| Abstract|| |
Saphenous neuralgia is characterized by persistent neuropathic pain at the distribution of the saphenous nerve. Injury to the saphenous nerve, and specifically to its infrapatellar branch of the saphenous nerve has been implicated as a cause of medial knee pain after orthopedic knee surgery or trauma. We present two cases of saphenous neuralgia, one after total knee arthroplasty and the other after anterior cruciate ligament reconstruction, that were adequately treated with ultrasound-guided saphenous nerve blocks distal to the adductor canal. Early recognition and treatment of saphenous neuralgia is essential to prevent persistent disabling pain, which significantly affects patients' quality of life.
Keywords: Knee, neuralgia, pain
|How to cite this article:|
Batistaki C, Saranteas T, Chloros G, Savvidou O. Ultrasound-guided saphenous nerve block for saphenous neuralgia after knee surgery: Two case reports and review of literature. Indian J Orthop 2019;53:208-12
|How to cite this URL:|
Batistaki C, Saranteas T, Chloros G, Savvidou O. Ultrasound-guided saphenous nerve block for saphenous neuralgia after knee surgery: Two case reports and review of literature. Indian J Orthop [serial online] 2019 [cited 2019 Feb 21];53:208-12. Available from: http://www.ijoonline.com/text.asp?2019/53/1/208/251709
| Introduction|| |
Saphenous neuralgia is characterized by persistent neuropathic pain at the distribution of the saphenous nerve. Total knee arthroplasty (TKA), anterior cruciate ligament (ACL) reconstruction, knee arthroscopy, tibial intramedullary nailing, and knee trauma, may all be complicated by saphenous nerve injury and especially the infrapatellar branch of the saphenous nerve (IPSN).,,,
Saphenous neuralgia must be included into the differential diagnosis of any persistent medial knee pain after knee surgery. Early diagnosis and prompt decision-making can obviate subsequent complications.
We present two cases of saphenous neuralgia, effectively treated with ultrasound-guided saphenous nerve blocks distal to the adductor canal. Both patients provided written informed consent for publication.
| Cases Reports|| |
A 66-year-old woman presented with severe knee pain, persisting for 2 years after TKA, with initial Numeric Rating Scale (NRS) up to 10/10 at movement and 7/10 at rest at the knee area, with strong neuropathic characteristics, with Leeds Assessmentof of Neuropathic Symptoms and Signs (LANSS) score 17/24. She described paroxysmic, burning pain, with the feeling of “pins and needles” over the knee. Clinical examination revealed allodynia, hyperalgesia, and hypoesthesia at the distribution of the saphenous nerve. After meticulous clinical and radiological examination, with normal laboratory tests and needle electromyography, any other potential etiologies of knee pain were excluded.
Diagnostic injection with 1% lidocaine at the site of maximum tenderness, at the knee scar, led to immediate but short-term relief. Alongside, a trial of systemic administration of gabapentin and duloxetine was commenced. Thereafter, an ultrasound-guided saphenous nerve block (linear 5–12MHz transducer/Vivid I; GE Healthcare, Waukesha, Wisconsin, USA) was conducted distal to the adductor canal, underneath the sartorius muscle, [Figure 1]a and [Figure 1]b. Both, ropivacaine 0.375% and triamcinolone 20 mg were administered, producing a 50% pain relief. The patient responded favorably, with the pain symptoms further subsiding at 30%, to having a second saphenous nerve block 2 weeks later. One year post-treatment, the patient appears significantly better (NRS = 2/10), using only paracetamol as a rescue analgesic.
|Figure 1: (a and b) Local anesthetic injection out of the subsartorial compartment for saphenous nerve block. The femoral artery (A) and vein (V) are seen below the sartorius (S). Local anesthetic injection is performed in the subsurtorial compartment between the femoral artery and the sartorius muscle (S) Cross sectional (3A) and longitudinal (3B) view of the femoral artery, vein and local anesthetic spread area (*) are also shown|
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A 34-year-old woman presented with severe knee pain, persisting for 18 months after ACL reconstruction, with initial NRS 6/10 and LANSS 19/24 over the distribution of the saphenous nerve. She had paroxysmic, burning pain, provoked by clothing, cold water, and touch, with severe allodynia and hyperalgesia. As before, all other causes of knee pain were excluded.
