No difference in sensory outcome between vertical and oblique incisions for hamstring graft harvest during ACL reconstruction

Sharaby, Mohamed; Alfikey, Arafat; Alhabsi, Ismail S; Al-Ghannami, Suwailim

doi:10.1007/s00167-018-5057-5

Cited by 12 publications

(9 citation statements)

References 26 publications

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“…The number of incisional injuries observed in this study is in line with clinical reports [9, 10, 12, 20–22, 24, 26], but it is unknown how macroscopically visible lesions in cadaver limbs compare to sensibility loss in a clinical study. While the number of incisional injuries observed was high, only one‐fourth of these injuries were complete discontinuations of IPBSN and MCCB.…”

Section: Discussionsupporting

confidence: 87%

“…Altered sensation following ACL reconstruction with medial hamstrings is usually attributed to IPBSN injuries. It affects 12–88% of patients [9, 10, 12, 20–22, 24, 26] and has been linked to the incision used for hamstring tendon harvest [4, 12, 14, 17, 20, 26]. A vertical incision appears to increase the risk of iatrogenic IPBSN injuries significantly [6, 18, 19], and therefore, it is recommended to use an oblique incision parallel to the expected course of the IPBSN [18, 19].…”

Section: Introductionmentioning

confidence: 99%

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Gracilis tendon harvest may lead to both incisional and non-incisional saphenous nerve injuries

Vange

Tranum‐Jensen

Krogsgaard

2019

Knee Surg Sports Traumatol Arthrosc

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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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Section: Discussionsupporting

confidence: 87%

Section: Introductionmentioning

confidence: 99%

Gracilis tendon harvest may lead to both incisional and non-incisional saphenous nerve injuries

Vange

Tranum‐Jensen

Krogsgaard

2019

Knee Surg Sports Traumatol Arthrosc

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“…Therefore, our hypothesis that there would be a difference in the presence or absence of hypoesthesia or in the affected surface area of sensory loss between the vertical and oblique incision groups was not supported. This is in agreement with a recent systematic review investigating saphenous nerve injury during ACL reconstruction 15,17 but contrary to the results of a more recent meta-analysis. 13 The cadaveric study supported the results of this meta-analysis because it confirmed that a safe zone for the incision angle is unlikely due to the large variability in the number and different angles of branches of the IBSN between cadavers.…”

Section: Discussionsupporting

confidence: 84%

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

Leiter

Peeler

McRae

et al. 2020

Orthopaedic Journal of Sports Medicine

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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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“…As concluded by a meta‐analysis on 11 studies, surgeons should avoid employing the vertical incision, which was associated with the highest rate of infrapatellar branches of the saphenous nerve (IPBSN) iatrogenic injury (51.4%) [43]. In contrast, Sharaby et al [47] revealed the high incidence of IPBSN injury during hamstring graft harvest, but did not prove a difference between oblique and vertical incisions, with regard to postoperative sensory loss. In addition to infrapatellar branches, injury of sartorial branch (SBSN) has been raised [39, 42] but rarely reported [7].…”

Section: Discussionmentioning

confidence: 99%

Lower donor-site morbidity using QT autografts for ACL reconstruction

Mouarbes

Dagneaux²,

Olivier

et al. 2020

Knee Surg Sports Traumatol Arthrosc

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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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No difference in sensory outcome between vertical and oblique incisions for hamstring graft harvest during ACL reconstruction

Abstract: II.

Cited by 12 publications

References 26 publications

Gracilis tendon harvest may lead to both incisional and non-incisional saphenous nerve injuries

Gracilis tendon harvest may lead to both incisional and non-incisional saphenous nerve injuries

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

Lower donor-site morbidity using QT autografts for ACL reconstruction

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