SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
Article
Relationship
between
peri-incisional
dysesthesia
and
the
vertical
and
oblique
incisions
on
the
hamstrings
harvest
in
anterior
cruciate
ligament
reconstruction
Marcos
Laube
Leite
a,∗,
Fernando
Amaral
da
Cunha
a,
Bruno
Quintão
Martins
da
Costa
b,
Rodrigo
Moura
Andrade
b,
Jose
Henrique
Diniz
Junior
a,
Eduardo
Frois
Temponi
caFundac¸ãoHospitalarSãoFranciscodeAssisdeBeloHorizonte,GrupodeCirurgiadoJoelho,BeloHorizonte,MG,Brazil
bFundac¸ãoHospitalarSãoFranciscodeAssisdeBeloHorizonte,Servic¸odeOrtopedia,BeloHorizonte,MG,Brazil
cHospitalMadreTereza,GrupodoJoelho,BeloHorizonte,MG,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received17November2015 Accepted7January2016 Availableonline18October2016
Keywords:
Anteriorcruciateligament Reconstruction
Dysesthesia
a
b
s
t
r
a
c
t
Objective:Tocomparethe incidenceofperi-incisionaldysesthesia accordingto theskin incisiontechniqueforhamstringtendongraftharvestinanteriorcruciateligament recon-struction.
Methods:Thirty-threepatientswithACLrupturewereseparatedintwogroups:group1,with 19patientssubmittedtotheobliqueskinincisiontoaccessthehamstringsandgroup2–14 patientsoperatedbyverticalskinincisiontechnique.Theselectedpatientswereassessed aftersurgery.Demographicdataandprevalenceofdysesthesiawasmeasuredbydigital pressurearoundtheskinincisionandclassifiedaccordingtotheHighetscale.
Results:Thetotalrateofdysesthesiawas42%(14patients).Fivepatients(26%)ontheoblique incisiongroupreporteddysesthesiasymptoms.Onthegroupsubmittedtothevertical inci-siontechnique,theinvolvementwas64%(ninepatients).Onthe33kneesevaluated,the superiorlateral areawasthemostaffected skinregion,while thesuperiormedialand inferiormedialregionswereaffectedinonlyonepatient(7.1%).Nostatisticaldifferences betweenbothgroupswereobservedregardingpatients’weight,age,andheight¸aswellas skinincisionlength.
Conclusion: Patientswhounderwentreconstructionoftheanteriorcruciateligamentusing theobliqueaccesstechniquehadfivetimeslowerincidenceofperi-incisionaldysesthesia whencomparedwiththoseinwhomtheverticalaccesstechniquewasused.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mail:[email protected](M.L.Leite). http://dx.doi.org/10.1016/j.rboe.2016.10.005
Disestesia operadospelatécnicacomincisãooblíquaparaoacessoaosflexores,eGrupo2,composto por 14pacientesoperadospela técnicacomincisãovertical.Ospacientesselecionados foramexaminadosnopós-operatório.Dadosdemográficosea prevalênciadadisestesia foramavaliadospormeiodedigitopressãoemtornodaregiãoincisadaeaprevalênciafoi classificadadeacordocomaescaladeHighet.
Resultados:Ataxatotaldedisestesiafoide42%(14pacientes).Cincopacientes(26%)dogrupo da incisãooblíquaapresentaramsintomasdedisestesia. Nogruposubmetidoàtécnica comincisãovertical,oacometimentofoide64%(novepacientes).Nos33joelhosavaliados, aregiãosuperior-lateralfoiaáreamaisacometida,enquantoasregiõessuperior-medial einferior-medialforamafetadasemapenasum paciente(7,1%).Nãoforamobservadas diferenc¸as estatísticasentreos doisgruposem relac¸ãoaopeso,à idadee àalturados pacientes,bemcomootamanhodaincisão.
