Abstract
Proximal hamstring avulsions, often seen in active adults, result from high-energy eccentric loading during hip flexion with knee extension. Open repair remains the gold standard, allowing direct visualization and sciatic nerve protection. Low-profile all-suture anchors have emerged as an alternative to traditional metal or PEEK (polyether ether ketone) devices. This technical note describes a reproducible technique using 3 Q-Fix all-suture anchors (Smith & Nephew, London, England) in a triangular tension-slide configuration. This construct offers strong anatomic fixation with minimal implant burden and reduced bone loss. It is particularly advantageous in cases of tendon retraction or poor tissue quality and is broadly adaptable, including for high-demand populations.
Technique Video
Proximal hamstring tendon injuries range from tendinopathy and partial tearing to complete avulsion of the tendon origin from the ischial tuberosity.1,2 The proximal hamstring origin consists of the conjoint tendon, formed by the semitendinosus and long head of the biceps femoris, and the adjacent semimembranosus tendon. Complete tendon avulsions are typically the result of high-energy eccentric loading during hip flexion with knee extension. These injuries most commonly occur in athletic or active adult populations.3,4 Early diagnosis and surgical repair are critical given that delayed intervention is associated with inferior functional outcomes, increased complication rates, and a higher risk of rerupture.5,6
Open surgical repair remains the gold standard for reattaching the tendon complex to the ischial tuberosity, offering direct visualization, thorough debridement, and reliable protection of the sciatic nerve.2,7 All-suture anchors have emerged as a low-profile alternative to traditional metal or PEEK (polyether ether ketone) devices, designed to reduce implant morbidity and preserve bone stock.8,9 When combined with a tension-slide suture configuration, these anchors offer a reliable fixation strategy for tendon-to-bone healing. Despite these advantages, there are limited technical descriptions detailing proximal hamstring repairs using this construct.
This technical note describes open proximal hamstring tendon repair using Q-Fix all-suture anchors (Smith & Nephew, London, England) in a tension-slide configuration. The construct provides strong anatomic fixation while minimizing implant burden and preserving soft tissue. This reproducible technique is adaptable across diverse patient populations, including high-demand individuals.
Surgical Technique
Preoperative Evaluation
Patients with proximal hamstring avulsions often present with ecchymosis (Fig 1), difficulty sitting, and weakness with knee flexion. Examination typically reveals a palpable defect near the ischial tuberosity and pain-limited strength testing. Magnetic resonance imaging is the diagnostic modality of choice, with coronal sequences showing fluid at the ischial origin and retraction of the tendon complex (Fig 2). The conjoint tendon is most frequently involved, whereas the semimembranosus may remain intact or may be partially torn. Magnetic resonance imaging also delineates tendon retraction, muscle atrophy, and the proximity of the sciatic nerve, all of which are essential for surgical planning.
Fig 1.
Preoperative image of the right lower extremity with the patient in the prone position. Ecchymosis is visible over the posterior thigh, a common finding associated with proximal hamstring avulsions.
Fig 2.
(A-C) Sequential coronal T2-weighted magnetic resonance imaging (anterior to posterior) showing complete proximal hamstring avulsion with retracted tendon stump (blue arrows) and fluid signal at the ischial origin. The healthy conjoint tendon (white arrow) is seen on the contralateral side attached to the ischial tuberosity. The sciatic nerve is visualized adjacent to the retracted tendon (pink arrow), highlighting its proximity and relevance for surgical planning. The asterisks identify the bilateral ischial tuberosity.
Patient Positioning and Preparation
The patient is placed prone on a surgical table. General anesthesia is administered, along with a preoperative peripheral nerve block and prophylactic antibiotics. All bony prominences are well padded, and the operative extremity is prepared and draped in standard sterile fashion. A timeout is performed to confirm the patient, procedure, and surgical site.
Surgical Exposure
A 6-cm transverse incision is made within the gluteal crease overlying the ischial tuberosity (Fig 3). Blunt dissection is carried down through the subcutaneous tissue to the level of the crural fascia. The fascia is incised longitudinally to expose the underlying musculature. A hematoma is commonly encountered overlying the retracted tendon and can serve as a reliable landmark to confirm the location of the torn proximal hamstring.
Fig 3.
