Research progress of anterior cutaneous nerve injury and repair in knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

PAN Enhao , WU Yingbin , TANG Lin ,  LU Weijie

Department of Joint Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Guangdong, 510120, P. R. China;

Corresponding author：

LU Weijie, Email: 13902280296@139.com

Keywords：

Knee arthroplasty; anterior cutaneous nerve injury; complication; prevention; treatment

DOI：

10.7507/1002-1892.202301071

Video：

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Objective To summarize the research progress of anterior cutaneous nerve injury and repair in knee arthroplasty. Methods The relevant literature at home and abroad in recent years was reviewed and summarized from the anatomy of anterior cutaneous nerve, nerve injury grade, clinical manifestations, prevention and treatment of anterior cutaneous nerve. Results The anterior cutaneous nerve injury is a common complication of knee arthroplasty. Because the anterior cutaneous nerve branches are many and thin, and mainly run between the first and second layers of fascia, this level is often ignored during surgical exposure. In addition, the knee arthroplasty does not routinely perform the exploration and repair of the cutaneous nerve. So the anterior cutaneous nerve injury is difficult to avoid, and can lead to postoperative skin numbness and knee pain. At present, studies have explored the feasibility of preventing its occurrence from the aspects of improved incision and intraoperative separation of protective nerve. There is no effective prevention and treatment measures for this complication. For patients with skin numbness after knee arthroplasty, the effectiveness of drug treatment is not clear. Local nerve block or nerve excision can be used to treat patients with painful symptoms after knee arthroplasty considering cutaneous pseudoneuroma. Conclusion Knee arthroplasty is widely used and anterior cutaneous nerve injury is common in clinic. In the future, more high-quality clinical studies are needed to further explore the prevention and treatment measures of this complication and evaluate the clinical benefits obtained.

Citation： PAN Enhao, WU Yingbin, TANG Lin, LU Weijie. Research progress of anterior cutaneous nerve injury and repair in knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(5): 635-640. doi: 10.7507/1002-1892.202301071 Copy

