Dr. Andrea Spiker...: Welcome, everyone, to the Arthroscopy Association's Arthroscopy Journal Podcast. I'm Dr. Andrea Spiker from the University of Wisconsin. Today I have the privilege of speaking with Dr. Shane Nho, who was the senior author of the Arthroscopy Techniques paper titled Endoscopic Partial Proximal Hamstring Repair, which was published in the July 2023 edition of Arthroscopy Techniques. Dr. Nho is the head of the Section for Young Adult Hip Surgery and co-director of the Division of Sports Medicine, as well as the Sports Medicine Fellowship, at Rush University Medical Center in Chicago, Illinois. He is also a repeat guest on our podcast. It's great to have you back, Shane.
Dr. Shane Nho: Thanks for having me. It's an honor to be here.
Dr. Andrea Spiker...: Shane, you've been a guest on our podcast before, but for those listeners who haven't yet had the chance to listen to your previous podcast, can you tell us a little bit about yourself and your practice?
Dr. Shane Nho: Sure. I am in Chicago, and I am at Rush University Medical Center, also part of Midwest Orthopaedics at Rush. My practice is largely a hip arthroscopy and hip preservation practice, which is how I stumbled into the hip and hamstring area, actually, which is the subject of our conversation tonight. I think, for those hip arthroscopists out there, the hamstring is in our area of interest, and I think that that's why we end up seeing a lot of hamstrings. Our partners typically refer them to us, and I do think it is a good supplement to a hip and a sports medicine practice.
I think the interesting thing about hamstring is it really allows us to have conversations and interact with our sports medicine colleagues, because hamstring injuries and hamstring tears are kind of ubiquitous in all types of sports. If you're taking care of teams on any level, you're going to see hamstring injuries, whether it's proximal avulsions or mid-substance tears or distal avulsions, or if you're just taking care of patients who like to water-ski, or sometimes patients who have bad slip and falls or work injuries, you'll see hamstring tears. Hopefully, we'll talk about the subject of this article, but we can get into more hamstring and hamstring type injuries that I see, and I'm sure that you see as well.
Dr. Andrea Spiker...: That's a great segue into what we're discussing today, which is your techniques paper on endoscopic partial proximal hamstring repair. In this technique, you present the case of a 52-year-old patient who injured herself in pickleball and sustained a partial-thickness proximal hamstring tear. That leads to the question, what are the typical patient presentations and symptom descriptions you see with partial-thickness proximal hamstring tears versus full-thickness hamstring tears?
Dr. Shane Nho: Yeah, so that's a good question to start. I would say full-thickness hamstring tears are hard to miss. Those are your classic, water-skiing on the lake in Wisconsin or in Illinois or wherever, and someone says that it feels like that they got hit with a baseball bat in the back of their leg. They get acute pain, swelling, bruising. It's really hard to miss. If you're water-skiing, it usually happens as you're trying to get up on the skis while the boat is accelerating, and sometimes, if it's accelerating too quickly as you're trying to eccentrically load those hamstrings, the boat's just always going to win. In that situation, it's pretty straightforward.
The other scenario that we see full-thickness hamstring tears, at least that I see, are usually slip and falls, usually for older patients. Typically, I'll see this in the wintertime when it's icy outside. They'll go out and they'll slip and fall, and they'll tear their hamstring off the... proximal avulsion of the hamstring. This is different than the partial-thickness hamstring tears. I would say that in general the partial tears are more chronic attritional tears. I see a lot of runners that have these.
They just complain of constant buttock pain, feel like their running tolerances decrease, and sometimes they get to the point where they just can't anymore. Then, in this particular case, this is more of a partial tear from a cutting, twisting type injury, created a partial tear, but obviously not a full-thickness tear. I do think that they do present differently, which is why I think you asked a really good question about it, and I think we are seeing more and more of these types of patients. I think we just have to start to think about how to best treat them and how to recognize them and what we need to do to help them.
Dr. Andrea Spiker...: Yeah, I agree, Shane, that was an excellent description. I agree with everything that you said, and I see the same thing in patients that present in my practice. It is interesting, with the complete hamstring tears, how they tend to get better. Patients have extreme pain initially, extreme bruising, and then oftentimes by the time they make it to clinic their symptoms have nearly completely resolved, whereas, you're absolutely right, with the partial tears, they do seem to be chronic; that gnawing, aching, deep pain that they can't quite put their finger on, that just really impacts their lives.
