Double-incision mini-invasive technique for BTB Harvesting: Its superiority in reducing anterior knee pain following ACL reconstruction

Abstract

Arthroscopically-assisted ACL-reconstructions are currently reliable, reproducible and thoroughly used methods. Residual anterior knee symptoms however, especially after patellar-BTB graft use, are not uncommon occurrences following ACL-reconstructions, and can downgrade patient's satisfaction. Anterior knee pain contributing factors are numerous and include injury to the saphenous nerve infrapatellar branches (SNIB) and/or histologic changes at the harvest site. We thus preferably suggest a double-incision minimal approach for the patellar transplant harvesting stage in order to prevent injury to the SNIB. This technical variation decreases the risk of injury to the saphenous nerve infrapatellar branches while preserving the peritenon. Prospective controlled trial. Two groups were alternatively constituted in 2004: ligament reconstructions were either performed via a two-incisions approach during the first 2004 semester or via a single-incision approach during the second 2004 semester. Pain, even at a mild level, was evaluated. Patients were assessed using objective pain provocative tests and sensory assessment, a Lille University femoropattelar score, the IKDC Knee evaluation, the SF36 quality of life score in combination with radiographic and ultrasonographic investigations. Forty patients were reviewed at a mean 33 months follow-up delay: 21 of these had a double-incision approach and 19 had a single-incision approach. Four patients from the double-incision sub-group and 11 from the single-incision sub-group reported anterior knee pain (p<0.01). The knee-walking test came out normal in 11 patients from the double-incision sub-group and in three from the single-incision sub-group (p<0.02). The Lille University patello-femoral score was 91/100, demonstrating no significant difference. At follow-up, sensory disorders were observed in 17 patients from the single-incision sub-group and in nine from the double-incision sub-group (p<0.002). However, no statistical correlation could be established between anterior knee pains and sensorial disturbances. SF36 and IKDC objective and subjective scores were similar in both groups. Ultrasonographic findings revealed a lesser degree of patellar tendon thickening in the double-incision sub-group. However, no statistically significant differences definitely emerged between the two groups (p=0.50). The results of this study strongly support our main hypothesis: The double-incision approach significantly reduces the mid-term incidence of anterior knee pains after ACL-reconstructions. Additionally, this technical variation markedly decreased the occurrence of sensory disorders and the extent of hypoesthesia. We thus advocate the use of a double-incision graft harvesting technique in ACL-reconstructions using a patellar-bone-tendon-bone transplant.