The combined treatment of entrapped Infrapatellar Branch of the Saphenous Nerve after ACL reconstruction: Ultrasound-guided perineural injection and acupotomy

BACKGROUND: The anterior cruciate ligament (ACL) reconstruction (ACLR) under the arthroscopy is a widespread procedure for ACL rupture, which could stabilize knee and promote recovery. However, one of its complications is the injury of infrapatellar branch of saphenous nerve (IBSN). In traditional Chinese medicine, acupotomy functions via releasing and stripping adhesion tissues. Accordingly, acupotomy is suitable for the treatment of entrapped nerve injury and tissues adhesion. CASE DESCRIPTION: A 14-year-old man, who had ACLR before and returned to normal activity, presented with severe pain after a mild strain two weeks ago. The physical and imaging examinations revealed the compression injury of IBSN. METHODS: We provided the ultrasound-guided perineural injection of 0.4% lidocaine, while it only alleviates the symptoms temporally and partially. Acupotomy using a small needle knife (0.4*40 mm) was performed. RESULTS: The severe pain was immediately resolved. The visual analog pain scale (VAS) decreased from 10 to 1 and return to normal walking. The diameter of IBSN became smaller and the signal of peripheral soft tissue became hypoechoic in ultrasound. CONCLUSION : In this case, the combined treatments of ultrasound-guided perineural injection and acupotomy are thought to be innovative procedures for IBSN entrapment with relative long-lasting therapeutic effects.

Download Full-text

Injury of the Infrapatellar Branch of the Saphenous Nerve During Hamstring Graft Harvest

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967114s00135 ◽

2014 ◽

Vol 2 (11_suppl3) ◽

pp. 2325967114S0013

Author(s):

Serkan Sipahioglu ◽

Sinan Zehir ◽

İslam Baykara ◽

Ali Bilge

Keyword(s):

Acl Reconstruction ◽

Cruciate Ligament ◽

Saphenous Nerve ◽

Sensory Loss ◽

Hamstring Graft ◽

Graft Harvest ◽

Vertical Incision ◽

Significant Difference ◽

Infrapatellar Branch ◽

Oblique Incision

Objectives: Sensory disturbance around the surgical incision due to injury of the infrapatellar branch of the saphenous nerve (IPBSN) can be seen in the anterior cruciate ligament (ACL) reconstruction after the operation. In this research, we aimed to compare the incidence, extent of sensory loss, its clinical effect and natural course caused by two different skin incisions used for autogenous hamstring graft harvest during ACL reconstruction. Methods: Seventy eight patients who underwent hamstring graft harvest during ACL reconstruction participated in the study. Among the 78 patients, vertical incision for 36 patients and oblique incision for 42 patients were used for graft harvest. The area of the sensory loss was documented at 6 weeks, 3 months and 6 months follow-ups. A blunt pin was used for pin prick examination starting from proximal end of the incision and the patient was asked to note the point of change in sensation from normal to abnormal. The abnormal points were joined and digital photographs of hypesthesia were taken and analysed by computer for area detection. The length of incision and subjective complain of sensory loss were also noted. Results Results: The patients’ age and incision length between the two groups had no significant difference. At 6 weeks, vertical incision was associated with persistent sensory loss in 77% (28/36) cases which was significantly higher when compared to the oblique incision (19/42). The measured area of hypesthesia was significantly higher in vertical incision (42.4±22.3 cm2) than that in oblique incision (9.3±15.3 cm2) at 6 weeks. On further follow-ups at 3 and 6 months, the area of hypesthesia gradually shrunk in size. The recovery pattern was from distal to proximal in direction. Also, subjective cutaneous anaesthesia was higher in vertical incision (15/36, 41%) than oblique incision (6/42, 14%) at 6 months. Conclusion: Injury to the IPBSN can be seen during hamstring graft harvest. Vertical incision has maximum incidence of IPBSN injury. Oblique incision with less risk of nerve damage may be better for graft harvesting in ACL reconstruction. Area of hypesthesia gradually reduces with time and even recovers totally. Sensory loss does not impair normal daily activities in most of these patients. As a possible complication, nerve injury and its benign prognosis should be explained to the patient before surgery.

