Fig. 17.1
Complete avulsion of the proximal hamstrings’ tendon from the ischial tuberosity in a 40-years-old female
Quadriceps disinsertions from the patella are instead an uncommon problem with an incidence of 1.37/100,000 patients per year, affecting predominantly middle-aged males (male/female [4.2:1]; mean age, 51.1 years) and even more rare is the proximal complete avulsion from the anterosuperior iliac spine (Clayton and Court-Brown 2008).
Concerning the distal biceps avulsions and/or ruptures, they are relatively rare with an incidence rate of about 1.2–2.5 per 100,000 (Safran and Graham 2002; Kelly et al. 2015).
The pathogenetic causes are different: studies support eccentric overload as the most common mechanism of injury. High-energy contact trauma is also reported in the quadriceps disinsertions, while the most common mechanism by which distal biceps, pectoralis major, and hamstring avulsions occur is a fall on the outstretched hand or a final phase of a jump. Degeneration, inflammation, hypovascularization, or friction of the tendon is known to contribute to the possibility of rupture (Devereaux and ElMaraghy 2013; Belli et al. 2001; Weiss et al. 2000; LaPrade et al. 2015).
Also medications can predispose to muscle avulsion such as anabolic steroids, statins, locally injected corticosteroids, prolonged use of systemic corticosteroids, and antibiotics (e.g., fluoroquinolones) (Celic et al. 2012; David et al. 1995; Liow and Tavares 1995). Not so rare is then the involvement, caused by the same injured mechanisms, of other anatomical structures during a muscles avulsion. For example, there is a strict relation between distal hamstring disinsertion (i.e., distal origin of the semimembranosus) and other tears like the anterior cruciate ligament (ACL), menisci, and/or the posterior cruciate ligament (PCL) (Khoshnoodi et al. 2014; Vanek 1994). Khoshnoodi et al. reported, for example, a case of an isolated semimembranosus insertional avulsion with a PCL tear, medial meniscal tear, and capsular rupture in a 26-year-old football player (Khoshnoodi et al. 2014). According to the literature, the surgical treatment is recommended in case of complete disinsertion, especially in young active sportsmen, and generally if the retraction from the bone is greater than 2 cm (i.e., hamstring injuries) (Fig. 17.2). One of the most important aspects in these situations is the early identification and a well-timed surgical treatment. The results of previous studies regarding the timing of surgery are conflicting: today, the common consensus is that patients with acute repairs have better outcomes when compared with chronic surgical treatment, due to an easier and faster postoperative recovery (Sallay et al. 2008; Sarimo et al. 2008). The literature suggests also that the early surgical reattachment gives the athletes a greater chance of returning to their pre-injury level of sport, especially for the lower limb muscle avulsions (Harris et al. 2011; Kurosawa et al. 1996). Ten patients presenting with complete proximal hamstring tendon tears were confirmed on MRI. All patients underwent surgical exploration and repair of the torn tendons with the aim of returning to normal activities and sports. All patients were semi-professional or professional athletes and presented within five weeks of their injury (average 12 days, range 4–35 days).An excellent outcome was found in terms of return to normal activities and sports. Early surgical repair and physiotherapy has been noted to be associ- ated with a good outcome and enables an early return to high level sports after complete tear of the proximal hamstring tendons (Konan and Haddad 2010). Lempainen et al. showed, with a case series of 18 operatively treated distal hamstring muscle tears in athletes, excellent results in 13 cases. Fourteen of the 18 patients were able to return to their former level of sport after an average of 4 months (range 2–6 months) (Lempainen et al. n.d.). O’Shea et al. demonstrated in 27 patients after quadriceps reinsertion (average 17 days between injury and surgery) excellent clinical outcomes over a period of seven years, and they were all able to return to pre-injury levels of activity (2002). In a review that evaluated 18 studies, including 286 operative and 14 nonoperative cases, Harris JD et al. concluded that surgical repair of complete proximal hamstring ruptures improved clinical outcomes