Hüfte

Ruptur der proximalen Hamstring-Sehne

DieHamstring-Sehne reißt typischerweise direkt am lateralen Tuber ischiadicum ohneknöchernen Ausriss.

Procedure

Das Tuber ischiadicum des Beckens wird in offener oder endoskopischer Technik lokalisiert und dargestellt. Der Muskel-Sehnen-Übergang des Hamstring-Muskels wird lokalisiert und am Tuber ischiadicum refixiert.

Michael B. Gerhardt, MD (Santa Monica, CA), demonstrates an open repair of the proximal hamstring tendon using a SpeedBridge™ construct to create a low-profile, anatomic repair.

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Open Proximal Hamstring Tendon Repair Using a Knotless SpeedBridge™ Construct

Today we'll be demonstrating a proximal open hamstring repair utilizing the Arthrex SpeedBridge Proximal Hamstring repair kit. This is a right lower extremity. To orient you, this is the proximal ischial tuberosity. This is the posterior right thigh. This is lateral. The greater trochanter of the hip and the skin incision should be made just distal to the tip of the ischial tuberosity. With palpation you should be able to easily identify the ischial tuberosity. And we will work off of that. Typically the incision is made approximately three centimeters distal to the tip of the ischial tuberosity in the gluteal crease. The incision will be made in a transverse fashion, typically 3 to 4cm in length. For demonstration purposes, we'll extend the incision just slightly before getting started. It's important to identify the other important anatomic landmark, which is the sciatic nerve. It runs roughly in this orientation. Identifying the sciatic nerve will be demonstrated later in the procedure. Let's go ahead and make the skin incision. The skin will be incised and the dissection will be carried down to the subcutaneous fascia. Retractors will be placed in the subcutaneous tissue in anticipation of identifying the next anatomic structure, which is the fibers of the gluteus Maximus fascia. As you can see, as we get through the subcutaneous fat, the whitish structure here is the fascia of the gluteus Maximus muscle. This will be incised sharply so as to mobilize the gluteus Maximus muscle. As you can see, the gluteus Maximus fascia can be dissected and repaired later before closure. We can digitally dissect and identify the distal aspect of the gluteus Maximus muscle complex. The fibers typically look like they are vertically oriented, as they make their way towards the lateral aspect of the proximal femur. Amer. Once the gluteus Maximus inferior border is identified, we can start to retract it approximately, which will expose the proximal hamstring attachment. Now that we've identified the gluteus Maximus inferior border, we're going to simply retract it proximally. It should be noted that the posterior femoral cutaneous nerve runs right in this region and also should be protected. A retractor can be placed on the inferior border of the gluteus Maximus, which retracts the muscle proximally, thus allowing for us to visualize the next important anatomic region, which is the proximal hamstring. The proximal hamstring fascia is identified here as it makes its way to the ischial tuberosity. Typically, the proximal hamstring fascia is intact, and when incised in an acute rupture, the hematoma can be identified and oftentimes leads you directly to the ischial footprint. Before we embark on proximal hamstring repair, we need to make sure that we identify the sciatic nerve, which is located just lateral and ventral to the proximal hamstring muscle and tendon. It can be digitally palpated, and it can be identified as we attempt to visualize the sciatic nerve. The proximal hamstring muscle can be carefully retracted medially, which allows for us to not only palpate the sciatic nerve, but allows for us to visualize it and track it proximally and distally to make sure there are no adhesions. It's important that we know that there are no retractors anywhere near or on the sciatic nerve throughout the remainder of the procedure. With the gluteus Maximus muscle retracted proximally and the sciatic nerve effectively identified and protected, the proximal hamstring tendon stump can be identified as such in this specimen. The entire conjoint tendon is ready for repair. As we retract proximally, we're able to see the ischial tuberosity, which similarly will be prepared to accept the proximal hamstring. To better visualize the ischial tuberosity footprint, it's important to carefully place retractors on the ventral and dorsal surfaces of the bone. This is a demonstration of the ventral portion of the ischial tuberosity and a home and retractor going into place. Similarly, a second retractor is placed proximally over the dorsal aspect of the ischial tuberosity. As such. This gives an excellent view of the footprint of the ischium. Now, with the proximal hamstring mobilized and retractors placed on either side of the ischial tuberosity footprint, we can prepare the bone for repair. A combination of rasping curettage in rongeur will remove any remnants of soft tissue in anticipation of our repair, it's important to note that the ischial tuberosity footprint is laterally and obliquely oriented. If repair is performed on the distal aspect of the ischium, the patient may present with sitting pain after the repair. The proper anatomic position for docking is here in the lateral oblique part of the ischial tuberosity. The rangers used to remove some of the soft tissue remnants. In preparation for anchor placement. Once adequately cleaned, repair can ensue. We can mark the area. For demonstration purposes where our SpeedBridge construct will be applied, the first anchor, which is a preloaded swivel lock, will be placed here on the most distal aspect of the footprint. The second will be placed more proximally. The third and fourth anchors Thinkers will be oriented as such in a double row configuration to enhance healing potential. Microfracture bone marrow stimulation technique can be applied. This is actually the drill guide with the trocar that can be utilized for this purpose. Once multiple punctures have been made, we'll prepare for anchor placement. As we prepare for suture anchor placement. The drill guide will be placed in the more distal position. The trocar can be removed and the drill can be applied. Drilling will proceed to the appropriate depth. We will then proceed with the power tap. Without removing the entire drill sleeve. We will leave the slotted cannula portion in place, which allows for us to place. The suture anchor. 4.75 SwiveLock is then inserted. Prior to passage of the sutures through the tendon itself. It should be noted that the standard sliding suture can also be used to augment the repair in a knotted fashion, if the surgeon desires. For our purposes, this will be removed. We will proceed with passage of the sutures through the tendon. At this point, the sutures are swaged, as with the typical SpeedBridge orientation. This could be passed through a single pass through the tendon with this needle. However, if the surgeon desires the swaged part of the suture can be cut, thus allowing for four separate passes with the four separate sutures. There's two. And here's the other two. Now we have four suture strands, which will be individually passed through the proximal hamstring stump, and the sutures are passed through the tendon accordingly. The proximal hamstring can now be reduced to the footprint prior to tensioning before final reduction. We'll prepare for a second row of suture anchors in preparation for our double row fixation. We will select one blue and one white suture, and these will be passed through the first SwiveLock anchor, and the second white and blue sutures will be passed through the SwiveLock. We will now drill in anticipation of placement of our second row of SwiveLock anchors. The power tap will be utilized. We now will place our first of the double row anchors. Placement of the SwiveLock can ensue. If possible. And that provides excellent fixation. However, if we'd like to augment or further compress the tendon, we can use this sliding suture to further enhance our repair. And the final anchor will now be placed. Reduction appears to be adequate and this will further tension as the swivel lock is placed. And similarly we can augment our fixation with this sliding suture. Once final tensioning has been secured and we're satisfied with the reduction of the tendon, we can then cut sutures. And this will allow for double row repair. So that completes our SpeedBridge double row construct. The tendon is nicely reduced to the ischial tuberosity. The four strands of sutures which are crossed here are so nicely compressed that you can't even actually see them here. And excellent fixation as we pull on there reveals that there's no sliding, no lift off. And this should allow for a great repair.

