(aspects of sports medicine)

Infrapatellar Branch of Saphenous Neurectomy for Painful Neuroma: A Case Report Joshua D. Harris, MD, Joseph J. Fazalare, MD, Michael J. Griesser, MD, and David C. Flanigan, MD

Abstract tendinous junction, the saphenous includes a spectrum ranging from We present the case of an 18-year-old receives coalescing branches anesthesia, hypoesthesia, hyperes- woman who was healthy other than a from the descending branch (cours- thesia, hyperalgesia, and allodynia history of multiple arthroscopic right ing distally along the medial leg to reflex sympathetic dystrophy, all surgeries culminating in subto- to just anterior to the medial mal- stemming from varying degrees of tal lateral meniscectomy in a valgus knee. The patient was referred to our leolus and branching farther to vari- Wallerian degeneration commenc- 11,12 office for evaluation for realignment ably supply sensation to the medial ing at site and time of injury. osteotomy and meniscal transplan- hindfoot, midfoot, and forefoot) Although saphenous nerve and tation. Her diagnosed case of neuro- and the infrapatellar branch of the IBSN damage are of the less com- ma of the infrapatellar branch of the saphenous nerve, or IBSN (coursing mon causes of medial knee pain, saphenous nerve was managed with anteriorly, laterally, and distally).3 when unrecognized it may lead neurectomy, which produced prompt Numerous investigators (Tables I, to chronic, severe, painful saphe- and complete resolution of pain. II) have described the surgical anat- nous neuritis,2 reflex sympathetic omy of the IBSN.1-9 dystrophy,13 and painful saphenous he saphenous nerve is the largest cutaneous branch of the in “Although saphenous nerve and IBSN dam- Tthe lower extremity.1 It is age are of the less common causes of medi- a purely sensory nerve, with input to L3 and L4 nerve root derma- al knee pain, when unrecognized it may tomal sensory distributions.1,2 In lead to chronic, severe, painful saphenous proximity to the pes anserinus of the medial knee at the posterior neuritis, reflex sympathetic dystrophy, and aspect of the sartorius musculo- painful saphenous neuromata.’’

Dr. Harris is Resident Physician, Department of Orthopaedics, Ohio State University The IBSN may be injured by neuromata.2,9 Management of Medical Center, Columbus, Ohio. traumatic contusion, inflamma- painful saphenous neuromata first Dr. Fazalare is Attending Physician, United Hospital Center Orthopaedics, tion, compression, or iatrogenic requires diagnosing the cause of the Bridgeport, West Virginia. causes, such as needles or surgical neuroma(ta), as the diagnosis com- Dr. Griesser is Fellow, Department of 2,9,10 Orthopaedic Surgery, Cleveland Clinic, incisions. Unintentional surgi- monly goes unrecognized early in Cleveland, Ohio. cal damage to the IBSN has been presentation. Nonsurgical treatment Dr. Flanigan is Associate Professor of reported after anterior cruciate liga- then includes use of nonsteroidal Clinical Orthopaedics, Department of Orthopaedics, Ohio State University ment (ACL) reconstruction using anti-inflammatory drugs (NSAIDs), Medical Center, and Team Physician, hamstring autograft,3,5-8 after stan- oral gamma-aminobutyric acid ana- Ohio State University Sports Medicine Center, Columbus, Ohio. dard anteromedial knee arthroscopy logue medications, capsaicin cream, portal placement,3,5,10 and after total physical therapy modalities, trans- Address correspondence to: David knee arthroplasty (TKA).2,9 Other cutaneous electrical nerve stimula- C. Flanigan, MD, Department of Orthopaedics, Ohio State University causes of iatrogenic IBSN surgical tion, oral antidepressant medica- Medical Center, 2050 Kenny Rd, Suite injury are vascular surgery tech- tions, and therapeutic local anes- 3300, Columbus, OH 43221 (tel, 614- niques—varicose vein surgery, fem- thetic and corticosteroid injections. 293-2663; fax, 614-293-4399; e-mail, [email protected]). oropopliteal bypass, Surgical management may consist thrombectomy, and femoral artery of saphenous or IBSN neurolysis, Am J Orthop. 2012;41(1):37-40. 2 Copyright Quadrant HealthCom Inc. embolectomy. The pathophysiolog- saphenous or IBSN decompression, 2012. All rights reserved. ic mechanism of pain generation and saphenous or IBSN neurec- www.amjorthopedics.com January 2012 37 Infrapatellar Branch of Saphenous Neurectomy for Painful Neuroma

