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Herteleer M, Roussel N, Deroubaix L, Drizenko A, Demondion X. Selective distal block of the infrapatellar branch of the saphenous nerve: anatomical and ultrasonographic insights. Surg Radiol Anat 2025; 47:87. [PMID: 40047960 DOI: 10.1007/s00276-025-03598-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2024] [Accepted: 02/11/2025] [Indexed: 05/13/2025]
Abstract
PURPOSE The infrapatellar branch of the saphenous nerve (IPBSN) plays a critical role in cutaneous innervation of the anterior knee and is frequently implicated in both acute and chronic post-surgical pain. Due to its anatomical variability, precise localization is essential for effective nerve blocks and minimizing iatrogenic injury. This study evaluates the feasibility of two distal ultrasound-guided approaches for selective IPBSN blocks, with the aim of addressing the limitations of proximal techniques. METHODS Anatomical layer-by-layer dissections of two paired lower limbs and transverse cross-sections of a third limb were used to map the IPBSN's course and its relationship to the sartorius muscle. Based on these findings, two distal ultrasound-guided approaches were tested: a proximal medial para-patellar approach at the level of the patella's superior aspect and a distal medial para-patellar approach near the medial femoral condyle. Ultrasound-guided injections (0.1-0.3 mL) targeting the IPBSN were performed on four lower limbs, followed by anatomical validation through dissection. RESULTS The IPBSN was consistently identified as a honeycomb structure within a distinct fascial compartment. Both approaches effectively localized the nerve, with observed diffusion suggesting a potential compartment for selective nerve block. This dual-modality approach of ultrasound imaging and dissection enabled precise IPBSN localization, overcoming topographical variability relative to the sartorius muscle. CONCLUSION Distal ultrasound-guided IPBSN blocks show promise for knee pain management by achieving targeted analgesia while preserving muscle function. Further studies are needed to validate these techniques and refine injection protocols for clinical use.
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Affiliation(s)
- Matthias Herteleer
- Department of Anesthesia and Intensive Care, Lille University Hospital, Lille, F-59000, France.
- Department of Anatomy, University of Lille, UFR 3S, Lille, F-59045, France.
| | - Nathan Roussel
- Department of Anatomy, University of Lille, UFR 3S, Lille, F-59045, France
| | - Lucie Deroubaix
- Department of Anatomy, University of Lille, UFR 3S, Lille, F-59045, France
| | - Antoine Drizenko
- Department of Anesthesia and Intensive Care, Lille University Hospital, Lille, F-59000, France
- Department of Anatomy, University of Lille, UFR 3S, Lille, F-59045, France
| | - Xavier Demondion
- Department of Anatomy, University of Lille, UFR 3S, Lille, F-59045, France
- University of Lille, Lille University Hospital, ULR 7367 - UTML&A - Unité de Taphonomie Médico-Légale & d'Anatomie, Lille, France
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Peng MS, Clendenen SR, Shi GG, Tsui BCH. Infrapatellar branch of saphenous nerve: from anatomy, sonoanatomy to its clinical implications. Reg Anesth Pain Med 2025:rapm-2025-106383. [PMID: 40015723 DOI: 10.1136/rapm-2025-106383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2025] [Accepted: 02/05/2025] [Indexed: 03/01/2025]
Abstract
The infrapatellar branch of the saphenous nerve (IPBSN) is implicated in nerve injury from different knee surgeries because of its intimate course relative to the knee joint capsule. Pain physicians encounter patients in their practice for the management of neuralgia of this nerve or in the context of advanced management of knee osteoarthritis. This article aims to provide a comprehensive review of the anatomy, sonoanatomy, and the intervention of the IPBSN in pain management of infrapatellar neuralgia and chronic knee pain.
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Affiliation(s)
- Michael Sj Peng
- College of Osteopathic Medicine, Kansas City University, Joplin, MO, USA
| | | | - Glenn G Shi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Florida, USA
| | - Ban C H Tsui
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, The Chinese University of Hong Kong - Shenzhen, Shenzhen, Guangdong, China
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Duraiswamy G, Ashraf M, Paul E, K SS, Rajan DV. A randomized controlled trial on oblique incisions for ACL reconstruction: Minimizing sensory deficit without compromising outcome. J Clin Orthop Trauma 2025; 60:102865. [PMID: 39759468 PMCID: PMC11697362 DOI: 10.1016/j.jcot.2024.102865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Revised: 10/27/2024] [Accepted: 12/07/2024] [Indexed: 01/07/2025] Open
Abstract
Aim This randomized controlled trial aimed to evaluate the impact of different incision types (oblique, vertical, and horizontal) for hamstring graft harvest on sensory disturbances and functional outcomes after anterior cruciate ligament (ACL) reconstruction. Methods A total of 118 patients were randomized into three groups: oblique incision (n = 40), vertical incision (n = 40), and horizontal incision (n = 38). Sensory deficits were assessed using Von Frey Filaments at three weeks, three months, and six months postoperatively. Functional outcomes were measured using the International Knee Documentation Committee (IKDC) 2000 Subjective Knee Evaluation score at the 6-month mark. Statistical analyses included ANOVA and post-hoc tests to compare sensory disturbances across groups. Results At 6 months, the oblique incision group demonstrated significantly less sensory disturbance (34.7 mm2 ± 38.6) than the vertical (43.8 mm2 ± 39.1) and horizontal (63.4 mm2 ± 42.4) incision groups (p = 0.031). No significant differences were found between the oblique and vertical incisions. The functional outcomes were comparable across all groups (P > 0.05). Conclusion Compared with vertical and horizontal incisions, oblique incisions for hamstring graft harvesting significantly reduced sensory disturbances without compromising functional outcomes. These findings suggest that careful selection of incision type can improve postoperative sensory outcomes in ACL reconstruction.
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Affiliation(s)
- Gopinath Duraiswamy
- Ortho One Orthopaedic speciality centre, coimbatore, India
- Be Well Hospitals, Chennai, India
| | - Munis Ashraf
- Ortho One Orthopaedic speciality centre, coimbatore, India
- Department of Orthopedics, Saveetha Institute of Medical and Technical Sciences, Thandalam, Tamilnadu, India
| | - Earnest Paul
- Ortho One Orthopaedic speciality centre, coimbatore, India
- Abhinav Bindra Targeting Performance (ABTP) Center, India
| | | | - David V. Rajan
- Ortho One Orthopaedic speciality centre, coimbatore, India
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Egerci OF, Dogruoz F, Asoglu MM, Ertan MB, Yapar A, Kose O. The prognosis of iatrogenic saphenous nerve injuries during hamstring tendon harvesting in anterior cruciate ligament reconstruction. J Orthop Surg Res 2024; 19:428. [PMID: 39049103 PMCID: PMC11267848 DOI: 10.1186/s13018-024-04929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE This study aims to evaluate the long-term outcomes of saphenous nerve (SN) injuries from hamstring tendon harvesting during ACL reconstruction, focusing on clinical results and patient satisfaction after at least two years. Additionally, it investigates the incidence, recovery patterns, and impact of these injuries on functional outcomes, daily activities, and ACL re-rupture rates immediately post-surgery and at final follow-up. MATERIALS AND METHODS A retrospective review was conducted on patients who had undergone ACL reconstruction with hamstring tendon grafts at a single institution between January 2015 and January 2020. The incidence of SN injuries was assessed immediately after surgery and at final follow-up. Additionally, the recovery rate and time were evaluated, and the impact of these injuries on functional outcomes was measured using the Lysholm Knee Score (LKS) and patient-reported effects on daily activities. RESULTS Of the 159 patients analyzed, iatrogenic SN injuries were initially observed in 87 (54.7%) patients post-ACLR. By the final follow-up, paresthesia had resolved in 36 (22.6%) patients within an average of 11.1 months. Persistent SN injuries were recorded in 51 (32.1%) patients, affecting various extents of the infrapatellar branch (IPBSN) and the sartorial branch (SBSN) of the saphenous nerve. Patients with persistent SN injuries experienced a significant impact on daily activities and had lower LKS scores compared to those without injuries or with recovered injuries. Furthermore, a higher re-rupture rate was associated with persistent SN injuries. CONCLUSIONS The study finds that SN injuries during hamstring graft harvesting for ACL reconstruction are common, with a significant portion of patients experiencing persistent sensory deficits for at least two years postoperatively. These injuries are observed to adversely affect patient satisfaction and functional outcomes and to increase the re-rupture rate.
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Affiliation(s)
- Omer Faruk Egerci
- Department of Orthopedics and Traumatology, University of Health Sciences, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd, Muratpasa, Antalya, 07100, Turkey
| | - Fırat Dogruoz
- Department of Orthopedics and Traumatology, University of Health Sciences, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd, Muratpasa, Antalya, 07100, Turkey
| | - Mehmet Melih Asoglu
- Department of Orthopedics and Traumatology, University of Health Sciences, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd, Muratpasa, Antalya, 07100, Turkey
| | - Mehmet Barıs Ertan
- Department of Orthopedics and Traumatology, University of Health Sciences, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd, Muratpasa, Antalya, 07100, Turkey
| | - Aliekber Yapar
- Department of Orthopedics and Traumatology, University of Health Sciences, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd, Muratpasa, Antalya, 07100, Turkey.
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, University of Health Sciences, Antalya Training and Research Hospital, Varlık mah., Kazım Karabekir cd, Muratpasa, Antalya, 07100, Turkey
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Panta S, Joshi A, Basukala B, Sharma R, Singh N, Pradhan I. A comparative study of Infra patellar branch of saphenous nerve injury between vertical and horizontal portal incisions in knee arthroscopy. J Clin Orthop Trauma 2024; 53:102441. [PMID: 38947858 PMCID: PMC11214199 DOI: 10.1016/j.jcot.2024.102441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/29/2024] [Accepted: 06/05/2024] [Indexed: 07/02/2024] Open
Abstract
Background An Infrapatellar Branch of Saphenous Nerve (IPBSN) injury is one of the complications leading to sensory loss in the operated knee. A high incidence of IPBSN injury was reported during hamstring harvest, but there are only a few studies analyzing IPBSN injury during arthroscopy portals. However, there was a lack of randomized comparative studies comparing the incidence of IPBSN injury in horizontal and vertical portals. This study aimed to identify the overall incidence of IPBSN injury and compare the difference between vertical and horizontal portal incisions. We also aimed to observe the recovery pattern of IPBSN injuries in both groups. We hypothesize that since the portal incisions are very small, the incidence of IPBSN injury will be very low, and it will occur more in the vertical incision. Methods After obtaining IRC approval from B&B Hospital IRC, this prospective comparative study was conducted at the AKB center for arthroscopy, sports injury, and regenerative medicine, B&B Hospital. The calculated sample size of 128 consecutive patients was included and divided into groups by the block randomization method. A total of 64 patients were allocated to both groups. Demographic data was recorded. The sensory loss along the IPBSN was examined and documented on the first postoperative day. Their recovery was documented during two weeks and three months of follow-up visits. Parametric and non-parametric tests were applied to analyze the variables. Results IPBSN injury was seen in 12 patients (9.37 %) among 128 study participants. Five patients (7.81 %) had IPBSN injuries in the vertical group compared to seven (10.93 %) in the horizontal group. Recovery was earlier in the horizontal incision group. Conclusion The overall incidence of IPBSN injury during the arthroscopy portal is low. They occur equally in vertical and horizontal portal incisions. The recovery of the IPBSN injury was better and earlier in the horizontal incision group.
