Endoscopic Repair of the Proximal Hamstring

Background: Proximal hamstring injuries are increasingly common. While open repair with suture anchors placed in the ischial tuberosity has long been the gold standard technique for surgical management, endoscopic techniques can allow for smaller incisions, reduced wound complications, and an expedited recovery. Indications: Patients with full-thickness 3-tendon proximal hamstring tears, 2-tendon tears with retraction >2 cm, or partial tears that remain symptomatic despite conservative management are considered for surgery. High-demand patients are often treated acutely, and low-demand patients may be offered surgery after a conservative management period. Technique Description: In the prone position, 2 arthroscopic portals are created in the gluteal fold. Fluoroscopy is used to verify safe portal placement, and the sciatic nerve is visualized along with the retracted tendon origin. The ischial tuberosity is identified, and the hamstring origin is debrided and decorticated. An accessory portal is created for suture anchor placement. Two double-loaded anchors are placed in the tuberosity, the sutures of which are used to repair the hamstring tendons using a horizontal mattress configuration. Patients undergo a stepwise postoperative physical therapy protocol. Results: An 85% return to sport rate can be expected following all hamstring repairs, with some studies reporting as high as 95% after endoscopic repair. Compared with nonoperative treatment, proximal hamstring repair overall results in higher patient satisfaction and return to sport. While large studies have yet to report on outcomes compared with the traditional open technique, the smaller incisions look to reduce wound complications and postoperative pain. Discussion/Conclusion: Recent advancements in endoscopic techniques have allowed for adequate visualization and robust repair of proximal hamstring avulsions. We present our endoscopic technique of the proximal hamstring, which, compared with the traditional open repair, can decrease perioperative complications and accelerate recovery.

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Biomechanical Comparison of Open and Endoscopic Proximal Hamstring Repair Techniques

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00148 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0014

Author(s):

Michael K. Ryan ◽

Matthew W. Crozier ◽

David P. Beason ◽

Benton A. Emblom

Keyword(s):

Ultimate Load ◽

Open Repair ◽

Biomechanical Properties ◽

Ischial Tuberosity ◽

Endoscopic Repair ◽

Surgical Fixation ◽

Proximal Hamstring ◽

Repair Group ◽

Optimal Visualization ◽

Repair Techniques

Objectives: Proximal hamstring tendon avulsions are a rare subset of hamstring injuries, and surgical fixation has become standard, given superior outcomes compared to nonoperative treatment. Open surgical techniques employ a large incision near the gluteal crease and necessitate extensive retraction for optimal visualization, which may increase risk for infection, numbness and potential sciatic nerve injury. Recently described endoscopic repair techniques enable optimal visualization and access to the tendon and ischial tuberosity through several small incisions, potentially reducing risks associated with open repair. Prior cadaveric studies have evaluated biomechanical properties of open repair techniques. The purpose of this study was to compare the biomechanical properties of open and endoscopic suture anchor repair of proximal hamstring ruptures to validate the structural integrity of the endoscopic technique. Methods: Nine fresh-frozen cadaver pelvises (5 M, 4F) were randomly assigned open proximal hamstring repair, with subsequent contralateral endoscopic proximal hamstring repair. Laterality was evenly distributed. Open repair was performed after reflection of the gluteus maximus to optimize visualization and anchor placement during repair, while endoscopic repair was performed via four small incisions surrounding the ischial tuberosity. Proximal hamstring ruptures were simulated by subperiosteal dissection of the entire tendon from its insertion. Repairs were performed using two double-loaded 3.0 mm polyether ether ketone (PEEK) suture anchors and two 3.75 mm PEEK knotless screw-in anchors in a double-row configuration. After repair, the ischial tuberosity was harvested by cutting the inferior pubic ramus and superior aspect of the ischial tuberosity as far away from the repair site as possible. The bony inferior ramus and ischial tuberosity was potted into an acrylic cylinder using polymethylmethacrylate, while the musculotendinous junction was wrapped in gauze and clamped 3 cm from the insertion. Reference lines were marked at the insertion site and 1, 2, and 3 cm from the insertion to aid optical measurements. Potted specimens were mounted into an MTS 858 MiniBionix servohydraulic test frame and tested according to a previously established protocol. Each specimen was cycled 50 times within a pre-established range, with the range increased every 50 cycles until failure. Values were then compared using a paired t-test. Results: The open repair group failed at a mean of 119 cycles with an average displacement of 12.7 mm at a mean ultimate load of 574.5 N. The endoscopic repair group failed at a mean of 117 cycles with an average displacement of 14.9 mm at and mean ultimate load of 563.4 N. No statistically significant difference was noted among any of these parameters. Conclusion: This biomechanical analysis demonstrated no difference in the structural properties comparing open and endoscopic techniques. Endoscopic proximal hamstring repair is a viable option for surgical fixation of proximal hamstring avulsions, with the potential to decrease risks encountered using open techniques.

