Fixation of the Proximal Hamstring Tendon Using an All-Suture Tensionable Knotless Technique

Abstract

Proximal hamstring injuries are a common sports and recreational injury among the active patient population. Surgical fixation of the tendons of the hamstring muscle complex, as opposed to conservative treatment alone, has shown improved patient outcomes, prompting the evolution of the suture anchors utilized in these repairs. Previous studies investigating the biomechanical properties of hamstring repair anchors have focused on double-row knotless techniques, in which the fixation of the overall construct relies on each individual anchor to maintain fixation. While these constructs have demonstrated biomechanical strength and clinical durability, each suture anchor represents a potential point of failure for the entire construct due to the crossed stitch anchor configuration. To address this limitation, recent tensionable knotless all-suture anchor designs have been implemented with success due to their smaller size and biomechanical strength. The aim of this technical note is, thus, to describe a technique for proximal hamstring repair using a tensionable knotless all-suture anchor construct that has 5 independent mattress sutures and, in doing so, employs the biomechanical strength of knotless fixation but eliminates the potential single point of failure seen with current knotless suture anchor designs.

Fig 1

Patient is placed into the prone position. A padded roll is placed over the chest. All bony prominences are well padded. The bed is adjusted into a slight jack knife and Trendelenburg position.

Fig 2

The proximal hamstring is isolated, and an Alice clamp is placed over tendon. A simple traction stitch is placed in the proximal tendon. A tenolysis is performed removing all fibrous attachments to the tendon and allowing for full excursion.

Fig 3

(A) Fluoroscopy setup to confirm the location of the hamstring anatomic footprint. (B) Fluoroscopy image demonstrating correct anatomic placement of suture anchors in the proximal hamstring footprint.

Fig 4

Medical illustration of hamstring tendon footprint with anchors.

Fig 5

Image demonstrating anchor placement in the lateral ischium.

Fig 6

A free needle is used to pass both the repair and passing sutures through the proximal hamstring tendon in a mattress fashion.

Fig 7

The repair suture is then shuttled through the tendon and anchor using the looped passing suture. Tension is then applied sequentially starting with proximal limbs and distal limbs to advance the tendon back to its footprint on the ischium.

Fig 8

Image demonstrating the completed proximal hamstring construct.