Reconstruction of a Chronic,Retracted Proximal Hamstring Rupture Using Achilles Tendon Allograft

Abstract

Background:

Chronic, retracted proximal hamstring ruptures are a challenging problem and can be a significant cause of pain and disability if left untreated. Allograft augmentation is a viable surgical option with good clinical outcomes.

Indications:

Indications are symptomatic patients with chronic hamstring ruptures unable to be primarily repaired. Patients typically present with pain, instability, or lack of push of strength.

Technique Description:

An L-shaped extensile incision is made at the level of the gluteal crease. The gluteus maximus is retracted proximally. The sciatic nerve is identified, neurolysed, and tagged. Following the release of adhesions of the native tendon and confirmation of the inability to complete a primary repair, the Achilles tendon allograft is prepared. The allograft is incorporated with the native tendon and the subsequent hamstring construct is fixed and reduced to the ischial tuberosity with suture anchors. After copious irrigation, the incision is closed with Monocryl and Dermabond (Johnson and Johnson) and a sterile dressing is applied. The patient is placed in a hip brace locked in extension.

Results:

In a study by Rust et al, examining 72 patients with proximal hamstring ruptures, patients who underwent allograft reconstruction reported activities of daily living and postoperative sports activity equal to those of chronic repair, and inferior to those of acute repair. However, there were no significant differences between groups for patient-reported outcomes among acute and chronic repairs and allograft reconstruction. Moreover, a systematic review, by Van Der Made et al, published in the American Journal of Sports Medicine, included 13 studies that found that Achilles allograft repair for delayed proximal hamstring repair results in outcomes comparable to acute primary repair.

Discussion/Conclusion:

Although the literature on chronic proximal hamstring repair is fairly limited, studies have shown that proximal hamstring repair with allograft augmentation can be favorable in symptomatic patients. Allograft augmentation for chronic, retracted proximal hamstring ruptures provides increased functional outcomes in comparison with nonoperative management.

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

This is Dr David Swanson at New England Baptist Hospital, presenting our technique on the Reconstruction of a Chronic, Retracted Proximal Hamstring Rupture Using Achilles Tendon Allograft.

The following are the authors’ disclosures.

Chronic, retracted proximal hamstring ruptures are a challenging problem and can be a significant cause of pain and disability if left untreated. ² Adhesions and excessive retraction may prevent adequate reduction of the native tendon. Allograft augmentation is a viable surgical option with good clinical outcomes.^1-7 Surgical technique includes an extensile incision, sciatic neurolysis and release of tendon from adhesions, preparation of allograft, incorporation of the allograft with the native tendon, and fixation to the ischial tuberosity.

The patient is a 35-year-old man who presented with left proximal posterior thigh pain. He slipped and did a split while running during a softball game approximately 4 months prior to presentation. He was treated with physical therapy at an outside institution, but complained of persistent weakness, sitting intolerance, and pain. On physical examination, he had tenderness to palpation over the ischial tuberosity, a palpable deformity, 4 out of 5 hamstring strength, and an otherwise normal physical examination. He was distally neurovascularly intact.

Indications for this procedure include active patients requiring push-off strength, complaints of instability, and difficulty with activities of daily living. Contraindications include significant muscle atrophy, inability to comply with rehabilitation, smoking, and a high body mass index.

There are several factors that should be considered during preoperative planning. The first is patient expectations, including brace and crutch usage, need for physical therapy, length of recovery, and a home support system for activities of daily living. The second is preoperative magnetic resonance imaging (MRI). This enables us to evaluate the degree of muscle atrophy, determine the amount of tendon retraction, and look at the proximity to the sciatic nerve and any surrounding scar tissue. The third is the surgery itself, including allograft availability and preparing for sciatic neurolysis.

Coronal T2-weighted MRI of the pelvis demonstrates a 9-cm retracted tear of the conjoint tendon and semimembranosus tendon. Axial MRI sequencing demonstrates the bare ischium at the origin of the conjoint tendon and semimembranosus tendon.

The patient is placed in the prone position, with gel padding to support the torso. The hip is held in slight flexion, and slight Trendelenburg positioning of the table helps retract the gluteus maximus superiorly during the procedure. The extremity is then formally prepped and draped, including Ioban at the surgical site.

An L-shaped incision is made using a 10 blade beginning at the level of gluteal crease, extending medially and distally. Subcutaneous flaps are elevated using electrocautery. The gluteal fascia is identified and incised horizontally with Metzenbaum scissors. A Richardson retractor is gently placed under the gluteus maximus muscle belly for exposure of the hamstring tendon sheath. The hamstring sheath is identified and incised longitudinally. The sciatic nerve, which lies outside the sheath, is then identified, neurolysed, and gently tagged with a vessel loop. A traction stitch is placed in the native tendon.

The tendon is freed from adhesions circumferentially. Care is taken when releasing adhesions laterally, as the sciatic nerve is in close proximity. Once the tendon is fully mobilized, the ischial tuberosity is prepared for anchor placement using a Cobb elevator.

The distance from the native tendon to the ischial tuberosity is measured to be approximately 5 cm. Since the tendon is unable to be fully reduced, even with 90° of knee flexion, the decision to proceed with allograft augmentation is made. We begin with the allograft preparation. Our graft of choice is an all soft tissue Achilles tendon. A longitudinal split is made in the allograft and the graft is slid down onto the native hamstring tendon. The native hamstring is then sewn to the allograft both medially and laterally. The allograft is then doubled over according to our previous measurements. Our desired graft length is then confirmed with a ruler and secured with sutures in figure-of-8 fashion.

Two, double-loaded suture anchors are then inserted into the ischial tuberosity. One suture limb from each anchor is weaved in a running locking configuration down the medial and lateral sides of the allograft. Another suture limb from each anchor is then weaved in a modified Mason-Allen configuration down the medial and lateral sides of the allograft. The final construct is shown here.

The suture ends that are not passed are used to reduce the construct to the ischial tuberosity. They are tied into place under appropriate tension. Here we can see the final repair construct, demonstrating the relationship of the sciatic nerve to the hamstring tendon.

The incision is copiously irrigated. The deep gluteal fascia is closed with a number 1 Vicryl suture. The deep dermal layer is closed with a 2-0 Monocryl suture. The skin is closed with 3-0 Monocryl suture and sealed with Dermabond. A sterile dressing is applied.

Complications of this procedure include infection, neurologic injury to sciatic and posterior femoral cutaneous nerves, hip and knee stiffness due to immobilization after surgery, and venous thromboembolism, for which patients are given a postoperative anticoagulant. Postoperatively, the patient is made flat foot weightbearing with crutches. A locked hip brace in neutral alignment is applied, and the goal of the brace is to limit hip flexion and active knee flexion. No sitting is permitted in the early postoperative period. The patient is placed on chemical anticoagulation for 4 weeks. Physical therapy is initiated at 1 month. The patient can begin a light run or jog at 4 months, and full activity is resumed at 6 months.

While the literature on this topic is fairly limited, studies have shown that results for this procedure are generally favorable.^1-7 Folsom et al ¹ looked at 26 patients with complete proximal hamstring ruptures, 5 of which were chronic. They found no significant difference in mean hamstring strength deficits for acute versus chronic tears. Similarly, Rust et al ⁶ looked at 72 patients with traumatic proximal hamstring ruptures, 14 of whom underwent allograft Achilles reconstruction. They found that activities of daily living and sports activity for reconstruction were equal to those of chronic repair, and inferior to those of acute repair. However, they found no significant differences between groups for patient-reported outcomes among acute and chronic repairs and allograft reconstruction.