Rev. bras. ortop. vol.50 número2

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rev bras ortop.2015;50(2):164–167

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Original

Article

Anatomical

reference

point

for

harvesting

a

flexor

graft

during

arthroscopic

reconstruction

of

the

cruciate

ligament

夽

Clécio

de

Lima

Lopes

∗

_,

_Gabriel

_Arantes,

_Rodrigo

_Victor

_Lapenda

_de

_Oliveira,

Dilamar

Moreira

Pinto,

Marcelo

Carvalho

Krause

Gonc¸alves,

Romeu

Carvalho

Krause

Gonc¸alves

InstitutodeTraumatologiaeOrtopediaRomeuKrause,Recife,PE,Brazil

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Articlehistory:

Received5February2014 Accepted13March2014

Availableonline28February2015

Keywords:

Anteriorcruciateligament Tendons/anatomyandhistology Tendons/transplantation

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Objectives:Toevaluatetheprevalenceofavascularnetworkadjacenttotheinsertionof thepesanserinus,sothatitcouldbeusedasananatomicalreferencepointtofacilitate harvestingflexorgraftsforarthroscopicreconstructionoftheanteriorcruciateligament (ACL).

Methods:ThirtypatientswithACLtearswhoweregoingtoundergoACLreconstructionusing thetendonsofthesemitendinosusandgracilismusclesasgraftswereselectedrandomly. Duringtheharvestingofthesetendons,thepresenceorabsenceofthisanatomicalreference pointwasnoted.

Results:Allthepatientspresentedavascularnetworkofgreaterorlesserdiameter.

Conclusion:Thevascularnetworkseemstobeagoodreferencepointduringharvestingof thetendonsofthesemitendinosusandgracilismuscles,forfacilitatinggraftharvesting.

Referência

anatômica

para

retirada

de

enxerto

de

flexores

na

reconstruc¸ão

artroscópica

do

ligamento

cruzado

r

e

s

u

m

o

Objetivos:Avaliaraprevalênciadatramavascularadjacenteàinserc¸ãodapatadeganso, paraquepossaserusadacomoreferênciaanatômicaparafacilitararetiradadeenxertodos flexoresnareconstruc¸ãoartroscópicadoligamentocruzadoanterior(LCA).

Métodos:Foramselecionadosdeformaaleatória30pacientescomroturadoLCA,osquais foramsubmetidosàreconstruc¸ãodoLCAtendocomoenxertoostendõesdosemitendíneo

夽

Workdeveloped attheOrthopedicsandTraumatology Service,Institutode TraumatologiaeOrtopediaRomeuKrause,Hospital Esperanc¸a,RedeD’Or,Recife,PE,Brazil.

∗ _{Corresponding}_author_.

E-mail:cleciolimopes@yahoo.com.br(C.L.Lopes).

http://dx.doi.org/10.1016/j.rboe.2015.02.010

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rev bras ortop.2015;50(2):164–167

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(ST)egrácil(G).DurantearetiradadostendõesdoSTeG,foiobservadaapresenc¸aou ausênciadareferênciaanatômica.

Resultados: Todosospacientesapresentaramtramavascularemmenoroumaiordiâmetro.

Conclusão: OusodatramavascularduranteretiradadostendõesdoSTeGpareceseruma boareferênciaanatômicaparafacilitararetiradadoenxerto.

Introduction

Arthroscopicreconstructionsurgeryontheanteriorcruciate ligament(ACL)hasbecomeoneofthecommonestprocedures withinorthopedicstoday.

Oneofthestepswithinthisprocedureconsistsof choos-ingthegraft.Thesemitendinosusandgracilisflexortendons (STandG)havebecomeaverycommongraftoptionusedin reconstructingtheACL.Incomparisonwithgraftsfromthe patellartendon,useoftheSTandGenableharvestingwith asmall incision andcause less pain atthedonor siteand lessdysfunctionoftheextensormechanism,butwithsimilar long-termclinicalresults.1

Useofautologousgrafts from the STand G,in relation toheterologousgrafts,presentsthefollowingbenefits:lower riskoffailure, absence ofrisk ofdisease transmissionand rapidincorporationofthegraft.Ontheotherhand, harvest-ing ofthis typeofgraft hassome potentialcomplications, suchas:difficulty inappropriatelyidentifying thetendons; nerveinjury;dehiscenceofthewound;amputationofthegraft andinadequatelength;andcosmeticallydisagreeableanterior scarontheknee.2

Theaimofthepresent studywastoevaluatethe preva-lenceofvasculartraumaadjacenttotheinsertionofthepes anserinus(PA),inordertouse thisasananatomical refer-encepointandtofacilitategraftharvestingfromtheflexors inarthroscopicreconstructionoftheACL.

Materials

and

methods

Thirty patients with ACL injuries were selected non-probabilisticallyandconsecutively.Thefollowingweretaken asinclusion criteriafor this study: the patients needed to presentACLinjurieswithoutassociatedinjuries(except possi-blymeniscalinjuries);therewerenoagerestrictions,andthe meanagewas30.7years(range:16–52);therewereno restric-tionsonsex,andtherewere23men(76.67%)andsevenwomen (23.33%);andtherewerenorestrictionsonside,andtherewere 21injuries(70%)intherightkneeandnine(30%)intheleft knee.Patientswhopresentedassociatedinjuriesor anatomi-caldeformitiesorprevioussurgeryinthekneeaffectedwere excludedfromthestudy.

