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Du T, Chen J, Yan C, Fang H, Shang Z. The effect of preoperative ultrasound localization on the incidence of infrapatellar branch of the saphenous nerve injury after hamstring tendon harvesting. J Orthop Surg Res 2025; 20:316. [PMID: 40140833 PMCID: PMC11948820 DOI: 10.1186/s13018-025-05689-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2024] [Accepted: 03/06/2025] [Indexed: 03/28/2025] Open
Abstract
BACKGROUND The potential of ultrasound-guided labelling of the inferior patellar branch of the saphenous nerve (IPBSN) to reduce IPBSN injury during anterior cruciate ligament reconstruction (ACLR) has not been explored. The primary objective of this retrospective cohort analysis was to assess whether intraoperative hamstring tendon harvesting avoiding the marked IPBSN would be effective in reducing the incidence of postoperative skin sensory disturbances and the mean area of sensory disturbances. METHODS AND ANALYSIS A retrospective cohort study involving 60 patients who underwent autograft ACLR at Yichang Central People's Hospital from October 2020 to October 2024 was conducted. Patients were divided into two groups on the basis of the use of preoperative ultrasound localization of the IPBSN, including the nonultrasound localization group (control group) and the ultrasound localization group (experimental group), with 30 patients in each group. The control group underwent standard ACLR with a diagonal incision for hamstring tendon harvesting, whereas the experimental group underwent preoperative ultrasound-guided localization of the IPBSN to avoid the nerve during incision. The primary outcome measures include the incidence of skin sensory disturbances and the average sensory disturbance area. The secondary outcomes include the Lysholm score and VAS score at the 6-month postoperative follow-up. RESULTS The incidence of skin sensory disturbances in the experimental group was lower than that in the control group, and the average area of sensory disturbance was smaller in the experimental group (P < 0.05). At the 6-month postoperative follow-up, no statistically significant differences in the Lysholm knee scores or visual analogue scale (VAS) pain scores were noted between the two groups (P > 0.05). CONCLUSION Preoperative ultrasound-guided localization of the IPBSN can reduce the risk of nerve injury during ACLR. The ultrasound-guided approach leads to a lower incidence of sensory disturbances and a smaller average area of sensory disturbance. IPBSN injury was not related to anterior knee pain or knee ROM limitations. Patients can choose whether to use ultrasound localization before surgery according to their needs. The study protocol adhered to strict standards of ethical conduct and patient safety. The results of this trial are expected to provide valuable insights into the prevention of injury to the IPBSN during hamstring tendon harvesting.
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Affiliation(s)
- Tianli Du
- The First College of Clinical Medical Science, China Three Gorges University, Department of orthopedics, Yichang Central People's Hospital, Yichang, 443002, Hubei, China
| | - Jianfeng Chen
- The First College of Clinical Medical Science, China Three Gorges University, Department of orthopedics, Yichang Central People's Hospital, Yichang, 443002, Hubei, China
| | - Chao Yan
- The First College of Clinical Medical Science, China Three Gorges University, Department of orthopedics, Yichang Central People's Hospital, Yichang, 443002, Hubei, China
| | - Hongzhi Fang
- The First College of Clinical Medical Science, China Three Gorges University, Department of orthopedics, Yichang Central People's Hospital, Yichang, 443002, Hubei, China
| | - Zhenghui Shang
- The First College of Clinical Medical Science, China Three Gorges University, Department of orthopedics, Yichang Central People's Hospital, Yichang, 443002, Hubei, China.
