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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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Abstract
Continued advancements in magnetic resonance (MR) neurography and ultrasound have made both indispensable tools for the workup of peripheral neuropathy. Ultrasound provides high spatial resolution of superficial nerves, and techniques such as "sonopalpation" and dynamic maneuvers can improve accuracy. Superior soft tissue contrast, ability to evaluate both superficial and deep nerves with similar high resolution, and reliable characterization of denervation are strengths of MR neurography. Nevertheless, familiarity with normal anatomy, anatomic variants, and common sites of nerve entrapment is essential for radiologists to use both MR neurography and ultrasound effectively.
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3
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Optimization of surgical exposure for harvesting gracilis-semitendinosus tendons. INTERNATIONAL ORTHOPAEDICS 2023; 47:131-140. [PMID: 36239745 DOI: 10.1007/s00264-022-05598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE This study was conducted to provide anatomical data and surface markers for the safe and efficient exposure of surgical incisions for harvesting gracilis tendons (GT) and semitendinosus tendons (STT) while avoiding technical pitfalls and nerve injury during harvest for ligament reconstruction. METHODS Seventy-four Chinese cadaveric lower limbs were dissected to expose the infrapatellar branch of the saphenous nerve (IPBSN) and pes anserinus (PA). Measurements of the borders and accessory bands of the PA tendons were taken. The arrangement of PA tendons and distribution of the IPBSN were assessed. RESULTS The PA was roughly shaped like a quadrangle, with its superior border at the horizontal plane of the tibial tuberosity (TT). The GT and STT bifurcation point was located on the medial border of the PA. From medial side to lateral side, the sartorius tendons (ST), GT, and STT fused gradually and formed the lateral border of the PA at the distal end. The tendon arrangement of the PA was primarily affected by ST, which commonly covered GT and STT completely. Variant tendons were found in 41.9% of specimens. The insertion of the accessory bands was distal but close to the inferior border of the PA. Accessory bands were observed only in STT and ST, and STT accounted for the most. The width of the first accessory band of STT was similar to the width of the STT. Additionally, most of the IPBSNs were proximal to the horizontal plane of the TT. CONCLUSION For clearly exposing the GT and STT, it is crucial to expose the GT and STT bifurcation point on the medial border of the PA, whether directly or indirectly through the incision.The influence of ST insertion and the variability of tendons within the PA must be paid attention to during the operation. To protect IPBSNs highly, the incision should not be higher than the TT level.
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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: 2] [Impact Index Per Article: 1.0] [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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Takahashi T, Watanabe S, Ito T. Current and future of anterior cruciate ligament reconstruction techniques. World J Meta-Anal 2021; 9:411-437. [DOI: 10.13105/wjma.v9.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/09/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Sports and Health Science, Ehime University, Matsuyama 790-8577, Ehime, Japan
| | - Seiji Watanabe
- Department of Orthopedic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Ehime, Japan
| | - Toshio Ito
- Department of Orthopaedic Surgery, Murakami Memorial Hospital, Saijo 793-0030, Ehime, Japan
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Szwedowski D, Ambroży J, Grabowski R, Dallo I, Mobasheri A. Diagnosis and treatment of the most common neuropathies following knee injuries and reconstructive surgery - A narrative review. Heliyon 2021; 7:e08032. [PMID: 34611563 PMCID: PMC8477214 DOI: 10.1016/j.heliyon.2021.e08032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/06/2021] [Accepted: 09/16/2021] [Indexed: 01/09/2023] Open
Abstract
The main nerves in the knee region are the tibial nerve, the common peroneal nerve, and the saphenous nerve. These three nerves innervate the lower leg and foot, providing sensory and motor function. The large sciatic nerve splits just above the knee to form the tibial and common peroneal nerves. The tibial nerve travels down in the posterior region, while the common peroneal nerve runs around the lateral side of the knee and runs down the front of the leg to the foot. Although all these nerves can be affected by injuries of the knee, the infrapatellar branch of the saphenous nerve (IPBSN) and the common peroneal nerve (CPN) are most affected. In this narrative review we focus on neuropathies associated with nerves located in the region of the knee joint in the context of their injuries and possible iatrogenic damage during reconstructive surgery.
