Rev. bras. ortop. vol.48 número5

r e v b r a s o r t o p . 2013;48(5):417–420

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

Original

article

Hamstring

tendons

insertion

–

an

anatomical

study

夽

,

夽夽

Cristiano

Antônio

Grassi

_,

_Vagner

_Messias

_Fruheling

_,

_João

_Caetano

_Abdo

_,

Márcio

Fernando

Aparecido

de

Moura

_,

_Mário

_Namba

_,

_João

_Luiz

_Vieira

_da

_Silva

_,

Luiz

Antônio

Munhoz

da

Cunha

_,

_Ana

_Paula

_Gebert

_de

_Oliveira

_Franco

_,

Isabel

Ziesemer

Costa

_,

_Edmar

_Stieven

_Filho

a_{StudyingforSpecialisttitleinSportsTraumatology,UniversidadeFederaldoParaná(UFPR);DepartmentofOrthopedicsand}

Traumatology,UFPR,Curitiba,PR,Brazil

b_{ResidentinOrthopedicsandTraumatology,UFPR;DepartmentofOrthopedicsandTraumatology,UFPR,Curitiba,PR,Brazil}

c_{PhDinOrthopedicsandTraumatologyfromUniversidadeFederaldeSãoPaulo(UNIFESP);ProfessorofHumanAnatomy,UFPR;}

DepartmentofOrthopedicsandTraumatology,UFPR,Curitiba,PR,Brazil

d_{MScinSurgeryfromUFPR;DepartmentofOrthopedicsandTraumatology,UFPR,Curitiba,PR,Brazil}

e_{PhDinSurgeryfromUFPR;DepartmentofOrthopedicsandTraumatology,UFPR,Curitiba,PR,Brazil}

f_{PhDinOrthopedicsandTraumatologyfromEscolaPaulistadeMedicina,UNIFESP;TitularProfessorofOrthopedics,UFPR;Department}

ofOrthopedicsandTraumatology,UFPR,Curitiba,PR,Brazil

g_{PhDinDentistryfromUniversidadeCatólicadoParaná;CoordinatorofClinicalResearch,SportsTraumatologyandArthroscopyCenter,}

Curitiba,PR,Brazil

h_{UndergraduateMedicalStudent,UniversidadeEvangélicadoParaná;DepartmentofOrthopedicsandTraumatology,UFPR,Curitiba,}

PR,Brazil

i_{ProfessorofOrthopedicsandTraumatology,UFPR;DepartmentofOrthopedicsandTraumatology,UFPR,Curitiba,PR,Brazil}

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Articlehistory:

Received13June2012 Accepted23July2012

Keywords:

Anatomy Cadaver Knee

a

b

s

t

r

a

c

t

Objective:Tostudytheanatomyofthehamstringtendonsinsertionandanatomical rela-tionships.

Methods:Tencadaverkneeswithmedialandanteriorintactstructureswereselected.The dissectionwasperformedfromanteromedialaccesstoexposureoftheinsertionoftheflexor tendons(FT),tibialplateau(TP)andtibialtuberosity(TT).Aneedleof40×12andacaliper wereusedtomeasurethedistanceofthetibialplateauofthekneeflexortendonsinsertion at15mmfromthemedialborderofthepatellartendonandtibialtuberositytotheinsertion oftheflexortendonsoftheknee.Theanglebetweentibialplateauandtheinsertionofthe flexortendonsoftheknee(A-TP-FT)wascalculatedusingImageProPlussoftware.

夽_{Pleasecitethisarticleas:GrassiCA,FruhelingVM,AbdoJC,deMouraMFA,NambaM,daSilvaJLV,etal.Estudoanatômicodainserc¸ão}

dostendõesflexoresdojoelho.RevBrasOrtop.2013;48:417–420.

夽夽

StudyconductedattheBiologicalSciencesSector,UniversidadeFederaldoParaná,Curitiba,PR,Brazil.

∗ _{Correspondingauthorat:HospitaldeClínicas,RuaGeneralCarneiro,181,6}◦_{andar,Curitiba,PR,Brazil,CEP80060-900.} Tel.:+4133151785;fax:+4133151785.

E-mail:[email protected](E.S.Filho).

2255-4971/$–seefrontmatter©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

418

Results: ThemeandistanceTP-FTwas41±4.6mm.ThedistancebetweentheTT-FTwas 6.88±1mm.The(A-TP-FT)was20.3±4.9◦_.

