Open Proximal Hamstring Repair

Abstract

Background:

Proximal hamstring ruptures meeting operative criteria may be treated through endoscopic, open, or combined techniques. Open techniques allow for facilitated tendon visualization and mobilization with ease of suture passage.

Indications:

Proximal hamstring repairs are indicated for complete 3 tendon avulsions; partial avulsions with 2 or more tendons involved with more than 2 cm of retraction in young, active patients; and partial avulsion injuries or chronic tears that remain refractory to conservative treatment.

Technique Description:

Through an incision along the gluteal crease, the tendon stump is identified and mobilized. Anchors are placed in the prepped ischium and sutures are passed through the tendon in a running fashion. The tendon is secured to its origin in a docking technique.

Results:

Patients undergoing hamstring repair have high satisfaction rates and patient-reported outcome scores. Competitive and elite athletes have demonstrated reliable return-to-sport rates at presurgical levels.

Discussion:

Open proximal hamstring repairs produce reliable results. The open technique is advantageous for its ease of tendon mobilization, direct visualization, and suture passage.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

We will be reviewing our technique for open repair of proximal hamstring ruptures.

The authors’ disclosures are listed here.

Here is our overview.

Proximal hamstring tears are common particularly in athletes and in those who have rapid acceleration and deceleration in their sport.^1-4 The mechanism of injury is typically an eccentric contraction of the hamstring in a high-tension state, such as during hip flexion and knee extension. This leads to an injury pattern in adults which is more common at the myotendinous junction and in children, an avulsion of the ischial tuberosity or its apophysis.^1-4 Patients may feel a pop or tearing sensation in the posterior proximal thigh; have immediate swelling, pain, and ecchymoses; and have difficulty bearing weight as they may limit knee flexion.^1-5

The case presented includes a 40-year-old man who presented 1 week after an injury while playing volleyball. He landed with his left leg out in front of his body with the knee extended and felt a pop in the posterior proximal thigh. In the clinic, he had 10/10 pain that was minimally improved with non-steroidal anti-inflammatory drugs and limited his activities.

On examination, he had an antalgic gait, ecchymoses on the posterior thigh, and was exquisitely tender at the ischial tuberosity and proximal hamstring. Although he had good strength, resisted knee flexion reproduced pain.

Magnetic resonance imaging (MRI) of his femur demonstrated a proximal hamstring tear with 6-cm retraction, edema, and hematoma.

Here, we demonstrate the T2 coronal, T2 axial, and T2 sagittal MRI sequences demonstrating the left proximal hamstring rupture.

Representative images from each are re-demonstrated here.

In general, surgical indications include complete 3 tendon hamstring ruptures, partial avulsions with 2-tendon injury and more than 2 cm of retraction in active patients, and partial avulsions or tendinosis refractory to conservative measures for typically 6 months.^1,4-6

Repair may be performed endoscopically or open as we describe in this technique. Benefits of an open repair include direct visualization of the tendon with easier mobilization, which may be particularly beneficial for full-thickness tears with retraction especially greater than 5 cm or more chronic tears. Open repair is less technically demanding than endoscopic techniques, and by being able to pull the tendon out of the wound, it allows for easier suture passage and more suture strands within the tendon repair construct.

The patient is positioned in the prone position with well-padded bony prominences, including those of the face and head, shoulders and chest, anterior pelvic bones, and patellae. Standard prepping and draping techniques are used.

We now present our surgical technique.

The ischium is palpated and marked, the gluteal crease is identified, and a 5-cm incision is made within the gluteal crease, centered over the palpable ischium, aiming to stay lateral and away from the rectal region. If greater exposure is needed, a T-shaped incision may be used.

After cautery is used to dissect through subcutaneous tissues, the gluteal fascia is identified, and a transverse fascial incision is made.

Blunt retractors are placed deep into the fascia and the gluteus maximus is retracted.

Blunt dissection is used to identify the tendon stump.

Blunt dissection and sharp dissection are used to identify the tendon stump, and throughout the case, the sciatic nerve is visualized lateral to the ischium.

If there are substantial adhesions from the stump to the nerve or surrounding soft tissues, carefully release these adhesions with a scissor.

Once the stump is identified, the stump is mobilized proximally and traction sutures are placed into the stump and further blunt dissection is performed for mobilization.

For improved visualization for this video, we demonstrate the ischial-sided work using a camera. Cautery is used to mobilize soft tissue off the bony base. The bony surface is then prepared with elevators and a high-speed burr. Throughout this time, the tendon is mobilized away from the surgical field and the sciatic nerve is protected laterally by a blunt retractor placed on the lateral ischial border.

