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Proximal hamstring tendon avulsion surgery: evaluation of the Perth Hamstring Assessment Tool

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Abstract

Purpose: The purpose of the present study was to validate a new scoring system for proximal hamstring injury-the Perth Hamstring Assessment Tool (PHAT). Methods: This is a prospective series of 74 consecutive proximal hamstring surgical repairs in 72 patients, with a median age of 50.5 years (range 16-74). Patients completed the PHAT, SF12 Health Survey and Lower Extremity Functional Scale (LEFS). The scoring system was validated by calculating its internal consistency, reproducibility, reliability and sensitivity to change. Construct validity was evaluated using Pearson's correlation analysis to examine the strength of association between the PHAT, LEFS and SF-12 scores. Results: The PHAT showed high completion rate (100 %), high internal consistency (Cronbach's alpha 0.80), high reproducibility (ICC 0.84) and high sensitivity to change. There was moderate correlation with the LEFS and low correlation with the Physical Component Score of the SF-12. Conclusion: This study has validated the PHAT as an assessment tool for proximal hamstring tendon injuries. The new questionnaire provides a measure of outcome that is reliable and sensitive to clinically important change. This simple questionnaire provides the clinician with a quick and practical tool for assessing patients with proximal hamstring injuries: to assess pre-operative disability and monitor recovery post-operatively. Level of evidence: II.
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Knee Surgery, Sports Traumatology,
Arthroscopy
ISSN 0942-2056
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-016-4214-y
Proximal hamstring tendon avulsion
surgery: evaluation of the Perth Hamstring
Assessment Tool
William G.Blakeney, Simon R.Zilko,
Steven J.Edmonston, Natalie E.Schupp
& Peter T.Annear
1 23
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1 3
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-016-4214-y
HIP
Proximal hamstring tendon avulsion surgery: evaluation of the
Perth Hamstring Assessment Tool
William G. Blakeney1,2 · Simon R. Zilko1 · Steven J. Edmonston3 ·
Natalie E. Schupp2 · Peter T. Annear4,5
Received: 28 December 2015 / Accepted: 14 June 2016
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2016
The new questionnaire provides a measure of outcome that
is reliable and sensitive to clinically important change. This
simple questionnaire provides the clinician with a quick
and practical tool for assessing patients with proximal ham-
string injuries: to assess pre-operative disability and moni-
tor recovery post-operatively.
Level of evidence II.
Keywords Proximal hamstring tendon · Validation ·
Questionnaire · Surgical repair
Introduction
Proximal hamstring tendon avulsions from the ischial
tuberosity result from forceful eccentric muscle contraction
or excessive passive lengthening, which occurs with sud-
den hyperflexion of the hip with an extended knee [1, 33].
Avulsion injuries most frequently involve the biceps femo-
ris–semitendinosus conjoint tendon and semimembrano-
sus tendon at the ischial tuberosity. Some patients sustain
incomplete avulsions, usually the conjoint tendon in isola-
tion, but occasionally semimembranosus in isolation or a
portion of all three tendons.
There is, to the authors’ knowledge, no validated scoring
system for proximal hamstring tendon avulsions. A range
of non-validated heterogeneous outcome measures have
been utilized to date, including return to sport rates, isoki-
netic strength testing, Harris Hip scores [26], subjective rat-
ing scales [14, 22, 28, 31] and custom hamstring question-
naires which are non-validated [3, 8, 29].
A recent meta-analysis [23] included studies with MRI or
ultrasound-confirmed diagnosis of proximal hamstring ten-
don rupture with a minimum 12 months of follow-up. Of the
13 eligible studies, there were 11 case series (of which only
Abstract
Purpose The purpose of the present study was to validate
a new scoring system for proximal hamstring injury—the
Perth Hamstring Assessment Tool (PHAT).
Methods This is a prospective series of 74 consecutive
proximal hamstring surgical repairs in 72 patients, with
a median age of 50.5 years (range 16–74). Patients com-
pleted the PHAT, SF12 Health Survey and Lower Extremity
Functional Scale (LEFS). The scoring system was validated
by calculating its internal consistency, reproducibility, reli-
ability and sensitivity to change. Construct validity was
evaluated using Pearson’s correlation analysis to examine
the strength of association between the PHAT, LEFS and
SF-12 scores.
Results The PHAT showed high completion rate (100 %),
high internal consistency (Cronbach’s alpha 0.80), high
reproducibility (ICC 0.84) and high sensitivity to change.
There was moderate correlation with the LEFS and low cor-
relation with the Physical Component Score of the SF-12.
Conclusion This study has validated the PHAT as an
assessment tool for proximal hamstring tendon injuries.
* William G. Blakeney
blakeney@gmail.com
1 Department of Orthopaedic Surgery, Fremantle Hospital,
Fremantle, WA, Australia
2 Department of Orthopaedic Surgery, Sir Charles Gairdner
Hospital, Nedlands, WA, Australia
3 Shenton Park Physiotherapy Clinic, Shenton Park, WA,
Australia
4 Department of Orthopaedic Surgery, Mount Hospital, Perth,
WA, Australia
5 Perth Orthopaedic and Sports Medicine, West Perth, WA,
Australia
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Knee Surg Sports Traumatol Arthrosc
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1 was prospective), 1 cohort study and 1 case–control study.
Quality assessment of the studies using the Physiotherapy
Evidence Database (PEDro) scale rated all of the studies as
poor (between 2 and 4 out of 10). The main limitations of the
meta-analysis were the low quality of the included trials and
the heterogeneity of outcome data reported.
Another literature review evaluated 18 studies, including
286 operative and 14 non-operative cases [15]. The authors
concluded that surgical repair of proximal hamstring rup-
tures improved clinical outcomes. Whilst good results have
been reported for patients undergoing surgical repair, the
majority of studies are retrospective reviews with small
case numbers and the potential for significant recall bias.
Previous reviews have been unable to quantify clinical
improvement due to a lack of prospective study design and
pre-operative evaluation, and the majority have used non-
validated outcome measures. There is no validated scoring
system specifically tailored to this type of injury.
The aim of the present study is to validate a self-reported
outcome tool designed to evaluate patients with proximal
hamstring tendon ruptures both pre- and post-operatively,
the Perth Hamstring Assessment Tool (PHAT). The scor-
ing system was administered in a prospective consecutive
series of seventy-four cases with a mean of 34-month fol-
low-up. Once the questionnaire is validated, it will provide
the clinician with a simple and practical tool for assessing
patients with proximal hamstring injuries.
Materials and methods
A prospective series of seventy-four successive proximal
hamstring tendon re-attachments were performed in sev-
enty-two patients between August 2010 and March 2013.
There were 36 females and 36 males with a median age of
50.5 years (range 16–74). All patients who underwent sur-
gery with a minimum duration of follow-up of 12 months
were included. There were no exclusions.
Injuries were confirmed with MRI and classified accord-
ing to the method described by Wood et al. [35] for prox-
imal hamstring avulsion. Type-1 injuries are osseous
avulsions; Type-2 injuries are avulsions at the musculo-
tendinous junction; Type-3 injuries are incomplete tendon
avulsions from bone; Type-4 injuries are complete tendon
avulsions with no or minimal retraction of the tendon ends;
and Type-5 injuries are complete tendon avulsions from
bone with retraction of the tendon ends.