Conclusion: Intheanteriortibialflexortendonsareabout40mmfromtheplateauwithan averageof20◦_.

©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Estudo

anatômico

da

inserc¸ão

dos

tendões

flexores

do

joelho

Palavras-chave:

Anatomia Cadáver Joelho

r

e

s

u

m

o

Objetivo: Determinarparâmetrosanatômicosparalocalizarainserc¸ãodostendõesflexores dojoelhonatíbia.

Métodos: Foramselecionados10 joelhosde cadáverescomestruturasmediaise anteri-oresíntegras.Adissecc¸ãofoifeitaporacessoântero-medialatéaexposic¸ãoadequadada inserc¸ãodostendõesflexores(TF),doplanaltotibial(PT)edatuberosidadeanteriordatíbia (TAT).Umaagulha40×12eumpaquímetrodigitalforamusadosparaaferiradistância doplanaltotibialdainserc¸ãodostendõesflexoresdojoelhoa15mmdabordamedialao tendãopatelaredatuberosidadeanteriordatíbiaàinserc¸ãodostendõesflexoresdojoelho. Oânguloformadoentreoplanaltotibialeainserc¸ãodostendõesflexoresdojoelho(ÂPT-TF) foicalculadocomoauxíliodosoftwareImageProPlus®.

Resultados: AdistânciaPT-TFfoide41±4,6mmemmédia.AdistânciaentreaTAT-TFfoi de6,88±1mm.Aangulac¸ão(ÂPT-TF)foide20,3±4,9graus.

Conclusão:Naregiãoanteriordatíbiaostendõesflexoresestãoacercade40mmdoplanalto comumângulomédiode20graus.

©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Reconstructionoftheanteriorcruciateligamentisthe prin-cipal surgical procedure performed in sports medicine.1

Thearthroscopictechniqueusedforreconstructionsofthe anteriorcruciateligamentpresentssatisfactoryresultswith regardtostability,whichallowspatientstoreturntosports practise.2,3

Semitendinosusandgracilistendons(kneeflexors)are cur-rentlythemainsourceofgraftsforintraandextra-articular ligamentreconstruction.4_{Amongtheadvantagesofusingthis}

graftisthefactthatitisautologous,givesrisetolessmorbidity atthedonorsite,preservestheintegrityofthekneeextensor andhasalowerrateofanteriorkneepain.4,5

Lackofknowledgeoftheanatomyoftheinsertionsofthe flexortendonsmay leadtotechnical problemsduring har-vesting,suchasinjurytothesaphenousnerveandtechnical difficultyinharvestingbecausetheincisionwasmadeinan inappropriatelocation.4,6 _{Itisnotuncommonfortheflexor}

tendonstobelost,withaconsequentneedtoharvestanother graftfromaseconddonorsite.6,7_{Thereisashortageofarticles}

intheliteraturerelatingtoappliedanatomyofthekneeflexor tendons.

Theaimofthisstudywastodetermineanatomical param-etersforlocatingtheinsertionsofthekneeflexortendonsin thetibia.

Materials

and

methods

ThisstudywasconductedintheDepartmentofAnatomyof theBiologicalSciencesSectorofUFPR,duringAprilandMay

2011.Theinclusioncriteriawerethatthematerialshouldbe knees fromcadaverswithintactmedialandanterior struc-tures. Ten knees from cadaversthat fulfilled these criteria were dissected. All ofthese were conserved in formol.An anteromedialaccesswasused,withdissectioninlayersuntil obtainingacompleteviewofthetibialplateauandthe inser-tionofthekneeflexortendons.

Thedistancefromthetibialplateautotheinsertionofthe knee flexortendonswasmeasured 15mmfromthe medial borderofthepatellartendon.Thehorizontaldistancefrom theanteriortibialtuberositytotheinsertionofthekneeflexor tendonswasalsomeasured(Fig.1).

Thequalitativenatureofthisspecificregionoftheflexor tendonswasalsoobserved.

Thepointswerepreviouslymarkedoutusing40×12needle andweremeasuredwiththeaidofdigitalcalipers(AeroSpace –150mm).

Theangleformedbetweenthetibialplateauandthe inser-tionofthekneeflexortendonswasalsomeasuredwiththe aidoftheImageProPlus® _{software4.5forWindows(Media}

Cybernetics,Inc.,USA).