Diagnostic injection of 1% lidocaine was initially injected over the scar, and the subsequent 50% reduction of pain confirmed the diagnosis. An ultrasound-guided saphenous nerve block was performed with ropivacaine 0.375% and triamcinolone 20 mg. Three consecutive injections followed, with a lockout period of 2 weeks (two with corticosteroid). The pain was significantly reduced (NRS = 3/10), and the patient one year post-treatment experiences only sporadically paroxysmic pain, of low intensity.
| Discussion|| |
Saphenous neuralgia presents with a broad spectrum of symptoms, including sharp burning pain, hyperalgesia, allodynia, as well as hypoesthesia and dysesthesia at the distribution of the saphenous nerve. A positive Tinel sign can facilitate the diagnosis. An extensive workup consisting of laboratory tests with inflammatory markers and knee radiological imaging should be normal. The use of specific diagnosing questionnaires such as LANSS and DN4 is helpful, to support the neuropathic pain diagnosis., The differential diagnosis is cumbersome, including tendonitis of the distal sartorius, pes anserinus bursitis, ligament pathology, knee joint pathology, peripheral vascular disease, lumbar nerve root compression, and other causes of peripheral neuropathic pain., Final diagnosis is achieved by symptomatic pain relief after injection of local anesthetic at the distribution of the saphenous nerve.,,
The rate of saphenous nerve injury, and especially of IPSN is approximately 21%–69%, after knee procedures,,,,,,, [Table 1], implicating not only total TKA but also arthroscopic knee surgery., This is often related to inappropriate trocar/portal placement, or injury secondary to the use of a tourniquet. Surgical incisions at the medial part of the knee always entail a risk,,,,,,, especially midline incisions with medial parapatellar approach. Therefore, special care should be taken in such incisions if they cannot be avoided. In ACL reconstruction, this complication occurs frequently with both bone-patellar tendon-bone and hamstring autograft technique, with an incidence ranging between 14.9% and 59%. In this case, knee flexion and hip external rotation may reduce the tension applied on the nerve during harvesting of the semitendinosus and gracilis tendons and prevent postoperative saphenous neuralgia.,,, Several authors have recommended the use of horizontal or oblique incisions instead of vertical ones, to expose the tibial insertions of the hamstring tendons, since with this technique there is less chance of infrapattelar saphenous nerve (IPS) injury., In a cadaveric study, where vertical incisions were used, the IPS was injured in 80% of the knees., However, there seems to be a safe zone to prevent saphenous nerve injury. Boon et al. in a cadaveric study stated that a safe area on the right knee may be at the tibial tuberosity plane, between 3.7 and 5.5 cm, with an angle of incision of 51.6°, and at the left knee was between 3.6 and 4.9 cm, with an angle of incision of 52.5°, respectively. Kartus et al. in another cadaveric study described also this great variation of the IPS, and proposed two vertical 25 mm incisions for harvesting consistent bone-patellar tendon–bone autographs, leaving the IPS intact during the procedure. Other causes of damage include traction from medial retractors placed during surgery or adhesions which may develop between the injured nerve and adjacent fascial planes, resulting in neuritis.,, Some propose that in every case, smaller incisions minimize the possibility of nerve injury, in addition, with proper preparation of the nerve and cutting of the pulleys, which should be performed under direct visual control with a blunt technique. Finally, care should also be taken during anteromedial portal placement for ankle arthroscopy, or during lower leg fasciotomies, where the saphenous nerve may also be damaged along with the saphenous vein. However, in all cases, as described in multiple cadaveric studies, there is a great variation in the course of IPS, and therefore, damage of the nerve cannot always be prevented. Early identification of saphenous neuralgia and aggressive treatment are essential in alleviating patients' pain. Systemic drugs for the management of neuropathic pain, in addition to local anesthetic injections and capsaicin or lidocaine patches, have been proposed; with variable results., Injections of local anesthetic around saphenous nerve neuromas are diagnostic; however, it might be only with the ultrasound-guided saphenous nerve blocks that the pain relief is more persistent., However, the volume of the local anesthetic injected, the anatomic approach and the success rate of the block show a significant variability among studies., Clendenen et al., showed ultrasound-guided injections of the IPS to be effective, with a response rate of 56.3%. In the adductor canal, the high anatomic variability of the saphenous nerve and the vessel sheath may result to incomplete spread of the local anesthetic, leading to the variable success rate of the block. In our cases, the saphenous nerve blocks were undertaken more distal to the adductor canal, providing significant pain reduction. Moreover, the vastus medialis nerve was not blocked avoiding the subsequent weakness of the corresponding muscle, which is important for immediate patient ambulation. To the best of our knowledge, there have been no clinical series or comparative trials discussing a technique similar to that used in this series. If the injection provides temporary comfort, there are multiple other options available, such as neurolysis, pulsed radiofrequency, cryoneuroablation, and surgical excision of neuroma, with the insertion of the proximal end into adjacent muscle.
| Conclusion|| |
Saphenous neuralgia can be a distressing condition leading to severe disabling pain. Prevention of saphenous nerve injury during knee procedures and high index of suspicion may help minimize its incidence. Saphenous nerve block should always feature at the armentarium of our therapeutic options.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Trescot AM, Brown MN, Karl HW. Infrapatellar saphenous neuralgia – Diagnosis and treatment. Pain Physician 2013;16:E315-24.
