Abstract
Aim
This randomized controlled trial aimed to evaluate the impact of different incision types (oblique, vertical, and horizontal) for hamstring graft harvest on sensory disturbances and functional outcomes after anterior cruciate ligament (ACL) reconstruction.
Methods
A total of 118 patients were randomized into three groups: oblique incision (n = 40), vertical incision (n = 40), and horizontal incision (n = 38). Sensory deficits were assessed using Von Frey Filaments at three weeks, three months, and six months postoperatively. Functional outcomes were measured using the International Knee Documentation Committee (IKDC) 2000 Subjective Knee Evaluation score at the 6-month mark. Statistical analyses included ANOVA and post-hoc tests to compare sensory disturbances across groups.
Results
At 6 months, the oblique incision group demonstrated significantly less sensory disturbance (34.7 mm2 ± 38.6) than the vertical (43.8 mm2 ± 39.1) and horizontal (63.4 mm2 ± 42.4) incision groups (p = 0.031). No significant differences were found between the oblique and vertical incisions. The functional outcomes were comparable across all groups (P > 0.05).
Conclusion
Compared with vertical and horizontal incisions, oblique incisions for hamstring graft harvesting significantly reduced sensory disturbances without compromising functional outcomes. These findings suggest that careful selection of incision type can improve postoperative sensory outcomes in ACL reconstruction.
Keywords: ACL reconstruction, Hamstring graft harvest, Incision types, Sensory disturbance, Von frey filaments, Safe zones, Functional outcomes
1. Introduction
Anterior cruciate ligament reconstruction (ACLR) is widely considered the gold standard for treating knee instability caused by anterior cruciate ligament (ACL) insufficiency.1 Among the various autograft options, hamstring grafts have gained prominence owing to their favorable outcomes and lower donor site morbidity than patellar tendon grafts.2,3 However, hamstring graft harvest is associated with a risk of injury to the saphenous nerve and its branches, particularly the infrapatellar branch of the saphenous nerve (IPBSN), which innervates the anteromedial part of the knee.4,5
Injury to the IPBSN during graft harvest can lead to postoperative sensory deficits, most commonly numbness in the anteromedial region of the knee.6 Although common, this numbness is often well tolerated by patients and typically does not result in functional impairment or significant distress.7 However, minimizing these sensory disturbances remains important for optimizing patient comfort and satisfaction following surgery.8
Although sensory deficits, particularly numbness over the anteromedial knee, are generally well tolerated, minimizing them can enhance patient satisfaction and postoperative experience.9 The infrapatellar branch of the saphenous nerve's proximity to the hamstring tendons, combined with variability in its course, necessitates careful incision planning to avoid unnecessary nerve injury during graft harvest.6,10, 11, 12, 13, 14, 15
This study aimed to evaluate the extent and pattern of sensory disturbances associated with three distinct incision types (vertical, oblique, and horizontal) used for hamstring graft harvesting in ACL reconstruction. We hypothesize that different incision types may lead to significant variations in sensory disturbances without affecting functional outcomes. Specifically, we expect that oblique incisions will result in smaller areas of sensory disturbance than vertical or horizontal incisions.
2. Methodology
2.1. Trial design
This prospective, parallel-group, randomized controlled trial (RCT) was conducted from January 2019 to June 2019 at a single sports injury referral center. This trial aimed to compare the sensory disturbance and functional outcomes associated with three different incision patterns used during hamstring graft harvesting for ACL reconstruction.
2.2. Eligibility criteria
Participants were aged between 20 and 60 years, with isolated ACL injury and no history of prior knee surgeries. Exclusion criteria included a body mass index (BMI) > 32, associated ipsilateral ligament injuries, and unwillingness to participate in the trial.
2.3. Setting
The trial was conducted at an exclusive sports injury referral center.
2.4. Informed consent
All patients provided written informed consent prior to participation.
The 118 patients were divided into three groups: oblique incision (Group A n = 40), vertical incision (Group B, n = 40), and horizontal incision (Group C, n = 38). To determine the type of incision to be used before each surgery, a lot containing the incision type was selected by the surgeon and performed accordingly, thereby eliminating selection bias.