Surgical technique
Surgical repair was performed for all acute Type-3 and
Type-5 injuries with >2 cm retraction and chronic Type-
1, Type-4 and Type-3 or Type-5 injuries with <2 cm
retraction. These were injuries that remained symptomatic
following non-operative treatment of more than 3-month
duration.
All procedures were performed by the senior author. The
hamstring tendons were repaired to the ischial tuberosity
with three 5.5-mm suture anchors with two #2 Fibrewire
sutures. The sutures were passed through the hamstring
tendons using a Krakow locking technique on one end with
a sliding suture on the other end. This allowed the tendons
to be reduced anatomically onto the tuberosity, prior to
tying off the sutures.
Outcome measures
The Perth Hamstring Assessment Tool (PHAT) was devel-
oped to evaluate functional outcomes of proximal ham-
string re-attachment surgery (see “Appendix”). The PHAT
provides a score out of 100, with a higher score corre-
sponding to higher function.
The questionnaire was developed prior to this trial to
assess patients undergoing proximal hamstring surgery.
Patient interviews as well as the senior author’s experience
were used to draft the questionnaire. The questionnaire
uses a visual analogue scale for pain scores as well as cat-
egorical scores for activity levels.
Patients prospectively completed the PHAT and SF12
Health Survey [34] when they were booked for sur-
gery 1–2 weeks pre-operatively and at yearly intervals
post-operatively.
The SF-12 is a peer-reviewed, multipurpose short-form
(SF) generic measure of health status [13]. The SF-12 has
2 subscores: a physical (PCS) and mental (MCS) health
summary measures. The Lower Extremity Functional
Scale (LEFS) was also performed 1 year post-operatively.
All results were collected and evaluated by an independent
observer.
The study was approved by the hospital research and
ethics committee (Mount Hospital EC67.1) and was per-
formed in accordance with the Declaration of Helsinki ethi-
cal standards. All patients gave informed consent prior to
inclusion in the study.
Statistical analysis
The psychometric properties of the PHAT score were tested
as part of this study. Internal consistency was tested at
baseline and 1-year follow-up using Cronbach’s alpha and
calculation of internal correlations between PHAT item
scores and total score.
Reproducibility of the PHAT score was assessed by ask-
ing patients to fill out a repeat questionnaire 1-week later
after the 1-year follow-up. For the reliability analysis, the
intra-class correlation coefficient (ICC) and the standard
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Knee Surg Sports Traumatol Arthrosc
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error of measurement (SEM) for repeated measures were
calculated. The minimal detectable change (MDC) was cal-
culated using the formula MDC = 2*1.96*SEM and used
to define the sensitivity to change. Construct validity was
evaluated using Pearson’s correlation analysis to examine
the strength of association between the PHAT, LEFS and
SF-12 scores. A correlation of r > 0.7 was considered high,
0.5 < r > 0.7 was considered moderate, 0.3 < r < 0.5 was
considered low, and r > 0.3 was negligible [16]. The ceil-
ing effect was assessed by calculating the percentage of
patients with a maximum score. Ceiling effects were con-
sidered to be present if more than 15 % of respondents
achieved the highest possible score.
Descriptive statistics were calculated to summarise
patient characteristics and dependent variables at baseline
and 1-year follow-up. Paired t tests were used to test for
significant change in the PHAT score between baseline and
follow-up. For all analyses, the criterion for statistical sig-
nificance was set at p < 0.05. Measurement of the PHAT
score allowed accuracy to 1 decimal place. The results are
presented with accuracy to 1 decimal place.
Sample size was calculated using a subject-to-variables
ratio of 8. Given there are 8 questions in the PHAT, a mini-
mum sample size of 64 was required.
Results
At 12-month follow-up, seventy-four proximal ham-
string tendon re-attachments in seventy-two patients were
reviewed (see Table 1).
Comparison of pre-operative and post-operative PHAT
scores showed significant improvement at the 1-year fol-
low-up, with a mean increase of 36.4 points (p < 0.001,
95 % CI 30.7–42.1) (Figure 1). An ancillary subgroup
analysis by injury type showed that groups 3, 4 and 5 all
improved by a similar amount at the 1-year mark (see
Table 2). No significant difference was seen in 1-year out-
comes between the 3 main groups.
Evaluation of the PHAT score
Completion rate
None of the patients missed out an item on the pre-opera-
tive or post-operative PHAT questionnaires.
Internal consistency
Cronbach’s alpha for the PHAT questionnaire was 0.80
pre-operatively and 0.77 post-operatively. There were high
correlations between each PHAT question and total PHAT
score pre-operatively (r = 0.53–0.78). Post-operatively,
there were also high correlations between PHAT questions
and overall PHAT score (r = 0.62–0.75), except for local
tenderness (r = 0.27). This suggests, together with the
Cronbach’s alpha scores, that the PHAT questionnaire has
overall high internal consistency.
Reproducibility and sensitivity to change
Sixty-two patients completed a repeat PHAT questionnaire
1-week after the 1-year follow-up. Twelve of the seventy-
four patients (16.2 %) did not return or complete the repeat
questionnaire within an appropriate time. The mean 1-year
Table 1 Demographics
* Re-classified at time of surgery from Type 5 to Type 2
Age
Median (range) 50.5 (16–74)
Sex
Male 36
Female 36
Side
Right 39
Left 35
Chronicity
Acute (within 3 months of injury) 37
Chronic 37
Injury Type
Type 1 2
Type 2 1*
Type 3 22
Type 4 6
Type 5 43
Fig. 1 Perth Hamstring Assessment Tool (PHAT) scores
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PHAT score was 76.7 (SD 16.0), and the mean of the retest
1 week later was 76.0 (SD 15.1). The ICC for the repeated
PHAT measures was 0.84 (95 % CI 0.76–0.90), and corre-
sponding SEM was 5.9 points. The MDC was 16.4 points,
which represents the minimum change required in order to
be 95 % confident that real clinical change has occurred.
Construct validity
Correlation between the PHAT and the LEFS was moder-
ate (r = 0.68). Correlation with the PCS component of the
SF-12 was low (r = 0.47). There was negligible correlation
between the PHAT and the MCS component of the SF-12
(r = 0.02).
Ceiling effect
Four patients (5 %) of the seventy-four had a maximum
score at 1-year follow-up.
Discussion
The key findings of this study are that the Perth Hamstring
Assessment Tool showed high completion rate, high inter-
nal consistency and high reproducibility. The sensitivity to
clinically important change is the aspect of greatest impor-
tance in a prospective outcome study [9]. The standard
error of measurement (5.9) represents the difference needed
between two separate measurements (e.g. before versus
after treatment) for the difference to be considered statis-
tically significant. Therefore, if a patient’s PHAT score
changes more than 5.9 points, they demonstrate significant
change. The effect size of 1.7 is considered to be large [10].
There was moderate correlation with the LEFS and
low correlation with the Physical Component Score of the
SF-12. The responsiveness of the SF-12 and in particular
the physical component summary score have been shown
to be superior or equivalent to some condition-specific
scales for the lower extremity [2, 18]. The capacity of the
LEFS, however, to detect change in lower extremity func-
tion has been shown to be superior to that of the SF-12
physical function subscale [2]. One would anticipate the
more specific questionnaire (LEFS) to show a higher cor-
relation. Similarly, the physical subsection of the SF-12
(PCS) should display less of a correlation, and the mental
subsection (MCS) shows little or no correlation.
