Delayed proximal hamstring tendon repair after ischial tuberosity apophyseal fracture in a professional volleyball athlete: a case report

Abstract Background Ischial tuberosity apophyseal fractures are avulsion fractures of the anatomic footprint of the proximal hamstring tendons. Generally, these injuries are rare and frequently occur in skeletally immature, active patients due to incomplete ossification. Depending on the fragment displacement, non-operative or operative treatment approaches are used. Case presentation We report a case of a 29-year-old professional volleyball athlete who has suffered from a nonunion avulsion fracture for 14 years. Isolated suture anchor fixation was performed after open excision of a large bony fragment followed by excellent clinical and functional outcome at 1 year postoperatively. Conclusion In conclusion, avulsion fractures of the ischial tuberosity with large fragments and restrictions to activities of daily living due to pain can, in individualized cases, be treated with an open excision of the fragment followed by repair of the proximal hamstring tendons using suture anchors.

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A Novel Technique for Proximal Hamstring Tendon Repair: High Reoperation Rate in a Series of 56 Patients

Advances in Orthopedic Surgery ◽

10.1155/2014/891875 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

William Blakeney ◽

Simon Zilko ◽

Wael Chiri ◽

Peter Annear

Keyword(s):

Functional Outcomes ◽

Assessment Tool ◽

Tendon Repair ◽

Return To Sport ◽

Hamstring Tendon ◽

Reoperation Rate ◽

Ischial Tuberosity ◽

Novel Technique ◽

Proximal Hamstring Rupture ◽

Proximal Hamstring

This investigation looked at functional outcomes, following a novel technique of surgical repair using table staples. Patients underwent surgery for proximal hamstring rupture with table staples used to hold the tendon reapproximated to the ischial tuberosity. Functional outcomes following surgery were assessed. We also used a combined outcome assessment measure: the Perth Hamstring Assessment Tool (PHAT). A total of 56 patients with a mean age of 51 (range 15–71) underwent surgery. The mean follow-up duration was 26 months (range 8–59 months). A large proportion of patients (21/56, 37.5%) required reoperation for removal of the staple. Patients that did not require removal of the table staple did well postoperatively, with low pain scores (0.8–2 out of 10) and good levels of return to sport or running (75.8%). Those that required removal of the staple had a significantly lower PHAT score prior to removal, 47.8, but this improved markedly once the staple was removed, with a mean of 77.2 (P<0.001). Although our patients achieved similar outcomes in terms of pain and function, we thought the reoperation rate was unacceptably high. We would not recommend proximal hamstring tendon repair using this technique.

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Mid-term Functional Outcome and Return to Sports after Proximal Hamstring Tendon Repair

International Journal of Sports Medicine ◽

10.1055/s-0035-1564170 ◽

2016 ◽

Vol 37 (07) ◽

pp. 570-576 ◽

Cited By ~ 19

Author(s):

G. Sandmann ◽

D. Hahn ◽

M. Amereller ◽

S. Siebenlist ◽

A. Schwirtz ◽

...

Keyword(s):

Functional Outcome ◽

Tendon Repair ◽

Hamstring Tendon ◽

Return To Sports ◽

Proximal Hamstring

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Excellent clinical outcome and low complication rate after proximal hamstring tendon repair at mid-term follow up

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-019-05748-0 ◽

2019 ◽

Vol 28 (4) ◽

pp. 1230-1235 ◽

Cited By ~ 3

Author(s):

Lukas Willinger ◽

Sebastian Siebenlist ◽

Lucca Lacheta ◽

Markus Wurm ◽

Markus Irger ◽

...

Keyword(s):

Clinical Outcome ◽

Complication Rate ◽

Tendon Repair ◽

Hamstring Tendon ◽

Proximal Hamstring ◽

Excellent Clinical Outcome

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Mid-term Functional Outcome and Return to Sports after Proximal Hamstring Tendon Repair

International Journal of Sports Medicine ◽

10.1055/s-0036-1582349 ◽

2016 ◽

Vol 37 (07) ◽

pp. e8-e8 ◽

Cited By ~ 2

Author(s):

G. Sandmann ◽

D. Hahn ◽

M. Amereller ◽

S. Siebenlist ◽

A. Schwirtz ◽

...