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Affiliation(s)
- Sunil Panta
- AKB Center for Arthroscopy, Sports Injuries and Regenerative Medicine, B & B Hospital, Lalitpur, Nepal
| | - Amit Joshi
- AKB Center for Arthroscopy, Sports Injuries and Regenerative Medicine, B & B Hospital, Lalitpur, Nepal
| | - Bibek Basukala
- AKB Center for Arthroscopy, Sports Injuries and Regenerative Medicine, B & B Hospital, Lalitpur, Nepal
| | - Rajiv Sharma
- AKB Center for Arthroscopy, Sports Injuries and Regenerative Medicine, B & B Hospital, Lalitpur, Nepal
| | - Nagmani Singh
- AKB Center for Arthroscopy, Sports Injuries and Regenerative Medicine, B & B Hospital, Lalitpur, Nepal
| | - Ishor Pradhan
- AKB Center for Arthroscopy, Sports Injuries and Regenerative Medicine, B & B Hospital, Lalitpur, Nepal
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Fahandezh-Saddi Díaz H, Ríos Luna A, Villanueva Martínez M, Cantero Yubero ME, Prado R, Padilla S, Anitua E. Surgical Treatment of Saphenous Nerve Injury Assisted by Plasma Rich in Growth Factors (PRGF): Lessons from a Case Report. Clin Pract 2023; 13:1090-1099. [PMID: 37736933 PMCID: PMC10514825 DOI: 10.3390/clinpract13050097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
The infrapatellar branch of the saphenous nerve (SN) is a widely described anatomic and functional structure; however, its relevance in daily clinical practice is underestimated. All surgical procedures performed on the anteromedial aspect of the knee are associated with a risk of iatrogenic injury to this nerve, including knee arthroscopy, knee arthroplasty, tibial nailing, etc. We present the case of a saphenous nerve neuroma after treatment with radiofrequency thermal ablation due to a knee pain problem. After conducting an anaesthetic suppression test, we decided to perform a denervation of the medial saphenous nerve in Hunter's canal. We performed surgery on the anteromedial aspect of the knee. The distal end of the medial SN was coagulated with a bipolar scalpel. The proximal end of the nerve was released proximally, and a termino-lateral suture was made at the free end of the nerve after creating an epineural window to inhibit its growth. A double crush was produced proximally to the suture site to create a grade II-III axonal injury. Autologous plasma rich in growth factors (PRGF) was used to reduce potential post-surgical adhesions and to stimulate regeneration of the surgical lesions. One year after surgery, the patient was living a completely normal life.
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Affiliation(s)
- Homid Fahandezh-Saddi Díaz
- Hand and Upper Extremity Surgery Unit, Hospital Universitario Fundación Alcorcón, 28922 Alcorcón, Spain
- Unit for Ultrasound-Guided Surgery, Hospital Beata María Ana, 28007 Madrid, Spain;
- Department of Traumatology and Orthopedic Surgery, Avanfi Institute, 28015 Madrid, Spain
| | - Antonio Ríos Luna
- Department of Traumatology and Orthopedic Surgery, Clínica Orthoindal, 04004 Almería, Spain;
| | - Manuel Villanueva Martínez
- Unit for Ultrasound-Guided Surgery, Hospital Beata María Ana, 28007 Madrid, Spain;
- Department of Traumatology and Orthopedic Surgery, Avanfi Institute, 28015 Madrid, Spain
| | | | - Roberto Prado
- Regenerative Medicine Laboratory, BTI—Biotechnology Institute I MAS D, 01007 Vitoria, Spain; (R.P.); (S.P.); (E.A.)
| | - Sabino Padilla
- Regenerative Medicine Laboratory, BTI—Biotechnology Institute I MAS D, 01007 Vitoria, Spain; (R.P.); (S.P.); (E.A.)
| | - Eduardo Anitua
- Regenerative Medicine Laboratory, BTI—Biotechnology Institute I MAS D, 01007 Vitoria, Spain; (R.P.); (S.P.); (E.A.)
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Sundararajan SR, Ramakanth R, Jha AK, Rajasekaran S. Outside-in technique versus inside-out semitendinosus graft harvest technique in ACLR: a randomised control trial. Knee Surg Relat Res 2022; 34:16. [PMID: 35346395 PMCID: PMC8962090 DOI: 10.1186/s43019-022-00144-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/28/2022] [Indexed: 11/22/2022] Open
Abstract
Background Paraesthesia after hamstring graft harvest is a ubiquitous complication in the early post-operative period, and its correlation with vertical versus horizontal skin incision are well documented. The purpose of the study is to evaluate the incidence and extent/area of sensory loss of saphenous nerve branches occurring with the outside-in (OI) versus inside-out technique (IO) of semitendinosus graft harvest from the sartorius fascia and to determine a better method of graft harvest. Methods Sixty patients who underwent isolated semitendinosus graft harvest during anterior cruciate ligament reconstruction (ACLR) between 2016 and 2017. Patients were randomised into two groups depending on the graft harvest technique: 30 in the OI group and 30 in the IO group. The area of sensory loss was mapped on the patients’ skin using tactile feedback from the patients at each follow-up (10 days, 1 month, 3 months, 6 months and 1 year). Then, the area of sensory changes for the infrapatellar branch (IPBSN) and sartorial branch (SBSN) of the saphenous nerve, incision length, graft harvest duration, and graft length were analysed statistically between the groups. Results In groups 1 and 2, 18/30 (60%) and 19/30 (63%) of patients, respectively, developed sensory changes, with no significant difference between the groups (p = 0.79). Isolated SBSN and IPBSN paraesthesia occurred in 2/60 (3%) and 19/60 (32%), respectively. Combined SBSN and IPBSN paraesthesia was present in 16/60 (27%) of patients. There was no significant difference in the area of the sensory deficit between OI and IO groups on the 10th post-operative day or at 1-month, 3-month or 1-year follow-up (p = 0.723, p = 0.308, p = 0.478, p = 0.128, respectively). However, at 6-month follow-up, the area of paraesthesia was significantly higher in the IO group (p = 0.009). The length of incision and duration of graft harvest was higher in the OI group than in the IO group (p = 0.002 and p = 0.007, respectively), and the total length of the graft was greater in the IO group (p = 0.04). Conclusion Incidence is equally distributed, area of iatrogenic saphenous nerve injury gradually decreases, and recovery is seen in the majority of the patients in both graft harvest techniques. IO graft harvesting technique is better in terms of graft harvest time and cosmetics and yields longer graft; however, area of paraesthesia, though not significant, was two-fold higher than the OI technique at 1-year follow-up. Clinical relevance IO graft harvest technique would enable the surgeon to adopt quicker graft harvest, smaller surgical scar and lengthier graft than the OI technique. Level of evidence Therapeutic randomised controlled prospective study, Level II.
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Posterior hamstring harvest improves aesthetic satisfaction and decreases sensory complications as compared to the classic anterior approach in anterior cruciate ligament reconstruction surgery. J Exp Orthop 2022; 9:109. [PMID: 36326935 PMCID: PMC9633883 DOI: 10.1186/s40634-022-00547-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose The use of the posterior approach for harvesting hamstring grafts has recently become popular thanks to new all-inside techniques and retrograde drills. This study aims to compare the classic anterior approach with the posterior approach in the popliteal fossa. Methods Retrospective comparative study of 100 consecutive cases of primary ligamentoplasty performed using ipsilateral semitendinosus autograft with at least one year of follow-up. 50 patients with anterior approach (group A) and 50 patients with posterior approach (P). Ratio men/women: 9/1. Mean age: 32 ± 13 years. Mean operative time: 64.88 ± 12.28 min. Study variables Graft harvest time; intraoperative complications (semitendinous [ST] tendon cut); postoperative neurological complications (allodynia, paresthesia, pain) or hematoma in the donor area; atrophy of the operated thigh compared to the contralateral thigh, postoperative VAS score, aesthetic satisfaction and overall satisfaction. Results Graft harvest time of 9.5 min in group A versus 5.25 min in group P (p < 0.05). Sensory complications: 16% in group A versus 2% in group P (p < 0.05). Regarding the patient’s evaluation of the aesthetic result of the surgery, 80% in group A and 92% in group P were very satisfied, 16% in group A and 8% in group P were satisfied and 4% in group A and no patients in group P not very satisfied (p < 0.05). No significant differences were found in terms of total operative time, postoperative joint movement, atrophy of the operated thigh, postoperative VAS, or overall patient satisfaction. Conclusions The posterior approach to harvesting the ipsilateral hamstring graft obtained better results than the anterior approach in terms of aesthetic satisfaction of the patient, lower rate of neurological complications (allodynia, paresthesias and hypoesthesia in the anterior region of the knee and leg) and shorter hamstring harvest time. Level of evidence IV.
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Albishi W, Baltow B, Albusayes N, Sayed AA, Alrabai HM. Hamstring autograft utilization in reconstructing anterior cruciate ligament: Review of harvesting techniques, graft preparation, and different fixation methods. World J Orthop 2022; 13:876-890. [PMID: 36312526 PMCID: PMC9610869 DOI: 10.5312/wjo.v13.i10.876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/16/2022] [Accepted: 08/15/2022] [Indexed: 02/06/2023] Open
Abstract
Rupture of the anterior cruciate ligament (ACL) is a common orthopedic injury. Various graft options are available for the reconstruction of ruptured ACL. Using the hamstring muscle as an autograft was first described in 1934, and it remains a commonly harvested graft for ACL reconstruction. Hamstring autografts can be harvested using the traditional anteromedial approach or the newer posteromedial technique. An isolated semitendinosus tendon can be used or combined with the gracilis tendon. There are numerous methods for graft fixation, such as intra-tunnel or extra-tunnel fixation. This comprehensive review discusses the different hamstring muscle harvesting techniques and graft preparation options and fixation methods. It provides a comprehensive overview for choosing the optimal surgical technique when treating patients.
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Affiliation(s)
- Waleed Albishi
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
| | - Baraa Baltow
- Department of Orthopedic Surgery, AlHada Armed Forces Hospital, Ministry of Defense, AlHada 26792, Saudi Arabia
| | - Nora Albusayes
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
| | - Ameer A Sayed
- Department of Orthopedic Surgery, King Fahad Armed Forces Hospital, Ministry of Defense, Jeddah 23311, Saudi Arabia
| | - Hamza M Alrabai
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
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10
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Zhu B, Li X, Lou T. A modified oblique incision in hamstring tendon graft harvesting during ACL reconstruction. J Orthop Surg Res 2021; 16:206. [PMID: 33752724 PMCID: PMC7983293 DOI: 10.1186/s13018-021-02341-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/09/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND During anterior cruciate ligament (ACL) reconstruction, different methods of harvesting hamstring tendon may lead to different degrees of injury to the inferior patellar branch of the saphenous nerve (IPBSN). Most of recent studies in the literature suggest that the classic oblique incision (COI) can reduce the incidence of IPBSN injury. We proposed a modified oblique incision (MOI) and compared it with the COI in terms of the resulting levels of injury and sensory loss and the clinical outcome. METHODS Patients with ACL injury admitted to our hospital from April 2015 to July 2019 were randomly selected and included in our study. Thirty patients underwent the COI to harvest hamstring tendons, and the other 32 patients underwent the MOI. The pin prick test was performed to detect the sensation loss at 2 weeks, 6 months, and 1 year after the operation. Digital photos of the region of hypoesthesia area were taken, and then, a computer software (Adobe Photoshop CS6, 13.0.1) was used to calculate the area of the hypoesthesia. The length of the incision and knee joint functional score were also recorded. RESULTS At the final follow-up, the incidence of IPBSN injury in COI and MOI were 33.3% and 9.4%, and the areas of paresthesia were 26.4±2.4 cm2 and 9.8±3.4 cm2 respectively. There was no significant difference in the incision length or knee functional score between the two groups. CONCLUSION The MOI can significantly reduce the risk of injury to the IPBSN, reduce the area of hypoesthesia, and lead to high subjective satisfaction. Therefore, compared with the COI, the MOI is a better method of harvesting hamstring tendons in ACL reconstruction.
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Affiliation(s)
- Biao Zhu
- Department of Joint Orthopaedic Surgery and Sports Medicine, Xuzhou Medical University Affiliated Hospital of Tengzhou Central People's Hospital, Xingtan Road 181, Tengzhou, 277500, Shandong, China.
| | - Xuelei Li
- Department of Orthopedics, Guanxian People's Hospital, Dongfeng West Road 51, Liaocheng, Guanxian, 25250, Shandong, China
| | - Tengteng Lou
- Postpartum Health Care Department, Maternal and Child Health Hospital of Tengzhou, Longquan Road 3966, Tengzhou, 277500, Shandong, China
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11
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Boyle J, Eason A, Hartnett N, Marks P. Infrapatellar branch of the saphenous nerve: A review. J Med Imaging Radiat Oncol 2021; 65:195-200. [PMID: 33506584 DOI: 10.1111/1754-9485.13141] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 11/23/2020] [Indexed: 01/11/2023]
Abstract
Iatrogenic injury to the infrapatellar branch of the saphenous nerve (IPBSN) is an uncommon but important complication of both open and arthroscopic procedures causing neuropathic pain symptoms in the anteromedial aspect of the knee. Whilst the use of ultrasound in the assessment of peripheral neuropathies is well-established, sonographic knowledge in the routine assessment of the IPBSN remains poor. We describe the sonographic assessment of the IPBSN by means of a review article, promulgating radiology's role in providing anatomical information pertaining to the IPBSN and its relationship to adjacent anatomical structures, surgical fixations or fibrous scar tissue.