Dr. Shane Nho: Yeah, I agree. As you alluded to, while their clinical symptoms from the full-thickness tears may get better from the dramatic amount of pain, swelling and bruising that they had, I guess I would say that in most cases, a lot of these patients, while they can get back to their daily life activities, when it comes to more athletic type activities, at least I find that they have problems with those. This is obviously outside the topic of our talk, but the chronic tears that we see, the chronic full-thickness tears, are also things that we see in the office as well, and those are always one that are probably the most challenging to treat.
Dr. Andrea Spiker...: Yeah, absolutely. We can perhaps talk a little bit about, when those are encountered, whether the endoscopic techniques that you describe here could be applied to that treatment algorithm as well, but first, can you take us through your indications for surgical intervention for partial-thickness proximal hamstring tear, and what kinds of conservative treatments are you trying first?
Dr. Shane Nho: Yeah, great questions. For me, I would say a partial-thickness tear is one that I would say is less than 2 centimeters. It may involve one, two, or three tendons. I would say noticeable on MRI. I think the MRI to me is usually pretty telling in terms of how significant they are, in terms of how large the tears are and whether or not these might be amenable to surgical repair. In some cases, for example in that runner who is a distance runner and this chronic gnawing pain that just hasn't gone away, and they may get to the point where they're like, "Look, I can't even run anymore, let alone... I used to run marathons. Now it's just, it's done."
In that case, I think it's pretty easy to say, "Hey, look. Clearly these patients have tried conservative management, including therapy and NSAIDs and oftentimes injections, and they just can't get back to running." You get an MRI. You can see a pretty obvious partial-thickness hamstring tear that is clearly where their pain and symptoms are, and I think those patients are a great patient to consider surgical repair. Those patients usually have nothing else wrong with them, in terms of the rest of their hip and pelvis, and that is the only thing that's stopping them.
I think what I've seen is that these runners, they just can't tolerate these partial tears, even though the tears don't seem to be that large on MRI, but for some reason they're large enough that they impair their ability to do these activities. Then, in terms of conservative treatments, I mean, oftentimes, if they have the symptoms, I usually will get an MRI just for prognostication purposes. Typically, we'll undergo a course of physical therapy, anti-inflammatories. I've tried injections in the past, both cortisone and PRP, and I think they work sometimes. Certainly not something that is with any level of predictability, but clearly if they fail all those, then typically we'll offer them endoscopic repair.
Dr. Andrea Spiker...: Speaking of injections, one of the concerns we have with intraarticular injections is potential damage to the intraarticular cartilage. At least in my practice, I tend to be a little bit more liberal with cortisone injections or other injections around the ischial bursa when it's necessary, because I'm not as worried about cartilage, although I do use intraarticular injections as needed, just conservatively, but I've definitely had some responses from radiologists who worry that by injecting around the ischial bursa we're going to cause the tendon to completely tear off of the ischium. What are your thoughts on that? If patients ask you about that, what do you tell them?
Dr. Shane Nho: Yeah, I think those are legitimate concerns. Approach is very similar to either rotator cuff partial-thickness tears or Achilles tendinitis, with partial tears in the Achilles as well. I think in both situations frequent cortisone use might lead to full-thickness tears. That being said, I agree with you; I don't really have a problem trying it, just in the event that it might alleviate their pain and symptoms, especially in the case where their MRI is not that significant, or I should say the tear is not that large, in which case it's hard to make a case to go forward with surgery. I mean, PRP's a good alternative. I think that addresses the concerns of tendon injury or tendon propagation, but also allows for the potential for healing. I haven't had anything predictable in terms of my experience with PRP for hamstring injuries, but I don't have a problem with it. I think it's pretty low yield, at least in my own practice.
Dr. Andrea Spiker...: Yeah, I agree. I think one other thing, with the concern that cortisone might complete a tear and make it full-thickness, I feel that in that case it just makes our treatment pretty obvious. Then the treatment would be to fix it, so it almost helps us in multiple ways, and I agree with you, there's really no big downside to trying it.
Dr. Shane Nho: Yeah, and then the diagnostic component to it too is helpful.
Dr. Andrea Spiker...: Yeah, absolutely. Now, would you ever consider an open takedown and repair instead of an endoscopic for this partial-thickness hamstring tear?
