Greetings, from Rochester, New York. This is Brian Giordano and I'm very pleased at the opportunity to be able to present for the Orthopedic Learning Center on Merging Techniques in Hip Arthroscopy, Innovations and Controversy. I'm going to be presenting for a few minutes on open proximal hamstring repair as a debate point counterpoint supporting the role and rationale for open proximal hamstring repair. Proximal hamstring tears are largely considered the water skier's injury, or in this case the 40-year-old dad sprinting against an 18-year-old at his kid's soccer game injury. This actually is my brother who I promised I would not share this video. Let's watch it one more time just for entertainment value. He's third from the right, charging ahead, giving it his best when all of a sudden, sniper attack out of the sky. These injuries obviously can be quite devastating. They can lead to a significant amount of functional impairment. Historically, the injuries are treated non-operatively and in some cases, because the sheath may stay intact, there's an excellent biologic milieu for healing. Some patients have better coping and compensating strategies. The robust healing response can actually, in some cases, best case scenario lead to an equivalent outcome to a repair. While these equivalent outcomes may largely be seen in older populations, this certainly is possible in many cases. Here we see the typical radiographic picture of an acute three-tendon proximal hamstring rupture with acute surrounding seroma, complete detachment. This particular tear was more of a muscle tendon injury tear, but understandably, these injuries can lead to significant consequences if not treated appropriately. Unfortunately, the worst case scenario, we've all often seen this in both acute and chronic cases when treated injudiciously, including hamstring syndrome, ischiofemoral impingement syndrome, ischial tunnel syndrome. Some of the more extreme cases seen here on the right, sequela of proximal hamstring rupture with ischial avulsion in younger populations, but these can lead to chronic sitting pain, weakness, sciatic neural tension symptoms, sciatic neuritis, and athletic dysfunction. At this point in the last 10 to 20 years, we have a multitude of studies reporting favorable outcomes in isolation as a clinical case series cohort or direct comparative trials. We've seen improved strength and endurance over non-operative care, low risk of re-rupture, improved functional outcomes favoring operative over non-operative treatment with a high rate of return to athletic performance in the operatively treated group. Contrast that with outcomes demonstrating poor return to sport up to 50 to 60% in some non-operative series, a very high rate of patient satisfaction in the surgically treated group, and injuries of both the acute and chronic variety treated surgically, both with primary repair and L-graft augmentation can lead to excellent patient-reported outcomes as well. The question is not do surgically repaired hamstring tendons lead to a favorable outcome or are they more favorable or superior to non-operative treatments, but technically how should these be done? Nowadays, like many things, we've seen an evolution in the available techniques, the options in the implants, the versatility of our surgical equipment and our resources. We have the ability now to repair these tears, partial thickness, full thickness, generally indication being small partial thickness or minimally retracted full thickness type tears treated endoscopically. These images, courtesy of Mike Gerhart, showing a quite cosmetic approach with excellent anatomic repair and quite favorable patient outcomes clinically with normalization of gait parameters. These outcomes have borne out in the peer-reviewed literature, not just as small case reports and case series now, but larger case series, all demonstrating longevity and excellent outcomes. However, it's still clear that certain scenarios obviously favor an open approach over an endoscopic approach, specifically conditions such as severe ischial femoral impingement or ischial tunnel syndrome. This was a case that we treated with significant heterotopic bone formation, bony overgrowth of the ischium in a young athletic patient. We used a T-shaped incision to access proximally and distally, isolating and protecting the sciatic nerve. Many of these hamstring repair images are deep hole and very little anatomic visualization, but kind of a boomerang-shaped fragment of bone being excised. And fortunately, in this case, we were able to excavate this bone from intact tendon tissue, which was capable of being repaired primarily. In addition, some of the more chronic tears, retracted tears, poor tissue quality requiring graft augmentation, more of an extensile approach required. Open approach is clearly favorable to an endoscopic approach. In our hands, in many hands, the open repair technique consists of a prone-positioned patient on a table, broken at the waist or flexed. We use a relatively small incision, three to five centimeters in the subgluteal region in the gluteal crease. We're able to carefully expose and protect the posterior femoral cutaneous nerve. The interior border of the gluteus maximus is identified and retracted superior and superlaterally. Sciatic nerve, in cases of primary non-retracted tears, no sciatic neuritis. We simply palpate the nerve and are aware of its position. In more chronic cases where significant sciatic neuritis or sciatic nerve entrapment is present, we make sure to fully expose the nerve. After the neuralysis, the proximal hamstring sheath is split. If it's intact, this usually leads to the expression of a large seroma. In chronic cases, sometimes the sheath can be more difficult to identify because of the scar matrix. Once you're in the sheath, you're generally safe, assuming that your retractor placement is judicious and cautious. Retractors are placed within the sheath around the ischial tuberosity. Generally we use three, one proximal, usually a DEVA retractor, and then two, one medially and one laterally to get full exposure of the ischium and to climb up as proximally as we can in the lateral facet of the ischium. Simple ischial bursectomy is completed with rangers or debridement devices. And then bone preparation of the lateral facet, either a rasp, drilling, or shingling with osteotomes. Obviously, footprint anatomy is exceedingly critical to a successful anatomic repair. Also knowing where you are regionally and a complete restoration of the anatomic footprint with a nice broad tendon to bone interface. This is an excellent and elegant study performed by Dr. LaPrade and Philippon demonstrating the footprint anatomy. I