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Vermorel PH, Stordeur A, Grange S, Klasan A, Philippot R, Neri T. Oblique or short incisions reduce the risk of saphenous nerve damage during hamstrings harvesting: A model for mapping nerve pathways at the harvest site. J ISAKOS 2024; 9:100358. [PMID: 39489420 DOI: 10.1016/j.jisako.2024.100358] [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: 09/28/2024] [Revised: 10/21/2024] [Accepted: 10/27/2024] [Indexed: 11/05/2024]
Abstract
INTRODUCTION Hamstring autografts are frequently used for ligament reconstruction surgery. Between 12% and 84% of patients report hypoesthesia or dysaesthesia secondary to injury of the saphenous nerve or one of its branches after hamstring harvesting. Type of incision (orientation and length) is subject of much regarding limiting the risk of nerve damage. A cadaveric study was performed to determine which type of incision limits the risk of injury to the saphenous nerve or one of its branches, based on an anatomic model for mapping nerve pathways at the harvest site. METHODS An anatomical study was performed on 20 knees from 12 embalmed bodies. Distance between saphenous nerve branches and 4 points of interest along the tibial crest was measured. Based on these measurements, a digital model of the saphenous nerve and its branches was created. A model of three common types of incision (vertical, horizontal and oblique) was overlaid. Each incision was modeled for three lengths (2, 3, and 4 cm). Percentage of collision between nerve course model and incision model was then calculated to determine the risk of nerve damage for each type of incision. Based on the nerve course model, a 'low-collision-risk' safe zone was identified. RESULTS Nerve damage risk after an oblique incision was significantly lower than for a horizontal or vertical incision, for incision lengths of 3 and 4 cm (p < 0.05). For a specific incision orientation, the length of the incision did not affect the risk of nerve damage. A trapezoidal space close to the tibial crest and distal to the anterior tibial tuberosity appears to reduce risk of nerve damage. CONCLUSION This cadaveric study suggests that during hamstring harvesting, incisions shorter than 2 cm reduce the risk of saphenous nerve's branches injuries. For incisions longer than 2 cm, using an oblique incision may reduce the risk compared to vertical or horizontal incisions. LEVEL OF EVIDENCE Level of evidence not applicable: Laboratory experiments.
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Affiliation(s)
- Pierre-Henri Vermorel
- Inter-university Laboratory of Human Movement Science, University Lyon - University Jean-Monnet Saint-Étienne, Saint-Étienne, France; Department of Orthopaedic Surgery, University Hospital Centre of Saint-Étienne, Saint-Étienne, EA 7424, France.
| | - Alban Stordeur
- Department of Orthopaedic Surgery, University Hospital Centre of Saint-Étienne, Saint-Étienne, EA 7424, France
| | - Sylvain Grange
- Department of Radiology, University Hospital Centre of Saint-Étienne, Saint-Étienne, EA 7424, France
| | - Antonio Klasan
- AUVA UKH Steiermark, Graz, Austria; Johannes Kepler University Linz, Austria
| | - Rémi Philippot
- Department of Orthopaedic Surgery, University Hospital Centre of Saint-Étienne, Saint-Étienne, EA 7424, France
| | - Thomas Neri
- Inter-university Laboratory of Human Movement Science, University Lyon - University Jean-Monnet Saint-Étienne, Saint-Étienne, France; Department of Orthopaedic Surgery, University Hospital Centre of Saint-Étienne, Saint-Étienne, EA 7424, France
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Yau W. Comparison of Medial Hamstring Length Between Harvesting Methods Using Anterior and Posterior Approaches. Orthop J Sports Med 2024; 12:23259671241287525. [PMID: 39534391 PMCID: PMC11555724 DOI: 10.1177/23259671241287525] [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: 03/06/2024] [Accepted: 04/09/2024] [Indexed: 11/16/2024] Open
Abstract
Background Medial hamstring tendons harvesting can be performed through either an anterior or a posterior approach. It has been suggested that using a posterior approach may result in a longer length of harvestable tendon compared with an anterior approach. Hypothesis There would be no difference in the length of the harvestable tendon between the anterior and posterior approaches. Study Design Case-control study; Level of evidence, 3. Methods A retrospective study was conducted at the primary institution using prospectively collected data from skeletally mature Chinese patients who underwent medial hamstring tendons harvesting between January 2008 and December 2021. Patients were excluded if they had experienced graft harvesting complication or if only 1 medial hamstring tendon was harvested. One-to-one exact matching was performed between the 2 approaches based on body height and sex. The outcome assessed was the length of the harvested tendon. Results A total of 536 patients underwent medial hamstring tendons harvesting using an anterior approach, while 58 underwent it using a posterior approach, all of whom met the inclusion criteria. A group of 54 matched pairs were identified. The length of the harvested semitendinosus tendon was 263 ± 29 mm in the anterior approach and 256 ± 28 mm in the posterior approach (P = .09; Student t test). The mean difference in the length of the harvested semitendinosus tendon between the 2 approaches was 7 mm. The length of the gracilis tendon was 226 ± 29 mm and 223 ± 29 mm in the anterior approach and the posterior approach, respectively (P = .30; Student t test). Conclusion In a retrospective 1:1 case-control study with exact matching of body height and sex, it was found that there was no difference in the length of the semitendinosus tendon and the gracilis tendon harvested using a posterior approach compared with an anterior approach. The mean difference between the 2 approaches was 7 mm for the semitendinosus tendon and 3 mm for the gracilis tendon, respectively.