Dr. Shane Nho: Sure. I mean, I used to do the open takedown and repair until I started to migrate to the endoscopic. I would say the endoscopic is easier. I would say it's definitely easier to visualize. I think it's easier to perform. I think it's safer, to be honest, because I think you get a better look at the sciatic nerve. I think for any partial tear, I would say that in my estimation the endoscopic approach is probably, I would argue, better, except in the case where... I mean, sometimes we'll get a single tendon acute avulsion.
In that case, I would say, where it's definitely avulsed with a pretty decent, let's say, greater than 2 centimeter gap between its attachment to the ischium, in that case I think you can do that open, just because typically you'll be able to find that avulsed tendon, whereas in many cases it's hard. I mean, because most of the tendon is still attached, it's hard to know how much to go through. I think in an open situation, the problem with hamstring management in general is just being cautious of the nerve and knowing where the nerve is the whole time. I just find, with the open approach in a chronic attritional tear, it's just harder to see, just because you're really trying to visualize way up into the ischium, and it's not fully torn where you can start passing your sutures outside the wound, so you have to do it almost like in situ, and the nerve gets awfully close. That's my only concern about it.
Dr. Andrea Spiker...: Yeah, absolutely. At this point, can you take us through your endoscopic technique, starting with positioning, portal placement, insertion of the scope and instruments? I should mention here before you start that the video and techniques paper that you published really show this extremely clearly, so I encourage all the listeners to take a look at it online, but if you can do your best here just telling us how you approach this surgically.
Dr. Shane Nho: Sure, love to. Yes, the patient has to undergo general anesthesia. They're placed in a prone position, and we set it up the same way that we do open. It is easy to convert from endoscopic to open. If you're just getting started and you want to try it and see what it's like, you can always convert to open without much of a problem at all. We used to use a Wilson Frame, but we actually went away from that, and now we just use gel padding to just make sure we pad the iliac crest and the anterior chest wall. It also gives you a little bit of flexion at the hips as well to provide better exposure. You can also jackknife the table as well. That can help too.
I would definitely encourage listeners who aren't doing a lot of endoscopic repairs to use fluoroscopy, because sometimes you can get lost, especially when you're starting out, you're just not used to the anatomy and so forth. I typically actually don't even use fluoro at this point, because it's pretty straightforward. If you look at the article, you can see that we've kind of prepped everything out. Then our incision will be just along the gluteal crease, and typically we'll start with that inferomedial portal, which will be pretty much in line with the midpoint of the ischium. You want to make it at the gluteal crease, so in the event that you have to convert to open, you'll just follow the incision and connect your two portals, which will be your inferomedial and your inferolateral.
Oftentimes, I won't even use a spinal needle. I'll just use my 11 blade, make a portal incision, take the trocar, and just insert it to the point where you can actually feel the ischium. Once you feel the ischium, like you know you're pretty safe, you can sweep the bursal tissue back and forth, and you just want to make sure you're underneath the subgluteal space, or in the subgluteal space, I should say. Once you do that, it's a pretty open potential space. It's just like going into the subchondral space. Everything really starts to open up. You can start your fluid at that point. I typically like to start at usually about 30, a pump pressure of 30, and then we'll go ahead and establish that inferolateral portal under spinal needle localization.
Then, once you can see the spinal needle, you can use either a switching stick or a shaver. I like to use a 4.0 millimeter smooth shaver without teeth. I think that that helps. Just as you're doing your bursectomy, as well as when you're dissecting around the sciatic nerve, I think it's just a little bit safer. At that point, you'll just perform your bursectomy, and the bursectomy will then allow you to completely see the ischium. You'll see the hamstring muscle, you'll see the hamstring tendon, and then the next thing you want to do is you want to find the sciatic nerve. The nerve is obviously really important. You just want to make sure you know where it is throughout the entirety of the case, and it's hard to miss. You can't miss it.
Once you know where the ischium is, and you can, again, use your fluoro to localize it, use a switching stick if you're uncomfortable using a shaver at first, palpate the ischium, and then you just want to sweep laterally. As you go laterally, oftentimes there'll be some bursal tissue, and in some cases you might actually see some of the cutaneous nerve branching off the sciatic nerve. Obviously you want to try to preserve those as much as you can, but you can just use a switching stick to just bluntly sweep away some of the bursal tissue until you can clearly see the sciatic nerve.
