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AOSSM and ISHA Webinar - Tendon Injuries of the Hi ...
Proximal hamstring injuries: Current treatment tre ...
Proximal hamstring injuries: Current treatment trends in 2022 (Chad Mather)
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I appreciate the opportunity to participate in this on-demand webinar series. I think it's another great educational format, illustrates ISH's commitment to advancing medical education. I'll talk about my experience and the current evidence for treatment of proximal hamstring tears today. These are my disclosures. The consultancy for STRIKER is relevant. The others, the royalties are not. The others can be found in the Academy's disclosure program. When I talk about proximal hamstring pathology, I like to start with talking about the spectrum, beginning with things like tendinopathies here, often occurring in the athletic or young population. Those can then advance into chronic partial thickness tears. I think the point I always like to make with these is that if you focus on this area here, it's fairly detached, so it really functions a lot like a full thickness, a non-retracted full thickness tear than it does a tendinopathy, and I think responds similarly with those types of treatments. I always say, if you turn it sideways, it looks a lot like a rotator cuff tear. This is a type that you probably would, if you think about it in the context of rotator cuff tears, probably less likely to respond to biologic injection therapy, and often when non-injection therapy fails, it's more likely to respond to surgical treatment. You then get into the full thickness tears, so the ones that are minimally retracted, like this MRI here. What I mean by that largely is that the tendon is near the ischium. These are ones where you're less likely to see cramping chronically because there's minimal shortening of the muscle tendon unit, and they can be often accessed well endoscopically. You then get into your full thickness retracted acute tears. Those are the classic ones with the large hematoma and all that chemosis upon presentation. Then the hardest of them all, really, these retracted chronic tears. These are most difficult to fix, often requiring a graft. These are the patients where you'll see the concomitant sciatic nerve symptom, as well as cramping as a common presenting complaint. Anatomy of the proximal hamstring is important to understand as well. Approximately, of course, the hamstring inserts on really largely one location, distally it spreads out, and so that affects how tears become pathologic and symptomatic. The proximal hamstring is made up largely of the conjoint tendon, the semimembranosus, the one and two there. When you look closer at the footprint, you see that they make up about half of that each, the semimembranosus tends to wrap up around the, approximately wraps up around posterior, and then it's, again, harder to access, typically, with repair. It's also important to understand the functional pathology associated with this. The hamstring is the dominant hip extensor, especially when the knee is extended. Especially in the tendinopathies and chronic partial thickness tears, the absence of gluteal function or hamstring dominant extension pattern will often be associated with symptomatology in these tendinopathies that are often present in an asymptomatic fashion. What we don't know is, is that hamstring dominant pattern, does that just cause a degenerative tendon to be symptomatic, or does it contribute to the degeneration overall? That's an unanswered question, but it is, where that matters is that in a non-operative setting what I like to focus on then is a neuromuscular training and strengthening to resolve that hamstring dominant pattern and engage the gluteal muscles. The presentation, so it takes a few different presentations, again, depending on where you're along the spectrum. The tendinopathy and chronic partial thickness tears are more likely to present with a larger component of sitting pain as part of the problem. The more you get into actual tears, including the partial thickness, high-grade partial thickness tears, they will have functional pain. Functional pain includes, typically, pain with acceleration, stairs, and then, of course, bending over and extending at the hip. The chronic retracted tears, that's where you'll see the neuropathic presentation with sciatic nerve irritation and the cramping associated with that shortened hamstring muscle. This test here on the right, this is an approximate hamstring stretch test. I like this one quite a bit. It starts by flexing the hip with a bent knee and then slowly extending the knee. This does transmit the force there more to the proximal origin rather than the distal insertion. It also helps to separate proximal hamstring pathology and symptoms from other posterior hip pathologies and lumbar radiculopathy. Non-operative treatment is certainly the mainstay for a lot of these. To start with, especially on the patients on the left side that tend to present with chronic conditions, it's important to follow the biopsychosocial approach to care, so recognizing that this is a chronic pain condition and that there are factors other than the tendinopathy or partially extended tear contributing to the phenotype of pain and dysfunction. This is important here to educate patients about pain or to collaborate in a multidisciplinary model. I spend a fair bit of time educating them on the function of the hamstring, again, being the dominant hip extensor, as well as, again, assessing them for hamstring dominant pattern and educating them on gluteal activation. Activity modification can be key. This is especially appropriate with sitting, so decreasing the amount of sitting time and then understanding how to avoid excessive hamstring loading and activation. That can sometimes help with some of