Results

rev bras ortop.2013;48(5):417–420

419

Fig.1–Muscletendons:S–semimembranosus,G– gracilis,ST–semitendinosus.

tendonsandthetibialplateau(TP-FTangle)was20.3±4.9◦

(Table1).

Itwasobservedthatthegracilisandsemitendinosus ten-donswere coveredwith a thin fibrotic cap formedby the tendonofthesartoriusmuscle,whichhasabroadinsertion (Fig.1).Itstendonisshorterandthinnerthantheother flex-ors.

Thesemitendinosustendonwasthethickestandlongest ofthetendonsanalyzed.Theinsertionsofthesemitendinosus andgraciliswereinthesamedissectionlayerandweremore restrictedthantheinsertionofthesartorius.

Discussion

Graftsfromtendonflexorsarecommonlyusedforligament reconstructions.8_{Knowledgeoftheanatomyoftheinsertions}

Table1–Meanvaluesoftheanatomicalmeasurements

ontheinsertionsofthekneeflexortendons.

TP-FT (mm)

ATT-FT (mm)

TP-FT angle(◦₎

Mean 40.96 6.88 20.30

Standarddeviation(SD) 4.59 0.96 4.89

TP-FTangle,anglebetweenthetibialplateauandtheinsertionof theflexortendons;SD,standarddeviation;TP-FT,distancefromthe tibialplateautotheinsertionoftheflexortendons;ATT-FT,distance fromtheanteriortibialtuberositytotheflexortendons.

ofthesetendonsisimportantforensuringthattheharvesting processispreciseandsafe.

Incisionatthecorrectlocationisthefirststeptoward

suc-cessinthisprocedure.Onecommonmistakeistomakethe

incisiontooproximally,whichcreatesdifficultyinfindingthe flexortendons.Insuchcases,greaterwoundingofsofttissues isnecessaryinordertoharvestthetendon.Theparameterof 40mmfromthetibialplateaumayhelpthesurgeontomake theincisionintheappropriatelocation.

Theincision toharvesttheflexortendonmay be

trans-verse, vertical or oblique.Oblique and transverse incisions facilitatereleasingthetendonfromdeepbindings.Sometimes thetendonispalpableandtheincisioncanbemadeby fol-lowingitsupperedge.Inobesepatients,thetendoncannot bepalpated.Inordertomakeanobliqueincisionthatfollows alongthetendon,theparameterof20◦_canbeused.

Withamorepreciseincision,thesoft-tissueinjuryis less-ened.Thisleadstoalesspainfulpostoperativeperiod.The anatomicalparametersoftheinsertionsofthekneeflexion tendonshelpinthe precisionoftheprocedure.Itis impor-tanttoemphasizethatmakingapreciseincisionwithalow degreeofsoft-tissueinjurydoesnotsignifyasmallincision. Theincisionneedstobeofasizethatmakesitcomfortableto performtheprocedure.Incisionsthataretoosmallmaycause skinlacerationsthroughpullingtheskinbackorthrough los-ingthetendonbecauseofdifficultyinviewingthestructures. Thesizeoftheincisiondiminishesnaturallywiththenumber ofproceduresthatthesurgeonperforms.Thislearningcurve shouldnotbeartificiallyaltered.

Theanatomyoftheinsertionsofthekneeflexortendons

hasbeendescribedinsomeimportantorthopedictextbooks

inthefollowingorderfromproximaltodistal:sartorius, gra-cilisandsemitendinosus.9_{Althoughitiscorrecttoteachthis}

inthismanner,itmayleadtoconfusionwithregardto surgi-calanatomybecausethetendonofthesartoriusisnotinthe samedissectionlayerastheothertwotendons.Itisshorter and moresuperficial,and its insertionisbroader.The ten-donofthe sartoriuscovers the tendonsofthegracilis and semitendinosus, whichare just below,withinsertions that aremuchmorerestricted(Fig.1).Bettersurgical comprehen-sionoftheanatomicalimagescanbeachievedthroughusing 3Dimages.10_{Thistypeoftechnologycanplacetheteaching}

materialstudiedclosertotherealityofsurgicalprocedures.

Conclusion

The flexortendonsare inserted onaverage 40mm distally tothetibialplateauand7mmmediallytotheanteriortibial tuberosity.

Theinsertionofthekneeflexortendonsisobliqueandis atanangleof20◦_{inrelationtothetibialplateau.}

Thesartoriusismoresuperficialandbroaderthantheother tendonsandisnotinthesamedissectionlayer.

Conflicts

of

interest

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