitude running | – | i |
| Pole vault | 1 | – |
| Powerlifting | – | 1 |
| Total | 13 | 15 |
There were 32 men and 15 women with an mean historic period of 33 years (range 16–61). The mean age of the professional and competitive level athletes was 25 years and that of the recreational athletes 45 years. The right side was affected in 31 cases and the left in 17 cases.
In all patients, the injury mechanism was similar: an astute hyperflexion of the hip with the ipsilateral knee in extension oftentimes combined with a violent eccentric hamstring muscle contraction. Direct trauma to the ischial tuberosity was not reported in whatever of the cases. Forty six of the injuries occurred during sporting activities. The most common sport was soccer (xvi cases). The two non‐sports related cases resulted from slipping on ice.
Ten of the 28 professional and competitive level athletes were able to participate in their sport earlier surgery. Yet, despite conservative treatment and rehabilitation, their athletic performance decreased and they suffered hurting and weakness during able-bodied activity. Their symptoms prevented the remaining eighteen athletes from participating.
All patients complained of hurting and discomfort of the posterior thigh as well every bit weakness of the affected lower extremity. Other commonly reported symptoms were poor leg control and instability of the knee joint while walking. On clinical exam, tenderness to palpation was reported slightly below or at the ischial tuberosity. A haematoma was found in the posterior thigh in the patients that were seen early. In most chronic injuries, atrophy of the hamstring muscles was a common finding.
A diagnosis of partial tear of the proximal hamstring muscle was suspected on the basis of history, clinical examination, and radiological findings. Magnetic resonance imaging was performed to confirm the diagnosis and evaluate more precisely the extent of the injury (fig 1 ).
Figure 1 Magnetic resonance images of a patient with a partial proximal hamstring tear. (A) Axial image (proton density (PD) TR/TE 3217/xv milliseconds) with an intact left hamstring muscle origin (white arrow). A partially torn right anterior tendon with some intact fibres (black pointer caput) can be seen at the level of the ischial tuberosity. (B,C) Coronal images (PD with fat suppression TR/TE 3200/9.5 milliseconds) showing torn tendon, indicated with blackness arrows, and a haematoma between the muscle bellies, indicated with a blackness star. The biceps femoris part of the conjoint tendon has remained intact (white arrow).
All of the patients were treated surgically betwixt 1994 and 2005. 2 patients were operated on twice. The filibuster from the injury to the functioning varied from two weeks to 9 years (hateful thirteen months; median six months). Five of the operations were performed within 4 weeks of the injury. The remaining patients had at first undergone conservative treatment with unsatisfactory results. At the time of the surgical handling, none of the patients were satisfied with their athletic performance because of the symptoms of the proximal hamstring tear.
Spinal anaesthesia was used in all cases. The patient was placed in a decumbent position, the afflicted leg was draped to allow free motility, and the knee was kept in 30° of flexion. A vertical skin incision was made over the posterior thigh starting from the ischial tuberosity extending 10–15 cm distally. In ii operations, a transverse gluteal crease incision was used. The lower border of the gluteus maximus musculus was freed, and haemostasis was performed. The posterior cutaneous femoral nerve was identified and spared. Fasciotomy was connected distally approximately 15 cm from the origin of the hamstring muscles. The ischial tuberosity was exposed past retracting superiorly the inferior border of the gluteus maximus muscle. In acute injuries, the sciatic nerve was easily exposed lateral to the ischial tuberosity. In chronic cases, careful neurolysis was performed if the sciatic nervus was surrounded by adhesions and scar.
In 43 cases, the torn tendon(s) was reattached using suture anchors (Mitek, Norwood, Massachusetts, USA). The bony surface of the ischial tuberosity was debrided, and ane or ii anchors were used to reattach the tendon(s) usually slightly distal and medial to the original site of the ischial tuberosity to avoid tension. However, in operations performed early, the re‐fixation could be carried out in the anatomical location. In cases in which the torn tendon(s) was distally retracted, the muscles were first mobilised to achieve tension‐complimentary contact with the ischial tuberosity. In five cases, the fixation was performed by suturing the torn tendon(s) to the periosteal bone and to the proximal tendon stump.
An elastic bandage was used for one to ii weeks later the operation. No immobilisation, casts, or orthoses were used. The patients were allowed to begin partial weight‐bearing within two weeks of the operation, and total weight bearing was allowed two to 4 weeks after surgery. Sitting was avoided for the first two weeks. Swimming and water training was allowed two to three weeks after surgery. Isometric muscle exercises and cycling, with gradually increasing fourth dimension and intensity, were begun after four to six weeks. Heavier weight preparation was started two months and running 2 to four months subsequently the operation.
The patients were followed at our outpatient clinic. During the beginning four to five months, there were monthly routine visits, and after that if necessary. Boosted long term follow ups were scheduled for report purposes. At the nigh recent follow up, the patients were asked virtually possible symptoms (pain, weakness, stiffness), overall satisfaction, and their return to pre‐injury level of sport.
The result was graded as fantabulous if the patient was asymptomatic and able to return to the pre‐injury level of sporting activity. If in that location were minor symptoms in the affected leg during sport only the patient was able to render to the pre‐injury level of sport, the result was classified as good. A classification of fair was assigned to the consequence when moderate training was possible merely the patient was unable to carry out strenuous exertion. Finally, the result was classified as poor when the patient had disturbing symptoms fifty-fifty in activities of daily living.
Results
In all 48 cases, a partial proximal hamstring tear was found during surgery. The conjoint tendon of the biceps femoris and the semitendinosus was involved in all cases. In 17 cases, the conjoint tendon alone was torn and the semimembranosus tendon was intact, whereas in 31 cases the semimembranosus tendon and the conjoint tendon were both torn. However, in all 31 cases either the medial or the lateral part of the conjoint tendon remained attached to the ischial tuberosity. In other words, no complete ruptures of the hamstring musculus group were included in the study. Two examples of the surgical findings are presented as schematic drawings ( figs ii and 3 ).
