Gracilis tendon harvest may lead to both incisional and non-incisional saphenous nerve injuries

Mid-term Follow-up Outcomes for Medial Patellofemoral Ligament Reconstruction After Acute First-Time Patellar Dislocation Using Nonresorbable Suture Tape: A Case Series

Background

Reconstruction of the medial patellofemoral ligament (MPFL) with nonresorbable suture tape (FiberTape) could be an alternative to MPFL reconstruction (MPFLR) using an autologous tendon graft after a first-time patellar dislocation.

Purpose

To investigate whether good clinical and radiological results are achievable with this technique.

Level of Evidence

Case series; Level of evidence, 4.

Methods

Between January 2017 and September 2020, a total of 30 patients with acute first-time patellar dislocation and a low anatomic risk factor constellation of patellar instability underwent MPFLR using nonresorbable suture tape combined with cartilage surgery if necessary. After a minimum 2-year follow-up, the Banff Patella Instability Instrument 2.0 (BPII 2.0)-a numerical analog scale (NAS, 0-10) for patellofemoral pain (PFP) (NAS pain) and subjective knee joint function (NAS function)-was used to assess patients' reported quality of life after surgery in 20 patients (men/women: 14/6; age, 22.2 ± 6.1 years; 67% follow-up rate). Magnetic resonance imaging (MRI) scans of the surgically treated knee joint were conducted, and the Area Measurement And DEpth & Underlying Structures (AMADEUS) scores were evaluated pre- and postoperatively.

Results

The BPII 2.0 score was 81 ± 12.5 (55.2-94.7) points postoperatively. The subjective rating of knee joint function (NAS function) was 8.5 ± 1.5 (4-10), and the PFP (NAS pain) was 1.5 ± 1.7 (0-5) postoperatively. MRI evaluations showed an increase in the AMADEUS score in all patients from 79 ± 24.3 points (40-100 points) preoperatively to 92.3 ± 9 points (75-100 points) postoperatively (P = .02).

Conclusion

MPFLR with nonresorbable suture material can achieve satisfactory clinical and radiological outcomes after an acute first-time patellar dislocation.

Injury to the Main Branch of the Saphenous Nerve following Hamstring Tendon Graft Harvesting: A Report of 3 Cases

Background

Hamstring tendon grafts are commonly utilized tendon autografts; however, the harvesting procedure can result in saphenous nerve injury due to its proximity to the semitendinosus and gracilis tendons. Injury to the main branch of the saphenous nerve is a less commonly reported and understood injury during these procedures.

Purpose

This case report aimed to identify and present cases of iatrogenic injury to the main branch of the saphenous nerve during hamstring tendon graft harvesting.

Methods

A retrospective chart review of a tertiary-care hospital over the past 10 years was conducted. The search included clinical notes mentioning "saphenous neuropathy, neuralgia or neuritis" and magnetic resonance imaging (MRI) reports indicating saphenous nerve involvement. Patients with a history of a hamstring graft harvesting procedure and radiographically confirmed injury to the main branch of the saphenous nerve were included. Injury characteristics, symptoms, and sequential treatment were evaluated.

Results

Three cases of iatrogenic injury to the main branch of the saphenous nerve during hamstring graft harvesting were identified. Reported symptoms included pain, paresthesia, numbness, hypersensitivity, swelling, and discoloration. All 3 patients had persistent symptoms despite non-operative treatment and therefore underwent surgical intervention, which involved resection and reconstruction using allograft or burial into adjacent musculature. Postoperatively, 2 of 3 patients demonstrated resolution of symptoms.

Conclusion

Iatrogenic injury to the main branch of the saphenous nerve is a complication that can occur during hamstring tendon harvesting procedures, leading to severe, persistent symptoms. A better understanding of the mechanism of injury is needed to minimize the risk of iatrogenic injury.

CAN SENSORY DISTURBANCES DUE TO INJURY TO THE INFRAPATELLAR BRANCH OF THE SAPHENOUS NERVE BE PREVENTED BY AN OBLIQUE INCISION?

