Ochiai et al. Journal of Orthopaedic Surgery and Research (2017) 12:101
DOI 10.1186/s13018-017-0596-x

RESEARCH ARTICLE

Open Access

Injury to infrapatellar branch of saphenous
nerve in anterior cruciate ligament
reconstruction using vertical skin incision
for hamstring harvesting: risk factors andthe influence of treatment outcome
Satoshi Ochiai1* , Tetsuo Hagino1, Shinya Senga1, Takashi Yamashita1, Kotaro Oda1 and Hirotaka Haro2

Abstract
Background: Injury to the infrapatellar branch of the saphenous nerve (IPBSN) is a high-frequency complication inanterior cruciate ligament (ACL) reconstruction. We analyzed the risk factor of IPBSN injury in ACL reconstruction.
Moreover, we investigated the influence on treatment outcome by this complication.
Methods: One hundred twenty-three patients who underwent ACL reconstruction using semitendinosus tendon
graft were studied. Gender, age, BMI, and additional use of gracilis tendon were recorded. Treatment outcome wasassessed by Lysholm score, visual analog scale (VAS) pain score, anterior knee pain, knee range of motion (ROM),and the patient-based SF-36. Patients who developed sensory disturbance at 24 months after reconstruction werecompared with those without sensory disturbance.
Results: Twenty-six of 123 patients (21.1%) developed postoperative sensory disturbance caused by IPBSN injury.
Baseline parameters were not significantly different compared to those in the non-sensory disturbance group.
In the sensory disturbance group, treatment outcome evaluated at 24 months post-reconstruction showed Lysholm
score of 94.1, VAS of 9.8 mm, anterior knee pain in 7.7%, and limitation of knee extension of 5° in 7.7%. SF-36
scores in all subscales were above the mean national standard scores. Treatment outcome parameters were also
not significantly different compared to those in the non-sensory disturbance group, and none of the patients hadserious impairment of knee function and activities of daily living.
Conclusion: Injury to IPBSN in ACL reconstruction was not related to age, gender, and physique, and injury
frequency did not increase. Evaluation of postoperative treatment outcome showed that IPBSN injury was not
related to anterior knee pain or knee ROM limitation, and patients’ subjective evaluation confirmed no serious
impact on physical and mental health.
Keywords: Anterior cruciate ligament injury, Reconstruction, Infrapatellar branch of saphenous nerve,
Sensory disturbance, SF-36* Correspondence: hxcmk230@ybb.ne.jp
1
The Sports Medicine and Knee Center, National Hospital Organization, Kofu
National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi 400-8533, Japan
Full list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Ochiai et al. Journal of Orthopaedic Surgery and Research (2017) 12:101

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Background
Anterior cruciate ligament (ACL) reconstruction isassociated with relative low risk, because the procedurecan be conducted as less invasive arthroscopy-assisted
surgery and almost all the patients undergoing reconstruction belong to the healthy young age group. However, comparing to the complication rate of all knee
arthroscopic surgeries [1–3], the complication rate of
ACL reconstruction was not low [4–6]. ACL reconstruction involves bone invasion, harvest of tendon graft, andretention of internal fixation material, and technicalproblems during these procedures may contribute to thehigh complication rate.
Injury to the infrapatellar branch of the saphenous
nerve (IPBSN) is the most common complication in
ACL reconstruction [7], and high incidence of 22–59%
has been reported [8, 9]. This injury occurs during
placement of the anteromedial portal for arthroscopic
viewing, during harvest of the patellar tendon or medial
hamstring tendon, and while drilling the tibial bonetunnel [10–12].
While the prevention of IPBSN injury by paying attention to the skin incision has been discussed, it is difficult
to completely avoid the injury [10, 13]. Although several
studies suggested that injury to the saphenous nerve andits branches causes relatively mild impairment of activities of daily living (ADL) [13–15], no prospective study
that investigates IPBSN injury in detail has been reported. In this study, we hypothesized that IPBSN injury
during ACL reconstruction causes some degree of decline in patient satisfaction even if the injury does not
result in functional impairment. The purpose of thisstudy was to verify in detail the effects of IPBSN injury
on postoperative outcome using conventional treatment
evaluation methods together with SF-36, a patient-based
evaluation method. Furthermore, for the purpose offinding prevention methods, we also investigated thefactors related to IPBSN injury in patients who developed sensory disturbance after ACL reconstruction presumably caused by IPBSN damage.

