In an open or endoscopic manner, the ischial tuberosity of the pelvis is located and debrided. The tendinous origin of the hamstring muscle group is found and reattached back to the ischial tuberosity.

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Hip Next Generation in Soft-Tissue Repair and Reconstruction

Thomas Youm, MD (New York, NY), performs a cadaveric demonstration of an endoscopic hamstring tendon repair using a Knotless SpeedBridge™ construct.&nbsp;

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Endoscopic Hamstring Tendon Repair Using a Knotless SpeedBridge™ Construct

Hi, my name is Doctor Thomas. I'm presenting a endoscopic proximal hamstring repair using the Arthrex SpeedBridge technique. My starting working portals are distal, medial, and a distal lateral portal right along the gluteal crease, where my scope will be facing towards the ischial tuberosity. As we get further in the case, we will be having further working portals for anchor placement as well as suture management and suture passage, which will be more proximal. So I currently have my 30 degree scope through this distal lateral portal facing towards the ischial tuberosity and a shaver here. My first landmark is the ischial Bursa and the ischial tuberosity, from which we will then demonstrate the hamstring tear as well as the sciatic nerve. Here I have the shaver on the ischial tuberosity, and we are starting to see the fibers of the hamstring tendon. I'm going to expose this area, remove any bursitis so I can see clearly before any repair. We will locate the sciatic nerve. Here I've identified the ischial tuberosity with the hamstring tendon. As I come lateral through this perineal fat, we're seeing the sciatic nerve, and this is the structure that is most at risk with this type of operation and something that we will keep in mind as far as location. Throughout this case, we have created our distal, medial and lateral portal. Here I have my 30 degree scope through the distal lateral portal. I have prepped the specimen here. We have exposed the ischial tuberosity. Here is the proximal hamstring tendon which we released from the ischial tuberosity. You can see from the outside of the specimen I've also created under spinal needle localization two portals more proximally, which is going to be on the medial and lateral borders of the tuberosity by the hamstring origin. With this drill guide, we can drill as well as tap with the same sleeve, which is a nice feature. We don't have to pull this out. We took the obturator out and right now we're going to drill. We can go on power tap. So this is FiberTape that later will need to be cut. Right. To separate the two strands. But there's one strand here. And this is extra suture which we don't need for the for this type of SpeedBridge technique. This is the insertion of our distal medial anchor. Let's make sure the anchor is below the bone. So the sutures in the SwiveLock anchor include the white here which is the tape which are two tapes conjoined into one. Easier for passage either with a lasso or some sort of Scorpion device. The blue suture here is a suture that slides, and that can be used to reinforce your repair. For the purposes of the SpeedBridge technique, we don't need the blue. We'll take that out. So here I have a soft tissue grasper on the torn hamstring tendon just to see how it wants to reduce right back onto the footprint over here. And we have sufficient tendon for a double row repair. This is a switching stick for the TRIM-IT cannula. We measure approximately a 4 or 5 and it's been cut. And we're going to screw this cannula in right over the guy. So our plan here is to retrieve the white sutures through our proximal cannula. Once we retrieve those white sutures. So that proximal cannula, I'm going to pass it through the hamstring tendon and retrieve it percutaneously at this distal medial portal to get it out of our way. Then we're going to go grab the blue FiberTape sutures and once again through this cannula, pass it through the