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Affiliation(s)
- Jerome Boyle
- Imaging Associates Group, Melbourne, Victoria, Australia
| | - Alastair Eason
- Imaging Associates Group, Melbourne, Victoria, Australia
| | - Nigel Hartnett
- Melbourne Arthroplasty Sports Knee, Melbourne, Victoria, Australia
| | - Paul Marks
- Imaging Associates Group, Melbourne, Victoria, Australia
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Determinants of regeneration and strength of hamstrings after anterior cruciate ligament reconstruction-fate of hamstring tendon. INTERNATIONAL ORTHOPAEDICS 2021; 45:1751-1760. [PMID: 33409561 DOI: 10.1007/s00264-020-04932-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/29/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Arthroscopic reconstruction of anterior cruciate ligament (ACL) surgical procedure using hamstring autograft is the most common surgery performed in the arena of sports medicine and arthroscopy. Most studies in literature are ambiguous regarding the fate of hamstrings based on function, regenerative potential, and cross-sectional area (CSA). The aim of this research study is analysis of the fate of hamstring tendons (both semitendinosus and gracilis) during the time course for determinants of regeneration and strength. METHODS Fifty patients who were operated for unilateral isolated ACL reconstruction from July 2015 to June 2018 were evaluated for the fate of harvested hamstring tendons which included the following: regeneration, cross-sectional area (CSA), strength, and insertion of regenerated hamstrings by isometric torque and isokinetic strength. MRI of knee was performed for both knees concerning the semitendinosus (ST), gracilis (G), Sartorius, biceps femoris, and medial head of gastrocnemius. RESULTS Eighty-four percent men and 16% women within a mean patient age of 34 ± 4.12 years were evaluated and all 50 (100%) patients demonstrated hamstring regeneration by the MRI measurements at six months and at one year post-ACL reconstruction. The torque of isometric knee flexion measured in 60° was found to be remarkably lower in the ACL-reconstructed lower extremity compared to that of the contralateral limb (87.13 ± 20.18% of BW), at 90° (49.17 ± 15.09% BW), and at 105° (43.91 ± 13.17% BW), respectively (p < 0.01). However, at 30° flexion and 45° flexion, the difference was insignificant (116.48 ± 21.07% BW for 30° and 100.16 ± 25.12% BW for 45°). CONCLUSIONS It was found that the properties of musculotendinous units of ST and G were significantly transformed after their harvesting for ACL reconstruction and these weaknesses contribute to the flexion deficit of knee in the deeper range of flexion in the operated limb. Therefore, approaches facilitating tendon regeneration and preservation must be warranted.
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Luciano AP, Honda RTM, Kamar AR, Franco Filho N, Vieira MC. Anatomical Study of the Infrapatellar Branch of the Saphenous Nerve in Humans. Rev Bras Ortop 2020; 55:557-563. [PMID: 33093719 PMCID: PMC7575379 DOI: 10.1055/s-0040-1701287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 10/30/2019] [Indexed: 11/01/2022] Open
Abstract
Objective To perform an anatomical study of the location of the infrapatellar branch of the saphenous nerve in relation to the structures of the knee. Methods An anatomical study was performed by dissection of 18 humans knees (9 right and 9 left knees). After exposure of the infrapatellar branch and its direct and indirect branches, they were then measured. We adopted a quadrant in the medial region of the knee delimited by two transversal planes as a parameter of the study. Results In 17 of the 18 knees (94.4%) studied, a single infrapatellar branch was observed. The infrapatellar branch emerged as fibers of the womb of the sartorius muscle in 17 of the 18 knees (94.4%). In relation to the branch, we observed that in 100% of the knees the infrapatellar branch had at least one primary branch, resulting in a superior branch and an inferior branch. In 9 limbs (50% of the cases) this branch occurred outside the proposed quadrant, and, in the remaining limbs, it occurred within the quadrant. Conclusion The infrapatellar saphenous nerve branch was found in all dissected knees, and, in 94.4% of the cases, it was of the penetrating type; in 100% of the cases, it originated two primary direct branches. The direct and indirect branches presented great variability regarding their path.
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Affiliation(s)
- Alexandre Paiva Luciano
- Disciplina de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de Taubaté, Taubaté, SP, Brasil.,Serviço de Ortopedia e Traumatologia, Hospital Universitário de Taubaté, Taubaté, SP, Brasil
| | - Renan Toshio Melo Honda
- Serviço de Ortopedia e Traumatologia, Hospital Universitário de Taubaté, Taubaté, SP, Brasil
| | - Anuar Ralio Kamar
- Serviço de Ortopedia e Traumatologia, Hospital Universitário de Taubaté, Taubaté, SP, Brasil
| | - Nelson Franco Filho
- Disciplina de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de Taubaté, Taubaté, SP, Brasil.,Serviço de Ortopedia e Traumatologia, Hospital Universitário de Taubaté, Taubaté, SP, Brasil
| | - Magno César Vieira
- Disciplina de Anatomia Descritiva e Topográfica, Faculdade de Medicina, Universidade de Taubaté, Taubaté, SP, Brasil
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Plancher KD, Alwine JT, Chan JJ, Petterson SC. The Accessory Medial Portal for Anterior Cruciate Ligament Reconstruction: A Safe Zone to Avoid Neurovascular Complications. Orthop J Sports Med 2020; 8:2325967120952674. [PMID: 33029544 PMCID: PMC7522840 DOI: 10.1177/2325967120952674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/09/2020] [Indexed: 01/11/2023] Open
Abstract
Background: The accessory medial portal (AMP) used for anatomic anterior cruciate ligament reconstruction (ACLR) is gaining popularity. This portal is routinely created at 60° of knee flexion, placing the infrapatellar branch of the saphenous nerve (IBSN) and, less commonly, the descending and superior medial genicular arteries at risk. Purpose/Hypothesis: The purpose of this study was to identify a safe zone for AMP placement in ACLR to minimize the risk of injury to the IBSN. We hypothesized that increased knee flexion angles would decrease the risk to neurovascular structures when creating an AMP. Study Design: Descriptive laboratory study. Methods: A total of 20 cadaveric (10 matched pairs) knees were used for dissection to identify the IBSN and other neurovascular structures. A 30° arthroscope was used to make the central medial portal and AMP at 3 knee flexion angles (60°, 90°, and 110°). Distances were measured from the AMP to branches of the IBSN. Safety of AMP placement was analyzed by assessing the frequency at which spinal needles pierced a neurovascular structure or violated a safe zone. Results: The superior IBSN was significantly closer to the AMP than inferior IBSN. The AMP was significantly farther from the superior IBSN at 110° (8.56 ± 5.28 mm) compared with 60° (5.63 ± 5.00 mm; P = .015) and 90° (6.69 ± 5.03 mm; P = .006). A triangular safe zone was identified at 110° of knee flexion. No neurovascular structures were pierced, and the IBSN was not present in the safe zone. At 90°, the IBSN was not pierced; however, the IBSN did violate the safe zone at 90° of knee flexion. Conclusion: The superior IBSN is at risk for iatrogenic injury with an AMP placed at 60° of knee flexion. The nerve moved distally with knee flexion. While no neurovascular structures were compromised at 90° of knee flexion, the nerve was found to course through the safe zone. A safe zone at 110° of knee flexion decreases the risk of neurovascular injury and makes the AMP safe for ACLR. Clinical Relevance: The AMP at 60° of knee flexion for ACLR poses risk to the IBSN. The IBSN did violate the safe zone at 90° of flexion. We recommend creating an AMP with increased knee flexion to 110° to decrease the risk of iatrogenic injury. When establishing an AMP, one should aim for the center of the defined safe zone, given that the spinal needle used in this study has a smaller diameter than a stab incision.
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Affiliation(s)
- Kevin D Plancher
- Department of Orthopaedics, Albert Einstein College of Medicine, New York, New York, USA.,Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | | | - Jimmy J Chan
- Orthopaedic Foundation, Stamford, Connecticut, USA
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15
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Leiter J, Peeler J, McRae S, Wiens S, Hammond A, Froese W, MacDonald P. The Effect of Graft Harvest and Skin Incision Angle on Sensory Disturbance in ACL Reconstruction With Semitendinosus-Gracilis Tendon Graft: A Randomized Controlled Trial and Cadaveric Study. Orthop J Sports Med 2020; 8:2325967120948954. [PMID: 32974411 PMCID: PMC7495944 DOI: 10.1177/2325967120948954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/07/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Injury to the inferior branch of the saphenous nerve (IBSN) and the subsequent loss of skin sensation after anterior cruciate ligament (ACL) reconstruction are common. The literature suggests that the incision angle may affect the incidence and area of loss of skin sensation. Purpose: To determine whether there is a difference in the incidence and area of altered sensory loss on the tibia between vertical (VI) and oblique (OI) incisions for semitendinosus-gracilis tendon graft harvest during ACL reconstruction. The cadaveric component was designed to determine whether there is a “safe zone” for incision by identifying the location and number of branches of the IBSN. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients (n = 37) were randomized to receive either VI or OI. Incidence and area of altered skin sensation were documented during at least 1 postoperative visit. In addition, 18 cadaveric knees were dissected. Results: The presence or absence of hypoesthesia did not differ between groups postoperatively. Although no statistical differences between groups were seen in the total area of perceived altered skin sensation at 3 (P = .57), 6 (P = .08), 12 (P = .65), and 24 months (P = .27), data demonstrated a trend toward VI participants having a larger area of hypoesthesia at every time point. Among the 18 cadaveric specimens, 4 variations in the distribution of IBSN were noted: 18 (100%) had 1 branch, 14 (78%) had 2 branches, 6 (33%) had 3 branches, and 1 (6%) had 4 branches. No safe zone for incision could be identified. Conclusion: No difference was found between a vertical and an oblique incision with respect to incidence or area of sensory loss. Furthermore, it was not possible to identify a safe zone that would prevent transection of all nerves branches of the IBSN based on the cadaveric component of this study.
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Affiliation(s)
- Jeffrey Leiter
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada.,Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jason Peeler
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada.,Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sheila McRae
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada.,Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Scott Wiens
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada
| | - Allan Hammond
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada.,Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Warren Froese
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada
| | - Peter MacDonald
- Pan Am Clinic Foundation, Winnipeg, Manitoba, Canada.,Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
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Clinical and electrophysiological assessment of injury to infrapatellar branch(es) of saphenous nerve during anterior cruciate ligament reconstruction using oblique incision for hamstring graft harvest: A prospective study. Knee 2020; 27:709-716. [PMID: 32563427 DOI: 10.1016/j.knee.2020.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/10/2020] [Accepted: 04/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND One of the complications of arthroscopic reconstruction of anterior cruciate ligament (ACL) using hamstring autograft is injury to the infrapatellar branch of the saphenous nerve (IPBSN) leading to loss of sensation around the knee. Its incidence varies according to the orientation of incision for hamstring graft harvest, with oblique incision having the lowest chance of this injury. Aim of this study was to assess clinically and electrophysiologically injury to IPBSN after ACL reconstruction using oblique incision for hamstring graft harvest. METHODS Fifty patients that were scheduled to undergo arthroscopic ACL reconstruction were included. All the patients were evaluated both clinically and electrophysiologically preoperatively and at three weeks and six months postoperatively to determine injury to IPBSN. Patient satisfaction after surgery was also compared. RESULTS IPBSN injury was found to be present in 12 out of 50 patients (24%). Both clinical and electrophysiological data correlated completely. The difference in the length of the skin incisions between IPBSN injured and IPBSN intact patients was found to be statistically significant (P = .0043). The difference in the satisfaction score between patients with injured and intact IPBSN was also found to be statistically significant (P = .02). CONCLUSIONS Oblique incision for hamstring graft harvest results in lower incidence of IPBSN injury and subsequent sensory loss when compared with similar studies with different skin incisions carried out in the past. Patients undergoing ACL reconstruction should be counseled preoperatively regarding this potential complication, and if this complication occurs, improvement can be expected with time.
