Abstract
Background:
No validated score is available for the prediction of return to sport (RTS) after proximal hamstring avulsion (PHA) surgery.
Purpose:
To validate a new assessment tool for patients after PHA surgery: the Parisian Hamstring Avulsion Score (PHAS).
Study Design:
Cohort study (Diagnosis); Level of evidence, 3.
Methods:
All patients at our clinic who had surgery for PHA between January 2015 and March 2018 were included in this study. A suspected clinical diagnosis of PHA was confirmed by magnetic resonance imaging. PHA was repaired by surgical reinsertion with suture anchors. Minimum postoperative follow-up was 2 years, and the PHAS, University of California, Los Angeles (UCLA), score, and Tegner score were used. The PHAS is a patient-reported outcome measure, evaluating the effect of PHA injury with 9 items. It was validated by calculating its psychometric properties, and then correlation analysis was performed to determine the relationship between the PHAS, UCLA score, and Tegner score. Cutoff values for the prediction of RTS were determined.
Results:
A prospective case series study was performed. A total of 156 patients were included. Median age (first quartile; third quartile) was 54.2 years (44.7 years; 61.3 years), and the mean ± SD time of the final follow-up was 69 ± 11.6 months. Two years after surgery, 66.7% (n = 104) of patients were able to RTS. A strong correlation was noted between all 3 scores at 1 year postoperatively. Overall internal consistency was high, with a Cronbach alpha coefficient of 0.86. The intraclass correlation coefficient was 0.96, showing excellent reliability. The minimal detectable change was 12.9. No patients reached the maximum score at 2 years. Analysis of the receiver operating characteristic curves of the 3 scores at postoperative 9 months in relation to the RTS at 1 and 2 years showed area under the curve values of >0.7, indicating significant discriminant capacity for the RTS. A PHAS cutoff value of 86 at 9 months for the prediction of RTS at postoperative 1 year had a sensitivity of 65.6% (95% CI, 53.7%-77.5%) and a specificity of 81.4% (95% CI, 69.8%-93%).
Conclusion:
PHAS is a valid and reliable tool for follow-up after PHA surgery. It also offers a simple way to predict RTS.
Keywords: thigh, general sports trauma, grading scales, hamstring
Although proximal avulsion of the hamstring tendons can significantly compromise a patient’s sports activities, it remains underdiagnosed. Proximal hamstring avulsion (PHA) mainly occurs in middle-aged patients of both sexes, but it tends to be due to domestic accidents in older women and sports-related injuries in younger men. 13 The most frequent mechanism of the tear is eccentric contraction of the hamstring that occurs with the hip in the flexed position and the knee in extension.2,4,8,9,21,29 Better understanding of the anatomic and biomechanical characteristics of the proximal insertion of the hamstrings has made it possible to optimize the indications and corresponding surgical techniques.19,24 The clinical outcome and return to sport (RTS) after surgery are good, with few complications.1-3,7,8,16,22,23,27-29 However, the methods used to evaluate these outcomes lack specificity because of the use of generic, nonspecific, functional scores of proximal hamstring injuries, such as the Lower Extremity Functional Scale, Marx Activity Rating Scale, 12-item Short Form Health Survey, and Tegner scores, or the isokinetic strength test.8,14,23,29
The use of patient-reported outcome measures (PROMs) to evaluate and follow patients has increased and gradually become the method of choice in everyday practice in orthopaedic surgery as well as in clinical research.10,17
The Tegner and the University of California, Los Angeles (UCLA), scores, 2 evaluation techniques developed nearly 40 years ago, have become, over time, the main PROMs used to assess physical activity after surgery.21,22 The Tegner score rates physical activity from 0 (existence of a handicap) to 10 (plays sports at a national or international level) and the UCLA score from 1 (inactive patient) to 10 (participation in high-impact sports).22-25 Although both are used to evaluate the outcome of surgery for the reinsertion of proximal hamstring tendon, they are not specific for this injury.6,11,21
The Perth Hamstring Assessment Tool (PHAT) was the first PROM developed to evaluate the outcome of surgical repair of proximal hamstring tendon avulsions. 4 This score evaluates the different functional parameters of the hamstring tendons (flexibility, strength) and their effect on daily life (sports activities, driving). The psychometric properties of this score have been validated, and it is the score evaluated in the greatest number of publications to date.9,11,20,21 The Sidney Hamstring Origin Rupture Evaluation (SHORE) is another PROM developed for the same purpose that has psychometric results similar to those of the PHAT. Although these 2 scores have been validated for the assessment of PHAs, there is no consensus on their use because of the limited number of studies in the literature and the small study groups. 21 Their discriminant and predictive capacities for the RTS have also not been reported, and they seem to have a significant ceiling effect. 9
The Parisian Hamstring Avulsion Score (PHAS) is a new PROM developed specifically to assess and follow patients who undergo surgery for PHA and to evaluate readiness to RTS (see the Appendix, available in the online version of this article).