the symptoms, but sometimes just understanding why that pain is coming and how that pain is originating in their activities is often enough. They can live with it. From a rehab standpoint, again, I mentioned a few times already that we focus on gluteal activation and strengthening, stretching as well, especially if their palpateal femoral angle is tight. Pelvic control is a key part of this because when that's poor, there's an over-activation of the hamstring and reliance on them for stability. And then eccentric strengthening is a classic treatment as well. PRP does not have good evidence in these conditions, especially those more high-grade partial thickness tears. I tend to use it for tendonopathy, especially in those younger patients where we know that PRP is more effective. As of this point in time, there is minimal evidence for the efficacy of PRP. Operative indications, those traditionally have been greater than 2 centimeters of retraction or high-demand patients. Of course, on the left side of this, the tendonopathy chronic partial thickness tears, that would be more of a failure to non-operative treatment. There is no operative indication without non-operative treatment in those. As you get to those acute tears and the full thickness tears, that's where the decision making is important as to whether to pursue operative treatment prior to non-operative treatment. Again, in those, that's where the 2 centimeters of retraction and considerations of higher-demand patients, especially those pursuing activities that do require a lot of hamstring force. An example of that would be a farmer. A farmer does a lot of picking up and lifting from the ground and therefore utilizing a lot of their hamstring. They're often an occupation that cannot stop doing that because it's often been their livelihood since they were a child. That would be a good example of a patient who would benefit from early repair. Some of the evidence suggests that early post-acute injury also has better outcomes. When is that? In this study here, that was defined as 6 weeks. I find that even as early as 2 weeks, they've started to heal and the repair isn't much different than it is 2 to 3 months down the road. If they don't have a clear benefit to repair, that's beyond about 3 weeks. I usually, in the trial of non-operative treatment, assess whether they're going to be symptomatic because, again, I think that repair at 3 months is no different than that repair at 4 to 6 weeks. In the chronic setting, I think cramping is a good indication for repair and there's neuropathic symptoms as well because we know that the strength will not return to normal, but if we can get that muscle out to length, it does stop the cramping and, of course, cramping of the hamstring muscle, given its size, is a very painful problem. The evidence suggests that with acute repair, there is improved outcomes, again, with faster return to play, reduced re-rupture rate, and less sciatic nerve dysfunction. So, again, acute repair has some benefits. It's probably primarily relevant for, again, these more high-demand patients, but, again, I think a brief trial of non-operative treatment when they present outside that really acute period is very reasonable and many will not be symptomatic. When we do get to surgical treatment, I utilize a combination of endoscopic and open treatments as well as grafts when necessary. We're going back to our spectrum of pathology here at the top, and then these treatments are kind of lined up with how I utilize them. So for chronic partial thickness tears, I do all of those endoscopically. I also do all the full thickness minimally retracted tears endoscopically, and this video here is an example of that. This is a suture bridge construct in a minimally retracted full thickness tendon tear. You get into those retracted ones, that's where I'll start to utilize an open repair and really using an overlap of both of these. So that's where I'll utilize the scoping approach, as Mike Salata coined, where we'll do the work around the ischium endoscopically to start with, the debride scar tissue along that track, and then we'll make an incision and get the hamstring distally and then pull the sutures out through the hamstring in an open fashion and then tie. For the chronic tears, I do those virtually exclusively with a graft. I think if they're symptomatic in a chronic setting, they're almost always retracted. There are a few that aren't, but they're almost always retracted, and I don't trust repairing that primarily, so I've gone utilizing grafts on all these using Achilles graft, wrapping the proximal end of the Achilles, the part that attaches to the muscle, wrap that around the native tendon. You can put a lot of sutures into that. It's a really, really strong repair. Then the distal end of the Achilles graft attaches to the calcaneus. That fits very nicely into the proximal insertion of tuberosity. I'll still use a scope to prepare those as well by preparing the footprint there, the anchors. I think the scope can also be helpful looking at it later to ensure the sutures are not tangled. So I'll share a video with you on how I do the endoscopic repair. So we start with, we place them in the prone position with a little bit of hip and knee bend. We utilize four portals primarily, typically in a diamond pattern. Try to put two to three of those in the luteal crease and then the middle one, the AD portal, I'll often bring that down distally to separate them. Again, often orient them in a diamond pattern. So the exposure is really the most delicate and important part of this case. Here we're about a couple of minutes into the case where we've been spreading longitudinally in line with the nerve, so always moving in line with the nerve until it's identified clearly as it is here and retracted. I do stimulate it gently with the blunt instrument to ensure that it is reactive so that