What a gentleman. I'm not done yet. So okay, we'll look at the other side of the equation here. These are my disclosures. So that was a nice presentation on endoscopic and we'll decide, you know, after this discussion maybe what we should be doing, open versus endoscopic. For some reason in Southern California we have a lot of these injuries. It's originally described as the water skier injury, but we see surfing accidents, kite surfing, skateboarding, Hollywood is right there, stuntmen doing crazy things and injuring their proximal hamstrings. So we have a high volume of this and in fact we have rare footage of a gym in Hollywood where I'd like you to see this mechanism of injury. Big breath, exhale, hold it, hold it, hold it. Hold and release. And release. Too much? I just felt a straining, a tightness on the front of my ass. Well you are pretty tight down there. You have to. Something snapped in my ass. I'm going to check in with my office. I'll be right back. When we do, we're going to work on opening those in. Rare footage. So if you do think that the patient comes in and they might have a proximal hamstring the first thing we should do is get an MRI. MRI will help us define exactly what it is. Is it truly a hamstring tear? Is it a hamstring strain? And then of course how retracted it is or isn't and that will help us decide on what surgical approach perhaps would be best for this patient. But before we talk about surgical approaches, I think the question that was originally asked was should proximal hamstrings be repaired at all? And presumably these were treated non-operatively until relatively recently. And it wasn't until Peter Chalet's study in AJSM in 1996 where he showed that non-operative treatment of these injuries provided return to sports in only about 60% of the cases. So it got us thinking, hmm, maybe surgery would be better. So a whole slew of open proximal hamstring studies were filling our literature. And it was clear that surgery, open surgical repair provided a much higher return to sport, high satisfaction rates with fairly low complication rate as well. The goal of any type of hamstring repair regardless of the approach is that you want to restore the normal anatomy, really rigid fixation at time zero and make sure that the approach is safe and is reproducible. Most importantly as we know in this surgery, the most important thing is to identify the sciatic nerve and to make sure you protect it and preserve it throughout the procedure. This is how I do the open procedure. It's a very simple six-step technique. It's very reproducible. My staff has affectionately called this the FYA procedure which stands for Fix Your Ass procedure. So this is how I do an FYA right here. The first step is positioning, making sure that they're in a prone position. Draw the landmarks, know where the ischium is and then make that incision through the gluteal crease using a headlamp is very helpful. Step two is managing the gluteus maximus, probably the hardest part of an open surgery and some of these muscular athletes, retracting that can be a little bit of a chore. But once that's done you have good visualization of what lies below. And before you get too excited about going and fixing the hamstring, we've got to identify that sciatic nerve. And identifying it can be either through digital palpation and if you're unsure you need to do a meticulous dissection to visualize it before moving on. Step four is identifying the stump. If it's retracted you can use digital excision or freeing up of the adhesions to make sure that there's good excursion. And then identifying the footprint, the anatomic footprint where this should go, not on the tip of the ischium, that provides more sitting pain, but the true lateral facet where that hamstring should be repaired and preparing it just like you would any tendon to bone interface. The last step is putting in your anchors. I like doing a double row repair using three to four anchor pattern. If there's any tension on the tendon at all you can flex the knee. It takes a little bit of tension, allows for rock solid fixation. This is what the incision looks like with Dermabond, one week post-op and then at three months post-op you can see a very cosmetic result. Side by side a very bikini friendly incision. So if the open repair is so good and so simple then why do we even need an endoscopic technique? And I think that I'm partially to blame for that as well as Carlos as we were amongst the first to publish on this technique over ten years ago now showing that this technique actually may have some advantages and something that can be done safely in the right situation. So these were kind of the case reports published way back when. More recently we've seen a small series of endoscopic proximal hamstring repairs that do show good satisfaction rates. As you can see with this study from arthroscopy in 2020, 95% return to sport. That's great. But if you look closely there were 42% subjective weakness, 16% sitting pain. And some of the other studies also show high functional activity but subjectively they only return back 76%, 75% complete pain relief. So not a perfect procedure if you look closely at the recent studies. And even looking at the study that Carlos showed us, there were a couple of pearls that I took from it. One was that the endoscopic technique he says may be a viable option for proximal hamstring repair. Not as superior, not as the best, but maybe. He also says that endoscopic repair is indicated if it's not too far retracted. So again, something to keep in mind and then of course further studies need to be done. So in closing here the endoscopic repair certainly has been shown to be an effective option. But is it better? If you've got an athlete who is, you know, a high-level college athlete, he has a hamstring tear, I'm doing that open and for the following reasons. There's still some questions in my mind as to whether the endoscopic technique is completely all that has been built. So number one, is the endoscopic less invasive? Well generally arthroscopic procedures are. But endoscopic procedures can get tricky because it's not inside the joint. That fluid can extravasate. It can go in strange places. I've seen patients who've had scrotal swelling, labial swelling, their gluteal area gets massive. So you want to be really careful with the amount of pump pressure that you're exposing these patients to. Secondly, visualization. The videos that Carla showed are beautiful and sometimes that's how it goes. But if you get a bleeder, if you get any type of problem with visualization, it can be tricky, especially if you haven't found the nerve yet. And that can be a very dicey situation. In cases like that, the good news is that you can convert to an open procedure if you're struggling at all with an endoscopy. And then which is best for fixation at time zero? Certainly can get several passes just like a rotator cuff. But in my hands with an athlete, I like multiple passes through the tendon in an open fashion with the modified Krakow procedure allows rock solid fixation allowing for earlier PT, no braces necessary and low risk of re-tear. This was a patient of mine that I performed endoscopic repair. And she's six weeks out. She's walking. She's happy. She's back to work. But when I asked her if she was satisfied with the procedure, she actually said no. And I said, why is that? And she said, because I don't like the incision. So you can see here the incision is not quite as cosmetic as the open procedure. So my final thought on this is a question actually for Carlos. If Kim Kardashian walks into your office next week with a proximal hamstring injury, what do you think she would want? The endoscopic on the right with that awful scar or with a Hollywood friendly incision there on the elbow? She'd want more filler. Fair, fair. And with that, I close my case. Thank you.

proximal hamstring injuries

surgical options

open surgical repair

sciatic nerve

patient preferences