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Wisbech Vange S, Tranum-Jensen J, Krogsgaard MR. Gracilis tendon harvest may lead to both incisional and non-incisional saphenous nerve injuries. Knee Surg Sports Traumatol Arthrosc 2020; 28:969-974. [PMID: 31270589 DOI: 10.1007/s00167-019-05605-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/24/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE The purpose of this study was to map saphenous nerve injuries after gracilis tendon harvest, with the aim of contributing knowledge that makes it possible to prevent these injuries. METHODS Twenty-two cadaver limbs were used. Three were dissected to examine fascial structures between the saphenous nerve and the gracilis tendon. In 19 limbs, the gracilis tendon was harvested according to standard operative routine. The saphenous nerve was subsequently exposed by dissection and injuries were recorded. RESULTS A well-defined sub-sartorial fascial layer separated the saphenous nerve from the gracilis tendon. Incisional injuries involving either a medial cutaneous crural branch or the infrapatellar branch were found in 14 of the 19 cases. Non-incisional injuries affecting the sartorial branch of the saphenous nerve (to conform to most surgical literature, we use the term 'sartorial branch' to denote the continuation of the saphenous nerve after departure of the infrapatellar branch) were found in six cases located 5-8 cm proximal and posterior to the gracilis tendon insertion on tibia. The fascia separating the saphenous nerve from the gracilis tendon had been perforated in relation to all non-incisional injuries. CONCLUSIONS Small subcutaneous branches of the saphenous nerve are at risk of injury from the incision, while the sartorial branch is at risk outside the incision area. Descriptions of the location of non-incisional injuries have not been published before and are of clinical relevance, as they can contribute to the prevention of saphenous nerve injuries during gracilis tendon harvest.
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Affiliation(s)
- Signe Wisbech Vange
- Department of Cellular and Molecular Medicine, The Panum Institute, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark.
| | - Jørgen Tranum-Jensen
- Department of Cellular and Molecular Medicine, The Panum Institute, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - Michael Rindom Krogsgaard
- Section for Sports Traumatology M51, Bispebjerg-Frederiksberg Hospital, A Part of IOC Research Center Copenhagen, Nielsine Nielsens Vej 3, 2400, Copenhagen NV, Denmark
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Olivos-Meza A, Suarez-Ahedo C, Jiménez-Aroche CA, Pantanali N, Valdez-Chávez MV, Pérez-Jiménez FJ, Olivos-Díaz B, Olivos-Gárces NA, González-Hernández A, Ibarra C. Anatomic Considerations in Hamstring Tendon Harvesting for Ligament Reconstruction. Arthrosc Tech 2020; 9:e191-e198. [PMID: 32021795 PMCID: PMC6993570 DOI: 10.1016/j.eats.2019.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/24/2019] [Indexed: 02/03/2023] Open
Abstract
Hamstring tendon autograft remains a popular graft choice for anterior cruciate ligament reconstruction. Although the technique of hamstring autograft harvest is relatively straightforward, it is critical to pay attention to several technical steps to avoid iatrogenic anatomic or neurovascular damage as well as to reduce the risk of premature amputation of the graft when using a tendon stripper. We describe a technique of hamstring autograft harvesting using only 2 anatomic references that makes it a simple and reproducible technique for surgeons, especially those in training.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Clemente Ibarra
- Address correspondence to Clemente Ibarra, M.D., Ph.D., Orthopaedic Sports Medicine and Arthroscopy, Instituto Nacional de Rehabilitación “Luis Guillermo Ibarra Ibarra,” Calzada México-Xochimilco 289, ZC 14389, Mexico City, Mexico.
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Abstract
A small portion of patients suffer from severe knee pain following previous knee surgery or a trauma. Awareness among traumatologists regarding a neuropathic origin of this persistent knee pain is poor. Ongoing pain close to the knee may be caused by damage of the infrapatellar nerve (IN). This branch of the saphenous nerve is purely sensory and is at risk for iatrogenic damage due to its superficial medial course. Once recognized using simple tests during physical examination, a variety of treatment modalities may be proposed. However, a standard treatment algorithm was hitherto absent. This study includes 15 patients having IN damage who were offered a step-up regimen including lidocaine injections, pulsed radiofrequency (PRF) or neurectomy. Success (>50% drop in numeric rating scale pain score) was attained in 11 (73% success rate, 9 month median follow-up). The aim of this contribution is to increase knowledge regarding this illusive entity and to discuss the efficacy of our treatment protocol.
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20
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Xiang Y, Li Z, Yu P, Zheng Z, Feng B, Weng X. Neuroma of the Infrapatellar branch of the saphenous nerve following Total knee Arthroplasty: a case report. BMC Musculoskelet Disord 2019; 20:536. [PMID: 31722713 PMCID: PMC6854730 DOI: 10.1186/s12891-019-2934-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/05/2019] [Indexed: 01/11/2023] Open
Abstract
Background Injury to the infrapatellar branch of the saphenous nerve (IBSN) is common during total knee arthroplasty (TKA) with a standard midline skin incision. Occasionally, painful neuromas form at the transection of nerve and cause pain and limitation of the range of motion of the knee joint. Case presentation A 70-year-old woman experienced right knee pain and stiffness for 4 years after TKA. Physical assessment revealed medial tenderness; Tinel’s sign was positive. Radiographs revealed that the prosthesis was well-placed and well-fixed. She was diagnosed with arthrofibrosis and possible neuroma after TKA. She underwent right knee exploration, neurectomy, adhesiolysis and spacer exchange. The neuroma-like tissue was sent for pathological examination. The patient recovered uneventfully and at 3-month follow-up reported no recurrence of pain or stiffness. The pathological report confirmed the diagnosis of neuroma. Conclusions IBSN injury should be a concern if surgeons encounter a patient who has pain and stiffness after TKA. Tinel’s sign, local anesthetic injection, MRI and ultrasound could help the diagnosis and identify the precise location of neuroma. Surgical intervention should be performed if necessary.
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Affiliation(s)
- Yongbo Xiang
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical Colleage, Chinese Academy of Medical Science, No.1 Shuaifuyuan, Dongcheng District, Beijing, 10073, China
| | - Zeng Li
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical Colleage, Chinese Academy of Medical Science, No.1 Shuaifuyuan, Dongcheng District, Beijing, 10073, China
| | - Peng Yu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical Colleage, Chinese Academy of Medical Science, No.1 Shuaifuyuan, Dongcheng District, Beijing, 10073, China
| | - Zhibo Zheng
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical Colleage, Chinese Academy of Medical Science, No.1 Shuaifuyuan, Dongcheng District, Beijing, 10073, China
| | - Bin Feng
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical Colleage, Chinese Academy of Medical Science, No.1 Shuaifuyuan, Dongcheng District, Beijing, 10073, China
| | - Xisheng Weng
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical Colleage, Chinese Academy of Medical Science, No.1 Shuaifuyuan, Dongcheng District, Beijing, 10073, China.
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21
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van Dijk W, van Eerten P, Scheltinga M. [Infrapatellar nerve damage : A neglected cause of severe localized leg pain-German version]. Unfallchirurg 2019; 122:860-863. [PMID: 31712851 DOI: 10.1007/s00113-019-00721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A small portion of patients suffer from severe knee pain following previous knee surgery or a trauma. Awareness among traumatologists regarding a neuropathic origin of this persistent knee pain is poor. Ongoing pain close to the knee may be caused by damage of the infrapatellar nerve (IN). This branch of the saphenous nerve is purely sensory and is at risk for iatrogenic damage due to its superficial medial course. Once recognized using simple tests during physical examination, a variety of treatment modalities may be proposed. However, a standard treatment algorithm was hitherto absent. This study includes 15 patients having IN damage who were offered a step-up regimen including lidocaine injections, pulsed radiofrequency (PRF) or neurectomy. Success (>50% drop in numeric rating scale pain score) was attained in 11 (73% success rate, 9 month median follow-up). The aim of this contribution is to increase knowledge regarding this illusive entity and to discuss the efficacy of our treatment protocol.
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Affiliation(s)
- William van Dijk
- Máxima Medical Center, De Run 4600, Postbus 7777, 5500MB, Veldhoven, Niederlande
| | - Percy van Eerten
- Máxima Medical Center, De Run 4600, Postbus 7777, 5500MB, Veldhoven, Niederlande
| | - Marc Scheltinga
- Máxima Medical Center, De Run 4600, Postbus 7777, 5500MB, Veldhoven, Niederlande.
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Kim KI, Juh HS, Kim GB, Lee SH. Lateral numbness in the lower leg: An underestimated complication following medial open-wedge high tibial osteotomy. Knee 2019; 26:1041-1048. [PMID: 31350156 DOI: 10.1016/j.knee.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/28/2019] [Accepted: 07/01/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aimed to investigate the incidence, degree, and natural course of lateral numbness following medial open-wedge high tibial osteotomy (MOWHTO). It also evaluated which predisposing factors would affect lateral numbness following MOWHTO. METHODS One-hundred and sixty-nine knees that underwent MOWHTO for treatment of varus osteoarthritis with a minimum follow-up of three years were enrolled. Lateral numbness in the lower leg was assessed with the light-touch method using a cotton wool ball and compared with the contralateral leg. Patients were classified into groups based on a scale according to grading of sensation to light touch. To assess the improvement of lateral numbness, lower leg sensation was investigated using a sensory score compared with the contralateral leg. The predisposing factors that would affect lateral numbness were assessed. RESULTS Lateral numbness was observed in 87 knees (51.5%) at six weeks postoperatively. Although 69 knees improved over time, 18 knees showed no improvement to the latest follow-up. The level of skin incision showed a significant association with lateral numbness on univariate and multivariate analyses: the higher the level of skin incision, the greater the degree of estimated numbness. CONCLUSIONS About half the patients reported postoperative lateral numbness in the lower leg following MOWHTO. Of the patients with lateral numbness, approximately one-fifth remained symptom until the last follow-up. The level of skin incision might be a risk factor for lateral numbness. Pre-operative patient education concerning the likelihood of lateral numbness is recommended. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Kang-Il Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea; Department of Orthopedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Hyung-Suk Juh
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Gi Beom Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea.
| | - Sang Hak Lee
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea; Department of Orthopedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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Lösungen für häufige Komplikationen bei vorderer Kreuzbandoperation. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-00310-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Keyhani S, Kazemi SM, Sajjadi MM, Elmi A. A Comparison between Oblique and Vertical Incisions on the Hamstring Tendon Harvesting in Anterior Cruciate Ligament Reconstruction and Infrapatellar Branch Injury of the Saphenous Nerve. Rev Bras Ortop 2019; 55:374-379. [PMID: 32616985 PMCID: PMC7316540 DOI: 10.1055/s-0039-1692695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/13/2019] [Indexed: 01/26/2023] Open
Abstract
Objective The present study aimed to compare the oblique and vertical incisions in hamstring tendon harvesting in anterior cruciate ligament (ACL) reconstruction and in infrapatellar branch injury of the saphenous nerve. Methods The present study was conducted at a tertiary referral center for 12 months. Patients with an indication of reconstruction of ACL tear were included in the study, who were then randomized into two groups (vertical [VG] and oblique [OG] groups). After excluding a few cases, 92 patients were eligible for further analysis (VG: n= 44; OG: n = 48). They were followed-up for 9 months after the surgery, and loss of sensation over the knee and over the proximal aspect of the operated leg was recorded. Results The mean lengths of the incisions were 27 mm and 38 mm for the OG and VG groups, respectively. The total rate of hypoesthesia was 40% (27 patients). A total of 12 (25%) and 25 patients (56.8%) on the OG and VG groups, respectively, reported hypoesthesia symptoms. The presence of hypoesthesia in patients in the VG group was two times higher than in the OG group. No statistical correlation was observed between the nerve injury and age, gender, education, and delay from injury to reconstruction. Conclusion Oblique incision, which showed lower risk of nerve damage, might be more recommended for graft harvesting. Patients who underwent reconstruction of the ACL in the OG group had a lower incidence of peri-incisional hypoesthesia when compared to those in the VG group.