than a conservative treatment (2011). Also Sallay et al. with a retrospectively reviewed 25 cases surgical repaired over a 12-year period using bone anchors reported good results: in 92% cases no pain and in 98% no differences with the isokinetic test comparing the injured limb with the uninvolved one. In that study all the patients had an avulsion from the bone of all the three tendons (2008). But other papers have shown a low rate of return to pre-injury activity levels. For example, Konrath et al. found that 51% of patients who underwent a quadriceps reinsertion were unable to return to their pre-injury activity level. In this study, although 79% of players were described as recovering fully from their injury, only 50% of all injured players returned to play in regular-season NFL games (1998). Several series and descriptions are available in the literature about different surgical techniques, and good/excellent results are reported by the authors (Mica et al. 2009; Sarimo et al. 2008; Chakravarthy et al. 2005; LaPrade et al. 2015; Branch and Anz 2015; Boublik et al. 2013; Petilon et al. 2005). The fixation of the tendons usually is performed using an open surgical approach in order to have a better anatomical exposure and an easier technique. Different devices can be used due to an anatomical reconstruction and to obtain a stronger suture of the tendons to the bone (Gidwani et al. 2004; Wooton et al. 1990; West et al. 2008). In this way, some authors have proposed reinforcements of the damaged tissue using, for example, autograft, allograft, or synthetic mesh augmentation (Sarimo et al. 2008; West et al. 2008; Ding et al. 2016; Morrey et al. 2016). Recently, mini-invasive techniques such as a percutaneous fixation of the muscle’s avulsion (Watts et al. 2014) or an endoscopic approach allowing a safe approach to the area of injury were also showed. The benefit of it is to reduce the morbidities associated with an open approach (Guanche 2015; Bhatia 2016). Concluding, the management of muscle avulsions must be focused at first time in a correct diagnosis and at second in the reconstruction/reinsertion thinking about the dimension of the damage, the quality of the muscle origin, and the type of patients. In order of this reason, according with the literature, we remember some useful tips for a correct management of these situations, due to simplifying of the surgical procedure and reducing the operative time:
Use the most simple surgical approach considering our surgical skills.
Identify and protect the vascular and nervous complex.
Identify and mobilize the muscle’s origin.
Clean and remove completely the hematoma, fibrotic, and soft tissue.
Denude the bone from the periosteum to enhance healing of the muscle insertion.
Suture the insertional origin of the muscle reducing any tension of the tissue (i.e., flexion of the knee if proximal hamstring reinsertion).
Protect the surgical gesture and the healing process employing an immobilization with a cast or plaster for some days (7–15) after surgery.
Fig. 17.2
Reinsertion and fixation of the bone fragment of the ischial tuberosity after the complete proximal hamstrings’ tendon avulsion using metal screws in a young 17-year-old football player
17.3.2 Acute Muscle Belly Injuries
Direct muscle contusions are one of the most common causes of discontinuity of muscle bellies.
More rarely the cause depends on a violent contraction or forceful stretching of the muscle or an uncoordinated force acting on the tightly contracted muscle (Praemer et al. 1992; Zarins and Ciullo 1983).
The surgical treatment of acute damage is therefore necessary in the grade III–IV (total) muscle tissue injuries (Almekinders 1991; Kujala et al. 1997).
In these situations there is a subtotal or complete loss of the contractile muscle capacity (caused from the interruption of the muscle fibers) compromising its function. The regenerative capacity of the injured skeletal muscle is limited, and therefore suturing the transected muscle may help the tissue heal and prevent complications. Some authors have reported good/excellent results after repair, but unfortunately it does not prevent the formation of scar tissue (Chien et al. 1991; Gilcreest 1933). Aarimaa et al. showed, in an experimental study, that volumetric muscle loss greater than 50% cannot be biologically repaired and, consequently, result in a residual important loss of function (2004).