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Affiliation(s)
- W.P. Yau
- Queen Mary Hospital, University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China
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Like BJ, Soffin EM, Ortolan S, Guheen CR, Yang E, Sneag DB, Kramskiy VN, Ranawat AS, Beckman JD. Incidence and Etiology of Rare Saphenous Nerve Injury After Knee Surgery with Adductor Canal Block: A Retrospective Observational Study. HSS J 2024; 20:490-497. [PMID: 39494428 PMCID: PMC11528913 DOI: 10.1177/15563316231194614] [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: 03/07/2023] [Accepted: 05/25/2023] [Indexed: 11/05/2024]
Abstract
Background Adductor canal block (ACB) is commonly included in multimodal analgesia regimens for knee surgery. Nonetheless, the incidence, etiology, and procedure-specific risk of saphenous nerve injury after knee surgery with ACB have not been established. Purpose We sought to identify the risk of saphenous nerve injury during knee surgery with ACB. Methods We conducted a retrospective cohort study of patients at a single institution who underwent elective knee surgery with ultrasound-guided ACB between January 1, 2014, and December 31, 2018, and had subsequent saphenous nerve injury. The primary outcome was the incidence of saphenous nerve injury within 3 months of surgery, by surgical type and approach. Secondary outcomes included attribution of the most likely etiology and clinical outcome of the injury. Results In 28,196 cases of knee surgery with ACB, we identified 18 cases (0.06%) of saphenous nerve injury. The most common surgery associated with saphenous nerve injury was anterior cruciate ligament (ACL) reconstruction with autograft (8/18 cases); 3 cases of injury were seen after TKA, 2 after medial patellofemoral ligament reconstruction, 2 after arthroscopy/meniscal surgery, and 1 after patellar fixation. The most likely etiology of nerve injury was attributed to ACB in 5 of 18 cases (28%) and to non-ACB cause in 13 of 18 (72%). Prognosis was rated as unknown in 11 of 18, poor in 2 of 18, favorable in 3 of 18, and full recovery in 2 of 18. Conclusions This 5-year retrospective, single-institution cohort study found a low overall incidence of saphenous nerve injury after knee surgery with ACB, but the injury likelihood varied based on surgery and approach. Although not statistically significant, ACL reconstruction with hamstring autograft and ACB performed for postoperative rescue analgesia were most frequently associated with nerve injury.
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Affiliation(s)
- Brian J. Like
- Department of Anesthesia, Critical Care, & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ellen M. Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Sarah Ortolan
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Carrie R. Guheen
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Elaine Yang
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Darryl B. Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Vladimir N. Kramskiy
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Anil S. Ranawat
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - James D. Beckman
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
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Gali JC, Holtz RDS, Lepispico MS, Barrio E, Senechal JOPL, Gali JC. CAN SENSORY DISTURBANCES DUE TO INJURY TO THE INFRAPATELLAR BRANCH OF THE SAPHENOUS NERVE BE PREVENTED BY AN OBLIQUE INCISION? ACTA ORTOPEDICA BRASILEIRA 2024; 32:e277962. [PMID: 39386292 PMCID: PMC11460665 DOI: 10.1590/1413-785220243204e277962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/20/2023] [Indexed: 10/12/2024]
Abstract
Objective To evaluate the incidence of injuries to the infrapatellar branch of the saphenous nerve (IPBSN) after anterior cruciate ligament reconstruction (ACLR) with an oblique incision for hamstring graft harvesting. Methods In total, 59 knees (from 57 patients) were evaluated in the follow-up of ACLR for six months. We drew a horizontal line parallel to the ground, passing through the most medial portion of the surgical incision and another, perpendicular to the first, starting at the tibial tuberosity (TT). We measured the length and angle of the cut, the distances from its most medial point to the perpendicular line, and from the TT to the horizontal line. Skin sensitivity was tested with a brush and the altered sensitivity area was measured. Patients were asked about difficulties in activities daily of living (ADL). Results A total of 27 knees (45.7%) had sensory disorders, which persisted until the sixth postoperative month in 92.6% of them. The ADL were compromised in one knee (3.7%). No significant differences were found between the groups with and without changes in sensitivity regarding age, affected side, incision angle, or measured distances. The incision size was larger in the group without alteration in sensitivity. Conclusions An oblique incision did not avoid IPBSN injuries. This condition rarely compromised the ADL. Level of Evidence II, Lesser Quality Prospective Study.
