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The inferior medial genicular artery and its vascularization of the pes anserinus superficialis

A cadaveric study

  • Original Article
  • Published:
Indian Journal of Orthopaedics Aims and scope Submit manuscript

Abstract

Background

A common method for reconstruction of the anterior cruciate ligament (ACL) is it’s replacement by a free avascular graft, using the gracilis and/or semitendinosus tendons. These grafts pass a vulnerable phase in the ligamentization-process during the 1st year after reconstruction. The aims of this study were first to evaluate the vascularization of the pes anserinus superficialis (PAS) by the inferior medial genicular artery (IMGA) and second to develop a pedunculated surgical technique for ACL reconstruction, to preserve a maximal amount of natural vascularization of the tendons inserting at the PAS.

Materials and Methods

First, the vascularization of the PAS was assessed in 12 fresh-frozen lower extremities. The IMGA was identified at its origin at the popliteal artery and perfused with a methylene blue solution. Second, a pedunculated ACL reconstruction was performed in 5 fresh-frozen lower extremities under maintenance of the distal tendon insertion at PAS.

Results

The PAS is a highly vascularized structure. Vessels originate from the IMGA, running along the three tendons of the PAS in the paratendinous tissue. Histologically intratendinous vessels exist; however, perfusion of the inserting tendons through intratendinous vessels was not proven macroscopically. The pedunculated grafts could be positioned and fixed successfully into the bone tunnels in all knees.

Conclusion

Although intratendinous vascularization of the tendons of the PAS via the IMGA was not proven, this study indicates a new possibility of ACL reconstruction. The described operation technique can be conducive to shorten the vulnerable phase of the graft-ligamentization after ACL reconstruction.

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References

  1. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clin J Sport Med 2012;22:116–21.

    Article  Google Scholar 

  2. Herbort M, Raschke MJ, [Ligament ruptures of the lower extremity in the elderly]. Unfallchirurg 2011;114:671–80.

    Article  CAS  Google Scholar 

  3. Hadjicostas PT, Soucacos PN, Paessler HH, Koleganova N, Berger I. Morphologic and histologic comparison between the patella and hamstring tendons grafts: A descriptive and anatomic study. Arthroscopy 2007;23:751–6.

    Article  Google Scholar 

  4. Sadoghi P, Kröpfl A, Jansson V, Müller PE, Pietschmann MF, Fischmeister MF. Impact of tibial and femoral tunnel position on clinical results after anterior cruciate ligament reconstruction. Arthroscopy 2011;27:355–64.

    Article  Google Scholar 

  5. Gobbi A, Mahajan V, Karnatzikos G, Nakamura N. Single-versus double-bundle ACL reconstruction: Is there any difference in stability and function at 3-year followup? Clin Orthop Relat Res 2012;470:824–34.

    Article  Google Scholar 

  6. Kondo E, Merican AM, Yasuda K, Amis AA. Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic single-bundle anterior cruciate ligament reconstructions. Am J Sports Med 2011;39:279–88.

    Article  Google Scholar 

  7. Chen CH, Gadikota HR, Gill TJ, Li G. The effect of graft fixation sequence on force distribution in double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2011;19:712–8.

    Article  Google Scholar 

  8. Strauss EJ, Barker JU, McGill K, Cole BJ, Bach BR Jr, Verma NN. Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction? Am J Sports Med 2011;39:1263–9.

    Article  Google Scholar 

  9. Amiel D, Kleiner JB, Roux RD, Harwood FL, Akeson WH. The phenomenon of “ligamentization”: Anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res 1986;4:162–72.

    Article  CAS  Google Scholar 

  10. Falconiero RP, DiStefano VJ, Cook TM. Revascularization and ligamentization of autogenous anterior cruciate ligament grafts in humans. Arthroscopy 1998;14:197–205.

    Article  CAS  Google Scholar 

  11. Li H, Chen C, Ge Y, Chen S. Spray-painted human fibronectin coating as an effective strategy to enhance graft ligamentization of a polyethylene terephthalate artificial ligament. Biotechnol Lett 2014;36:1079–88.

    Article  CAS  Google Scholar 

  12. Janssen RP, Scheffler SU. Intraarticular remodelling of hamstring tendon grafts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014;22:2102–8.

    Article  Google Scholar 

  13. Keklikci K, Yapici C, Kim D, Linde-Rosen M, Smolinski P, Fu FH. The effect of notchplasty in anterior cruciate ligament reconstruction: A biomechanical study in the porcine knee. Knee Surg Sports Traumatol Arthrosc 2013;21:1915–21.

    Article  Google Scholar 

  14. Rougraff B, Shelbourne KD, Gerth PK, Warner J. Arthroscopic and histologic analysis of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am J Sports Med 1993;21:277–84.

    Article  CAS  Google Scholar 

  15. Vogrin M, Rupreht M, Dinevski D, Hašpl M, Kuhta M, Jevsek M, et al. Effects of a platelet gel on early graft revascularization after anterior cruciate ligament reconstruction: A prospective, randomized, double-blind, clinical trial. Eur Surg Res 2010;45:77–85.