1.	Price AJ, Alvand A, Troelsen A, et al. Knee replacement. Lancet, 2018, 392(10158): 1672-1682.
2.	Song MH, Kim BH, Ahn SJ, et al. Preventing lateral skin numbness after medial unicompartmental knee arthroplasty. Clin Orthop Surg, 2010, 2(4): 232-236.
3.	韩燕鸿, 潘建科, 刘军, 等. 人工全膝关节置换后切口周围皮肤麻木: 如何治疗? 中国组织工程研究, 2017, 21(31): 5048-5053.
4.	Howell R, Hill B, Hoffman C, et al. Peripheral nerve blocks for surgery about the knee. JBJS Rev, 2016, 4(12): e1. doi: 10.2106/JBJS.RVW.16.00003.
5.	马松鹤. 去神经化治疗膝关节置换后膝关节顽固性疼痛. 中国组织工程研究, 2016, 20(31): 4589-4595.
6.	余正红, 蔡胥, 赵卫东, 等. 膝关节神经分布的解剖学研究及其临床意义. 中国临床解剖学杂志, 2008, 26(1): 11-16.
7.	高兴华, 刘永轶, 王敏聪, 等. 膝关节置换术后皮肤麻痹的解剖基础及相关临床研究. 中国临床解剖学杂志, 2016, 34(2): 121-125.
8.	黄晓华, 张卫国, 杨阳, 等. 隐神经髌下支解剖及切除后对膝关节置换术后膝前疼痛的影响. 中国骨与关节损伤杂志, 2009, 24(2): 121-122.
9.	Kerver AL, Leliveld MS, den Hartog D, et al. The surgical anatomy of the infrapatellar branch of the saphenous nerve in relation to incisions for anteromedial knee surgery. J Bone Joint Surg (Am), 2013, 95(23): 2119-2125.
10.	Boyle J, Eason A, Hartnett N, et al. Infrapatellar branch of the saphenous nerve: A review. J Med Imaging Radiat Oncol, 2021, 65(2): 195-200.
11.	Henry BM, Tomaszewski KA, Pękala PA, et al. The variable emergence of the infrapatellar branch of the saphenous nerve. J Knee Surg, 2017, 30(6): 585-593.
12.	Lee SR, Dahlgren NJP, Staggers JR, et al. Cadaveric study of the infrapatellar branch of the saphenous nerve: Can damage be prevented in total knee arthroplasty? J Clin Orthop Trauma, 2019, 10(2): 274-277.
13.	Lee SK, Wolfe SW. Peripheral nerve injury and repair. J Am Acad Orthop Surg, 2000, 8(4): 243-252.
14.	Sunderland S. A classification of peripheral nerve injuries producing loss function. Brain, 1951, 74(4): 491-516.
15.	Hussain G, Wang J, Rasul A, et al. Current status of therapeutic approaches against peripheral nerve injuries: a detailed story from injury to recovery. Int J Biol Sci, 2020, 16(1): 116-134.
16.	Black R, Green C, Sochart D. Postoperative numbness of the knee following total knee arthroplasty. Ann R Coll Surg Engl, 2013, 95(8): 565-568.
17.	Yap WMQ, Ho SWL, Kau CY. Numbness after medial unicompartmental knee arthroplasty: Prevalence and effect on functional outcome. Knee, 2020, 27(6): 1833-1840.
18.	刘洪文, 徐杰, 林院, 等. 不同皮肤切口对全膝关节置换术后切口外侧皮肤感觉障碍的影响: 前瞻性随机对照研究. 中华骨与关节外科杂志, 2019, 12(9): 681-685.
19.	杨立新, 吕厚山, 孙铁铮, 等. 人工膝关节置换术后切口外侧皮肤感觉障碍的观察与研究. 中华骨科杂志, 2010, 30(8): 800-801.
20.	Hopton BP, Tommichan MC, Howell FR. Reducing lateral skin flap numbness after total knee arthroplasty. Knee, 2004, 11(4): 289-291.
21.	Johnson DF, Love DT, Love BR, et al. Dermal hypoesthesia after total knee arthroplasty. Am J Orthop (Belle Mead NJ), 2000, 29(11): 863-866.
22.	Borley NR, Edwards D, Villar RN. Lateral skin flap numbness after total knee arthroplasty. J Arthroplasty, 1995, 10(1): 13-14.
23.	刘恒, 文立成, 曹永平, 等. 膝关节置换术后切口周围皮肤麻木的研究. 北京大学学报 (医学版), 2012, 44(6): 882-886.
24.	Johnson DP, Eastwood DM, Bader DL. Biomechanical factors in wound healing following knee arthroplasty. J Med Eng Technol, 1991, 15(1): 8-14.
25.	Itoh M, Itou J, Kuwashima U, et al. Correlation of patient-reported numbness around surgical scars with patient-reported outcome measures and joint awareness after knee replacement: a cohort study. BMC Musculoskelet Disord, 2022, 23(1): 14. doi: 10.1186/s12891-021-04971-6.
26.	Gurler D, Buyukceran I. Is the numbness after knee replacement a more critical complication than thought? A detailed analysis of neuropathic pain and functional outcomes. Medicina (Kaunas), 2022, 58(10): 1369. doi: 10.3390/medicina58101369.