2.5. Sample size calculation
The sample size was calculated to detect a significant difference in the area of sensory disturbance between the three incision groups (oblique, vertical, and horizontal). Based on prior literature and pilot data from our institution, we estimated that the mean area of sensory disturbance at six months would be approximately 45 mm2, with a standard deviation (SD) of 15 mm2 across groups. Using a two-sided alpha level of 0.05 and a desired statistical power of 80 % (β = 0.20), we calculated that a minimum of 36 patients per group would be required to detect a clinically meaningful difference of at least 10 mm2 in the sensory disturbance area. This was determined using ANOVA) for three independent groups.
To account for potential loss to follow-up, we increased the sample size by 10 %, resulting in a final enrollment target of 40 patients per group, for a total of 120 patients. The actual sample size included 118 patients, which was deemed sufficient to detect significant differences between groups.
2.6. Randomization and allocation concealment
The randomization process was conducted using a simple randomization technique. Before each surgery, a random lot containing incision type (oblique, vertical, or horizontal) was drawn. The randomization sequence was computer-generated using random number tables, which assigned participants to one of three incision groups in a 1:1:1 allocation ratio. This method minimized selection bias and ensured that each patient had an equal chance of being assigned to any of the three groups.
2.7. Allocation concealment
Allocation was concealed using sealed, opaque, sequentially numbered envelopes that were opened just before the surgical procedure. The surgeon was not involved in the randomization process and was informed of the allocated group immediately before the surgery. This method ensured that the surgeon remained blinded to allocation during the preoperative assessment and planning stages, thereby reducing potential bias.
2.8. Interventions
A contributing surgeon harvested the hamstring grafts. A 3 cm incision was made medial to the tibial tuberosity to harvest the hamstring graft. The minimum length of the graft harvested in this study was 3 cm, which ensured adequate tissue for successful ACL reconstruction. In each patient, the sartorius fascia was incised and repaired after graft harvesting. A closed tendon stripper was used in all the patients. The skin was closed using subcuticular absorbable sutures and reinforced with SteriStrips. Care was taken to avoid excessive retraction of the tissues to minimize trauma to the surrounding nerves. The type of incision (oblique, vertical, or horizontal) was performed as per the randomization lot allocated prior to the skin incision. ACL reconstruction was performed using the transportal technique with standard instrumentation. The femoral tunnel was drilled through the anteromedial portal. The tibial tunnel was then drilled using a jig fixed at 550 mm through the same incision used for graft harvesting. Care was taken to avoid injuring the skin during reaming with the help of the retractors. The graft was fixed with suspensory fixation on the femoral side, and a bioabsorbable interference screw on the tibial side. All patients underwent a regular rehabilitation program, which consisted of full weight bearing by 3rd week, ROM up to 900 by the end of 4th week.
2.9. Rehabilitation program
Postoperative rehabilitation was standardized for all patients. Full weight bearing was allowed by the third week, and the range of motion was increased to 90 °by the end of the fourth week. When performed, meniscal repair did not alter the weight-bearing regimen.
2.10. Follow-up and functional assessment
Patients were followed up at 3 weeks, 3 months, and 6 months postoperatively. Functional outcomes were assessed using the International Knee Documentation Committee (IKDC) 2000 Subjective Knee Evaluation score at the 6-month mark.
2.11. Assessment of sensory impairment
The subjective area of sensory impairment was recorded with a dedicated Von Frey Filament of 300 g (Baseline® Tactile™ Monofilaments) with the patient lying supine with both legs extended. The von Frey filament was chosen over pin-prick methods, as used in other studies, so that the induced pressure was uniform and avoided any pressure bias. The examination usually starts from the incision and extends in all directions until the patient perceives normal sensation. The area of deficit is marked by dots with skin markers, and all dots are connected to complete the area of deficit (Fig. 3). A tracing sheet was then placed over the marked area and an impression was obtained. Tracing sheets with impressions were placed over a graph sheet to calculate the number of square millimeter boxes that fit within the area. A similar procedure was performed for each follow-up period. The area of deficit measured with tracing sheets during each follow-up was compared with previous follow-up sheets for improvement. Trained physiotherapists, who were blinded to the incision type, performed sensory and functional assessments.
