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The Surgical Anatomy of the Infrapatellar Branch of the Saphenous Nerve in Relation to Incisions for Anteromedial Knee Surgery
A.L.A. Kerver, MD1; M.S. Leliveld, MD2; D. den Hartog, MD, PhD1; M.H.J. Verhofstad, MD, PhD1; G.J. Kleinrensink, PhD1
1 Department of Neuroscience and Anatomy (A.L.A.K. and G.J.K.), and Trauma Research Unit, Department of Surgery (M.H.J.V. and D.d.H.), Erasmus MC, University Medical Center Rotterdam, Postbus 2040, Room Number 1485, 3000 CA, Rotterdam, The Netherlands. E-mail address for A.L.A. Kerver: antonkerver@gmail.com
2 Department of Surgery, Gelderse Vallei Hospital, Postbus 9025, 6710 HN, Ede, The Netherlands
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Investigation performed at the Department of Neuroscience and Anatomy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, and the Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Dec 04;95(23):2119-2125. doi: 10.2106/JBJS.L.01297
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Abstract

Background: 

Iatrogenic injury to the infrapatellar branch of the saphenous nerve is a common complication of surgical approaches to the anteromedial side of the knee. A detailed description of the relative anatomic course of the nerve is important to define clinical guidelines and minimize iatrogenic damage during anterior knee surgery.

Methods: 

In twenty embalmed knees, the infrapatellar branch of the saphenous nerve was dissected. With use of a computer-assisted surgical anatomy mapping tool, safe and risk zones, as well as the location-dependent direction of the nerve, were calculated.

Results: 

The location of the infrapatellar branch of the saphenous nerve is highly variable, and no definite safe zone could be identified. The infrapatellar branch runs in neither a purely horizontal nor a vertical course. The course of the branch is location-dependent. Medially, it runs a nearly vertical course; medial to the patellar tendon, it has a –45° distal-lateral course; and on the patella and patellar tendon, it runs a close to horizontal-lateral course. Three low risk zones for iatrogenic nerve injury were identified: one is on the medial side of the knee, at the level of the tibial tuberosity, where a –45° oblique incision is least prone to damage the nerves, and two zones are located medial to the patellar apex (cranial and caudal), where close to horizontal incisions are least prone to damage the nerves.

Conclusions: 

The infrapatellar branch of the saphenous nerve is at risk for iatrogenic damage in anteromedial knee surgery, especially when longitudinal incisions are made. There are three low risk zones for a safer anterior approach to the knee. The direction of the infrapatellar branch of the saphenous nerve is location-dependent. To minimize iatrogenic damage to the nerve, the direction of incisions should be parallel to the direction of the nerve when technically possible.

Clinical Relevance: 

These findings suggest that iatrogenic damage of the infrapatellar branch of the saphenous nerve can be minimized in anteromedial knee surgery when both the location and the location-dependent direction of the nerve are considered when making the skin incision.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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