Download Full-text

A Randomized, Double-blind, Comparative Study of the Analgesic Efficacy of Perineural Dexmedetomidine as Adjuvant to Ropivacaine versus Ropivacaine Alone in Ultrasound Guided Saphenous Nerve Block after Anterior Cruciate Ligament Reconstruction Surgery

Archives of Anesthesia and Critical Care ◽

10.18502/aacc.v7i3.6898 ◽

2021 ◽

Author(s):

Shideh Dabir ◽

Faramarz Mosaffa ◽

Hamed Tanghatari ◽

Behnam Hosseini

Keyword(s):

Anterior Cruciate Ligament ◽

Anterior Cruciate Ligament Reconstruction ◽

Nerve Block ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Saphenous Nerve ◽

Ultrasound Guided ◽

Cruciate Ligament Reconstruction ◽

Pain Scores ◽

Anterior Cruciate

Background: The saphenous nerve block has been effectively used for pain treatment after knee surgeries, however, a single-shot saphenous nerve block with a long-acting local anesthetic usually provides a relatively short duration of postoperative analgesia. Dexmedetomidine is a highly selective alpha-2 adrenoceptors agonist and its perineural injection as an additive to local anesthetics has been shown to improve postoperative analgesia. The aim of this prospective, randomized double-blind study was to evaluate the effects of adding dexmedetomidine to ropivacaine on the quality of postoperative analgesia with ultrasound-guided saphenous nerve block after anterior cruciate ligament reconstruction surgery of the knee. Methods: 40 ASA class I–II patients undergoing arthroscopic anterior cruciate ligament reconstruction surgery under general anesthesia were randomly divided into 2 groups of 20 patients each. At the end of surgery, ultrasound-guided saphenous nerve block was performed with either 10 ml ropivacaine 0.5% alone, or 1 µg/kg dexmedetomidine added to 10 ml of ropivacaine 0.5%. The total volume of injected solutions was increased to 12 ml by adding normal saline. The postoperative pain scores as well as fentanyl consumption through intravenous patient-controlled analgesia pump, hemodynamic parameters, sedation scores, and adverse effects were assessed every 1 hour to 6 hours and then every 2 hours to 24 hours. Results: There were significantly lower postoperative pain scores in the ropivacaine plus dexmedetomidine group compared to ropivacaine alone group at all postoperative measured time points. The total amount of fentanyl consumption and sedation scores after surgery was significantly higher in group ropivacaine alone than in group ropivacaine plus dexmedetomidine. Systolic blood pressure and heart rate within 24 hours after surgery were significantly lower in the dexmedetomidine+ ropivacaine group than in the ropivacaine alone group. However, no bradycardia and hypotension were detected in any of the patients. Conclusion: Perineural administration of 1 µg/kg of dexmedetomidine as an adjuvant to ropivacaine 0.5% for ultrasound guided saphenous nerve block significantly reduced pain scores and opioid requirements in the first 24 h after ACLR surgery compared to ropivacaine alone without any significant side effects.

Download Full-text

Injury of the infrapatellar branch of the saphenous nerve due to hamstring graft harvest

Journal of Orthopaedic Surgery ◽

10.1177/2309499017690995 ◽

2017 ◽

Vol 25 (1) ◽

pp. 230949901769099 ◽

Cited By ~ 3

Author(s):

Serkan Sipahioglu ◽

Sinan Zehir ◽

Baran Sarikaya ◽

Ali Levent

Keyword(s):

