Endoscopic Proximal Hamstring Tendon Repair for Nonretracted Tears: An Anatomic Approach and Repair Technique

Abstract

Proximal hamstring injuries are common, and open surgical repair with suture anchors has been the gold standard when surgical intervention is warranted. Endoscopic techniques offer the opportunity of surgical repair with smaller incisions to limit complications and expedite rehabilitation. The purpose of this technique guide is to describe a modified endoscopic technique that allows a safe and anatomic repair of proximal hamstring injuries. The patient is positioned prone with the feet at the head of the bed, table in reverse Trendelenburg, and knees flexed to 90°. Four portals are used, 3 in horizontal alignment within the gluteal fold and 1 directly superior to the ischial tuberosity. The sciatic nerve is identified, dissected, and mobilized away from the operative field. Retraction sutures help retract the gluteus maximus and further protect the sciatic nerve. Dissection is within the interval between the conjoint and semimembranosus tendons. The tendons are freed and mobilized, the ischial tuberosity is decorticated, and an anatomic repair is performed via 4 suture anchors, 2 at each tendon footprint. Advancements in arthroscopy have permitted adequate visualization and exposure of the hamstring footprint, thus allowing for an anatomic repair with increased protection of the sciatic nerve and decreased resources and cost.

Figure 1

Clinical photograph showing patient positioning. The patient is positioned prone on a standard operating room table. The bed is then flexed at both points to flex the torso and the knees. The knees are bent close to 90° to decrease tension on the sciatic nerve and hamstring. The bed is then placed in reverse Trendelenburg to level the spine in relation to the floor. The operative foot is left out of the sterile field and free. A paddle is placed on the lateral side of the operative leg at about midcalf level to protect the leg. The contralateral leg is secured with a safety strap. The gluteal cleft is protected with Ioban dressing, and the sterile field is draped out from the lumbar spine to the distal thigh ∼2-3 cm above the knee.

Figure 2

Clinical photograph showing landmarks and portal placement. The ischial tuberosity and gluteal fold are palpated and drawn, as well as the anticipated corresponding locations of the hamstring tendon and sciatic nerve. Four portals are used, 3 in horizontal alignment within the gluteal fold and 1 directly superior to the ischial tuberosity. The accessory distal (AD) portal is established first as the primary working portal and the accessory proximal (AP) portal second as the primary viewing portal. The posteromedial (PM) and posterolateral (PL) portals are created in horizontal alignment with the AD portal at the level of the gluteal crease.

Figure 3

Exposure. Endoscopic visualization of a right hamstring repair through the posterolateral portal with the patient positioned prone. (A) The hamstring insertion at the ischial tuberosity and sciatic nerve more laterally are identified. The sciatic nerve is probed and gently mobilized away from the operative field. (B) The proximal hamstring insertion is examined, and the interval between the conjoint and semimembranosus tendon is probed. Mobility of the tendons indicates a tear and can assist in the diagnosis and severity assessment. (C) Blunt dissection with a switching stick or probe and radiofrequency ablation are used to develop the interval between the hamstring origin at the ischial tuberosity and the sciatic nerve. Radiofrequency ablation is also used to clear adhesions and fatty tissue surrounding the sciatic nerve and proximal hamstring origin. (D) Once the sciatic nerve is identified and dissected with good mobilization, the nerve is mobilized to allow access for a safe tendon repair. The switching stick placed in the accessory distal (AD) portal is used to carefully retract the nerve laterally and anteriorly, away from the surgical field. CT, conjoint tendon; H, hamstring; SMT, semimembranosus tendon; SN, sciatic nerve.

Figure 4

Retraction sutures and tuberosity preparation. Endoscopic visualization of a right hamstring repair through the posterolateral portal with the patient positioned prone. (A) Once the sciatic nerve is adequately mobile, retraction sutures are placed. A nonabsorbable suture is looped at its midpoint, and the looped end is inserted through the accessory distal (AD) portal and retrieved from the posterolateral (PL) portal as shown in the figure. Outside the body, the nonlooped end is inserted through the retrieved looped end in a cinch fashion and pulled taut at the skin level to retract tissue. These steps are repeated from the AD to accessory proximal (AP) portal. This creates 2 retraction sutures: 1 from the AD to PL portal and 1 from the AD to AP portal, helping retract the gluteus maximus and protect the exposure. (B) The tear is accessed through the conjoint tendon and semimembranosus interval to facilitate repair of the entire footprint. (C) Using radiofrequency ablation, dissection is carried down to the ischial tuberosity in the interval between the conjoint and semimembranosus tendons, and the footprint is detached in its entirety. (D) An endoscopic burr is used to carefully decorticate the ischial tuberosity to promote healing. CT, conjoint tendon; H, hamstring; IT, ischial tuberosity; SMT, semimembranosus tendon; SN, sciatic nerve.

Figure 5

Anchor placement and suture repair. Endoscopic visualization of a right hamstring repair through the posterolateral portal with the patient positioned prone. (A) The first suture anchor is placed. The red outline represents the conjoint tendon footprint, and the blue outline represents the semimembranosus tendon footprint. The X’s indicate the target suture anchor placement. (B) The semimembranosus tendon is reflected back to its footprint, confirming proper anchor placement for anatomic repair. (C) Additional anchors are placed for a total of 4: 2 at the footprint of the conjoint tendon and 2 at the footprint of the semimembranosus tendon. A double row configuration is created. After placement of the anchors, the tendon is reduced, and a Slingshot (Stryker) suture passer is placed from outside in. A horizontal mattress configuration is created for each suture. Once all sutures have been passed, the knots are tied arthroscopically through a transport cannula. (D) The final repair is visualized with anatomic restoration of both the conjoint and semimembranosus tendons to the ischial tuberosity. CT, conjoint tendon; CT_O, conjoint tendon origin; IT, ischial tuberosity; SMT, semimembranosus tendon; SMT_O, semimembranosus tendon origin; SN, sciatic nerve.