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Affiliation(s)
- Julio Cesar Gali
- Pontificia Universidade Paulista, Faculdade de Ciencias Medicas, Sorocaba, SP, Brazil
| | | | | | - Enzo Barrio
- Pontificia Universidade Paulista, Faculdade de Ciencias Medicas, Sorocaba, SP, Brazil
| | | | - Julio Cesar Gali
- Pontificia Universidade Paulista, Faculdade de Ciencias Medicas, Nucleo de Ortopedia e Traumatologia Esportiva, Sao Paulo, SP, Brazil
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Thamrongskulsiri N, Limskul D, Tanpowpong T, Kuptniratsaikul S, Itthipanichpong T. The Posteromedial Approach for Harvesting Hamstring Autografts Results in Fewer Incidents of Saphenous Nerve Injury Compared to the Conventional Anteromedial Approach: A Systematic Review and Meta-Analysis. Clin Orthop Surg 2024; 16:559-569. [PMID: 39092309 PMCID: PMC11262950 DOI: 10.4055/cios23396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/23/2024] [Accepted: 03/01/2024] [Indexed: 08/04/2024] Open
Abstract
Background The hamstring autograft can be harvested using various skin incisions, such as vertical, transverse, and oblique incisions, and from different localizations, including anteromedial and posteromedial harvest sites. The aim of this study was to compare studies on the anteromedial and posteromedial approaches for hamstring autograft harvest in terms of clinical outcomes, saphenous nerve injury, infection, operative time, graft length, incision length, range of motion, and patient satisfaction. Methods Following the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a search was conducted in PubMed and Scopus, focusing on studies comparing anteromedial and posterior approaches for hamstring harvest. This study was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42023450249). Methodological quality was evaluated using the Modified Coleman Methodology Score. Odds ratios (ORs) and mean differences (MDs) quantified dichotomous and continuous outcomes, respectively. Results Five articles, involving 405 knees, underwent analysis. Four studies were level 3 evidence, while 1 was level 1. The anteromedial hamstring harvest showed higher rates of saphenous nerve injury (OR, 9.77; 95% confidence interval [CI], 2.19-43.65; p = 0.003) and longer operative times, with an MD of about 13 minutes (MD, 13.33; 95% CI, 0.68-25.97; p = 0.04), compared to the posteromedial approach. The anteromedial method yielded a longer semitendinosus graft, with an MD of about 17 mm (MD, 17.57; 95% CI, 7.17-27.98; p = 0.0009). However, no significant differences existed in range of motion, flexion contracture, unintentional graft harvest, infection rates, and patient-reported outcomes. Notably, the posteromedial group reported higher cosmetic satisfaction, with 92% being very satisfied, compared to the anteromedial group with 80% (p = 0.005). However, overall satisfaction levels were similar between the 2 groups (p = 0.35), with a very satisfied rate of 72% for the anteromedial group and 78% for the posteromedial group. Conclusions The anteromedial hamstring harvest showed greater saphenous nerve injury and longer operative times compared to the posteromedial approach, along with a longer graft. However, no significant differences were observed in the range of motion, flexion contracture, graft harvest, infection, or patient outcomes.
