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Association between incision technique for hamstring tendon harvest in anterior cruciate ligament reconstruction and the risk of injury to the infra-patellar branch of the saphenous nerve: a meta-analysis

Knee Surgery, Sports Traumatology, Arthroscopy volume 26, pages 2410–2423 (2018)Cite this article

Abstract

Purpose

To determine how the incision technique for hamstring tendon (HT) harvest in anterior cruciate ligament (ACL) reconstruction affects the risk of injury to the IPBSN and clinical outcome.

Methods

A systematic literature search of the MEDLINE/Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL) and EBSCOhost electronic databases and clinicaltrials.gov for unpublished studies was performed to identify comparative studies investigating injury to the IPBSN after HT ACL reconstruction by comparing at least two different incision techniques. Data were extracted for the number of patients with evidence of any neurologic deficit corresponding to injury to the IPBSN, area of sensory deficit, the Lysholm score and patient satisfaction. The mean difference (MD) in study outcome between incision groups was assessed. The relative risk (RR) and the number needed to treat (NNT) were calculated. The Chi-square and Higgins’ I2 tests were applied to test heterogeneity. Data were pooled using a Mantel–Haenszel random-effects model if the statistical heterogeneity was > 50% and a fixed-effects model if the statistical heterogeneity was < 50%. The risk of bias was evaluated according to the Cochrane Database questionnaire and the quality of evidence was graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

Results

A total of eight studies (three randomized controlled trials (RCTs) and five comparative studies) were included, of which six compared vertical and oblique incisions, one horizontal and vertical incisions, and one compared all three techniques. HT harvest was performed through a vertical incision in 329 patients, through an oblique incision in 195 patients and through a horizontal incision in 151 patients. Considering the meta-analysis of the RCTs, the performance of a vertical incision significantly increased the risk of causing IPBSN deficiency compared with both oblique and horizontal incision [RR 1.65 (CI 1.10–2.49, p = 0.02) and RR 2.45 (CI 1.73–3.47, p < 0.0001), respectively]. A significantly larger area of sensory deficit was found with vertical incisions compared with oblique ones, with an MD of 22.91 cm2 (95% CI 7.73–38.08; p = 0.04). No significant differences were found between the incision techniques in relation to patient-reported outcomes. The same trend was obtained after the performing a meta-analysis of all eight included studies. The quality of evidence in this meta-analysis was determined as “low” to “moderate”, mostly due to inadequate methods of randomization and high heterogeneity among the included studies.

Conclusion

The performance of a vertical incision to harvest HTs for ACL reconstruction significantly increased the risk of iatrogenic injury to the IPBSN compared with both oblique and horizontal incisions.

Level of evidence

Level I–III, meta-analysis of comparative studies.

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References

  1. Arthornthurasook A, Gaew-Im K (1990) The sartorial nerve: its relationship to the medial aspect of the knee. Am J Sports Med 18:41–42

    Article  PubMed  CAS  Google Scholar 

  2. Balshem H, Helfand M, Schunemann HJ, Oxman AD, Kunz R, Brozek J et al (2011) GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 64:401–406

    Article  PubMed  Google Scholar 

  3. Figueroa D, Calvo R, Vaisman A, Campero M, Moraga C (2008) Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: clinical and electrophysiological study. Knee 15:360–363

    Article  PubMed  CAS  Google Scholar 

  4. Gianotti SM, Marshall SW, Hume PA, Bunt L (2009) Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport 12:622–627

    Article  PubMed  Google Scholar 

  5. Hedges LV, Vevea JL (1998) Fixed-and random-effects models in meta-analysis. Psychological methods 3:486

    Article  Google Scholar 

  6. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. Bmj 327:557–560

    Article  PubMed  PubMed Central  Google Scholar 

  7. Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of intervention version 5.1.0. The Cochrane Collaboration. http://handbook.cochrane.org

  8. Hunter LY, Louis DS, Ricciardi JR, O’Connor GA (1979) The saphenous nerve: its course and importance in medial arthrotomy. Am J Sports Med 7:227–230

    Article  PubMed  CAS  Google Scholar 

  9. Jameson S, Emmerson K (2007) Altered sensation over the lower leg following hamstring graft anterior cruciate ligament reconstruction with transverse femoral fixation. Knee 14:314–320

    Article  PubMed  Google Scholar 

  10. Kaczmarczyk J, Sergiew M, Adamcewicz F, Kruczynski J (2007) Lower limb dysaesthesia after anterior cruciate ligament reconstructions with hamstring tendons. A comparison of vertical versus oblique harvest site incisions. Chir Narzadow Ruchu Ortop Pol 72:247–248

    PubMed  Google Scholar 

  11. Kalthur SG, Sumalatha S, Nair N, Pandey AK, Sequeria S, Shobha L (2015) Anatomic study of infrapatellar branch of saphenous nerve in male cadavers. Ir J Med Sci 184:201–206

    Article  PubMed  CAS  Google Scholar 

  12. Kerver AL, Leliveld MS, den Hartog D, Verhofstad MH, Kleinrensink GJ (2013) The surgical anatomy of the infrapatellar branch of the saphenous nerve in relation to incisions for anteromedial knee surgery. J Bone Joint Surg Am 95:2119–2125

    Article  PubMed  CAS  Google Scholar 

  13. Kjaergaard J, Fauno LZ, Fauno P (2008) Sensibility loss after ACL reconstruction with hamstring graft. Int J Sports Med 29:507–511

    Article  PubMed  CAS  Google Scholar 

  14. Lai CC, Ardern CL, Feller JA, Webster KE (2017) Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med. https://doi.org/10.1136/bjsports-2016-096836

