A combined endoscopic and open surgical approach for chronic retracted proximal hamstring avulsion

Abstract

Proximal hamstring avulsion is an uncommon injury which usually requires surgical intervention. When possible, primary surgical fixation is recommended. In chronic hamstring avulsion with significant retraction of the tendon, hamstring reconstructions using an autograft or allograft are required in order to bridge the gap. This is mainly performed using an open surgical technique. We describe a combined endoscopic and open surgical approach to hamstring reconstruction surgery.

Reconstruction of Chronic Proximal Hamstring Tear: Description of a Surgical Technique

“… 10 , 11 These chronic ruptures present a more challenging operation, as the tendon is often significantly retracted. 9 Outcomes for return to sport and activities of daily living tend to be better with acute repair within 6 weeks of injury; however, overall patient satisfaction is still comparable with delayed repair and reconstruction. In addition, patients who undergo surgical reconstruction after chronic injuries have a greater incidence of return to sport and preinjury functional status compared with nonoperatively managed patients.…”

“…Previously, multiple surgical approaches and techniques have been reported. Atzmon et al 9 described a combined endoscopic and open approach to allograft reconstruction involving endoscopic preparation of the ischial tuberosity proximally with open preparation of the retracted stump and Achilles tendon allograft bridging. They advised that while an endoscopic approach requires a smaller incision with reduced soft tissue undermining, it is technically difficult.…”

“…The knee was positioned in 90 flexion for fixation to the ischial tuberosity, which was accomplished using 2 suture anchors. Others have similarly used only 2 to 3 suture anchors for attachment to the tuberosity such as in the previously cited series by Klingele and Sallay, Ebert, as well as Atzmon et al 9,13,14 However, as described in a study by Moatshe et al, 17 the use of 5 anchors is biomechanically stronger and more similar to native hamstring tendon strength. While this technique was used in repair of acute injuries, the use of 5 suture anchors may improve strength of chronic reconstructions as well.…”

“…Surgical management is generally recommended for proximal hamstring avulsions involving all 3 tendons, 2 tendon avulsions with >2-cm retraction, displaced bony avulsions, and patients with resulting chronic pain and functional impairment. 2 , 9 This is most easily accomplished acutely after injury as a direct or primary repair. However, many patients still have a delayed presentation either secondary to missed diagnosis or an initial trial of nonoperative management.…”

Outcomes of Open and Endoscopic Repairs of Chronic Partial- and Full-Thickness Proximal Hamstring Tendon Tears: A Multicenter Study With Minimum 2-Year Follow-up

“…The open technique was regularly performed and has been the mainstay for hamstring tears recalcitrant to nonoperative management on account of its ability to fully expose the bony footprint, especially in chronic cases where tendon retraction, tendon scarring, and sciatic nerve scarring make repair more difficult. 2 Nevertheless, given the proximity of the incision to the perineal region, superficial and deep wound infections are a concern. 40 Dierckman and Guanche 14 noted that the management of these injuries and morbidities associated with the open approach are much improved with an endoscopic repair.…”