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Affiliation(s)
| | - Danaithep Limskul
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanathep Tanpowpong
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somsak Kuptniratsaikul
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thun Itthipanichpong
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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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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Wagala NN, Fatora G, Brown C, Lesniak BP. Complications in Anterior Cruciate Ligament Surgery and How to Avoid Them. Clin Sports Med 2024; 43:465-477. [PMID: 38811122 DOI: 10.1016/j.csm.2023.08.009] [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] [Indexed: 05/31/2024]
Abstract
Complications following anterior cruciate ligament (ACL) reconstruction can be detrimental to a patient's recovery and limit their ability to successfully return to sport. Arthrofibrosis, graft failure, and infection are a few examples of complications that can arise. Therefore, it is important for surgeons to recognize that each step during perioperative surgical decision making can impact patients' risk for such complications. The purpose of this paper is to discuss common complications following ACL reconstruction and how surgeons can avoid or reduce the risk of complications.
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Affiliation(s)
- Nyaluma N Wagala
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gabrielle Fatora
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cortez Brown
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Cakar A, Kose O, Selcuk H, Egerci OF, Tasatan E, Dogruoz F. Complications of peroneus longus tendon harvesting: a retrospective review of 82 cases. Arch Orthop Trauma Surg 2023; 143:6675-6684. [PMID: 37453933 DOI: 10.1007/s00402-023-04988-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Peroneus longus tendon (PLT) has become a reliable autologous graft option for various ligament reconstructions. But there are potential risks and complications associated with its use as a graft. This retrospective study aimed to examine the complications and donor site morbidity following PLT harvesting. PATIENTS AND METHODS A retrospective review was performed on an institutional digital patient database, and all patients who underwent ligament reconstruction using PLT autograft were identified. Intraoperative, early, and late complications were reviewed using digital patient notes and patients underwent a complete physical examination during their final follow-up. Ankle function was assessed using the AOFAS score, and manual ankle muscle testing was performed on both sides. Sural nerve iatrogenic injury was evaluated with a dermatomal light touch examination. Cosmetic satisfaction due to incision scar and footwear complaints were also assessed. RESULTS 82 patients (74 male, eight female) with a mean age of 31.9 ± 10.4 years (range, 16-66) were included in the final analysis. The mean follow-up time was 46.6 ± 30.3 months (range, 6-109). The mean AOFAS score for the donor side was 98.7 ± 3.3 (range, 87-100), and the contralateral side score was 100, with manual muscle testing graded as 5 in all movements and similar to the contralateral side. Fifteen patients (18.3%) had hypoesthesia over the dorsolateral aspect of the foot distal to the incision scar, two patients (2.4%) had hyperalgesia over the distal incision scar, and one patient (1.2%) had mild ankle instability. There were two cases (2.4%) of compartment syndrome, both of which were treated with fasciotomy and had complete regression of symptoms after 5 days. One patient (1.2%) had a transient peroneal nerve injury and foot drop that resolved in the sixth month. CONCLUSIONS The results of this retrospective study suggest that harvesting the PLT is associated with a high rate of complications and donor site morbidity. The most common complication was hypoesthesia around the lateral side of the foot, although the ankle functions were not affected significantly. Two cases of compartment syndrome and one transient peroneal nerve injury were observed. Care should be taken while harvesting PLT autograft, and it should be kept in mind that peroneal nerve injury might occur. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Albert Cakar
- Department of Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey.
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık Mah., Kazım Karabekir cd., Antalya, 07100, Muratpasa, Turkey.