Fig. 3.
Graphical representation of change in sensory deficit over Time.
2.12. Measurement accuracy and precision
This study adhered to the high standard of measurement accuracy. The monofilament-based sensory deficit assessment allowed for precise and standardized pressure application, minimizing variability in measurements. All procedures were conducted with meticulous attention to detail, and the measurement accuracy was maintained throughout the study.
2.13. Test-retest reliability
Test-retest reliability for sensory deficit assessment was assessed by the same examiner (intraobserver reliability) on different days, with a 2-week interval between the tests. This study was conducted on 30 randomly selected patients to assess consistency. The intraclass correlation coefficient (ICC) was calculated using SPSS, and the test-retest reliability showed an ICC of 0.84, indicating good reliability.
2.14. Outcomes
The primary outcome was the area of sensory disturbance, measured using Von Frey Filaments at three weeks, three months, and six months postoperatively. The sensory disturbance was mapped and calculated in square millimeters using a graph sheet. The secondary outcome was functional performance assessed using the International Knee Documentation Committee (IKDC) 2000 Subjective Knee Evaluation score at six months.
2.15. Statistical methods
Nominal variables were analyzed using the chi-square test to explore associations. Analysis of variance (ANOVA) was used to detect significant differences between groups in the sensory disturbance area and functional outcomes. Post-hoc analyses using Tukey's honest significant difference (HSD) and Bonferroni tests were performed for intergroup comparisons. Statistical significance was defined as a p-value <0.05. Data were analyzed using SPSS software version 23.
3. Results
3.1. Participant flow
A total of 135 patients were assessed for eligibility between January and June 2019, of which 118 met the inclusion criteria. Participants were randomly assigned to the oblique incision group (n = 40), vertical incision group (n = 40), or horizontal incision group (n = 38). Seven patients were lost to follow-up, resulting in 111 patients being analyzed(Fig. 1).
Fig. 1.
Flow diagram based on the CONSORT guidelines.
All 118 patients who were randomized were included in the analysis, including the 7 patients who reported no sensory deficit. These patients were assigned a value of "0″ for the area of sensory disturbance in the final analysis to ensure accurate data representation.
3.2. Outcomes
Table 1 shows the characteristics of the study participants. Of the 118 participants enrolled in this prospective, randomized study conducted from January 2019 to June 2019, the majority were male (114 males and 14 females). The mean BMI of the cohort was 28.3 ± 4, and the mean age was 31.6 ± 9.4. Prior to the analysis, seven patients, distributed across the vertical, horizontal, and oblique groups, reported no sensory deficits.
Table 1.
Characteristics of the study population.
| Baseline Characteristic | Oblique Incision (n = 40) | Vertical Incision (n = 40) | Horizontal Incision (n = 38) | p-value (t-test/chi-square) |
|---|---|---|---|---|
| Mean Age (years) | 31.2 ± 8.7 | 30.8 ± 9.2 | 33.1 ± 10.1 | 0.51 |
| Mean BMI (kg/m2) | 27.9 ± 3.8 | 28.6 ± 4.1 | 28.4 ± 3.9 | 0.67 |
| Gender (Male) | 36 (90 %) | 35 (87.5 %) | 34 (89.5 %) | 0.93 |
| Gender (Female) | 4 (10 %) | 5 (12.5 %) | 4 (10.5 %) |
The subsequent 111 patients, followed up for 6 months, revealed notable variations in the area of sensory deficit among the incision groups; the horizontal incision group displayed a significantly larger sensory deficit area than the vertical and oblique groups (Fig. 2). Interestingly, the oblique incision group exhibited the smallest sensory deficit at the final follow-up.
Fig. 2.
Sensory mapping over the patient's skin concerning the incision.
