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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
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

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Cochrane Central Register of Controlled Trials (CENTRAL) and EBSCOhost electronic databases and clinicaltrials.gov for unpublished studies was performed to identify comparative studies investigating injury to the IPBSN after HT ACL reconstruction by comparing at least two different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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Authors and 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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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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