Allograft versus Autograft

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Hamstring Avulsions: What should you do?

Jack M. Bert, MD Adjunct Clinical Professor University of Minnesota School of Medicine Minnesota Bone & Joint Specialists, Ltd St. Paul, Minnesota

Disclosures Consultant: Smith & Nephew Exactech Wright Medical Technology Arthrex Sanofi Exscribe Associations & Editorial Boards: Editorial Board, Orthopedics Today BOD Retired NFL Player’s Association Executive Advisor, AANA

When should you operate distally? • Distal attachment of biceps most commonly injured with varus hyperextension • Isolated distal semitendinosus avulsion is more common than semimembranosus • Nonoperative failure common, up to 42% in elite athletes…ave. recovery is 12.8 weeks Schilders et al, Knee,2006 Sekhon, J Knee Surg., 2007 Kusma et al, Arch Orthop Traum Surg, 2007 Cooper, AJSM, 2010 McGoldrick, Arch Orthop Trauma Surg,1990

When should you operate proximally? • Surgical indications for proximal hamstring injuries include those involving 2 tendons with ≥ 2 cm of retraction and 3-tendon tears. • Nonop reserved for 1 or 2 tendon ruptures with < 2 cm of retraction • Identification and treatment of surgical proximal hamstring injuries are best managed within 4 weeks. Cohen et al. AJSM, 2012 Cohen & Bradley, JAAOS, 2007

Results of proximal repair • 94% of the 31 patients were satisfied with their results after surgery but only 58% of the 31 patients had returned to their preinjury activity level.

Skaara et al, AJSM, 2013

Physical Exam

• Antalgic gait • Difficulty sitting on affected side • Evaluate in prone position

• Posterior thigh ecchymosis – • Can be delayed 3-5 days • May extend to foot • Tender to palpation proximal thigh/ischial tuberosity • Possible sciatic nerve irritation • Tinel’s type of symptoms with palpation

Physical Exam • Provocative testing • Hamstring resistance test • Assess peroneal nerve (neuropraxia) • Palpate for popeye deformity

Diagnosis - Imaging • Radiographs • US • MRI

Nonoperative Treatment • Historically most common treatment and recent trend toward more aggressive surgical treatment since up to 42% unable to return to sports • Most tears will heal but retear common • Risks of nonoperative treatment w tendon retraction causes weakness and cramping – esp. in athletes • Sciatic nerve adhesions can cause radiculitis Sally, AJSM, 1996

Open Surgical Technique • Prone position • Transverse incision gluteal crease inferior to ischial tuberosity • Or vertical incision (for chronic) at the proximal hamstring

Surgical Technique • Retract gluteus •

•

maximus proximally Identify sciatic nerve – may require nerve stimulator Identify posterior femoral cutaneous nerve

• Mobilize

Surgical Technique

hamstring tendon • Identify ischial tuberosity and clear of soft tissue • Avoid sharp retractors to prevent iatrogenic injury to sciatic nerve

Surgical Technique • Insert 1 or 2 double or triple loaded corkscrew anchors

Surgical Technique • Place one limb of each suture through the tendon and tie it down

Surgical Technique • Reapproximate tendon w knee at 45 degrees of flexion • Ensure can extend knee to 10 degrees of flexion

Endoscopic Repair • May be used in acute tear setting • • • • •

Absence of extensive retraction and scarring Allows evaluation of partial thickness tears Minimally invasive Learning curve Requires endoscopic anatomic orientation to avoid iatrogenic neurovascular injury • Increased operative time may lead to swelling and decreased visualization

Endoscopic Repair

Postoperative Rehab • Hinged knee brace locked at 30 degrees of flexion for 6 weeks • Toe-touch WB with crutches • Begin PT at 2 weeks post op • PROM of hip at 2 weeks postop • Active hip flexion at 4 weeks postop • Core strengthening at 4 weeks postop • Isotonic hamstring strengthen at 6 weeks postop • Isokinetic hamstring strengthen at 8 weeks postop

Postoperative Rehab • Jogging permitted at 3 months postop • Begin return to sport exercises at 4 months postop • Return to sport at 4-6 months • Assess hamstring to quadriceps ratio • Need 50-60% • Assess strength of injured limb • Need at least 90% of contralateral limb

Thank You