It is useful for an assessment tool to be capable of
assessing function without having a ceiling effect. Schlegel
et al. assessed outcomes of 10 NFL players with hamstring
avulsions [24]. Although 9 of 10 returned to play, only 5
played more than one season. Ceiling effects are considered
to be present if more than 15 % of respondents achieved the
highest possible score [27]. This was not the case in this
study at either pre-operative or post-operative analysis—
only four patients (5 %) had a maximum score at 1-year
follow-up, which is well below the ceiling effect threshold.
There has been much published regarding surgical repair
of proximal hamstring tendon avulsions, especially with
regard to the outcome measures used. A range of non-vali-
dated heterogeneous outcome measures have been utilized
to date, including return to sport rates [6, 7, 11, 12, 17, 20,
22, 27, 30, 35], isokinetic strength testing [3, 4, 6, 7, 12,
1921, 25, 27, 35], Harris Hip scores [26], subjective rat-
ing scales [14, 22, 28, 31] and custom hamstring question-
naires [3, 8, 29].
Sallay et al. [29] retrospectively reviewed 25 cases
repaired over a 12-year period using bone anchors. Patients
were evaluated with a lengthy custom Proximal Hamstring
Injury Questionnaire (PHIQ) which is non-validated. There
was no indication of how this questionnaire was scored,
and results were not statistically analysed. Birmingham
et al. [3] retrospectively evaluated 23 repairs utilising a
non-validated questionnaire and isokinetic muscle testing.
They showed some correlation between certain questions
in the questionnaire and isokinetic testing. The majority of
questions, however, showed no correlation. Furthermore,
no other validated outcome measures were compared with
their questionnaire.
Cohen et al. [8] retrospectively reviewed 52 patients
who had undergone hamstring repairs over a 4-year period.
Recognising the lack of validated outcome measures used
in papers to date, they evaluated patients using the Lower
Extremity Functional Scale (LEFS), which is a non-specific
validated scoring system for general lower limb function,
and the Marx Activity Scale, which is a validated scoring
system for knee pathology. They were unable to demon-
strate statistically significant outcome differences using
these tools between acute and chronic injuries, and their
conclusion that surgical repairs led to “excellent return
to function and activity as well as a return of hamstring
strength” must be met with caution given that patients were
Table 2 Injury classification and PHAT score
1, Bone avulsion; 2, MT junction; 3, Partial; 4, Complete (no retrac-
tion); 5, Complete (with retraction)
Group Number of
patients
Pre-Op PHAT
Mean (SD)
Post-Op PHAT
Mean (SD)
1 2 63.0 (21.2) 62.0 (26.9)
2 1 58 (NA) 94 (NA)
3 22 42.1 (19.1) 75.5 (15.3)
4 6 40.0 (25.5) 79.0 (10.0)
5 43 38.0 (18.8) 77.3 (15.9)
All patients 74 40.3 (19.6) 76.7 (15.5)
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not scored pre-operatively, nor with scoring tools which
are specific to hamstring function. They also introduced
“custom” Marx and LEFS scores by changing questions in
the original systems to reflect symptoms particular to ham-
string ruptures, but these new scores were not validated.
Bowman et al. [5] retrospectively reviewed 17 patients
who underwent repair of partial hamstring origin tears.
They scored patients using the Marx and LEFS scores
(original and custom) used by Cohen et al. and concluded
that satisfactory results are achieved with surgical repair
of this subset of proximal hamstring injuries. Skaara et al.
[32] retrospectively reviewed 31 hamstring repairs done
over a 5-year period using the validated LEFS score and
Sallay’s non-validated PHIQ. They concluded that patients
continued to experience low levels of pain after surgical
repair with ongoing limits in their activities of daily living.
All of these trials are retrospective with small patient
numbers. They use a variety of non-validated hamstring
questionnaires to assess their patients. This study looked at
a wide variety of patients, from age 16–74, both acute and
chronic, and with different tear types. It found the PHAT to
be a satisfactory scoring system for all.
There are some limitations in this study. All patients in
the series were referred to an orthopaedic sports centre, and
the potential for referral bias exists. The study did not look
at patients that underwent non-operative treatment success-
fully. Most surgeons would not operate on a 74-year-old
patient with a hamstring tendon injury. The included patient
in this cohort was an exception—as they were still very
active, playing regular competitive tennis. The 16-year-
old was another exception, in that one would generally not
operate on patients this young. Both these patients were
included in the analysis to maintain a heterogeneous group.
Finally, no evaluation of post-operative strength was per-
formed and no MRIs were obtained to evaluate tendon
healing.
Conclusion
The Perth Hamstring Assessment Tool showed high com-
pletion rate, high internal consistency and high reproduc-
ibility. There was moderate correlation with the LEFS and
low correlation with the Physical Component Score of the
SF-12. Calculation of the sensitivity to clinically impor-
tant change demonstrated that if a patient’s PHAT score
changes more than 5.9 points, they demonstrate significant
change.
This study has validated a scoring system, the Perth
Hamstring Assessment Tool, tailored to proximal hamstring
tendon ruptures. This provides the clinician with a short,
simple and practical tool for clinical assessment of patients
with these injuries.
Compliance with ethical standards
Conflict of interest The authors have no conflict of interest.
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Appendix
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ment of partial-thickness tears of the proximal hamstring mus-
cles in athletes. Am J Sports Med 41:1363–1371
6. Brucker PU, Imhoff AB (2005) Functional assessment
after acute and chronic complete ruptures of the proximal
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... 17 Previous studies on proximal hamstring avulsions have relied on a variety of PROMs, many of which are not designed specifically for hamstring injuries. 9,34 Although there has been a recent impetus toward creating proximal hamstring-specific PROMs, 8,16,29 it is unclear how these measures compare with their nonhamstringspecific counterparts. As the number of PROMs that have been used in outcome studies on proximal hamstring injuries continues to grow, there is still a lack of consensus as to which specific PROMs are the most suitable for evaluating outcomes after these injuries. ...
... 6 The PHAT, SHORE, and PHIQ were designed specifically to assess patients who sustained proximal hamstring injuries. 8,16,29 Of these, the PHAT and SHORE are the only validated proximal hamstring-specific PROMs. 8,16 However, the SHORE was validated by correlating its functional outcome scoring to that of the PHAT. ...
... 8,16,29 Of these, the PHAT and SHORE are the only validated proximal hamstring-specific PROMs. 8,16 However, the SHORE was validated by correlating its functional outcome scoring to that of the PHAT. 16 Additionally, the PHAT is the most frequently used of these proximal hamstring-specific PROMs in the literature (6/34 included studies) and has been gaining recognition as the preferred PROM for proximal hamstring injury studies. ...