Intraoperative image of the right lower extremity with the patient in the prone position. A 6-cm transverse incision is made in the gluteal crease, directly overlying the ischial tuberosity, to allow exposure of the proximal hamstring origin.
The retracted conjoint tendon of the semitendinosus and biceps femoris is identified and mobilized (Fig 4). The semimembranosus is evaluated and found to be intact. The gluteus maximus is retracted superiorly to expose the ischial tuberosity.
Fig 4.
Intraoperative image of the right lower extremity with the patient in the prone position. The retracted conjoint tendon of the semitendinosus and long head of the biceps femoris is identified and mobilized. The gluteus maximus is retracted superiorly to expose the ischial tuberosity.
The sciatic nerve is visually identified, often located beneath the fascial layer lateral and deep to the conjoint tendon at the ischial tuberosity. Once localized, it is carefully mobilized and retracted laterally using blunt instruments or a vessel loop to prevent traction injury and allow safe anchor placement.
Footprint Preparation and Anchor Placement
The ischial tuberosity is prepared using a curette and rasp to promote biologic healing (Fig 5). The retracted conjoint tendon is mobilized and brought to the ischial footprint to confirm adequate reduction before anchor placement and drilling (Fig 6). The Q-Fix all-suture anchor system (anchor and drill guide; Smith & Nephew) is prepared on the surgical table prior to insertion (Fig 7). A 3.0-mm pilot hole is created at the lateral facet of the ischial tuberosity using a drill guide (Fig 8). One 2.8-mm Q-Fix all-suture anchor (Smith & Nephew) is inserted and tapped flush with the cortical surface (Fig 9). Two additional 1.8-mm Q-Fix anchors are placed medially and inferiorly in a triangular configuration to optimize tendon contact area and distribute fixation forces (Fig 10). Each anchor is preloaded with suture tape.
Fig 5.
(A, B) Intraoperative images of the right lower extremity with the patient in the prone position. A rasp and curette are used to prepare the ischial tuberosity footprint (blue arrows) to promote biologic healing prior to anchor placement. A retractor (asterisks) protects the sciatic nerve laterally.
Fig 6.
(A, B) Intraoperative images of the right lower extremity with the patient in the prone position. The retracted conjoint tendon (white arrows) is mobilized and brought to the ischial footprint (blue arrow) to confirm adequate reduction before anchor placement and drilling. This step ensures that the tendon can be anatomically reapproximated without undue tension. A retractor (asterisk) protects the sciatic nerve laterally.
Fig 7.
Q-Fix all-suture anchor system (anchor and drill guide; Smith & Nephew) prepared on surgical table prior to insertion.
Fig 8.
Intraoperative image of the right lower extremity with the patient in the prone position. A drill guide is used to create a 3.0-mm pilot hole on the lateral facet of the ischial tuberosity for placement of the initial Q-Fix anchor. A retractor (asterisk) protects the sciatic nerve laterally.
Fig 9.
(A, B) Intraoperative images of the right lower extremity with the patient in the prone position. The 2.8-mm Q-Fix anchor (blue arrows) is inserted and tamped flush with the cortical surface of the ischial tuberosity. Traction is applied to the suture tails to evaluate anchor integrity. The conjoint tendon (white arrows) is secured with a clamp. A retractor (asterisks) protects the sciatic nerve laterally.
Fig 10.
Intraoperative image of the right lower extremity with the patient in the prone position. Three all-suture anchors (blue arrows)—one 2.8-mm and two 1.8-mm anchors—are shown placed in a triangular configuration on the ischial tuberosity to optimize footprint coverage and fixation strength. A retractor (asterisk) protects the sciatic nerve laterally.
Tendon Passage and Fixation
The conjoint tendon is brought back to its anatomic origin and held with a clamp. With a free needle, the suture limbs from each anchor are passed through the tendon approximately 3 cm from the torn edge, creating a tension-slide construct (Fig 11). The sutures are sequentially tensioned to reduce the tendon to bone and are tied securely with multiple alternating half-hitches (Fig 12). The final repair is inspected for gapping and stability with gentle manual stress testing (Fig 13).
Fig 11.
