Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model

ObjectiveTo prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions.MethodsPatients with an MRI-confirmed proximal hamstring tendon avulsion were included. Operative or non-operative treatment was selected by a shared decision-making process. The primary outcome was the Perth Hamstring Assessment Tool (PHAT) score. Secondary outcome scores were Proximal Hamstring Injury Questionnaire, EQ-5D-3L, Tegner Activity Scale, return to sports, hamstring flexibility, isometric hamstring strength and MRI findings including proximal continuity.ResultsTwenty-six operative and 33 non-operative patients with a median age of 51 (IQR: 37–57) and 49 (IQR: 45–56) years were included. Median time between injury and initial visit was 12 (IQR 6–19) days for operative and 21 (IQR 12–48) days for non-operative patients (p=0.004). Baseline PHAT scores were significantly lower in the operative group (32±16 vs 45±17, p=0.003). There was no difference in mean PHAT score between groups at 1 year follow-up (80±19 vs 80±17, p=0.97). Mean PHAT score improved by 47 (95% CI 39 to 55, p<0.001) after operative and 34 (95% CI 27 to 41, p<0.001) after non-operative treatment. There were no relevant differences in secondary clinical outcome measures. Proximal continuity on MRI was present in 20 (95%, 1 recurrence) operative and 14 (52%, no recurrences) non-operative patients (p=0.008).ConclusionIn a shared decision-making model of care, both operative and non-operative treatment of proximal hamstring tendon avulsions resulted in comparable clinical outcome at 1-year follow-up. Operative patients had lower pretreatment PHAT scores but improved substantially to reach comparable PHAT scores as non-operative patients. We recommend using this shared decision model of care until evidence-based indications in favour of either treatment option are available from high-level clinical trials.

Comparison of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction using a Bone-patellar Tendon-bone Autograft and that Using a Double-Bundle Hamstring Tendon Autograft

Purpose The purpose of this study was to compare clinical outcomes between revision anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft and that using a double-bundle hamstring tendon (HT) autograft. Methods Consecutive cases of revision ACLRs were reviewed. The Lysholm knee scale and Knee Osteoarthritis Outcome Score (KOOS) were recorded at the final follow-up. The pivot shift test, Lachman test, and anterior knee laxity measurement using an arthrometer were evaluated before revision ACLR and at final follow-up. Contralateral knee laxity was also evaluated, and side-to-side differences noted. The Lysholm knee scale, KOOS, the pivot shift test, Lachman test, and anterior knee laxity were compared between HT versus BPTB autograft recipient groups using the Mann–Whitney test or the t-test. Results Forty-one patients who underwent revision ACLR and followed up for at least 2 years were included. The graft source was a BPTB autograft in 23 patients (BPTB group) and a double-bundle HT autograft in 18 patients (HT group). The mean postoperative follow-up period was 44 ± 28 months in the BPTB group and 36 ± 18 in the HT group (p = 0.38). The HT group had significantly higher KOOS in the pain subscale (less pain) than the BPTB group at the final follow-up (BPTB group 84.2 vs. HT group 94.4; p = 0.02). The BPTB group showed significantly smaller side-to-side difference in anterior knee laxity (superior stability) than the HT group (0.3 vs. 2.6 mm; p < 0.01). The percentage of patients with residual anterior knee laxity in the BPTB group was significantly lower than that in the HT group (9.5% vs. 46.7%; odds ratio, 8.3; p = 0.02). Study Design This was a level 3 retrospective study. Conclusion Revision ACLR with a BPTB autograft was associated with superior results regarding restoration of knee joint stability as compared with that with a double-bundle HT autograft, whereas double-bundle HT autograft was superior to BPTB autograft in terms of patient-reported outcomes of pain. The rest of the patient-reported outcomes were equal between the two groups.

