Relationship between different skin incisions and the injury of the infrapatellar branch of the saphenous nerve during anterior cruciate ligament reconstruction

Background After anterior cruciate ligament （ACL） reconstruction, some patients suffered from sensory disturbance around the surgical incision of the leg. This research was aimed to investigate the relationship between the different skin incisions and the injury of the infrapatellar branch of the saphenous nerve （IPBSN） post ACL reconstruction.Methods ACL reconstructions were performed with quadruple hamstring tendon for 60 patients. Sensory disturbance around the skin incision was followed up at an average of 14.5±4.7 months post operation. Among the 60 patients, vertical incision for 35 patients and oblique incision for 25 patients were used for graft taking during ACL reconstruction. The lengths of the incisions were measured. The patients were asked to mark the sensory disturbance zone at follow up time, and then the marked area was measured. The IPBSN of 15 cadaver knees were anatomized. The distance between the IPBSN and the upper edge of the pes anserinus tendon at the middle point of the incision was measured. independent-samples t-test, chi-square and Mann-Whitney tests were used for statistical analyses. Results The patients＇ age （P=0.329）, the follow-up time （P=0.661）, and the incision length （P=0.732） between the two groups had no significant difference. Twenty-three patients （65.7%） in the vertical incision group had IPBSN injury compared with 6 patients （24.0%） in oblique incision group （P=0.002）. The average sensory disturbance area in vertical incision group （（48.0±75.3） cm^2） was significantly larger （P=0.004） than that in the oblique group （（8.4±19.4） cm^2）. The anatomy measurement showed the average distance between IPBSN and the upper edge of the pes anserinus tendon was 0.6 cm at the incision. Conclusions Oblique incision with less risk of damage for IPBSN may be better for graft harvesting in ACL reconstruction. As the IPBSN is so near and parallel to the hamstring tendons, damage to the IPBSN is one of the potential complications for graft harvesting, regardless of the incision used. That＇s why even in the oblique incision group, 24% patients also had sensory disturbance complication.

Comparative study on early period of recovery between minimally invasive surgery total knee arthroplasty and minimally invasive surgery-quadriceps sparing total knee arthroplasty in Chinese patients

Background Different kinds of minimally invasive surgery （MIS） procedures have now been used in total knee arthroplasty （TKA）. Compared with traditional TKA procedure with a long skin incision, clinical studies showed MIS procedures had some advantages. Quadriceps sparing （QS） procedures are the most minimally invasive MIS procedure until now. This study was aimed to find the insertion types for Chinese patients＇ vastus medialis and if the QS procedure had some advantages in patients＇ early recovery. Methods Between February 2006 and May 2007, 120 consecutive patients underwent unilateral primary TKA under general anesthesia, among whom 14 patients were lost to follow-up, the remaining 106 cases were enrolled in this study. Among the 106 cases there were 85 right knees, 21 left knees （15 men and 91 women, with a mean age of 65.1±7.4 years）; osteoarthritis in 97 patients （91.5%） and rheumatoid arthritis in 9 patients （8.5%）. MIS TKA was performed in 49 cases （MIS TKA group）, while MIS-QS TKA in 57 cases （MIS-QS TKA group）. During the operation, the type Ⅰ, Ⅱ and Ⅲ insertions of the vastus medialis for all patients were recorded. Each knee was rated post-operatively according to the Hospital of Special Surgery （HSS） scoring system. Clinical follow-up was undertaken at 1 week, 2, 6, 12 and 24 weeks. Operating time and complications were recorded. Results There was no statistically significant difference between the two groups for gender distribution, age, left or right knee incidence, pre-operative diagnosis, incidence of varus or valgus deformity. Of the 106 cases there was 1 （0.9%） case with a type Ⅰ insertion of the vastus medialis, 4 （3.8%） cases with type Ⅱ insertions, 101 （95.3%） cases with type Ⅲ insertions. The HSS scoring was significantly different between the MIS-QS TKA group and MIS TKA group within the first two weeks post operation. From 2 weeks later to 24 weeks, no significant difference was found. The average operating time was （53.3±12.4） minutes in the MIS TKA group and （64.1±15.1） minutes in the MIS-QS TKA group （P 〈0.001）. In the MIS-QS TKA group, 1 patient had delayed healing of the partial skin incision （1.8%）. No other complications were found in either group. Conclusions Although most of the Chinese patients had type Ⅲ insertions of the vastus medialis, the MIS-QS TKA procedure showed less injury to the quadriceps than the standard MIS TKA and this could contribute to the earlier recovery of of the patients. But a shorter-skin incision and more tension on the skin may also lead to more skin complications.