(A, B) Intraoperative images of the right lower extremity with the patient in the prone position. The suture limbs (blue arrows) are passed through the tendon approximately 3 cm distal to the edge using a free needle. The conjoint tendon (white arrows) is secured with a clamp. A retractor (asterisk) protects the sciatic nerve laterally.
Fig 12.
(A, B) Intraoperative images of the right lower extremity with the patient in the prone position. The suture limbs (blue arrows) are tensioned to reduce the tendon to bone and are tied securely with alternating half-hitches. The conjoint tendon (white arrows) is reduced to its footprint. A retractor (asterisks) protects the sciatic nerve laterally.
Fig 13.
(A, B) Intraoperative images of the right lower extremity with the patient in the prone position: final repair construct showing anatomic reduction of the conjoint tendon (blue arrows) without gapping, confirmed via gentle manual stress testing. A retractor (asterisks) protects the sciatic nerve laterally.
Wound Closure
The wound is copiously irrigated. Hemostasis is confirmed. The crural fascia is closed with No. 0 Vicryl sutures (Ethicon, Somerville, NJ), followed by layered subcutaneous closure using No. 2-0 Vicryl and No. 4-0 Monocryl (Ethicon) (Fig 14). The complete proximal hamstring repair is shown in Video 1. Dermabond (Ethicon) and sterile dressings are applied. The patient can be placed in a hinged hip brace locked in neutral or a hinged knee brace locked in 30° to 60° of flexion. A complete list of pearls and pitfalls is found in Table 1.
Fig 14.
Intraoperative image of the right lower extremity with the patient in the prone position: final layered closure of the incision site in the gluteal crease (blue arrow), including fascial, subcutaneous, and skin closure.
Table 1.
Pearls and Pitfalls
| Pearls | Pitfalls |
|---|---|
| Make an incision in the gluteal crease to improve cosmesis and provide direct access to the ischial tuberosity. | Failing to fully expose ischial tuberosity and retracted tendon, limiting visualization and anchor placement |
| Follow the hematoma to identify the retracted tendon; it typically localizes the avulsion site. | Drilling anchors without identifying and protecting sciatic nerve, increasing risk of iatrogenic injury |
| Identify the sciatic nerve early; retract gently with a vessel loop or malleable retractor to prevent traction injury. | Failing to thoroughly debride ischial footprint, which can impair tendon healing and integration |
| Place 3 Q-Fix anchors in a triangular configuration to maximize footprint coverage and force distribution. | Passing sutures through compromised tendon or too close to edge, reducing repair strength and increasing risk of suture pullout |
| Pass suture limbs in a tension-slide configuration to optimize tendon-to-bone compression. | Using thin sutures instead of tape in degenerative tendon, increasing risk of cut-through |
| Use suture tape instead of round sutures to reduce the risk of tendon cut-through and improve contact pressure. | Failing to apply postoperative bracing when tendon is difficult to reduce, placing repair at higher risk of failure |
| Apply a hinged knee or hip brace postoperatively when tendon reduction is under tension or difficult to achieve intraoperatively. |
Postoperative Protocol
Patients remain non–weight-bearing for 4 to 6 weeks with a hinged knee brace locked in 30° to 60° of flexion or a hinged hip brace locked in neutral extension. Hip flexion and extension are restricted. Formal physical therapy begins after the initial postoperative visit and progresses in phases focused on protected range of motion, gradual strengthening, and functional return to activity. Return to sport is determined by resolution of symptoms and restoration of symmetrical strength and neuromuscular control.
Discussion
All-suture anchors have emerged as a biomechanically sound alternative to traditional metal or PEEK-based anchors for proximal hamstring repair, offering reduced implant prominence, preservation of bone stock, and improved anatomic footprint placement on the ischial tuberosity.8,9 When paired with a tension-slide configuration, these constructs show superior cyclic stability, higher load-to-failure strength, and reduced gap formation at the tendon-bone interface compared with knotted metallic anchors.9, 10, 11
In our construct, 3 Q-Fix all-suture anchors are placed in a triangular configuration to maximize contact area and distribute forces evenly across the tendon footprint. This technique optimizes early tendon-to-bone healing by minimizing micromotion and enhancing compression, as supported by recent cadaveric studies.9,11 In addition, suture tape can be used to further increase contact pressure and reduce the risk of suture pull-through.8 These biomechanical properties make this construct especially beneficial in cases of poor tendon quality or significant retraction.