tendon. And then once that's completed, I will remove that through this portal in a percutaneous fashion. So then we can get to our proximal row anchors. This is loading of our Scorpion suture. Passer one conjoined limb of the two FiberTape sutures. Easier for suture, passing both FiberTape through the tendon. This is similar to a rotator cuff repair. We have tension on the cuff, bringing it proximally so we can get a nice medial row bite. Now we're going to retrieve the FiberTape through our distal medial portal here. Now we'll repeat the same steps for the blue suture. We're retrieving the blue FiberTape sutures through our proximal cannula. So what's important for passage of our distal lateral FiberTape is exposing, or at least viewing the sciatic nerve before insertion of the suture, as the nerve is just lateral to the tendon. So this is the conjoint tendon. This is our first medial pass. We're going to put a lateral pass here. And right down here is going to be our sciatic nerve. I'm going to get my blue sutures out of the way through this proximal lateral accessory portal. Percutaneously. And now we have our proximal row on the tuberosity planned. And you can see our footprint here, which is where we're going to put our two proximal anchors. Okay. So here you see the conjoined limb that we had passed through the tendon. And now it's time to separate the two limbs of the FiberTape by cutting. And you see the two suture limbs. Now of the two separate FiberTape, we'll do the same thing for the white FiberTape sutures. So now that we've separated our FiberTape into both sutures for both the blue and the white, we're planning positioning of our proximal row anchors. I found this position with our switching stick to be the best for two anchors in this position. Our plan here is to put a TRIM-IT cannula for passage one FiberTape blue, one FiberTape white through the proximal row anchor and the proximal portion of the repair. And this will be repeated for both the lateral and the medial anchor. Now that we have our cannula in and we have good exposure, our plan here is to drill and tap for both proximal row anchors. And then we will insert the anchors after tapping and drilling both. Good. Okay. Now we're going to go through the cannula to prep our proximal lateral SwiveLock anchor which you will see us drill and tap. So here we have the torn hamstring tendon. We have our blue FiberTape suture through the lateral portion of the tendon, the white FiberTape suture through the medial portion of the tendon. Our plan here is through our cannula to retrieve one blue and one white, and through this cannula perform our proximal row, which we had already pre-drilled. So I just retrieved the blue FiberTape. And through the same cannula I'm going to be retrieving the white FiberTape. Perfect. Next we're going to load our SwiveLock. Anchor the blue and white limbs through the eyelet. And our plan here for suture management is to first insert the SwiveLock proximal and medial. Good. You have secure fixation. We can remove the introducer. Perfect. And we can get the tape cutter to cut the ends of these two limbs. Retrieve the two remaining FiberTape the blue and white for the proximal lateral anchor. And my tape passer blue. Fibertape coming out. And we're going to load these two fiber tapes through our second proximal lateral SwiveLock anchor. And let's find our pilot hole. We're going to mail it to the laser line. Pull tension on the sutures. There we go. There's the laser line. Keep malleting that down. Okay, so we can unload the extra suture in the SwiveLock. And we'll use a tape cutter to cut the remaining limbs. And you can see our double row repair SpeedBridge technique. Here we have our SpeedBridge technique. We have four SwiveLock anchors 4.75mm in size with FiberTape. And you see the nice SpeedBridge cross technique. We have good tension and fixation on this tendon. We've maintained visualization of the sciatic nerve. The whole case which you see right here. This is our completed repair.