Allthepatientswereoperatedbythekneesurgerygroupof theRomeuKrauseInstituteofTraumatologyandOrthopedics, betweenJanuaryandDecember2013.

Thisproject was approvedbythe Institution’s Research Ethics Committee,inaccordance withResolution 196/96of

theNationalHealthCouncil(GuidelinesandRulesRegulating ResearchInvolvingHumanBeings).Eachpatientwasinformed abouttheaimsofthestudyandwasaskedtosignafreeand informedconsentstatement.Ifthepatientwasconsideredto beincapableofdoingthis,acloserelativewasaskedtodoit.

Anatomical

considerations

The pes anserinus is the common insertion point, on the anteromedialfaceofthetibia,ofthetendonsofthe semitendi-nosus,gracilisandsartoriusmuscles.3

Thetendonsusedasgraftswerethesemitendinosusand gracilis. Althoughthese are separatestructuresproximally, they convergetowardstheir anterior insertionin thetibia. Theinsertionofthegracilisisabovethatofthe semitendi-nosus. The pes anserinus is located around 19mm (mean value, between10 and25mm)distallyand 22.5mm (mean value, between13 and30mm)mediallytothe apex ofthe anteriortuberosityofthetibia.4

Theinsertionofthepesanserinusissurroundedbya vas-culararchforwhichthebloodsupplycomesfromthethree mainarteriesoftheknee:(1)medialinferiorgenicularartery (superficialanddeepbranches);(2)lateralinferiorgenicular artery;and(3)anteriortibialrecurrentartery5₍_Fig.₁_).

Surgical

technique

AllthepatientsoperatedarthroscopicallyforACL reconstruc-tionusingSTandGgraftsunderwentemptyingofthelimb bymeansofelevationandischemiausinganEsmarchband andpneumatictourniquetatapressureof300mmHg, inde-pendent ofthe diameter ofthe thighor the mean arterial pressure.

Inallcases,thevascularnetworkoftheinsertionofthepes anserinuswasidentifiedandusedasareferencepointfor har-vestingthegraft,inaccordancewiththetechniquedescribed above.

ToharvestthegraftfromtheSTandG,ananteromedial accessofaround2cmwasmadeinthetibia,starting2cm dis-tallyand2cmmediallytotheapexoftheanteriortuberosity ofthetibia.

Aftersectioningtheskinandsubcutaneoustissue,the vas-culararchadjacenttotheinsertionofthepesanserinuswas identified(Fig.2).

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rev bras ortop.2015;50(2):164–167

Fig.1–Anatomicalspecimenfromthekneeofafresh

cadaverinwhichthefemoralarterywascatheterizedand

receivedadministrationofagelatinoussolutionofIndia

ink,whichshowedthevasculararchthatsurroundsthe

insertionofthepesanserinus.Arrowsshowthetributaries

ofthevasculararch:(1)medialinferiorgenicularartery

(superficialanddeepbranches);(2)lateralinferiorgenicular

artery;(3)anteriortibialrecurrentartery.5

noted(Fig.4).TheSTandGtendonswerethenidentifiedand distinguished(Fig.5).

Results

Outofthe30patientswhounderwenttheprocedureof arthro-scopicreconstructionoftheACLinvolvinguseofthetendons

Fig.2–Presenceofthevasculararchadjacenttothe

insertionofthepesanserinus.

Fig.3–Incisioninthepesanserinus,whichfollowsthe

pathofthevasculararch.

oftheflexormuscles(STand G),all ofthempresentedthe vasculararchwithagreaterorsmallerdiameter.

Discussion

Theproceduresforligamentreconstructionarewell dissemi-natedwithinorthopedics,andparticularlythoseoftheknee. ToreconstructtheACL,surgeonshavearangeofpossibilities forchoosingthegraft.Theseincludeallografts,forthosewho haveaccesstotissuebanks;graftsfromthequadricepsand patellartendons;and,overthelastfewyears,graftsfromthe semitendinosusandgracilistendons.

InparallelwithuseoftheSTandGtendons,various com-plications relating to their harvesting have arisen.Among these, thefollowingcan behighlighted:injurytothe tibial

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Fig.5–Identificationofthesemitendinosusandgracilis

tendons.

collateral ligament; erroneous harvesting of the sartorius muscle;prolongeddurationoftheoperationduetodifficulty inisolatingandextractingtheSTandGtendons6_;_injury_to theinfrapatellarbranchofthesaphenousnerve7_; _and_even healingproblemsattheincisionthatismadeforharvesting thegrafts.8

Thesecomplicationscanbeexplainedpartlybythelack ofreports in the literature,particularly with regard to the techniquesforgraftharvesting,fromananatomicalreference pointthatwouldguideandfacilitatetheirharvesting.

Inthepresentstudy,theprevalenceofavascularnetwork intheformofanarch,adjacenttotheinsertionofthepes anserinus,wasanalyzed.A100%associationbetweenthis vas-culararchandtheareaofincisionforgraftharvestingwas seen,whichfavoredeasierharvestingwithoutcomplications, inaccordancewiththetechniquedescribedhere.

Conclusion

Giventheprevalenceandeaseofidentificationofthevascular network of the pes anserinus, this is a useful and repro-ducibleanatomicalreferencepointforharvestinggraftsfrom thesemitendinosusandgracilistendons.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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