Once you can get past that, then you feel much more at ease as far as continuing with the case, because you know where the dangers are. Some surgeons like to actually place a switching stick and just put it in between the ischium and the sciatic nerve. There are other surgeons that like to abduct the leg, because that'll then bring the nerve less in tension and also more lateral. Those are some strategies that might help just to get the nerve out of the way. Then at that point, with these high-grade partial-thickness tears, they're kind of like glute med tears or rotator cuff tears. If you're looking at it from the bursal side, you will see an area that looks like it's less competent, so you'll just use a switching stick or the back of your shaver or your radiofrequency device to just palpate.
Where it feels like it's kind of ballotable is, I guess, the entry point of where you would start to interrogate where the tear exists. Using the MRI I think is pretty helpful, just to understand, "Is this tear more along the conjoint tendon, or the semi-T or semimembranosus?" This will also help as you're starting to recognize which of the footprints you want to reattach and where you want to enter the common hamstring peritenon. Oftentimes, right when you incise that hamstring peritenon, basically everything will start to open up and it'll look like a full tendon avulsion just with that superficial layer of the peritenon still intact. Then at that point, what I'll do is I'll put the camera, and again, the camera is still in that inferomedial portal, and go into that hamstring tendon where the avulsion exists.
That way you can clearly see the issue, so if you're following along in the article, like figure five, the camera's looking at the ischium itself and the tendon is behind us, and then at that point it's like doing a rotator cuff repair. You'll go ahead and use your spinal needle, and in some cases you can place your anchor through that inferolateral portal, or sometimes you might have to use a spinal spinal needle to then put the anchor at a different angle, just percutaneously. Whatever type of anchor you're using, you'll go ahead and insert the anchor. Then at that point you just want to pass sutures through the tendon, so you can use a tissue-penetrating device; you can use a Spectrum type of device or a SutureLasso type of device, whatever seems like it's most amenable. Usually the Penetrator is pretty good, and oftentimes I'll use the Penetrator just from that inferomedial.
You'll go ahead and penetrate it through the tendon and retrieve, as you're going into the peritenon and just hugging the ischium, and then just start retrieving it out. I think one of the things to keep in mind as you're doing a lot of hamstring work is that the footprint of the hamstring actually goes much more lateral than what you think. It sits lateral, so you want to make sure that your anchor is not at, I guess, the tip of the ischium, but rather more lateral too. Then, as you're passing your stitches, you want to make sure you reapproximate the lateral nature of the hamstring footprint. With the partial tears, I'll typically use one triple-loaded anchor or two double-loaded anchors, just depending on the extent of it. I think in this article we had mattress suture configuration, but we have a follow-up article where we started to use a different locking configuration with a running suture.
Dr. Andrea Spiker...: Yeah, that'd be great, if you could just talk us through how you perform a locking suture configuration.
Dr. Shane Nho: Similar to what we had just talked about, you can start with a mattress configuration, so you could either just tie it right there if you feel like you've got nice tissue, nice tissue bites and you feel like you've got pretty substantive repair, but if you're concerned at all, what I would do is I would then either use like a Scorpion type device. I think that tends to work well, like a rotator cuff grabbing and passing device, whatever it's called. We'll just call it the Scorpion for now.
Yeah, you can use a Scorpion, and then you've got one mattress in. You can grab it again. You can pass it continuously through. You can do it up to three times if you want to, and that'll then allow you to use the same suture and run a running stitch through it. Now, the one thing to keep in mind is that, as you're passing the stitch, oftentimes the needle will start to go more lateral and inferior, which is where the nerve is, so you do want to see where that needle is coming out to make sure that you're far away enough from the nerve that that's not going to be a problem.
Dr. Andrea Spiker...: Shane, do you use a new portal with this different mattress technique or this different locking technique?
Dr. Shane Nho: No, same portal.
Dr. Andrea Spiker...: Okay, great.
Dr. Shane Nho: Just put a cannula through that inferolateral portal, and typically we'll use the Scorpion through that portal and just do a series of stitches, like two or three down and two or three up; tie that to the other stitch that has also been passed through the tendon in the initial mattress configuration.
Dr. Andrea Spiker...: Well, that sounds like an excellent solution to sometimes the concern that endoscopic repairs are not as robust as open, so what a great technique that you've described. We talked a little bit briefly earlier about full thickness-tears that might be treated endoscopically. Very briefly, can you tell us a little bit about what type of full-thickness tear you could approach with this same technique?