The main goal of this study was to evaluate the psychometric properties of the PHAS. We also determined the predictive value of the PHAS for RTS.
Methods
Study Design
A prospective, single-center, nonrandomized study was performed between January 2015 and March 2018. All patients underwent surgery by the same specialized surgeon (N.L.). Patients were fully informed, gave a written consent at their inclusion, and the study was approved by the ethics committee for a noninterventional study.
Participants and Data Collection
All patients who underwent surgery for proximal hamstring tendon avulsion between January 2015 and March 2018 were included in this study. The tear was confirmed by preoperative magnetic resonance imaging (MRI). Our criteria for surgery were complete acute avulsion with >2 cm retraction, partial acute avulsion after failure of functional treatment, or chronic avulsion after failure of functional treatment. The minimum postoperative follow-up was 2 years. Patients were reviewed by the surgeon at 6 weeks, 3 months, and 1 year postoperatively. Functional score data were prospectively recorded with WebSurvey software. The functional score questionnaires were sent to patients by email 9 months, 1 year, and 2 years after surgery. These scores included the PHAS, UCLA score, and Tegner score. Inclusion criteria were the presence of functional score results at 9 months, 1 year, and 2 years after surgery. Test-retests were administered to 20 patients at 1-year follow-up, 15 days apart. An absence of response to scores during follow-up was a criterion for exclusion. RTS was defined as the athlete’s ability to return to his or her predefined sport, without necessarily reaching his or her previous level. Return to the same sport, at the same or higher level, was also specified. The PHAS was also carried out on 33 healthy individuals in order to allow comparison with patients’ values at each follow-up time.
Surgical Technique
Surgery was performed with the patient in the prone position with the knee flexed at 60° on a knee rest. The incision was vertical in case of a full tear of the 3 tendons or retraction of >6 cm as seen on the preoperative MRI scan. The incision was horizontal in case of a partial tear (<3 tendons) or a retraction of <6 cm. Sciatic neurolysis was performed in the presence of fibrotic perineural scar tissue. Reinsertion was performed on the ischial tuberosity with 3 or 4 suture anchors. These were metal anchors associated with nonabsorbable sutures (Mitek GII SuperAnchor; DePuy Mitek) or absorbable anchors (Mitek Lupine Loop Anchor; DePuy Mitek) associated with absorbable sutures (Orthocord suture; Depuy Synthes).
