Early Surgical Repair of Acute Complete Rupture of the Proximal Hamstring Tendons

Complete rupture of the proximal hamstring origin normally arises from a violent overstretching of the contracted hamstring muscles while the hip is flexed and the knee is extended. Reports of surgical treatment of a proximal hamstring rupture are few, include relatively small number of patients, and contain both acute and chronic tears. Often there is a considerable delay in diagnosis because of its rarity, difficulty in clinical diagnosis by deep seating of the injured tendons beneath the thick layer of adipose tissue and the belly of the gluteus maximus muscle, initial attempt of conservative care, and under-appreciation of the residual loss of function in non-surgically treated cases. MRI is essential for a correct diagnosis in cases where a tear is suspected.3, 5, 7-9)

Interest in the surgical treatment of these injuries has increased as poor functional results have been reported among patients treated non-surgically.4, 6, 7, 9, 10) Sally et al.10) reported the functional outcomes of 12 patients who had hamstring injuries (six complete and the other six partial) and treated initially non surgically. Six patients who sustained partial tears could return to most of their preinjury sports but five patients, all with complete tears, were unable to run or participate in any sports requiring agility. Only one female patient with a complete tear was satisfied with her function.

Recently, many authors reported that early surgical repair of complete proximal hamstring ruptures, which is defined as those repaired less than 4 weeks after the injury, produced better results and a high return to full activity than late surgery.3-6) Folsom and Larson6) reported excellent results with a high return to full activity in 21 acute and 5 chronic injuries treated surgically. They suggested early repair for active patients to allow easier repair and an early return to function. Sarimo et al.5) reported the surgical treatment of complete proximal hamstring tendon ruptures in 41 patients. When the patients were divided into 3 groups (0-3 months, 3-6 months, and > 6 months) according to the delay from injury to surgery, there were significant diff erences in the result. According to the results, they concluded that early surgical treatment produces better results than late surgery and is therefore recommended.

The surgical techniques advocated most frequently for acute repair of complete ruptures of the proximal hamstring tendons include transosseous fixation methods using multiple drill holes in the ischium or a bone-anchorsuture-tendon system.1, 2, 5, 6)

In chronic cases, the anatomical reattachment of torn tendons is much more difficult than acute cases and often the knee has to be flexed and immobilized more to achieve apposition and reduce the tension on the repaired tendons until complete healing. Many authors deem extensile exposure necessary to identify scarred, retracted muscles in chronic cases. In addition, the sciatic nerve is frequently encased in scar tissue and requires neurolysis, which poses a risk to the nerve branches. Proximal tendinous tissue is normally tenuous as the torn tendons were successfully mobilized to the ischium and call for additional augmentation. When it is impossible to pull the torn tendons back to the ischial tuberosity, various types of reconstructions are needed to bridge the torn end to the ischial tuberosity.5, 6, 9, 10) Based on the literature available and our own experience, it is believed that acute injuries are easy to repair, and early repair yields excellent functional results. Furthermore, the surgeon can avoid the problems of chronic scarring in delayed repair.

Postoperatively, immobilization of the knee at a considerable degree of flexion and hip in neutral position with orthosis lasting for 4 to 6 weeks has been recommended to avoid stress on the repaired hamstrings.2-4, 8) Folsom and Larson6) found it unnecessary to restrict the hip range of motion when knee motion is controlled and used a standard hinged knee brace instead of a hip/knee orthosis. After 2 to 6 weeks, the brace was opened gradually and range of motion exercises combined with isometric exercises were started. After the brace was discontinued at postoperative 6 to 8 weeks, the patient was allowed to bear weight where tolerated. Overstretching of the hamstrings must be avoided for the first 4 weeks and simultaneous hip flexionknee extension is not allowed for 2 months after surgery. More intensive physical therapy with special regard to stretching and strengthening of the hamstrings, should begin at 2 to 4 months, and sports activities be allowed 6 months after surgery depending on the type of sports and the patient's progress. The two patients in this report underwent a postoperative physical therapy regimen based on the protocol above.

A complete proximal hamstring rupture is a serious injury that can lead to significant disability. The authors believe that early surgical repair is recommended for young, active male and female patients because non-surgical treatment result in complications, such as muscle weakness including a sense of poor leg control, sciatic neuralgia, and distal bulge caused by the retracted muscles. For female patients, a transverse incision in the gluteal crease is recommended when cosmetic problems are considered. These injuries might be more common than previously appreciated. We believe that a high clinical suspicion of the examiner based on the reported mechanism and clinical findings, and the prescription of a MRI scan in cases where a tear is suspected would reveal the injury in the early stage and make acute repair possible.