performed by the first author (SO), an orthopedic surgeon.
Based on the presence and absence of IPBSN injury,
patients were divided into a sensory disturbance group
and a non-sensory disturbance group. Three patients who
had sensory disturbance presumably caused by injuries
other than IPBSN were excluded from analysis. In thesethree patients, the injury was in the main trunk of thesaphenous nerve in one patient and in the sciatic nerve in
two patients. Patients who had fractures, injury of otherligaments, and radiographic changes of severe osteoarthritis
were also excluded from this study.
The risk factors of IPBSN injury were analyzed by comparing gender, age, BMI, and additional use of gracilis tendon
between the sensory disturbance and non-sensory disturbance groups. Furthermore, treatment outcomes were evaluated by comparing preoperative and 24-month postoperative
Lysholm score (minimum score 0, maximum score 100;
scores below 65 are interpreted as poor function) [17], visual
analog scale (VAS) for pain [18], rate of anterior knee pain
[19, 20], knee range of motion (ROM), and the patient-based
scale SF-36 [norm-based scoring (NBS): the absolute scoresof 0–100 are recalculated such that the mean national
standard score is 50 and the standard deviation is 10] [21,22]. Treatment outcome was compared between the sensory
disturbance and non-sensory disturbance groups to examine
whether IPBSN injury affects treatment outcome. The SF-36
is composed of eight subscales: physical functioning (PF),role-physical (RP), bodily pain (BP), and general health (GH)that are related to physical health, as well as vitality (VT),social functioning (SF), role-emotional (RE), and mental
health (MH) that are related to mental health.

Methods
We studied prospectively 123 patients who underwent
primary ACL reconstruction using the semitendinosus
tendon graft between April 2012 and March 2014 at theSports Medicine and Knee Center, National Hospital
Organization, Kofu National Hospital. This study wasapproved by the institutional review boards of the
Hospital Ethics Committees (registration number 27-8).
At 24 months after reconstruction, we examined all
patients for sensory disturbance caused by IPBSN injury
based on the anatomical distribution of IPBSN and
Romanes’s innervation map [16] by pain stimulation
using a needle and touch. All sensory examinations were

Operative technique [23]Single-bundle trans-tibial reconstruction was used in all
the patients. All surgeries were conducted by the firstauthor (SO) as the main operator.
First, a 1.8- to 2.5-cm longitudinal skin incision wasplaced on the medial side of the tibial tubercle, and thesemitendinosus tendon was harvested. To construct thetendon graft, the harvested semitendinosus tendon was
folded four to six times to obtain a bundle with adiameter of 7.5 mm or larger. When the thickness of the
prepared semitendinosus tendon was less than 7.5 mm,
the gracilis tendon was also harvested. Then theharvested tendon was bundled, and artificial tendons(Endobutton Tape, CL Endobutton, Acufex; Smith &Nephew, Mansfield, Massachusetts) were attached toboth ends of the bundle to prepare the tendon graft.
From the incision used for harvesting the tendon, a
ProTrac ACL guide system (Acufex; Smith & Nephew)
was used to produce a tibial tunnel with the same diameter as the tendon graft at the site of ACL insertion to
the tibia. Next, in the femoral bone approximately 6 mm
anterior to the posterior margin of the intercondylar

Ochiai et al. Journal of Orthopaedic Surgery and Research (2017) 12:101

fossa and at 10 o’clock (for the right knee) or 2 o’clock(for the left knee) position, a femoral tunnel with thesame diameter as the tendon graft was made by thetrans-tibial method. The tendon graft attached to a guidesuture was passed through the tibial tunnel into the femoral tunnel. The femoral side was fixed with Endobutton(Acufex; Smith & Nephew) and the tibial side with spike
staples by double stapling. The graft was fixed with theknee flexed at 30° while a tension of 45 N was applied tothe tendon graft. All the tendon grafts prepared had diameters of 7.5 mm or larger (7.5–8.5 mm) and lengthsof 55 mm or longer (55–65 mm) [24, 25].
Postoperative management

From day 3 after surgery, range of motion training wasstarted using a hinge brace with angle restriction. Extension was restricted to 20° and flexion to 90° up to
4 weeks after surgery. Partial weight bearing was allowedfrom 2 weeks, and full weight bearing was allowed at
4 weeks. Competitive sports activities were restarted
around 9 months after surgery.
Concomitant intra-articular injuries

In both groups, concomitant intra-articular injuries wereobserved under arthroscopic examination during reconstruction (Table 1). There were no significant differencesin the rate of concomitant meniscal tears necessitating
surgical intervention, the sites of these tears, and thesurgical modality between the sensory disturbance andnon-sensory disturbance groups. The prevalence ofserious cartilage injury graded according to the ICRS
classification [26] was also not significantly different
between the two groups.