Successful Outcome of Anterior Cruciate Ligament (ACL) Reconstruction by Hamstring Tendon for Anterior Cruciate Ligament Deficit Knee at a University Hospital: A Descriptive Cross-sectional Study

Introduction: Anterior cruciate ligament is a commonly injured and reconstructed ligament in the knee. Unlike in urban areas where sports activities and road accidents are common mechanisms of injuries, the semi-urban and rural population has a different mode of injuries, needs, and expectations. This study explores the prevalence of successful outcome of anterior cruciate ligament reconstruction in by hamstring tendon for anterior cruciate ligament deficit knee at a university hospital. Methods: A descriptive cross-sectional study was conducted at Dhulikhel Hospital, Kathmandu University Hospital from 2018 February to 2020 January among patients having anterior cruciate ligament injuries after ethical approval. Whole sampling technique was used. Functional outcome was assessed with Lysholm scale at the end of at least one year. Data was analysed using Statistical Package for Social Sciences version 11. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage. Results: Out of 66 anterior cruciate ligament reconstruction, 35 (59%) cases had successful outcomes. Excellent outcomes were seen in 9 (15%) cases and 26 (44%) had good outcomes. The mean Lysholm score was 84. Conclusions: Anterior cruciate ligament injuries were seen in heterogeneous populations during their activities of daily living or recreational sports activities. Anatomic anterior cruciate ligamentreconstruction with hamstring grafts provided good functional outcomes, especially among the young population. Our findings are similar to current studies on anterior cruciate ligament-reconstruction.

Double-Layered Quadriceps Tendon Autografts Provide Lower Failure Rates and Improved Clinical Results Compared With Hamstring Tendon Grafts in Revision ACL Reconstruction

Background: We developed a quadriceps-tendon graft technique using a double-layered, partial-thickness, soft tissue quadriceps tendon graft (dlQUAD) for anterior cruciate ligament reconstruction (ACLR). This technique allows simple femoral loop button fixation and a limited harvest depth of the quadriceps tendon. Purpose: To evaluate the outcome of patients undergoing revision ACLR using the dlQUAD technique compared with a hamstring tendon graft (HT). Study Design: Cohort study; Level of evidence, 3. Methods: A total of 114 patients who underwent revision ACLR between 2017 and 2018 were included in this retrospective case series. At a mean follow-up of 26.9 ± 3.7 months (range, 24-36), 89 patients (dlQUAD: n = 43, HT: n = 46) were clinically examined. In addition, patients completed the Lysholm score, Tegner activity scale, subjective International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score, and visual analog scale (VAS) for pain. Postoperative failure of the revision ACLR was defined as a side-to-side difference (SSD) in Rolimeter testing ≥5 mm or a pivot-shift grade of 2 or 3. Results: Nine patients (10.1%) were identified with a failed revision ACLR. There was a significantly lower failure rate with dlQUAD versus the HT group (2.3% vs 17.4%; P = .031). The mean postoperative SSD was significantly less in the dlQUAD group (1.3 ± 1.3 mm [range, 0-5] vs 1.8 ± 2.2 mm [range, 0-9]; P = .043). At the latest follow-up, Tegner and IKDC scores significantly improved in the dlQUAD group compared with the HT group (Tegner: 5.8 ± 1.8 vs 5.6 ± 1.5; P = .043; IKDC: 83.8 ± 12.2 vs 78.6 ± 16.8; P = .037). The pain VAS score was also significantly reduced in the dlQUAD group compared with the HT group (0.9 ± 1.1 vs 1.6 ± 2.0; P = .014). Conclusion: The dlQUAD and HT techniques both demonstrated significant improvement of preoperative knee laxity and satisfactory patient-reported outcome measures after revision ACLR. Compared with the HT grafts, the dlQUAD technique showed lower failure rates and small increases in Tegner and IKDC scores.

Return-to-Sport Outcomes After Primary Ulnar Collateral Ligament Reconstruction With Palmaris Versus Hamstring Tendon Grafts: A Systematic Review

