Rev. bras. ortop. vol.50 número5

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r e v b r a s o r t o p . 2015;50(5):546–549

w w w . r b o . o r g . b r

Original

Article

Saphenous

nerve

injury

during

harvesting

of

one

or

two

hamstring

tendons

for

cruciate

ligament

reconstruction

夽

Vitor

Barion

Castro

de

Padua

∗

_,

_Paulo

_Emílio

_Dourado

_Nascimento,

Sergio

Candido

Silva,

Sergio

Marinho

de

Gusmão

Canuto,

Guilherme

Nunes

Zuppi,

Sebastião

Marcos

Ribeiro

de

Carvalho

SchoolofMedicine,UniversidadedeMarília,Marília,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received16July2014 Accepted17August2014 Availableonline29August2015

Keywords:

Anteriorcruciateligament Paresthesia

Hamstring

a

b

s

t

r

a

c

t

Objective:Theaimofthisstudywastoassesswhetherharvestingoftwohamstring ten-dons(semitendinosusandgracilis)hasthesamerateofnerveinjuryasharvestingofthe semitendinosustendonalone,usedasatriplegraft.

Methods:Changesinsensitivityrelatingtoinjuryoftheinfrapatellarbranchofthe saphe-nousnervewereevaluatedin110patientssixmonthsaftertheyunderwentanteriorcruciate ligament(ACL)reconstructionusinghamstringtendons.Theyweredividedintotwogroups: oneinwhichonlythesemitendinosuswasusedandtheother,thesemitendinosusand gracilis.

Results:Thegroupinwhichonlythesemitendinosuswasusedasagraftpresentedanerve injuryrateof36.1%.Inthegroupinwhichthesemitendinosusandgracilistendonswere used,58.1%ofthepatientspresentedalteredsensitivity.Inthegeneralassessmentonall thepatients,thenerveinjuryratewas50.9%.

Conclusion:Harvestingthesemitendinosusaloneandusingitintripleformisaviableoption forACLreconstructionandmaygiverisetofewernerveinjuriesrelatingtobranchesofthe saphenousnerve.

Lesão

do

nervo

safeno

na

retirada

de

1 ou

2 tendões

flexores

na

reconstruc¸ão

do

ligamento

cruzado

r

e

s

u

m

o

Objetivo:Avaliarsearetiradadosdoistendõesflexores(semitendíneo[ST]egrácil[GC])tem omesmoíndicedelesãonervosaquearetiradaisoladadotendãoSTusadocomoenxerto triplo.

夽

WorkperformedintheDepartmentofOrthopedicsandTraumatology,SchoolofMedicine,UniversidadedeMarília,Marília,SP,Brazil. ∗ _{Corresponding}_author_.

E-mails:drvitorpadua@gmail.com,vtrpadua@yahoo.com.br(V.B.C.dePadua).

http://dx.doi.org/10.1016/j.rboe.2015.08.007

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rev bras ortop.2015;50(5):546–549

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Tendõesflexores Métodos: Foiavaliadaaalterac¸ãodesensibilidaderelacionadaàlesãodoramoinfrapatelar donervosafenoem110pacientesseismesesapósseremsubmetidosàreconstruc¸ãodo LCAcomousodostendõesflexores,divididonumgruponoqualseusousomenteoSTe outrocomoSTeoGC.

Resultados: OgruponoqualseusousomenteoSTcomoenxertoapresentouumíndice delesãonervosade36,1%enogrupocomostendõesSTeGC58,1%dospacientestiveram alterac¸ãodasensibilidade.Naavaliac¸ãogeraldetodosospacientesoíndicedelesãonervosa foide50,9%.

Conclusão: A retirada do ST isolado e usado de forma tripla é uma opc¸ãoviável na reconstruc¸ãodoLCAepodeocasionarummenornúmerodelesãonervosarelacionada aramosdonervosafeno.

Introduction

Anteriorcruciateligament(ACL)injuries,whichare incapaci-tatingforcertainphysicalactivitiesbecauseoftheinstability that is caused, predispose toward meniscal and cartilage lesions that may evolve to arthrosis.1 _ACL _{reconstruction}

seekstorestorejointstability.

WiththeevolutionofsurgicalproceduresforACL recon-struction, patients’ expectations regarding the results are becominggreater.Theyseektoreturntotheirdailyactivities earlierandwithlessmorbidity.2

Thetendonsthataremostusedforthisprocedurearethe flexortendons(semitendinosusandgracilis)andthecentral thirdofthepatellarligament.Theliteratureshowsthatthe resultsfrom using thesetwo grafts are similar,3–6 _but _it _is

believedthatusingtheflexortendonsleadstolower postop-erativemorbidity.7

However,graftharvestingisnotrisk-free.Thecommonest complicationisregionalparesthesiaoranesthesiaintheleg, causedbyinjurytotheinfrapatellarbranchofthesaphenous nerve(IPSN). There have been reportsof incidencegreater than70%.8,9

Toreducetheincidenceofthiscomplication,someauthors havechosentouse amoreoblique incision,10_while_others

haveattemptedtoexploreandidentifythenerveatthetime ofharvestingthegraft.2

Theaimof the present study was to compare whether harvesting a flexortendon (semitendinosus) has the same incidenceofnerveinjuriesasdoesharvestingofbothtendons (semitendinosusandgracilis)bymeansofaverticalincision, foruseasgraftsinACLreconstruction.

