The Accessory Medial Portal for Anterior Cruciate Ligament Reconstruction: A Safe Zone to Avoid Neurovascular Complications

Abstract

Background: The accessory medial portal (AMP) used for anatomic anterior cruciate ligament reconstruction (ACLR) is gaining popularity. This portal is routinely created at 60° of knee flexion, placing the infrapatellar branch of the saphenous nerve (IBSN) and, less commonly, the descending and superior medial genicular arteries at risk. Purpose/Hypothesis: The purpose of this study was to identify a safe zone for AMP placement in ACLR to minimize the risk of injury to the IBSN. We hypothesized that increased knee flexion angles would decrease the risk to neurovascular structures when creating an AMP. Study Design: Descriptive laboratory study. Methods: A total of 20 cadaveric (10 matched pairs) knees were used for dissection to identify the IBSN and other neurovascular structures. A 30° arthroscope was used to make the central medial portal and AMP at 3 knee flexion angles (60°, 90°, and 110°). Distances were measured from the AMP to branches of the IBSN. Safety of AMP placement was analyzed by assessing the frequency at which spinal needles pierced a neurovascular structure or violated a safe zone. Results: The superior IBSN was significantly closer to the AMP than inferior IBSN. The AMP was significantly farther from the superior IBSN at 110° (8.56 ± 5.28 mm) compared with 60° (5.63 ± 5.00 mm; P = .015) and 90° (6.69 ± 5.03 mm; P = .006). A triangular safe zone was identified at 110° of knee flexion. No neurovascular structures were pierced, and the IBSN was not present in the safe zone. At 90°, the IBSN was not pierced; however, the IBSN did violate the safe zone at 90° of knee flexion. Conclusion: The superior IBSN is at risk for iatrogenic injury with an AMP placed at 60° of knee flexion. The nerve moved distally with knee flexion. While no neurovascular structures were compromised at 90° of knee flexion, the nerve was found to course through the safe zone. A safe zone at 110° of knee flexion decreases the risk of neurovascular injury and makes the AMP safe for ACLR. Clinical Relevance: The AMP at 60° of knee flexion for ACLR poses risk to the IBSN. The IBSN did violate the safe zone at 90° of flexion. We recommend creating an AMP with increased knee flexion to 110° to decrease the risk of iatrogenic injury. When establishing an AMP, one should aim for the center of the defined safe zone, given that the spinal needle used in this study has a smaller diameter than a stab incision.