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Affiliation(s)
- Sohrab Keyhani
- Departamento Ortopédico, Shahid Beheshti University of Medical Sciences, Akhtar Hospital, Tehran, Iran
| | - Seyyed Morteza Kazemi
- Departamento Ortopédico, Shahid Beheshti University of Medical Sciences, Akhtar Hospital, Tehran, Iran
| | | | - Asghar Elmi
- Departamento Ortopédico, Shahid Beheshti University of Medical Sciences, Akhtar Hospital, Tehran, Iran.,Departamento Ortopédico, Tabriz University of Medical Sciences, Shohada Hospital, Tabriz, Iran
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Campos GCD, Nunes LFB, Arruda LRP, Teixeira PEP, Amaral GHA, Alves Junior WDM. CURRENT PANORAMA OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION SURGERY IN BRAZIL. ACTA ORTOPEDICA BRASILEIRA 2019; 27:146-151. [PMID: 31452610 PMCID: PMC6699397 DOI: 10.1590/1413-785220192703182208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aims to establish the current panorama of the anterior cruciate ligament reconstruction surgery in Brazil. METHODS A survey that consisted of a 24-item questionnaire including surgeon's demographics, preferred technique, graft selection, graft positioning, use of braces, drains, antibiotic prophylaxis and most common complications was conducted at the last three editions of a national knee surgery event. RESULTS Six hundred eight questionnaires were analyzed. Brazilian knee surgeons are mostly male, with mean age of 42 years (26-68) and are affiliated to at least one orthopedic society. Thirty-six percent (36%) perform more than 50 reconstructions per year. The preferred graft is the hamstring tendons graft (64%). The frequency of use of anatomical technique increased approximately from 55% from 2011 to 2013, to 85.5% in 2015 (p<0.001). From 2011 to 2015, there was a progressive reduction from 56.8% to 18.1% in the frequency of use of transtibial femoral tunnel drilling (p<0.001). CONCLUSION Our findings show that Brazilian knee surgeons' preferences are evolving according to the current world practice. Level of Evidence V, Economic and Decision analysis study.
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Babu S, Gupte C, Gajjar S, Morris H. The 'sentinel' vessel: an anatomical landmark to identify the pes anserinus during hamstrings harvest for ACL reconstruction. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1115-1118. [PMID: 30826874 DOI: 10.1007/s00590-019-02408-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/25/2019] [Indexed: 01/11/2023]
Abstract
Hamstrings identification and subsequent graft harvest can be made difficult by body habitus and variability in tendon anatomy. We describe a 'sentinel' blood vessel near the insertions of gracilis and semitendinosus to facilitate identification. A prospective study of 100 patients (100 knees) undergoing primary arthroscopic ACL reconstruction (via the anterior approach) with hamstrings graft was conducted. We searched for a 'sentinel' vessel and studied its position, orientation and perpendicular distance from the pes tendons. The 'sentinel' vessel was present in 98/100 knees. It passed from the superficial fascia to the periosteum at the pes insertion at a mean perpendicular distance of 8 mm from the upper border of the pes tendons. The 'sentinel' vessel was a consistent anatomical finding and served as a reliable guide in determining the pes insertion. Identifying this anatomical landmark allowed a small skin incision with limited wound dissection minimising risk of injury to the infra-patellar branch of the saphenous nerve.
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Affiliation(s)
- Satish Babu
- Frimley Park Hospital, Portsmouth Road, Frimley, GU16 7UJ, UK.
| | | | | | - Hayden Morris
- St. Vincent's & Mercy Hospitals, Melbourne, Australia
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No difference in sensory outcome between vertical and oblique incisions for hamstring graft harvest during ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:146-152. [PMID: 30019072 DOI: 10.1007/s00167-018-5057-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 07/11/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE To compare the incidence, extent of sensory loss, its clinical effect and natural course caused by sensory nerve injury, during two different skin incisions used for autogenous hamstring graft harvest during ACL reconstruction. METHODS This randomized prospective study was carried out on 84 patients, divided into two groups, all of them underwent arthroscopic ACL reconstruction using hamstring tendon graft with two incisions; a vertical incision used in 43 patients, and an oblique incision in 41 patients. The location and area of sensory loss were evaluated during follow-up as well as the degree of improvement and patient satisfaction. RESULTS The average age in this study was 29.8 ± 7.2 in the vertical group and 29.9 ± 6.3 in the oblique group. Both semitendinosus and gracilles were harvested in 34 patients, semitendinosus in 49 patients and gracilles in one patient. In the vertical group, a higher incidence of sensory loss was recorded with 21 patients (51.2%), relative to the oblique group with 18 patients (41.9%). However, there was no statistically significant difference (p = n.s). Most of the sensory loss affected the distribution of the IPBSN (infrapatellar branch of saphenous nerve) in 27 patients (69.2%) in both groups, and to a lesser extent in the lower medial area [distribution of SBSN (sartorial branch of saphenous nerve)] in 12 patients (30.8%). CONCLUSION This study clearly revealed the high incidence of nerve injury particularly the IPBSN during hamstring graft harvest, but did not prove a difference between oblique and vertical incisions, with regard to postoperative sensory loss. It was clear that harvesting the semitendinosus alone is not a factor that can diminish nerve injury. LEVEL OF EVIDENCE II.
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Batistaki C, Saranteas T, Chloros G, Savvidou O. Ultrasound-guided Saphenous Nerve Block for Saphenous Neuralgia after Knee Surgery: Two Case Reports and Review of Literature. Indian J Orthop 2019; 53:208-212. [PMID: 30906004 PMCID: PMC6394177 DOI: 10.4103/ortho.ijortho_520_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Saphenous neuralgia is characterized by persistent neuropathic pain at the distribution of the saphenous nerve. Injury to the saphenous nerve, and specifically to its infrapatellar branch of the saphenous nerve has been implicated as a cause of medial knee pain after orthopedic knee surgery or trauma. We present two cases of saphenous neuralgia, one after total knee arthroplasty and the other after anterior cruciate ligament reconstruction, that were adequately treated with ultrasound-guided saphenous nerve blocks distal to the adductor canal. Early recognition and treatment of saphenous neuralgia is essential to prevent persistent disabling pain, which significantly affects patients' quality of life.
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Affiliation(s)
- Chrysanthi Batistaki
- 2nd Department of Anaesthesiology School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece,Address for correspondence: Dr. Chrysanthi Batistaki, 2nd Department of Anaesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, 1 Rimini Street, Chaidari, Athens, 12462, Greece. E-mail:
| | - Theodosios Saranteas
- 2nd Department of Anaesthesiology School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece
| | - George Chloros
- 1st Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece
| | - Olga Savvidou
- 1st Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, Athens, Greece
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Palazzolo A, Rosso F, Bonasia DE, Saccia F, Rossi R. Uncommon Complications after Anterior Cruciate Ligament Reconstruction. JOINTS 2018; 6:188-203. [PMID: 30582108 PMCID: PMC6301892 DOI: 10.1055/s-0038-1675799] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023]
Abstract
Anterior cruciate ligament reconstruction (ACL-R) is a common surgical procedure, with good outcome in 75 to 97% of the cases. However, different complications have been described including infection, hemarthrosis, deep vein thrombosis (DVT), and pulmonary embolism (PE) with a rate ranging from 1 to 15%. There are few case reports in the literature describing rare complications after ACL-R and they can be divided into: (1) complications related to the fixation device (rupture, migration); (2) fractures (tibial or femoral side); (3) infections due to uncommon bacteria, mycobacterium, and mycosis; (4) rare vascular injuries; (5) nerve injuries; and (6) other rare complications. In case of fixation device rupture or migration, device removal can be easy but the diagnosis may be challenging. Patellar fracture after ACL-R may be related to harvesting and it is not uncommon. Conversely, femoral or tibial fractures are most frequently due to bone weakness related to bone tunnels. Some rare infections related to uncommon bacteria or mycosis are also described with potentially devastating joint damage. Popliteal artery injuries are uncommon in ACL-R but minor vessels damages are described with possible severe consequences for patients. Injuries to the infrapatellar branch of the saphenous nerve are not uncommon in ACL-R. However, there are few case reports also describing injuries to the saphenous nerve, the common peroneal nerve and the sciatic nerve. The aim of this paper is to review the literature describing uncommon complications after ACL-R, giving some more information about diagnosis and treatment.
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Affiliation(s)
- Anna Palazzolo
- Department of Orthopedics and Traumatology, Università degli studi di Torino, Turin, Italy
| | - Federica Rosso
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano, Turin, Italy
| | | | - Francesco Saccia
- Orthopaedics and Traumatology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Roberto Rossi
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano, Turin, Italy
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Olewnik Ł, Gonera B, Kurtys K, Podgórski M, Polguj M, Sibiński M, Topol M. The Anterolateral Ligament of the Knee: A Proposed Classification System. Clin Anat 2018; 31:966-973. [PMID: 30144325 DOI: 10.1002/ca.23267] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/08/2018] [Accepted: 08/17/2018] [Indexed: 12/30/2022]
Abstract
The anterolateral ligament (ALL) is a potential stabilizer of the knee and cooperates with the anterior cruciate ligament (ACL). It originates on the lateral epicondyle of the femur, to which it is mainly posterior and proximal; insertion is posterior to Gerdy's tubercle. Its anatomical characteristics vary. Recent publications have focused on morphological variations concerning mainly the femoral and tibial attachments, and on morphometric measurements. Histological and cystochemical examinations have also been performed. Classical anatomical dissection was performed on 111 lower limbs (25 isolated and 86 paired) fixed in 10% formalin. The knee region was dissected using traditional techniques and the morphological features of the ALL were assessed: morphometric measurements and the types of ALL. The ALL was present in 70 individuals (37 woman and 33 men). In 30 cases, it was absent symmetrically, and in 11, it was present on just one side (P = 0.0011). The ALL was morphologically very variable. In type I (the most common form - 64.3%), a single band traveled parallel to the fibular collateral ligament (FCL); in type II the band crossed it. In type III, the origin was located on the lateral epicondyle of the femur and also on the lateral-posterior surface of the joint capsule, and the insertion was in the deep fascia of the leg: this type could be called a capsule. Type IV was characterized by a double ALL, type IIb by ligaments that bifurcated, and type V by the ALL starting directly from the FCL rather than the femoral epicondyle. The ALL is characterized by high morphological variability, both in its femoral and in its tibial attachments and in its course. Clin. Anat. 31:966-973, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Łukasz Olewnik
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
| | - Bartosz Gonera
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
| | - Konrad Kurtys
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
| | - Michał Podgórski
- Department of Diagnostic Imaging Lodz, Polish Mother's Memorial Hospital Research Institute, Poland
| | - Michał Polguj
- Department of Angiology, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
| | - Marcin Sibiński
- Clinic of Orthopaedics and Paediatric Orthopaedics, Medical University of Lodz, Poland
| | - Mirosław Topol
- Department of Normal and Clinical Anatomy, Interfaculty Chair of Anatomy and Histology, Medical University of Lodz, Poland
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Grassi A, Perdisa F, Samuelsson K, Svantesson E, Romagnoli M, Raggi F, Gaziano T, Mosca M, Ayeni O, Zaffagnini S. Association between incision technique for hamstring tendon harvest in anterior cruciate ligament reconstruction and the risk of injury to the infra-patellar branch of the saphenous nerve: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2018; 26:2410-2423. [PMID: 29423546 DOI: 10.1007/s00167-018-4858-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 02/02/2018] [Indexed: 12/24/2022]
Abstract
PURPOSE To determine how the incision technique for hamstring tendon (HT) harvest in anterior cruciate ligament (ACL) reconstruction affects the risk of injury to the IPBSN and clinical outcome. METHODS A systematic literature search of the MEDLINE/Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL) and EBSCOhost electronic databases and clinicaltrials.gov for unpublished studies was performed to identify comparative studies investigating injury to the IPBSN after HT ACL reconstruction by comparing at least two different incision techniques. Data were extracted for the number of patients with evidence of any neurologic deficit corresponding to injury to the IPBSN, area of sensory deficit, the Lysholm score and patient satisfaction. The mean difference (MD) in study outcome between incision groups was assessed. The relative risk (RR) and the number needed to treat (NNT) were calculated. The Chi-square and Higgins' I2 tests were applied to test heterogeneity. Data were pooled using a Mantel-Haenszel random-effects model if the statistical heterogeneity was > 50% and a fixed-effects model if the statistical heterogeneity was < 50%. The risk of bias was evaluated according to the Cochrane Database questionnaire and the quality of evidence was graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. RESULTS A total of eight studies (three randomized controlled trials (RCTs) and five comparative studies) were included, of which six compared vertical and oblique incisions, one horizontal and vertical incisions, and one compared all three techniques. HT harvest was performed through a vertical incision in 329 patients, through an oblique incision in 195 patients and through a horizontal incision in 151 patients. Considering the meta-analysis of the RCTs, the performance of a vertical incision significantly increased the risk of causing IPBSN deficiency compared with both oblique and horizontal incision [RR 1.65 (CI 1.10-2.49, p = 0.02) and RR 2.45 (CI 1.73-3.47, p < 0.0001), respectively]. A significantly larger area of sensory deficit was found with vertical incisions compared with oblique ones, with an MD of 22.91 cm2 (95% CI 7.73-38.08; p = 0.04). No significant differences were found between the incision techniques in relation to patient-reported outcomes. The same trend was obtained after the performing a meta-analysis of all eight included studies. The quality of evidence in this meta-analysis was determined as "low" to "moderate", mostly due to inadequate methods of randomization and high heterogeneity among the included studies. CONCLUSION The performance of a vertical incision to harvest HTs for ACL reconstruction significantly increased the risk of iatrogenic injury to the IPBSN compared with both oblique and horizontal incisions. LEVEL OF EVIDENCE Level I-III, meta-analysis of comparative studies.