A vertical incision; B horizontal incision; C oblique incision. AM denotes anteromedial part of leg and AL denotes anterolateral part of the leg.
Sensory deficits generally originate from the incision scar and extend into specific zones, depending on the incision type. Statistical analysis demonstrated a significant overall difference (p-value <0.05) among the three incision groups. Subsequent intergroup comparisons, including oblique vs. Vertical, Oblique vs. Horizontal, and Vertical vs. horizontal, indicated a statistically significant difference (p < 0.001) in sensory deficit areas between oblique vs. Horizontal and Vertical vs. horizontal, while no significant difference was observed between oblique and vertical.
Pairwise comparisons revealed that oblique incisions were associated with a significantly smaller area of sensory disturbance than horizontal (p < 0.001) and vertical incisions (p = 0.041). Horizontal and vertical incision comparisons were also statistically significant (p = 0.002). These p-values were adjusted for multiple comparisons using Tukey's HSD test.
Further categorization of the hypoesthesia within each incision group revealed distinct patterns. Notably, 90 % of the patients in the vertical and horizontal incision groups experienced sensory deficits in the anterolateral aspect of the leg, whereas 68 % of the patients in the oblique incision group presented with sensory deficits in the anteromedial aspect of the leg (Table 2).
Table 2.
Pattern of sensory deficit among the three incisions.
| Incision | No sensory deficit (n = 7) | Antero-lateral sensory deficit (n = 70) | Antero-medial sensory deficit (n = 41) |
|---|---|---|---|
| Vertical | 6.06 % | 88.23 % | 5.71 % |
| Horizontal | 4 % | 88 % | 8 % |
| Oblique | 7.4 % | 22.2 % | 70.4 % |
The relationship between the area of sensory deficit and the number of grafts harvested was explored, differentiating between isolated Semi Tendinosus (ST) grafts and combined ST and Gracilis (G) grafts. Among the 111 patients analyzed, 13 received isolated ST grafts, and 98 underwent surgery with both ST and G grafts. The results indicated no statistically significant difference in the area of sensory deficit between the two graft groups (Table 3).
Table 3.
Area of sensory deficit (in mm2) in each incision at 3 weeks, 3 months, and 6 months follow up.
| Follow up | Vertical |
Horizontal |
Oblique |
P value | |||
|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | Mean | SD | ||
| 3 weeks | 59.6 | 52.7 | 84.4 | 70.3 | 50.1 | 54.5 | 0.083 |
| 3 months | 50.1 | 44.5 | 71.0 | 51.1 | 42.8 | 43.6 | 0.071 |
| 6 months | 43.8 | 39.1 | 63.4 | 42.4 | 34.7 | 38.6 | 0.031 |
Significant value < 0.05.
Regarding functional outcomes assessed using the International Knee Documentation Committee (IKDC) 2000 Subjective Knee Evaluation score at the 6-month mark, all three incision groups demonstrated positive progression with no clinically or statistically significant differences observed among them (Table 4).
Table 4.
Clinical outcome of patients involved in the study measured with IKDC score.
| Evaluation | Vertical |
Horizontal |
Oblique |
P- value | |||
|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | Mean | SD | ||
| Pre-operative IKDC | 32.380 | 7.7538 | 32.760 | 8.1868 | 29.341 | 6.8959 | 0.174 |
| IKDC @ 6 months | 78.864 | 6.5537 | 79.520 | 7.2002 | 78.815 | 5.9228 | 0.902 |
Significant value < 0.05.
4. Discussion
Our study provides significant insights into sensory disturbances associated with different incisions during hamstring graft harvesting for ACL reconstruction. The major findings highlighted that the oblique incision group exhibited a reduced area of sensory disturbance, the pattern of sensory loss varied among the incisions, the number of grafts (ST ± Gr) had no impact on the extent of sensory loss, and the clinical outcomes at 6 months were comparable among the three groups.