27.	Jariwala AC, Parthasarathy A, Kiran M, et al. Numbness around the total knee arthroplasty surgical scar: prevalence and effect on functional outcome. J Arthroplasty, 2017, 32(7): 2256-2261.
28.	Blackburn J, Wylde V, Greenwood R, et al. The effect of numbness on outcome from total knee replacement. Ann R Coll Surg Engl, 2017, 99(5): 385-389.
29.	Phillips JR, Hopwood B, Arthur C, et al. The natural history of pain and neuropathic pain after knee replacement: a prospective cohort study of the point prevalence of pain and neuropathic pain to a minimum three-year follow-up. Bone Joint J, 2014, 96-B(9): 1227-1233.
30.	Shi SM, Meister DW, Graner KC, et al. Selective denervation for persistent knee pain after total knee arthroplasty: a report of 50 cases. J Arthroplasty, 2017, 32(3): 968-973.
31.	彭徐云, 陶冶. 周围神经损伤修复的研究进展. 沈阳医学院学报, 2020, 22(2): 174-178.
32.	Chalidis B, Kitridis D, Givissis P. Surgical treatment outcome of painful traumatic neuroma of the infrapatellar branch of the saphenous nerve during total knee arthroplasty. World J Orthop, 2021, 12(12): 1008-1015.
33.	Giannetti A, Valentino L, Giovanni Mazzoleni M, et al. Painful total knee arthroplasty: Infrapatellar branch of the saphenous nerve selective denervation. A case series. Knee, 2022, 39: 197-202.
34.	Tilbury C, Haanstra TM, Leichtenberg CS, et al. Unfulfilled expectations after total hip and knee arthroplasty surgery: there is a need for better preoperative patient information and education. J Arthroplasty, 2016, 31(10): 2139-2145.
35.	Von Keudell A, Sodha S, Collins J, et al. Patient satisfaction after primary total and unicompartmental knee arthroplasty: an age-dependent analysis. Knee, 2014, 21(1): 180-184.
36.	Wylde V, Artz N, Howells N, et al. Kneeling ability after total knee replacement. EFORT Open Rev, 2019, 4(7): 460-467.
37.	Maniar RN, Singhi T, Nanivadekar A, et al. A prospective randomized study in 20 patients undergoing bilateral TKA comparing midline incision to anterolateral incision. J Orthop Traumatol, 2017, 18(4): 325-333.
38.	Tsukada S, Kurosaka K, Nishino M, et al. Cutaneous hypesthesia and kneeling ability after total knee arthroplasty: a randomized controlled trial comparing anterolateral and anteromedial skin incision. J Arthroplasty, 2018, 33(10): 3174-3180.
39.	Slattery D, Langston J, Shumack M, et al. Midline versus anterolateral incisions for total knee arthroplasty-a systematic review and analysis of the angiosomes of the knee. ANZ J Surg, 2021, 91(10): 2167-2173.
40.	Ruangsomboon P, Nepal S, Udomkiat P, et al. No effect of oral mecobalamin on skin numbness at 3 months after total knee arthroplasty: a randomized, double-blinded, placebo-controlled superiority trial. JBJS Open Access, 2022, 7(2): e22.00002. doi: 10.2106/JBJS.OA.22.00002.
41.	Worth RM, Kettelkamp DB, Defalque RJ, et al. Saphenous nerve entrapment. A cause of medial knee pain. Am J Sports Med, 1984, 12(1): 80-81.
42.	Shi GG, Schultz DS, Whalen J, et al. Midterm outcomes of ultrasound-guided local treatment for infrapatellar saphenous neuroma following total knee arthroplasty. Cureus, 2020, 12(1): e6565. doi: 10.7759/cureus.6565.
43.	Kachar SM, Williams KM, Finn HA. Neuroma of the infrapatellar branch of the saphenous nerve a cause of reversible knee stiffness after total knee arthroplasty. J Arthroplasty, 2008, 23(6): 927-930.
44.	Nahabedian MY, Johnson CA. Operative management of neuromatous knee pain: patient selection and outcome. Ann Plast Surg, 2001, 46(1): 15-22.

