Hamstring Reattachment Surgery: A Comprehensive Guide to Recovery and Success

Introduction

Hamstring injuries are among the most common muscle injuries in athletes and active individuals. While most hamstring strains can be treated conservatively, complete proximal hamstring avulsions often require surgical intervention. This comprehensive guide explores hamstring reattachment surgery, its indications, techniques, and outcomes to help you understand this increasingly common procedure.

Understanding Proximal Hamstring Avulsions

Proximal hamstring avulsions occur when the tendons tear away from their attachment point on the ischial tuberosity (sit bone). These injuries typically result from rapid, forceful hip flexion with the knee extended, such as during waterskiing accidents or slips and falls. Aleksi Jokela et al. (2022) note that while most hamstring injuries are mild strains, severe 2- or 3-tendon avulsions often require surgical treatment, especially in athletes.

Indications for Surgical Repair

Not all hamstring injuries require surgery. However, certain criteria indicate when surgical intervention is necessary:

• Complete 3-tendon avulsions
• 2-tendon avulsions with more than 2 cm retraction
• Significant functional impairment
• Athletes or highly active individuals

E Karlsson emphasizes that in patients with 2-tendon tears/ruptures with more than 2 cm retraction or complete 3-tendon tears, surgical fixation should be performed.

Surgical Techniques

Hamstring reattachment surgery has evolved over the years, with both open and endoscopic techniques now available. The primary goal is to reattach the avulsed tendons to the ischial tuberosity.

Open Repair

Traditionally, open repair has been the gold standard. Steven Cohen et al. (2007) describe the procedure:

1. A transverse incision is made in the gluteal crease
2. The sciatic nerve is identified and protected
3. Ruptured tendons are mobilized
4. Tendons are reattached to the ischial tuberosity using suture anchors

Endoscopic Repair

More recently, endoscopic techniques have been developed to minimize invasiveness. Amanda N Fletcher et al. (2020) outline an endoscopic approach using four portals:

• Three portals in horizontal alignment within the gluteal fold
• One portal directly superior to the ischial tuberosity

This technique offers better visualization and potentially reduced complications.

Post-Operative Care and Rehabilitation

Proper rehabilitation is crucial for optimal outcomes. Carl M Askling et al. (2013) describe a postoperative protocol that has been used successfully for over 200 patients:

1. Initial period of protected weight-bearing (usually 6 weeks)
2. Progressive range of motion exercises
3. Gradual strengthening program
4. Return to sport-specific activities (typically 4-6 months post-surgery)

Interestingly, this protocol avoids postoperative bracing, which has shown good results.

Outcomes and Success Rates

Research indicates that hamstring reattachment surgery generally leads to positive outcomes. A J Barnett et al. (2015) reported:

• 90% of patients were satisfied with surgical results at 1 year post-op
• 75% reached their previous activity level
• Mean postoperative hamstring strength was 83% compared to the uninjured side

However, it's important to note that outcomes can vary based on factors such as injury severity, time to surgery, and patient compliance with rehabilitation.

The Importance of Early Intervention

Multiple studies highlight the benefits of early surgical repair. David G Wood et al. (2008) found that delays in surgical repair can:

• Make the repair more technically challenging
• Increase the likelihood of sciatic nerve involvement
• Necessitate more extensive postoperative bracing
• Reduce postoperative outcomes in terms of strength and endurance

Conclusion

Hamstring reattachment surgery has become an effective treatment option for complete proximal hamstring avulsions, particularly in athletes and active individuals. When performed early and followed by appropriate rehabilitation, this procedure can lead to high satisfaction rates and successful return to pre-injury activity levels. As surgical techniques continue to evolve, including the development of less invasive endoscopic approaches, outcomes are likely to improve further. If you suspect a severe hamstring injury, prompt evaluation by a sports medicine specialist is crucial to determine the best course of action and optimize your chances for a full recovery.