we'll be able to identify irritation later. We then assess the footprint for access. So here's a great look at the posterior femocutaneous nerve branch, which is one of the reasons I like the endoscopic approach. I do find there's less injury to the posterior femocutaneous nerve branch. Here we're mobilizing the nerve proximally. There's a pretty consistent anatomic band there that I was just breaking up, and that allows you to retract the nerve and access the semimembranosus. Then lastly, as part of the exposure, we'll put in this gluteus maximus retraction stitch that spans the portals. So here it's important to look back and revisit our anatomy here. The way I like to access the chronic portion thickness here is through that normal anatomic separation distally. So here I'm going distally to where the fat is. That allows you to identify that separation between the semimembranosus and the conjoined tendon, and then we track that up to the footprint. All along the way here, if you're pressing with the radiofrequency device, you can see where those tendons kind of separate. It allows you to stay within the interval. And here we're identifying the degeneration and tear. And here we've completely accessed it here, ensuring that we're able to get to the entire footprint. And here we have great access here again just by going through the interval. We'll often put a stitch into that to lift it up like the instrument is there for passing stitches. So now we'll start to pursue normal tendon repair techniques. And again, you can see here we're retracting through that lateral portal with a switching stick. So we'll burr the footprint up. There's oftentimes significant spurs that may contribute to issue of femoral impingement. Then place sutures, two in each of the footprints, usually in that type of pattern there with two, again, two proximal, two distal, and two within each of the tendon footprints. We'll pass those in a mattress fashion. And then we'll pass some through each of the tendons in a ridge fashion to help close the interval. And this is what the final repair looks like here, a nice anatomic repair. Again, accessing it through that normal anatomic interval there. Again, some other factors of when I do an endoscopic repair. So factors that would favor the endoscopic repair would be when that tendon is near the ischium. So when it's under gluteus maximus, it's hard to sew up there, especially when the tendon's not retracted and you're working up there. That's where the nerve's probably at the most risk. And so if everything's up under the ischium there, I'm more likely to use an endoscopic approach. Actually, for a larger patient, it can be easier as well because retracting all that tissue can be very difficult. And then the history of acute injury. If they have a history of acute injury, it may favor some more open approaches because sometimes those patients will have a lot of scar tissue and you're just not comfortable mobilizing the nerve. I think over time, the more of these that I've done, I do that less and less, but it's something to be aware of. So the outcomes, I mean, I always like to talk about outcomes, level set again on how we're measuring those outcomes. So the ways we can categorize that for this condition would be the safety, function, pain, and re-rupture. So with safety, the main things we're concerned about are infection, nerve injury to the sensory and the sciatic nerve, and then DVTs. The DVT rate is 0.5%, so it's a reasonably high rate. And we use prophylaxis with aspirin as my baseline in these patients. I have found that there is a lower rate of infection. In my population, there's been a lower rate of infection and injury to the post-traumatic cutaneous nerve in the endoscopic approach. With function, measure that by strength. And then with patient-reported outcomes, the question is which one. And there isn't a clear favorite here, and it has been looked at recently in the literature. The IHOT seems to have the least amount, or measures the most number of domains, and so that's what I'll use to measure outcomes in these patients. From a pain standpoint, there's sitting, there's cramping pain, and then of course there's pain that was reflected on the patient-reported outcomes. We know that our functional patient outcomes are actually mostly influenced by pain rather than objective function. And then with re-rupture, that can be two causes. It can be biologic and biomechanical. I do find that it's a biologic cause and a lot of the partial thickness degenerative tears and then your chronic tears should be concerned about the biomechanical contributions if the repair is too tight. This is the outcomes of this cohort here. We published this a couple of years ago. It showed that the scores are both high, 82 in the post-operative score at the IHOT, and then 80% achieving the patient's acceptability symptomatic state of 63. 77% returned to their prior baseline activity level, and again at a relatively low 7% re-rupture rate. This cohort was a mixed cohort of both minimally attracted full thickness tears and refractory like insertional tendinosis, high-grade partial thickness tears. In the return to sport, 100% of them that were involved in organized sports returned to them. 72% of those involved recreational sports returned, and 75% of patients had complete resolution of pain with 90% satisfaction. So overall, a safe and efficacious approach to these injuries. Other authors have presented a series with similar results. The outcomes of open repair, there's a lot more published literature on this. So full thickness tears, some of the things that we know are that acute repair is superior for a sports function, as I mentioned, so faster return to play, better strength. With chronic repair, patients receive about 87% of normal ADL function. We know that with allograft reconstruction relative to direct repair, it's relative equal to direct repair, so there is no deficit using allograft and achieve the results of direct repair. There's a high rate of tendon healing of these at 100% in the study by Shahal et al. When the strength is tested, it does say about 78% of the contrail on the hamstrings, which is not unexpected given what we know from other chronic tendon ruptures. 