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Background: Surgical treatment of patients with proximal hamstring avulsions provides good results; however, less is known about the outcome in patients who are offered conservative treatment. Purpose: To investigate the effect of surgical or conservative treatment (decided by a shared decision strategy) of proximal hamstring avulsions. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 24 patients with magnetic resonance imaging–verified proximal hamstring avulsion were included and had either surgical treatment (11 patients, 45% women; mean age, 50 ± 16 years) or conservative treatment (13 patients, 46% women; mean age, 50 ± 17 years). At baseline, 6 months and 12 months, all patients answered the Perth Hamstring Assessment Tool (PHAT) (0-100 scale) and Hip Sports Activity Scale (0-8 scale). Patients had their maximal hip extension strength and maximal strength at 30° and 90° of knee flexion measured in newton meters per kilogram using a handheld dynamometer. A minimal important change in PHAT was considered >7 points and a minimal important change in strength was considered >0.15 N·m/kg, respectively. Results: The surgical group had a shorter time from injury to initiation of treatment compared with the conservative group (median: 15 vs 64 days; P =.02). The surgical group had a greater amount of retraction of the tendons compared with the conservative group (3 vs 2 cm; P =.04). From baseline to 12-month follow-up, the surgical and conservative groups improved their mean PHAT scores (35 points [95 CI, 24-45 points] and 20 points [95% CI, 9-31 points], respectively) reaching a median of 79 points (interquartile range [IQR], 66-95 points) in the surgical group and 75 points (IQR, 66-85 points) in the conservative group at the 12-month follow-up. Their Hip Sports Activity Scale levels at 12 months were 3 points (95% CI, 1-4 points) and 1 point (95% CI, 0-3 points) (not significant). Furthermore, the surgical and conservative groups improved their maximal hip extension strength by 0.61 N·m/kg (IQR, 0.42-0.80 N·m/kg) and 0.62 N·m/kg (IQR, 0.13-1.10 N·m/kg), respectively. Their maximal knee flexion strength at 30° improved by 0.52 N·m/kg (IQR, 0.29-0.74 N·m/kg) and 0.32 N·m/kg (IQR, 0.12-0.52 N·m/kg) and their maximal knee flexion strength at 90° improved by 0.28 N·m/kg (IQR, 0.19-0.37 N·m/kg) and 0.22 N·m/kg (IQR, 0.02-0.41 N·m/kg). At the 12-month follow-up, the side-to-side difference in maximal muscle strength was 6% and 7%, respectively, during hip extension and 19% to 25% and 16% to 17%, respectively, during knee flexion. Conclusion: Twelve months after treatment of proximal hamstring avulsion, good clinical outcomes were seen when using a shared decision strategy regardless of whether the strategy led to surgical or conservative treatment. [ABSTRACT FROM AUTHOR]

An MRI-based scoring tool assessing surgical repair after proximal hamstring avulsions may provide benefit in the context of research, while serial post-operative MRI will provide insight of what to expect in the clinical context of early re-injury requiring imaging. This study developed and assessed the reliability of a Proximal Hamstring Objective Magnetic Resonance Imaging Score (PHOMRIS), further assessing MRI-based repair status and its correlation with patient-reported outcome. 15 patients that underwent proximal hamstring surgical repair underwent MRI and clinical review pre-operatively and at 3-, 6- and 12-months. Clinical scores included the Lower Extremity Functional Scale (LEFS), the Perth Hamstring Assessment Tool (PHAT) and Tegner Activity Scale (TAS). The MRI-based tool assessed the conjoint (semitendinosus & biceps femoris) and semimembranosus insertion components based on bone-tendon healing, signal and retraction. Inter- and intra-observer reliability of the tool was assessed. Inter-observer reliability indicated a strong correlation for the semimembranosus (rho = 0.827, p < 0.0001) and conjoint (rho = 0.851, p < 0.0001) components. Intra-observer reliability indicated a strong correlation for the semimembranosus (rho = 0.852, p < 0.0001) and conjoint (rho = 0.996, p < 0.0001) components. All clinical scores and the semimembranosus hamstrings component MRI score significantly improved (p < 0.05) over time, though the conjoint component did not (p = 0.219). At 12 months, a higher LEFS was significantly associated with a better semimembranosus MRI score (r = −0.57, p = 0.042), though no other significant correlations (p > 0.05) were observed between clinical and MRI measures. Excellent reliability was observed for the MRI-based scoring tool, which may prove useful in both a research and clinical setting. [ABSTRACT FROM AUTHOR]

Key points Proximal hamstring avulsion results in muscle atrophy and fatty infiltration. The muscle degeneration after proximal hamstring avulsion is correlated to reduction in muscle strength. The muscle degeneration and its correlation to reduction in muscle strength hold true also for operatively treated patients.

Background: Proximal hamstring tendon avulsions (PHAs) may be treated nonoperatively or operatively. Little is known about the result of the injury, and its treatment, on the quality and function of the hamstring muscle after healing and rehabilitation. We hypothesized that the injured leg would have greater fatty infiltration and atrophy than the uninjured leg at follow-up and that these findings would correlate to muscle weakness. Methods: In a cross-sectional cohort study, 48 patients treated for PHA, either operatively or nonoperatively, were re-examined 2–11 years post-treatment. We measured muscle strength with isokinetic strength tests, and muscle volume and fatty infiltration with MRI. Primary outcomes were hamstring muscle quality, quantified by outlining the cross-sectional area slice-by-slice, and the degree of fatty infiltration estimated using the Goutallier grading method. Secondary outcome was concentric isokinetic hamstring muscle strength measured using BioDex at 60°/sec and tendon attachment assessed on MRI. Comparisons with the outcomes of the uninjured leg were made. Results: The total hamstring muscle volume was on average reduced by 9% (SD ± 11%, p < 0.001) compared to that of the uninjured leg. Fatty infiltration was significantly more severe in the injured hamstrings than in the uninjured hamstrings (p < 0.001). This was also true when only analyzing operatively treated patients. The reduction in muscle volume and increase in fatty infiltration correlated significantly (r = 0.357, p = 0.013), and there was also a statistically significant correlation with muscle atrophy and reduction in isokinetic strength (r = 494, p < 0.001). Conclusion: PHA injuries result in fatty infiltration and muscle atrophy and the muscle quality impairment correlates with residual muscle weakness. Key points: Proximal hamstring avulsion results in muscle atrophy and fatty infiltration. The muscle degeneration after proximal hamstring avulsion is correlated to reduction in muscle strength. The muscle degeneration and its correlation to reduction in muscle strength hold true also for operatively treated patients. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]