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Affiliation(s)
- Dawid Szwedowski
- Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, Milan, Italy
| | - Jarosław Ambroży
- Lesser Poland Orthopedic and Rehabilitation Hospital, Krakow, Poland
| | - Radosław Grabowski
- Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, Milan, Italy
- Department of Orthopaedics and Traumatology, Medical University of Lodz, Lodz, Poland
| | - Ignacio Dallo
- Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, Milan, Italy
| | - Ali Mobasheri
- Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland
- Departments of Orthopedics, Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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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: 1.0] [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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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: 0.3] [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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Mouarbes D, Dagneaux L, Olivier M, Lavoue V, Peque E, Berard E, Cavaignac E. Lower donor-site morbidity using QT autografts for ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28:2558-2566. [PMID: 32020251 DOI: 10.1007/s00167-020-05873-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 01/21/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction. METHODS Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS. RESULTS Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm2 vs. 88.2 ± 57 cm2; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm2 vs. 8.7 ± 5.1 cm2; p < 0.0001). CONCLUSION Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dany Mouarbes
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France
| | - Louis Dagneaux
- Department of Orthopedic Surgery, Lower Limb Surgery Unit, Lapeyronie University Hospital, Montpellier, France
| | - Matthieu Olivier
- Department of Orthopedic Surgery and Traumatology, Saint Marguerite University Hospital, Marseille, France
| | - Vincent Lavoue
- Department of Orthopaedic Surgery, University Hospital of Nice, Nice, France
| | - Enrique Peque
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France
| | - Emilie Berard
- Department of Epidemiology, Health Economics and Public Health, UMR1027 INSERM-University of Toulouse III, Toulouse University Hospital, Toulouse, France
| | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France. .,Department of Orthopedic Surgery, Hopital Pierre Paul Riquet, CHU Toulouse, Rue Jean Dausset, 3105, Toulouse, France.
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10
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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: 2] [Impact Index Per Article: 0.5] [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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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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12
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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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13
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Abstract
Iatrogenic peripheral nerve injuries from orthopaedic surgery can occur via many scenarios, including direct injury to the nerve during surgery, indirect injury via retraction or compartment syndrome, and injury from nonsurgical treatments such as injections and splinting. Successful management of iatrogenic nerve injuries requires an accurate diagnosis and timely, appropriate treatment. All orthopaedic surgeons must understand the preclinical study of nerve injury and the evaluation and treatment options for iatrogenic nerve injuries. Although a sharply transected nerve can be repaired immediately in the operating room under direct visualization, many injuries are not appreciated until the postoperative period. Advances in diagnostic studies and nerve repair techniques, nerve grafting, and nerve transfers have improved our ability to identify and treat such injuries.
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14
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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: 7] [Impact Index Per Article: 1.4] [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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Mizia E, Pękala PA, Chomicki-Bindas P, Marchewka W, Loukas M, Zayachkowski AG, Tomaszewski KA. Risk of injury to the sural nerve during posterolateral approach to the distal tibia: An ultrasound simulation study. Clin Anat 2018; 31:870-877. [PMID: 29737558 DOI: 10.1002/ca.23205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 04/30/2018] [Indexed: 12/19/2022]
Abstract
When surgeons operate on the foot and ankle, the most common complication that may arise is injury of the cutaneous nerves. The sural nerve (SN) is potentially at risk of being injured when treating fractures involving the distal tibia using the posterolateral approach. The aim of this study was to evaluate how differences in length and position of the surgical treatment of fractures involving the distal tibia can affect the risk of SN injury. The study involved 40 healthy volunteers (n = 80 lower limbs). Ultrasound simulation of each potential surgical incision site was used to locate the SN and to assess the risk of injury. The study showed that the SN predominantly travels more posteriorly at levels more proximal from the tip of the lateral malleolus. At these more proximal points of the SN's course, it was proven that there was an overall increased incidence of iatrogenic injury to the SN in incisions made closer to the Achilles tendon. Based on these results, a quasi 3 dimensional figure was created showing the anatomical structures of this region to identify areas at high risk for SN injury. By revealing how length and position of the surgical incision can influence the risk of SN injury, we hope to provide information to surgeons on the optimal technique to avoid iatrogenic SN injury while operating on the distal tibia via a posterolateral approach. Clin. Anat. 31:870-877, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Ewa Mizia
- Department of Anatomy, Jagiellonian University Medical College, Poland
| | - Przemysław A Pękala
- Department of Anatomy, Jagiellonian University Medical College, Poland.,International Evidence-Based Anatomy Working Group, Krakow, Poland
| | | | | | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada
| | | | - Krzysztof A Tomaszewski
- Department of Anatomy, Jagiellonian University Medical College, Poland.,International Evidence-Based Anatomy Working Group, Krakow, 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: 1.5] [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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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: 1.4] [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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