Review Question - QID 219940

The patient has a complete three-tendon rupture of his hamstrings with massive retraction that is still in the acute phase; thus, he should undergo a primary repair with suture anchor fixation.

Proximal hamstring ruptures most commonly occur at the myotendinous junction in running athletes as a result of sudden hip flexion and knee extension, or in older patients via similar hyperflexion accidents that occur during slips and falls. Less commonly, an ischial tuberosity avulsion fracture can also be seen in skeletally immature patients, though this finding has also been seen in water skiers. Risk factors include prior injury, which increases the risk of rupture by a factor of up to 6x, and reduced baseline hip flexion with strength imbalance denoted by a hamstring to quadriceps ratio < 0.6. In terms of anatomy, there are three tendons that attach to the ischial tuberosity, with the semimembranosus attaching more laterally and the more medial two tendons (semitendinosus and long head of the biceps femoris) forming a conjoined tendon (Illustration A). Single-tendon tears and two-tendon tears with < 2cm of retraction can be treated non-operatively with protected weightbearing and can take up to 6 weeks to heal. Proximal avulsions involving 2 tendons with > 2 cm of retraction in active patients and 3 tendon tears require operative intervention for tendon repair, which involves prone surgery with a transverse incision over the gluteal crease that can be extended distally in a "T" configuration for larger retracted and chronic tears (Illustration B).

Cohen et al. review acute proximal hamstring ruptures. The authors note that non-surgical treatment of complete ruptures can result in complications such as muscle weakness and sciatic neuralgia; they advocate for surgical repair, which involves a transverse incision in the gluteal crease, protection of the sciatic nerve, mobilization of the ruptured tendons, and repair to the ischial tuberosity with the use of suture anchors. They conclude that surgical repair results project a 58% to 85% rate of return to function and sports activity, near normal strength, and decreased pain.

Van der Made et al. performed a systematic review of the outcomes after surgical repair of proximal hamstring avulsions. The authors included 13 studies with a total of 387 patients and found that after surgical repair of proximal hamstring avulsions, 76% to 100% returned to sports, 55% to 100% returned to pre-injury activity level, and 88% to 100% were satisfied with surgery. They concluded that, though the quality of the studies included was low, surgical repair of proximal hamstring avulsions appears to result in a subjective highly satisfying outcome.

Bodendorfer et al. published a systematic review and meta-analysis of the outcomes after operative and non-operative treatment of proximal hamstring avulsions. The authors included 24 studies with a combined 795 proximal hamstring avulsions and found that, overall, repairs had significantly higher patient satisfaction (90.81% vs. 52.94%), hamstring strength (85.01% vs. 63.95%), Lower Extremity Functional Scale scores (72.77 vs. 69.53), and single-legged hop test results (119.1 vs. 56.62 cm). They concluded that proximal hamstring avulsion repair resulted in superior outcomes as compared with non-operative treatment, although
the complication rate was 23.17%.

Figure A is a clinical photograph showing the posterior thigh ecchymosis characteristic of proximal hamstring tendon ruptures. Figures B-D represent coronal T2-weighted, sagittal PD fat-saturated, and axial T2-weighted MRI images, respectively, demonstrating complete, retracted three-tendon tearing of the proximal hamstrings without evidence of an ischial tuberosity avulsion fracture. Illustration A demonstrates the insertion sites of the three hamstring tendons. Illustration B demonstrates the typical surgical incision utilized for proximal hamstring repair.

Incorrect Answers:
Answers 1 and 2: Non-operative treatment of three-tendon tears with significant retraction, as above, is not the standard of care for an active patient.
Answer 3: There is no evidence of ischial tuberosity avulsion fracture on this patient's imaging.
Answer 5: This patient has an acute tear that should be able to be mobilized sufficiently for primary suture anchor fixation alone. The addition of bracing has not been shown to be necessary and can be used at the provider's discretion.