Figueroa D, Calvo R, Vaisman A, Campero M, Moraga C. Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: Clinical and electrophysiological study. Knee 2008;15:360-3.
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;23:927-30.
Leliveld MS, Verhofstad MH. Injury to the infrapatellar branch of the saphenous nerve, a possible cause for anterior knee pain after tibial nailing? Injury 2012;43:779-83.
Adoni A, Paraskeuopoulos T, Saranteas T, Sidiropoulou T, Mastrokalos D, Kostopanagiotou G, et al.
Prospective randomized comparison between ultrasound-guided saphenous nerve block within and distal to the adductor canal with low volume of local anesthetic. J Anaesthesiol Clin Pharmacol 2014;30:378-82.
] [Full text]
Clendenen S, Greengrass R, Whalen J, O'Connor MI. Infrapatellar saphenous neuralgia after TKA can be improved with ultrasound-guided local treatments. Clin Orthop Relat Res 2015;473:119-25.
Heare A, Mitchell JJ, Bravman JT. Posttraumatic saphenous neuroma after open tibial fracture. Am J Orthop (Belle Mead NJ) 2015;44:E461-4.
Bertram C, Porsch M, Hackenbroch MH, Terhaag D. Saphenous neuralgia after arthroscopically assisted anterior cruciate ligament reconstruction with a semitendinosus and gracilis tendon graft. Arthroscopy 2000;16:763-6.
Sanders B, Rolf R, McClelland W, Xerogeanes J. Prevalence of saphenous nerve injury after autogenous hamstring harvest: An anatomic and clinical study of sartorial branch injury. Arthroscopy 2007;23:956-63.
Portland GH, Martin D, Keene G, Menz T. Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: Comparison of horizontal versus vertical harvest site incisions. Arthroscopy 2005;21:281-5.
Papastergiou SG, Voulgaropoulos H, Mikalef P, Ziogas E, Pappis G, Giannakopoulos I, et al.
Injuries to the infrapatellar branch(es) of the saphenous nerve in anterior cruciate ligament reconstruction with four-strand hamstring tendon autograft: Vertical versus horizontal incision for harvest. Knee Surg Sports Traumatol Arthrosc 2006;14:789-93.
Jameson S, Emmerson K. Altered sensation over the lower leg following hamstring graft anterior cruciate ligament reconstruction with transverse femoral fixation. Knee 2007;14:314-20.
Lidén M, Ejerhed L, Sernert N, Laxdal G, Kartus J. Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: A prospective, randomized study with a 7-year followup. Am J Sports Med 2007;35:740-8.
Mochizuki T, Akita K, Muneta T, Sato T. Anatomical bases for minimizing sensory disturbance after arthroscopically-assisted anterior cruciate ligament reconstruction using medial hamstring tendons. Surg Radiol Anat 2003;25:192-9.
Sgaglione NA, Warren RF, Wickiewicz TL, Gold DA, Panariello RA. Primary repair with semitendinosus tendon augmentation of acute anterior cruciate ligament injuries. Am J Sports Med 1990;18:64-73.
Hunter LY, Louis DS, Ricciardi JR, O'Connor GA. The saphenous nerve: Its course and importance in medial arthrotomy. Am J Sports Med 1979;7:227-30.
Mochida H, Kikuchi S. Injury to infrapatellar branch of saphenous nerve in arthroscopic knee surgery. Clin Orthop Relat Res 1995;320:88-94.
Gali JC, Resina AF, Pedro G, Neto IA, Almagro MA, da Silva PA, et al.
Importance of anatomically locating the infrapatellar branch of the saphenous nerve in reconstructing the anterior cruciate ligament using flexor tendons. Rev Bras Ortop 2014;49:625-9.
Boon JM, Van Wyk MJ, Jordaan D. A safe area and angle for harvesting autogenous tendons for anterior cruciate ligament reconstruction. Surg Radiol Anat 2004;26:167-71.
Kartus J, Ejerhed L, Eriksson BI, Karlsson J. The localization of the infrapatellar nerves in the anterior knee region with special emphasis on central third patellar tendon harvest: A dissection study on cadaver and amputated specimens. Arthroscopy 1999;15:577-86.
Pyne D, Jawad AS, Padhiar N. Saphenous nerve injury after fasciotomy for compartment syndrome. Br J Sports Med 2003;37:541-2.
Dr. Chrysanthi Batistaki
2nd Department of Anaesthesiology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” Hospital, 1 Rimini Street, Chaidari, Athens, 12462
Source of Support: None, Conflict of Interest: None