1. Price AJ, Alvand A, Troelsen A, et al. Knee replacement. Lancet, 2018, 392(10158): 1672-1682.
2. Song MH, Kim BH, Ahn SJ, et al. Preventing lateral skin numbness after medial unicompartmental knee arthroplasty. Clin Orthop Surg, 2010, 2(4): 232-236.
3. 韩燕鸿, 潘建科, 刘军, 等. 人工全膝关节置换后切口周围皮肤麻木: 如何治疗? 中国组织工程研究, 2017, 21(31): 5048-5053.
4. Howell R, Hill B, Hoffman C, et al. Peripheral nerve blocks for surgery about the knee. JBJS Rev, 2016, 4(12): e1. doi: 10.2106/JBJS.RVW.16.00003.
5. 马松鹤. 去神经化治疗膝关节置换后膝关节顽固性疼痛. 中国组织工程研究, 2016, 20(31): 4589-4595.
6. 余正红, 蔡胥, 赵卫东, 等. 膝关节神经分布的解剖学研究及其临床意义. 中国临床解剖学杂志, 2008, 26(1): 11-16.
7. 高兴华, 刘永轶, 王敏聪, 等. 膝关节置换术后皮肤麻痹的解剖基础及相关临床研究. 中国临床解剖学杂志, 2016, 34(2): 121-125.
8. 黄晓华, 张卫国, 杨阳, 等. 隐神经髌下支解剖及切除后对膝关节置换术后膝前疼痛的影响. 中国骨与关节损伤杂志, 2009, 24(2): 121-122.
9. Kerver AL, Leliveld MS, den Hartog D, et al. The surgical anatomy of the infrapatellar branch of the saphenous nerve in relation to incisions for anteromedial knee surgery. J Bone Joint Surg (Am), 2013, 95(23): 2119-2125.
10. Boyle J, Eason A, Hartnett N, et al. Infrapatellar branch of the saphenous nerve: A review. J Med Imaging Radiat Oncol, 2021, 65(2): 195-200.
11. Henry BM, Tomaszewski KA, Pękala PA, et al. The variable emergence of the infrapatellar branch of the saphenous nerve. J Knee Surg, 2017, 30(6): 585-593.
12. Lee SR, Dahlgren NJP, Staggers JR, et al. Cadaveric study of the infrapatellar branch of the saphenous nerve: Can damage be prevented in total knee arthroplasty? J Clin Orthop Trauma, 2019, 10(2): 274-277.
13. Lee SK, Wolfe SW. Peripheral nerve injury and repair. J Am Acad Orthop Surg, 2000, 8(4): 243-252.
14. Sunderland S. A classification of peripheral nerve injuries producing loss function. Brain, 1951, 74(4): 491-516.
15. Hussain G, Wang J, Rasul A, et al. Current status of therapeutic approaches against peripheral nerve injuries: a detailed story from injury to recovery. Int J Biol Sci, 2020, 16(1): 116-134.
16. Black R, Green C, Sochart D. Postoperative numbness of the knee following total knee arthroplasty. Ann R Coll Surg Engl, 2013, 95(8): 565-568.
17. Yap WMQ, Ho SWL, Kau CY. Numbness after medial unicompartmental knee arthroplasty: Prevalence and effect on functional outcome. Knee, 2020, 27(6): 1833-1840.
18. 刘洪文, 徐杰, 林院, 等. 不同皮肤切口对全膝关节置换术后切口外侧皮肤感觉障碍的影响: 前瞻性随机对照研究. 中华骨与关节外科杂志, 2019, 12(9): 681-685.
19. 杨立新, 吕厚山, 孙铁铮, 等. 人工膝关节置换术后切口外侧皮肤感觉障碍的观察与研究. 中华骨科杂志, 2010, 30(8): 800-801.
20. Hopton BP, Tommichan MC, Howell FR. Reducing lateral skin flap numbness after total knee arthroplasty. Knee, 2004, 11(4): 289-291.
21. Johnson DF, Love DT, Love BR, et al. Dermal hypoesthesia after total knee arthroplasty. Am J Orthop (Belle Mead NJ), 2000, 29(11): 863-866.
22. Borley NR, Edwards D, Villar RN. Lateral skin flap numbness after total knee arthroplasty. J Arthroplasty, 1995, 10(1): 13-14.
23. 刘恒, 文立成, 曹永平, 等. 膝关节置换术后切口周围皮肤麻木的研究. 北京大学学报 (医学版), 2012, 44(6): 882-886.
24. Johnson DP, Eastwood DM, Bader DL. Biomechanical factors in wound healing following knee arthroplasty. J Med Eng Technol, 1991, 15(1): 8-14.
25. Itoh M, Itou J, Kuwashima U, et al. Correlation of patient-reported numbness around surgical scars with patient-reported outcome measures and joint awareness after knee replacement: a cohort study. BMC Musculoskelet Disord, 2022, 23(1): 14. doi: 10.1186/s12891-021-04971-6.
26. Gurler D, Buyukceran I. Is the numbness after knee replacement a more critical complication than thought? A detailed analysis of neuropathic pain and functional outcomes. Medicina (Kaunas), 2022, 58(10): 1369. doi: 10.3390/medicina58101369.
