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- Laszlo, Sofia, 1990-, et al.
(författare)
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Initial tendon retraction is Associated with muscle degeneration after nonoperatively treated proximal hamstring avulsions
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Background and purposeMagnetic resonance imaging (MRI) is important for diagnosing proximal hamstring avulsions (PHA), assessing the number of ruptured tendons, and their degree of retraction. Alongside clinical findings and patient characteristics, MRI findings guide surgeons in treatment decisions. However, the importance of pre-treatment MRI findings for radiological and clinical outcomes remains unclear.MethodsThis study is a post hoc analysis of nonoperatively treated patients (n=95) from the Proximal Hamstring Avulsion Clinical Trial (PHACT). Diagnostic MRIs were reassessed for tendon retraction, Wood classification, number of tendons avulsed, and hematoma size. The primary outcome was muscle degeneration, defined by the loss of lean muscle volume (LMV) and an increase in muscle fat fraction (MFF) on MRI at 24 months. The secondary outcome was maximum hamstring muscle isometric force (Newton, N) at 24 months. Outcome data was expressed as the limb symmetry index (LSI) which was the measurement of the injured hamstring expressed as a percentage of measurement of the uninjured hamstring. The association between measurements on the diagnostic MRIs and LSIs for LMV, MFF, and maximum isometric force was analyzed using linear regression.ResultsThe median LSIs of the LMV, MFF and maximum strength were 78.3%, 139%, and 84%, respectively, at the 24 month follow-up. A multivariate linear regression model including tendon retraction, age, sex, hematoma size and whether the dominant limb was injured explained 47 %, 47% and 21% of the variance in the LSIs of LMV, MFF and maximum force, respectively. Tendon retraction was the strongest explanatory factor for the variance of muscle degeneration observed in patients with nonoperatively treated PHA. InterpretationGreater initial tendon retraction is associated with increased muscle atrophy and fat infiltration in the hamstring muscles in patients with PHA.
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| 2. |
- Laszlo, Sofia, et al.
(författare)
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Proximal Hamstring Tendon Avulsions : A Survey of Orthopaedic Surgeons' Current Practices in the Nordic Countries
- 2022
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Ingår i: SPORTS MEDICINE-OPEN. - : Springer. - 2199-1170 .- 2198-9761. ; 8:1
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Tidskriftsartikel (refereegranskat)abstract
- Background and purpose Evidence guiding the decision on whether to treat proximal hamstring tendon avulsions (PHA) operatively or non-operatively is very limited. The aim of this study was to identify the current practices and the rationale behind PHA treatment decisions in the Nordic countries. Methods A survey was sent to orthopaedic surgeons in Sweden, Norway, Finland and Denmark. The study population consisted of responding surgeons with exposure to surgical treatment of PHA (n = 125). The questions covered surgeon and unit characteristics, and surgeons' understanding of the evidence for treatment, and they explored which patient and injury factors influence treatment allocation. Results Although some surgeons indicated a preference for one of the treatments, 84% stated that the treatment decision was based on patient and injury-related factors. Severe obesity, drug abuse, a sedentary lifestyle, age > 60 years and delayed diagnosis (> 6 weeks) were considered contraindications to surgical treatment. Also, there was agreement that patients expressing a preference for non-operative treatment should not be operated. Complete avulsions with tendon dislocation >= 2-3 cm on MRI were relative indications for surgical treatment. The majority of surgeons did not believe that operatively treated patients did better than non-operatively treated patients and experienced that patients, generally, were satisfied with the treatment result, regardless of the type of treatment. Most surgeons had experienced significant complications to operative treatment. Conclusion Current practices varied among different units, and despite the lack of evidence for their prognostic value, several factors were inconsistently being used as decision modifiers when selecting patients for surgical treatment.
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| 3. |
- Pihl, Elsa, et al.
(författare)
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At mid- to long-term follow-up after proximal hamstring tendon avulsion; there was greater fatty infiltration, muscle atrophy and strength deficit in the hamstring muscles of the injured leg than in the uninjured leg
- 2023
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Ingår i: Journal of Orthopaedic Surgery and Research. - : BioMed Central (BMC). - 1749-799X. ; 18:1
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundProximal 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.MethodsIn 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 degrees/sec and tendon attachment assessed on MRI. Comparisons with the outcomes of the uninjured leg were made.ResultsThe 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).ConclusionPHA injuries result in fatty infiltration and muscle atrophy and the muscle quality impairment correlates with residual muscle weakness.
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| 4. |
- Pihl, Elsa, et al.
(författare)
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Exploring the Perth Hamstring Assessment Tool and Lower Extremity Functional Scale in a Proximal Hamstring Avulsion Cohort : A Cross-sectional Study
- 2021
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Ingår i: American Journal of Sports Medicine. - : Sage Publications. - 0363-5465 .- 1552-3365. ; 49:7, s. 1732-1740
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Tidskriftsartikel (refereegranskat)abstract
- 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.
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| 5. |
- Pihl, Elsa
(författare)
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Proximal hamstring avulsions : surgery or not?
