Hamstring Injury: When to Consider Surgical Treatment

Transcription

1 Hamstring Injury: When to Consider Surgical Treatment Prof. dr. Gino Kerkhoffs Orthopaedic Surgery

2 Gino Kerkhoffs Hans Tol Guus Reurink Mario Maas Pau Golanó Rolf Peters Maarten Moen Vincent Gouttebarge Claire Verheul Anne van der Made

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5 Typical hamstring injury or candidate for surgery?

6 When to consider surgery?

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8 Free tendon Intramuscular tendon

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12 Mechanism Typically forced hip flexion + knee extension Alternatively: with hip abduction (sideways split) van der Made et al. Abduction in Proximal Hamstring Tendon Avulsion Injury Mechanism -A Report on 3 Athletes. Clin J Sport Med Dec 1.

13 Operate or not? Operative Nonoperative P<0.05 Satisfaction (%) Return to Sports (%) Strength (% of other leg) Single-legged hop test (cm) Lower Extr. Functional Scale SF-12 (QoL) Bodendorfer et al. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Am J Sports Med Oct 1.

14 Operate or not? Operative Nonoperative P<0.05 Satisfaction (%) 91 (n=300) 53 (n=17) Return to Sports (%) 80 (n=553) 71 (n=17) Strength (% of other leg) 85 (n=376) 64 (n=10) Single-legged hop test (cm) 119 (n=14) 57 (n=21) Lower Extr. Functional Scale 73 (n=58) 70 (n=28) SF-12 (QoL) 53 (n=72) 53 (n=17) Quality assessment indicated low methodological quality of included studies Bodendorfer et al. Outcomes After Operative and Nonoperative Treatment of Proximal Hamstring Avulsions: A Systematic Review and Meta-analysis. Am J Sports Med Oct 1.

15 Indications for surgery Top 3 decision modifiers : 1. Extent of retraction Median 2 cm (IQR: 2-3 cm) 2. Function Inability to perform activities of daily life / participate in sports 3. Involved tendons Combined conjoint & semimembranosus tendon rupture Expert opinion survey (prepared for submission)

16 Ischial tuberosity 3. Vertical ridge Divides upper region into: 4. Lateral facet Semimembranosus (SM) 5. Medial facet Biceps Femoris (BF) Semitendinosus (ST) van der Made AD et al. The hamstring muscle complex. Knee Surg Sports Traumatol Arthrosc Jul;23(7):

17 van der Made AD et al. The hamstring muscle complex. Knee Surg Sports Traumatol Arthrosc Jul;23(7):

18 Incision based on pre-operative planning Horizontal (gluteal crease) Longitudinal (medial of midline) Combined incision! Beware of PFCN

19 Minimal retraction / free sciatic nerve

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21 Retraction / trapped sciatic nerve

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23 Exposure Retractor on ischial tuberosity for gluteus maximus! Beware of proximal nerves Opening of fascia and exploration of hematoma Identification & protection of sciatic nerve

24 Identification & mobilisation of tendon stump(s) Release of adhesions to obtain adequate length Reapproximate in knee flexion

25 Preparation of ischial tuberosity Debridement of ischial tuberosity Drilling & suture anchor placement

26 Fixation of tendon stump(s) Sutures are secured thoroughly to the tendon stump(s) Tendon stump(s) are tightened to the ischial tuberosity

27 Fixation of tendon stump(s) Assessment of tension on repair Post-operative bracing/casting

28 Fixation of tendon stump(s) Assessment of tension on repair Post-operative bracing/casting

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30 Metzmaker & Pappas. Avulsion fractures of the pelvis. Am J Sports Med Sep-Oct;13(5): Webber & Barr. Age- and gender-dependent values of skeletal muscle mass in healthy children and adolescents. J Cachexia Sarcopenia Muscle Mar;3(1):25-9.

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32 Pelvic avulsion fractures Overall Surgical Nonoperative P<0.05 Excellent outcome 88% 79% RTS (pre-injury level) 92% (µ:12.6 wks) 80% (µ:17.0 wks) N=596. Mean follow-up: 12.4±11.7 months 90% treated nonoperatively Eberbach et al. Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskelet Disord Apr 19;18(1):162.

33 Pelvic avulsion fractures Overall Surgical Nonoperative P<0.05 Excellent outcome 88% 79% RTS (pre-injury level) 92% (µ:12.6 wks) 80% (µ:17.0 wks) >15mm displacement Surgical Nonoperative P<0.05 Excellent outcome 84% 50% Eberbach et al. Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC Musculoskelet Disord Apr 19;18(1):162.

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36 Do these injuries require surgery? Following a rehabilitation program only: 1. Is intramuscular tendon injury associated with delayed RTP? 2. Does intramuscular tendon injury confer an increased re-injury rate?

37 Intramuscular tendon disruption Absent <50% or 50-99% 100%

38 Waviness

39 22 days* 24 days 25 days 32 days* 23 days* 30 days* van der Made AD et al. Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury. Br J Sports Med Jan;52(2):83-88.

40 And with surgery? 8 athletes with intramuscular tendon injury 2 acute, 6 recurrent Excision of scar tissue and suturing of ruptured tendon Additional suture anchor used for very proximal lesions RTP: months Lempainen et al. Central Tendon Injuries of Hamstring Muscles: Case Series of Operative Treatment. Orthop J Sports Med Feb 15;6(2)

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44 Heterotopic ossification Non-neoplastic extraskeletal bone formation Hereditary, non-traumatic or traumatic Traumatic: erroneous healing response in inflammatory environment Typically following direct injury with hematoma formation (contusion) Areas prone to direct impact (e.g. anterior thigh) Sporadically following (repeated) indirect injury

45 Kaplan et al. Heterotopic ossification. J Am Acad Orthop Surg Mar-Apr;12(2):

46 Surgical intervention Persisting complaints restricting ADL or sports activities 6 months Intramuscular lesion (myositis ossificans) N=32, isolated excision 81% returned to pre-injury activity level with no to minimal residual symptoms At the proximal hamstring tendons (following bony/tendinous avulsion) N=11, excision and suture fixation of debrided tendon 64% returned to pre-injury activity level with no to minimal residual symptoms Orava et al. Surgical excision of symptomatic mature posttraumatic myositis ossificans: characteristics and outcomes in 32 athletes. Knee Surg Sports Traumatol Arthrosc Dec;25(12): Orava et al. Surgical excision of posttraumatic ossifications at the proximal hamstrings in young athletes: technique and outcomes. Am J Sports Med Jun;43(6):

47 When to consider surgery? Acute injuries: Full-thickness free tendon avulsion/rupture (retracted 3-hamstring avulsions) Displaced apophyseal avulsion/avulsion fracture Chronic/recurrent injuries: Chronic full-thickness free tendon avulsion Chronic avulsion fracture (i.e. non-union) Persistent/recurrent intramuscular tendon injury Persistent symptomatic heterotopic ossification