Figure. Intraoperative photographs (A, B) of medial-sided neuroma (infrapatellar branch of saphenous nerve). (C) Surgical neuroma specimen (sent to pathology). tomy. Saphenous and IBSN neu- Case Report remained. Continued severe knee rectomy relieves symptoms by 80% An 18-year-old female college stu- pain prompted referral to our clin- to 100% in patients who undergo dent was referred to our clinic for ic for possible meniscal transplant primary neurectomy or neurectomy continued right knee pain after and realignment osteotomy. The after failed decompression or neu- multiple knee arthroscopies. Three patient already had been treated rolysis.14-16 years earlier, the right knee sus- with courses of physical therapy, In this article, we present the tained a twisting-type injury. On a cortisone injection, viscosupple- case of an 18-year-old woman who presentation to another institu- mentation, NSAIDs, and a lateral was healthy other than a history tion, a lateral meniscus tear was compartment unloader brace. All of multiple arthroscopic right knee diagnosed, and an inside-out later- these treatments provided mini- surgeries culminating in subtotal al meniscus repair was performed mal or no relief. Further, because lateral meniscectomy in a valgus uneventfully. One year after sur- of the severe pain, the patient knee. The patient was referred gery, the patient sustained another had stopped all physical activity to our office for evaluation for injury and felt a pop in the knee. for more than 2 years, and her realignment osteotomy and menis- The meniscal repair had failed, narcotic use was chronic. On a cal transplantation. Despite lateral and a partial lateral meniscectomy daily basis, she had pain with any pathology, however, the patient’s was performed. The patient con- ambulation and activities of daily pain was medial. Her diagnosed tinued to have pain in the opera- living and even at rest. A pain case of neuroma of the IBSN was tive knee. She described the pain management consultation workup managed with neurectomy, which then as severe, sharp, and start- also had been pursued. produced prompt and complete ing medially and radiating later- At our clinic, the patient reported resolution of pain. The patient pro- ally. One year before coming to 9/10 constant knee pain. The pain vided written informed consent for our clinic, she underwent another was mostly medial in the area of one print and electronic publication of partial lateral meniscectomy, after of the previous anteromedial knee this case report. which 30% of the lateral meniscus arthroscopy portals. It was sharp and

Table I. Cadaveric Studies of Anatomy of Infrapatellar Branch of Saphenous Nerve (Variety of Nerve Course Is Based on Study)

Specimen Source Study (No. of specimens) Anatomical Nerve Description

Ebraheim & Mekhail4 Cadaver (28) -8 mm posterior to AT at level of junction of inferior pole of and medial PT (knee extended) -At joint line, nerve anterior to AT (53% of specimens), posterior to AT (43%), at AT (4%) -Nerve crossed to lateral border PT in 36% of specimens Tifford et al3 Cadaver (20) -2.4 cm from inferior pole of patella (knee extended) -2.5 cm from inferior pole of patella (knee flexed 90°) -Nerve 5.1 mm (knee extended) and 4.8 mm (knee flexed) from landmark 2 cm medial to medial border PT at joint line -Nerve traverses anterior knee medial to lateral and proximal to distal Mochida & Kikuchi5 Cadaver & in vivo (68) -Blind puncture safe within 3-cm area from medial margin patella at level of midpatella -Blind puncture safe within 1-cm area from medial margin PT at level of inferior pole of patella -22% incidence of sensory disturbance in IBSN distribution

Abbreviations: AT, adductor tubercle; IBSN, infrapatellar branch of saphenous nerve; PT, patellar tendon.

38 The American Journal of Orthopedics® www.amjorthopedics.com J. D. Harris et al

Table II. In Vivo Clinical Studies of Incidence of Saphenous Nerve and Infrapatellar Branch of Saphenous Nerve Damage After Arthroscopic Procedures

Specimen Source Study (No. of specimens) Anatomical Nerve Description and Incidence of Damage

Figueroa et al6 In vivo (22) -77% incidence of hypoesthesia in IBSN distribution with area of 36 cm2 -68% incidence of electrophysiologic evidence of IBSN injury -9% incidence of injury to saphenous nerve proper Papastergiou et al7 In vivo (230) -39.7% incidence of disturbed sensitivity in IBSN distribution with vertical incision for hamstring graft harvest -14.9% incidence of disturbed sensitivity in IBSN distribution with horizontal incision for hamstring graft harvest Portland et al8 In vivo (76) -59% incidence of IBSN damage with vertical incision for BTB graft harvest -43% incidence of IBSN damage with horizontal incision for BTB graft harvest Mochida & Kikuchi5 In vivo (68) & cadaver -Blind puncture safe within 3-cm area from medial margin patella at level of midpatella -Blind puncture safe within 1-cm area from medial margin patellar tendon at level of inferior pole of patella -22% incidence of sensory disturbance in IBSN distribution