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Scope This Out, Volume 23, Number 1

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

A general overview including the relevant steps of an Arthrex surgical technique. These animations always include a voice-over explaining the process.

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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.

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.

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.

A step-by-step demonstration of how a product would (or could) be used in a surgical technique.

Eine schrittweise Demonstration, wie ein Produkt in einer Operationsanleitung verwendet werden würde (oder könnte).

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Demonstração passo a passo de como um produto seria utilizado em uma técnica cirúrgica.

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Surgical Technique Guides

Proximal Hamstring Tendon Repair Using a SpeedBridge™ Technique

Michael Gerhardt, MD, (Santa Monica, CA) presents his surgical protocol and rationale for treating proximal hamstring tears off of the ischial tuberosity. He discusses the relevant hip anatomy, mechanism of injury, and the endoscopic and open surgical technique for treating partial and full thickness proximal hamstring ruptures.

A video of a live presentation reviewing Arthrex products or techniques.

Video einer Live-Präsentation, die Arthrex Produkte oder Techniken überprüft.

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Vídeo de apresentação ao vivo analisando produtos ou técnicas da Arthrex.

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Presentation Videos

Proximal Hamstring Repair: Open vs. Endoscopic

Again, just a brief review. The common mechanism of injury, the so-called water skier injury, where the amateur water skier gets pulled violently out of the water and they have a very violent hyperflexion of the hip with the knee in an extended position. And there's not a lot of water skiing going on in my area, but I do see athletes who get it middle aged weekend warriors, and then mostly just random kind of occurrences where people are dancing and they're drunk and they slip and inadvertently do the splits on the on the dance floor and they get this pop. So it is a fairly, fairly common injury and you don't want to miss it. The most common you know, cardinal thing that I see when I examine them is they get this massive ecchymosis. And if a normal proximal or a normal hamstring strain isn't going to give you that kind of profound ecchymosis in the posterior thigh. So that'll kind of give you a clue and get an MRI and make the diagnosis. So a couple comments on the anatomy of the hamstring. You know, if you look in some of the anatomic anatomy books, the proximal hamstring attachment can be depicted in an area that's really not accurate. You don't want to stick it right down on the the tip of the ischium. That's not anatomically where it belongs. If you do that, you put them at risk for sitting pain. The true anatomic footprint as we we just published on is, is really a more proximal and lateral to the tip of the ischium. And that really sits off of the edge of the sitting surface so that when they they eventually sit down, they don't feel that kind of golf ball sensation that, that they really don't like. So that's an important point. The other anatomic point is that whether you're doing these repairs open or endoscopic, the first and foremost, most important part of the procedure is clearly finding the sciatic nerve, whether it's an acute injury or chronic injury, I always find it, make sure I know where it's at, and that makes me feel a lot better throughout the procedure. Again, MRI is really the diagnostic study of choice in full proximal hamstring ruptures. The diagnosis is quite obvious. In the chronic cases, it can be a little more subtle. The so-called crescent sign or tendinopathy subtle edema in that area usually is present to help you make a diagnosis in those situations. So should these proximal hamstring injuries be repaired at all? Historically, these were all treated non-operatively, and most of these actually would heal fine and there'd be very little disability. But some won't. And it's those few that won't that we really worry about. And so when I'm counseling and talking to my patients on how to treat these hamstrings, I really just kind of present the data and let them make the decision. And the data suggests that if you let these heal on their own, about 60% of them will be fine. They'll return to sport. They'll have very little, you know, sequelae, but some of them won't heal real well. And the things that we worry about