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Endoscopic Proximal Hamstring Repair: Portal Site Anatomy - A Cadaveric Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00147 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0014

Author(s):

Michael K. Ryan ◽

David P. Beason ◽

Benton A. Emblom

Keyword(s):

Surgical Repair ◽

Intraclass Correlation ◽

Portal Tract ◽

Ischial Tuberosity ◽

Cadaveric Study ◽

Endoscopic Repair ◽

Musculotendinous Junction ◽

Hamstring Injuries ◽

Proximal Hamstring ◽

Portal Tracts

Objectives: Hamstring injuries commonly cause pain, weakness and functional limitations. While most hamstring injuries involve the musculotendinous junction or muscle belly, proximal hamstring tendon avulsions are a subset of hamstring injuries that are frequently more debilitating. Nonoperative treatment has demonstrated poor outcomes, thus surgical repair has become the mainstay. Open surgical repair has been the standard, but improved endoscopic techniques have enabled proximal hamstring fixation with decreased risk of infection and numbness, without the morbidity of a large, posterior incision. Prior anatomic studies described relevant anatomy near the proximal hamstring origin at the ischial tuberosity in the setting of an open repair, but literature describing pertinent anatomy during endoscopic repair is sparse. This cadaveric study enhances knowledge and safety of endoscopic proximal hamstring repair by describing pertinent anatomy surrounding four commonly used endoscopic portals. Methods: Ten fresh-frozen pelvis specimens (5 M, 5F) underwent endoscopic proximal hamstring repair and dissection with evenly distributed laterality (5 R, 5 L). Proximal hamstring ruptures were simulated endoscopically with an arthroscopic knife. Endoscopic repair was then completed on each specimen through four endoscopic portals (Inferolateral, Medial, Superolateral and Accessory Superior) using two double-loaded 3.0 mm polyether ether ketone (PEEK) suture anchors and two 3.75 mm PEEK knotless screw-in anchors. After repair, portal tracts were maintained by inserting four 2.0 mm k-wires through cannulas placed through the portals, securing the wires in bone in the ischial tuberosity beyond the zone of repair. The specimen was dissected in layers around the wires, and measurements from portal tracts to nine pertinent anatomic structures were obtained using a digital caliper. Each measurement was repeated three times, then averaged to obtain a composite mean. Measurements were statistically verified with an intraclass correlation coefficient (ICC), all but two of which were above 0.90. Results: Ten cadaveric specimens demonstrated a mean age and BMI of 45.4 and 27.3, respectively. With respect to anatomic measurements, on average no portal tract was closer than 2.0 cm to the sciatic nerve, inferior gluteal neurovascular bundle or posterior cutaneous nerve, and all double-row repairs were easily completed with good fixation through these four portals (Table 1). Additional anatomic landmarks surrounding the hamstring origin were identified endoscopically, and when routinely located, each landmark helped improve reproducibility and safety of endoscopic proximal hamstring repair (Figure 1). Conclusion: This cadaveric study of the proximal hamstring origin maps the anatomic landscape encountered endoscopically, and supports the efficacy and safety of endoscopic proximal hamstring repair. [Table: see text][Figure: see text]

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Proximal Hamstring Injuries: Review of Operative and Nonoperative Management

The Journal of Hip Surgery ◽

10.1055/s-0038-1676285 ◽

2018 ◽

Vol 02 (04) ◽

pp. 176-188

Author(s):

Kyle Duchman ◽

Ned Amendola ◽

Joseph Buckwalter V

Keyword(s):