Abbreviations: BTB, bone–patellar tendon–bone; IBSN, infrapatellar branch of saphenous nerve. accompanied by episodes of tingling 30% immediate relief of symptoms. pain. She was completely off pain around the portal, and it worsened Two weeks later, she returned to medications for the first time in more with activity, long periods of stand- our clinic with continued medial- than 2 years. The surgical pathology ing, and pressure. The patient report- sided symptoms. Repeat MRI was report identified a nerve segment ed some mechanical symptoms. She not performed secondary to insur- with focal changes consistent with reported no recurrent effusions and ance issues. A diagnostic arthros- a traumatic neuroma. At 2 months, constitutional symptoms. copy with exploration of the medi- the patient was continuing to do On examination, the patient was al arthroscopy portal for a pos- well, and there had been no recur- mildly overweight, there was no sible neuroma was performed. The rence of medial knee pain. calf or quadriceps atrophy, and medial compartment and cruciate she walked with an antalgic, stiff- ligaments were intact. The patel- Discussion legged gait. All surgical incisions lofemoral joint had Outerbridge We have presented the case of an were well-healed, and there were grade II chondral damage, which 18-year-old female college stu- no signs of infection. No effusion was debrided. The lateral femo- dent with a history of multiple was evident, active knee range of ral condyle and tibial plateau had arthroscopic right knee surger- motion was 0° to 135°, and the liga- grade II focal changes, which were ies culminating in subtotal lateral mentous examination was stable. debrided along with minimal lat- meniscectomy in a valgus knee. Tenderness was exquisite medially eral meniscal fraying. Despite lateral pathology, however, with hyperflexion and hyperexten- A 2-cm longitudinal skin incision the patient’s pain was medial. Her sion but without lateral tender- was then made over an area that diagnosed case of neuroma of the ness. The Tinel sign was present. had been marked before surgery IBSN was managed with neurec- Pain occurred with the McMurray as the area of maximal tenderness. tomy, which produced prompt and maneuver medially. Weight-bearing Blunt dissection in the subcutane- complete resolution of pain. knee radiographs showed no signifi- ous tissue revealed that a branch Iatrogenic damage to the saphe- cant decline in joint space and a val- of the saphenous nerve (IBSN) was nous nerve or one of its branches gus shift of the knee. Magnetic reso- scarred and adhering to the joint has been reported after both ortho- nance imaging (MRI) performed 3 capsule. A portion of the nerve pedic and other general surgical months earlier showed no medial branch was bulbous, consistent procedures, including ACL recon- compartment pathology. with a neuroma (Figure, A & B). A struction with both hamstring and Saphenous neuroma was suspect- 3-cm segment of nerve was sharp- bone–patellar tendon–bone auto- ed along with possible new medial ly dissected from the branch, and grafts, medial collateral ligament meniscal pathology, not identified the proximal and distal ends were surgery, TKA, high tibial osteot- on the earlier MRI. A superficial, allowed to retract. The specimen omy, and knee surgeries using a extra-articular local anesthetic injec- was sent to pathology (Figure, C). medial parapatellar arthrotomy.2,3,5 tion of lidocaine 1% and bupivic- The incisions were closed, and the Cadaveric anatomy studies have aine 0.25% was given in the area patient’s immediate postoperative demonstrated “safe zones” for blind of maximal tenderness around the course was uneventful. puncture in knee arthroscopy por- medial arthroscopy portal. The At 1-week follow-up, she had total tal placement to be within a 3-cm patient experienced approximately resolution of the medial-sided knee area from the medial margin of www.amjorthopedics.com January 2012 39 Infrapatellar Branch of Saphenous Neurectomy for Painful Neuroma the patella at the level of the midpa- portal and that, with IBSN neu- don autograft: vertical versus horizontal inci- sion for harvest. Knee Surg Sports Traumatol tella and within a 1-cm area from the rectomy, was managed successfully Arthrosc. 