Article
Full-text available
Background: There is controversy regarding which patient-reported outcome measures (PROMs) should be used for proximal hamstring tendon injuries. Hypothesis: It was hypothesized that (1) most (>50%) of the questions on the 13 most common PROMs for proximal hamstring injuries would demonstrate extensive overlap in the health domains and question categories and (2) each of the PROMs would contain a variable distribution of questions within each health domain. Study Design: Systematic review. Methods: We conducted a literature review through PubMed, Scopus, and CINAHL and identified the 13 most common PROMs for proximal hamstring injuries: Lower Extremity Functional Scale (LEFS), Marx activity rating scale (MARS), 12-item Short Form Survey (SF-12), Tegner activity scale (TAS), Single Assessment Numeric Evaluation (SANE), Perth Hamstring Assessment Tool (PHAT), Proximal Hamstring Injury Questionnaire (PHIQ), modified Harris Hip Score (mHHS), University of California, Los Angeles activity score (UCLA), International Hip Outcome Tool (iHOT-12), Hip Outcome Score (HOS), Sydney Hamstring Origin Rupture Evaluation (SHORE), and Non-Arthritic Hip Score (NAHS). All PROM questions were sorted into 5 health domains (pain, symptoms, activities of daily living, sports, and mindset) and further divided into question categories if they referred to similar tasks or aspects of health. Questions in the same health domain and question category were considered overlapping, and those within a health domain that did not fit into a question category were considered unique. For each PROM, we analyzed the distribution of questions within particular health domains and question categories as well as the amount of overlapping and unique questions. Results: Of the 165 questions evaluated, 116 (70.3%) were overlapping, and 49 (29.7%) were unique. The SF-12 contained the most unique questions (9/12 [75.0%]). The MARS, TAS, SANE, and UCLA had 0 unique questions. The PHIQ and iHOT-12 contained questions in all 5 health domains. The PHAT, SHORE, and NAHS contained questions in every health domain except mindset. The LEFS, MARS, SF-12, TAS, mHHS, SANE, UCLA, and HOS contained questions in ≤3 health domains. Conclusion: The evaluated PROMs had a high degree of overlapping questions (≥50%) and demonstrated a statistically significant variance in the distribution of questions within each health domain.
... The literature search yielded 1316 reports after the exclusion of duplicates. After full-text review, 24 publications [7,10,[13][14][15][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] were included ( Figure 1). A thorough review of the bibliographies of the remaining studies was carried out and one additional publication [11] was identified through this method. ...
... A thorough review of the bibliographies of the remaining studies was carried out and one additional publication [11] was identified through this method. Sixteen studies [7,11,14,15,18,19,21,22,25,26,[28][29][30][31][32][33] included both acute and chronic ruptures. Three studies included only acute ruptures [23,24,34]. ...
... Twelve studies [7,11,14,[20][21][22][23]25,[28][29][30][31] included both complete and partial ruptures. Five studies included only complete [15,17,19,32,33] and three only partial [10,13,26,34]. ...
... After the retrospective chart review was performed, forty-six patients were identified as meeting all inclusion and exclusion criteria. All forty-six eligible patients were contacted by e-mail and telephone to complete a battery of validated PROs, including the Perth Hamstring Assessment Tool (PHAT) [10], Modified Harris Hip Score (MHHS) [11], Visual Analogue Scale for pain (VAS), and the Tegner Activity Scale [12]. The PHAT is one of the few PROs that was specifically developed and validated for use in proximal hamstring injuries [10], while the MHHS is one of the most commonly used PROs for assessing hip symptoms. ...
... All forty-six eligible patients were contacted by e-mail and telephone to complete a battery of validated PROs, including the Perth Hamstring Assessment Tool (PHAT) [10], Modified Harris Hip Score (MHHS) [11], Visual Analogue Scale for pain (VAS), and the Tegner Activity Scale [12]. The PHAT is one of the few PROs that was specifically developed and validated for use in proximal hamstring injuries [10], while the MHHS is one of the most commonly used PROs for assessing hip symptoms. Higher scores on the PHAT and MHHS represent greater patient function and satisfaction, and higher scores on the VAS indicate greater levels of pain. ...
... This study used a PRO that has been specifically validated for the assessment of proximal hamstring injuries, the PHAT. The initial validation study for the PHAT reported cutoffs of 5.9 points for statistically significant change and 16.4 points for being 95% confident that there was a meaningful difference in clinical outcomes [10]. Thus, the difference in the PHAT of 16.3 points between the acute and chronic cohorts in this study likely represents a clinically significant difference. ...
Article
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Introduction Prior studies of hamstring tendon tears have reported varied findings on whether increased delay from injury to surgery is associated with worse outcomes. The purpose of this study was to determine whether increased time from injury to surgical repair is associated with worse clinical outcomes in patients with proximal hamstring ruptures. Materials and methods Patients who underwent surgical repair of a proximal hamstring rupture from 2010 to 2019 were followed for a minimum of 24 months from surgery. A cutoff of 6 weeks from injury to the time of surgery was used to distinguish between acute and chronic ruptures. All patients completed patient-reported outcome measures (PROs) at the final follow-up. Multiple factors were analyzed for their effects on PROs including time to surgery, amount of tendon retraction, and demographics such as sex and age. Results Complete data sets were obtained for 38 patients at a mean follow-up of 4.9 years. All data is reported as a mean ± standard deviation. Patients who underwent acute repair of proximal hamstring ruptures had significantly greater Perth Hamstring Assessment Tool (PHAT) scores than those who underwent chronic repair (76.9 ± 18.8 vs 60.6 ± 18.2, p = 0.01). Increased time to surgery was significantly correlated with worse PHAT scores (ρ = − 0.47, p = 0.003). There was no difference in PROs based on the amount of tendon retraction, number of tendons torn, sex, smoking status, or BMI. Conclusions This study found that acute repair performed within 6 weeks of injury appears to yield improved PROs compared to chronic repair. These data highlight the importance of timely and accurate diagnosis of proximal hamstring ruptures and early operative intervention for surgical candidates.
... 3,13,17,29,30,32 These studies have, however, revealed inconsistent conclusions-to some extent debatably describing the timing of surgery to be of inferior relevance regarding surgical outcome results. 13,29,32 In any case, the current knowledge has been gathered from reviews, meta-analyses, 8,17 and studies whose conclusions are based on the investigation of comparably small cohorts 9,19,22,25 with univariate analyses, including a great variety of partially validated or non-injury-specific outcome scores, 1,2,[6][7][8]17,21,26,32 such as the Lower Extremity Functional Scale (LEFS) or the Marx activity score. 4,20 However, using outcome scores, especially validity and specificity, has recently been debated regarding their expressiveness if only "adjusted" to a type of injury instead of being injury specific. ...
... 4,20 However, using outcome scores, especially validity and specificity, has recently been debated regarding their expressiveness if only "adjusted" to a type of injury instead of being injury specific. 2,7 To the best of the authors' knowledge, larger studies using validated, hamstring injury-specific outcome measurements that also focus on predicting factors such as time of surgery or preoperative magnetic resonance imaging (MRI) findings regarding the surgical outcome, are rare. 3,27 The aim of our study was to investigate a large patient group of surgically treated patients in our institution regarding their postoperative functional outcome using an injury-specific patient-reported outcome score, the Perth Hamstring Assessment Tool (PHAT). ...
... 3,27 The aim of our study was to investigate a large patient group of surgically treated patients in our institution regarding their postoperative functional outcome using an injury-specific patient-reported outcome score, the Perth Hamstring Assessment Tool (PHAT). 6,7 To identify predictive factors for postoperative outcome, the obtained results were evaluated and correlated to concomitant factors such as patient age, sex, surgical timing and length, and amount of stump retraction on preoperative MRI. We hypothesized that the results of the PHAT would significantly correlate with the time between trauma and surgery, as well as with the degree of stump retraction on preoperative MRI. ...