Surgical Repair ◽

Nonoperative Management ◽

Current Evidence ◽

Surgical Indications ◽

Endoscopic Repair ◽

Hamstring Injuries ◽

Partial Tears ◽

And Function ◽

Proximal Hamstring ◽

Repair Techniques

AbstractWhile uncommon, proximal hamstring injuries can result in significant pain and dysfunction, while also posing considerable treatment dilemmas due to the spectrum of injury that exists. Recent literature suggests that outcomes are improved with acute surgical repair of complete proximal hamstring avulsions, highlighting the importance of timely management of these unique injuries. While chronic repair or reconstruction can result in predictable improvements in pain and function postoperatively, the results are less predictable than acute surgical repair. Nonoperative management should be considered as the initial treatment strategy for patients with proximal hamstring tendinopathy or partial tears, as delayed surgical intervention in this setting has not been shown to significantly affect outcomes. Although current evidence is limited, evolving therapeutic techniques, including biologic injections and endoscopic repair techniques, need to be carefully evaluated to determine their role moving forward. This review aims to provide updated information on the relevant anatomy, mechanism of injury, diagnosis, and management of proximal hamstring injuries, with a specific focus on surgical indications, techniques, and outcomes.

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Portal Placement and Biomechanical Performance of Endoscopic Proximal Hamstring Repair

The American Journal of Sports Medicine ◽

10.1177/0363546519866453 ◽

2019 ◽

Vol 47 (12) ◽

pp. 2985-2992 ◽

Cited By ~ 2

Author(s):

Michael K. Ryan ◽

David P. Beason ◽

Glenn S. Fleisig ◽

Benton A. Emblom

Keyword(s):

Functional Limitations ◽

Biomechanical Testing ◽

Portal Tract ◽

Hamstring Tendon ◽

Measured Parameter ◽

Endoscopic Repair ◽

Safety And Efficacy ◽

Working Zone ◽

Endoscopic Techniques ◽

Proximal Hamstring

Background: Proximal hamstring tendon avulsions are debilitating and commonly cause pain, weakness, and functional limitations. Open surgical repair has been the standard, but improved endoscopic techniques have enabled proximal hamstring fixation with decreased risk of infection and numbness, without the morbidity of a large incision. Purpose/Hypothesis: The purpose was to (1) describe pertinent anatomy surrounding the proximal hamstring origin in relation to 4 endoscopic portal sites and (2) test for biomechanical differences between open and endoscopic repair. It was hypothesized that (1) endoscopic proximal hamstring repair is efficacious with respect to commonly used portals and (2) there is no biomechanical difference between open and endoscopic techniques. Study Design: Descriptive and controlled laboratory study. Methods: Proximal hamstring ruptures were simulated endoscopically in 10 fresh-frozen human cadaveric pelvis specimens. Endoscopic repair was then completed on 1 limb from each specimen through 4 portals. After repair, each specimen was dissected in layers and measurements from portal tracts to pertinent anatomy were obtained. Open repair was performed on all contralateral limbs, followed by cyclical biomechanical tensile testing to failure of both the open and endoscopically repaired hamstring tendons to assess failure load and local tissue strain. Results: On average, no portal tract was closer than 2.0 cm to the sciatic nerve or inferior gluteal neurovascular bundle. Anatomic landmarks were identified that could improve the reproducibility and safety of the procedure. Biomechanical testing revealed no differences between the open and endoscopic repair techniques for any measured parameter. Conclusion: This study supports the safety and efficacy of endoscopic proximal hamstring repair through anatomic and biomechanical analyses and helps establish reproducible and recognizable landmarks that define a safe working zone. Clinical Relevance: This study maps the anatomic landscape of the proximal hamstring as encountered endoscopically and demonstrates equivalent biomechanical strength of endoscopic proximal hamstring repair, supporting this technique’s safety and efficacy.

