Proximal Hamstring Tear

EpidemiologyProximal Hamstring Tear

 

Adolescent apophyseal avulsion

- treat non operatively

- unless displaced > 2 cm

 

Adult

- soft tissue avulsion

 

Aetiology

 

Usually associated with sporting activities

- skiing

- water skiing

 

Violent contraction

- knee extended

- hip flexing

 

Anatomy

 

Biceps / Semimembranosus / Semitendinosus all attach here

 

Symptoms

 

Pain

Unble to run

 

Chronic tears

- may have some neuralgia symptoms

 

Signs

 

Large haematoma / bruise

Palpable defect

Distal retraction of muscle into thigh with contraction

 

Proximal Hamstring Rupture Bruise

 

Xray

 

May see bony avulsion

 

MRI

 

Proximal Hamstring Avulsion MRI CoronalProximal Hamstring Avulsion MRI Axial

 

Management

 

Non operative

 

Results

 

Harris et al Int J Sports Med 2011

- systematic review

- better subjective outcome / return to sport / hamstring strength with repair c.f. non operative

- better outcomes with acute (< 4 weeks) than chronic repair

 

Operative

 

Surgical Technique

 

Patient prone

- knee flexed over sterile gowns

 

Incision

- longitudinal incision centred on ischial tuberosity

- starting at gluteal crease

 

Superficial dissection

- divide fascia in line with incision

- preserve posterior femoral cutaneous nerve

- identify and elevate inferior edge of gluteus maximus

 

Deep dissection

- identify and preserve sciatic nerve (lateral to hamstring)

- identify hamstring tendon

- repair with multiple large suture anchors

- ensure no kinking of sciatic nerve at end of case

 

Hamstring Repair Sciatic NerveHamstring Repair Sciatic Nerve 2

 

Proximal Hamstring Rupture Post Op

 

Post op

- splint with knee flexed

- prevent hip flexion

- crutches

 

Proximal Hamstring Brace

 

Complications

 

Residual weakness (60 - 90% other side)

Neuralgia

 

Chronic > 4 weeks

 

Indication

- patient complains they cannot run

 

More difficult

- careful dissection of sciatic nerve from adhesions

- release hamstring tendon

 

Augment options

- autologous ITB

- allograft

 

Technique

 

Release hamstring

- identify nerve, and use vessiloops

- avoid denervating the muscle, must preserve the nerve branches

- identify the ischial tuberosity

- see if hamstring will reach, sometimes will, but cannot repair under tension

 

Sciatic Nerve ReleaseChronic Hamstring Tear 1Chronic Hamstring Tear 2Chronic Hamstring Tear 3

 

Prepare allograft

- tendo achilles

- 9 x 20 mm bone block

- drill to 10 x 25 mm tunnel using ACL instruments

- ensure that beath pin does not advance

- secure with 7 x 20 mm screw, bone typically very strong

 

Drill hole ischial tuberositySecure allograft bone plug with screwSecure allograft bone plug with screw 2

 

Pulvetaft weave tendon through muscle stump

- through the strongest, thickest part of the stump

- high strength suture tendon to tendon

- can pass again

- tension leg, must be able to reach full extension

- brace for 6 weeks, no sport for 6 months

 

Hamstring Allograft ReconstructionHamstring Allograft ReconstructionPost Proximal Hamstring Reconstruction

 

Results

 

Sarimo et al Am J Sports Med 2008 36

- 41 patients

- 5 chronic requiring achilles allograft

- 96% would have it done again, 80% return to sport

- no difference in strength between acute and chronic

 

Cohen Am J Sports Med 2012

- 52 patients

- 40 acute, 12 chronic

- 98% satisfied

- minimal difference in outcome between acute and chronic

 

Murray KSSTA 2009

- achilles allograft recon of chronic (6 months) rupture

- good outcome