are sciatic adhesions so they can get some radicular symptoms. They can get significant weakness if the tendon is really far retracted down the leg. And that can lead to some athletic dysfunction or this cramping sensation, particularly if they're doing any plyometric running types of activities. And and that can lead to chronic disability if you miss that acute window to fix them. So I try to fix them acutely if it's what the patient would like. So there's been several studies now showing that if we do an open proximal hamstring repair, the results in getting these people back to sports comfortably are far higher than if you let them heal on their own. So that leads us to the actual surgery itself. So the fire that we do, it's a very small incision. It's a transverse incision right through the gluteal crease and usually an average 2 to 4 suture anchors. And it's broken down into a simple six step technique. This is the incision the patients placed in a prone position. Draw your landmarks. Kind of build around the ischial tuberosity. That's the most reliable landmark. As long as you're kind of centered over that, you won't migrate too far laterally and put the sciatic nerve at risk when you're making your approach. I use a headlamp because it ends up being a deep, dark hole in there, and that really helps to visualize what's going on. The first step, once you get through the subcutaneous tissue, is you'll find the gluteus Maximus fascia. Divide it and then look for the inferior border of the gluteus Maximus and retract that proximally. You can then palpate the sciatic nerve. Once the gluteus Maximus is out of the way, you can palpate the sciatic nerve just lateral to the proximal hamstring fascia. And I palpate it. And then I'll take a peek at it. If there's adhesions they can be dissected free. And just making sure that you're not putting a retractor on that nerve. You palpate the stump in a full retracted tear, just like in a biceps tendon or something when you're palpating the area underneath the hamstring fascia. You can feel that stump, and that's really a confirmation that that you're in the right neighborhood. When you penetrate that fascia, there's usually a hematoma or seroma, and you want to warn your staff about that because it can be quite impressive. This was actually a about a 50 year old female who was sprinting and felt a pop in her hamstring and and went to the bar afterwards, which I like her style. But when she was at the bar having a beer, she passed out and and the reason that she passed out is because she bled so much into her leg from the proximal hamstring rupture that she was actually hypovolemic. So it's usually not quite that impressive, but it can occur. So this was that gal in the operating room. Can you see in there the stretcher. I'm about to penetrate through the fascia and you'll see this. Is in the way. Hematoma. And can you move a light? That's my nurse filming that. Move a light a little bit. There you go. Better. That's better. It just looks like a lot of blood. Doesn't it? I'll say. Wow. I was a little nervous, actually. Dropped down to, like, seven. [00:06:46] Or 8 or 7. So. Basically, once you've evacuated the hematoma, it takes you right down to the footprint. And so you can put retractors on the bone. I put a retractor posterior to the ischial cortex there. Identify the footprint, prepare the footprint just like you would for a cuff repair or something. Microfracture. The surface debride it. Make sure it's a nice bleeding surface and then filling the footprint The size of the footprint is variable, and usually I'll use anywhere from 2 to 4 anchors. I like using peak anchors. I know somebody had said they like to use metal anchors. I agree with that, that you should use more of an inert substance in that area. If they do get any type of reaction to the to the bio anchors or any license in that area, it can just be another cause. I think of of sitting discomfort and it's a sensitive part of the area we spend half our lives sitting. So I think using a peak anchor has worked out pretty well for me. When you repair the tendon, you flex the knee, taking the tension off the hamstring and then a modified Krakow repair hoisting the tendon back down to the bone. This is one week post-op and we put dermabond over the incision. And then this is three months post-op. You can see it's a very bikini friendly incision. And it's only when you kind of spread that crease there that you can see where the actual incision is. So cosmetically a great procedure. And That's this is our results from the cases that we reported on. 23 patients, 38 month follow up, almost 90% good or excellent results. One Rerupture was, which was our single major