Article
Full-text available
Background Although debilitating, proximal hamstring tendon avulsion injuries are rare and often overlooked or misdiagnosed. Consequently, delayed diagnosis and surgical treatment may result in poor outcomes. Studies investigating a correlation between postoperative functional outcomes and this delay in surgical treatment or other concomitant factors in large cohorts have not yet been performed to our knowledge. Purpose/Hypothesis The purpose of this study was to conduct an investigation in a large patient group regarding factors that could influence a patient’s functional outcome after hamstring surgery. We hypothesized that this outcome would significantly correlate to the time between trauma and surgery. Study Design Case series; Level of evidence, 4. Methods Patients who received surgical treatment of proximal hamstring tendon avulsion injuries in our institution between the years 2010 and 2020 were asked to complete a validated, injury-specific outcome measurement, the Perth Hamstring Assessment Tool (PHAT; 0-100 points). In addition to calculating these outcomes, we evaluated the association of the obtained results with possible predictive factors such as age, sex, stump retraction shown on magnetic resonance imaging (MRI), and timing and duration of surgery. Results A total of 226 patients (227 operations) were eligible for the study, and 204 cases of hamstring tendon avulsion injury met our inclusion criteria. The return rate for the PHAT questionnaire was 85.3%. The mean PHAT score revealed good results (79.8 ± 19.1). Irrespective of concomitant factors, the scores of male patients were significantly higher compared with those of female patients (83.8 ± 16.9 vs 75.8 ± 20.6 respectively; P = .004). The mean time to surgery was 5.7 weeks after trauma, and more delayed surgery correlated significantly with lower PHAT scores ( P = .003; r = –0.228). The mean degree of stump retraction on MRI (5 cm) did not significantly influence PHAT scores ( P = .525; r = –0.06). Conclusion Delay of surgery and female sex were disadvantageous in terms of a good functional outcome measure (PHAT score) after hamstring tendon refixation surgery. By contrast, patient age as well as the retraction of the tendon stump on preoperative MRI did not influence PHAT scores in the present study.
... Proximal hamstring avulsions result from forceful eccentric muscle contractions or excessive passive lengthening, which occurs with sudden hyperflexion of the hip with an extended knee (eg, maximum sprinting, hurdling, and water skiing). 4,11 Avulsion injuries often involve the biceps femorissemitendinosus conjoint tendon and semimembranosus tendon at the ischial tuberosity. These injuries can be classified as complete or incomplete avulsions with or without retraction. ...
... One article by Shambaugh et al 34 discussed operative and nonoperative management of proximal hamstring repair; however, only data from patients treated operatively were included in analysis. Quality assessment of studies per the MINORS criteria demonstrated a mean score of 12.9 (range, [11][12][13][14][15]. Given the nature of the clinical research, all included studies had a reduced quality assessment score owing to a lack of control groups, patient groups representative of the general population, and in-depth statistical analysis of data, making their ideal score 16. ...
... PHAT is the only validated outcome measure designed to evaluate patients with proximal hamstring ruptures pre-and postoperatively (Table 4). 10,11 Journal Impact Factor When articles in journals with an impact factor <3 were compared with those with an impact factor 3, there was a statistically significant difference in mean sample size (21.5 vs 45.4, respectively; P ¼ .01). There was no statistically significant difference between these groups by number of outcome scores reported, mean follow-up, or mean age of patients (Table 5). ...
Article
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Background Patient-reported outcome measures are important to determine outcomes after orthopaedic procedures. There is currently no standard for outcome measures in the evaluation of patient outcomes after proximal hamstring repair. Purpose To identify and evaluate outcome measures used after proximal hamstring repair. Study Design Systematic review; Level of evidence, 4. Methods A systematic review was performed to identify all English-language articles assessing outcomes after proximal hamstring repair in PubMed, Embase, CINAHL via EBSCOhost, MEDLINE via OvidSP, and Web of Science between 2000 and 2019. After duplicates were removed, studies were selected using eligibility criteria established by the authors. Image reviews, anatomic/histology studies, literature reviews, surgical technique reports, systematic reviews, narrative reviews, case studies, and studies with <5 patients were excluded. Extraction, synthesis, and analysis of outcome measure data were performed using Microsoft Excel. Quality assessment of included studies was performed using Methodological Index for Non-Randomized Studies criteria. Results After duplicate articles were removed, a total of 304 unique articles were identified and 27 met the inclusion criteria. The mean number of patients with proximal hamstring repairs per study was 40. The most frequently reported outcome measures were return to sport (14/27; 51.9%), custom survey/questionnaire (13/27; 48.1%), and isokinetic hamstring strength testing (13/27; 48.1%). Six of the 10 most commonly used outcome measures were validated and included Lower Extremity Functional Scale, 12-Item Short Form Health Survey, visual analog scale for pain, Perth Hamstring Assessment Tool (PHAT), Single Assessment Numeric Evaluation, and Tegner Activity Scale. Of those, PHAT was the only validated outcome measure designed for proximal hamstring repair. Conclusion There is currently no consensus on the best outcome measurements for the evaluation of patients after proximal hamstring repair. We recommend an increased commitment to the use of return to sport, isokinetic strength testing, Lower Extremity Functional Scale, and PHAT when assessing such injuries. Future studies should aim to define the most reliable methods of outcome measurement in this patient population through consistent use of tools that are clinically relevant and important to patients and can easily be employed in a variety of clinical scenarios.
... 3 PHAT was developed and validated specifically for patients with PHA, taking a broad perspective with questions about pain during activities, discomfort, and activity level. 5 The LEFS is a generic questionnaire focusing on the lower extremities as a unidimensional activity-based questionnaire. 2,3,5,6 Both questionnaires examine postinjury activity limitations, but there are no studies that systematically and open-endedly interview patients to identify activity limitations that result from this injury. ...
... 5 The LEFS is a generic questionnaire focusing on the lower extremities as a unidimensional activity-based questionnaire. 2,3,5,6 Both questionnaires examine postinjury activity limitations, but there are no studies that systematically and open-endedly interview patients to identify activity limitations that result from this injury. ...
... 16,18,19 Thus, many different outcome measures have been used to assess patient function and satisfaction after PHA, but only PHAT, which was specifically developed for patients with PHA, has, to some extent, been validated. 5 This cross-sectional study, with up to 9 years of followup, aimed to evaluate previously used PROMs and functional tests in terms of covariance and validity. We also sought to ascertain self-described activity limitations from patients after PHA injury. ...