Repair of muscle belly lacerations is technically demanding because the sutures pull out, and the likelihood of clinical failure is high. Thereby, a complete MI like a laceration can bring about permanent functional disability and muscle weakness (Julien and Mudgal 2011). Different suture techniques have been described in literature, but still the best suture is debated: today the therapeutic management is unclear with no definite guidelines. This is caused by the great heterogeneity of the muscle belly lesions and of patients. Many features are already identified: dimension and extension of the lesion, quality and kind of the damage tissue, type of suture, and time between injury and surgery (Jarvinen and Lehto 1993). For example, the role of epimysium (the connective tissue sheath around a muscle) is not well defined in surgical repair. Furthermore, the epimysium-based repair has been reported to be important for superior stitching of forearm muscle belly lacerations (Botte et al. 1987). As for the hand surgeons, where the epitendinous repair has become a common practice because of its biomechanical strength, different authors found similar advantages in epimysial-based repair in muscle bellies. The incorporation of the epimysium improves surgical repair because incorporation of fibrous portions of the muscle improves tension bearing and may permit a better sliding (Heckman and Levine 1978).
Heterogeneous outcomes are also reported using different types of sutures. Chien et al., for example, showed better results with the modified Kessler suture (with 5–0 Mersilene) than either simple suturing with 2–0 Dexon or simple suturing with a tendon graft (1991). Contrary to Chien, Kragh J.F. Jr. et al. had shown that the better method of repair for suturing muscle is the use of combination stitches and not only the same type (2005).
In this paper the authors tested Kessler stitches and the combination of Mason-Allen and perimeter stitches. Individual stitches were placed in the muscle belly of quadriceps femoris from a pig cadaver and were tensioned mechanically. The maximum loads and strains were measured and failure modes recorded. The mean load and strain for the Kessler stitches were significantly less than those for combination stitches. Despite these considerations, it is a common consensus that immediate repair strength is important because healing is better when motion is started 5 days after repair, and this is useful to prevent hard anelastic scar (Jarvinen and Lehto 1993).
During an acute muscle injury, another important indication for a surgical approach is also when a large intramuscular hematoma is associated with the tissue damage (Fig. 17.3) (Almekinders 1991; Kujala et al. 1997).
Fig. 17.3
Intramuscular rectus femoris III grade lesion hematoma in 26-year-old sportsman
In some situations, especially after a direct trauma, a localized bleeding can form a hematoma associated with the tissue damage. There are two types of hematoma: intramuscular and intermuscular. The prognosis for intermuscular hematomas is better, but the persistence of swelling after 48–72 h increases pain intensity, extension of tenderness, prolonged restricted limb range of motion, and pain. In few of these cases, the hematoma becomes so large as to generate a compartment syndrome giving compression of vessels and nerves with a reduction of the distal pulses or paresthesia (Botte et al. 1987; Heckman and Levine 1978; Kragh et al. 2005; McQueen et al. 2000).
It is crucial to identify these situations adopting a mini-invasive surgical approach to remove the hematoma aimed to prevent a complete invasive fasciotomies.
17.3.3 Chronic Muscles Injuries
The surgical management of chronic muscle injuries is today unclear, and no definite guidelines are yet published. Very often the persistence of discomfort and pain are the symptoms most frequently reported by the patients for a long time (duration > 4–6 months) after an acute damage, and the loss of function with worsening performances sometimes may require in these situations a remote surgical treatment (Hope and McQueen 2004; Ramdass et al. 2007; Erturan et al. 2013). Several studies showed a closed correlation between acute muscle injuries and chronic ones: Murray and Lowe have demonstrated that a previous hamstring damage displays the greatest risk factor with two to six times elevated re-injury rates (2009).
In literature, there is discrepancy of the results about the surgical treatment of chronic muscle injuries, as there is no common consensus because authors often apply an experience-based medicine. Two are then the most important correlated difficulties occurring during the surgical approach in these situations, and often they are the cause of poor outcome: the quality of the residual tissue and the retraction of the previous scar. Regarding the first complication, in literature different strategies in order to reinforce the peri-lesional cloth, especially if the injury takes place in the extremities of the muscle tissue (miotendinous/tendinous side), are described. Some papers reported good results using the autografts, allografts, and also muscular transpositions. Lempainen et al., for example, proposed surgical reconstruction technique for complete chronic proximal hamstring rupture by use of fascia lata autograft augmentation in five cases with good results at 12 months follow-up. The authors suggest this technique when the primary repair has failed or in chronic injuries where there is a large defect with loss of healthy tissue (Lempainen et al. 2007).