complication. We had 14% minor complication rate. And most of these were numbness around the area. But we did have one superficial infection. So that's kind of the proximal open approach, the fire procedure. But I'll now share with you kind of our experience with endoscopic management. We've been doing this for about four years now, and I know several of you in the room have attempted this. And and I'll just share with you kind of my experience with this. The indications at this point are really partial thickness tears, chronic tendinopathies and cases of chronic ischial bursitis. And we all have these patients in our office not quite sure what to do with them. You're a little nervous giving a corticosteroid injection in that area cause you don't want to weaken the tendon. Yet. These people are pretty miserable. And so you know, platelet injections can be tried. It's hit or miss, I think. But I think an endoscopic approach for some of these chronic tendinopathies is reasonable to do. So the approach for this is really exploiting that space between the gluteus Maximus and the hamstring fascia. There's a potential space in there. And I think that's the biggest advantage to doing this Endoscopically, is that you don't have to retract the gluteus Maximus out of the way. You penetrate right through it and you kind of take it out of play, and it's not as cumbersome of a procedure in that regard. You want to identify the Bursa right out of the gates. Using fluoroscopy can be helpful. As you're first getting started, make sure you're not getting off track and getting too lateral where the the nerve lies. You want to identify the sciatic nerve and perform a neurolysis if necessary, or at least identify where it is and then address the pathology. So this is an overview of the technique. Patient is in the prone position. You make sure that their their leg is free so that you can flex the leg when you're doing the Doing the actual repair. The gluteal crease there is where two of the portals will go in line with the ischial tuberosity, and then you can put accessory portals in more proximally as needed. Establishing the portals is just like you would for any other endoscopic or arthroscopic surgery around the hip, dilating and getting into that space directly over the ischial tuberosity. That's my landmark. Once you're on top of the ischial tuberosity, you can then establish your second portal under direct visualization. And once you've got your second portal in, then you can really exploit that space. Clear out the ischial Bursa. Then you can see and immediately I'm going to look laterally looking for the nerve. I'm using the shaver here as kind of an extension of my finger. Not on oscillation mode, just as a blunt dissector pushing the soft tissue out of the way. And usually the nerve is very easily identified. At this point you want to make and make sure that you identify it and and take your time doing that. Once you've done that, you can then identify the tear. In this case this is a partial thickness tear. It's easily. Or you can merge it back up to the footprint and preparing the footprint, shaving it using a bur sometimes drilling it. I like to microfracture the area and then put in your suture anchors accordingly. And then it just simply becomes a matter of passing the sutures. Here's a fast pass device used to put it through the tendon and then anchoring it back down, making sure the footprint is covered. So that's that's all there is to it. So there's been a little bit in the literature at this point. I think we'll see more. I know Carlos in LA is working on this series and has reported on that at the meeting. We've got a series in conjunction with a couple of the guys here, Doctor Kramer and Doctor Dome, as well as Doctor Banfield in Los Angeles, and we'll be reporting on our experience 24 patients thus far. 22 patients were able to be done endoscopically. In our experience, four patients had extravasation. Two patients had significant labial swelling which resolved. And those patients were quite relieved. Again, that is a reasonable thing to consider. And I think thus far it's best reserved for the acute partial ruptures. I think a big full thickness retracted tendon in a big, strong muscular patient probably not best approached endoscopic. It makes me a little nervous having to go down to far distal and hunt for the stump. I think it's better approached in an open fashion for the for the big tears. But for these little partial ones, or particularly in the in the chronic tendinopathy cases, I think it's reasonable as long as you know your anatomy, respect, protect the sciatic nerve, and don't be afraid to convert to an open procedure if things aren't going your way.

