Proximal Hamstring Repair CPT
Proximal Hamstring Repair Indications
- Acute Complete promimal hamstring avulsion from its ischial origin: MRI demonstrates >2cm retraction. Leads to significant long-term disability and should be repaired acutely.
- Chronic Complete hamstring avulsions: function generally improved with reconstruction. Sciatic nerve neurolysis is typically required. Achilles tendon allograft should be available if direct repair is not possible after mobilization. Achilles bone block is attached to the ischium withan interference screw; the allograft is then suture to the native tissues. (Larson, C)
Proximal Hamstring Repair Contraindications
- Medically unstable patient
- Active infection
Proximal Hamstring Repair Alternatives
Proximal Hamstring Repair Pre-op Planning
- Use a head lamp to improve visualization of the ischial tuberosity, especially for larger patients.
- Average distance from the superior border of the ischium to the inferior border of the gluteus maximus is 6.3 ± 1.3 cm.
- Distance from the inferior gluteal nerve and artery to the inferior border of the gluteus maximus is 5.0 ± 0.8 cm. It is possible to inadvertently cause a traction injury to the nerve or vessel with retractors.
Proximal Hamstring Repair Technique
- Prone position on Wilson spine table with hips flexed slightly. Hip Flexion helps with retraction of the gluteus maximus superiorly improving exposure of the ischium.
Transverse incision made in the gluteal crease. Incision can be extended by performing a longitudinal limb incision extending from the center of the transverse incision.
- Disect through the subcutaneous tissues to the gluteal fascia.
- Transverse incision in the gluteal fascia to expose the inferior border of the gluteus maximus muscle. The gluteus maximus is retracted superiorly.
- Longitudinal incision in the hamstring fascia. Evacuate hematoma or fluid collection.
- Hamstring tendons identified. Divide the posterior fascia of the hamstring compartment.
- Inferior border of the gluteus maximus muscle mobilized and retracted superiorly
- Identifying the sciatic nerve to avoid injury. Sciatic nerve lies 1.2 ± 0.2 cm lateral to the most lateral aspect of the ischial tuberosity. For chronic injury, the sciatic nerve often is scarred into the hamstring tendons. Identified the nerve distally where it appears to be normal and then proceed proximally.
- Avulsed ends of the tendons are identified. Ends are débrided and freshened
- Ischial tuberosity exposed by removing any residual soft tissue with cautery, and the bone is freshened with use of a curette or periosteal elevator.
- Suture anchors are placed at the common site of origin of the semitendinosus and biceps femoris on the ischium, lying medial to the origin of the semimembranosus. Generally use 2-3 anchors.
- One end of the suture is used to place a running locking stitch from proximal to distal and then from distal to proximal in the tendon.
- Opposite ends of each suture are then used to pull the tendon to the ischium and are tied with the knee flexed to 30°
- Copiously irrigate.
- Fascia is closed.
- Subcutaneous tissues closed.
- Skin is closed with a running subcuticular stitch.
Proximal Hamstring Repair Complications
Proximal Hamstring Repair Follow-up care
- Custom hinged brace that prevents hip flexion.
- Crutches with foot-flat touch-down weight-bearing for two weeks.
- Partial weight-bearing to 25% is permitted at 2 weeks. Weight-bearing is increased weekly with a goal of full weight-bearing by six weeks.
- Six weeks: brace is discontinued, full weight-bearing is allowed, and active range of motion is initiated.
- Passive stretching to restore full range of motion and to further improve hamstring flexibility.
- 3 months: aerobic conditioning begins. Non-impact activity begins such as the use of an elliptical trainer or StairMaster followed by a light jogging program.
- 6 months: when at least 80% of the strength of the uninjured limb my return to sports.
Proximal Hamstring Repair Outcomes
Proximal Hamstring Repair Review References