Well, I'm sorry that we couldn't do this in person, but I look forward to the next time we can, and I'll be participating in giving the pro-endoscopic proximal hamstring repair viewpoint. Here are my disclosures. So I always like to start talks about the hamstring by making sure we understand what we're talking about across that full spectrum of pathology, and that ranges from our tendinopathies to more severe tendinopathies and advancement of that into what really is a chronic partial thickness tear. Or if you always say, if you turn it on the side, it looks a lot like a rotator cuff tear. You then, these, an acute exacerbation of a chronic partial thickness tear often looks like this, where you have a full thickness tear then with minimal retraction, and then of course you have the classic full thickness retracted acute tears and the full thickness retracted chronic tears. So in general, the operative indications for either endoscopic or open include greater than two centimeters of retraction, high demand patient, early post-acute injury, as I often say that the primary indication to repair an acute hamstring tear is to prevent a late hamstring repair, and then signs of cramping. So cramping is due to that shortened muscle, and that with the hamstring is particularly painful, so that's a good indication and something that should resolve by getting that hamstring out to length. Where do I use endoscopic repair? So again, across the spectrum, I primarily use it for the occasional tendinopathies. It's rare that those need surgery, but in the event they do that, that's an indication for endoscopic approach. The chronic partial thickness tears, I do all of those endoscopic. I do the majority of my full thickness minimally retracted tears endoscopically as well, and then occasionally we'll use an endoscopic assisted approach for some of the more significant tears. In open repair, we'll use primarily for those acute full thickness retracted tears as well as the chronic tears, and then we utilize a graft for really any retracted chronic tear. Here's a technical video of how we do the endoscopic repair. I think once you see that, you'll understand the advantages and why we utilize it the way that we do. We start in the prone position and carefully drape off the perineum. Utilize typically anywhere from four to five portals, and putting as many of those as possible in the gluteal crease. We start the case with a careful exposure with utilizing primarily blood dissection in line with the sciatic nerve in the two middle portals there. Here we are about two minutes into the case where we were able to open up the space pretty quickly. This is a pretty typical and reliable access. I'll typically stimulate the nerve a bit to ensure it is responsive, and then we'll have one of our assistants hold the foot during this phase of dissection. There I'm poking on and showing the tendon that is detached from underneath those footprint. We'll then carefully open up any of these bands that surround the sciatic nerve, and this allows us to access fully the anterior aspect of the ischium and the semimembranous footprint. We also see both the sciatic nerve and the posterior femoral cutaneous branch there in that view. I think the senescope approach allows you to protect that well. We utilize a gluteus maximus retraction stitch, one to two of these. Again, as we get into the repair, I wanted to show the anatomy again. Remember there are two distinct tendons at the proximal junction here, the semimembranosus and the conjoined tendon. They have a clear interval here, and you'll see here we're identifying that just distal to the ischium in the fatty interval, and we track that up along the distinction of the two tendons. You can see as we press on here, you can see they'll distinguish themselves, and then we carefully continue the dissection through this interval down to the detached footprint underneath. You can see as we move here, you can see the tendon is detached underneath, confirming the pathology, and as we lift it up, further confirming that. Typically, you will notice the traditional osteophytes consistent with degenerative tendinosis in these types of cases. MRI is definitely very helpful here to understand the extent and location of the degeneration so that you don't open up or access a portion that may still be attached unless it needs to be repaired. So at this point, we're ready for the repair. We've got the nerve retracted there through one of our other portals. This point, we pursue typical tendon repair techniques. I typically utilize anywhere from three to four all suture anchors, depending on the bone quality, two in the semimembranosus footprint and two in the conjoined tendon footprint. We'll pass some of those in a mattress fashion and some of those through in a bridge fashion to close the interval. There's the completed repair, a nice anatomic repair that restores the interval and repairs each of the tendons anatomically. We then release the retraction of the sciatic nerve and identify that and confirm that it is also safe throughout the remainder of the procedure. We recently assessed our outcomes in a minimum two-year follow-up. This is a cohort of 30 patients, mixed types of injuries with half of them being chronic tendinopathies and then half being acute minimally retracted full thickness tears. The mean postoperative IHOP 12 was 82 points and 80% of the patients who achieved the pass as defined, at least for FAI, as of 63, has not yet been defined for endoscopic hamstring repair. 63% were able to return to their pre-injury baseline activity level and 7% had a re-rupturing. These were both in patients near age 70. So the last thing I wanted to finish up with, going over some of the factors that favor each of the techniques. So if the location of the tendon is a big part of this, if the location of the tendon is near the ischium and under the gluteus maximus, it can be harder to get to and access open and that, for me, would favor the endoscopic approach. If it's below the gluteus maximus, they will, at a minimum, do an endoscopic-assisted approach. Patient size, for larger patients that were, again, you'll see we favor endoscopic repair where the open technique is more difficult. So for larger patients, it's actually easier to work endoscopically. Smaller patients can sometimes be simpler to work open. You can access that ischium in the tendon easily as well as protecting the nerve. And then with the history of acute injury, when there is not a history of acute injury, there's going to be less scar around the nerve and it's easier to get that good view pretty quickly. If there is a history of acute injuries, sometimes that can be where an open sciatic neuralysis is helpful. I have a low threshold to have one of my hand colleagues and peripheral nerve surgeons help with this portion of the case. But again, as far as protection of the sciatic nerve, I have seen fewer superficial nerve you know, posterior femoripotentiasis nerve injuries with the endoscopic approach, lower infection rate. And I think in general, the nerve, it's easier to protect the nerve while doing a comprehensive repair with an endoscopic approach. And lastly, these are my reasons for why I use an endoscopic repair when possible. They have better access, you can perform a better repair, it's safer with regard to infection and injury to posterior femoripotentiasis nerve, and then there's also less muscle injury. And you know, these are all the same reasons we have used over the years for why we perform arthroscopic rotator cuff repair rather than an open rotator cuff repair. And I think as time goes on, it will follow some of the same development and progression where we're doing more and more endoscopic repairs. Thank you.

hamstring injuries

endoscopic repair

operative indications

cohort study

technique demonstration