Objective

To evaluate the incidence of injuries to the infrapatellar branch of the saphenous nerve (IPBSN) after anterior cruciate ligament reconstruction (ACLR) with an oblique incision for hamstring graft harvesting.

Methods

In total, 59 knees (from 57 patients) were evaluated in the follow-up of ACLR for six months. We drew a horizontal line parallel to the ground, passing through the most medial portion of the surgical incision and another, perpendicular to the first, starting at the tibial tuberosity (TT). We measured the length and angle of the cut, the distances from its most medial point to the perpendicular line, and from the TT to the horizontal line. Skin sensitivity was tested with a brush and the altered sensitivity area was measured. Patients were asked about difficulties in activities daily of living (ADL).

Results

A total of 27 knees (45.7%) had sensory disorders, which persisted until the sixth postoperative month in 92.6% of them. The ADL were compromised in one knee (3.7%). No significant differences were found between the groups with and without changes in sensitivity regarding age, affected side, incision angle, or measured distances. The incision size was larger in the group without alteration in sensitivity.

Conclusions

An oblique incision did not avoid IPBSN injuries. This condition rarely compromised the ADL. Level of Evidence II, Lesser Quality Prospective Study.

The Arthroscopic Subscapular Sling Procedure Results in Low Recurrent Anterior Shoulder Instability at 24 Months of Follow-Up

PURPOSE

To analyze the results of the subscapular sling procedure developed for anterior shoulder instability in patients with less than 10% anterior glenoid bone loss.

METHODS

Patients were treated surgically with the arthroscopic subscapular sling procedure. A semitendinosus graft was used to reconstruct the anterior labrum and to establish a sling suspension around the upper part of the subscapularis tendon. The patients were followed up with radiographs (at 12 and 24 months). Magnetic resonance imaging (MRI) of the shoulder region and clinical examinations were performed at 3, 12, and 24 months. Recurrent dislocation was the primary endpoint. The Western Ontario Shoulder Instability Index (WOSI) and MRI results were secondary outcome measures. An independent physiotherapist assessed residual instability and range of motion.

RESULTS

Fifteen patients were included with a dislocation rate of 0% after 24 months follow-up. There was a significant clinical improvement of the WOSI score from 57% (904) at baseline to 88% (241) at 24 months (P < .001). The proportion of patients with an improvement in the WOSI Total score larger than the estimated minimal clinically important difference was 100% both at 12 and 24 months. MRI showed an intact sling in all patients. External rotation was not significantly reduced (52° at baseline vs 47° at 24 months, P = .211). Flexion and abduction were significantly improved from 152° to 174° (P = .001) and 141° to 170° (P < .001) after 24 months. The surgical procedures were completed without any intraoperative complications.

CONCLUSIONS

The subscapular sling procedure resulted in low recurrent shoulder instability and improved patient-reported outcome measures at 24 months of follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

The prognosis of iatrogenic saphenous nerve injuries during hamstring tendon harvesting in anterior cruciate ligament reconstruction

PURPOSE

This study aims to evaluate the long-term outcomes of saphenous nerve (SN) injuries from hamstring tendon harvesting during ACL reconstruction, focusing on clinical results and patient satisfaction after at least two years. Additionally, it investigates the incidence, recovery patterns, and impact of these injuries on functional outcomes, daily activities, and ACL re-rupture rates immediately post-surgery and at final follow-up.

MATERIALS AND METHODS

A retrospective review was conducted on patients who had undergone ACL reconstruction with hamstring tendon grafts at a single institution between January 2015 and January 2020. The incidence of SN injuries was assessed immediately after surgery and at final follow-up. Additionally, the recovery rate and time were evaluated, and the impact of these injuries on functional outcomes was measured using the Lysholm Knee Score (LKS) and patient-reported effects on daily activities.

RESULTS

Of the 159 patients analyzed, iatrogenic SN injuries were initially observed in 87 (54.7%) patients post-ACLR. By the final follow-up, paresthesia had resolved in 36 (22.6%) patients within an average of 11.1 months. Persistent SN injuries were recorded in 51 (32.1%) patients, affecting various extents of the infrapatellar branch (IPBSN) and the sartorial branch (SBSN) of the saphenous nerve. Patients with persistent SN injuries experienced a significant impact on daily activities and had lower LKS scores compared to those without injuries or with recovered injuries. Furthermore, a higher re-rupture rate was associated with persistent SN injuries.