To date, there is a lack of consensus regarding the standard incision method for hamstring graft retrieval. Although clear descriptions of vertical,12 oblique,11 and horizontal incisions15,16 exist in the literature, our study adds valuable data on the sensory implications of these incisions. Injuries to the infrapatellar branch of the saphenous nerve and sartorial branch of the saphenous nerve during hamstring graft harvest have been associated with postoperative numbness17, 19, 18, 22, 21, b, a, 20 and reflex sympathetic dystrophy.22,23 Consistent with previous studies, Mochizuki et al.24, 25, 26 reported 58 % sensory disturbance in patients undergoing ACL reconstruction.
At the end of six months, our findings support the existing literature,2,7,13,27, 28, 29 indicating that the oblique incision group had a lesser area of sensory disturbance. However, a unique observation in our study was that the horizontal group exhibited a larger area of sensory loss, in contrast to previous reports.27,30,31 Notably, the area of sensory loss decreased in all three groups at the 6-month assessment. Although a small number of patients (7/118) remained unaffected, statistical significance could not be established, suggesting that this occurrence might have occurred by chance.
The inconsistent course and distribution pattern of the infrapatellar branch of the saphenous nerve make it susceptible to injury during incisions.20,32, 33, 34 Both vertical and horizontal incisions carry a higher risk of damaging the nerve and its branches, contributing to the observed sensory deficit.35 In contrast, a more parallel course of oblique incision reduces the risk of nerve injury, providing a plausible anatomical explanation for the lower area of deficit in the oblique incision group.30
Our study introduced a novel finding regarding the predictive nature of sensory disturbances associated with the incision used. The oblique incision group exhibited a sensory deficit of almost 70 % on the anteromedial aspect of the proximal leg, whereas the vertical and horizontal incisions resulted in an 88 % sensory deficit in the anterolateral aspect. Although previous studies27,30,36 have noted sensory changes in the anterolateral aspect, the anatomical reason for the involvement of the anteromedial aspect in the oblique incision group remains unclear.
In our study, we found that 70 % of patients in the oblique incision group exhibited sensory deficits localized to the anteromedial aspect of the proximal leg. In contrast, 90 % of patients in the vertical and horizontal incision groups reported sensory deficits in the anterolateral region. It is important to clarify that these percentages reflect the proportion of patients within each group who experienced sensory deficits in the specified areas, rather than suggesting that all patients in those groups experienced significant sensory loss. This distinction is crucial because it emphasizes that while a substantial number of patients report sensory disturbances, it does not imply a uniform experience of sensory loss across the entire patient population.
While descriptions exist for the sartorial branch of the saphenous nerve close to the gracilis for a mean of 4.6 cm, theoretically posing a risk for injury during graft harvesting, our study compared the outcome of sensory deficits among isolated ST-harvested and ST/G-harvested patients. The mean deficit area was comparatively smaller in the ST group than in the ST-G group, but the difference was not statistically significant.
Several authors have attempted to delineate a safe zone for hamstring graft harvesting over the years, providing insights into high-risk and low-risk areas for skin incision.7,10,24,35 These studies have identified specific anatomical considerations and variations in the course of nerves, such as the infrapatellar branch of the saphenous nerve and sartorial branch of the saphenous nerve, which are vulnerable to injury during the incision process. Although these studies have provided valuable information on potential risk zones, translating these findings into practical guidelines for surgeons in clinical settings remains challenging. The intricacies of individual patient anatomy, variations in nerve courses, and dynamic nature of surgical procedures contribute to the complexity of implementing a standardized safe zone for hamstring graft harvesting. Despite the wealth of available information, the practicality of applying these identified risk areas consistently and universally remains an ongoing issue in the field.
Our study provides valuable insights into the sensory disturbances associated with the different incision types used during hamstring graft harvesting for ACL reconstruction.11 These findings suggest that oblique incisions result in a significantly smaller area of sensory disturbance than horizontal and vertical incisions.12 This is consistent with previous studies that have emphasized the importance of incision type in minimizing the risk of infrapatellar branch saphenous nerve injury.
