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injuryupdate
06-04-2005, 07:47 PM
Interesting article on the Buckley surgery from AAP below.

Worth considering:
(1) surgery may be required on chronic hamstring problems, even when the MRI scan suggests that the tendon is intact.
(2) maybe ultrasound might be better at picking a rupture, as the radiologist can concentrate on the exact spot where the pain is.
(3) that most hamstring injuries will still respond to conservative treatment, even though lots of patients are now going to ask for the same surgery that Buckley had.
(4) that the media can come up with some crap, "the first player to ever have had hamstring surgery in the AFL" - since when, last month????

Article:

COLLINGWOOD doctor Paul Blackman has operated on hamstrings "a handful of times" in his 10 years as a sports physician.

"Generally, they heal very well with non-operative measures," he said.

But Blackman and orthopaedic surgeon Julian Feller quickly saw the problem last Thursday night when they opened up the back of Nathan Buckley's right leg with a 7-10cm incision.

"It was immediately apparent – surprising, but immediately apparent," Dr Blackman said.

Buckley had a tear about 1cm long on the surface of a tendon attached to the biceps femoris muscle, just above the back of the knee.

While the surgery was highly unusual, the solution was nothing more complicated than stitching up the tear with some surgical thread.

They were in and out in half an hour.

The rupture had been missed by scans because it was covered with scar tissue.

It is understood to be the first time an AFL player has undergone hamstrings surgery.

Buckley's problem will probably force a change in how medical scans assess hamstrings injuries, with the images likely to be taken at different angles to make sure nothing is missed.

The Collingwood captain was able to train fully before the round-one match against the Western Bulldogs, but had to sit out the final quarter because the muscle was too weak.

hhh
06-04-2005, 08:29 PM
Also worth considering:
1) since when does key hole surgery involve a 7-10cm incision?
2) since when should a case report, that is yet to be demostrated to be successful, suggest that a epidemic of similar surgery is required, particularly for lower level athletes receiving sub standard injury management?
3) Why is surgery called successful simply because the patient didn't have a massive complication (particularly for elective type surgery)?
4) Does this case suggest that perhaps advanced imaging is possible WOFTAM (waste of time and money)? MRI has been shown in a few studies to be successful at predicting prognosis but not chacne of recurrence. What information does it really give us?? A recent study showed 45% of hamstring injuries don't even image posing the question as to what is the tissue in lesion and pain generating structure.
5) Why does it always seem in sports medicine that the radiologists and surgeons always seem to be the ones to cash in when virtually 0 evidence exists for anything they do? Has any surgeon ever got up at SMA and shown some class 2 evidence?
6) In conclusion evidence based approaches for the management of hamstirng injuries need to be investigated to instigate definitive management to lessen the chance of recurrence, developing chronicity and other associated sequalae. There is a paltry supply of evidence for successful management of any chronic conditions so it can be assumed that this rings tru for hamtsring injuries.

injuryupdate
07-04-2005, 04:53 PM
Last year, one of the Roosters' players suffered a proximal tendon rupture of the hamstring (not from the bone but a few cms down closer to the M/T junction). This was picked up via MRI and you could see tendon retraction, big gap (3-4cm between tendon ends). The surgeons would have loved the case. Except we were 8 weeks out from the finals and we didn't want to rule him out for the season with surgery.

The guy played 4 weeks later and actually was one of our best in the finals series. Admittedly was a younger front rower so doesn't have to do the same running as Buckley or any AFL player, so may not have survived in that sport.

However, goes to show that:
(1) hamstring "tendon" ruptures probably have the ability, in many people, to functionally heal fully with non-surgical treatment. The exceptions would be complete ruptures of proximal bony tendon attachment (at the ischial tuberosity) and biceps bony attachments at the head of fibular (usually combined with posterolateral complex injuries). Tendon to bone injuries are the worst, but from the media description the Pies have given, Buckley's injury was tendon to tendon repair.
(2) Buckley's treatment is very unlikely to become the standard protocol for management of hamstring "tendon" ruptures. It is attempt of a desperate club and player with no obvious plan B to stem the tide of an ageing superstar that they are still reliant upon because their younger players aren't standing up. Compare Ben Hart to Nathan Buckley. Admittedly they probably have different hamstring injuries but they are the same age and they have "torn" hamstrings the same number of times. They probably both have degenerative lumbar spines (at a wild guess). Adelaide is just easing Hart out of the action and I'm sure he will retire soon, and they will just look to replace him with someone younger. Collingwood are trying the radical approach. It may pay off, if it doesn't they will say they had a dip. The only tragedy will be if a young player does a similar injury just before the finals one year (who would have recovered in time) and someone wants to be a hero and do the "Nathan Buckley" tendon repair on him and puts him out for the year.
(3) The same surgeons who might start telling people that they need to have stitches put in their hamstring tendon tears "to allow them to heal properly" will have patients on other operating lists where they are doing ACL recos and butchering patella and hamstring tendons to use for grafts for the ACL, and in THIS SITUATION, they will say "chopping out tendons is no problem, they just grow back".