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A Novel Technique for Proximal Hamstring Tendon Repair: High Reoperation Rate in a Series of 56 Patients

Advances in Orthopedic Surgery ◽

10.1155/2014/891875 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

William Blakeney ◽

Simon Zilko ◽

Wael Chiri ◽

Peter Annear

Keyword(s):

Functional Outcomes ◽

Assessment Tool ◽

Tendon Repair ◽

Return To Sport ◽

Hamstring Tendon ◽

Reoperation Rate ◽

Ischial Tuberosity ◽

Novel Technique ◽

Proximal Hamstring Rupture ◽

Proximal Hamstring

This investigation looked at functional outcomes, following a novel technique of surgical repair using table staples. Patients underwent surgery for proximal hamstring rupture with table staples used to hold the tendon reapproximated to the ischial tuberosity. Functional outcomes following surgery were assessed. We also used a combined outcome assessment measure: the Perth Hamstring Assessment Tool (PHAT). A total of 56 patients with a mean age of 51 (range 15–71) underwent surgery. The mean follow-up duration was 26 months (range 8–59 months). A large proportion of patients (21/56, 37.5%) required reoperation for removal of the staple. Patients that did not require removal of the table staple did well postoperatively, with low pain scores (0.8–2 out of 10) and good levels of return to sport or running (75.8%). Those that required removal of the staple had a significantly lower PHAT score prior to removal, 47.8, but this improved markedly once the staple was removed, with a mean of 77.2 (P<0.001). Although our patients achieved similar outcomes in terms of pain and function, we thought the reoperation rate was unacceptably high. We would not recommend proximal hamstring tendon repair using this technique.

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Check-rein technique for Achilles tendon elongation following conservative management for acute Achilles tendon ruptures: a two-year prospective clinical study

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-021-02830-7 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Nicola Maffulli ◽

Francesco Oliva ◽

Filippo Migliorini

Keyword(s):

Achilles Tendon ◽

Conservative Management ◽

Performance Status ◽

Return To Sport ◽

Wound Complications ◽

Invasive Technique ◽

Prospective Clinical Study ◽

Calf Circumference ◽

The Mean

Abstract Background Following conservative management for acute Achilles tendon (AT) ruptures, the tendon may heal in continuity, and some patients may present with an elongated Achilles tendon–gastrosoleus complex. This study investigated the efficacy and feasibility of a novel minimally invasive technique, which we named “check-rein procedure”, in patients with intact and elongated AT following conservative management for AT ruptures. Methods All patients who underwent the check-rein procedure for elongation of the gastrosoleus–AT complex by one experienced surgeon were prospectively enrolled. The AT resting angle (ATRA) and AT rupture score (ATRS) were assessed at baseline and repeated at 2-year follow-up, as were calf circumference and isometric plantarflexion strength of both ankles. Results Forty-three patients (43 procedures) were analysed. The mean time elapsed from injury to surgery was 28.7 ± 7.9 weeks. The mean age at surgery was 38.5 ± 5.7 years. At the last follow-up, ATRS, ATRA, isometric strength difference, and calf circumference of the affected side were increased (P < 0.0001). The rate of the return to sport was 98% (42 of 43). No wound complications or rupture were experienced by any patient. Conclusion The check-rein technique for AT elongation after conservative management of AT tears is effective and feasible to restore tendon length and calf function. The surgical outcome was influenced by the preoperative performance status, and longer time elapsed from injury to surgery worsens the outcomes.

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Is Brace Immobilization Needed Following Surgical Repair Of Proximal Hamstring Tears?

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00418 ◽

2019 ◽

Vol 7 (7_suppl5) ◽

pp. 2325967119S0041

Author(s):

Lionel E. Lazaro ◽

Michael B. Banffy

Keyword(s):