    PubMed  Article  Google Scholar 

  15. Lefevre N, Klouche S, Mirouse G, Herman S, Gerometta A, Bohu Y (2017) Return to sport after primary and revision anterior cruciate ligament reconstruction: a prospective comparative study of 552 patients from the FAST cohort. Am J Sports Med 45:34–41

    Article  PubMed  Google Scholar 

  16. Leite ML, Cunha FA, Costa BQ, Andrade RM, Diniz Junior JH, Temponi EF (2016) Relationship between peri-incisional dysesthesia and the vertical and oblique incisions on the hamstrings harvest in anterior cruciate ligament reconstruction. Rev Bras Ortop 51:667–671

    Article  PubMed  PubMed Central  Google Scholar 

  17. Luo H, Yu JK, Ao YF, Yu CL, Peng LB, Lin CY et al (2007) Relationship between different skin incisions and the injury of the infrapatellar branch of the saphenous nerve during anterior cruciate ligament reconstruction. Chin Med J (Engl) 120:1127–1130

    Google Scholar 

  18. Marder RA, Raskind JR, Carroll M (1991) Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med 19:478–484

    Article  PubMed  CAS  Google Scholar 

  19. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012

    Article  PubMed  Google Scholar 

  20. Mohtadi NG, Chan DS, Dainty KN, Whelan DB (2011) Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD005960.pub2Cd005960

    PubMed  Article  Google Scholar 

  21. Pagnani MJ, Warner JJ, O’Brien SJ, Warren RF (1993) Anatomic considerations in harvesting the semitendinosus and gracilis tendons and a technique of harvest. Am J Sports Med 21:565–571

    Article  PubMed  CAS  Google Scholar 

  22. Papastergiou SG, Voulgaropoulos H, Mikalef P, Ziogas E, Pappis G, Giannakopoulos I (2006) Injuries to the infrapatellar branch(es) of the saphenous nerve in anterior cruciate ligament reconstruction with four-strand hamstring tendon autograft: vertical versus horizontal incision for harvest. Knee Surg Sports Traumatol Arthrosc 14:789–793

    Article  PubMed  Google Scholar 

  23. Parkkari J, Pasanen K, Mattila VM, Kannus P, Rimpela A (2008) The risk for a cruciate ligament injury of the knee in adolescents and young adults: a population-based cohort study of 46,500 people with a 9 year follow-up. Br J Sports Med 42:422–426

    Article  PubMed  CAS  Google Scholar 

  24. Portland GH, Martin D, Keene G, Menz T (2005) Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of horizontal versus vertical harvest site incisions. Arthroscopy 21:281–285

    Article  PubMed  Google Scholar 

  25. Sabat D, Kumar V (2013) Nerve injury during hamstring graft harvest: a prospective comparative study of three different incisions. Knee Surg Sports Traumatol Arthrosc 21:2089–2095

    Article  PubMed  Google Scholar 

  26. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ (2017) Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res. https://doi.org/10.1007/s11999-017-5278-9

    Article  PubMed  Google Scholar 

  27. Sanders B, Rolf R, McClelland W, Xerogeanes J (2007) Prevalence of saphenous nerve injury after autogenous hamstring harvest: an anatomic and clinical study of sartorial branch injury. Arthroscopy 23:956–963

    Article  PubMed  Google Scholar 

  28. Sipahioglu S, Zehir S, Sarikaya B, Levent A (2017) Injury of the infrapatellar branch of the saphenous nerve due to hamstring graft harvest. J Orthop Surg (Hong Kong) 25:2309499017690995

    Article  Google Scholar 

  29. Spicer DD, Blagg SE, Unwin AJ, Allum RL (2000) Anterior knee symptoms after four-strand hamstring tendon anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 8:286–289

    Article  PubMed  CAS  Google Scholar 

  30. Tavakoli Darestani R, Bagherian Lemraski MM, Hosseinpour M, Kamrani-Rad A (2013) Electrophysiological assessment of injury to the infra-patellar branch(es) of the saphenous nerve during anterior cruciate ligament reconstruction using medial hamstring auto-grafts: vertical versus oblique harvest site incisions. Arch Trauma Res 2:118–123

    PubMed  PubMed Central  Google Scholar 

  31. Warren LF, Marshall JL (1979) The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg Am 61:56–62

    Article  PubMed  CAS  Google Scholar 

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Affiliations

  1. Sicily Department, Rizzoli Orthopaedic Institute, Bagheria, Palermo, Italy

    Alberto Grassi, Francesco Perdisa, Matteo Romagnoli, Federico Raggi, Teide Gaziano & Stefano Zaffagnini

  2. Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    Kristian Samuelsson & Eleonor Svantesson

  3. Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden

    Kristian Samuelsson

  4. Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada

    Olufemi Ayeni

  5. II Orthopaedic Clinic, Rizzoli Orthopadic Institute, University of Bologna, Via di Barbiano 1/10, 40136, Bologna, Italy

    Alberto Grassi, Francesco Perdisa, Massimiliano Mosca & Stefano Zaffagnini

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  1. Alberto Grassi
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  2. Francesco Perdisa
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Correspondence to Francesco Perdisa.

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Grassi, A., Perdisa, F., Samuelsson, K. et al. Association between incision technique for hamstring tendon harvest in anterior cruciate ligament reconstruction and the risk of injury to the infra-patellar branch of the saphenous nerve: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 26, 2410–2423 (2018). https://doi.org/10.1007/s00167-018-4858-x

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Keywords

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