Biomechanical Comparison of Proximal Hamstring Reconstruction Using Distal Hamstring Graft Versus Fascia Lata Graft for Treatment of Chronic Hamstring Injury
Authors: Nishimura Haruki , Yamaura Kohei , Stetzelberger Vera M. , Garcia Alexander R. , Hollenbeck Justin F.M. , Brown Justin R. , Mologne Mitchell S. , Uchida Soshi , Philippon Marc J. 
Published: November 2023

Background: Surgical reconstruction using autografts is often required in treating chronic proximal hamstring injuries where the hamstring has retracted >5 cm. There is a paucity of evidence that evaluates reconstructive procedures using the 2 most popular autografts, distal hamstring and fascia lata. Purpose: To (1) compare failure load and elongation at failure between the proximal hamstring tendon reconstruction with distal hamstring and fascia lata grafts and (2) compare the stiffness between these reconstructions and the native state. Study design: Controlled laboratory study. Methods: Seven pairs of human cadaveric hemipelvises (mean age, 60.4 ± 5.0 years; 6 male, 1 female) with no evidence of previous injury or abnormality were dissected to the proximal hamstring origin. Through use of a dynamic tensile testing system, each specimen underwent preconditioning followed by a distraction test to determine the native specimen stiffness. Each pair of specimens was assigned to undergo proximal hamstring reconstruction with distal hamstring and reconstruction with fascia lata. Each specimen then underwent preconditioning followed by pull to failure. The failure load, elongation at failure, mode of failure, and stiffness were determined for each repair. Results: The distal hamstring group exhibited a greater failure load (mean, 334 ± 108 N; P = .031) and higher stiffness (mean, 47.6 ± 16.0 N/mm; P = .009) compared with the fascia lata group (mean, 179 ± 78 N and 23.0 ± 11.2 N/mm, respectively). Although the stiffness of the repair state in the distal hamstring group (mean, 61.4 ± 13.4 N/mm) was not significantly different from that of the native state (mean, 47.6 ± 16.0 N/mm), the stiffness of the repair state in the fascia lata group (mean, 23.0 ± 11.2 N/mm) was significantly lower than that of the native state (mean, 60.1 ± 17.7 N/mm) ( P < .0001). The elongation at failure of the distal hamstring graft group (mean, 33.0 ± 6.6 mm) was not significantly different from that of the fascia lata graft group (mean, 29.2 ± 14.9 mm) ( P = .58). The most common modes of failure for the distal hamstring group (29% each) were at the repair site, at the graft-muscle interface, and at the muscle, while the most common modes of failure for the fascia lata graft were at the tendon-graft interface. Conclusion: The distal hamstring group achieved higher failure load and stiffness than the fascia lata group, and stiffness of the distal hamstring group was not significantly different from that of the native tendon. Elongation at failure was not different between repair techniques. Although distal hamstring graft failure predominantly occurred in 3 distinct locations, failure of the fascia lata repair occurred predominantly at the tendon-graft interface. These cadaveric results suggest that it may be more clinically appropriate to use distal hamstring versus fascia lata for proximal hamstring reconstruction. Clinical Relevance: Our time-zero study suggests that the proximal hamstring reconstruction with distal hamstring could be the preferred surgical treatment for chronic hamstring injury over reconstruction with fascia lata. The failure load of reconstruction with distal hamstring was inferior to that of primary suture anchor, suggesting that rehabilitation after reconstruction should not be more aggressive than the standard postoperative rehabilitation protocol for acute repair.