The patients had postoperative immobilization with the knee flexed at 30° to 45° for 3 to 5 days, followed by an articulated knee brace allowing free flexion for 45 days. Weightbearing began on postoperative day 1, protected by 2 forearm crutches, and an early physical rehabilitation protocol was begun. Details of the surgical technique and the rehabilitation protocol used were presented in a previous publication. 15
The PHAS
The PHAS is a functional score specifically developed by a senior surgeon (N.L.) to evaluate postoperative outcome after reinsertion of PHAs (see the Appendix, available online). This score, which includes 9 items, provides an evaluation of the effect of proximal hamstring tears by assessing the effect of its different components. This includes an assessment of the effect of pain on daily activities and sports (eg, in the seated position, walking, going up and down stairs), the need for pain medication, the effect of muscular weakness due to the tear on daily life and sports activities (walking, going up and down stairs, short- and long-distance jogging, sprinting, intense sports), and the overall function of the hamstrings and symptoms of nerve irritation (numbness, tingling, burning of the surface of the buttocks) and more specifically sciatica (radiating electric shocks). The PHAS can be completed in <5 minutes by the patient on his or her own. The maximum possible score is 100; the higher the score, the better the function. The final version of the PHAS was validated according to COSMIN (Consensus-based Standards for the Selection of Health Measurement Instruments) international guidelines. 18
Statistical Analysis
In this study, a sample size of 156 participants resulted in a 2-sided 95% CI with a width <0.18 (indicating a narrow CI suggesting a high precision estimating the true value of the Spearman rank correlation coefficient) when the estimate of Spearman rank correlation was >0.7. Analysis of descriptive data was performed according to the type of criteria.
Proportions were estimated with their exact 95% CI when appropriate. Qualitative data were compared using the chi-square test or the Fisher exact test, according to the expected values with variables that were assumed to be independent. Paired data were compared using the McNemar test.
Quantitative data included means, standard deviations, medians, first and third quartiles, and minimums and maximums. Quantitative data were compared using the Student t test or Mann-Whitney-Wilcoxon test where appropriate. Paired data were evaluated using the Student t test (parametric test) or the Wilcoxon test (nonparametric test) where appropriate. Comparison of 2 quantitative variables was performed using the Pearson or Spearman correlation coefficient depending on the type of correlation.
Correlation coefficients were considered as follows: very weak (–0.2 to 0.2); weak (–0.4 to −0.2) and (0.2 to 0.4); moderate (–0.6 to −0.4) and (0.4 to 0.6); strong (–0.8 to −0.6) and (0.6 to 0.8); or very strong (–1.0 to −0.8) and (0.8 to 1.0).
The intraclass correlation coefficient (ICC) determines the reliability of measurements. The ICC and its 95% CI were calculated to measure intraobserver reliability based on the Cicchetti guidelines to interpret the ICC: poor, <0.40; fair, 0.40-0.59; good, 0.60-0.74; and excellent, 0.75-1.00. 12
The standard error of measurement (SEM), which is the standard deviation of a number of measurements made on the same person, was calculated. The minimal detectable change (MDC) was calculated using the formula MDC = √2 × 1.96 × SEM.
Receiver operating characteristic (ROC) curves for scores at 9 months were performed for the RTS at 1 and 2 years. ROC curves were compared using an area under the curve (AUC) of 0.5. The AUC and its 95% CI were calculated, and the threshold was defined according to Youden index. P < .05 was considered to be statistically significant for all comparisons.
All calculations were made with SAS for Windows (Version 9.4; SAS Institute).
Results
General Characteristics
The inclusion criteria were fulfilled by 156 of the 194 patients who had surgery between January 2015 and March 2018 (Figure 1).
Figure 1.
Flowchart of patients in the study.
The baseline characteristics of the study population are presented in Table 1.
Table 1.