Article
Background: The goal of treatment for a proximal hamstring avulsion (PHA) is an objectively restored muscle and a subjectively satisfied, pain-free patient at follow-up. Different self-reported and performance-based outcome measures have been used to evaluate recovery, but their validity is poorly investigated. Purpose: To investigate 1) the correlation between the commonly used self-reported outcome measurements, the Perth Hamstring Assessment Tool (PHAT) and the Lower Extremity Functional Scale (LEFS); 2) to what extent these scores can be explained by physical dysfunction as measured by performance-based tests; 3) whether performance-based tests can discriminate between the injured and uninjured extremity; and 4) which activity limitations are perceived by patients several years after the injury. Study design: Cohort study (Diagnosis); Level of evidence, 3. Methods: We included a consecutive series of patients treated for or diagnosed with PHA in our department between 2007 and 2016 having at least 2 tendons avulsed from the ischial tuberosity. Participants attended 2 study visits, answered questionnaires (PHAT, LEFS, and Patient-Specific Functional Scale [PSFS]), and performed physical performance-based tests (single-leg hop tests, single-step down test, and isometric and isokinetic strength tests). Results: A total of 50 patients were included (26 men [52%], 24 women [48%]; mean age, 50.9 years [SD, 9.8 years]). The mean follow-up time was 5.5 years (SD, 2.7 years), and 74% had been surgically treated. The correlation between PHAT and LEFS was strong (r = 0.832) and statistically significant (P < .001). Seven of the performance-based tests exhibited a statistically significant but weak correlation with LEFS (0.340-0.488) and 3 of the tests to PHAT (-0.304 to 0.406). However, only peak torque could significantly discriminate between the extremities. The activity limitation most commonly mentioned in PSFS was running (16 patients [32%]). Conclusion: Although PHAT and LEFS correlated strongly, the correlations between functional tests and the patient-reported outcome scores were weak, and most functional tests failed to discriminate between the injured and uninjured lower extremity in patients with PHA 5 years after injury. In general, patients alleged few activity limitations, but running difficulty was a common sequela after PHA.
... Questionnaires included the Perth Hamstring Assessment Tool (PHAT), 13 Proximal Hamstring Injury Questionnaire (PHIQ), 14 EQ-5D-3L and Tegner Activity Scale (TAS). 15 The PHAT (0-100, higher scores correspond with better outcome) consists of four questions on symptoms of pain/discomfort and level of activity specific for proximal hamstring tendon injury. ...
... It has high reproducibility (ICC: 0.84) and a minimal detectable change of 16.4 points. 13 The PHIQ is a hamstring avulsion-specific questionnaire consisting of 11 questions on proximal hamstring tendon-specific symptoms, functional restrictions, subjective rate of recovery, and sports participation. No data on its psychometric properties are available. ...
Article
Objective To prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions. Methods Patients 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. Results Twenty-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). Conclusion In 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.
... Twelve months postoperatively, the patient was extremely satisfied with the surgical outcome and was able to perform all kind of desired sport activities (volleyball, beachvolleyball, hiking, kite-surfing, climbing, and skiing) and activities of daily living without difficulty or pain. At final follow-up, Perth Hamstring Assessment Tool [12] was 94/100 points. ...
Article
Full-text available
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.
... However, in 10-30%, an apophyseal avulsion fracture may also affect the ischial tuberosity [2,4] [ Fig. 1]. Despite patients often report a clear crack in the pelvic region [2], not rarely without proper imaging the injury is misdiagnosed as pure muscular or musculotendinous injury [5][6][7]. ...
Article
Full-text available
Purpose Among juvenile apophyseal avulsion injuries of the pelvis in adolescents, fractures of the ischial tuberosity are rare but sustainably debilitating. Also because informations on surgical repair options are very sparse and so far limited to general reviews, reports of individual cases or heterogeous small case series, practitioners, patients and their parental environment still feel a comprehensible hesitation regarding operative treatment. Therefore we intended to investigate patient related outcome measurements and return to sports rates after different types of surgical intervention in an own case series, so far unprecendented in its size. Methods Patient data of adolescents that underwent surgical intervention for a displaced apophyseal avulsion fracture of the ischial tuberosity between 01/2015 and 12/2019 in our institution were gathered. Patients were then evaluated using the hamstring injury specific Perth Hamstring Assessment Tool (PHAT). Furthermore the return to sports level in comparison to the particular pre-injury level was rated. Results Eleven adolescents with an acute or chronic mean fragment dislocation of 3.3 cm (SD ± 1.7) underwent surgical intervention in the assigned period. The mean post-operative PHAT score was 86.9 (0–100, SD ± 11.9) and thus good to excellent. The majority of adolescents (10/11) was able to return to their pre-injury sports, whereas 63.6% achieved full or nearly full level. Conclusions Surgical refixation or restoration of aphoyseal avulsion fractures of the ischial tuberosity result in good to excellent outcomes and return to sport rates, irrespective of the type of intervention. Here prompt diagnosis with a timely intervention seems more promising than delayed interventions in chronic cases. Beyond 1.5 cm of fragment displacement affected patients should be counselled for surgical intervention.
Article
Case: Proximal hamstring tendon avulsions are rare injuries that can be successfully treated with surgical intervention. However, there are limited reports on the surgical and postoperative management of patients with bilateral avulsions. We report a 54-year-old male gym teacher with acute bilateral proximal hamstring 3-tendon nonbony avulsions who underwent simultaneous surgical repairs and a unique postoperative rehabilitation course. At 1-year clinical follow-up, the patient demonstrated significant improvements in activity levels and functionality, with no complications. Conclusion: Bilateral proximal hamstring 3-tendon nonbony avulsions can be successfully treated with a simultaneous surgical repair and a modified postoperative rehabilitation course.
Article
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Regression methods were used to select and score 12 items from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to reproduce the Physical Component Summary and Mental Component Summary scales in the general US population (n = 2,333). The resulting 12-item short-form (SF-12) achieved multiple R squares of 0.911 and 0.918 in predictions of the SF-36 Physical Component Summary and SF-36 Mental Component Summary scores, respectively. Scoring algorithms from the general population used to score 12-item versions of the two components (Physical Component Summary and Mental Component Summary) achieved R squares of 0.905 with the SF-36 Physical Component Summary and 0.938 with the SF-36 Mental Component Summary when cross-validated in the Medical Outcomes Study. Test-retest (2-week) correlations of 0.89 and 0.76 were observed for the 12-item Physical Component Summary and the 12-item Mental Component Summary, respectively, in the general US population (n = 232). Twenty cross-sectional and longitudinal tests of empirical validity previously published for the 36-item short-form scales and summary measures were replicated for the 12-item Physical Component Summary and the 12-item Mental Component Summary, including comparisons between patient groups known to differ or to change in terms of the presence and seriousness of physical and mental conditions, acute symptoms, age and aging, self-reported 1-year changes in health, and recovery from depression. In 14 validity tests involving physical criteria, relative validity estimates for the 12-item Physical Component Summary ranged from 0.43 to 0.93 (median = 0.67) in comparison with the best 36-item short-form scale. Relative validity estimates for the 12-item Mental Component Summary in 6 tests involving mental criteria ranged from 0.60 to 1.07 (median = 0.97) in relation to the best 36-item short-form scale. Average scores for the 2 summary measures, and those for most scales in the 8-scale profile based on the 12-item short-form, closely mirrored those for the 36-item short-form, although standard errors were nearly always larger for the 12-item short-form.
Article
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Proximal hamstring ruptures are increasingly treated surgically, despite little high-level supporting evidence. We sought to determine whether there are differences in clinical outcome after surgical vs. non-surgical treatment of proximal hamstring tendinous avulsions/ruptures and acute vs. chronic surgical repair of tendinous avulsions. Multiple medical databases were searched for Level I-IV evidence. 18 studies were included. 298 subjects (300 proximal hamstring injuries) were analyzed with mean age of 39.7 years. 286 injuries were managed with surgical repair vs. 14 non-operative. 95 surgical cases were performed within 4 weeks of the injury (acute), while 191 were performed beyond 4 weeks (chronic). 292 injuries were tendinous avulsions while 8 were bony tuberosity avulsions. Surgical repair resulted in significantly (p < 0.05) better subjective outcomes, greater rate of return to pre-injury level of sport, and greater strength/endurance than non-surgical management. Similarly, acute surgical repair had significantly better patient satisfaction, subjective outcomes, pain relief, strength/endurance, and higher rate of return to pre-injury level of sport than chronic repair (p < 0.001) with reduced risk of complications and re-rupture (p < 0.05). Chronic surgical repair also improves outcomes, strength and endurance, and return-to-sport, but not as well as acute repair. Non-operative treatment results in reduced patient satisfaction, with significantly lower rates of return to pre-injury level of sport and reduced hamstring muscle strength.
