DOI: 10.1177/03635465261452818 ISSN: 0363-5465

Two-Year Outcomes of the Proximal Hamstring Avulsion Rehabilitation Regimes: Longitudinal Versus Accelerated Protocol (PHARRLAP) Study: A Randomized Controlled Trial

Jay R. Ebert, Peter K. Edwards, Steven Cecchi, Shahbaz S. Malik, Randeep S. Aujla, Brendan Ricciardo, Peter Annear, Peter A. D’Alessandro
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Background:

Significant variation has been reported within published postoperative rehabilitation protocols after proximal hamstring tendon repair undertaken for acute tendon avulsion injuries, particularly with respect to bracing and the restriction and progression of weightbearing.

Purpose:

To investigate clinical outcomes, the recovery of strength and functional symmetry, and complications and reinjuries in patients undergoing proximal hamstring repair for acute tendon avulsions involving at least 2 tendons, following a conservative (CR) or accelerated (AR) rehabilitation pathway.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

This prospective RCT allocated patients undergoing proximal hamstring tendon repair to the CR pathway (n = 30), which included 6 weeks of knee bracing and restricted weightbearing, or the AR pathway (n = 27), which did not require knee bracing and allowed full weightbearing as tolerated. All patients underwent repair due to an acute avulsion injury involving at least 2 tendons and due to a specific traumatic incident. Patients were assessed presurgery and at 3-, 6-, 12-, and 24-month postoperatively using patient-reported outcome measures (PROMs), peak isokinetic knee flexor (PKFT) and extensor (PKET) torque, and the single-leg horizontal hop test for distance (SLHD). Normalized outcomes and limb symmetry indices (LSIs) were presented for objective measures. Complications and reinjuries were reported. The primary study outcome was the 6-month postoperative LSI for PKFT.

Results:

While the AR group reported a significantly better 12-item Short-Form Health Survey physical score at 3 months ( P = .039) and lower severity of hamstring pain at 3 months ( P = .034) and 12 months ( P = .010), no other group-based differences were observed. The normalized PKFT ( P < .001), PKET ( P < .001), and SLHD ( P < .001) improved over time, as did the PKFT ( P < .001) and SLHD ( P < .001) LSIs. No group differences ( P > .05) were observed for hop or strength outcomes. Four patients were reinjured over the 24 months, including 2 CR patients (at 6 weeks and 3 months) and 2 AR patients (at 10 and 12 months), with an overall rerupture rate of 7%.

Conclusion:

After proximal hamstring repair undertaken due to an acute avulsion injury involving at least 2 tendons, patients demonstrated improved PROMs, a sound recovery of strength and function, and a low reinjury rate over a 2-year postoperative period. The AR pathway that did not employ bracing and permitted full weightbearing as tolerated demonstrated subjective, functional, and reinjury outcomes that were largely comparable over the 2 years. However, the study was not powered to investigate differences in reinjury risk.

Registration:

Australian New Zealand Clinical Trials Registry (ACTRN12621000913875).

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