Keyword(s):

Functional Outcome ◽

Tendon Repair ◽

Hamstring Tendon ◽

Return To Sports ◽

Proximal Hamstring

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Variability of United States Online Rehabilitation Protocols for Proximal Hamstring Tendon Repair

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118755116 ◽

2018 ◽

Vol 6 (2) ◽

pp. 232596711875511 ◽

Cited By ~ 7

Author(s):

Harry M. Lightsey ◽

David E. Kantrowitz ◽

Hasani W. Swindell ◽

David P. Trofa ◽

Christopher S. Ahmad ◽

...

Keyword(s):

United States ◽

Range Of Motion ◽

Tendon Repair ◽

Hamstring Tendon ◽

Search Term ◽

Postoperative Rehabilitation ◽

Professional Literature ◽

Rehabilitation Protocol ◽

Rehabilitation Protocols ◽

Proximal Hamstring

Background: The optimal postoperative rehabilitation protocol following repair of complete proximal hamstring tendon ruptures is the subject of ongoing investigation, with a need for more standardized regimens and evidence-based modalities. Purpose: To assess the variability across proximal hamstring tendon repair rehabilitation protocols published online by United States (US) orthopaedic teaching programs. Study Design: Cross-sectional study. Methods: Online proximal hamstring physical therapy protocols from US academic orthopaedic programs were reviewed. A web-based search using the search term complete proximal hamstring repair rehabilitation protocol provided an additional 14 protocols. A comprehensive scoring rubric was developed after review of all protocols and was used to assess each protocol for both the presence of various rehabilitation components and the point at which those components were introduced. Results: Of 50 rehabilitation protocols identified, 35 satisfied inclusion criteria and were analyzed. Twenty-five protocols (71%) recommended immediate postoperative bracing: 12 (34%) prescribed knee bracing, 8 (23%) prescribed hip bracing, and 5 (14%) did not specify the type of brace recommended. Fourteen protocols (40%) advised immediate nonweightbearing with crutches, while 16 protocols (46%) permitted immediate toe-touch weightbearing. Advancement to full weightbearing was allowed at a mean of 7.1 weeks (range, 4-12 weeks). Most protocols (80%) recommended gentle knee and hip passive range of motion and active range of motion, starting at a mean 1.4 weeks (range, 0-3 weeks) and 4.0 weeks (range, 0-6 weeks), respectively. However, only 6 protocols (17%) provided specific time points to initiate full hip and knee range of motion: a mean 8.0 weeks (range, 4-12 weeks) and 7.8 weeks (range, 0-12 weeks), respectively. Considerable variability was noted in the inclusion and timing of strengthening, stretching, proprioception, and cardiovascular exercises. Fifteen protocols (43%) required completion of specific return-to-sport criteria before resuming training. Conclusion: Marked variability is found in both the composition and timing of rehabilitation components across the various complete proximal hamstring repair rehabilitation protocols published online. This finding mirrors the variability of proposed rehabilitation protocols in the professional literature and represents an opportunity to improve patient care.

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Proximal hamstring tendon avulsion: state of the art

Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine ◽

10.1136/jisakos-2019-000420 ◽

2020 ◽

pp. jisakos-2019-000420

Author(s):

Pablo Bertiche ◽

Nicholas Mohtadi ◽

Denise Chan ◽

Per Hölmich

Keyword(s):

Surgical Treatment ◽

State Of The Art ◽

Treatment Options ◽

Diagnostic Testing ◽

Biceps Femoris ◽

Hamstring Tendon ◽

Ischial Tuberosity ◽

Patient Reported ◽

Proximal Hamstring ◽

Non Surgical Treatment

Complete proximal hamstring tendon avulsions from the ischial tuberosity, though infrequent, are the most severe type of hamstring muscle injury in the field of sport medicine. These serious injuries are commonly associated with a delayed or even misdiagnosis, despite obvious clinical findings. The published literature favours surgical repair even though the studies represent lower levels of evidence. Non-surgical treatment is a viable option for lower physical demand patients. This state-of-the-art article reviews the relevant anatomy, the clinical assessment including specific physical examination signs and diagnostic testing in patients suspected of a proximal hamstring avulsion. Up-to-date evidence is reviewed to address surgical and non-surgical treatment options and outcome assessment. The authors provide a detailed description of what would be considered the current worldwide standard of care; an open, suture-anchor-based repair of the avulsed tendon complex (semitendinosus, long head of biceps femoris and semimembranosus) securely to the ischial tuberosity. Also included are surgical tips and tricks, with advice on postsurgical management and rehabilitation. Future perspectives should involve higher quality, prospective research to better define the indications for surgery, evaluate the emerging role of endoscopic repair and disclose complications along with measuring patient-reported outcomes.