Article
We have developed a 12-item questionnaire for patients having a total knee replacement (TKR). We made a prospective study of 117 patients before operation and at follow-up six months later, asking them to complete the new questionnaire and the form SF36. Some also filled in the Stanford Health Assessment Questionnaire (HAQ). An orthopaedic surgeon completed the American Knee Society (AKS) clinical score. The single score derived from the new questionnaire had high internal consistency, and its reproducibility, examined by test-retest reliability, was found to be satisfactory. Its validity was established by obtaining significant correlations in the expected direction with the AKS scores and the relevant parts of the SF36 and HAQ. Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at follow-up. We also compared change in scores with the patients’ retrospective judgement of change in their condition. The effect size for the new questionnaire compared favourably with those for the relevant parts of the SF36. The change scores for the new knee questionnaire were significantly greater (p < 0.0001) for patients who reported the most improvement in their condition. The new questionnaire provides a measure of outcome for TKR that is short, practical, reliable, valid and sensitive to clinically important changes over time.
Article
Background and Purpose. The purpose of this study was to assess the reliability, construct validity, and sensitivity to change of the Lower Extremity Functional Scale (LEFS). Subjects and Methods. The LEFS was administered to 107 patients with lower-extremity musculoskeletal dysfunction referred to 12 outpatient physical therapy clinics. Methods. The LEFS was administered during the initial assessment, 24 to 48 hours following the initial assessment, and then at weekly intervals for 4 weeks. The SF-36 (acute version) was administered during the initial assessment and at weekly intervals. A type 2,1 intraclass correlation coefficient was used to estimate test-retest reliability. Pearson correlations and one-way analyses of variance were used to examine construct validity. Spearman rank-order correlation coefficients were used to examine the relationship between an independent prognostic rating of change for each patient and change in the LEFS and SF-36 scores. Results. Test-retest reliability of the LEFS scores was excellent (R=.94 [95% lower limit confidence interval (CI)=.89]). Correlations between the LEFS and the SF-36 physical function subscale and physical component score were r=.80 (95% lower limit CI=;73) and r=.64 (95% lower limit CI=.54), respectively. There was a higher correlation between the prognostic rating of change and the LEFS than between the prognostic rating of change and the SF-36 physical function score. The potential error associated with a score on the LEFS at a given point in time is +/-5.3 scale points (90% CI), the minimal detectable change is 9 scale points (90% CI), and the minimal clinically important difference is 9 scale points (90% CI). Conclusion and Discussion. The LEFS is reliable, and construct validity was supported by comparison with the SF-36. The sensitivity to change of the LEFS was superior to that of the SF-36 in this population. The LEFS is efficient to administer and score and is applicable for research purposes and clinical decision making for individual patients.
Article
Background: At the present time, no systematic review, including a quality assessment, has been published about the outcome after proximal hamstring avulsion repair. Purpose: To determine the outcome after surgical repair of proximal hamstring avulsions, to compare the outcome after acute (≤4 weeks) and delayed repairs (>4 weeks), and to compare the outcome after different surgical techniques. Study design: Systematic review and best-evidence synthesis. Methods: PubMed, CINAHL, SPORTdiscus, Cochrane library, EMBASE, and Web of Science were searched (up to December 2013) for eligible studies. Two authors screened the search results separately, while quality assessment was performed by 2 authors independently using the Physiotherapy Evidence Database (PEDro) scale. A best-evidence synthesis was subsequently used. Results: Thirteen studies (387 participants) were included in this review. There were no studies with control groups of nonoperatively treated proximal hamstring avulsions. All studies had a low methodological quality. After surgical repair of proximal hamstring avulsion, 76% to 100% returned to sports, 55% to 100% returned to preinjury activity level, and 88% to 100% were satisfied with surgery. Mean hamstring strength varied between reporting studies (78%-101%), and hamstring endurance and flexibility were fully restored compared with the unaffected side. Symptoms of residual pain were reported by 8% to 61%, and reported risk of major complications was low (3% rerupture rate). No to minimal difference in outcome was found between acute and delayed repair in terms of return to sports, patient satisfaction, hamstring strength, and pain. Achilles allograft reconstruction and primary repair with suture anchors led to comparable results. Conclusion: The quality of studies included is low. Surgical repair of proximal hamstring avulsions appears to result in a subjective highly satisfying outcome. However, decreased strength, residual pain, and decreased activity level were reported by a relevant number of patients. Minimal to no differences in outcome of acute and delayed repairs were found. Limited evidence suggests that an Achilles allograft reconstruction yields results comparable with primary repair in delayed cases where primary repair is not possible. High-level studies are required to confirm these findings.
Article
Background: Because a proximal hamstring avulsion results in residual loss of function, surgical repair is recommended. Few studies have investigated postoperative function with validated outcomes. Purpose: To examine lower extremity function after surgical repair of proximal hamstring avulsions using validated self-reported and performance-based functional outcomes. Study design: Case series; Level of evidence, 4. Methods: Operative records from 2006 to 2010 were retrospectively reviewed in 3 hospitals. A total of 39 patients who had undergone surgical repair of a proximal hamstring avulsion were identified, and 36 met the inclusion criteria. Thirty-one patients completed questionnaires with demographic background data and quality of life-related questions: the Lower Extremity Functional Scale (LEFS) and the Proximal Hamstring Injury Questionnaire (PHIQ). Thirty patients were evaluated using a Biodex dynamometer for isokinetic quadriceps and hamstring strength measurements at a velocity of 60 deg/s, and 27 patients performed 4 single-legged hop tests. Results: Twenty-eight repairs were acute (<4 weeks), and 3 were chronic. There were complete ruptures of all 3 tendons in 17 (55%) cases. The mean follow-up was 30 months. Most patients experienced little or no pain or limitations during activities of daily living. The mean LEFS score was 89%, and 29 (94%) of the 31 patients were satisfied with the result after surgery. Eighteen (58%) of the 31 patients had returned to their preinjury activity level. Significant differences in the mean hamstring strength (peak torque) (P < .001) and single-legged hop test (P = .01) between the uninvolved and involved leg were found. Twenty-two (71%) of the 31 patients did not fully trust their operated leg during physical activities and feared sustaining a hamstring injury. Return to activity significantly correlated with the single-legged hop test, the LEFS score, and the questions regarding trust and fear. Conclusion: In this study, using both validated self-reported and performance-based outcome measures after surgical repair of proximal hamstring avulsions, minor pain and limitations to activities of daily living were seen. Isokinetic hamstring strength in the operated leg was significantly lower compared with the nonoperated leg, and a majority of the patients did not trust the operated leg completely during physical activity.