Cruciate Ligament ◽

Saphenous Nerve ◽

Sensory Loss ◽

Hamstring Graft ◽

Surgical Incision ◽

Graft Harvest ◽

Vertical Incision ◽

Infrapatellar Branch ◽

Oblique Incision ◽

Anterior Cruciate

Purpose: Sensory disturbance around the surgical incision due to injury of the infrapatellar branch of the saphenous nerve can be seen in the anterior cruciate ligament reconstruction. In this research, we aimed to compare the incidence, extent of sensory loss, its clinical effect, and natural course caused by two different skin incisions used for hamstring graft harvest. Methods: Vertical incision for 36 patients and oblique incision for 42 patients used for graft harvest were included in this study. Sensory loss areas were documented at 6th week, 3rd month and 6th month. Pin prick examination is used to detect the change in sensation. Digital photographs of hypaesthesia were taken and analysed by computer for area detection. The length of incision and subjective complain of sensory loss were also noted. Results: At 6th month, 77% (28/36) of the vertical incisions were associated with persistent sensory loss when compared to the oblique incision (45%, 19/42). The measured area of hypaesthesia was significantly higher in vertical incision (42.4 ± 22.3 cm2) than that in oblique incision (9.3 ± 15.3 cm2) at 6th month. The area of hypaesthesia gradually shrunk in size from distal to proximal in direction. Also, subjective cutaneous anaesthesia was higher in vertical incision (15/36, 41%) than oblique incision (6/41, 14%) at 6th month. Conclusion: Oblique incision with less risk of nerve damage is better for graft harvesting. Area of hypaesthesia gradually reduces with time and even recover totally. As a possible complication, nerve injury and its benign prognosis should be explained to the patient before surgery.

Download Full-text

Ultrasound-Guided Needle Localization of the Saphenous Nerve for Removal of Neuroma in the Infrapatellar Branches

Neurosurgery ◽

10.1227/neu.0000000000000515 ◽

2014 ◽

Vol 75 (6) ◽

pp. 717-722 ◽

Cited By ~ 7

Author(s):

Jean Jose ◽

Marvin K. Smith ◽

Lee D. Kaplan ◽

Bryson P. Lesniak ◽

Allan D. Levi

Keyword(s):

Imaging Modality ◽

Saphenous Nerve ◽

Sensory Nerves ◽

Needle Placement ◽

Ultrasound Guided ◽

Main Trunk ◽

Needle Localization ◽

Preoperative Ultrasound ◽

Infrapatellar Branch ◽

Arthroscopic Knee

Abstract Background: Neuromata formation in the infrapatellar branch of the saphenous nerve (IPBSN) has been well described as a potential complication of arthroscopic knee surgery and knee trauma. Resection has been proven to provide improvement of pain and increased range of motion. Currently, physical examination and surgical exploration based on anatomic landmarks are the standard for intraoperative localization of IPBSN neuromas. Objective: To demonstrate the anatomy of the IPSBN and the use of preoperative ultrasound and needle placement for localization of the nerve before sectioning. Methods: Using both anatomic dissections and the combination of preoperative ultrasound and curved-needle placement, we demonstrate the technical nuances to localize the IPBSN before operative section. Results: Cadaveric dissection is used to illustrate the main trunk of the IPSBN and its branches. In 2 cases, ultrasound guidance was effectively used to localize the saphenous nerve and its branches and facilitate the operative treatment of patients with symptomatic IPBSN neuromas. Conclusion: Ultrasound is a widely accepted and commonly utilized imaging modality; however, in this report, ultrasound-guided needle localization was used to aid in the resection of neuromas of small, painful sensory nerves.

Download Full-text

Incidence and Characterization of Hypoesthesia in the Distribution of the Infrapatellar Branch of the Saphenous Nerve after Anterior Cruciate Ligament Reconstruction: A Prospective Study of Patient-Reported Numbness

The Journal of Knee Surgery ◽

10.1055/s-0037-1605559 ◽

2017 ◽

Vol 31 (06) ◽

pp. 585-590 ◽

Cited By ~ 3

Author(s):

Steven Cohen ◽

Russell Flato ◽

Jocelyn Wascher ◽

Ryan Watson ◽

Matthew Salminen ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Anterior Cruciate Ligament Reconstruction ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Saphenous Nerve ◽