| | - Huseyin Selcuk
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık Mah., Kazım Karabekir cd., Antalya, 07100, Muratpasa, Turkey
| | - Omer Faruk Egerci
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık Mah., Kazım Karabekir cd., Antalya, 07100, Muratpasa, Turkey
| | - Ersin Tasatan
- Department of Orthopedics and Traumatology, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Fırat Dogruoz
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Varlık Mah., Kazım Karabekir cd., Antalya, 07100, Muratpasa, Turkey
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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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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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12
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Artuso M, Protais M, Soubeyrand M. Arthroscopic proximal carpal row replacement by semitendinosus and gracilis graft (CArpus Row Plasty Using the Semitendinosus: CARPUS procedure). An anatomical study of 16 cases. Orthop Traumatol Surg Res 2022; 108:103124. [PMID: 34700056 DOI: 10.1016/j.otsr.2021.103124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/13/2021] [Accepted: 07/16/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Post-traumatic lesions of the carpus (scapholunate rupture, scaphoid non-union) frequently evolve into disabling osteoarthritis (scapholunate advanced collapse or scaphoid non-union advanced collapse: SLAC or SNAC wrist). Proximal row carpectomy (PRC) is a reliable option but with poorer prognosis in case of osteoarthritis of the distal radius or capitate head. In such situations, radiocarpal arthrodesis may be necessary, sacrificing wrist motion. To circumvent this limitation, we propose a new procedure consisting in arthroscopic PRC and replacing the proximal row by tendon graft. METHODS This was a study on 16 cadaver specimens. A scapholunate pin was introduced via an approach into the anatomical snuffbox and used as a guide for a cannulated drill bit (9mm) to create a tunnel through the proximal row. The arthroscope and a reamer were introduced into the tunnel via its radial and ulnar ends. PRC was performed under arthroscopic control. The gracilis and semitendinosus tendons were harvested and folded so as to obtain a graft with the same length and diameter as the proximal row. The graft was threaded through the radial approach and fixed to the capsule. RESULTS Mean procedure time was 68min. There was no pre- to postoperative difference in joint motion or carpal height. On radiocinematography, the graft was stable between the radius and the second row of the carpus. The radial and ulnar sensory branches, median nerve and radial artery were intact at end of procedure. DISCUSSION This technique could be a solution in SLAC or SNAC wrist with osteoarthritis of the capitate head or radial glenoid. It also conserves carpal height. Being arthroscopic, the procedure avoids the major edema observed after a dorsal approach of the carpus, and also ensures graft stability, since the radiocarpal ligaments are conserved. Harvesting from a second anatomical site and the in vivo fate of the transplant are two issues that need to be discussed. CONCLUSION This anatomical study paves the way for clinical experimentation. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Mickaël Artuso
- Service de chirurgie orthopédique, traumatologique et reconstructrice, CHU de Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France.
| | - Marie Protais
- Service de chirurgie orthopédique, traumatologique et reconstructrice, CHU de Saint-Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Marc Soubeyrand
- Service de chirurgie orthopédique, clinique Saint-Jean de l'Hermitage, 272, avenue Marc-Jacquet, 77000 Melun, France
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Leliveld MS, Van Lieshout EMM, Polinder S, Verhofstad MHJ. Effect of Transverse Versus Longitudinal Incisions on Anterior Knee Pain After Tibial Nailing (TRAVEL): A Multicenter Randomized Trial with 1-Year Follow-up. J Bone Joint Surg Am 2022; 104:2160-2169. [PMID: 36367768 DOI: 10.2106/jbjs.22.00389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Anterior knee pain is common after tibial nailing, and its origin is poorly understood. Literature suggests it may be related to infrapatellar nerve injury. The aim of this study was to compare the effect of a transverse (potentially infrapatellar nerve-sparing) incision versus a longitudinal incision for the insertion of a tibial nail with respect to anterior knee pain. METHODS Patients with a tibial shaft fracture undergoing treatment with use of an intramedullary nail were randomized to a transverse incision (n = 68) or longitudinal incision (n = 68) in multiple centers. The primary outcome measure was kneeling pain based on a numeric rating scale (NRS). Secondary outcome measures included knee pain during daily activities, functional outcome (Short Musculoskeletal Function Assessment and Lower Extremity Functional Scale), quality of life (EuroQol-5 Dimensions), activity resumption, complications, reoperations, and costs within 1 year after trauma. RESULTS At 12 months, the estimated marginal mean for kneeling pain was 2.4 (95% confidence interval [CI], 1.6 to 3.2) in the transverse incision group and 3.7 (95% CI, 3.0 to 4.5) in the longitudinal incision group. Regression analysis showed no significant difference between the groups over time. Knee pain scores for daily activities, functional outcome scores, and quality of life were also comparable between the groups. Signs of infrapatellar nerve injury were found less often after a transverse incision (18% versus 54%; p < 0.001). The median total (direct and indirect) costs per patient were €10,468 in the transverse incision group and €11,066 in the longitudinal incision group. Loss of productivity accounted for 67% and 52% of the total costs in the 2 groups, respectively. CONCLUSIONS A transverse incision reduces injury to the infrapatellar nerve, but anterior knee pain scores and function are comparable after use of a transverse or longitudinal incision for tibial nail insertion. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mandala S Leliveld