Clinical outcomes after proximal hamstring repair have shown high patient satisfaction, improved function, and reliable return to activity, particularly when performed in a timely fashion.12,13 Although both open and endoscopic techniques have been described, open repair remains the gold standard in cases of delayed presentation or significant tendon retraction. The described technique allows for controlled dissection, direct visualization of the sciatic nerve, and secure reattachment without excessive dissection or implant prominence.
Bracing after proximal hamstring repair remains debated. A hinged knee or hip brace can be used for 4 to 6 weeks to restrict hip flexion and protect the repair during early healing. Recent evidence suggests lower rerupture rates, higher return-to-sport percentages, and greater patient satisfaction when bracing is used.14 It is important to note that the need for bracing may be greater in cases in which tendon reduction is challenging, such as in chronic tears or when retraction necessitates extensive mobilization. In a recent study evaluating an accelerated rehabilitation protocol with bracing in extension, Wong et al.15 reported excellent patient-reported outcomes, high satisfaction, and no reruptures at 1-year follow-up after repair with all-suture anchors.
The complication rate of proximal hamstring repair is relatively low, with most events being minor and transient. Sciatic nerve irritation, wound complications, and peri-incisional numbness are the most commonly reported events.16,17 The low-profile nature of all-suture anchors may further reduce the risk of symptomatic hardware-related issues.10
The described open repair technique using all-suture anchors in a tension-slide configuration offers strong fixation, minimal implant morbidity, and reproducibility across patient populations. It provides an ideal approach in both acute and subacute settings. Further clinical studies are necessary to compare its outcomes with those of traditional constructs.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: J.L.C. receives speaking and lecture fees from Arthrex. All other authors (P.W., D.K., D.H., K.C., E.V., L.V., P.M., A.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
Open proximal hamstring tendon repair using Q-Fix all-suture anchors in a tension-slide configuration. The patient is positioned prone, and a 6-cm transverse incision is made along the left gluteal crease. After subcutaneous dissection and fascial release, the retracted conjoint tendon of the semitendinosus and long head of the biceps femoris is identified. The gluteus maximus is retracted superiorly, and the sciatic nerve is visualized and protected throughout the procedure. The ischial tuberosity is prepared using a curette and rasp, followed by placement of 3 all-suture anchors in a triangular configuration: one 2.8-mm anchor and two 1.8-mm anchors. Suture tape from each anchor is passed through the tendon approximately 3 cm from the tendon edge. The sutures are tensioned sequentially to reduce the tendon to its anatomic footprint and are tied securely. The repair is tested for stability, and layered wound closure is performed.
References
- 1.Fletcher A.N., Cheah J.W., Nho S.J., Mather R.C., III Proximal hamstring injuries. Clin Sports Med. 2021;40:339–361. doi: 10.1016/j.csm.2021.01.003. [DOI] [PubMed] [Google Scholar]
- 2.Sheean A.J., Arner J.W., Bradley J.P. Proximal hamstring tendon injuries: Diagnosis and management. Arthroscopy. 2021;37:435–437. doi: 10.1016/j.arthro.2020.12.201. [DOI] [PubMed] [Google Scholar]
- 3.Chang J.S., Kayani B., Plastow R., Singh S., Magan A., Haddad F.S. Management of hamstring injuries: Current concepts review. Bone Joint J. 2020;102-B:1281–1288. doi: 10.1302/0301-620X.102B10.BJJ-2020-1210.R1. [DOI] [PubMed] [Google Scholar]
- 4.Bertiche P., Mohtadi N., Chan D., Hölmich P. Proximal hamstring tendon avulsion: State of the art. J ISAKOS. 2021;6:237–246. doi: 10.1136/jisakos-2019-000420. [DOI] [PubMed] [Google Scholar]
- 5.Kanakamedala A.C., Mojica E.S., Hurley E.T., Gonzalez-Lomas G., Jazrawi L.M., Youm T. Increased time from injury to surgical repair in patients with proximal hamstring ruptures is associated with worse clinical outcomes at mid-term follow-up. Arch Orthop Trauma Surg. 2023;143:951–957. doi: 10.1007/s00402-022-04421-5. [DOI] [PubMed] [Google Scholar]