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Affiliation(s)
- Alberto Grassi
- Sicily Department, Rizzoli Orthopaedic Institute, Bagheria, Palermo, Italy
- II Orthopaedic Clinic, Rizzoli Orthopadic Institute, University of Bologna, Via di Barbiano 1/10, 40136, Bologna, Italy
| | - Francesco Perdisa
- Sicily Department, Rizzoli Orthopaedic Institute, Bagheria, Palermo, Italy.
- II Orthopaedic Clinic, Rizzoli Orthopadic Institute, University of Bologna, Via di Barbiano 1/10, 40136, Bologna, Italy.
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Eleonor Svantesson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Matteo Romagnoli
- Sicily Department, Rizzoli Orthopaedic Institute, Bagheria, Palermo, Italy
| | - Federico Raggi
- Sicily Department, Rizzoli Orthopaedic Institute, Bagheria, Palermo, Italy
| | - Teide Gaziano
- Sicily Department, Rizzoli Orthopaedic Institute, Bagheria, Palermo, Italy
| | - Massimiliano Mosca
- II Orthopaedic Clinic, Rizzoli Orthopadic Institute, University of Bologna, Via di Barbiano 1/10, 40136, Bologna, Italy
| | - Olufemi Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Stefano Zaffagnini
- Sicily Department, Rizzoli Orthopaedic Institute, Bagheria, Palermo, Italy
- II Orthopaedic Clinic, Rizzoli Orthopadic Institute, University of Bologna, Via di Barbiano 1/10, 40136, Bologna, Italy
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Grabowski R, Gobbi A, Zabierek S, Domzalski ME. Nonspecific Chronic Anteromedial Knee Pain Neuroma as a Cause of Infrapatellar Pain Syndrome: Case Study and Literature Review. Orthop J Sports Med 2018; 6:2325967117751042. [PMID: 29404377 PMCID: PMC5791473 DOI: 10.1177/2325967117751042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Radoslaw Grabowski
- Department of Orthopaedics and Traumatology, Medical University of Lodz, Lodz, Poland
| | | | - Sebastian Zabierek
- Department of Orthopaedics and Traumatology, Medical University of Lodz, Lodz, Poland
| | - Marcin E Domzalski
- Department of Orthopaedics and Traumatology, Medical University of Lodz, Lodz, Poland
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Henry BM, Tomaszewski KA, Pękala PA, Graves MJ, Pękala JR, Sanna B, Mizia E. Oblique incisions in hamstring tendon harvesting reduce iatrogenic injuries to the infrapatellar branch of the saphenous nerve. Knee Surg Sports Traumatol Arthrosc 2018; 26:1197-1203. [PMID: 28573437 PMCID: PMC5876253 DOI: 10.1007/s00167-017-4590-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/26/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE Iatrogenic injury to the infrapatellar branch of the saphenous nerve (IPBSN) is associated with many surgical interventions to the medial aspect of the knee, such as anterior cruciate ligament (ACL) reconstruction. Different types of surgical incisions during hamstring tendon harvesting for ACL reconstruction are related to a variable risk of IPBSN injury. This study aimed to evaluate the risk of iatrogenic IPBSN injury during hamstring tendon harvesting for ACL reconstruction with different incision techniques over the pes anserinus. METHODS This study was performed on 100 cadavers. Vertical, horizontal, or oblique incisions were simulated on each cadaveric limb to determine the incidence of iatrogenic IPBSN injury. RESULTS The vertical incision caused the IPBSN injury during hamstring tendon harvesting in 101 (64.7%), the horizontal incision in 78 (50.0%), and the oblique incision in 43 (27.6%) examined lower limbs. The calculated odds ratios (OR) for risk of injury in vertical versus horizontal and horizontal versus oblique incisions were 2.4 (95% CI 1.5-3.6) and 1.8 (95% 1.2-2.8), respectively. CONCLUSIONS The vertical incision technique over the pes anserinus should be avoided during hamstring tendon harvesting for ACL reconstruction. The adoption of an oblique incision, with the shortest possible length, will allow for the safest procedure possible, thus minimizing the risk of iatrogenic IPBSN injury, and improving patient outcomes and postoperative quality-of-life.
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Affiliation(s)
- Brandon Michael Henry
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31–034 Krakow, Poland ,0000 0001 2162 9631grid.5522.0Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31–034 Krakow, Poland
| | - Krzysztof A. Tomaszewski
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31–034 Krakow, Poland ,0000 0001 2162 9631grid.5522.0Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31–034 Krakow, Poland
| | - Przemysław A. Pękala
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31–034 Krakow, Poland ,0000 0001 2162 9631grid.5522.0Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31–034 Krakow, Poland
| | - Matthew J. Graves
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31–034 Krakow, Poland ,0000 0001 2162 9631grid.5522.0Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31–034 Krakow, Poland
| | - Jakub R. Pękala
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31–034 Krakow, Poland ,0000 0001 2162 9631grid.5522.0Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31–034 Krakow, Poland
| | - Beatrice Sanna
- International Evidence-Based Anatomy Working Group, 12 Kopernika St, 31–034 Krakow, Poland ,0000 0004 1755 3242grid.7763.5Faculty of Medicine and Surgery, University of Cagliari, S.S. 554 Bivio Sestu, 09042 Monserrato, CA, Sardinia Italy
| | - Ewa Mizia
- 0000 0001 2162 9631grid.5522.0Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika St, 31–034 Krakow, Poland
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Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: Systematic review of literature. Orthop Traumatol Surg Res 2017; 103:S245-S248. [PMID: 28888527 DOI: 10.1016/j.otsr.2017.09.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 08/23/2017] [Indexed: 02/02/2023]
Abstract
UNLABELLED Anterior cruciate ligament (ACL) reconstruction can be performed with an autograft, which is most often harvested from the patient's hamstring tendon (HT) or patellar tendon (PT). However, autograft harvesting leads to morbidity that is by no means insignificant. A systematic review of literature was performed to define the incidence of complications related to graft harvesting and the methods to prevent these complications. In March 2017, a systemic review of literature was performed using the keywords"harvesting", "harvest", "morbidity", "complication", "cruciate ligament". No time limit was applied. The studies had to be written in French or English with their abstract available online. This initial search based on the title and abstract identified 133 articles. Two independent observers analyzed each article entirely, including the references. In all, 36 articles were retained. The main complication of HT harvesting was sensory deficit because of damage to the infrapatellar branches of the saphenous nerve. This complication occurred in 39.7% to 88% of patients. This risk can be reduced by using a horizontal or oblique incision. The main complication following PT harvesting is anterior knee pain, reported in up to 46% of patients. There are substantial numbers of short-, medium- and long-term complications related to the harvesting of the two main ACL autografts. Effective means of prevention exist to reduce the risk of these complications. LEVEL OF EVIDENCE II Systematic review of literature.
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Ruffilli A, De Fine M, Traina F, Pilla F, Fenga D, Faldini C. Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review. Knee Surg Sports Traumatol Arthrosc 2017; 25:3140-3145. [PMID: 27338956 DOI: 10.1007/s00167-016-4217-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 06/14/2016] [Indexed: 12/30/2022]
Abstract
PURPOSE Infrapatellar branch of saphenous nerve injury is a common complication following hamstring graft harvest during anterior cruciate ligament reconstruction. The direction of skin incision performed at proximal tibial metaphysis may affect the rate of iatrogenic nerve damage. Aim of the present systematic review was to evaluate evidence that would substantiate the adoption of one incision over another for hamstring graft harvesting. METHODS The available literature was systematically screened searching studies dealing with iatrogenic injury to the saphenous nerve after anterior cruciate ligament reconstruction using hamstring tendons. A search was performed using the keywords "Saphenous" and "Infrapatellar branch" in combination with "Anterior cruciate ligament", "arthroscopy" and "hamstrings", supplying no limits regard the publication year. Coleman methodological score was performed in all the retained articles. RESULTS Five articles matched the inclusion criteria. There were two randomized controlled trials, one prospective comparative study and two retrospective comparative series. Poor methodological quality was found overall. A vertical incision was found to significantly affect the presence of hypoesthesia and the extent of the area of sensory loss in three articles; no difference was registered in one, and a trend towards a lower rate of iatrogenic nerve damage using an oblique incision was found in the remaining one, without any statistical significance. CONCLUSION Although the low methodological quality of the analysed studies does not permit to draw definitive conclusions, the anatomical course of the nerve along with the results obtained in the available studies seems to suggest lower rate of neurological impairment adopting an oblique incision. This kind of incision may therefore be preferred in the routine clinical practice. LEVEL OF EVIDENCE Systematic review, Level II.
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Affiliation(s)
- A Ruffilli
- Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, Km 246, 90011, Bagheria, PA, Italy
| | - M De Fine
- Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, Km 246, 90011, Bagheria, PA, Italy.
| | - F Traina
- Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, Km 246, 90011, Bagheria, PA, Italy
| | - F Pilla
- Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, Km 246, 90011, Bagheria, PA, Italy
| | - D Fenga
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University Hospital "G.Martino", Messina, Italy
| | - C Faldini
- Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, SS 113, Km 246, 90011, Bagheria, PA, Italy
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Ochiai S, Hagino T, Senga S, Yamashita T, Oda K, Haro H. Injury to infrapatellar branch of saphenous nerve in anterior cruciate ligament reconstruction using vertical skin incision for hamstring harvesting: risk factors and the influence of treatment outcome. J Orthop Surg Res 2017; 12:101. [PMID: 28655325 PMCID: PMC5488375 DOI: 10.1186/s13018-017-0596-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 06/14/2017] [Indexed: 12/17/2022] Open
Abstract
Background Injury to the infrapatellar branch of the saphenous nerve (IPBSN) is a high-frequency complication in anterior cruciate ligament (ACL) reconstruction. We analyzed the risk factor of IPBSN injury in ACL reconstruction. Moreover, we investigated the influence on treatment outcome by this complication. Methods One hundred twenty-three patients who underwent ACL reconstruction using semitendinosus tendon graft were studied. Gender, age, BMI, and additional use of gracilis tendon were recorded. Treatment outcome was assessed by Lysholm score, visual analog scale (VAS) pain score, anterior knee pain, knee range of motion (ROM), and the patient-based SF-36. Patients who developed sensory disturbance at 24 months after reconstruction were compared with those without sensory disturbance. Results Twenty-six of 123 patients (21.1%) developed postoperative sensory disturbance caused by IPBSN injury. Baseline parameters were not significantly different compared to those in the non-sensory disturbance group. In the sensory disturbance group, treatment outcome evaluated at 24 months post-reconstruction showed Lysholm score of 94.1, VAS of 9.8 mm, anterior knee pain in 7.7%, and limitation of knee extension of 5° in 7.7%. SF-36 scores in all subscales were above the mean national standard scores. Treatment outcome parameters were also not significantly different compared to those in the non-sensory disturbance group, and none of the patients had serious impairment of knee function and activities of daily living. Conclusion Injury to IPBSN in ACL reconstruction was not related to age, gender, and physique, and injury frequency did not increase. Evaluation of postoperative treatment outcome showed that IPBSN injury was not related to anterior knee pain or knee ROM limitation, and patients’ subjective evaluation confirmed no serious impact on physical and mental health.