85% have returned to sport, but again, about half of those returning to sport will see some decrease in performance. Negative predictors from a patient-reported outcome standpoint were a delay greater than six weeks in female sex. It's important also to note that the age and the amount of retraction had no effect on outcomes. With the chronic tendinopathies, we see patients less likely to have limitations with ADLs, have high rate of return to running, and it's important because in a lot of these patients, that's the condition that they have. Return to sport is usually, on average, in these patients, has been about 11 months. When we test their strength from a self-reported strength, they have about 97% estimate their strength again at above 75%, so minimal deficits and a low re-operation rate. One of the things that was noted in these two studies here of chronic tendinopathies is that they do often still have sitting pain. I find that that is the case in my patients as well, but it really just takes longer for it to improve and go away, so I do counsel them that they'll have sitting pain for some time afterwards. Some other things that are noted in the literature is that functional outcomes and muscle strength return tend to be a little bit higher in those tendinopathy patients rather than a full thickness tear. I think it's important to note as we think about endoscopic repair and its role that it, certainly in my experience and increasingly in the literature, it gives us better access. I think it gives me a better repair construct for some of the ones that are up under the gluteus by the ischium. It's safer from an infection and nerve injury standpoint. There's less muscle injury. I think these are some of the exact same reasons we have used as to why we've moved to arthroscopic rotator cuff repair over time. I think we'll continue to see the endoscopic approach for hamstring repairs increasingly used as time goes on. Lastly, I just want to touch on post-op management and rehab. Again, there is a high rate of DVT, especially in those acute tears, so important to counsel them and prophylaxe against that. Perioperative protection. I use a hinged knee brace locked either at 50 to 90 degrees, whatever they can tolerate at night only. I do not use a hinged knee brace during the daytime. I don't think it tolerates well having it bent, but also I think it puts it in a position where it often loads the hamstring when the knee is bent. We've moved away from that and we'll use a partial weight bearing for six weeks. Returning to sport. We let them start to jog about four months. Again, that's very much dependent on them activating their glutes, correcting that hamstring dominant pattern so that the hamstring insertion is protected. In summary, there's a spectrum of pathology. Chronic injury is common. Most of what I'll see with these patients in these injuries are those chronic partial thickness tears. From a non-operative standpoint, focus on the biomechanics of addressing the hamstring dominant extension pattern, activity modification of excessive sitting, and of course the biopsychosocial approach, recognizing that in the chronic setting, this is a musculoskeletal pain problem largely. Surgical repair generally has high satisfaction rates, good functional outcomes, and restoration of muscle strength and return to sport, so it does have an important and valuable role. Acute repair is recommended when indicated if possible, except again in the high-risk and low-demand patients. In the vast majority of patients, I can't think of a patient that I did that was a low-demand patient that we did non-operative treatment with who came back and asked to have it repaired. Lastly, endoscopic repair has been shown by myself and other authors to be technically feasible and safe. I would encourage everyone, if you're interested, to try it out in the lab. I found it to be a very reproducible procedure in the lab. The cadavers work very well for it, and it will increase your comfort in starting to approach these. I think as you take that on, add that to your practice, you'll find you're doing that more and more and moving away from the open approach. Lastly, these are the resources here. I separated them into some surgical technique, etiology, and pathology overview type resources. There's a number of them from an outcome standpoint. There's still more references in the deck here that aren't even included here, so a lot of those for you to review. Again, thanks again for including me in this series.
Video Summary
In this video transcript, the speaker discusses his experience and the current evidence for the treatment of proximal hamstring tears. He explains that there is a spectrum of pathology for these tears, starting with tendinopathies and progressing to chronic partial thickness tears and full thickness tears. Different treatments are recommended based on the severity of the tear. Non-operative treatments focus on neuromuscular training, strengthening, and activity modification. Surgical treatments can be endoscopic or open, depending on the location and retraction of the tear. Grafts may be used for chronic tears. The speaker also discusses the outcomes of these treatments, including safety, function, pain, and re-rupture rates. He concludes by mentioning resources for more information on the topic.<br /><br />No credits are granted.
Keywords
proximal hamstring tears
treatment
evidence
spectrum of pathology
non-operative treatments
surgical treatments
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