    Article  CAS  Google Scholar 

  16. Bedi A, Kovacevic D, Fox AJ, Imhauser CW, Stasiak M, Packer J, et al. Effect of early and delayed mechanical loading on tendon-to-bone healing after anterior cruciate ligament reconstruction. J Bone Joint Surg Am 2010;92:2387–401.

    Article  Google Scholar 

  17. Matsumoto T, Kubo S, Sasaki K, Kawakami Y, Oka S, Sasaki H, et al. Acceleration of tendon-bone healing of anterior cruciate ligament graft using autologous ruptured tissue. Am J Sports Med 2012;40:1296–302.

    Article  Google Scholar 

  18. Wang CJ, Weng LH, Hsu SL, Sun YC, Yang YJ, Chan YS, et al. pCMV-BMP-2-transfected cell-mediated gene therapy in anterior cruciate ligament reconstruction in rabbits. Arthroscopy 2010;26:968–76.

    Article  CAS  Google Scholar 

  19. Butler DL, Grood ES, Noyes FR, Olmstead ML, Hohn RB, Arnoczky SP, et al. Mechanical properties of primate vascularized vs. nonvascularized patellar tendon grafts; changes over time. J Orthop Res 1989;7:68–79.

    Article  CAS  Google Scholar 

  20. Yao LW, Wang Q, Zhang L, Zhang C, Zhang B, Zhang YJ, et al. Patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction: A systematic review and meta-analysis. Eur J Orthop Surg Traumatol 2015;25:355–65.

    Article  Google Scholar 

  21. Yasuda K, Kondo E, Ichiyama H, Kitamura N, Tanabe Y, Tohyama H, et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 2004;20:1015–25.

    Article  Google Scholar 

  22. Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H. Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: Comparisons among 3 different procedures. Arthroscopy 2006;22:240–51.

    Article  Google Scholar 

  23. Zaffagnini S, Golanò P, Farinas O, Depasquale V, Strocchi R, Cortecchia S, et al. Vascularity and neuroreceptors of the pes anserinus: Anatomic study. Clin Anat 2003;16:19–24.

    Article  CAS  Google Scholar 

  24. Kawano CT, de Moraes Barros Fucs PM, Severino NR. Pretensioning of quadruple flexor tendon grafts in two types of femoral fixation: Quasi-randomised controlled pilot study. Int Orthop 2011;35:521–7.

    Article  Google Scholar 

  25. Marcacci M, Molgora AP, Zaffagnini S, Vascellari A, Iacono F, Presti ML. Anatomic double-bundle anterior cruciate ligament reconstruction with hamstrings. Arthroscopy 2003;19:540–6.

    Article  Google Scholar 

  26. Marcacci M, Zaffagnini S, Giordano G, Iacono F, Presti ML. Anterior cruciate ligament reconstruction associated with extra-articular tenodesis: A prospective clinical and radiographic evaluation with 10-to 13-year followup. Am J Sports Med 2009;37:707–14.

    Article  Google Scholar 

  27. Marcacci M, Zaffagnini S, Iacono F, Neri MP, Loreti I, Petitto A. Arthroscopic intra-and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons. Knee Surg Sports Traumatol Arthrosc 1998;6:68–75.

    Article  CAS  Google Scholar 

  28. Marcacci M, Zaffagnini S, Iacono F, Vascellari A, Loreti I, Kon E, et al. Intra-and extra-articular anterior cruciate ligament reconstruction utilizing autogeneous semitendinosus and gracilis tendons: 5-year clinical results. Knee Surg Sports Traumatol Arthrosc 2003;11:2–8.

    Article  Google Scholar 

  29. Zaffagnini S, Marcheggiani Muccioli GM, Bonanzinga T, Nitri M, Grassi A, Marcacci M. Anatomic double-bundle anterior cruciate ligament reconstruction leaving hamstrings tibial insertion intact: Technical note. Musculoskelet Surg 2013;97:39–43.

    Article  Google Scholar 

  30. Scapinelli R. Studies on the vasculature of the human knee joint. Acta Anat (Basel) 1968;70:305–31.

    Article  CAS  Google Scholar 

  31. Alm A, Strömberg B. Vascular anatomy of the patellar and cruciate ligaments. A microangiographic and histologic investigation in the dog. Acta Chir Scand Suppl 1974;445:25–35.

    PubMed  CAS  Google Scholar 

  32. Ginsburg JH, Whiteside LA, Piper TL. Nutrient pathways in transferred patellar tendon used for anterior cruciate ligament reconstruction. Am J Sports Med 1980;8:15–8.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria

    Manuel Ederer & Mike Faber

  2. Department of First Orthopedic, Orthopaedic Hospital Speising, Vienna, Austria

    Patrick Weninger

  3. Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Währinger Straße 13, 1090, Vienna, Austria

    Lena Hirtler

Authors
  1. Lena Hirtler
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  2. Manuel Ederer
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  3. Mike Faber
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  4. Patrick Weninger
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Correspondence to Lena Hirtler.

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Hirtler, L., Ederer, M., Faber, M. et al. The inferior medial genicular artery and its vascularization of the pes anserinus superficialis. IJOO 50, 677–685 (2016). https://doi.org/10.4103/0019-5413.193476

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  • DOI: https://doi.org/10.4103/0019-5413.193476

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