Conclusão:Ospacientessubmetidosàreconstruc¸ãodoligamentocruzadoanteriordojoelho comatécnicacomacessooblíquoapresentaramincidênciadedisestesiaperi-incisional cincovezesmenoremrelac¸ãoàquelesqueforamsubmetidosàtécnicacomacessovertical. ©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Planninganarthroscopicreconstructionoftheanterior cruci-ateligament(ACL)demandsseveralsurgicalconsiderations that may influence its clinical and functional outcomes. Amongthem,graftoptionsandtechniquesusedtoharvest themarenoteworthy.1Themostusedautologousgraftoptions
includethecentralthirdofthepatellartendon,theflexor ten-dons(semitendinosusandgracilis),andthequadriceps2;all
havebeenwidelyused,andtheirresultsandcomplications arewelldescribedintheliterature.1–3 Thetechniquesusing
graftsfromthesemitendinosusandgracilistendonsrequirea smallincisionandhavelowdonorsitemobility.3However,due
totheparticularanatomicallocation,thereisapotentialrisk ofinjurytotheinfrapatellarbranchofthesaphenousnerve (IPBSN)duringharvest,3whichcanleadtocomplicationssuch
aslocalpainandperi-incisionaldysesthesia.4
Thepercentageofperi-incisionaldysesthesiainACL recon-struction with flexor tendons ranges from 14.9% to 77%.3
Researchonthesubjectaddressespreventivemeasuresand comparisonsregardingwhichaccesswouldevolvewithlower incidenceratesofthissymptom,whichhasbecomea recur-ringthemeintheliterature.2,4–9
Severalauthorsrecommendtheuseofobliqueand hori-zontalincisionstoexposeandharvestthetibialinsertionof theflexortendonsinordertoreducedamagetoIPBSNwhen comparedwithverticalincisions;however,thereisno con-sensustodate.3,6–8Itishypothesizedthattheincisionswith
greaterrespecttotheanatomyofIPBSNmayensurealower complicationrate.Therefore,thisstudyaimedtocomparethe
prevalenceofperi-incisionaldysesthesiaaccordingtothetype ofincision(obliqueorvertical)inflexortendonsgraftremoval forACLreconstruction.
Material
and
methods
Thiscross-sectionalstudywasperformedinordertoassess theincidenceofdysesthesiaaccordingtothetypeofincision inpatientsundergoingACLreconstructionusing semitendi-nosusandgracilistendonsgrafts.Surgerieswereperformed by the seniorsurgeonof the KneeSurgery Groupbetween February2014andApril2015.Inclusioncriteriacomprisedall patientswhounderwentprimaryACLreconstructionusingan autograftoftheflexortendons.Thestudyexcludedpatients who had undergone any previous surgery inthe regionof the studied knee, as well as patients with any peripheral neurological abnormalitypriortothe procedure. A totalof 33 patientswere eligibleforthestudy,26males andseven females.Theywererandomlydividedbyacomputerprogram intotwogroups;onegroupcomprised19patientstreatedwith theobliqueincisiontechniqueandtheothergroupincluded 14patients,inwhomtheverticalincisiontechniquewasused. The followingdata were recorded:age, height, weight, the presenceorabsenceofperi-incisionaldysesthesia,andwhen present,thelocation(superior,inferior,lateral,ormedial) rel-ativetotheincision.4
Fig.1–Oblique(a)andvertical(b)incisiontoremoveflexorgraftsforthereconstructionoftheanteriorcruciateligament.
obliqueincisions,withaninclinationof45◦inrelationtothis
plane,fromsuperomedialtoinferolateral(Fig.1).Meanlength ofincisionswas3.07cmfortheobliquegroup(3–3.4cm)and 3.11cmfortheverticalgroup(3–3.5cm).Allgraftswere pre-paredinfreeform.Allpatientswereoperatedbytransportal arthroscopy,whichusedonlytwoarthroscopic portals.The rehabilitationprotocoldidnotdifferbetweenthetwogroups. Selectedpatientswereexaminedinanoutpatientcarefacility forpostoperativecontrolat14,30,90,180,and360days,when the final assessmentofthe neurological statuswas made. Clinicalevaluationwasperformedbyasingleresearcher.The sensitivityoftheperi-incisionalregionwasmeasuredbydigit pressureandclassifiedaccordingtoHighet’sscale(S0: anes-thesia; S1: deep sensitivity preserved; S2: pain and tactile sensitivitypreservedwith dysesthesia;S3: pain and tactile sensitivitypreservedwithoutdysesthesia;S3+presenceof dis-criminativesensitivity;S4normalsensitivity).10
The study was approved by the Ethics Committee in Researchunderthe CAAE number44637715.0.0000.5120; all patientsreceivedandsignedaninformedconsentform.
Statisticalanalysis
Aprevioussamplecalculationwasperformedandthenumber of28knees wasdefinedasnecessary forstatistical signifi-cance(14ineachgroup),consideringasignificancelevelof5%, 80%testpower,andthedysesthesiaprevalencesreportedin theliterature.Toassesstherelationshipbetweentheincision techniqueandthepresenceofdysesthesia,thechi-squared (2)testforindependencewasused,11witha5%significance
level.Theoddsratioswerethencalculatedtoassessthe prob-abilityoftheeventoccurringbetweengroups.Allotherdata werepresentedasmeanandstandarddeviation.The statis-ticalanalyseswereperformedwithSPSS(IBMCorp.Released
2011.IBMSPSSStatisticsforWindows,Version20.0.Armonk, NY:IBMCorp.).