Background: Ulnar collateral ligament (UCL) reconstruction is the current gold standard of treatment for overhead athletes with a symptomatic, deficient UCL of the elbow who have failed nonoperative treatment and wish to return to sport (RTS) at a high level. The palmaris longus and hamstring tendons are common graft choices, but no study has analyzed the existing literature to assess whether one graft is superior to the other. Purpose: To systematically report on the outcomes of UCL reconstruction using palmaris and hamstring autografts. Study Design: Systematic review; Level of evidence, 4. Methods: A combination of the terms “ulnar collateral ligament,” “valgus instability,” “Tommy John surgery,” “hamstring,” and “palmaris longus” were searched in PubMed, Embase, and the Cochrane Library. RTS and return-to-same-level (RSL) rates, patient-reported outcomes, and complications were included for analysis. We used the modified Coleman Methodology Score and risk-of-bias tool for nonrandomized studies to assess the quality of the included studies. Results: This review included 6 studies (combined total of 2154 elbows) that directly compared palmaris and hamstring graft use in UCL reconstruction. Follow-up ranged from 24 to 80.4 months, and the mean patient age across all studies was 21.8 years. The mean RSL across all studies and grafts was 79.0%, and the mean RTS was 84.1%, consistent with results previously reported in the literature. The mean RTS and RSL rates for the palmaris graft group were 84.6% and 82%, respectively; the hamstring graft group showed mean RTS and RSL rates of 80.8% and 80.8%. Meta-analysis revealed no significant difference in RSL between the 2 graft groups (odds ratio, 1.06; 95% CI, 0.77-1.46). The combined complication rate of the included studies was 18.2%, with failure rates ranging from 0% to 7.1%. Conclusion: Results of this review indicated that both palmaris and hamstring tendon grafts are viable options for primary UCL reconstruction. Graft choice should be determined by a combination of patient and surgeon preference.

Comparing the Stiffness of Peroneus Longus Tendon Versus Hamstrings in Anterior Cruciate Ligament Reconstruction: A Biomechanical Study

Background: The use of autografts originating from either hamstring tendons or peroneus longus tendons is a surgical option in anterior cruciate ligament (ACL) reconstruction. Objectives: This research aimed to compare the tensile strength between the hamstring tendon and the peroneus longus tendon in ACL reconstruction. The hypothesis of this study was: Peroneus longus grafts have tensile strength equal to hamstring grafts based on living donor patients. Methods: This cross-sectional study was a biomechanical study examining means and standard deviations (SD) by comparing the tensile strength of peroneus longus tendons and hamstring tendons when used as autograft donors in ACL reconstruction. Results: In this study, 51 patients with reconstructive ACL were enrolled. The mean diameter of the hamstring tendon was 7.86 with SD ± 0.69, while the mean diameter of peroneus longus tendon was 7.67 with SD ± 0.63. The mean diameter of the peroneus longus graft was not significantly different. The mean displacement on the hamstring tendon was 2.44 with SD ± 0.42, while the peroneus longus tendon was 2.06 with SD ± 0.14. The peroneus longus tendon had significantly more tensile strength compared to the hamstring tendon. Conclusions: Diameter of the peroneus longus graft was not significantly different from the hamstring graft. However, the peroneus longus graft had more tensile strength than the hamstring graft based on living donor patients.

Rotator cuff irreparability or failure of repair (re-tear): technical note on middle trapezius tendon transfer for reproduction of supraspinatus function

Purpose Based on its close anatomic features and nearly-collinear force vector to those of supraspinatus muscle, the current article describes a technique of middle trapezius tendon transfer for reproduction of supraspinatus function in the context of rotator cuff irreparability/re-tear management. Methods While seating the patient in beach-chair position, arthroscopic gleno-humeral examination and sub-acromial decompression are initially performed. Hamstring tendons are harvested and fashioned as flattened quadruple sheet. Through McKenzie approach, infraspinatus and subscapularis tendons are repaired. Then, medial half of middle trapezius insertion tendon is harvested from most medial 5-6 cm of the scapular spine. Through McKenzie approach, hamstring sheet is retrieved via a sub-trapezius/sub-acromial corridor from the scapular wound. Hamstring sheet is re-attached to cuff footprint by double row/suture bridge repair configuration. While retracting the scapula and placing gleno-humeral joint in 45O-abduction/45O-external rotation, hamstring sheet is re-attached to released middle trapezius tendon by non-absorbable sutures. Finally, tendon reconstruct is dynamically-tested in different positions of range of motion. Results Transfer of medial portion of middle trapezius insertion tendon (lengthened by interposition hamstring tendon sheet) to cuff footprint was technically feasible. Dynamic testing showed smooth sub-acromial gliding motion of the tendon reconstruct. Conclusion For reproduction of supraspinatus function, hamstring tendon augmented-middle trapezius tendon transfer to cuff footprint heralds a number of technical and biomechanical advantages; thus offering a potential effective modality of cuff irreparability/re-tear management in relatively young patients of high functional demands. However, current description should be investigated in further biomechanical and clinical studies to validate its long-term outcomes.