Materials

and

methods

Sixmonthsaftertheoperation,110patientswhohad under-goneACLreconstructionusingflexortendonswereassessed. Atriplegraftfromthesemitendinosustendonwasusedwhen remnantsofthetornACL hadbeenpreservedorwhenthe diameterofthegraftwasgreaterthan8mm,foratotalof36 patients.

WhentherewasnoremnantACLorthesemitendinosus tendondidnotreachadiameterof8mm,thereconstruction

was done usinga quadruple graft from the flexortendons (semitendinosusandgracilis),whilealwaysmaintainingtheir distalinsertioninthetibia,foratotalof74patients.

Patients whohad notundergonesuturingofthemedial meniscususingthe“in-out”or“out-in”technique(inwhich asmallmedialincisionwasmade)werenotincludedinthe evaluation.Likewise,patientswithscarsorprevioussurgery onthekneewerealsonotincluded.

Surgicaltechnique

ACLreconstructionwasperformedusingatourniquetatthe baseofthethighandspinalanesthesiainallcases.

Theprocedurewas startedwithharvesting ofthe semi-tendinosustendonbymeansofaverticalincisionthatwas madeapproximately1.5cmmediallyanddistallytothe ante-riortuberosityofthetibia,withanaveragelengthof2.8cm. Thefasciaofthesartorius,whichcoverstheflexortendons, wasopenedhorizontallyand,withtheaidoftwo“mixters”, thesemitendinosuswasisolatedandharvestedbymeansof an openstripper (pigtailtype),whilemaintaining itsdistal insertioninthetibia.6

The muscle portion was cleaned and the arthroscopic procedure was started through conventional anteromedial and anterolateral portals. After treatment of the asso-ciated lesions, the existence of any viable remains of the ACL was ascertained. The femur was then prepared for drilling the tunnel, which was done by means of independent “out-in” drilling, following the technique of Chambat.11

Inthetibia,whentherewereviableremainsoftheACL,we didthedrillingusingtheremainsasthelocation.Withtheaid ofashaver,apathwithintheremainswascreated.12

When there were no remainsofthe ACL or thesewere unviable,thetibialtunnelwasconstructedwithinthetibial footprint,usingtheanteriorcornuofthelateralmeniscusand themedialtibialspineasthelocationparameter.Inthiscase, orwhenthetriplegraftfromthesemitendinosuspresented a diameterof less than 8mm, wereturned to theincision overtheflexorsandharvestedthegracilistendoninthesame manner.

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Table1–Incidenceofnerveinjuries.

Sensitivitya _Total

Normal Altered

Numberoftendons

1tendon(ST) n 23 13 36

%oftendons 63.9% 36.1% 100.0% 2tendons(STandGC) n 31 43 74

%oftendons 41.9% 58.1% 100.0%

Total n 54 56 110

%oftendons 49.10% 50.90% 100.0% Chi-squaretest 2(df=1)=4.689;p=0.030

a _For_columns_with_difference_letters,_their_proportions_present_a_significant_difference_at_the_probability_level_of_5%.

inthetibia.Thefixationwasdoneusinginterferencescrews, firstlyinthetibiaandsecondlyinthefemur,fromouttoin, closetotheextension.

No drains were used. The patients were released 24h after the operation, and at this time physiotherapy was started,withprogressivepartialweight-bearingwiththeaid ofcrutchesfor15days.

The patients were assessedsix monthsafter the oper-ation and they were asked to define the area over which altered sensitivity was present in the leg that had been operated.

Statisticalanalysis

The data were summarized in tables showing the total numbersofindividualsandtheabsolutefrequenciesand per-centagesforthequalitativevariables.

Associationsbetweensensitivity(normaloraltered)and thenumber oftendons(semitendinosus orsemitendinosus plusgracilis)wereascertainedusingthePearsonchi-square test,andtheztestwasusedtomakecomparisonsbetween theproportionsofthecolumns.13

Results

Alteredsensitivitywasfoundin36.1%(13/36)ofthepatients inwhomonlythesemitendinosustendonhadbeenusedas agraft;and in58.1% (43/74)ofthe patients inwhom both tendonhad beenused(semitendinosus andgracilis).Inthe generalevaluationwithallthepatients,50.9%(56/110) pre-sentednerveinjuries(Table1).