The oblique incision group consistently demonstrated lower sensory disturbance, which can be attributed to the parallel alignment of the incision with the underlying nerve anatomy. In contrast, vertical and horizontal incisions may increase the risk of nerve damage owing to their proximity to the nerve path, leading to larger areas of hypoesthesia.37 Although the outcomes measured using the IKDC score were comparable among all groups, the reduction in sensory disturbance associated with oblique incisions may enhance overall patient satisfaction by reducing the incidence of postoperative numbness.
Our results align with those of previous studies that have highlighted the variability in nerve injury risk based on the incision orientation. Notably, the hited the largest area of sensory disturbance, contrary to earlier studies that suggested that horizontal incisions might be less damaging. This discrepancy may be due to anatomical variations or differences in surgical techniques, emphasizing the need for personalized approaches in graft harvest planning.
In addition to sensory disturbances, functional recovery after ACL reconstruction is a crucial aspect of post-operative care. The results of this study demonstrated that while there were significant differences in sensory outcomes among the incision types, functional performance, as assessed by the International Knee Documentation Committee (IKDC) score, remained comparable across all groups at the 6-month follow-up. This suggests that the type of incision used for graft harvesting may not have a direct impact on the overall functional recovery of patients.
However, it is essential to acknowledge that sensory deficits can influence patient perceptions of recovery and quality of life. Numbness or altered sensation in the knee region may affect activities of daily living such as walking, squatting, or participating in sports.38 Despite the absence of significant differences in functional scores, sensory disturbances can lead to psychological distress and dissatisfaction, potentially hindering a patient's overall rehabilitation experience.
Future research should explore the long-term effects of sensory deficits on functional activity and overall patient satisfaction. Additionally, understanding how sensory disturbances influence a patient's willingness to engage in rehabilitation exercises and return to sports could provide valuable insights into optimizing surgical techniques and postoperative management.
The strengths of this study include its randomized controlled design and the use of standardized assessment methods, such as Von Frey Filaments, to quantify sensory disturbance. The randomization process minimized selection bias and the use of a single surgeon ensured consistency in the surgical technique. However, our study had several limitations, including a relatively short follow-up period of six months and a small sample size. Future studies with longer follow-up durations could provide more comprehensive insights into the long-term impact of incision type on sensory recovery and functional outcome.
4.1. Clinical implications
The clinical relevance of our findings lies in guiding surgeons in selecting oblique incisions for hamstring graft harvesting to reduce the risk of postoperative sensory deficits. Given the growing emphasis on minimizing donor-site morbidity in ACL reconstruction, these results provide evidence that small adjustments in surgical techniques can have meaningful benefits for patients.
4.2. Future research
Further research should aim to refine the safe zones for hamstring graft harvesting by incorporating larger and more diverse patient populations. Understanding individual anatomical variations and their impact on incision choice could help develop tailored surgical guidelines that reduce sensory complications, while preserving graft integrity and functional outcomes.
5. Conclusion
Our study suggests that the use of oblique incisions in hamstring graft harvesting offers a clear advantage in minimizing sensory disturbance compared to vertical and horizontal incisions without compromising functional outcomes. These findings support the careful consideration of incision type in ACLreconstruction procedures to enhance patient outcome and comfort.
Ethics committee approval
The study was conducted in ortho one orthopedic specialty center and started after the approval of hospital ethics committee at Ortho OneOrthopaedic specialty centre. (IHEC OOSPC2391)
CRediT author statement
Gopinath Duraiswamy: Methodology, Writing-draft preparation, Software Munis Ashraf.: Data curation, Writing- Original draft preparation, Methodology. Earnest Paul: Methodology, Visualization, Investigation. Santosh Sahanand: Conceptualization, Methodology, Supervision, Validation.: David V Rajan: Supervision, Validation.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Contributor Information
Gopinath Duraiswamy, Email: drgopi1311@gmail.com.
Munis Ashraf, Email: munis6@gmail.com.
Earnest Paul, Email: earnestpauld@gmail.com.
Santosh Sahanand K, Email: sahanand@gmail.com.
David V. Rajan, Email: ortho.one@gmail.com.
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