2006;14(8):789-793. medial margin of the patellar tendon (immediate and complete resolution 8. Portland GH, Martin D, Keene G, Menz T. Injury to the infrapatellar branch of the saphe- at the level of the inferior pole of pain). nous nerve in anterior cruciate ligament recon- of the patella.5 As the IBSN and struction: comparison of horizontal versus vertical harvest site incisions. Arthroscopy. its superior and inferior branches Authors’ Disclosure 2005;21(3):281-285. traverse medial to lateral and some- Statement 9. Nahabedian MY, Johnson CA. Operative man- what proximal to distal (medial to The authors report no actual or agement of neuromatous knee pain: patient selection and outcome. Ann Plast Surg. the extensor mechanism), and as the potential conflict of interest in rela- 2001;46(1):15-22. nerve moves distally with knee flex- tion to this article. 10. Sherman OH, Fox JM, Snyder SJ, et al. Arthroscopy—“no-problem surgery”. An ion, horizontal anteromedial portal analysis of complications in two thousand six incisions (vs vertical incisions) may References hundred and forty cases. J Bone Joint Surg Am. 1. Llusa M, Meri A, Ruano D. Surgical Atlas of 1986;68(2):256-265. reduce the risk for IBSN damage, the Musculoskeletal System. Rosemont, IL: 11. Lindenfeld TN, Bach BR Jr, Wojtys EM. Reflex as Tifford and colleagues3 recom- American Academy of Orthopaedic Surgeons; sympathetic dystrophy and pain dysfunction mended. Once standard anterome- 2008. in the lower extremity. Instr Course Lect. 2. Morganti CM, McFarland EG, Cosgarea AJ. 1997;46:261-268. dial and anterolateral knee arthros- Saphenous neuritis: a poorly understood 12. Dumitru D. Electrodiagnostic Medicine. copy portals are made with vertical cause of medial knee pain. J Am Acad Orthop Philadelphia, PA: Hanley & Belfus; 1995. Surg. 2002;10(2):130-137. 13. Poehling GG, Pollock FE Jr, Koman LA. Reflex incisions, the incidence of clinical 3. Tifford CD, Spero L, Luke T, Plancher KD. The sympathetic dystrophy of the knee after sen- and electrophysiologic IBSN sensory relationship of the infrapatellar branches of sory nerve injury. Arthroscopy. 1988;4(1):31- the saphenous nerve to arthroscopy portals 35. disturbance or damage ranges from and incisions for anterior cruciate ligament 14. Worth RM, Kettelkamp DB, Defalque RJ, less than 1% to 22%.5,10,17 These surgery. An anatomic study. Am J Sports Med. Duane KU. Saphenous nerve entrapment. A 2000;28(4):562-567. cause of medial knee pain. Am J Sports Med. disturbances primarily consist of 4. Ebraheim NA, Mekhail AO. The infrapatellar 1984;12(1):80-81. branch of the saphenous nerve: an anatomic anesthesia or hypoesthesia and, less 15. Luerssen TG, Campbell RL, Defalque study. J Orthop Trauma. 1997;11(3):195-199. RJ, Worth RM. Spontaneous saphenous commonly, dysesthesia. Saphenous 5. Mochida H, Kikuchi S. Injury to infrapatellar or IBSN neurectomy denervation branch of saphenous nerve in arthroscopic neuralgia. Neurosurgery. 1983;13(3):238- knee surgery. Clin Orthop. 1995;(320):88-94. 241. has been performed successfully 6. Figueroa D, Calvo R, Vaisman A, Campero M, 16. Dellon AL, Mont MA, Mullick T, Hungerford after multiple nonsurgical and surgi- Moraga C. Injury to the infrapatellar branch DS. Partial denervation for persistent neu- of the saphenous nerve in ACL reconstruc- roma pain around the knee. Clin Orthop. cal etiologies of saphenous neuritis tion with the hamstrings technique: clini- 1996;(329):216-222. or neuroma(ta).15,16,18 To our knowl- cal and electrophysiological study. Knee. 17. Small NC. Complications in arthroscopic sur- 2008;15(5):360-363. gery performed by experienced arthrosco- edge, however, the present report is 7. Papastergiou SG, Voulgaropoulos H, Mikalef pists. Arthroscopy. 1988;4(3):215-221. the first to describe a painful IBSN P, Ziogas E, Pappis G, Giannakopoulos I. 18. Dellon AL, Mont MA, Krackow KA, Hungerford Injuries to the infrapatellar branch(es) of the DS. Partial denervation for persistent neuroma neuroma that was caused by a stan- saphenous nerve in anterior cruciate ligament pain after total knee arthroplasty. Clin Orthop. dard anteromedial knee arthroscopy reconstruction with four-strand hamstring ten- 1995;(316):145-150.

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