Greetings from Houston, Texas, this is Joshua Harris and this is a presentation on endoscopic proximal hamstring repair. The patient is positioned prone on a flat top Jackson table with the limb draped free so that a complete range of motion can be performed during surgery. After the limb is prepped and draped, the hip is positioned in a position of 20 degrees of hip flexion, 20 degrees of hip abduction and neutral rotation. A three or four portal approach is frequently used. You have your ischial tuberosity outlined with a dotted line, three gluteal crease portals and one proximal transgluteal suture management portal. Your medial portal is for the arthroscope. The central portal is for your radiofrequency device, your shaver, burr, for suture passage and for knot tying. The lateral portal is for suture anchor placement and the proximal transgluteal portal is for suture management. The arthroscope is initially placed in the medial portal as you can see here. The cannula and interoperator are placed directly onto the ischial tuberosity. The interoperator removed and the arthroscope then inserted. We turn fluid on at this point to open the deep gluteal space and the central portal is then created. A switching stick is inserted through the central portal into the ischial bursa and with gentle blunt dissection, a working space is created. Bursectomy is performed of the ischial bursa. This helps for visualization and also helps for identification of the posterior femoral cutaneous nerve and the sciatic nerve laterally. As we're moving further lateral, multiple adhesions typically are visualized between the proximal hamstring and the neurovascular structures and with continued bursectomy, especially proximal, this will allow visualization of the entire proximal hamstring origin. As you can see here, the sacro tuberous ST ligament is identified proximally and is the proximal extent of the origin. Interlateral dissection allows you to identify the entire course of the posterior femoral cutaneous nerve. There's typically a minimum of one vertical branch that you can see here us doing a neurolysis deep to the posterior femoral cutaneous nerve is where you can identify the sciatic nerve with gentle blunt dissection and short low voltage pulses of your radiofrequency device allows you to identify the neurovascular bundle. This is a lateral structure. As you can see, your proximal hamstring is a central structure. This cruciate leash of vessels attaches between posterior femoral cutaneous branches. And as you can see the sciatic nerve underneath here, since most high grade partial thickness proximal hamstring tears or undersurface tears, you can typically see a wave sign. As you can see here using your radiofrequency device and tendon instability. So you can see a bubble sign in which either air or saline is injected into the undersurface tear and you see the tendon elevate. The tendon is then elevated through a trans tendinous approach, either with an arthroscopic blade or with a radiofrequency device. Once the tendon is incised, you can clearly see the high grade partial thickness near full thickness tear. The tendon is elevated from its medial margin up against the adductor and the soft tissue elevated to expose the tear. Soft tissue is removed off of your ischial tuberosity to expose the bone from the inferior to superior and then from the anterior to posterior margins. Then a high speed burr on a combination of both reverse and forward is used to decorticate the bone for varying degrees of ischioplasty. This will expose the marrow elements for improved biology of healing once suture anchor placement is performed. The soft tissue and bony arthroscopic debris is then evacuated with suction. Your proximal transgluteal portal for suture management is then created next. This is a 6-5 cannula being placed just off the medial margin of your gluteus maximus tendon. This is far below the inferior gluteal nerve course, so this is a safe portal placement. Once the cannula is in the appropriate position, the lateral portal is then utilized for percutaneous suture anchor placement. Straight guides and curved guides of varying sizes can be used. The first anchor placed is typically the most proximal and the most anterior and laterally placed and then anchors are placed sequentially, further inferiorly and medially. This is a straight guide being used with a 2mm diameter guide drilling approximately 21mm of depth. The ischial tuberosity thickness at this location typically is between 25 and 30mm depending on the patient's anatomy. Once your hole is drilled, the anchor is then placed and once the anchor is placed, the security of the anchor will be assessed. This is a double loaded with tape suture anchor and you can see we have about a 3-4mm margin to the anterior aspect of your ischial tuberosity. A variety of different suture passing instruments can be used. Sutures are typically placed proximally to distally in a variety of different suture configurations. This configuration being used for our first pair of suture is with a Mason-Allen construct and you can see the bridge of suture being placed. You must be careful when placing these lateral and anterior sutures for any device and the proximity of the neurovascular bundle and arthroscopic visualization is critical to ensure safety throughout suture passage. You can see the Mason-Allen technique here. This is a separate case showing just how close the PFCN and the sciatic nerve can be with suture management and the surgeon must be very careful to ensure safety with suture passage. Back to our original case. This is a penetrating and grabbing suture management device. Most arthroscopic companies have a similar device to this or a grabbing, penetrating and passing device as you can see here. This is an all soft tissue suture anchor that is double loaded with tape. Bio-composite and bioabsorbable sutures can also be used as alternatives to tape or all suture constructs. A second double loaded anchor is placed inferiorly, however anteriorly on the lateral aspect of the tuberosity. Different colors of sutures are used to make it easier for the surgeon for suture management and subitizing with suture passage, knot tying and suture management. As you can see again, approximately 3-4mm from that lateral anterior margin of the tuberosity. And with each passage of suture, the suture is managed out the proximal transgluteal suture management portal. Side to side sutures can also be used, both horizontal and vertical mattress sutures can also be used. Surgeon preference can indicate the suture anchor type and size, the suture passage technique and the arthroscopic knot tying technique. Once all of your sutures are placed, the sutures are managed out the suture management portal. As you can see here, there's a variety of different techniques that can be used with side to sides, horizontal mattresses, vertical mattresses and Mason-Allen configurations. These photos show a full thickness tear that was retracted approximately 13cm in the proximity of the posterior femoral cutaneous nerve to suture passage and knot tying. Back to our case, arthroscopic knot tying can be performed based on surgeon preference. The technique used here is with a surgeon's knot and reversing half hitches on alternating posts. We begin distally and progress proximally. Once you reach the proximal suture, you can use your suture management portal to tie. Once your repair is complete, the repair construct is assessed for stability and security. It's also critical to check the neurovascular bundle with extension, adduction and external rotation and its proximity to your repair construct, as this can help guide and even sometimes modify the rehabilitation process following surgery.

endoscopic proximal hamstring repair

arthroscopic tools

suture anchors

bursectomy

neurovascular proximity