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In paper 1, a retrospective cohort study of patients treated for proximal hamstring avulsions at Danderyd Hospital from 2007–2013 was conducted. The study was performed in 2015. The primary outcome was the subjective patient reported outcome Lower Extremity Functional Scale (LEFS), and the exposure was surgical treatment. We hypothesized that there would be no difference in the LEFS, between the two treatments at this long-term follow-up. The results showed similar LEFS scores in the surgically treated 74 (SD±12) and nonsurgically treated 72 (SD±16) patients, which were also true after adjusting for confounders. There were some differences between the groups, with surgically treated patients having more severe injuries and reporting more hours of physical activity at the follow-up than nonsurgically treated patients. To obtain an evidence-based treatment decision for proximal hamstring avulsions, studies at higher scientific levels are needed. Paper 2 consists of a cross-sectional cohort study. Patients treated for proximal hamstring avulsions at Danderyd Hospital between 2007 and 2016 were included. The study was performed from 2018-2019. The main outcomes were the correlation among subjective, patient-reported outcome measurements (PROMS), the Perth Hamstring Assessment Tool (PHAT) score and the Lower Extremity Functional Scale (LEFS) score and their correlation. The secondary outcomes were the correlation of PROMs with objective performance-based tests. Moreover, we explored which activity patients perceived to be most limited several years after injury. We hypothesized that there would be good correlations between the PHAT and LEFS scores and at least moderate correlations between these questionnaires and performance-based tests. We found strong correlations between the PHAT and LEFS scores (r=0.832, p<0.001). The LEFS was more appropriately aligned with the performance-based tests than the PHAT. Of all the physical performance tests performed at follow-up, only the isokinetic test could discriminate between injured and uninjured legs. Patients most frequently reported activity limitation was running. Since the PHAT, LEFS and physical performance-based tests seem to assess different aspects of recovery, both subjective and objective outcome measures are recommended to be used for follow-up after proximal hamstring avulsion. In paper 3, we performed a cross-sectional study on the same cohort of patients in the same setting as in Study 2. The primary outcomes were hamstring muscle volume and fatty infiltration at least 2 years after injury. The secondary outcome was the correlation of these parameters with isokinetic muscle strength. The conditions of the injured and uninjured legs were compared. 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 with muscle weakness. We found that, on average, the hamstring muscle volume was reduced by 9% (SD±11%) 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). Reduced muscle volume and increased fatty infiltration were significantly weakly correlated with isokinetic strength test results (r=0.357-494, p< 0.001-0.013). At follow-up, we concluded that fatty infiltration and muscle atrophy are likely to occur as a result of proximal hamstring avulsions, and muscle quality impairment is weakly correlated with muscle weakness in the injured leg. In Study 4, a randomized, noninferiority, multicentre, preference-tolerated clinical trial was performed. Patients from ten study sites in Sweden (8) and Norway (2) participated. Patients were eligible for inclusion if they had an acute (within 4 weeks) proximal hamstring injury and were aged 30 to 70 years. Patients were randomly selected to undergo surgical or nonsurgical treatment. Surgical treatment included reinsertion of the tendons followed by rehabilitation, and nonsurgical treatment included rehabilitation only. If the patients and doctors could not reach a consensus on treatment, the patients were invited to join an observational follow-up cohort. The primary outcome was the PHAT score at two years post treatment. A noninferiority margin of 10 points on the PHAT was set for the lower limit of the two-sided 95% CI. The secondary outcomes consisted of the LEFS score, physical performance-based test results and muscle quality analysis results on MRI. We enrolled 119 patients in the randomized trial and 97 in the observational cohort. According to the intention-to-treat analysis, the mean PHAT scores were similar, with mean (±SD) scores of 80.4(±19.3) and 77.7(±20.0) in the surgical and nonsurgical groups, respectively. The prespecified inferiority limit was not crossed (mean difference, -2.1; (95%CI -9.3 to 5.1) p =0.017 for noninferiority). According to the inverse probability weighted analysis of both cohorts combined, the mean difference in the PHAT score was -2.6 (95%CI, -7.9 to 2.8). Analyses of secondary outcomes including the mean LEFS score difference of -2.1 (95%CI, -5.7 to 1.5) supported noninferiority. The conclusion was that patients with proximal hamstring avulsions who were treated nonsurgically do not have worse PHAT scores than patients who were treated surgically; therefore, the treatment of choice for middle-aged patients should be nonsurgical treatment.
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| 6. |
- Pihl, Elsa, et al.
(författare)
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The proximal hamstring avulsion clinical trial (PHACT)-a randomised controlled non-inferiority trial of operative versus non-operative treatment of proximal hamstrings avulsions : study protocol
- 2019
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Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 9:9
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Tidskriftsartikel (refereegranskat)abstract
- Introduction The treatment of proximal hamstring avulsions is controversial. While several trials have investigated the outcome for patients treated surgically, there is today no prospective trial comparing operative treatment with non-operative treatment. This protocol describes the design for the proximal hamstring avulsion clinical trial (PHACT)-the first randomised controlled trial of operative versus non-operative treatment for proximal hamstring avulsions. Methods and analysis PHACT is a multicentre randomised controlled trial conducted across Sweden, Norway and Finland. Eligible patients (60 participants/treatment arm) with a proximal hamstring avulsion of at least two of three tendons will be randomised to either operative or non-operative treatment. Participants allocated to surgery will undergo reinsertion of the tendons with suture anchors. The rehabilitation programme will be the same for both treatment groups. When patient or surgeon equipoise for treatment alternatives cannot be reached and randomisation therefore is not possible, patients will be invited to participate in a parallel observational non-randomised cohort. The primary outcome will be the patient-reported outcome measure Perth hamstring assessment tool at 24 months. Secondary outcomes include the Lower Extremity Functional Score, physical performance and muscle strength tests, patient satisfaction and MR imaging. Data analysis will be blinded and intention-to-treat analysis will be preformed. Ethics and dissemination Ethical approval has been granted by the Ethical Committee of Uppsala University (DNR: 2017-170) and by the Norwegian ethical board (REC: 2017/1911). The study will be conducted in agreement with the Helsinki declaration. The findings will be disseminated in peer-reviewed publications.
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