Sarimo et al. reported, for example, on 41 proximal hamstring ruptures, of which 19 patients had surgical repair with greater than 3 months’ delay. The risk for a poor outcome was 28 times greater for those with a delay in treatment. The authors found also a strict correlation between outcomes and quality of the peri-lesional residual muscular tissue (Sarimo et al. 2008).
In a cohort study, about 72 patients comparing the functional outcomes and return to sports after acute, chronic repair, and allograft reconstruction for proximal hamstring ruptures, the authors showed that surgery after 6 weeks from the injury had poorer outcomes for return to sports (70.2% cases versus 80.3%) and a trend toward inferior outcomes compared with the acute repair (Rust et al. 2014).
The retraction and the scarring pose are another significant dilemma for the surgeon, very often directly related to the severity of the soft tissue damage. Therefore, the surgical management should be considered if, after an adequate postoperative rehabilitation and stretching protocols, the patient complains of persistence of pain and stiffness after a previously injured muscle. In these chronic cases, the scar tissue formation and adhesions restricting the articular range of motion should be suspected, and surgical fibrinolysis and revision of the scar tissue can be considered. In literature several authors proposed, in addition of this procedure, also the use of autograft or allograft augmentation in order to resolve the muscular retraction of the scar. Murray and Lowe published a case report of a cyclist with a 6-year-old chronic proximal hamstring rupture treated with Achilles allograft reconstruction with a reinforcement of the footprint using suture anchors (2009).
Rust et al. proposed allograft reconstruction for chronic hamstring injuries with greater than 5–6 cm of scar retraction (2014).
Darlis and Widmer recommended the use of an allograft/autograft when anatomic repair of the distal biceps cannot be achieved by native tendon beyond 70–90 flexion (Darlis and Sotereanos 2006; Widmer and Tashjian 2010).
But the harvesting autograft may cause donor site morbidity and additional operating time to harvest and requires prepping and draping of the lower extremity. Allograft increases cost and carries a small but inherent risk of disease transmission (Robertson et al. 2006).
Another strategy to treat and resolve the muscular scar retraction after a wrong healing of an acute muscular complete tear is the musculotendinous surgical release. In the beginning this technique was introduced like a viable solution for the treatment of spastic hemiplegia in the cerebral palsy of the childhood. In these situations, due to a congenital damage of the central nervous system, children have a permanent hypertonia of the lower limbs generating a joint dysfunction by a fixed muscle contraction. Several authors proposed different surgical techniques: one of the most used is the transverse Vulpius recession of the gastroc-soleus, as to reduct the contraction of the calf in order to restore the proper functioning of affected limb (Tinney et al. 2015).
Today, the musculotendinous surgical release is also a useful trick very popular especially between the shoulder surgeons: the retraction is one of the most important limiting factors for successful surgical repair of the cuff (Meyer et al. 2012).
In literature this technique is also proposed like an excellent treatment in chronic miotendinous junction pathology, due to reducing the pain and discomfort of the tendinopathy. For example, several surgical techniques (arthroscopic, mini-open, and percutaneous) are described for the treatment of the chronic lateral epicondylitis (Grewal et al. 2009).
Concluding, the surgical treatment is required also in case of complications that occurred after acute muscle injuries. One example is the myositis ossificans (MO) (Fig. 17.4). Generally, it is related to trauma from a single blow or repeated episodes of microtraumas, and it can be diagnosed and monitored by serial X-rays, being radiologically evident 3–6 weeks after injury (Parikh et al. 2002; Renstrom 2003). The most common reported sites of MO are in the thigh and arm muscles: quadriceps femoris, brachialis, and the adductor. In the majority of cases, it is asymptomatic and can be managed with nonoperative treatments with spontaneous resolution monitored by imaging exams. If MO progress to permanently limit range of motion and function with pain or when the lesion is vulnerable to a repeated trauma causing disability, surgical intervention to remove persistent calcium deposits can be pointed out. Surgery should not be attempted until 4–6 months after trauma to allow for complete maturation of the process (De Maeseneer et al. 1997; Ben Hamida et al. 2004).