This animation demonstrates a proximal hamstring repair using the Hip SpeedBridge™ implant system with PEEK SwiveLock® anchors and FiberTape® suture.

Proximal Hamstring Tendon Repair

Open proximal hamstring tendon repair using the SpeedBridge system. Place the open drill guide, inner drill sleeve and obturator against the lateral facet of the ischial tuberosity. Remove the obturator and insert a drill bit to create a bone socket for the anchor insertion. Insert a power tap to create a thread pattern for the anchor. Then remove the inner drill sleeve by twisting it counterclockwise. Place a 4.75mm peak SwiveLock anchor preloaded with a blue FiberTape suture through the open drill guide and into the prepared bone socket. Remove the retention suture from the anchor and insert a second SwiveLock anchor with a black white FiberTape suture more proximally. Pass both of the FiberTape sutures through the proximal hamstring tendon using a free needle. Once both sutures are past, reduce the tendon back to the ischial tuberosity. Use a FiberWire scissor to cut the cut the FiberTape sutures below the single limb of suture, leaving four limbs of the FiberTape suture. Load one of each color of FiberTape sutures through a third SwiveLock anchor eyelet, and place the drill guide against the bone to create a more posterior bone socket. Insert the power drill and tap using the same technique as the previous anchors. Remove the drill sleeve. Slide the SwiveLock anchor through the open drill guide and into the bone socket to compress the tendon back to the tuberosity. Upon final tensioning and anchor insertion, remove the retention suture and insert a fourth and final anchor to complete the SpeedBridge technique.

James J. Guerra, MD (Naples, FL), demonstrates the repair of a proximal hamstring tear using the Hip SpeedBridge™ implant system with PEEK SwiveLock® anchors. In this cadaveric demonstration, Dr. Guerra outlines the surgical steps for repairing a proximal hamstring tear while identifying key anatomic structures.