Article
Although hamstring strains are common among professional football players, proximal tendon avulsions are relatively rare. Surgical repair is recommended, but there is no evidence on professional football players return to play (RTP). We hypothesized that surgical reattachment of complete proximal hamstring ruptures in these athletes would enable successful RTP. Ten proximal hamstring avulsions were identified in 10 National Football League (NFL) players between 1990 and 2008. Participating team physicians retrospectively reviewed each player's training room and clinical records, operative notes, and imaging studies. The ruptures were identified and confirmed with magnetic resonance imaging. Of the 10 injuries, 9 had palpable defects. Each of the ruptures was managed with surgical fixation within 10 days of injury. All of the players reported full return of strength and attempted to resume play at the beginning of the following season, with 9 of the 10 actually returning to play. However, despite having no limitations related to the surgical repair, only 5 of the 10 athletes played in more than 1 game. Most NFL players who undergo acute surgical repair of complete proximal hamstring ruptures are able to RTP, but results are mixed regarding long-term participation. This finding may indicate that this injury is a marker for elite-level physical deterioration.
Article
Background: Partial tears of the hamstring muscle origin represent a challenging clinical problem to the patient and orthopaedic surgeon. Although nonoperative treatment is frequently met with limited success, there is a paucity of data on the efficacy of surgical management for partial proximal hamstring tears in the active and athletic population. Purpose: To evaluate the results of an anatomic repair for partial tears of the hamstring muscle origin in athletes. Study design: Case series; Level of evidence, 4. Methods: The records of 17 patients with partial tears of the proximal hamstring origin were reviewed after institutional review board approval was obtained. All patients were treated with open debridement and primary tendon repair after failure of at least 6 months of nonoperative therapy. Clinical and operative records, radiographs, and magnetic resonance images were reviewed for all patients. A patient-reported outcomes survey was completed by 14 patients that included the Lower Extremity Functional Score (LEFS), Marx activity rating scale, custom LEFS and Marx scales, and subjective patient satisfaction scores. Early and late postoperative complications were recorded. Results: There were 3 male and 14 female patients; their average age was 43 years (range, 19-64 years) and average follow-up was 32 months (range, 12-51 months). There were 2 collegiate athletes (field hockey, track), 14 amateur athletes (distance running, waterskiing, tennis), and a professional bodybuilder. Postoperative LEFS was 73.3 ± 9.9 (range, 50-80) and custom LEFS was 66.7 ± 17.0 (range, 37-80) of a maximum 80 points. The most commonly reported difficulty was with prolonged sitting and explosive direction change while running. The average Marx score was 6.5 ± 5.3 (range, 0-16) of a maximum 16, correlating with a greater return to recreational running activities in this patient cohort than regular participation in pivoting or cutting sports. Marx custom scores were 20 of a maximum 20 in all patients, demonstrating no disability in the operative extremity with activities of daily living. No patient underwent a subsequent surgery. One patient was not satisfied with the result and reported persistent symptoms during competitive distance running. All patients were able to return to their preoperative level of activity after surgery. Conclusion: Anatomic surgical treatment of partial proximal hamstring avulsions can lead to satisfactory functional outcomes, a high rate of return to athletic activity, and low complication rate. This procedure should be reserved for patients who have failed an extended course of nonoperative treatment, and the proximity of the sciatic nerve mandates a careful assessment of the risk-benefit ratio before surgery is undertaken.
Article
The purpose of this study was to assess postsurgical outcomes in active patients after primary repair of acute and chronic proximal hamstring tears. Surgical treatment of both acute and chronic proximal hamstring avulsion injuries would result in improved patient outcomes using validated outcome scores and a hamstring-specific questionnaire, and operative repair of these injuries results in excellent outcomes with a high level of patient satisfaction, pain relief, and return to function. Case series; Level of evidence, 4. Fifty-two patients who underwent proximal hamstring repair (26 male and 26 female; average age, 47.7 years) completed the Lower Extremity Functional Scale (LEFS), a custom LEFS, the Marx Activity Scale, a custom Marx scale, a proximal hamstring score (which combines the sum of the custom LEFS and Marx), and a proximal hamstring questionnaire with subjective questions. Forty patients were characterized as having acute repairs, and 12 patients had chronic repairs. All patients underwent surgical repair with 5 suture anchors on the ischial tuberosity through a transverse incision. The rehabilitation protocol was also similar with the use of a hip orthosis for 6 to 8 weeks, allowing progressive weightbearing and range of motion. The mean follow-up in our study was 33 months (range, 12-76 months). The mechanism of injury in 28 patients was eccentric hip flexion and knee extension in the ipsilateral knee typically caused by a slip and fall accident. One patient's injury was caused by trauma to the proximal hamstring. In 23 patients, hamstring injuries were sports related. Overall, 51 (98%) were satisfied with their outcome after surgery. The LEFS, Marx, custom LEFS, custom Marx, and proximal hamstring scores for patients with acute injuries were 76.2, 10.0, 71.4, 20, and 91.7, respectively. For those with chronic injury, the scores were 71.5, 10.4, 70.8, 18.7, and 89.8, respectively. The scores were not statistically different for LEFS, Marx, custom LEFS, and proximal hamstring scores (P = .22, P = .6, P = .72, and P = .6, respectively). Patients with acute injury did have a greater custom Marx score (P = .001). Postoperatively, 5 patients (9.6%) had burning pain or numbness in the posterior thigh or foot, and 25 (48%) had at least some discomfort sitting. Thirty-five patients (67%) reported they could participate in strenuous activities at their latest follow-up. All patients estimated their strength recovery at ≥75%. Results of this study indicate successful outcomes for both acute and chronic repairs, although patients with the acute repairs had higher functional and hamstring scores, and estimated hamstring strength.
Article
Rupture of the proximal origin of the hamstrings leads to pain, weakness, and a debilitating decrease in physical activity. Repair of these injuries should be based on the expectation that these deficits can be addressed. The goal of this study was to objectively evaluate the efficacy of repair of proximal hamstring avulsions. Thirty-four patients were identified retrospectively to have a complete rupture of the proximal origin of the hamstrings based on the presence of a bowstring sign and the results of magnetic resonance imaging (MRI).Patients were contacted for follow-up evaluation to fill out a subjective questionnaire, to undergo functional testing, and to undergo isokinetic testing on a Cybex dynamometer. Twenty-three patients were evaluated. There were nine acute and fourteen chronic repairs, and the average period of follow-up was 43.3 months. Twenty-one of twenty-three patients reported returning to activity at an average of 95% of their pre-injury activity level at an average of 9.8 months. Eighteen patients reported excellent results; four, good results; and one, fair results. Hamstring strength was an average of 93% and 90% of that in the uninvolved limb at 240° per second and 180° per second, respectively. The hamstrings-to-quadriceps ratio was 56% for 240° per second and 48% at 180° per second. Hamstring endurance was an average of 81% and 91% of the nonoperative limb at 240° per second and 180° per second, respectively. Postoperative quadriceps strength and endurance were positively correlated with return to pre-injury level of activity (r = 0.6, p < 0.05; and r = 0.6, p < 0.05) and negatively correlated with time to return to sport (r = -0.5, p < 0.05; and r = -0.5, p < 0.05). There was no significant effect associated with age or time from injury. Repair of a symptomatic and displaced ruptured proximal hamstring tendon yields good subjective and objective functional results with minimal complications. Overall, patients are satisfied with surgical repair and experience return of functional activity with minimal postoperative weakness.