Results
Patients’agerangedfrom18to53years,withameanof34.5 (SD=9.18).Themeanweightofthepatientswas72kg,ranging from62kgto85kg.Heightrangedfrom1.62mto1.85m,with amean of1.73m. Therewasnodifferencebetweengroups regardingmeanage(ns),aswellasnodifferencesregarding weight,height,andgenderofpatients.
Obliqueincisionwasusedin19outof33kneesassessed. Ofthese,14(74%)haddysesthesiacomplaintsandfive(26%) had symptomsduringfollow-up. Amongpatients inwhom surgerywasperformedwithaverticalincision,five(36%)had nocomplaintsandnine(64%)hadsomedegreeof dysesthe-siaaroundtheincisedregionduringfollow-up.Accordingto the oddsratio test,the presenceofdysesthesiainpatients undergoingverticalincisionwasfivetimeshigher(5.04times; CI=95%)thaninpatients operatedwithobliqueaccess. All incisions were measuredand thegreatest differencefound was5mm,withnostatisticaldifference(ns).
In 33 knees evaluated, thesuperolateral region was the mostaffected;superomedial and inferomedialinvolvement wasobservedinonlyonepatient(7.1%). Ofthe 14patients withdysesthesia,71.4%hadcomplaintsinonlyoneregion, three(9.1%)intwo,andonlyonepatientcomplainedinthree regions(Table1).Allpatientswithdysesthesiawereclassified asS2onHighet’sscale.
Discussion
Vertical Inferolateral 5 56
Superolateral 7 78
reconstructionisdecisivefortheincidenceofpostoperative peri-incisionaldysesthesia.Anoverallprevalenceof26%of dysesthesiawasobserved,five-foldhigherinthegroupwith verticalincisioninrelationshiptotheobliqueincision, per-hapsduetogreaterconformitytotheanatomyoftheIPBSN inthiscase.
Gali et al.3 conducted a study in cadaveric knees and
demonstratedthattheIPBSNisalmostparalleltothesuperior border of the anserinus tendons (from medial to lateral-superior-inferior). Theproximity between thesestructures, associatedwiththesurfacepositionofitsterminalbranchin theanteromedialregionoftheknee,couldexplainthe inci-denceofiatrogenicIPBSNinjuriesinACLreconstructionwith flexortendons,which,accordingtotheliterature,canreach 77%.3,12,13 Theconsensus amongresearchers isbased
pre-ciselyontheexistenceofaparallelismbetweenthehorizontal andobliqueincisionsandtheanatomyoftheIPBSN.Portland etal.6 comparedthreecomplicationsassociatedwith
verti-calandhorizontalincisionsintheremovalofflexortendon: pain,cosmeticappearance,anddysesthesia.Inallassessed items,theverticalincisionpresentedahigherrateof com-plications.Regardingdysesthesia,thoseauthorsobservedan incidenceof59%intheverticalincision,vs.43%inhorizontal.6
Papastergiouetal.9foundsimilarresults.Luoetal.,8inastudy
publishedin2007,observeda24%riskofIPBSNinjuriesin patientswhounderwentobliqueincision vs.65.7%inthose whounderwent verticalincision,withnosignificant differ-enceinfollow-upperiodandthemeanageofpatients.
Several authors assessedoptions tominimize the com-plications during graft harvesting for ACL reconstruction. Letartreetal.14 suggestedatechniquethatusesthe
poste-rioraccessforremovingtheflexortendonsinordertoprevent lesions in the saphenous nerves and its branches in the anteromedialregionoftheknee.Inarecentpublication,De Paduaetal.15foundalowerrateofsaphenousnervelesions
incaseswhereonlythesemitendinosustendonwasremoved (thuspreserving thegracile)whencompared with harvest-ingofbothgrafts.Tiffordetal.7assessedtheeffectofIPBSN
positionondynamickneemobilityin20cadaverkneesand concludedthatincisionsinthe anterioraspectoftheknee shouldbemadeinflexion.Inagreementwiththoseauthors, allpatientsinthepresentstudyunderwentincisionwiththe kneeinflexion.
Thelimitationsofthepresentstudy areassociatedwith itstransversaldesign,whichassessedthepresenceof dyses-thesia over a maximum period of 12 months. This may notrepresenttheactualrateofdysesthesiafoundinthese patients,taking intoaccountthe possibilityofneurological
thisprocedure,becauseamajorimpactinthepreventionof postoperative dysesthesiacanbeachievedthrougha small technicalchangeinACLreconstruction.
