• Anatomical variations
• Infrapatellar branch of the saphenous nerve (IPBSN)
• Knee pain management
• Regional anesthesia
• Ultrasound

• Humans
• Ultrasonography, Interventional
• Nerve Block/methods
• Cadaver
• Feasibility Studies
• Patella/innervation
• Patella/diagnostic imaging
• Male
• Female
• Knee Joint/innervation
• Knee Joint/diagnostic imaging
• Dissection
• Femoral Nerve/diagnostic imaging
• Femoral Nerve/anatomy & histology

• Acute Pain
• Analgesia
• Cryoablation
• Pain Management

• ACL reconstruction
• Functional outcomes
• Hamstring graft harvest
• Incision types
• Safe zones
• Sensory disturbance
• Von frey filaments

• Humans
• Anterior Cruciate Ligament Reconstruction/adverse effects
• Anterior Cruciate Ligament Reconstruction/methods
• Female
• Male
• Adult
• Retrospective Studies
• Hamstring Tendons/transplantation
• Iatrogenic Disease
• Young Adult
• Prognosis
• Peripheral Nerve Injuries/etiology
• Tissue and Organ Harvesting/adverse effects
• Tissue and Organ Harvesting/methods
• Adolescent
• Follow-Up Studies
• Middle Aged
• Patient Satisfaction
• Recovery of Function
• Incidence
• Treatment Outcome

• Infrapatellar branch of saphenous nerve
• Knee arthroscopy
• Portal incisions

• PRGF
• pain
• platelet-rich plasma
• saphenous nerve
• surgery

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.

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.

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).

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.

IO graft harvest technique would enable the surgeon to adopt quicker graft harvest, smaller surgical scar and lengthier graft than the OI technique.

Therapeutic randomised controlled prospective study, Level II.

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.

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.

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.

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.

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.

IV.

• ACL reconstruction
• Popliteal fossa
• Posterior harvesting
• Saphenous nerve injury
• Semitendinosus tendon

• Anterior cruciate ligament
• Anterior cruciate ligament reconstruction
• Graft fixation
• Hamstring autograft
• Infrapatellar nerve injury
• Patient reported outcomes

• Anterior cruciate ligament
• Hamstring tendon
• Inferior patellar branch of saphenous nerve

• infrapatellar
• knee
• nerve
• post-operative
• ultrasound

• Anterior cruciate ligament (ACL) reconstruction
• Functional outcome
• Hamstring tendon autograft
• Hamstring tendon regeneration
• Knee arthroscopy
• Recovery

• anatomy
• knee/innervation
• nerve compression syndromes

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.

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.

Descriptive laboratory study.

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.

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.

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.

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.

• ACL reconstruction
• accessory medial portal
• infrapatellar branch of the saphenous nerve
• superior medial genicular artery

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.

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.

Randomized controlled trial; Level of evidence, 2.

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.

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.

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.

• anterior cruciate ligament
• hypoesthesia
• inferior branch of saphenous nerve
• oblique incision
• vertical incision

• Anterior cruciate ligament
• Electrophysiological study.
• Hamstring graft.
• Infrapatellar branch of saphenous nerve.
• Oblique incision.

• Cadaver study
• Gracilis tendon harvest
• Saphenous nerve injury

• Chronic pain
• Knee
• Lidocaine
• Neurectomy
• Pulsed radiofrequency treatment

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.

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.

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.

• Complication
• Neuroma
• Total knee arthroplasty

• Chronic pain
• Knee
• Lidocaine
• Neurectomy
• Pulsed radiofrequency treatment

• Complication
• High tibial osteotomy
• Infrapatellar branch
• Lateral numbness
• Medial open-wedge high tibial osteotomy
• Saphenous nerve

• anterior cruciate ligament
• oblique incision
• reconstruction
• saphenous nerve

• Anterior Cruciate Ligament
• Knee
• Reconstruction
• Surgery
• Survey

• ACL
• Graft
• Hamstrings
• Morbidity
• Pes anserinus
• Sentinel blood vessel

• ACL reconstruction
• Hamstring graft
• Oblique incision
• Saphenous nerve injury
• Vertical incision

• Knee
• neuralgia
• pain

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.

• anterior cruciate ligament
• complication
• rare
• reconstruction
• uncommon

• anterolateral ligament
• knee
• knee joint
• new classification

• ACL
• Anterior cruciate ligament
• Graft
• Hamstring
• Incision
• Infrapatellar
• Nerve injury
• Reconstruction

• Anterior Cruciate Ligament Injuries/surgery
• Anterior Cruciate Ligament Reconstruction/methods
• Hamstring Tendons/transplantation
• Humans
• Patella/innervation
• Peripheral Nerve Injuries/etiology
• Postoperative Complications
• Risk Factors
• Tissue and Organ Harvesting/adverse effects

• anteromedial knee pain
• infrapatellar branch of saphenous nerve
• infrapatellar nerve
• infrapatellar neuroma
• infrapatellar pain syndrome
• prepatellar nerve

• ACL
• Anterior cruciate ligament reconstruction
• Cadaveric simulation
• Hamstrings
• IPBSN
• Iatrogenic injury
• Infrapatellar branch of the saphenous nerve
• Tendon harvesting

• Hamstring
• Harvesting site
• Nerve complication
• Patellar ligament
• Patellar tendon
• Prevention

• ACL reconstruction
• Complications
• Hamstring tendons harvest
• Saphenous nerve injury

• Anterior Cruciate Ligament/surgery
• Anterior Cruciate Ligament Reconstruction/methods
• Female
• Hamstring Tendons/transplantation
• Humans
• Male
• Middle Aged
• Peripheral Nerve Injuries/etiology
• Peripheral Nerve Injuries/surgery
• Prospective Studies
• Retrospective Studies

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.

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.

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.

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.

• Anterior cruciate ligament injury
• Infrapatellar branch of saphenous nerve
• Reconstruction
• SF-36
• Sensory disturbance

• Anterior cruciate ligament
• Hamstrings
• Nerve injury
• Patellar tendon graft
• Saphenous nerve

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.

• anterior cruciate ligament reconstruction
• paraesthesia
• peripheral nerve injuries

• Anterior cruciate ligament
• Dysesthesia
• Reconstruction

• ACL reconstruction
• Minimally invasive tendon harvesting
• Popliteal fossa
• Saphenous nerve injury
• Semitendinosus tendon

• Anterior cruciate ligament
• Hamstring
• Paresthesia

• Anterior cruciate ligament
• Arthroscopy
• Infrapatella nerve
• Loss of sensation
• Nerve damage

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.

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.

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.

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°.

• Anterior cruciate
• Knee
• Ligament/innervation
• Ligament/surgery

• Anatomic study
• Gracilis tendon
• Minimally invasive surgery
• Popliteal fossa
• Semitendinosus tendon