27. Jariwala AC, Parthasarathy A, Kiran M, et al. Numbness around the total knee arthroplasty surgical scar: prevalence and effect on functional outcome. J Arthroplasty, 2017, 32(7): 2256-2261.
28. Blackburn J, Wylde V, Greenwood R, et al. The effect of numbness on outcome from total knee replacement. Ann R Coll Surg Engl, 2017, 99(5): 385-389.
29. Phillips JR, Hopwood B, Arthur C, et al. The natural history of pain and neuropathic pain after knee replacement: a prospective cohort study of the point prevalence of pain and neuropathic pain to a minimum three-year follow-up. Bone Joint J, 2014, 96-B(9): 1227-1233.
30. Shi SM, Meister DW, Graner KC, et al. Selective denervation for persistent knee pain after total knee arthroplasty: a report of 50 cases. J Arthroplasty, 2017, 32(3): 968-973.
31. 彭徐云, 陶冶. 周围神经损伤修复的研究进展. 沈阳医学院学报, 2020, 22(2): 174-178.
32. Chalidis B, Kitridis D, Givissis P. Surgical treatment outcome of painful traumatic neuroma of the infrapatellar branch of the saphenous nerve during total knee arthroplasty. World J Orthop, 2021, 12(12): 1008-1015.
33. Giannetti A, Valentino L, Giovanni Mazzoleni M, et al. Painful total knee arthroplasty: Infrapatellar branch of the saphenous nerve selective denervation. A case series. Knee, 2022, 39: 197-202.
34. Tilbury C, Haanstra TM, Leichtenberg CS, et al. Unfulfilled expectations after total hip and knee arthroplasty surgery: there is a need for better preoperative patient information and education. J Arthroplasty, 2016, 31(10): 2139-2145.
35. Von Keudell A, Sodha S, Collins J, et al. Patient satisfaction after primary total and unicompartmental knee arthroplasty: an age-dependent analysis. Knee, 2014, 21(1): 180-184.
36. Wylde V, Artz N, Howells N, et al. Kneeling ability after total knee replacement. EFORT Open Rev, 2019, 4(7): 460-467.
37. Maniar RN, Singhi T, Nanivadekar A, et al. A prospective randomized study in 20 patients undergoing bilateral TKA comparing midline incision to anterolateral incision. J Orthop Traumatol, 2017, 18(4): 325-333.
38. Tsukada S, Kurosaka K, Nishino M, et al. Cutaneous hypesthesia and kneeling ability after total knee arthroplasty: a randomized controlled trial comparing anterolateral and anteromedial skin incision. J Arthroplasty, 2018, 33(10): 3174-3180.
39. Slattery D, Langston J, Shumack M, et al. Midline versus anterolateral incisions for total knee arthroplasty-a systematic review and analysis of the angiosomes of the knee. ANZ J Surg, 2021, 91(10): 2167-2173.
40. Ruangsomboon P, Nepal S, Udomkiat P, et al. No effect of oral mecobalamin on skin numbness at 3 months after total knee arthroplasty: a randomized, double-blinded, placebo-controlled superiority trial. JBJS Open Access, 2022, 7(2): e22.00002. doi: 10.2106/JBJS.OA.22.00002.
41. Worth RM, Kettelkamp DB, Defalque RJ, et al. Saphenous nerve entrapment. A cause of medial knee pain. Am J Sports Med, 1984, 12(1): 80-81.
42. Shi GG, Schultz DS, Whalen J, et al. Midterm outcomes of ultrasound-guided local treatment for infrapatellar saphenous neuroma following total knee arthroplasty. Cureus, 2020, 12(1): e6565. doi: 10.7759/cureus.6565.
43. Kachar SM, Williams KM, Finn HA. Neuroma of the infrapatellar branch of the saphenous nerve a cause of reversible knee stiffness after total knee arthroplasty. J Arthroplasty, 2008, 23(6): 927-930.
44. Nahabedian MY, Johnson CA. Operative management of neuromatous knee pain: patient selection and outcome. Ann Plast Surg, 2001, 46(1): 15-22.

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