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Statistical analysis

Statistical analyses were conducted using MannWhitney U test, Fisher’s exact test, and two-way
ANOVA. A p value less than 0.05 was consideredsignificant.

Results
Among 123 patients who underwent ACL reconstruction, 29 patients developed sensory disturbance, 26 ofwhom were due to IPBSN injury and 3 were due toother nerve injuries. The prevalence of IPBSN injury inall patients who underwent ACL reconstruction was
21.1% (26 of 123 patients). After excluding the three patients with sensory disturbance due to other causes, thepresent study compared 26 cases of sensory disturbancedue to IPBSN injury and 94 cases without sensory disturbance. Comparison of the two groups showed no significant differences in gender ratio, age, BMI, and thetendons harvested (rate of harvesting both semitendinosus tendon and gracilis tendon) (Table 2).
Apart from sensory disturbance, no re-rupture or laxity of the tendon graft and no serious postoperativecomplications such as deep infections were observed. In
addition, none of the patients dropped out of the postoperative follow-up protocol.
Regarding treatment outcome, Lysholm score and
VAS pain score were improved significantly at 24 months
after reconstruction compared to before surgery in bothgroups, but no significant differences were observed
between the two groups. The two groups also did not
differ in the percentage of patients with anterior knee
pain, as assessed based on self-reporting by the patient
regarding the site and area of pain in the knee using
Spicer’s knee diagram [15]. None of the patients in both

Table 1 Complications of anterior cruciate ligament-deficient knees
Meniscus tear
no. of cases (%)[treatment: no. of cases]

Cartilage injurya
no. of cases (%)[site of injury with grade: no. ofcases]MedialLateralBilateral

Sensory disturbance group(n = 26)

4 cases (15.3%)[PE: 2, R: 2]

8 cases (30.8%)[PE: 6, R: 2]

5 cases (19.2%)
medial meniscus[PE: 4, R: 1]
lateral meniscus[PE: 3, R: 2]

6 cases (23.1%)
medial femoral condyle
grade 3: 2, grade 4: 1
lateral femoral condyle
grade 3: 0, grade 4: 1
medial femoral and tibial condyles
grade 3: 1, grade 4: 1

Non-sensory disturbance group(n = 94)18 cases (18.1%)[PE: 11, R: 7]

32 cases (34.0%)[PE: 18, R: 7]

15 cases (16.0%)
medial meniscus[PE: 11, R: 4]
lateral meniscus[PE: 8, R: 7]

18 cases (19.1%)
medial femoral condyle
grade 3: 7, grade 4: 2
lateral femoral condyle
grade 3: 3, grade 4: 0
both femoral condyles
grade 3: 3, grade 4: 0
medial femoral and tibial condyles
grade 3: 1, grade 4: 2

PE partial excision, R repairaGrade 3 or above in the ICRS classification

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Table 2 Comparison of the group with and the group without sensory disturbance

GenderSensory disturbance group(N = 26)

Non-sensory disturbance group(N = 94)

p value

Male

12

49

0.38

Female144524.7 ± 10.1

24.3 ± 11.9

Age (years)

0.87

BMI

24.6 ± 3.1

23.3 ± 3.7

0.40

Tendon grafta

3 patients (11.5%)

10 patients (10.6%)

0.57

BMI body mass indexa
Use of the gracilis tendon together with the semitendinosus tendon in the tendon graftgroups showed severe pain or occurrence of complex regional pain syndrome (CRPS) (Table 3).
In the assessment of knee ROM, none of the patients
showed a difference in ROM between the affected andunaffected knee (side-to-side difference in ROM) before
surgery, because reconstruction was scheduled only
when the side-to-side difference in ROM was resolved.
The two groups did not differ in the percentage ofpatients with a side-to-side difference in knee ROM of
5° or more at 24 months after surgery (Table 3). The
ROM limitation in all cases was confined to extension
only, and no limitation of flexion was observed.
In preoperative assessment using SF-36, the scores ofmore than half of the subscales were below the mean
Japanese national standard scores in both the sensory
disturbance and non-sensory disturbance groups (Fig. 1).
At 24 months after reconstruction, the scores of all thesubscales were improved to above the mean Japanesenational standard scores in both groups, with no significant differences between the two groups.

