Editorial Commentary: Suture Configuration Matters When Fixing Proximal Hamstring Tears

As endoscopic techniques for the management of proximal hamstring injuries have evolved, new challenges have emerged. Tendon-to-bone healing remains the ultimate goal, but a strong time-zero fixation construct is necessary to resist tension and facilitate healing. The constraints of an endoscopic environment limit the surgeon's ability to pass suture and create constructs that are relatively straightforward in an open procedure. Biomechanical studies have shown that suture configurations that distribute tension and maximize suture purchase achieve higher ultimate load to failure. Locking constructs, such as the Krackow or modified Mason-Allen stitch, have shown the best biomechanical performance, nearly doubling the load to failure of a simple suture. However, these configurations are technically more challenging to perform endoscopically. Horizontal mattress configurations have a load-to-failure profile similar to that of locking constructs but are technically more comparable to a simple suture. In our practice, we have found that Krackow sutures are well suited for retracted proximal hamstring tears, particularly those with macerated tissue and dissociation from the tendon sheath. In contrast, locking constructs may be unnecessary for partial tears. For these tears, we typically use a horizontal mattress configuration as it provides comparable strength while being technically simpler. Suture configuration matters when repairing these tendons, as the repair construct is subjected to substantial tension during the early postoperative period. Thus, fixation strength must be optimized while maintaining technical efficiency in an endoscopic setting. Although several biomechanical studies show the superiority of mattress and locking constructs, the next step is evaluating how these different configurations translate to clinical outcomes.