Filiep Bataillie, MD, (Herentals,Belgium) discusses the endoscopic treatment of proximal hamstring tendon tearsand gives an overview and describes the advantages of an endoscopic approach.Dr. Bataillie highlights pertinent anatomical landmarks and neurovascularstructures to consider when performing these repairs. Dr. Bataillie describeshis technique by utilizing Arthrex Corkscrew® Suture Anchors andBirdBeak® Suture Passers.

Proximal Hamstring Reconstruction

I will talk about the endoscopy. In the fourth compartment. We have the central compartment in the hip, the the peripheral compartment, and then the third compartment containing the work that the previous speaker was talking about. But for me around the issue is the fourth compartment and what we had to know. We want to look to the origin of the hamstrings. And there are two things we should remember. The semimembranosus is on the lateral side, upper lateral and lower medial is the conjoint tendon, the tendon of the semitendinosus and the bishops. And of course there are some nerves. There are some dangerous work. The important now is that we know is the sciatic nerve, the posterior femoral cutaneous nerve. The inferior gluteal nerve is higher up, and the pudendal nerve is not really in danger when we are looking in this compartment. This is a cadaver work I did. I did a reflection of the gluteus Maximus. This is This is the the sciatic nerve. And the first thing I showed was the posterior cutaneous nerve. This is the what I show now is the inferior gluteal nerve and artery who is really under the gluteus Maximus. And it is this structure who is in danger when we do open surgery, because this is the place where you put the retractor in and you try to lift up the gluteus Maximus. This is the semimembranosus with the split between the semimembranosus and the conjoint tendon and the conjoint tendon, like as I said on the medial part of the of the ischium, when we do the operation, I do it prone with the leg free drape it, and the landmarks we take is also the greater trochanter, the inferior part of the gluteus Maximus. And the most important, the tuber is the and we take for 3 to 4 portals. Sometimes even two can be the most important. One is the inferior one. We start with the inferior portal and then we take the lateral portal. The lateral portal is just just on the sciatic nerve. And then we have the medial part. And for suturing of the hamstrings of rupture we need also a superior portal. This is what we see is we start visualizing always the first the posterior femoral cutaneous nerve, then the sciatic nerve. And then we go on with the work on the ischium. So the advantages of doing an endoscopic work in this forward compartment is that we have a very nice view. Without the difficulty of elevating the gluteus Maximus, there is less danger for the inferior gluteal nerve. And we had a nurse we want to see always under endoscopic NanoScopic control. What is a pathology that we can address in this region? There are the tears of the hamstrings, the partial or the complete tears, or the chronic tears or the tendinopathy. And also there is something described as a bursitis. And for me it is a partial tear of the hamstrings from the ischium and then a bit newer the issue femoral impingement. What is the hamstring? Tendinopathy. It's an overused injury. Most of the part is a previous hamstring strain and there is some fibrosis. And I think this point the fibrosis is the most important thing because this is who provokes the symptoms. It gives the irritation of the sciatic nerve. And what we do during the surgery is also the release of the sciatic nerve. And this is, I think, the most important part of the surgery and the the clinical symptoms are gluteal pain. Most of during sports, during stretches, stretching and also during prolonged sitting, and they have some pain radiating to the popliteal fossa or to the lower leg. What is ischiofemoral impingement? Well, it's an impingement between the these structures, the quadratus femoris muscle, the lesser trochanter, the sciatic nerve and the ischium. And the causes can be positional by rotational flexion, extension, abduction, abduction, or even a congenital or even there are acquired after fractures, after an osteotomy, osteoarthritis, or even, in this case, with an osteochondroma. The clinical presentation of the issue of femoral impingement is quite similar to the hamstring tendinopathy. It is also a chronic pain. Most of the parts in the buttock, it's radiating to the lower leg. And there is no really specific clinical test to find out The the the technical investigation we do is an Mr.. The treatment for ischiofemoral impingement is who is described in literature is infiltrations and or if it's operative, it's a resection of the lesser trochanter. The first one who described ischiofemoral impingement is Johnson, in some cases all after a total hip. Who is who was an impingement of the lesser trochanter to the ischium. And Marc Safran has described a nice paper this year in arthroscopic surgery, who did an arthroscopic resection of the lesser trochanter. This case is a female water skiing, as he had an accident three months ago. On the left we see the the tuners, the femoral cutaneous nerve and the sciatic nerve. Now I go, go. This is the quadratus femoris we see. Now I go to to see the the rupture in the hamstrings, I do a small release. I immediately fall in a like a compartment. There I see the semimembranosus who is ruptured from the ischium, and I tried to to look in that that space like a seroma. And there you see that you can have a very nice view. And when I was looking more down, I saw the semimembranosus for far away. Too far to be possible. There you see them all down, and it was too far away to be possible to do a suturing. The second case is a female 55. There was no accident. Also the pain while sitting since more than one year, and she had clearly a bursitis or fluid against the ischium. Right. More than left. And we operated the right side. This is how she is on the table in the prone position. As I said, I start with the inferior portal. And then we go to the this. We go strictly to the ischium. And then with the RF probe we try to release, we go to the the nerves. This is the sciatic nerve that you can do a clear and nice release from the ischium. And I do the split between the semimembranosus and the conjoint tendon. And when I. When I look and I lift up the semimembranosus, I see all the space with the with. Described as a bursitis of the ischium. So what I want to do is to reattach the the. Semimembranosus against the ischium. I take away all the all the soft tissue. I make the bone bleeding. And then I put two Corkscrew anchors to suture the semimembranosus. Against against the ischium. Remember that in these cases, the proximal part of the semimembranosus is still intact. And what it makes easier to do this work Endoscopically. So we put a. In this case we did it with a the Corkscrew anchor. We go, we put a wire through the semimembranosus. And we do the suturing. We can suture. The. The tendon. Nice. Against. Against the. Ischium. I think that's it okay.

Proximal Hamstring Repair

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