- 6.Lefèvre N., Freiha K., Moussa M.K., et al. Risk factors for rerupture after proximal hamstring avulsion injury including the optimal timing for surgery. Am J Sports Med. 2024;52:1173–1182. doi: 10.1177/03635465241233734. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Arner J.W., Rothrauff B., Bradley J.P. Hamstring injuries in athletes: Anatomy, pathology, and treatment. J Am Acad Orthop Surg. 2025;33:e703–e714. doi: 10.5435/JAAOS-D-24-01162. [DOI] [PubMed] [Google Scholar]
- 8.Carbone A.D., Saeed S.K., Perez-Padilla P.A., Domb B.G. Fixation of the proximal hamstring tendon using an all-suture tensionable knotless technique. Arthrosc Tech. 2023;12:e1241–e1246. doi: 10.1016/j.eats.2023.03.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Otto A., DiCosmo A.M., Baldino J.B., et al. Biomechanical evaluation of proximal hamstring repair: All-suture anchor versus titanium suture anchor. Orthop J Sports Med. 2020;8 doi: 10.1177/2325967119892925. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ergün S., Akgün U., Barber F.A., Karahan M. The clinical and biomechanical performance of all-suture anchors: A systematic review. Arthrosc Sports Med Rehabil. 2020;2:e263–e275. doi: 10.1016/j.asmr.2020.02.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Gerhardt M.B., Assenmacher B.S., Chahla J. Proximal hamstring repair: A biomechanical analysis of variable suture anchor constructs. Orthop J Sports Med. 2019;7 doi: 10.1177/2325967118824149. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Fenn T.W., Brusalis C.M., Allahabadi S., Alvero A.B., Ebersole J.W., Nho S.J. Association between proximal hamstring tear characteristics and achievement of clinically significant outcomes after endoscopic and open repair at minimum 2-year follow-up. Am J Sports Med. 2024;52:390–400. doi: 10.1177/03635465231216118. [DOI] [PubMed] [Google Scholar]
- 13.Maldonado D.R., Annin S., Lall A.C., et al. Outcomes of open and endoscopic repairs of chronic partial- and full-thickness proximal hamstring tendon tears: A multicenter study with minimum 2-year follow-up. Am J Sports Med. 2021;49:721–728. doi: 10.1177/0363546520981767. [DOI] [PubMed] [Google Scholar]
- 14.Wyatt P.B., Ho T.D., Hopper H.M., et al. Systematic review of bracing after proximal hamstring repair. Orthop J Sports Med. 2024;12 doi: 10.1177/23259671241230045. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Wong S.E., Julian K.R., Carpio J.G., Zhang A.L. Proximal hamstring repair with all-suture anchors and an accelerated rehabilitation and bracing protocol demonstrates good outcomes at 1-year follow-up. Arthrosc Sports Med Rehabil. 2024;6 doi: 10.1016/j.asmr.2024.100891. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Yetter T.R., Halvorson R.T., Wong S.E., Harris J.D., Allahabadi S. Management of proximal hamstring injuries: Non-operative and operative treatment. Curr Rev Musculoskelet Med. 2024;17:373–385. doi: 10.1007/s12178-024-09911-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Lawson J.J., Abraham E.A., Imbergamo C.M., Sequeira S.B., Dreese J.C., Gould H.P. Systematic review of complications associated with proximal hamstring tendon repair. Orthop J Sports Med. 2023;11 doi: 10.1177/23259671231199092. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Open proximal hamstring tendon repair using Q-Fix all-suture anchors in a tension-slide configuration. The patient is positioned prone, and a 6-cm transverse incision is made along the left gluteal crease. After subcutaneous dissection and fascial release, the retracted conjoint tendon of the semitendinosus and long head of the biceps femoris is identified. The gluteus maximus is retracted superiorly, and the sciatic nerve is visualized and protected throughout the procedure. The ischial tuberosity is prepared using a curette and rasp, followed by placement of 3 all-suture anchors in a triangular configuration: one 2.8-mm anchor and two 1.8-mm anchors. Suture tape from each anchor is passed through the tendon approximately 3 cm from the tendon edge. The sutures are tensioned sequentially to reduce the tendon to its anatomic footprint and are tied securely. The repair is tested for stability, and layered wound closure is performed.