Nerve Wrapping of the Sciatic Nerve With Acellular Dermal Matrix in Chronic Complete Proximal Hamstring Ruptures and Ischial Apophyseal Avulsion Fractures

Abstract

Background:Patients with chronic injuries of the proximal hamstring can develop significant impairment because of weakness of the hamstring muscles, sciatic nerve compression from scar formation, or myositis ossificans.Purpose:To describe the surgical outcomes of patients with chronic injury of the proximal hamstrings who were treated with hamstring repair and sciatic neurolysis supplemented with nerve wrapping with acellular dermal matrix.Study Design:Retrospective case series; Level of evidence, 4.Methods:Fifteen consecutive patients with a diagnosis of chronic complete proximal hamstring rupture or chronic ischial tuberosity apophyseal avulsion fracture (mean age, 39.67 years; range, 14-69 years) were treated with proximal hamstring repair and sciatic neurolysis supplemented with nerve wrapping with acellular dermal matrix. Nine patients had preoperative sciatica, and 6 did not. Retrospective chart review recorded clinical outcomes measured by the degree of pain relief, the rate of return to activities, and associated postoperative complications.Results:All 15 patients were followed in the postoperative period for an average of 16.6 months. Postoperatively, there were 4 cases of transient sciatic nerve neurapraxia. Four patients (26%) required postoperative betamethasone sodium phosphate (Celestone Soluspan) injectable suspension USP 6 mg/mL. Among the 9 patients with preoperative sciatica, 6 (66%) had a good or excellent outcome and were able to return to their respective activities/sports; 3 (33%) had persistent chronic pain. One of these had persistent sciatic neuropathy that required 2 surgical reexplorations and scar excision after development of recurrent extraneural scar formation. Among the 6 without preoperative sciatica, 100% had a good or excellent outcomes and 83% returned to their respective activities/sports. Better outcomes were observed in younger patients, as the 3 cases of persistent chronic sciatic pain were in patients older than 45 years.Conclusion:This study suggests that when used as an adjunct to sciatic neurolysis, nerve wrapping with acellular dermal matrix can be a safe and effective method of treating younger patients with and preventing the development of sciatic neuropathic pain after chronic injury of the proximal hamstrings.

Sciatic Nerve Injury After Proximal Hamstring Avulsion and Repair

“…Most of the large series on proximal hamstring injury and repair do not report sciatic nerve–related symptoms or outcomes. Haus and colleagues 7 reported 15 consecutive patients with chronic proximal hamstring avulsions who underwent repair, sciatic neurolysis, and sciatic nerve wrapping. Nine of the 15 (60%) patients had preoperative sciatica.…”

Avulsion Fractures of the Ischial Tuberosity and Resulting Ischiofemoral Impingement – a Case Report with Literature Review

“…Zum Teil wurde der modifizierte "Harris Hip Score" und der "Hip Outcome Score" verwendet [4] und Blakeney et al entwickelten das "Perth Hamstring Assessment Tool" (PHAT), um das Outcome zu erfassen [5]. Des Weiteren wurden die Parameter Schmerzreduktion, Rate der Rückkehr zu sportlichen Aktivitäten und Komplikationen, die mit der Operation assoziiert werden können, zur Outcome-Auswertung genutzt [25]. Orava et al benutzten die subjektiven Aussagen der Patienten in der Abstufung "excellent", "moderate" und "poor" und zur Objektivierung die Tegner-Skala [20].…”

“…Da der Patient keine Ischiassymptomatik zeigte und der Nerv intraoperativ nicht ohne Weiteres darzustellen war, wurde auf eine Neurolyse in unserem Falle verzichtet, obwohl dies in der Literatur empfohlen wird [5]. Diese wird in der Literatur vor allem in chronischen Fällen betont und durch verschiedene Verfahren, wie der perkutanen Fenestrierung bis hin zur Ummantelung des Nervs mit Dermisersatzmaterial, ergänzt [7,25] Ziel der Operation bei unserem Fallbeispiel war die Resektion des hypertrophen Tuber ischiadicum, jedoch unter der Prämisse, dass der Ursprung der ischiokruralen Muskulatur belassen wird. Dieses Verfahren wurde im Vorfeld festgelegt, um den knöchernen Ursprung der ischiokruralen Muskulatur zu belassen, da eine muskuläre Refixation eine schlechte Einheilungstendenz aufweist, wenn eine initiale Avulsion konservativ behandelt und ein chronischer Zustand erreicht wurde [9].…”

Proximal Hamstring Injuries: Review of Operative and Nonoperative Management

“…5). 35,61,[99][100][101] Hamming et al reported that suture anchor constructs utilizing five small anchors provides biomechanical strength equivalent to the intact state and thus advocate for this construct when addressing complete proximal hamstring avulsions. 102 Avariety of suture configurations, including horizontal mattress, the Mason-Allen, and Krackow techniques may be utilized during proximal hamstring repair.…”

“…In cases where there is a true ischial apophyseal avulsion or bony fragments are present, good outcomes have been described with a variety of techniques including suture anchors incorporating the bony fragment, screw fixation for large fragments, bone tunnels, and fragment excision with advancement of the tendon. 88,101,[103][104][105] Ultimately, the repair construct should allow a relatively lowtension repair with the hip in neutral flexion and the knee flexed no more than 90 degrees while maximizing the surface area of fixation to optimize healing.…”