To The Editor:

We appreciate the interest in our article(1) by Dr. Packham as well as the issues raised in his letter. He is correct that we recommended a transverse incision in the gluteal crease for exposure. We incorrectly referenced Cross et al.(2) for this approach. The reference should have been Klingele and Sallay(3), who described this approach for the early treatment of complete ruptures. We acknowledge that a longitudinal or extensile approach may be more appropriate in cases of chronic rupture when the sciatic nerve must be identified in an area of normal anatomy. In our clinical series of acute repairs, which has not been published, the use of a transverse incision has provided adequate exposure for exposure of the sciatic nerve, the avulsed hamstring tendons and the ischium to facilitate repair.

With respect to the post operative strength following chronic repair, Dr. Packham points out that we incorrectly interpreted the results of the series by Sallay et al.(4) and indicated that the hamstring strength resulting from repair of a chronic avulsion is similar to nonoperative treatment. He correctly states that this study reports a strength deficit of 61% compared to the contralateral limb, suggesting a static strength of 39%. We agree with his interpretation of these results, and retract the statement that the results for chronic repair are similar to nonoperative treatment.

We thank Dr. Packham for his interest in our study and for clarifying the above important points.

References:

1. Miller SL, Gill J, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. J Bone Joint Surg Am. 2007;89(1):44-8.

2. Cross MJ, Vandersluis R, Wood D, et at. Surgical repair of chronic complete hamstring tendon rupture in the adult patient. Am J Sports Med. 1998;26:785-788.

3. Klingele KE, Sallay PI. Surgical repair of complete proximal hamstring tendon rupture. Am J Sports Med. 2002;30:742-747.

4. Sallay PI, Friedman RL, Coogan PG et al. Hamstring muscle injuries among water skiers. Functional outcome and prevention. Am J Sports Med. 1996;2

To The Editor:

We read with interest the article by Miller and colleages(1). Avulsion of the proximal origin of the hamstrings from the ischial tuberosity remains an under appreciated condition and surgical reattachment can be challenging as the approach may be unfamiliar. This article highlights some of the important anatomical issues relating to this surgery. However, there are a number of issues we would like to raise.

The authors advocate a transverse gluteal crease incision with the patient lying in a prone position and reference a previous publication from our unit by Cross et al.(2). However, this paper described a longitudinal incision. We strongly support the use of the extensile approach used by Cross et al. and other authors(3,4). While potentially not as cosmetically favourable as a transverse incision, it has the substantial advantage of allowing adequate identification and exposure of the hamstring tendons which may be retracted into the thigh, even in acute cases. It is also necessary to identify the sciatic nerve in an area of abnormal anatomy, where in chronic cases the nerve may be surrounded by scar tissue and require neurolysis.

In addition, Miller et al.(1) suggest that post operative strength following delayed chronic repair(2) was similar to that found by Sallay et al.(5) for patients who were managed non-operatively. The mean dynamic hamstring strength was correctly reported as being 60% that of the contra-lateral limb following chronic repair(2). Sallay et al. report a static strength deficit of 61% compared to the contra-lateral limb, suggesting an actual static strength of 39%. Sallay et al. report the mean static strength for two chronic cases which underwent delayed surgical repair was approximately 63%. While we support the suggestion that acute repair is preferable to a delayed repair “and avoids the problems of chronic scarring, retraction and atrophy”(5), we do not believe that the two referenced studies suggest that the results of non-operative and operative management of chronic complete hamstring avulsions are similar.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1. Miller SL, Gill J, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. J Bone Joint Surg Am. 2007;89(1):44-8.

2. Cross MJ, Vandersluis R, Wood D, et al. Surgical repair of chronic complete hamstring tendon rupture in the adult patient. Am J Sports Med. 1998;26:785-788.

3. Blasier RB, Marawa LG. Complete rupture of the hamstring origin from a water skiing injury. Am J Sports Med. 1990;18:435-437.

4. Lempainen L, Sarimo J, Heikkila J, Mattila K, Orava S. Surgical treatment of partial tears of the proximal origin of the hamstring muscles. Br J Sports Med. 2006;40(8):688-91. Epub 2006 Jun 21.

5. Sallay PI, Friedman RL, Coogan PG, et al. Hamstring muscle injuries among water skiers. Functional outcome and prevention. Am J Sports Med. 1996;24:130-136.