Epidemiology
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
Xray
May see bony avulsion
MRI
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
https://www.vumedi.com/video/repair-of-chronic-proximal-hamstring-tears/
Patient prone
- knee flexed over sterile gowns
Incision
- longitudinal incision centred on ischial tuberosity
- starting at gluteal crease
- allows identification of sciatic nerve distally
- can do a horizontal incision in the gluteal crease if injury very recent, minimal retraction
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 proximal hamstring tendon
Exposure ischial tuberosity
- use osteotomes to create bleeding if needed
- 2 - 3 5 mm metal anchors, double loaded
- whipstich on one side, then use other suture to slide knot
Post op
- splint with knee flexed
- prevent hip flexion
- crutches
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
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
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
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