General Characteristics of the Study Population a
| Characteristics | Median (1st; 3rd quartile) or % (n) |
|---|---|
| Age at surgery, y | 54.2 (44.7; 61.3) |
| Sex | |
| Men | 55.8 (87) |
| Women | 44.2 (69) |
| Body mass index | 24.30 (21.63; 26.56) |
| Sports activity | |
| Sedentary | 3.2 (5) |
| Recreational | 69.2 (108) |
| Competitive | 25 (39) |
| Professional | 2.6 (4) |
| Type of sport | |
| Pivot/contact | 25 (39) |
| Pivot/no contact | 17.9 (28) |
| Nonpivot/noncontact | 50.6 (79) |
| No sport | 6.4 (10) |
| Cause of tear | |
| Sports accident | 64.1 (100) |
| Domestic accident | 17.8 (28) |
| Work-related accident | 7.7 (12) |
| Traffic accident | 10.3 (16) |
| Mechanism of injury | |
| Split | 47.4 (74) |
| Fall forward with extension of the knees and flexion of the trunk | 14.7 (23) |
| Sudden acceleration | 17.3 (27) |
| Sudden extension of the knee | 11.5 (18) |
| Hyperflexion (missed shot) | 1.9 (3) |
| Side | |
| Left | 50 |
| Right | 50 |
| Preoperative MRI features | |
| Median delay injury–MRI, d | 19.0 (6.0; 62.0) |
| 3 injured tendons | 73.1 (114) |
| 2 injured tendons | 15.4 (24) |
| 1 injured tendon | 11.5 (18) |
| Retracted tendon, cm | 4.00 (3.00; 6.00) |
| Delay injury-surgery | |
| Median delay, d | 36.5 (17.5; 118.0) |
| Acute surgery (≤28 d) | 44.2 (69) |
| Chronic surgery (>28 d) | 55.8 (87) |
MRI, magnetic resonance imaging.
The mean follow-up was 69 ± 11.6 months.
Results of Scores and Correlations Over Time
The results of the different scores over time are presented in Table 2. The initial UCLA and Tegner scores (before injury) were 9 (6-10) and 5 (4-7), respectively. The maximum Tegner score and PHAS were reached 1 year after surgery.
Table 2.
Results of Functional Scores Over Time a
| Preoperative | 9 Months After Surgery | 1 Year After Surgery | 2 Years After Surgery | |
|---|---|---|---|---|
| UCLA score | 4 (2; 5) | 6 (4; 7) | 6 (5; 10) | 7 (6; 10) |
| P | <.001 | <.001 | <.001 | |
| Tegner score | 2 (1; 3) | 3 (3; 4) | 4 (3; 6) | 4 (3; 6) |
| P | <.001 | <.001 | <.001 | |
| PHAS | 55.00 (47.50; 66.50) | 83.00 (72.50; 94.50) | 88.50 (74.25; 96.50) | 86.75 (73.50; 93.25) |
| P | <.001 | <.001 | <.001 |
Scores are expressed as median (first quartile; third quartile). P values indicate comparison with preoperative scores. Boldface indicates statistical significance at P < .05. PHAS, Parisian Hamstring Avulsion Score; UCLA, University of California, Los Angeles.
The correlation between the scores was evaluated with the Spearman coefficient (Table 3). The 3 scores were strongly correlated 1 year after surgery. The Tegner and the UCLA scores remained strongly correlated 2 years after surgery and moderately correlated with the PHAS.
Table 3.
Correlation of Different Functional Scores Over Time a
| Assessment Point | Spearman Correlation Coefficient (95% CI) | Interpretation |
|---|---|---|
| Preoperative | ||
| UCLA and Tegner | 0.773 (0.700-0.829) | Strong correlation |
| PHAS and UCLA | 0.358 (0.152-0.531) | Weak correlation |
| PHAS and Tegner | 0.348 (0.141-0.523) | Weak correlation |
| Postoperative 9 mo | ||
| UCLA and Tegner | 0.779 (0.688-0.844) | Strong correlation |
| PHAS and UCLA | 0.578 (0.432-0.691) | Moderate correlation |
| PHAS and Tegner | 0.598 (0.456-0.708) | Moderate correlation |
| Postoperative 1 y | ||
| UCLA and Tegner | 0.804 (0.737-0.853) | Very strong correlation |
| PHAS and UCLA | 0.679 (0.582-0.756) | Strong correlation |
| PHAS and Tegner | 0.705 (0.613-0.776) | Strong correlation |
| Postoperative 2 y | ||
| UCLA and Tegner | 0.750 (0.668-0.811) | Strong correlation |
| PHAS and UCLA | 0.517 (0.388-0.624) | Moderate correlation |
| PHAS and Tegner | 0.594 (0.478-0.688) | Moderate correlation |
PHAS, Parisian Hamstring Avulsion Score; UCLA, University of California, Los Angeles.