Discussion
The saphenous nerve is a purely sensory nerve. The
infrapatellar branch of the saphenous nerve traverses theanteromedial aspect of the patella (Fig. 2). Injury to the
IPBSN results in the development of sensory disturbancefrom the anterior knee to the proximal lower leg. This
injury requires attention because it occasionally gives
rise to anterior knee pain, kneeling pain, painful neuroma, and CRPS [11, 27, 28]. In the present study, we
attempted to identify the risk factors associated with
IPBSN injury with the aim to help prevent IPBSN injury
associated with ACL reconstruction. However, we foundno relationship between IPBSN injury and patients’physical factors of gender, age, and BMI. Regarding surgical factors, Mirzatolooei and Pisoodeh [29] suggested
that the risk of IPBSN injury is increased accompanying
the harvest of the gracilis tendon, but we found nochange in the IPBSN injury rate even when the gracilis
tendon was harvested in addition to the semitendinosus
tendon. Regarding the skin incision during surgery, thelength of skin incision in our study was shorter than theconventional length used in ACL reconstruction, which
may account for the lower rate of IPBSN injury (21.1%)
compared to other reports (22–59%) [8, 9]. However,Figueroa et al. [30] found no correlation between the presence of sensory disturbance caused by IPBSN injury andthe size of the incision or the distance to the tibial
tubercle. Crude manipulation of the tendon stripper
during harvest of the medial hamstring has been reported
to be a cause of IPBSN injury [10]. A similar mechanism
may also cause damage to the main trunk of the saphenous

Table 3 Evaluations of treatment outcome
Sensory disturbance group
Lysholm score

Non-sensory disturbance groupp value

Preoperative

44.3 ± 29.6

54.2 ± 23.4

0.17

Postoperative

94.1 ± 6.5

91.6 ± 12.1

0.46

p value
Pre vs. post

5.2 × 10−7*

2.6 × 10−13*

Preoperative

32.5 ± 29.1

43.7 ± 27.7

0.26

Postoperative

9.8 ± 14.1

13.6 ± 19.6

0.57

p value
Pre vs. post

0.036*

2.0 × 10−6*

Rate of AKP

2 patients (7.7%)

2 patients (2.1%)

0.20

ROM limitation

2 patients (7.7%)

5 patients (5.3%)

0.64

VAS (mm)

Rate of AKP: For the evaluation of acute knee pain, Spicer’s knee diagram was used. The patient self-reported the site of pain on the diagram or the doctor marked
on the diagram based on the patient’s information [15]AKP anterior knee pain
*p < 0.05

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Fig. 1 Evaluation using SF-36. PF physical functioning, RP role-physical, BP bodily pain, GH general health, VT vitality, SF social functioning,
RE role-emotional, MH mental health. Preoperative SF-36 evaluation shows scores lower than the Japanese national standard scores in PF,
RP, BP, RE, and MH subscales in the sensory disturbance group, and in PF, RP, BP, VT, SF, and RE subscales in the non-sensory disturbancegroup. Evaluation at 24 months after surgery shows scores higher than national standard scores in all the subscales in both groups, with no significant
differences between the two groups. The asterisk indicates p < 0.05. Horizontal line at 50 points on the graph = national standard scores in Japan

nerve and sciatic nerve [11, 31]. There is a possibility that
inappropriate manipulation of the tendon stripper may also
be involved in IPBSN and other nerve injuries in our
institution.
Several techniques have been recommended for theprevention of IPBSN injury, such as performing surgery
with the knee in flexion to direct the course of the nerve
away from the incision or to use a horizontal or an
oblique incision that runs parallel to the course of thenerve [10, 13]. However, even using these methods, the
IPBSN injury rates have been reported to range from
14.7 to 43% [9, 32, 33]. Therefore, currently, the IPBSN
injury remains a complication that is difficult to avoid in
ACL reconstruction.
There are few reports on subjective evaluation of treatment outcome of ACL reconstruction in patients withinjury to branches of the saphenous nerve including theinfrapatellar branch. Mochizuki et al. [14] investigatedskin sensory change after ACL reconstruction using an
original questionnaire posted to 60 patients who were
followed for a mean of 31.6 months after surgery. They
reported that 80.8% of the patients felt no effect on their
daily living as a result of the sensory change. Sabat andKumar [13] evaluated sensory loss prospectively in 120

