Oblique incisions in hamstring tendon harvesting reduce iatrogenic injuries to the infrapatellar branch of the saphenous nerve

Knee Surgery, Sports Traumatology, Arthroscopy, Jun 2017

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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Oblique incisions in hamstring tendon harvesting reduce iatrogenic injuries to the infrapatellar branch of the saphenous nerve

Oblique incisions in hamstring tendon harvesting reduce iatrogenic injuries to the infrapatellar branch of the saphenous nerve Brandon Michael Henry 0 1 2 3 Krzysztof A. Tomaszewski 0 1 2 3 Przemysław A. Pe˛kala 0 1 2 3 Matthew J. Graves 0 1 2 3 Jakub R. Pe˛kala 0 1 2 3 Beatrice Sanna 0 1 2 3 Ewa Mizia 1 2 3 Brandon Michael Henry 1 2 3 Krzysztof A. Tomaszewski have contributed equally to this work. 1 2 3 0 International Evidence-Based Anatomy Working Group , 12 Kopernika St, 31-034 Krakow , Poland 1 Przemysław A. Pe ̨kala 2 Faculty of Medicine and Surgery, University of Cagliari , S.S. 554 Bivio Sestu, 09042 Monserrato, CA, Sardinia , Italy 3 Department of Anatomy, Jagiellonian University Medical College , 12 Kopernika St, 31-034 Krakow , Poland 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 Brandon Michael Henry 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. ACL; Anterior cruciate ligament reconstruction; Cadaveric simulation; Hamstrings; Iatrogenic injury; Infrapatellar branch of the saphenous nerve; IPBSN; Tendon harvesting - * Krzysztof A. Tomaszewski Fig. 1 A dissected right limb showing the course of the IPBSN branching off the saphenous nerve. IPBSN infrapatellar branch of the saphenous nerve; PTL patella; SN saphenous nerve; and TT tibial tuberosity The infrapatellar branch of the saphenous nerve (IPBSN) is a cutaneous nerve of the lower limb which arises distal to the adductor or subsartorial canal (Fig. 1) [10]. The nerve pierces the fascia lata running in a superficial course and innervating the skin over the anterior aspect of the knee, anterolateral aspect of the proximal lower limb, and anteroinferior aspect of the knee joint capsule [12, 14]. The anatomy of the IPBSN varies among individuals and can even vary in both limbs of the same individual [12]. Iatrogenic injury of the IPBSN is associated with many surgical interventions involving the medial aspect of the knee resulting in sensory symptoms, neuropathic pain, and painful neuroma [1, 2, 5, 6, 8, 12, 14, 18, 19, 27, 30]. Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures which may result in IPBSN injury. The procedure is often performed using either a hamstring tendon or a patellar tendon autograft [30]. Although hamstring tendon harvesting carries less risk of injury to the IPBSN between the two approaches, postoperative complications are not uncommon and vary between 12 and 88% [28]. Proximity of the hamstring tendons (semitendinosus and gracilis tendons) at the pes anserinus area to the IPBSN predisposes the nerve to damage during harvesting [25]. Specifically, different types of surgical incisions (Fig. 2) at the area for hamstring tendon harvesting are related to variable risk of injury to the IPBSN [28]. Vertical, horizontal, and even oblique incision methods have been proposed to reduce the risk of nerve injury based on anatomical findings of the IPBSN distribution [16, 19, 22, 24]. Nevertheless, no consensus has been reached regarding the optimal incision method at the pes anserinus area for hamstring Fig. 2 Different techniques of incision during hamstring tendon harvesting (vertical, horizontal, and oblique). The incisions are indicated with red dashed lines on the anterior view of the right knee tendon harvest. Various studies have attempted to identify the influence of incision orientation during the procedure and the incidence of postoperative IPBSN injury [15, 16, 21, 23, 25, 28]. Results of these studies may be incomparable due to the different sizes of incisions and the distance of the incision (...truncated)


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Brandon Michael Henry, Krzysztof A. Tomaszewski, Przemysław A. Pękala, Matthew J. Graves, Jakub R. Pękala, Beatrice Sanna, Ewa Mizia. Oblique incisions in hamstring tendon harvesting reduce iatrogenic injuries to the infrapatellar branch of the saphenous nerve, Knee Surgery, Sports Traumatology, Arthroscopy, 2017, pp. 1-7, DOI: 10.1007/s00167-017-4590-y