Figure 2 A schematic drawing of partial rupture of left hamstring muscle origin. The semimembranosus tendon and the lateral part of the conjoint tendon of biceps femoris and semitendinosus have torn away from the ischial tuberosity. The medial part of the conjoint tendon has remained intact. The sciatic nervus curves obliquely below the hamstring muscles from the lateral side of the ischial tuberosity.
Figure 3 A schematic drawing of partial rupture of the right hamstring muscle origin. The conjoint tendon of biceps femoris and semitendinosus has completely torn away from the ischial tuberosity. The semimembranosus tendon has remained intact.
The mean length of the follow up was 36 months (range half dozen–72; median 36). The final outcome of the operation was evaluated to be excellent in 33 (69%) cases, good in nine (19%), fair in four (8%), and poor in two (4%) (table two ). Forty one patients (87%; 42 cases, 1 bilateral with both first-class results) were able to return to their pre‐injury level of sports activity later surgical treatment. This took a mean of five months (range 1–12).
Tabular array two Last results of the surgical treatment in 48 cases of fractional proximal hamstring tears
| Group | Excellent | Skillful | Fair | Poor |
|---|---|---|---|---|
| Professional athletes | x | one | 2 | – |
| Competitive level athletes | 10 | 3 | ii | – |
| Recreational athletes | 13 | 5 | – | 2 |
| Total | 33 | 9 | 4 | two |
All 47 patients felt that they had benefited from the surgery, and their able-bodied performance besides as the strength of the operated thigh had improved after the operation. However, the six athletes with a off-white or poor result were non satisfied with their last outcome.
Two professional athletes underwent re‐functioning. The first ane had suffered a new hamstring injury of the operated proximal thigh. Later unsuccessful conservative treatment, a 2d functioning was performed two years after the primary performance. A new partial rupture of the proximal hamstring muscle group was surgically treated and the patient was able to return to the pre‐injury level of sport 7 months afterward this second operation. The last outcome was evaluated to be excellent.
The other professional athlete had a second operation because of an unsatisfactory result subsequently the first operation. He was non able to render to his pre‐injury level of sport despite the re‐functioning and suffered from continuing pain and weakness of the posterior thigh in strenuous sport activities. He finished his professional career but had no symptoms in recreational sports. The final outcome was graded as fair.
After the performance, there was one superficial wound infection, which was effectively treated with antimicrobial drugs. One patient had hypertrophic scarring, and one patient suffered from hyperesthesia of the incision expanse probably because of a partial injury of the posterior cutaneous femoral nerve.
Give-and-take
Hamstring strains and tears are common and can cause considerable morbidity, especially in athletes.14 Experimental and clinical studies have shown that hamstring muscle strains usually occur at the myotendinous junction.15 Most heal with time and generally approved conservative methods.x
If the tear is located at the tendinous function of the proximal hamstring muscles, it may have a trend to remain disabling in spite of conservative treatment. This kind of partial proximal hamstring tear in top level athletes such every bit soccer or track and field professionals may result in decreased able-bodied performance and prolonged fourth dimension out from sports activities considering of persistent hurting and weakness.
To our cognition there are only a few previously published clinical studies in the English literature on the surgical treatment of partial proximal hamstring tears.11 ,16 ,17 In these series, most patients take had a complete rupture of the proximal hamstring muscles, and only a few cases with partial tears have been included. The nowadays report was performed to evaluate the usefulness of surgical treatment in partial proximal hamstring tears in athletes. In our written report, all patients were actively involved in sports, and many were top level athletes.
The typical hamstring injury mechanism is a rapid flexion of the hip combined with knee extension in which the muscle develops tension while lengthening.1 Every bit noted in the present study, partial tears of the proximal hamstring muscles can occur in a diverseness of sports activities. However, in all injuries the mechanism was flexion of the hip with the ipsilateral knee in extension often combined with a trigger-happy eccentric hamstring muscle wrinkle. This kind of history should pb the doctor to suspect a proximal hamstring tear.
In this report, the delay from the injury to surgery was rather long in virtually cases with an average of thirteen months (median six months). In the acute stage, underestimation of the severity of the injury was often the case, besides as poor sensation by the primary care doctors of the treatment options of partial proximal hamstring tears. Therefore the operative handling was oft delayed fifty-fifty when the symptoms persisted despite bourgeois handling and the athletes were not able to participate in their sports activities.
In v of the half dozen cases in which the final outcome was graded as fair or poor, the filibuster from the injury to surgery was 6–34 months (hateful 21). In the sixth case, in which the result was evaluated to exist fair, the surgical repair was performed just over a month subsequently the injury. It seems that a long delay from injury to surgery may take an agin effect on the result. However, there were 17 cases in which the result was excellent or good despite the delay to surgery being over six months.
According to our results, it seems that first-class or good outcomes may be expected after surgical repair in most cases of fractional proximal hamstring tear. However, surgery is technically easier in the acute phase and in that location is often no need for neurolysis of the sciatic nervus. If conservative treatment is chosen, the possibility of surgical treatment should still be kept in listen, especially if the symptoms are prolonged. The awareness of this detail type of injury and the option of surgical repair of partial proximal hamstring tears is of swell importance. An active diagnostic and treatment arroyo is needed as fractional proximal hamstring tears may even threaten the career of an athlete. However, further studies are needed to evaluate who should be treated surgically and at which point surgery should be considered.
Acknowledgements
This study was supported financially past the Satakunta Fundamental Hospital Commune.
Footnotes
Competing interests: none alleged
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What Is Repair Option On Origin,
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