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Affiliation(s)
- Satoshi Ochiai
- The Sports Medicine and Knee Center, National Hospital Organization, Kofu National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi, 400-8533, Japan.
| | - Tetsuo Hagino
- The Sports Medicine and Knee Center, National Hospital Organization, Kofu National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi, 400-8533, Japan
| | - Shinya Senga
- The Sports Medicine and Knee Center, National Hospital Organization, Kofu National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi, 400-8533, Japan
| | - Takashi Yamashita
- The Sports Medicine and Knee Center, National Hospital Organization, Kofu National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi, 400-8533, Japan
| | - Kotaro Oda
- The Sports Medicine and Knee Center, National Hospital Organization, Kofu National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi, 400-8533, Japan
| | - Hirotaka Haro
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Yamanashi, 1110, Shimokato, Chuo, Yamanashi, 409-3898, Japan
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Pękala PA, Miza E, Henry BM, Popieluszko P, Loukas M, Tomaszewski KA. Injury to the infrapatellar branch of the saphenous nerve during tendon graft harvesting for knee ligament reconstruction: An ultrasound simulation study. Clin Anat 2017; 30:868-872. [DOI: 10.1002/ca.22904] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/26/2017] [Indexed: 01/26/2023]
Affiliation(s)
- Przemysław A. Pękala
- International Evidence-Based Anatomy Working Group; Krakow Poland
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
| | - Ewa Miza
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
| | - Brandon Michael Henry
- International Evidence-Based Anatomy Working Group; Krakow Poland
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
| | - Patrick Popieluszko
- International Evidence-Based Anatomy Working Group; Krakow Poland
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
| | - Marios Loukas
- Department of Anatomical Sciences; St. George's University; Grenada
| | - Krzysztof A. Tomaszewski
- International Evidence-Based Anatomy Working Group; Krakow Poland
- Department of Anatomy; Jagiellonian University Medical College; Krakow Poland
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Nerve injury during anterior cruciate ligament reconstruction: A comparison between patellar and hamstring tendon grafts harvest. Knee 2017; 24:564-569. [PMID: 28404457 DOI: 10.1016/j.knee.2017.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/08/2016] [Accepted: 03/24/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tendon harvesting for anterior cruciate ligament reconstruction often injures sensory branches of the saphenous nerve. The reports on the prevalence of these injuries are scarce, while the implications on patient satisfaction are not known. Our objective was to compare the prevalence of sensory nerve injuries in patellar to hamstring autograft harvesting for anterior cruciate ligament reconstructions and follow up their postoperative course. METHODS Between 2012 and 2014, patients who had a primary anterior cruciate ligament reconstruction with bone patellar tendon bone or hamstring autografts were included (n=94). We evaluated and compared demographic details, level of activity and postoperative sensation disturbances between both groups. Data was analyzed retrospectively. RESULTS The mean postoperative follow-up time was 23months. At the last follow-up 46 (77%) patients of the patellar tendon group and 22 (58%) of the hamstring tendons group reported on reduced sensation; however, in both groups a quarter of these patients experienced full recovery within an average of seven to eight months. There were more patients in the hamstring tendons group that reported on partial recovery. In most cases midline incisions for patellar tendons harvesting injured the infrapatellar branch and medial incisions for hamstring tendons harvesting injured the sartorial branch of the saphenous nerve. CONCLUSIONS Harvesting tendon autografts for anterior cruciate ligament reconstructions by vertical incisions had high prevalence of saphenous nerve branches injury with a minor possibility for complete recovery within the first year. The loss of sensation was perceived by patients as a minor complication. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Pękala PA, Tomaszewski KA, Henry BM, Ramakrishnan PK, Roy J, Mizia E, Walocha JA. Risk of iatrogenic injury to the infrapatellar branch of the saphenous nerve during hamstring tendon harvesting: A meta‐analysis. Muscle Nerve 2017; 56:930-937. [DOI: 10.1002/mus.25587] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2017] [Indexed: 12/29/2022]
Affiliation(s)
| | | | | | - Piravin Kumar Ramakrishnan
- International Evidence‐Based Anatomy Working GroupKrakow Poland
- Department of AnatomyJagiellonian University Medical College12 Kopernika St, 31–034Krakow Poland
| | - Joyeeta Roy
- International Evidence‐Based Anatomy Working GroupKrakow Poland
- Department of AnatomyJagiellonian University Medical College12 Kopernika St, 31–034Krakow Poland
| | - Ewa Mizia
- Department of AnatomyJagiellonian University Medical College12 Kopernika St, 31–034Krakow Poland
| | - Jerzy A. Walocha
- International Evidence‐Based Anatomy Working GroupKrakow Poland
- Department of AnatomyJagiellonian University Medical College12 Kopernika St, 31–034Krakow Poland
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Pectoralis Major Tear with Retracted Tendon: How to Fill the Gap? Reconstruction with Hamstring Autograft and Fixation with an Interference Screw. Case Rep Orthop 2017; 2017:2095407. [PMID: 28251005 PMCID: PMC5303850 DOI: 10.1155/2017/2095407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/05/2016] [Accepted: 01/09/2017] [Indexed: 01/11/2023] Open
Abstract
Rupture of the pectoralis major tendon is considered an uncommon injury and a significant number of ruptures are missed or diagnosed late, leading to a chronic tear. We report an open reconstruction technique and its outcomes in a case of chronic and retracted PM tear. At the last follow-up (12 months), the patient was pain-free, with a visual analogic scale at 0 all the time. He was very satisfied concerning the cosmetic and clinical results. The constant score was 93%, the SST value 95%, and the Quick DASH score 4.5. MRI performed one year postoperatively confirmed the continuity between PM tendon and graft, even if the aspect of the distal tendon seemed to be thinner than normal PM tendon. The excellent clinical outcomes at one-year follow-up suggest that PM tear with major tendon retraction can be reliably reconstructed with hamstring autograft, using a bioabsorbable screw to optimize the fixation device. This technique has proven its simplicity and efficiency to fill the gap.
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Sipahioglu S, Zehir S, Sarikaya B, Levent A. Injury of the infrapatellar branch of the saphenous nerve due to hamstring graft harvest. J Orthop Surg (Hong Kong) 2017; 25:2309499017690995. [PMID: 28219309 DOI: 10.1177/2309499017690995] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Sensory disturbance around the surgical incision due to injury of the infrapatellar branch of the saphenous nerve can be seen in the anterior cruciate ligament reconstruction. In this research, we aimed to compare the incidence, extent of sensory loss, its clinical effect, and natural course caused by two different skin incisions used for hamstring graft harvest. METHODS Vertical incision for 36 patients and oblique incision for 42 patients used for graft harvest were included in this study. Sensory loss areas were documented at 6th week, 3rd month and 6th month. Pin prick examination is used to detect the change in sensation. Digital photographs of hypaesthesia were taken and analysed by computer for area detection. The length of incision and subjective complain of sensory loss were also noted. RESULTS At 6th month, 77% (28/36) of the vertical incisions were associated with persistent sensory loss when compared to the oblique incision (45%, 19/42). The measured area of hypaesthesia was significantly higher in vertical incision (42.4 ± 22.3 cm2) than that in oblique incision (9.3 ± 15.3 cm2) at 6th month. The area of hypaesthesia gradually shrunk in size from distal to proximal in direction. Also, subjective cutaneous anaesthesia was higher in vertical incision (15/36, 41%) than oblique incision (6/41, 14%) at 6th month. CONCLUSION Oblique incision with less risk of nerve damage is better for graft harvesting. Area of hypaesthesia gradually reduces with time and even recover totally. As a possible complication, nerve injury and its benign prognosis should be explained to the patient before surgery.
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Affiliation(s)
- Serkan Sipahioglu
- 1 Department of Orthopedics and Traumatology, Harran University, Sanliurfa, Turkey
| | - Sinan Zehir
- 2 Department of Orthopedics and Traumatology, Hitit University, Corum, Turkey
| | - Baran Sarikaya
- 1 Department of Orthopedics and Traumatology, Harran University, Sanliurfa, Turkey
| | - Ali Levent
- 3 Department of Orthopedics and Traumatology, Harran University Medical Faculty, Sanliurfa, Turkey
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Leite ML, da Cunha FA, da Costa BQM, Andrade RM, Diniz Junior JH, Frois Temponi E. Relação da disestesia peri‐incisional com os acessos vertical e oblíquo na retirada dos tendões flexores na reconstrução do ligamento cruzado anterior do joelho. Rev Bras Ortop 2016. [DOI: 10.1016/j.rbo.2016.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Leite ML, Cunha FAD, Costa BQMD, Andrade RM, Diniz Junior JH, Temponi EF. Relationship between peri-incisional dysesthesia and the vertical and oblique incisions on the hamstrings harvest in anterior cruciate ligament reconstruction. Rev Bras Ortop 2016; 51:667-671. [PMID: 28050538 PMCID: PMC5198108 DOI: 10.1016/j.rboe.2016.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 01/07/2016] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To compare the incidence of peri-incisional dysesthesia according to the skin incision technique for hamstring tendon graft harvest in anterior cruciate ligament reconstruction. METHODS Thirty-three patients with ACL rupture were separated in two groups: group 1, with 19 patients submitted to the oblique skin incision to access the hamstrings and group 2-14 patients operated by vertical skin incision technique. The selected patients were assessed after surgery. Demographic data and prevalence of dysesthesia was measured by digital pressure around the skin incision and classified according to the Highet scale. RESULTS The total rate of dysesthesia was 42% (14 patients). Five patients (26%) on the oblique incision group reported dysesthesia symptoms. On the group submitted to the vertical incision technique, the involvement was 64% (nine patients). On the 33 knees evaluated, the superior lateral area was the most affected skin region, while the superior medial and inferior medial regions were affected in only one patient (7.1%). No statistical differences between both groups were observed regarding patients' weight, age, and height¸ as well as skin incision length. CONCLUSION Patients who underwent reconstruction of the anterior cruciate ligament using the oblique access technique had five times lower incidence of peri-incisional dysesthesia when compared with those in whom the vertical access technique was used.
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Affiliation(s)
- Marcos Laube Leite
- Fundação Hospitalar São Francisco de Assis de Belo Horizonte, Grupo de Cirurgia do Joelho, Belo Horizonte, MG, Brazil
| | - Fernando Amaral da Cunha
- Fundação Hospitalar São Francisco de Assis de Belo Horizonte, Grupo de Cirurgia do Joelho, Belo Horizonte, MG, Brazil
| | | | - Rodrigo Moura Andrade
- Fundação Hospitalar São Francisco de Assis de Belo Horizonte, Serviço de Ortopedia, Belo Horizonte, MG, Brazil
| | - Jose Henrique Diniz Junior
- Fundação Hospitalar São Francisco de Assis de Belo Horizonte, Grupo de Cirurgia do Joelho, Belo Horizonte, MG, Brazil
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Colombet P, Graveleau N. Minimally Invasive Anterior Semitendinosus Harvest: A Technique to Decrease Saphenous Nerve Injury. Arthrosc Tech 2016; 5:e139-42. [PMID: 27274445 PMCID: PMC4885910 DOI: 10.1016/j.eats.2015.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/27/2015] [Indexed: 02/03/2023] Open
Abstract
Hamstring tendon harvest, especially semitendinosus harvest, has been widely used in anterior cruciate ligament reconstruction for many years. However, donor site morbidity has been described regarding the infrapatellar branch of the saphenous nerve. Minimally invasive anterior semitendinosus harvest is a simple, safe, reproducible, and elegant technique. A 2-cm vertical incision above the pes anserinus is performed 2 cm medial to the tibial anterior tubercle. The fascia superficialis is opened with a horizontal incision, and the gracilis is isolated using a retractor. The semitendinosus is grabbed with a probe, and the vincula are hooked one by one. The tendon is harvested with a closed stripper. The expansions are cut, and the tendon is detached from the bone with part of the periosteum.