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Endoscopic Proximal Hamstring Tendon Repair for Nonretracted Tears: An Anatomic Approach and Repair Technique

Arthroscopy Techniques ◽

10.1016/j.eats.2019.11.022 ◽

2020 ◽

Vol 9 (4) ◽

pp. e483-e491

Author(s):

Amanda N. Fletcher ◽

Brian C. Lau ◽

Richard C. Mather

Keyword(s):

Tendon Repair ◽

Hamstring Tendon ◽

Repair Technique ◽

Proximal Hamstring

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Magnetic resonance neurography evaluation of chronic extraspinal sciatica after remote proximal hamstring injury: a preliminary retrospective analysis

Journal of Neurosurgery ◽

10.3171/2014.4.jns13940 ◽

2014 ◽

Vol 121 (2) ◽

pp. 408-414 ◽

Cited By ~ 11

Author(s):

Matthew D. Bucknor ◽

Lynne S. Steinbach ◽

David Saloner ◽

Cynthia T. Chin

Keyword(s):

Magnetic Resonance ◽

Soft Tissue ◽

Sciatic Nerve ◽

Hamstring Tendon ◽

Tendon Injury ◽

Ischial Tuberosity ◽

Magnetic Resonance Neurography ◽

Cross Sectional ◽

Tissue Abnormalities ◽

Proximal Hamstring

Object Extraspinal sciatica can present unique challenges in clinical diagnosis and management. In this study, the authors evaluated qualitative and quantitative patterns of sciatica-related pathology at the ischial tuberosity on MR neurography (MRN) studies performed for chronic extraspinal sciatica. Methods Lumbosacral MRN studies obtained in 14 patients at the University of California, San Francisco between 2007 and 2011 were retrospectively reviewed. The patients had been referred by neurosurgeons or neurologists for chronic unilateral sciatica (≥ 3 months), and the MRN reports described asymmetrical increased T2 signal within the sciatic nerve at the level of the ischial tuberosity. MRN studies were also performed prospectively in 6 healthy volunteers. Sciatic nerve T2 signal intensity (SI) and cross-sectional area at the ischial tuberosity were calculated and compared between the 2 sides in all 20 subjects. The same measurements were also performed at the sciatic notch as an internal reference. Adjacent musculoskeletal pathology was compared between the 2 sides in all subjects. Results Seven of the 9 patients for whom detailed histories were available had a specific history of injury or trauma near the proximal hamstring preceding the onset of sciatica. Eight of the 14 patients also demonstrated soft-tissue abnormalities adjacent to the proximal hamstring origin. The remaining 6 had normal muscles, tendons, and marrow in the region of the ischial tuberosity. There was a significant difference in sciatic nerve SI and size between the symptomatic and asymptomatic sides at the level of the ischial tuberosity, with a mean adjusted SI of 1.38 compared with 1.00 (p < 0.001) and a mean cross-sectional nerve area of 0.66 versus 0.54 cm2 (p = 0.002). The control group demonstrated symmetrical adjusted SI and sciatic nerve size. Conclusions This study suggests that chronic sciatic neuropathy can be seen at the ischial tuberosity in the setting of prior proximal hamstring tendon injury or adjacent soft-tissue abnormalities. Because hamstring tendon injury as a cause of chronic sciatica remains a diagnosis of exclusion, this distinct category of patients has not been described in the radiographic literature and merits special attention from clinicians and radiologists in the management of extraspinal sciatica. Magnetic resonance neurography is useful for evaluating chronic sciatic neuropathy both qualitatively and quantitatively, particularly in patients for whom electromyography and traditional MRI studies are unrevealing.

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