Dr. Shane Nho: Yeah, if you're looking at the MRI, I think as long as the tear is within the subgluteal space, I think it's fine to treat endoscopically, at least for me. I know there are other surgeons that will even treat the ones that are retracted much more distal, so they will even go past that subgluteal crease, but I think part of it is, if it's an acute avulsed hamstring tear and you get to it within a week or two, they're obviously a lot easier to do, and doing it open, it's pretty straightforward. To some degree, at least in my mind, I just want to be reasonable as far as the risks involved, the anesthesia, the OR time. For an acute avulsion with 4 to 6 to 8 centimeters of retraction, those can be done I think pretty quickly and pretty efficiently open, and safely as well, so I think that sometimes it's just like we're trying to do these techniques, and it's technique without reason, I guess. Some people might have an issue with that too.
Dr. Andrea Spiker...: Yeah, I agree with you. To end here, can you tell us a little bit about the rehab for this endoscopic partial-thickness hamstring repair? Is it any different than our previous full-thickness open repair rehab?
Dr. Shane Nho: It's slightly different. I would say that I typically... Obviously it's outpatient surgery. I'll place patients on crutches. I'll put them in a hinged knee brace, flexed and locked at 45 degrees, and then I'll allow them to unlock and begin weight-bearing at four weeks. With a full-thickness tear, I usually will lock them for like six weeks, so I will advance them a little bit quicker. Outside from that, the rehab is essentially the same.
They'll work on getting off their brace, crutches, reestablishing a normal gait, and then one of the things I always caution the patients and the physical therapist is not to do any isolated hamstring curls. Oftentimes the patients are like, "Well, when can I do that?" I'm like, "Well, I mean, really you probably shouldn't do that for several months or so. There's no real benefit to doing that." I try to bring them along as long as possible and focus on more core and pelvic strength, as well as closed-chain lower leg strength, rather than them focusing in on trying to do hamstring curls. I don't know. Do you get those questions too from patients, like, "I want to do hamstring curls; when can I do it?"
Dr. Andrea Spiker...: Right, absolutely. Yeah, and I think we've talked a little bit about the rotator cuff, and I think going back to rotator cuff treatment and post-op rehab is important to translate here, rotator cuffs in slings and restrict them from using the arms, and I would argue that the leg is bearing a lot more weight than the arm is, so we should be just as conservative, if not more conservative, with the hamstrings as we are with the rotator cuffs.
Dr. Shane Nho: Yeah. It's like repairing a distal bicep, and then patients asking, "When can I start curling the biceps?" You're like, "Well, let's pump the brakes here a little bit."
Dr. Andrea Spiker...: Yeah. Well, thank you so much, Shane. This was an excellent description of your endoscopic technique. Again, I encourage everybody to look at your techniques video and the paper, because you guys did an excellent job with your videos and photos, really helping us understand how you approach this. Just in closing, any final thoughts on this technique and the evolution of endoscopic hamstring treatment? Do you think there will continue to always be a role for open repair, or is this the way of the future?
Dr. Shane Nho: No, no, I think there's always going to be a role for open. I mean, as we talked about a little bit, if it's acute, greater than 4 or 5 centimeters, I mean, those are very straightforward. I think they're doing an open approach. Makes sense. They're pretty straightforward. They're efficient. You can get them done with pretty minimal concerns for complications, and you get a nice, and some people would argue a better, repair. More robust suture configuration in open, and definitely I think that that's the case.
I think that the one parting thought that I would say is that our traditional indication for hamstring repair, either a full-thickness three-tendon tear or two-tendon with greater than 2 centimeters, is the question that I think we've got to start to think about whether or not we should change the paradigm as far as when these hamstring tears are indicated, because I don't think it's as black and white as that anymore. Especially as we're seeing the results of endoscopic repairs and the dysfunction and disability of patients with these chronic attritional tears, I do think that we've got to start to rethink it, similar and along the lines of rotator cuff and partial rotator cuff tears, how that also has evolved too. I think that this will evolve in a similar way.
Dr. Andrea Spiker...: Well, an excellent point to end on, and thank you so much again, Shane. It's been a pleasure speaking with you.
Dr. Shane Nho: Yeah, thank you again. It's an honor to be a guest on this podcast, and look forward to future podcasts.
Dr. Andrea Spiker...: Dr. Nho's techniques paper titled Endoscopic Partial Proximal Hamstring Repair can be Found in the July 2023 issue of Arthroscopy Techniques online. This concludes our episode of the Arthroscopy Journal Podcast. Thank you for joining us. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.
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