The result from the chi-square test was significant (p=0.030)andmadeitpossibletostatethattherewasgreater occurrenceofalteredsensitivityafterthesurgerywhenboth ofthetendons(semitendinosusandgracilis)wereused.Inthe groupinwhichonlyonetendon(semitendinosus)wasused, itwas observedthattheproportionoftheindividuals who presentednormalsensitivity(63.9%)wasgreaterthanthe pro-portionwithalteredsensitivity(36.1%).Thiswastheinverse ofthesituationinthegroupinwhichtwotendons (semitendi-nosusplus gracilis)were used, sincethe proportionofthe individualswithnormalsensitivity(41.9%)waslowerthanthe proportionwithnervelesions(58.1%).

Discussion

ACLreconstructionusingflexortendonsisnotfreefrom com-plications.Thecommonestoftheseisinjurytoabranchofthe saphenousnerve,forwhichthereportedincidencecanbeas highas77%.8,9

Thisismostcommonlyseenintheinfrapatellarbranch (IPSN), which crosses the anterior regionof theknee, well belowthepatella.14_This_branch_is_{perpendicular}_and_at_risk

ofinjurybecauseoftheverticalincisionthatismadefor har-vestingtheflexortendonsandbecauseofthewoundcaused bythearthroscopyportal.14,15

Luoetal.10_compared_the_incidence_of_nerve_injuries_in

rela-tiontoflexortendonharvesting,betweenuseofobliqueand verticalincisions,andconcludedthatobliqueincisionsledto anerveinjuryrateof24%versus56%forverticalincisions.

Papastergiouetal.16_used_vertical_incisions_to_harvest_the

patellarligament andfoundthat39.7% ofthepatients pre-sented nerve injuries. Saglione et al.8 _harvested _only _the

semitendinosus and found that 37.5% presented injuries, whichwassimilartothefindingsfromourgroupthatused thesemitendinosusalone,inwhichtheratewas36.1%.

Mochizukiet al.17 _reported_that_the_incidence_of_altered

sensitivity through harvesting of the flexor tendons was 58%, which was similar to the findings from ourgroup in whichbothflexortendonswereharvestedandtheratewas 58.1%.

During the procedure for harvesting grafts from the flexortendons,MirzatolooeiandPisoodeh2_isolated_superficial

branchesofthesaphenousnerveandpreservedthem.They reportedthattheirnerveinjuryratewas20.5%,incomparison witharateof72%amongpatientsinwhom thesuperficial nervebrancheswerenotfound.Theyalsoreportedthat9.8% of the patientswho presentedaltered sensitivitysaid that this wason themedialfaceoftheleg, andmadethe sup-positionthatthisalterationwasnotrelatedtoinjuryofthe IFSNbranchbutrather,toinjuryofthesartoriusbranchofthe saphenousnerve(SBSN).Thelatterpresentsaninitially verti-calpathtogetherwiththesartoriusmuscleanditemergesin thesubcutaneouslayerbetweenthetendonofthesartorius andthegracilis.Itthencontinuesdistallytogetherwiththe saphenousveinandisresponsiblefortheinnervationofthe knee,lowerlegandankle.3,18_This_type_of_injury_is_thought_to

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SBSNinjurieswere alsodescribed bySanders etal.19 _In

theirstudyon164patients, theyfoundthat 23%presented injuryoftheSBSNaloneand19%oftheIPSNalone,while32% hadtheseinjuriesconcomitantly.TheyconcludedthatSBSN injuriesduetopassageofthestrippermaybemorecommon thanisreportedintheliterature,becausethepathofthisnerve isveryclosetothegracilisinthedistalregionofthethigh.

Inourstudy,36.1%ofthecasesofharvestingthe semitendi-nosusalonepresentednervealterations,whereas58.1%with harvestingofthesemitendinosusandgracilisdidso.This dif-ferencewasstatisticallysignificant.Weonlyhadonecasein whichalteredsensitivitywasreportedtobeexperiencedin theregionoftheSBSN,inapatientfromwhombothtendons wereharvested.

InanattempttoavoidSBSNinjury,someauthors20 _have

advisedthattheflexortendons(andespeciallythegracilis) shouldbeharvestedwiththekneeina“figure-four”position, soastorelaxthesaphenousnerve.However,others19 _have

reportedthatnerveinjuriesoccurredevenwiththisharvesting technique.

Preservationofoneoftheflexortendons(gracilis)inACL reconstructionsmayleadtolowerincidenceofnerveinjuries andlesslossofmusclestrength,whichmaybebeneficialfor therehabilitation.

Conclusion

Harvestingofthesemitendinosusalone,foruseintripleform inACLreconstruction,maybeaviablegraftingoptionwith lowerriskofinjurytobranchesofthesaphenousnervein com-parisonwithusinggraftsfromboththesemitendinosusand thegracilis.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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