patients followed for 6 months after surgery using the2000 IKDC Subjective Knee Evaluation Form. They
reported that the sensory loss did not impair normal
daily activities. Spicer et al. [15] investigated anteriorknee symptoms using the Shelbourne and Trumper [19]anterior knee pain questionnaire distributed clinically orby post or telephone to 44 patients followed for a meanof 30 months after surgery. They found that only 2% of
the patients experienced significant symptoms causing
limitation of daily activities, although anterior knee
symptoms involving the IPBSN occurred commonly.
Therefore, the effect of IPBSN injury on treatment outcome should be studied in more detail. In the present
prospective 2-year study, we evaluated treatment outcome using the SF-36, which is a patient-based healthsurvey with scientifically proven reliability and validity[34, 35], together with the conventional methods. Our
results obtained from the SF-36 survey confirmed goodtreatment outcome and that patients were not affectedby IPBSN injury, from the aspects of both physical andmental health. In addition, evaluation of the Lysholm
score, VAS pain score, and knee ROM also revealed favorable treatment outcome with no impact due to IPSN
injury. The prevalence of anterior knee pain tended toOchiai et al. Journal of Orthopaedic Surgery and Research (2017) 12:101

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Further study with a larger study population is required
to examine whether changing surgical method ameliorates symptoms of IPBSN injury.

Conclusion
Injury to IPBSN in ACL reconstruction is not related
to age, gender, or physique, and the frequency of injury does not increase even when the gracilis tendon
is harvested in addition to the semitendinosus tendon.
Regarding treatment outcome after reconstruction,
IPBSN injury is not related to anterior knee pain or
limitation of knee ROM and has no serious impact
on physical and mental health according to patients’subjective evaluation.
Abbreviations
ACL: Anterior cruciate ligament; ADL: Activities of daily living; BP: Bodily pain;
GH: General health; IPBSN: Infrapatellar branch of the saphenous nerve;
MH: Mental health; NBS: Norm-based scoring; PF: Physical functioning;
RE: Role-emotional; ROM: Range of motion; RP: Role-physical; SF: Social
functioning; SF-36: Patient-based 36-item short-form health survey;
VAS: Visual analog scale; VT: Vitality
Acknowledgements
The authors thank Professor Sen Takeda and Mr. Haruo Futamata of the
Department of Anatomy and Cell Biology, University of Yamanashi
Interdisciplinary Graduate School of Medicine and Engineering, for theirsupport in the dissection of the cadaver.

Fig. 2 Photograph of dissection of a cadaver showing the courseof the infrapatellar branch of the saphenous nerve. The saphenous
nerve branches near the medial side of the knee into the infrapatellar
branch and sartorial branch. The infrapatellar branch courses at theinferomedial side of the patella. The course has several variations.
The positional relationship with the sartorius muscle also varies; theinfrapatellar branch may pass over the muscle, under the muscle, or
through the muscle. Attention is needed

be slightly higher in patients with IPBSN injury, but thedifference was not significant.
The results of the present study demonstrated that
IPBSN injury during ACL reconstruction was not related
to anterior knee pain or limitation of knee ROM.
Subjective evaluation by the patients confirmed that
IPBSN injury had no serious impact on physical andmental health. However, since the risk factors related tothis injury have not been identified currently, prediction
and prevention remain difficult. Considering the possibility of the rare occurrence of CRPS [28, 36], further
studies are required.

Funding
None
Availability of data and materials
All the data and materials were in full compliance with the journal’s policy.
Authors’ contributions
SO designed and wrote the manuscript. SS, TY, and KO collected andanalyzed the research data. TH and HH interpreted the research data andedited the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
We carried out a prospective clinical trial, and ethical approval was obtained
from the institutional review board of the National Hospital Organization,
Kofu National Hospital. Informed consent was obtained from all the patients.
Consent for publication
Not applicableCompeting interests
The authors declare that they have no competing interests.

Limitations

Publisher’s Note

This study has several limitations. The extent and severity of sensory disturbance were not considered. Since thenumber of subjects was relatively small, the possibility ofoccurrence of CRPS and neuroma that have a very low
incidence cannot be excluded. Moreover, there is noconclusion regarding measures to prevent IPBSN injury.

Springer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Author details
1
The Sports Medicine and Knee Center, National Hospital Organization, Kofu
National Hospital, 11-35 Tenjin-cho, Kofu, Yamanashi 400-8533, Japan.
2
Department of Orthopaedic Surgery, Faculty of Medicine, University of
Yamanashi, 1110, Shimokato, Chuo, Yamanashi 409-3898, Japan.

Ochiai et al. Journal of Orthopaedic Surgery and Research (2017) 12:101

Received: 24 December 2016 Accepted: 14 June 2017

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