Surgical Repair ◽

Weight Bearing ◽

Healing Process ◽

Return To Sport ◽

Knee Extension ◽

Partial Weight Bearing ◽

Hamstring Injuries ◽

Hip Flexion ◽

Partial Weight ◽

Proximal Hamstring

Objectives: Braces are commonly used in Orthopaedic to protect repaired tissue from excessive stress that can compromise the healing process. Some of these braces can become a nuisance, especially the ones commonly used following proximal hamstring repairs. The idea is to limit hip flexion and knee extension to avoid stretching of the hamstrings. However, this immobilization creates discomfort and limitation during the basic daily needs, possibly compromising patient satisfaction. We hypothesis that proximal hamstring repairs can be safely managed, without brace immobilization and allowing partial weight bearing immediately after surgery, and result in excellent outcomes with minimal complications. Methods: We identify 57 patients that underwent surgical repair of proximal hamstring injuries. The repairs were fixed using suture anchors, and the same surgical technique were performed by a single sport medicine fellowship trained Orthopaedic surgeon. During the postoperative period the patient were allowed to bear partial weight with the assistance of crutches for 6 weeks. At the fourth week, light stretches begin with assistance of the physical therapist. Brace immobilization is not utilize at all, instead detail instruction are provide to the patient to avoid simultaneous hip flexion and knee extension. Subjective outcome measures included: the single assessment numeric evaluation (SANE); I-Holt 12 and KJOC hip scores. Clinical data was obtained from the electronic medical records. Results: Mean patient age was 52 years (range 29-69). The injury was chronic (> 6 weeks) in 55% of the patients. Mean length of follow-up was 32 months ( range 14-60). One patient failed repair, requiring revision surgery. The average SANE score were excellent at 97points, and representing a 43 points increase from the preoperative assessment. Similarly, the mean score for the I-Holt 12 and KJOC hip scores were very good with 99 and 83 points, respectively. In 68% of the patient the injury was sport related, and they all return to sport at an average of 7 months. Conclusion: A post-operative protocol that included immediate partial weight bearing and does not utilized immobilization brace can result in excellent subjective outcomes, high rate to return to sport in a timely matter and low failure rates. Based in our findings, brace immobilization following surgical repair of proximal hamstring appear to be excessive and may not provide additional benefit.

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ROLE OF PHYSICAL THERAPY IN THE TREATMENT OF POSTERIOR ANKLE IMPINGEMENT IN PEDIATRIC ATHLETES - A PROSPECTIVE STUDY

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00082 ◽

2021 ◽

Vol 9 (7_suppl3) ◽

pp. 2325967121S0008

Author(s):

Adam Saloom ◽

Nick Purcell ◽

Matthew Ruhe ◽

Jorge Gomez ◽

Jonathan Santana ◽

...

Keyword(s):

Physical Therapy ◽

Prospective Study ◽

Conservative Management ◽

Pediatric Patients ◽

Weight Bearing ◽

Return To Sport ◽

Time To Surgery ◽

Ankle Impingement ◽

Posterior Ankle Impingement

Background: Posterior ankle impingement (PAI) is a known cause of posterior ankle pain in athletes performing repetitive plantarflexion motion. Even though empirically recommended in adult PAI, there is minimal literature related to the role of conservative physical therapy (PT) in pediatric patients. Purpose: To identify patient characteristics and determine if there is a difference in pediatric patients with PAI who were successful with conservative PT and those who were unsuccessful, requiring surgical intervention. Methods: Prospective study at a tertiary children’s hospital included patients <18 years diagnosed with PAI and underwent PT. Patients who received PT at an external facility were excluded. Collected data included demographics, initial presentation at PT evaluation, treatment throughout PT, patient presentation at PT discharge, time to return to sport (RTS) from initial PT evaluation (if successful), time to surgery from initial PT evaluation (if unsuccessful). Visual Analogue Scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were collected. Group comparisons were conducted using independent t-tests or chi-square analyses (alpha level set at .05). Results: 31 (12 males, 19 females) patients diagnosed with PAI were enrolled with a mean age 12.61 years (range: 8-17). Gymnastics, football, and basketball were the most commonly implicated sports (42% patients). All patients underwent initial conservative PT for an average of 16.24 weeks (9.23 visits ±7.73). 20/31(64.5%) patients failed conservative management and underwent arthroscopic debridement. PAI pathology was predominantly bony in 61.3% and soft tissue 38.7%. Between the successful PT group and unsuccessful PT group, there was no difference in the proportion of athletes/non-athletes (p=.643). Average RTS time for successful group was 11.47 weeks and average time to surgery for unsuccessful group was 17.82 weeks. There were no significant differences in sex (p=.332), age (p=.674), number of PT visits (p=.945), initial weight-bearing status (p=.367), use of manual therapy (p=.074) including manipulation (p=.172) and mobilization (p=.507), sport (p=.272), initial evaluation ankle ROM (p>.05). Initial AOFAS scores for pain, function, alignment, or total were not significantly different (p=.551, .998, .555, .964 respectively). Conclusion: The first prospective study in pediatric patients with PAI demonstrates that even though success of PT is not dependent on age, sex, sport or PAI pathology, a notable proportion of patients who undergo PT do not need surgery. Conservative management including PT should be the initial line of management for PAI. PT treatment and surgery (if unsuccessful with PT) allowed patients to return to prior level of activity/sports. Tables/Figures: [Table: see text]

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