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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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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15
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He J, Byrne K, Ueki H, Kanto R, Linde MA, Smolinski P, Wu S, Fu F. Low to moderate risk of nerve damage during peroneus longus tendon autograft harvest. Knee Surg Sports Traumatol Arthrosc 2022; 30:109-115. [PMID: 34498132 DOI: 10.1007/s00167-021-06698-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aims to evaluate the proximity of the tendon stripper to both the peroneal and sural nerves during peroneus longus tendon (PLT) autograft harvesting. METHODS Ten fresh-frozen human cadaveric lower extremities were used to harvest a full-thickness PLT autograft using a standard closed blunt-ended tendon stripper. The distance to the sural nerve from the PLT (at 0, 1, 2 and 3 cm proximal to lateral malleolus (LM), and the distance to the peroneal nerve and its branches from the end of the tendon stripper were measured by two separate observers using ImageJ software. RESULTS The average distance from the PLT to the sural nerve increased significantly from 0 to 2 cm proximal to LM. The average distance to the sural nerve at the LM was 4.9 ± 1.5 mm and increased to 10.8 ± 2.4 mm (2 cm proximal to LM). The average distance from the tendon stripper to the deep peroneal nerve was 52.9 ± 11.4 mm. The average distance to the PLT branch of peroneal nerve was 29.3 ± 4.2 mm. The superficial peroneal nerve, which coursed parallel and deep to the tendon stripper, was on average 5.2 ± 0.7 mm from the end of the stripper. No transection injuries of the nerves were observed in any of the ten legs after harvesting. CONCLUSION This cadaver study found during a full-thickness PLT harvest, the distances between the tendon stripper and the nerves were greater than 5 mm with an initial incision at 2 cm proximal to LM which is recommended.
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Affiliation(s)
- Jinshen He
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA.,Department of Orthopaedic Surgery, Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, China
| | - Kevin Byrne
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Hiroko Ueki
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Ryo Kanto
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Monica A Linde
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA.,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Song Wu
- Department of Orthopaedic Surgery, Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, China
| | - Freddie Fu
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA. .,Department of Mechanical Engineering and Material Science, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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16
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Lucas K, Todd P, Ness BM. A Multi-Systems Approach to Human Movement after ACL Reconstruction: The Integumentary System. Int J Sports Phys Ther 2021; 17:74-80. [PMID: 35024207 PMCID: PMC8720252 DOI: 10.26603/001c.29454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/01/2021] [Indexed: 11/18/2022] Open
Abstract
Postoperative management of anterior cruciate ligament (ACL) reconstruction has traditionally focused on the evaluation and intervention of musculoskeletal components such as range of motion and patients' reports of function. The integumentary system can provide early indications that rehabilitation may be prolonged due to protracted or poor healing of the incision sites. Full evaluation of the reconstruction over time, including direction of the incisions, appearance of surgical sites, level of residual innervation, and health of the individual should be considered when determining time-based goals and plans for returning an athlete to activity. Skin care techniques should be used to minimize strain and promote wound healing at the surgical sites, which in turn allows for implementation of other interventions that target other body systems such as locomotion, strength training, and cardiopulmonary conditioning. The integration of the integumentary system with cardiovascular, neurological, and muscular systems is required for a successful return to activity. A multi-physiologic systems approach may provide a unique viewpoint when aiming to attain a greater appreciation of the integumentary system and its integration with other body systems following ACL reconstruction. The purpose of this clinical commentary is to discuss integumentary considerations within a multi-physiologic systems approach to human movement after ACL reconstruction, including an anatomical review, key elements of assessment, and integrated intervention strategies. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Kathryn Lucas
- Kosair Charities Center for Pediatric NeuroRecovery, University of Louisville; Kentucky Spinal Cord Injury Research Center; Department of Neurological Surgery, University of Louisville
| | - Patricia Todd
- Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Pediatric Dermatology
| | - Brandon M Ness
- Doctor of Physical Therapy Program, Tufts University School of Medicine