Cruciate Ligament Reconstruction ◽

Time Points ◽

Patient Reported ◽

Infrapatellar Branch ◽

Anterior Cruciate

AbstractThe purpose of this study was to determine the incidence of patient-reported numbness following anterior cruciate ligament reconstruction (ACLR), if postoperative numbness dissipates with time, and how the graft type affects numbness severity. A total of 218 patients undergoing ACLR were prospectively enrolled. At 6 weeks, 6 months, and 1 year postoperatively, patients completed a questionnaire assessing numbness severity and location. Each time, patients rated their sensory deficit from 0 to 10 (0 = no deficit; 10 = complete lack of sensation) and indicated the location of their sensory deficit by marking a picture of a knee divided into nine rectangular segments. A mixed effect linear regression model was used to identify predictors for the patient-reported numbness severity. Overall, 69.8% (150/218) of patients reported numbness at 6 weeks, 50.0% (97/194) at 6 months, and 42.2% (78/185) at 1 year. Allograft patients reported a mean numbness severity of 2.9 ± 0.3 (mean ± standard error), 1.7 ± 0.2, and 1.4 ± 0.3 at 6 weeks, 6 months, and 1 year, respectively. The 6-week, 6-month, and 1-year averages were 4.7 ± 0.4, 2.7 ± 0.4, and 1.7 ± 0.4 for bone-patellar tendon-bone (BTB) autograft patients and 4.3 ± 0.4, 2.9 ± 0.4, and 2.5 ± 0.4 for hamstring autograft patients. The model indicated that the use of hamstring autografts increased patient-reported numbness by an average of 1.4 ± 0.5 across all time points, and the use of a BTB autograft increased patient-reported numbness by 1.2 ± 0.4 across all time points. Time from surgery decreased the severity of patient-reported numbness for all graft types (−1.3 ± 0.2 at 6 months and −1.7 ± 0.2 at 1 year). Hypoesthesia in the distribution of the infrapatellar branch of the saphenous nerve is common after ACLR but is likely to dissipate with time. Patients undergoing ACLR with allograft may be less likely to develop sensory deficits, and these deficits may be less severe.

Download Full-text

Comparison of Ultrasound-Guided Femoral and Infrapatellar Nerve Block Effects after Anterior Cruciate Ligament Repair Surgery

10.32592/10.32592/ircmj.2020.22.12.211 ◽

2020 ◽

Keyword(s):

Anterior Cruciate Ligament ◽

Patient Satisfaction ◽

Acl Reconstruction ◽

Nerve Block ◽

Muscle Force ◽

Cruciate Ligament ◽

Ultrasound Guided ◽

Reconstruction Surgery ◽

The Mean ◽

Anterior Cruciate

Background: There are various protocols for pain management after anterior cruciate ligament (ACL) reconstruction surgery. Objective: This study aimed to compare two blocking protocols, including femoral nerve block (FNB) and infrapatellar nerve block (IPNB) in terms of pain severity, patient satisfaction, and muscle force preservation. Materials and Methods: This single-blind clinical trial study investigated the patients who underwent elective knee arthroscopic ACL surgery randomly either by ultrasound-guided FNB or IPNB. Subsequently, the patients were evaluated 1, 3, 6, 12, and 24 h following NB for pain severity, patient satisfaction level, and muscle force. Results: The pain score (both at rest and in flexion) was significantly lower in the first three h after the intervention in the FNB group. Moreover, the mean score of the patients’ satisfaction in the first hours was significantly higher in the FNB group after the procedure. Additionally, the IPNB group obtained a significantly faster mean time required for the first dose of opioid request. The mean dose of used opioids over 24 h was significantly lower in the FNB group. There was a significant difference between the groups in terms of the muscle strength score within 24 h; moreover, the FNB group obtained a significantly greater delay in muscle recovery. Conclusion: The FNB is associated with greater pain relief and satisfaction in patients who underwent arthroscopic ACL reconstruction surgery, compared to the IFNB technique. However, a further delay in the recovery of quadriceps muscle force is evident in the FNB group.

Download Full-text