Conclusion
In the present study, patients undergoing ACL reconstruc-tionwiththetechniqueofobliqueaccessshowedafive-fold lower prevalenceofperi-incisional dysesthesiawhen com-paredwiththegroupinwhomtheverticalaccesswasused.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
ToDr.BertrandSonnery-Cottet/CenterOrthopedicSanty,Fifa MedicalCenterofExcelence,Ramsay-GénéraledeSanté, Hôpi-talPrivéJeanMermoz,Lyon,France,andDr.LúcioHonóriode CarvalhoJúnior,HospitalMadreTeresa,BeloHorizonte,Brazil, fortheirhelpwiththemanuscript.
r
e
f
e
r
e
n
c
e
s
1.CarneiroM,NavarroRD,NakamaGY,BarrettoJM,Queiroz AAB,LuzoMVM.Reconstruc¸ãodoligamentocruzadoanterior comduplofeixeutilizandoostendõesdosmúsculos
semitendíneoegrácil:fixac¸ãocomdoisparafusosde interferência.RevBrasOrtop.2009;44(5):441–5.
2.CarvalhoJuniorLH,SoaresLFM,Gonc¸alvesMBJ,PiresJunior PR,BaumfeldDS,PereiraML,etal.Disestesiaperi-incisional apósreconstruc¸ãodoligamentocruzadoanteriorcomterc¸o centraldotendãopatelar.RevBrasOrtop.2011;46(1):37–9. 3.GaliJC,ResinaAF,PedroG,MoraNetoIA,AlmagroMAP,Silva
PAC,etal.Importânciadalocalizac¸ãoanatômicadoramo infrapatelardonervosafenonareconstruc¸ãodoligamento cruzadoanteriorcomtendõesflexores.RevBrasOrtop. 2014;49(6):625–9.
4.TemponiEF,CarvalhoJúniorLH,SoaresLFM,Gonc¸alvesMBJ, LeiteML,SilvaJuniorOM.Disestesiaperi-incisionalapós reconstruc¸ãodoligamentocruzadoanterior:comparac¸ão entredoisdiferentestiposdeenxerto.RevPortOrtop Traumatol.2013;21(3):389–94.
5.TennentTD,BirchNC,HolmesMJ,BirchR,GoddardNJ.Knee painandtheinfrapatellarbranchofthesaphenousnerve.JR SocMed.1998;91(11):573–5.
7. TiffordCD,SperoL,LukeT,PlancherKD.Therelationshipof theinfrapatellarbranchesofthesaphenousnerveto arthroscopyportalsandincisionsforanteriorcruciate ligamentsurgery.Ananatomicstudy.AmJSportsMed. 2000;28(4):562–7.
8. LuoH,YuJK,AoYF,YuCL,PengLB,LinCY,etal.Relationship betweendifferentskinincisionsandtheinjuryofthe infrapatellarbranchofthesaphenousnerveduringanterior cruciateligamentreconstruction.ChinMedJ(Engl). 2007;120(13):1127–30.
9. PapastergiouSG,VoulgaropoulosH,MikalefP,ZiogasE, PappisG,GiannakopoulosI.Injuriestotheinfrapatellar branch(es)ofthesaphenousnerveinanteriorcruciate ligamentreconstructionwithfour-strandhamstringtendon autograft:verticalversushorizontalincisionforharvest. KneeSurgSportsTraumatolArthrosc.2006;14(8):789–93. 10.ShawWigisEF,BrushartTM.Nerverepairandgrafting.In:
GreenDP,HotckisD,RobertsN,editors.Operativehand surgery.3rded.NewYork:ChurchillLivingstone;1993.p.1335. 11.PestanaMH,GageiroJN.Análisededadosparaciências
sociais.In:AcomplementaridadedoSPSS.Lisboa:Silabo; 1998.
12.TrescotAM,BrownMN,KarlHW.Infrapatellarsaphenous neuralgia–diagnosisandtreatment.PainPhysician. 2013;16(3):E315–24.
13.FigueroaD,CalvoR,VaismanA,CamperoM,MoragaC.Injury totheinfrapatellarbranchofthesaphenousnerveinACL reconstructionwiththehamstringstechnique:clinicaland electrophysiologicalstudy.Knee.2008;15(5):360–3.
14.LetartreR,IsidaR,PommepuyT,MileticB.Horizontal posteriorhamstringharvest.OrthopTraumatolSurgRes. 2014;100(8):959–61.
15.DePaduaVB,NascimentoPE,SilvaSC,deGusmãoCanuto SM,ZuppiGN,deCarvalhoSM.Saphenousnerveinjury duringharvestingofoneortwohamstringtendonsfor anteriorcruciateligamentreconstruction.RevBrasOrtop. 2015;50(5):546–9.
16.HornerG,DellonAL.Innervationofthehumankneejointand implicationsforsurgery.ClinOrthopRelatRes.
1994;(301):221–6.
17.SabatD,KumarV.Nerveinjuryduringhamstringgraft harvest:aprospectivecomparativestudyofthreedifferent incisions.KneeSurgSportsTraumatolArthrosc.
2013;21(9):2089–95.