Bland-Altman graphs showed good agreement between measurements of the difference between preoperative PHAS and the PHAS value at 9 months and 1 year, at 1 year and 2 years, and at 9 months and 2 years (Figures 2 -4).
Figure 2.
Bland-Altman plot of difference versus mean Parisian Hamstring Avulsion Score (PHAS) change from the preoperative (preop) assessment at 9 months and 1 year.
Figure 3.
Bland-Altman plot of difference versus mean Parisian Hamstring Avulsion Score (PHAS) change from the preoperative (preop) assessment at 9 months and 2 years.
Figure 4.
Bland-Altman plot of difference versus mean Parisian Hamstring Avulsion Score (PHAS) change from the preoperative (preop) assessment at 1 year and 2 years.
Psychometric Properties of the PHAS
The ICC was excellent, 0.96 95% CI (0.89-0.98) for test-retest of the PHAS. The corresponding SEM was 4.7. The MDC, corresponding to the minimum difference needed for a detectable clinical change, was 12.9. The Cronbach alpha coefficient, determining internal consistency, was 0.86. A value between 0.8 and 0.9 is considered good, whereas a value >0.9 may suggest that some elements are redundant. 26 The maximum score was reached in 1.9% (n = 3) of patients 9 months after surgery, in 5.8% (n = 9) of patients 1 year after surgery, and in none of the patients 2 years after surgery. There was no ceiling effect. 9 PHAS was carried out on a healthy population and showed a statistically significant difference with patients at each time point (Table 4).
Table 4.
Comparison With Healthy Participants a
| PHAS, Median (IQR) | P (Comparison With Healthy Participants) | |
|---|---|---|
| Healthy participants (n = 33) | 97.50 (92.50-99.50) | |
| Operated patients (N = 156) | ||
| Preoperative | 55.00 (47.50-66.50 | <.0001 |
| 9 mo after surgery | 83.00 (72.50-94.50) | <.0001 |
| 1 y after surgery | 88.50 (74.25-96.50) | <.0001 |
| 2 y after surgery | 86.75 (73.50-93.25) | <.0001 |
PHAS, Parisian Hamstring Avulsion Score. Boldface indicates statistical significance at P < .05.
Return to Sport
The RTS rate was 59.6% (n = 93) at 1 year after surgery and 66.7% (n = 104) at 2 years after surgery. A total of 41.7% (n = 65) of patients returned to sport at the same level of play 1 year and 41% (n = 64) 2 years after surgery. Table 5 shows the evolution of the sports practiced after the operation, according to the preoperative sport.
Table 5.
Evolution of Sports Practiced After Surgery, According to the Preinjury Sport (N = 156) a
| 2 Years After Surgery | |||||
|---|---|---|---|---|---|
| Type of Sport Before Injury | Before Injury | Same Sport, Same Level | Same Sport, Lower Level | Changed Sport | Stopped Sport |
| Pivot/contact: soccer, handball, rugby, basketball, judo | 25 (39) | 11.5 (18) | 1.9 (3) | 4.5 (7) | 7 (11) |
| Pivot/noncontact: tennis, badminton, skiing, volleyball | 17.9 (28) | 9.6 (15) | 0.6 (1) | 3.8 (6) | 3.8 (6) |
| Nonpivot/noncontact: running, biking, swimming | 50.6 (79) | 19.9 (31) | 1.9 (3) | 12.8 (20) | 16 (25) |
| No sport | 6.4 (10) | 6.4 (10) | |||
Values are expressed as % (n).
The results of the different scores over time were significantly higher in the RTS group than in those who did not return to a physical activity (Table 6).
Table 6.
