Treatment of proximal hamstring ruptures a systematic review

Proximal hamstring ruptures are increasingly treated surgically, despite little high-level supporting evidence. We sought to determine whether there are differences in clinical outcome after surgical vs. non-surgical treatment of proximal hamstring tendinous avulsions/ruptures and acute vs. chronic surgical repair of tendinous avulsions. Multiple medical databases were searched for Level IIV evidence. 18 studies were included. 298 subjects (300 proximal hamstring injuries) were analyzed with mean age of 39.7 years. 286 injuries were managed with surgical repair vs. 14 non-operative. 95 surgical cases were performed within 4 weeks of the injury (acute), while 191 were performed beyond 4 weeks (chronic). 292 injuries were tendinous avulsions while 8 were bony tuberosity avulsions. Surgical repair resulted in significantly (p<0.05) better subjective outcomes, greater rate of return to pre-injury level of sport, and greater strength/endurance than non-surgical management. Similarly, acute surgical repair had significantly better patient satisfaction, subjective outcomes, pain relief, strength/endurance, and higher rate of return to pre-injury level of sport than chronic repair (p<0.001) with reduced risk of complications and re-rupture (p<0.05). Chronic surgical repair also improves outcomes, strength and endurance, and return-to-sport, but not as well as acute repair. Non-operative treatment results in reduced patient satisfaction, with significantly lower rates of return to pre-injury level of sport and reduced hamstring muscle strength.