would encourage everybody to take a look at that and familiarize yourself. Obviously, we're seeing the close proximity of the sciatic nerve laterally. We're seeing the twisting of the conjoint tendon and semimembranosus and having an awareness of the individual differential attachment of these structures is important for our bone preparation and our anchor placement. The last few years has largely focused on technical aspects of both open and endoscopic repairs, suture anchor configurations, number of anchors, type of anchors, knotless, knotted, a variety of different options for suture and anchor configurations, metal, all suture, as I said, knotted and knotless, and partial thickness techniques. Partial thickness technique being essentially the same as a full thickness technique, smaller incision likely with exploration. Usually when you're down on these, the tendon largely looks intact until you split the tendon sheath, elevate the tendon away from bone, which reveals some kind of a grizzle or a fibrous, avascular network of tissue, which then is debrided, footprint is prepared, and the tendon is re-approximated with suture anchors depending on the extent of the damage. We like many use knee immobilizer locked in variable degrees of flexion depending on the tension and the degree of strain on the repair. We protect that for about four to six weeks with foot flat touchdown weight bearing, early supervised range of motion to promote muscle recruitment, myofascial therapies, range of motion, light isometric strength. We're able to remove the brace generally in about four to six weeks once range of motion at the knee and hip are normalized, and the patient's able to complete full weight bearing without the aid of crutches. Closed kinetic chain strengthening commences at about six weeks, and then an athletic progression usually begins at about three months. We now have a number of series looking at pull-out strength, biomechanical properties, material properties of the various repair constructs. Mike Gerhart's group has shown us that knotless repair is actually superior to knotted repair, normalizing the parameters of pull-out strength to a normal condition. We're seeing higher load to failure with an all-suture repair construct versus the traditional titanium corkscrew-type anchor constructs. Former series looking at two small versus two large or five small anchors have shown that the five-anchor repair is superior and normalizes pull-out strength and biomechanical loading properties in comparison with some of the other repair constructs. So there's a variety of excellent options in terms of the technical aspects of the security of the repair, and I would encourage everybody to make their own choices based on their technical preference and surgical preference as to which repair construct is right for them. Nonetheless, in terms of surgical morbidity, invasiveness, cosmesis, a subgluteal incision is essentially invisible by about two to three months post-operatively, standard ecchymosis at a week. And by three months, we're seeing essentially normalization and excellent contour of the gluteal crease. And these are Mike's images as well, so nowhere is cosmetic optimization better than the Southern California area, so his images are a little prettier than most. But the cosmesis of the scar is quite unnoticeable, and compare that to an endoscopic approach where you're essentially treating a small incision for three little poke holes. But really in reality, there's not a lot comparing endoscopic to open approaches. Here, we can derive some information secondarily from the series that includes both techniques. And in those series, we see no benefit in terms of clinical outcomes of endoscopic repair versus open repair in some of these large series. Of note, the tears repaired endoscopically that have been reported are largely small partial thickness or non-retracted tears. So we may be comparing two different types of apples here, but biomechanically, we're also in studies recently demonstrated in the last few years, we're not seeing a lot of difference biomechanically in the repair properties, the pull-out strength, the material properties between each approach. So I think either has extremely favorable and promising hope for the future and normalization of patient function, athletic participation, and all the parameters that we're seeking in our outcomes. And really, you know, when you look at the complication profile, it kind of depends on what you're looking at and what you're calling a complication. But really, in the open repair groups, you know, the risk of major complications is quite low, including re-rupture, thromboembolic event, major sciatic nerve injury. You know, the total gamut of complications may run up to the 23% range in some series. We're looking at posterior thigh numbness. And then things like sitting pain are quite common after repair, and they're quite common after non-surgical treatment as well. Of the sciatic nerve-related complications, you know, true motor weakness that is permanent is exceedingly rare. But sciatic neuritis, pain derived from sciatic nerve, tension, temporary numbness, these kind of things can happen. With the endoscopic repair group, we're also seeing some similar symptoms, posterior thigh numbness, with one of the bigger complications being fluid extravasation in some series up to 15%, with a conversion to open surgery around 7%. Persistent sitting pain, though, tends to be lower, which may portend a more favorable outcome in some aspects for an endoscopic approach. But all things considered, you know, I enjoy endoscopic and arthroscopic procedures. The technical exercise of it and the challenge, certainly fun to do. But in my hand, still, an open approach is advocated. I think it offers more versatility and diversity because of the spectrum of injuries that we see. It's quite reproducible. And, you know, the long-term outcomes are, you know, right now favorable. It's essentially the standard of care still in many practices. The complication rate is quite acceptable. And the biomechanical repair properties, when performed successfully and in the right conditions, normalize the native state. You're able to carefully expose and identify the posterior femoral cutaneous and sciatic nerves, minimizing soft tissue swelling. The incision, as you've seen, is cosmetic. We have the extensile approach, if needed, and as I said, it's quite versatile. So there's my pitch for an open approach for proximal hamstring injuries. And I appreciate the time to be able to present to you. Everyone stay well and healthy. Have a nice day.

hip arthroscopy

proximal hamstring repair

surgical repair

anatomical repair

open approach