Results of Scores in Relation to Return to Sport (N = 156) a
| Preoperative | 9 Months After Surgery | 1 Year After Surgery | 2 Years After Surgery | |
|---|---|---|---|---|
| PHAS | ||||
| RTS 1 y after surgery | ||||
| No (n = 62) | 53.06 ± 14.76 | 72.80 ± 15.74 | 73.21 ± 16.79 | 74.08 ± 15.73 |
| Yes (n = 94) | 59.26 ± 13.44 | 87.30 ± 12.29 | 90.51 ± 10.46 | 86.88 ± 10.51 |
| P | <.0001 | <.0001 | <.0001 | |
| RTS 2 y after surgery | ||||
| No (n = 52) | 54.09 ± 15.94 | 70.87 ± 15.68 | 71.19 ± 16.39 | 71.56 ± 14.84 |
| Yes (n = 104) | 57.75 ± 13.49 | 85.86 ± 13.17 | 89.60 ± 11.25 | 86.86 ± 10.79 |
| P | <.0001 | <.0001 | <.0001 | |
| UCLA score | ||||
| RTS 1 y after surgery | ||||
| No (n = 62) | 3.8 ± 1.4 | 4.9 ± 1.9 | 5.3 ± 2.0 | 6.1 ± 2.2 |
| Yes (n = 94) | 3.8 ± 1.7 | 7.0 ± 1.8 | 8.2 ± 2.0 | 8.2 ± 2.2 |
| P | <.0001 | <.0001 | <.0001 | |
| RTS 2 y after surgery | ||||
| No (n = 52) | 3.7 ± 1.5 | 4.7 ± 1.5 | 5.2 ± 2.1 | 5.8 ± 2.1 |
| Yes (n = 104) | 3.9 ± 1.6 | 6.8 ± 2.0 | 7.9 ± 2.1 | 8.1 ± 2.2 |
| P | <.0001 | <.0001 | <.0001 | |
| Tegner score | ||||
| RTS 1 y after surgery | ||||
| No (n = 62) | 2.2 ± 1.5 | 3.0 ± 1.3 | 3.1 ± 1.5 | 3.5 ± 1.7 |
| Yes (n = 94) | 2.3 ± 1.6 | 4.8 ± 2.3 | 5.6 ± 2.4 | 5.4 ± 2.4 |
| P | <.0001 | <.0001 | <.0001 | |
| RTS 2 y after surgery | ||||
| No (n = 52) | 2.1 ± 1.5 | 2.6 ± 1.0 | 2.9 ± 1.4 | 3.0 ± 1.5 |
| Yes (n = 104) | 2.4 ± 1.6 | 4.7 ± 2.2 | 5.5 ± 2.3 | 5.4 ± 2.3 |
| P | <.0001 | <.0001 | <.0001 | |
Scores are expressed as mean ± SD. P values indicate comparison with patients able or not to return to sport at different timepoint. Boldface indicates statistical significance at P < .05. PHAS, Parisian Hamstring Avulsion Score; RTS, return to sport; UCLA, University of California, Los Angeles.
AUC analysis of the results of the different scores at postoperative 9 months in relation to RTS 1 and 2 years after surgery showed a significant predictive value for RTS 1 and 2 years after surgery for the 3 scores, with no significant difference among the scores (Figures 5 and 6).
Figure 5.
ROC curve of the scores at 9 months (M9) in relation to the return to sport at 1 year. PHAS, Parisian Hamstring Avulsion Score; ROC, receiver operating characteristic; UCLA, University of California, Los Angeles.
Figure 6.
ROC curve of the scores at 9 months (M9) in relation to the return to sport at 2 years. PHAS, Parisian Hamstring Avulsion Score; ROC, receiver operating characteristic; UCLA, University of California, Los Angeles.
The cutoff value of the PHAS at 9 months was 86 for the RTS at 1 year with a sensitivity of 65.6% 95% CI (53.7%-77.5%) and a specificity of 81.4% 95% CI (69.8%-93%) and 88 for the RTS at 2 years with a sensitivity of 58.1% 95% CI (46.9%-69.3%) and a specificity of 90.3% 95% CI (79.9%-100%). Cohen d was 1.293 for RTS at 1 year and 1.245 for RTS at 2 years, with a value >0.8 considered a large effect and >1.3 a very large effect size. 25
Discussion
The main result of this study is that the PHAS is a reliable evaluation tool that can be used for the follow-up and prognosis of RTS after surgical reinsertion of PHA.