CONCLUSIONS

The study finds that SN injuries during hamstring graft harvesting for ACL reconstruction are common, with a significant portion of patients experiencing persistent sensory deficits for at least two years postoperatively. These injuries are observed to adversely affect patient satisfaction and functional outcomes and to increase the re-rupture rate.

Reconstruction of the medial patellofemoral ligament with nonresorbable suture tape normalizes patellar maltracking independent of patella-side fixation technique

PURPOSE

Patellar maltracking caused by a rupture of the medial patellofemoral ligament (MPFL) can be improved by MPFL reconstruction (MPFL-R) with a tendon graft. Nonresorbable suture tape (FiberTape^®, FT) is possibly becoming an option to tendon grafts for MPFL-R. Patella-side fixation of FT can be performed with suture anchors or via soft-tissue fixation. The aim of this study was to investigate patellar tracking considering soft-tissue-based and anchor-based patella-side fixation techniques.

METHODS

In eight fresh-frozen human knee joint specimens (m/f 4/4; age 75 ± 10 years), the MPFL was identified, and a rupture was placed near the femoral insertion site. In the study group (SG; 4 knees), soft-tissue fixation of the FT was performed at the medial patellar retinaculum; in the control group (CG; 4 knees), FT was fixed at the patella via suture anchors. For native MPFL (nMPFL), ruptured ("injured") MPFL (iMPFL) and reconstructed MPFL (FT-MPFL-SG, respectively, FT-MPFL-CG) cone beam CT scans were performed in 15°, 30°, and 45° of knee joint flexion. Patellar tracking was assessed using the radiological parameters patellar tilt (PT), congruence angle (CA) and posterior patellar edge-trochlear groove ratio (PTR).

RESULTS

All recorded radiological parameters increased, respectively, decreased in the CG and SG from the nMPFL to the iMPFL state. After MPFL-R, all parameters normalized when compared to the intact state (nMPFL), regardless of patella-side fixation technique. All investigated parameters of patellotrochlear alignment were positively, respectively, negatively significantly (p < 0.05) correlated throughout all evaluated conditions (nMPFL, iMPFL, FT-MPFL-SG, FT-MPFL-CG).

CONCLUSION

MPFL-R with a nonresorbable suture tape can normalize patellar maltracking in fresh-frozen human knee joint specimens in earlier degrees of knee joint flexion independent of patella-side fixation technique. The investigated parameters of patellotrochlear alignment correlate with each other.

A Systematic Review of Tissue Engineering Scaffold in Tendon Bone Healing in vivo

Background: Tendon-bone healing is an important factor in determining the success of ligament reconstruction. With the development of biomaterials science, the tissue engineering scaffold plays an extremely important role in tendon-bone healing and bone tissue engineering. Materials and Methods: Electronic databases (PubMed, Embase, and the Web of Science) were systematically searched for relevant and qualitative studies published from 1 January 1990 to 31 December 2019. Only original articles that met eligibility criteria and evaluated the use of issue engineering scaffold especially biomaterials in tendon bone healing in vivo were selected for analysis. Results: The search strategy identified 506 articles, and 27 studies were included for full review including two human trials and 25 animal studies. Fifteen studies only used biomaterials like PLGA, collage, PCL, PLA, and PET as scaffolds to repair the tendon-bone defect, on this basis, the rest of the 11 studies using biological interventions like cells or cell factors to enhance the healing. The adverse events hardly ever occurred, and the tendon bone healing with tissue engineering scaffold was effective and superior, which could be enhanced by biological interventions. Conclusion: Although a number of tissue engineering scaffolds have been developed and applied in tendon bone healing, the researches are mainly focused on animal models which are with limitations in clinical application. Since the efficacy and safety of tissue engineering scaffold has been proved, and can be enhanced by biological interventions, substantial clinical trials remain to be done, continued progress in overcoming current tissue engineering challenges should allow for successful clinical practice.