Nonoperative Treatment Equally Effective as Operative Approach for Proximal Hamstring Avulsions: NEJM
A new study conducted by researchers revealed that nonoperative treatment for proximal hamstring avulsions is as effective and noninferior to operative treatment. Drawing on a stringent noninferiority test across 10 centers in Sweden and Norway, it compared these two modalities of treatment between patients aged 30 to 70 years. These results were published in the The New England Journal of Medicine by Elsa Pihl and colleagues.
This was a randomized controlled trial with a parallel non-randomized observational cohort. Of the patients, 119 were enrolled in the randomized trial and 97 participated in the observational cohort. Patients were randomized either to operative reinsertion of tendons or to non-operative management, with a primary end-point of Perth Hamstring Assessment Tool (PHAT) score at the 2-year follow-up period. Secondary outcome measures included scores on the Lower Extremity Functional Scale (LEFS).
The key findings of the study were:
• In the randomized trial, the mean PHAT scores were 79.9 ± 19.5 for the operative group and 78.5 ± 19.4 for the nonoperative group.
• The noninferiority limit of 10 points was not crossed, with a mean difference of −1.2 (95% CI, −8.6 to 6.2; P=0.009 for noninferiority), indicating that nonoperative treatment is comparable to operative treatment in terms of functional outcomes.
• The LEFS scores showed a mean difference of −1.6 (95% CI, −5.2 to 2.0) between the groups, aligning with the primary outcome.
• The operative group experienced 9 adverse events, compared to 3 in the nonoperative group, resulting in an odds ratio of 0.3 (95% CI, 0.1 to 1.2),suggesting a lower incidence of complications with nonoperative treatment.
• In the observational cohort, the mean PHAT score difference between nonoperative and operative treatment groups was −2.6 (95% CI, −9.9 to 4.6), further supporting the equivalence of the nonoperative approach.
These findings of the study present that nonoperative treatment for avulsions of the proximal hamstring is not worse than operative treatment, and it is a feasible alternative to surgical intervention without harming the functional outcomes. Now, there is evidence for revisiting these traditional management strategies for such injuries and possibly even favoring less invasive methods.
Reference:
Pihl, E., Laszlo, S., Rosenlund, A.-M., Kristoffersen, M. H., Schilcher, J., Hedbeck, C. J., Skorpil, M., Micoli, C., Eklund, M., Sköldenberg, O., Frihagen, F., & Jonsson, K. B. (2024). Operative versus nonoperative treatment of proximal hamstring avulsions. NEJM Evidence, 3(8). https://doi.org/10.1056/evidoa2400056