In the present study, internal consistency evaluated by the Cronbach alpha coefficient was 0.84, whereas the values reported in the literature for the PHAT and SHORE scores were 0.77 and 0.78, respectively. The ICC for test-retest was 0.96 95% CI (0.89-0.98) at 1 year in the present study, compared with 0.84 95% CI (0.76-0.90) for the PHAT at 1 year and 0.82 95% CI (0.68-0.90) for the SHORE at 3 years in the literature.4,9,20 The SEM, corresponding to the smallest statistically different score, was 4.7 for the PHAS in the present study and 5.9 and 3.12 for PHAT and SHORE, respectively, in the literature. The MDC was 12.9 in our study and 16.4 and 7.6 for the PHAT and SHORE, respectively, in the literature.4,9,20 Another important element is the ceiling effect, which prevents a test from being discriminant at high values. A score is defined as having a ceiling effect if 15% of the participants achieve the best score. 9 This effect was not present in the PHAS 9 months, 1 year, or 2 years after surgery, confirming its discriminant value. In comparison, the SHORE and PHAT were found to have a ceiling effect at postoperative 3 years of 34.39% and 47.14%, respectively.4,9,20 All of these elements validate the use of the PHAS to assess and follow patients who undergo surgical repair of PHAs.
The PHAS effectively predicted RTS at 1 and 2 years and provided a prognostic assessment of postoperative recovery. Cohen d values showed a large effect size. The capacity to predict RTS makes it possible to present the patient with valid information regarding an estimated delay, which has become essential in the management of athletic patients who expect information about this timeline.5,16,21 The PHAS is the first score that specifically evaluates the outcome of surgical reinsertion of proximal hamstring tendon as well as predicting RTS.
The sensitivity of the PHAS was relatively low, demonstrating the importance of taking other factors into account. An assessment of the ability of the PHAS at 6 months postoperatively to predict RTS at 1 year would reinforce the validity of the information provided. Although the PHAS can be used to assess sports level in the short term, it is unable to do so in the medium term, as shown by its moderate correlation with Tegner score at 2-year follow-up.
This study has certain limits. Although data were prospective, they were analyzed retrospectively. This is a single-surgeon series, and the results need to be confirmed in larger multicentric studies. Although it would have been interesting to compare the PHAS with the PHAT and SHORE scores, the latter scores had not been published when the first patients were included in this study. In addition, the PHAS was created by the authors, without input from patients.
One of the important points of this study is that it evaluated all the psychometric properties of the PHAS, validating its use in clinical practice. To our knowledge, it was validated in the largest series in the literature, further confirming its value. We also reported the correlation between the PHAS and 2 scores that are references in the literature for athletic patients, as well as the predictive capacity of the PHAS for the RTS.
Conclusion
The PHAS is a reliable and reproducible score to evaluate outcome after surgical reinsertion of proximal hamstring tears. The PHAS also provides valid prognostic information on RTS.
Supplemental Material
Supplemental material, sj-pdf-1-ajs-10.1177_03635465241227434 for Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion by Nicolas Lefevre, Sammy Kassab Hassan, Eugenie Valentin, Yoann Bohu, Antoine Gerometta, Alain Meyer, Olivier Grimaud and Alexandre Hardy in The American Journal of Sports Medicine
Footnotes
Submitted April 15, 2023; accepted December 6, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: A.H. is a consultant for Arthrex and DePuy Synthes. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
ORCID iD: Sammy Kassab Hassan 
https://orcid.org/0000-0003-0999-725X
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental material, sj-pdf-1-ajs-10.1177_03635465241227434 for Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion by Nicolas Lefevre, Sammy Kassab Hassan, Eugenie Valentin, Yoann Bohu, Antoine Gerometta, Alain Meyer, Olivier Grimaud and Alexandre Hardy in The American Journal of Sports Medicine