Proximal Hamstring Repair Using a SpeedBridge™ Technique

So what you see here is Arthrex has put together this terrific kit to do an Arthrex SpeedBridge hamstring repair. The kit comes with everything you could absolutely need to do a hamstring repair. You can see it's got the taped anchors for your distal row, and then it has the standard anchors for the proximal row. Since the bone is very hard, they made the actual anchors peak anchors to aid with the insertion. What also comes in the kit is all the tools that you'll need to actually make your tunnels and your holes. It comes with this really nice paddle drill as well as a power tap. Since the bone is so hard and a nice guide, particularly for those heavier patients where you may have a pretty big soft tissue window to work through. It also comes with these two free needles to pass the tapes through the actual tendon. So Arthrex has this well thought out drill guide. It has an inner obturator which prevents soft tissue from getting in your cannula. It has this inner cannulation for drilling as well as power tapping that comes out. And then it becomes this nifty slotted guide to run your anchor down into the hole. The other thing I really like about the actual guide is it's got these little spikes on it, so you can tap it into the bone to hold your position. There are two classic incisions that are described. Typically, the more extensile is a vertical incision beginning at the ischial tuberosity and carrying down vertically distally. And then if you're just doing an insertion hamstring tendinopathy, then you can make the incision kind of in line with the buttocks crease, which is more cosmetic, particularly for your female athletes. For today's demonstration, we're going to go ahead and do the more extensile approach. It will be easier to see everything and it will make for better teaching points. So typically on a on a complete avulsion I'll go ahead and make a vertical incision like we talked about. I typically make it approximately five centimeters beginning at the ischial tuberosity and carrying it distally. For demonstration purposes we'll make the incision a little bigger. So this way we can all see well into the actual incision. So I'm going to go to go ahead and make about a 7 or 8 centimeter incision here. So once the skin incision is made, we'll go ahead and put in two rags to separate. And we want to basically dissect down to the coral fascia. So we're going to go ahead and come through this vertically. So we've dissected the subcutaneous fat down to the coral fascia. And you'll see that here. Sometimes there can be a longitudinal posterior nerve that you want to be careful for a little cutaneous nerve. So you want to stay well clear of that. In this case we don't actually see it. So I'm going to go ahead and make a vertical incision in the crural fascia. And when you do that if it's an acute tear many times then you'll go ahead and you can see that fashion just splits right open. You'll come into a seroma and you'll get a big squirt of seroma fluid as you come in with an acute tear. Good. So you can see now we're starting to see the muscle belly of the hamstring coming into view as we cut that crural fascia. So we've made a longitudinal cut in the coral fashion. You can actually see the common hamstring here. So we've gone ahead and cut the crural fascia. Fashion. And this here is our gluteus Maximus. Usually a little more robust in a in a healthy individual. We're going to put our Richardson retractor underneath the gluteus Maximus. And now you can see really just beautifully with the table jackknife like this. You can see this is the ischium. And remember that the common hamstring insertion site is onto the lateral facet of the ischium, which is right, right in here. It does not insert at the bottom of the ischium. It actually inserts on the lateral facet. So if we put a retractor medially, you can see I've exposed the medial border of the semitendinosus. And biceps tendon insertion site which is the more superficial of the two. So you can see this is the common insertion for the semitendinosus and biceps tendon which is the more superficial of the two tendons. And then the semimembranosus is the deeper of the two. We have exposed our adductor Magnus medially. But of course the most important thing is our lateral anatomy. We all know that the sciatic nerve is a lateral structure, so we need we need to identify the sciatic nerve at the beginning of the case to make sure that it's held well out of harm's way. Give me one more retractor so we can really show this. Hold that down like that. So we've taken the common attachment site medially, and we used our fingers. We used our finger to kind of roll over the nerve and then we exposed it. But what we want to do now is we want to develop the plane on the medial side of the nerve by just using some blunt dissection in this location here. Then we're going to take this glenoid retractor, which we borrowed from our shoulder team. And we're going to put this on the medial side of the nerve. Let me just slide that right in there. And we know now that the sciatic nerve is well protected and well out of our surgical field. And then we're going to place a third glenoid retractor. And you place that on the medial ischium. And you can take that retractor out. And that gives you really, really nice exposure. In this case the hamstring is intact. So I'm going to feel the edge of the lateral facet with my finger here, and I can kind of feel the edge of it. And the lateral facet is kind of in this orientation, if you will like that. So we can feel with my finger and this is the actual lateral facet of the ischium. This would be the inferior aspect over here. And we're going to go ahead now and cut the hamstring off of the lateral facet, just like you would do if you were doing an insertional