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Affiliation(s)
- Philippe Colombet
- Address correspondence to Philippe Colombet, M.D., Clinique du Sport, 2 rue Negrevergne, 33700 Mérignac, France.Clinique du Sport2 rue Negrevergne33700 MérignacFrance
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Minimally invasive semitendinosus tendon harvesting from the popliteal fossa versus conventional hamstring tendon harvesting for ACL reconstruction: A prospective, randomised controlled trial in 100 patients. Knee 2016; 23:106-10. [PMID: 26753501 DOI: 10.1016/j.knee.2015.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 08/01/2015] [Accepted: 09/01/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aims to compare a technique for hamstring tendon harvesting from a postero-medial incision in the popliteal fossa with the conventional method. METHODS One hundred patients who underwent anterior cruciate ligament (ACL)-reconstruction were randomised to either have their tendon graft harvested from postero-medial (group 1) or via an antero-medial approach (group 2). Time for tendon harvest, length of skin incision and duration of tendon harvest were recorded as well as complications and sensory disturbances in the lower leg. Pain scores were documented on the VAS scale. RESULTS Time for tendon harvesting averaged one minute 23 s in group 1 versus five minutes 20 s in group 2 (p<0.01). The skin incision measured 21 mm (group 1) versus 49 mm in group 2 (p<0.01). The length of the harvested tendon averaged 272 mm (group 1) and 292 mm in group 2 (p<0.01). There was one superficial wound infection in group 2 and none in group 1. Postoperative pain scores were similar in both groups. None of the patients in group 1 reported sensory disturbance in the lower leg, whilst seven patients in group 2 were found to have reduced sensation in the distribution of the saphenous nerve postoperatively (p<0.01). CONCLUSION This study confirms that harvesting the semitendinosus tendon from postero-medial is quicker, results in a shorter scar and reduces the risk of injury to branches of the saphenous nerve. However, harvesting the tendon from postero-medial resulted in a shorter tendon graft. LEVEL OF EVIDENCE Level I (Randomised, controlled trial).
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de Padua VBC, Nascimento PED, Silva SC, de Gusmão Canuto SM, Zuppi GN, de Carvalho SMR. Saphenous nerve injury during harvesting of one or two hamstring tendons for anterior cruciate ligament reconstruction. Rev Bras Ortop 2015; 50:546-9. [PMID: 26535201 PMCID: PMC4610978 DOI: 10.1016/j.rboe.2015.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/17/2014] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess whether harvesting of two hamstring tendons (semitendinosus and gracilis) has the same rate of nerve injury as harvesting of the semitendinosus tendon alone, used as a triple graft. METHODS Changes in sensitivity relating to injury of the infrapatellar branch of the saphenous nerve were evaluated in 110 patients six months after they underwent anterior cruciate ligament (ACL) reconstruction using hamstring tendons. They were divided into two groups: one in which only the semitendinosus was used and the other, the semitendinosus and gracilis. RESULTS The group in which only the semitendinosus was used as a graft presented a nerve injury rate of 36.1%. In the group in which the semitendinosus and gracilis tendons were used, 58.1% of the patients presented altered sensitivity. In the general assessment on all the patients, the nerve injury rate was 50.9%. CONCLUSION Harvesting the semitendinosus alone and using it in triple form is a viable option for ACL reconstruction and may give rise to fewer nerve injuries relating to branches of the saphenous nerve.
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Walshaw T, Karuppiah SV, Stewart I. The course and distribution of the infra patellar nerve in relation to ACL reconstruction. Knee 2015; 22:384-8. [PMID: 26100316 DOI: 10.1016/j.knee.2014.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 10/03/2014] [Accepted: 11/10/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A common complication after ACL (anterior cruciate ligament reconstruction) is injury to the infra-patellar branch of the saphenous nerve (IPBSN). Very little about its origin and course of this nerve has been described. The aim of this study was to understand the course of IPBSN in relation to surgery around the knee. MATERIALS AND METHOD The course of the nerve was dissected and traced in 25 knees from 14 cadaveric knees (10 males; four females). An incision was made posterior to the medial condyle of the tibia and continued deeper towards the saphenous nerve which is located under the sartorius muscle. The saphenous nerve branch was then followed to distally supply the anterior leg (IPBSN). The relationship of saphenous nerve and IPBSN to each other and the hamstrings were recorded. RESULTS Four paths of IPBSN, in relation to the sartorius muscle, were identified: (1) posterior--inferior posterior border of the muscle, (2) transmuscular--penetrating through the muscle, (3) anterior--anterior border of the muscle, (4) posterior patellar--posterior of the muscle at the level of the patellar bone and (5) combined. The posterior pathway of IPSBN was the most common (57%) and had the closest proximity to the tendons of semitendinosus and gracilis muscles. The terminal branches of the IPSBN crossed over the patellar tendon in every dissection. CONCLUSIONS A posterior path IPBSN is more prone to damage during a tendon harvest due to its proximity to the gracilis and semitendinosus muscle tendons.
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Affiliation(s)
- T Walshaw
- Aberdeen University, Department of Anatomy, Suttie Centre, Foresterhill, Aberdeen AB25 2ZD, United Kingdom
| | - S V Karuppiah
- Dept of Trauma & Orthopaedic Surgery, Nottingham University Hospital NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom.
| | - I Stewart
- Aberdeen University, Department of Anatomy, Suttie Centre, Foresterhill, Aberdeen AB25 2ZD, United Kingdom
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Padua VBCD, Nascimento PED, Silva SC, Canuto SMDG, Zuppi GN, Carvalho SMRD. Lesão do nervo safeno na retirada de 1 ou 2 tendões flexores na reconstrução do ligamento cruzado anterior. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2014.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Gali JC, Resina AF, Pedro G, Neto IAM, Almagro MAP, da Silva PAC, Caetano EB. Importance of anatomically locating the infrapatellar branch of the saphenous nerve in reconstructing the anterior cruciate ligament using flexor tendons. Rev Bras Ortop 2015; 49:625-9. [PMID: 26229872 PMCID: PMC4487444 DOI: 10.1016/j.rboe.2013.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/11/2013] [Indexed: 01/10/2023] Open
Abstract
Objective To describe the path of the infrapatellar branch of the saphenous nerve (IBSN) using the medial joint line, anterior tibial tuberosity (ATT), tibial collateral ligament and a horizontal line parallel to the medial joint line that passes over the ATT, as reference points, in order to help surgeons to diminish the likelihood of injuring this nerve branch during reconstruction of the anterior cruciate ligament (ACL) using flexor tendons. Methods Ten frozen knees that originated from amputations were examined. Through anatomical dissection performed with the specimens flexed, we sought to find the IBSN, from its most medial and proximal portion to its most lateral and distal portion. Following this, the anatomical specimens were photographed and, using the ImageJ software, we determined the distance from the IBSN to the medial joint line and to a lower horizontal line going through the ATT and parallel to the first line. We also measured the angle of the direction of the path of the nerve branch in relation to this lower line. Results The mean angle of the path of the nerve branch in relation to the lower horizontal line was 17.50 ± 6.17°. The mean distance from the IBSN to the medial joint line was 2.61 ± 0.59 cm and from the IBSN to the lower horizontal line, 1.44 ± 0.51 cm. Conclusion The IBSN was found in all the knees studied. In three knees, we found a second branch proximal to the first one. The direction of its path was always from proximal and medial to distal and lateral. The IBSN was always proximal and medial to the ATT and distal to the medial joint line. The medial angle between its direction and a horizontal line going through the ATT was 17.50 ± 6.17°.
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Affiliation(s)
- Julio Cesar Gali
- Orthopedics and Traumatology Service, School of Medical Sciences and Health of Sorocaba, Pontifical Catholic University of São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - André França Resina
- Orthopedics and Traumatology Service, School of Medical Sciences and Health of Sorocaba, Pontifical Catholic University of São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Gabriel Pedro
- Orthopedics and Traumatology Service, School of Medical Sciences and Health of Sorocaba, Pontifical Catholic University of São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Ildefonso Angelo Mora Neto
- Orthopedics and Traumatology Service, School of Medical Sciences and Health of Sorocaba, Pontifical Catholic University of São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Marco Antonio Pires Almagro
- Orthopedics and Traumatology Service, School of Medical Sciences and Health of Sorocaba, Pontifical Catholic University of São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Phelipe Augusto Cintra da Silva
- Orthopedics and Traumatology Service, School of Medical Sciences and Health of Sorocaba, Pontifical Catholic University of São Paulo (PUC-SP), Sorocaba, SP, Brazil
| | - Edie Benedito Caetano
- Orthopedics and Traumatology Service, School of Medical Sciences and Health of Sorocaba, Pontifical Catholic University of São Paulo (PUC-SP), Sorocaba, SP, Brazil
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Roussignol X, Bertiaux S, Rahali S, Potage D, Duparc F, Dujardin F. Minimally invasive posterior approach in the popliteal fossa for semitendinosus and gracilis tendon harvesting: an anatomic study. Orthop Traumatol Surg Res 2015; 101:167-72. [PMID: 25701163 DOI: 10.1016/j.otsr.2014.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 11/26/2014] [Accepted: 12/07/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Harvesting the semitendinosus (ST) and gracilis (GR) tendons at the anteromedial side of the knee may be hampered by a conjoint tendon insertion on the tibial metaphysis and an accessory bundle between the ST and the medial gastrocnemius. Locating and sparing the terminal branches of the saphenous nerve are difficult on an anteromedial approach. The principal objective of the present anatomic study was to assess the feasibility of ST and GR harvesting from a minimally invasive posterior approach in the popliteal fossa. The secondary objective was to analyze the risk of saphenous nerve branch lesion during harvesting. METHOD Ten cadaver knees, free of scarring, were used. The whole body was positioned supine. The tendons were located in the popliteal fossa with the knee in 30° flexion. A mini-incision was performed in the fossa. The ST and GR tendons were located, and retrograde followed by anterograde stripping was performed. Tendon lengths and diameters were measured. The knees were then dissected to check for saphenous nerve branch lesions (anterior, infrapatellar and posterior branches). RESULTS The GR and ST tendons were respectively located at 14.4 and 24 mm from the medial edge of the knee. In 90% of cases, there was an accessory ST bundle toward the medial gastrocnemius muscle, 26 mm below the posterior edge. Tendons could be harvested without deviation of the stripper. Knee dissection did not find any saphenous nerve branches, these being protected by the sartorius fascia. DISCUSSION Posterior ST and GR tendon harvesting in the popliteal fossa is reliable and reproducible. It allows easy sectioning of the accessory ST bundle, without deviation during retrograde stripping. Unlike anterior harvesting, which leads to a rate of saphenous branch lesion of 50-78%, posterior harvesting protects the nerve branches by keeping away from the sartorius. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- X Roussignol
- Département de chirurgie orthopédique et traumatologique, CHU Rouen - Charles-Nicolle, 1, rue de Germont, 76031 Rouen, France.
| | - S Bertiaux
- Hôpital privé de l'Estuaire, 505, rue Irène-Joliot-Curie, 76620 Le Havre, France
| | - S Rahali
- Département de chirurgie orthopédique et traumatologique, CHU Rouen - Charles-Nicolle, 1, rue de Germont, 76031 Rouen, France
| | - D Potage
- Département de chirurgie orthopédique et traumatologique, CHU Rouen - Charles-Nicolle, 1, rue de Germont, 76031 Rouen, France
| | - F Duparc
- Laboratoire d'anatomie, faculté de médecine de Rouen, 22, boulevard Gambetta, 76183 Rouen, France
| | - F Dujardin
- Département de chirurgie orthopédique et traumatologique, CHU Rouen - Charles-Nicolle, 1, rue de Germont, 76031 Rouen, France
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