(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 nerve 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 knee 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 femoral nerve 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, femoral artery 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 patella 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