After the bony preparation, in hard bone it may be beneficial to drill a pilot hole in the ischium for anchor placement. We began here with a posterolateral ischial anchor. The punch is used, followed by the tap, and here, a triple loaded anchor is placed. This process is then repeated for a posteromedial anchor. We perform a 2-anchor repair with triple-loaded anchors, but some biomechanical studies support more anchors. However, no clinical data have explored different anchor configurations.

After anchor placement, the retractors are then removed to decrease wound tension during suture passing. The traction sutures are used to apply additional tension on the tendons.

We began passing sutures from the posterolateral anchor. One end of each suture strand is identified as a post strand, and non–post strands are passed through the tendon on the lateral side. These non-post sutures are passed from proximal to distal and then back to proximal in a running fashion. Each post strand is then passed in a simple fashion through the tendon. All suture strands should exit on the superficial surface of the tendon, so the knots lay on top of the tendon. This is repeated on the medial side.

The tendon is then reduced to the ischial tuberosity using a docking technique. Tension is pulled on each of the post strands to bring the tendon down to the bone and anchors.

Tension should be maintained on the remaining posts as sutures are then tied sequentially. It is critical that the knee is held in ~45° of flexion during tying.

Care should be taken to lay each knot securely with the tendon reduced. In deep surgical fields, the surgeon may also consider using a knot pusher for assistance.

The suture strands are cut above the knot with either a deep knife or a knot cutter.

Here, we demonstrate the sciatic nerve lateral to the ischium and the tendon repair construct. The wound is irrigated, and the nerve is re-evaluated and ensured to be free from the repair. Meticulous hemostasis is obtained prior to layered wound closure, including closure of the gluteal fascia. A hinge knee brace is applied to the patient locked at ~45° of flexion prior to awakening from anesthesia.

The key steps from the procedure are listed here. The gluteal fascia should be incised and may be tagged per surgeon preference for later closure. The sciatic nerve should be protected throughout the case. The tendon is mobilized and held with traction sutures. Thereafter, the ischium is prepped, anchors are placed, and sutures are passed through the tendon. By pulling tension on the post strands, the tendon is docked onto the ischial tuberosity with knots tied on the superficial surface of the tendon. Prior to closing the gluteal fascia, meticulous hemostasis should be obtained, and the sciatic nerve should be re-evaluated to ensure it is free of tethers.

Some tips include performing repair early to minimize complications, and in chronic cases, they include taking care to release adhesions on the tendon or nerve. The ischial preparation should be thorough to increase the contact surface of healing. Sutures should be tied in 45° of knee flexion to decrease repair tension, and again, evaluation of the sciatic nerve should be performed throughout and at the end of the case.

Postoperatively, patients are placed in a hinge knee brace at 45° of flexion for 6 weeks. Weightbearing is progressed and the brace is weaned for the following 6 weeks. After 3 months, gentle strengthening begins and return to sporting activities is allowed at no sooner than 4 months.^1,3-5

Complications overall may range to up to 23%, including wound complications, infection, numbness at the incision site, additional neurologic complications, and re-rupture, as listed here. The risk of wound complications may be limited by the slightly lateral placement of the incision and obtaining hemostasis prior to closure.^3-5,7-10

Patients may expect high return to sport and satisfaction after hamstring repair. One systematic review of 13 studies and 387 patients found that 75% to 90% of elite and competitive athletes returned to sport at a presurgical or preinjury level, and high patient satisfaction has been reported throughout the literature. ⁹ Pain scores are typically low, although some may have pain during activities. Hamstring-to-quadricep strength ratios have not substantially differed from the contralateral leg, and functional outcome scores reported are high. ⁹

Chronic tears and complete tears may have worse outcomes than acute and partial tears, but mid-term follow-up results are still favorable. A retrospective study of 94 patients with mean 56.2-month follow-up divided patients into acute versus chronic and partial versus complete groups. ¹⁰ The acutely repaired group had a higher percentage return to sport than the chronic group, but there was no noted difference between partial and complete tear patients. Patient-reported outcome measures and pain scores did not differ between any groups. Complications were greater in the chronic group, with 21.7% chronic and 4.2% acute, and were also greater in the complete tear group, with 13.8% in those with complete tears compared with 0% in those with partial tears. ¹⁰

Here are our references, and we thank you for watching our video.