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17
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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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18
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Chuaychoosakoon C, Parinyakhup W, Boonriong T. Premature hamstring graft amputation during harvesting in ACL reconstruction. Int J Surg Case Rep 2021; 83:105991. [PMID: 34020403 PMCID: PMC8142245 DOI: 10.1016/j.ijscr.2021.105991] [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] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/08/2021] [Accepted: 05/09/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction There are some possible complications during or after hamstring graft harvesting such as premature graft amputation, medial collateral ligament injury and infrapatellar branch of the saphenous nerve injury. Premature graft amputation can occur by inadequate removal of the accessory branches of the hamstring tendons, poor surgical technique and/or too sharp tendon stripper. In this study, we report a case of premature hamstring graft amputation due to degeneration caused by osteochondroma at the posteromedial aspect of the proximal tibia. Case presentation We reported the case of a 28-year-old Thai male who had an ACL injury was scheduled for ACL reconstruction. In this case, we had planned to use a hamstring graft for double-bundle ACL reconstruction. During the gracilis tendon harvesting, the graft was prematurely amputated by a tendon stripper at the level of the osteochondroma. The premature graft amputation was sent for pathology, which showed degenerated tissue. Conclusion In cases of osteochondroma at the posteromedial aspect of the proximal tibia, it is a chance of premature hamstring graft amputation. We suggest removing the osteochondroma before harvesting the tendon grafts to avoid the risk of premature graft transection.
The incidence of premature graft amputation is rare. In this patient, premature graft amputation caused by osteochondroma at the posteromedial aspect of the proximal tibia. In cases of osteochondroma at the medial proximal tibia, we suggest removing the osteochondroma before harvesting the tendon grafts.
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Affiliation(s)
- Chaiwat Chuaychoosakoon
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, 15 Karnjanavanich Road, Hat Yai, Songkhla 90110, Thailand.
| | - Wachiraphan Parinyakhup
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, 15 Karnjanavanich Road, Hat Yai, Songkhla 90110, Thailand
| | - Tanarat Boonriong
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, 15 Karnjanavanich Road, Hat Yai, Songkhla 90110, Thailand.
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19
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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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20
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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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21
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Hong AJ, Agarwalla A, Liu JN, Gowd AK, McMillan S, Sethi PM, Amin NH. Neurological structures and mediators of pain sensation in anterior cruciate ligament reconstruction. Ann Anat 2019; 225:28-32. [PMID: 31195095 DOI: 10.1016/j.aanat.2019.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/03/2019] [Accepted: 05/28/2019] [Indexed: 02/05/2023]
Abstract
Anterior cruciate ligament (ACL) tears is a devastating injury and one of the most common knee injuries experienced by athletes in the United States. Although patients reach maximal subjective improvement by one-year following ACL reconstruction, many patients often experience moderate to severe post-operative pain. Opioids, intra-articular injections, and regional anesthesia have been previously implemented to mediate post-operative pain. However, chronic opioid usage has become an epidemic in the United States. Alternative analgesic modalities, such as nerve blocks, have been implemented in clinical practice to provide adequate pain relief and minimize opioid usage. Periarticular injections targeted towards local neurological structures performed concomitantly with nerve blocks provides superior pain relief and satisfaction than isolated nerve blocks. Therefore, it is imperative for physicians to understand local neurological anatomy around the knee joint in order to provide adequate analgesia while minimizing opioid consumption. This purpose of this investigation is to summarize (1) neurogenic origins of pain generators and mediators in sites affected by ACL reconstruction and autograft harvest sites and (2) analgesia utilized in ACL reconstruction.
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Affiliation(s)
- Andrew J Hong
- School of Medicine, Loma Linda University, Loma Linda, CA, United States.
| | - Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY, United States.
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States.
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States.
| | - Sean McMillan
- Our Lady of the Lourdes Health System, Burlington, NJ, United States.
| | - Paul M Sethi
- Orthopaedic and Neurosurgery Specialists for Clinical Research and Education, Greenwich, CT, United States.
| | - Nirav H Amin
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States.
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22
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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: 1.0] [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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