hamstring. So we've released the common common hamstring insertion from the lateral facet. And we're going to let that roll back. And you can see this is the beginning of the lateral facet. And it comes way down over here. This retractor right now is protecting our sciatic nerve. And I'm going to actually put it within the tear. I'm going to replace that retractor and put a two finger retractor. And now you can see you've got fantastic exposure of the lateral facet which begins about here. The mistake that you can easily make, particularly in a complete avulsion when this thing is retracted. I've taken a little bit of the Magnus down to show you, but a mistake you can make is try to attach it to the inferior aspect of the ischium. And not only is that not the anatomic insertion site, but also the patient will have significant pain when they sit because they'll be sitting right on the sutures and on the repair site. So you need to attach it back to its anatomic insertion, which is over here on the lateral, the lateral facet which I've outlined here. The next step, once you have everything exposed and you have this retracted within the tear, protecting your sciatic nerve is you want to come in with a rasp and rasp the bone to create a healing response, just like you would do a rotator cuff repair. So now we're going to go ahead and put our anchors in. Arthrex has made this really nice guide to help protect you. Sometimes these can be pretty deep. So we're going to go ahead and put our first anchor in the bone. And you have these nice nested cannulas. And then we have this nice paddle drill as well. So I'm going to slide that down. And I'm going to go ahead and drill our first anchor. Is a laser line here, which is very nice. And because this bone is hard, they have a nice power tap. You can also tap by hand of course, but I like the power tap. I'm coming in now with the power tap. It's got a nice stop on it. Now I'm going to go ahead and take the inner peace out. Okay. I'll take a little now to kind of get it started. I'll take that out at this point. And go ahead and seat the SwiveLock. You can save the inner suture to supplement your repair. I typically don't, so I'm going to go to go ahead and remove it. So I'm going to go ahead now and put my second anchor in. And in my mind's eye I'm trying to create a nice broad insertion site for our hamstring attachment. And there's a nice laser line that lets you know how far to seat the actual drill. I'm going to go ahead and insert the power tap, and it's best to go pretty slow, just like you would do by hand until you hit the positive stop and then just reverse it out. You just turn this counterclockwise and pull it out, and now you have everything lined up for your next anchor. I like to mount to the first line, make sure it's fully seated. Once again, you can use these sutures to supplement your repair. I typically don't, I just do a standard bridge. So I'm going to take that out. So the nice thing is the anchor comes with the two limbs together at the end. You can do a single pass with each set of the tapes, or if you want, you can cut them and do four individual passes through the tenon, which is typically my technique. But for the demonstration purposes here we're going to do a single pass. So I try to determine where I think the tenon is going to lie on the tuberosity. So I'll go ahead and come through the tendon now with my first pass. So now I'm going to go ahead and put my second pass. Now that we've passed the tapes through the actual tendon, we'll go ahead and cut the tapes. And we're going to do the same thing now for the blue. Hold it like that. Good. And now we're going to do a standard bridging technique. And we're going to load these onto a SwiveLock. So I've taken one blue and one white tape to each anchor. I'm going to go ahead and place my first proximal anchor. And this is going to be the more posterior one. And you can bring it on up onto the posterior aspect of the facet. If you like, to kind of have it come around the corner. So I'm going to go ahead and pick that spot. And then I like to kind of give it just a little love tap to kind of make sure that it's seated. And then we're going to go ahead and drill. And then I'm going to go ahead and power tap. And I typically at this point I'll go ahead now and drill my second hole as well. I like to do them both at the same time. So we'll go ahead and set everything up again okay. So now I'll do a standard bridging technique. So this is going to reduce up like that. And what I like to do is I like to put them in the hole both of them at the same time. So I'm going to go ahead now and see if the anchor kind of. I like that. And I'm going to go ahead and place my other anchor. I like to make a little purple mark where I think I should be. Good. And you could once again, you could use these sutures to further reinforce your repair. But I'm going to going to go ahead and take these out. And the last step, of course, is just to cut the suture tails. Here you can see our final contract. We got just a beautiful SpeedBridge. And what I really like about the SpeedBridge is you get that terrific broad footprint compression on the actual lateral facet of the ischium. It's low profile, which is particularly important in this location since this tends to be a pretty tender location. So there's no notch stack. So the low profile, the great compression footprint, compression we get and it's exceedingly strong. I'm going to slip my finger under here. And you can see I can kind of shake the entire cadaver. And the repair stays nice and nice and secure. So it's a really very satisfying procedure. When you do this, you leave the operating room feeling comfortable and confident that the patient's going to do well.

Ruptur der proximalen Hamstring-Sehne

Rekonstruktion der proximalen Hamstring-Sehne