The influence of preserving Infrapatellar fatpad in ACL reconstruction

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1 The influence of preserving Infrapatellar fatpad in ACL reconstruction Kazuki Asai 1), Junsuke Nakase 1), Kengo Shimozaki 1), Kazu Toyooka 1), Hiroyuki Tsuchiya 1) 1) Department of Orthopaedic Surgery, Graduate School of Medical Science Kanazawa University

2 Kazuki Asai, MD I have no financial conflicts to disclose.

3 Introduction Anterior knee pain (AKP) is one of the major complications that interrupts rehabilitation after anterior cruciate ligament (ACL) reconstruction. Infrapatellar fat pad (IPFP) plays various roles in the knee Supplying vascular into the anterior part of knee 1) Cushioning between the anterior tibial plateau and the patellar tendon 2) Secreting inflammatory factors 3) Repairing ability of adipose-derived stem cell from IPFP 4)

4 Introduction Partial IPFP resection is need to expose ACL and lateral intercondylar ridge. Damage to the IPFP during arthroscopy may cause AKP after ACL reconstruction. No studies have showed correlation the amount of IPFP resection during arthroscopy with AKP.

5 Purpose To evaluate the influence of preserving IPFP in ACL reconstruction

6 Materials and Methods We prospectively assessed 34 patients and 34 knees. Patients with injured ACL treated at our department from Nov to Apr was examined. They were alternatingly treated by resecting the IPFP around the intercondylar area to better visualize ACL or preserving it. Clinical evaluation The Kujala score (3 and 6 months postoperatively) International Knee Documentation Committee (IKDC) score (1 year) Knee injury and Osteoarthritis Outcome Score (KOOS) (1 year)

7 The size of total IPFP and its posterior part was calculated using a sagittal MRI at the level of the deepest portion of femoral trochlear groove in axial plane. The size of Total IPFP Preserving rate of total IPFP size 6 months after operation = Pre operation pre operation 6 month

8 The posterior part of IPFP The rich vascular supply found in the posterior part of IPFP 5). More substance-p nerves which relate to pain were located in the posterior part 6). The size of posterior part of IPFP Posterior part was defined as divided along a line connecting the vertical and horizontal clefts. The ratio of posterior part to total IPFP (RP) was calculated. Resorption rate of posterior part = RP (pre op) RP (6month) Vertical cleft Posterior part Horizontal cleft

9 Results All ACL reconstruction was performed using the semitendinosus tendon. Both groups had 10 meniscus tears. resection group (n=17) preservation group (n=17) Sex (Men : Female) 7 : 10 7 : Age 18.6± ± BMI 22.3± ± Time from injury to operation (day) 148± ± There were no significant difference in patients characteristics between two groups. P Mann Whitney U test, P<0.05

10 IPFP size (%) 100 P= (%) P<0.001 The resection group The preservation group Preserving rate of total IPFP size Resorption rate of posterior part Mann Whitney U test, P<0.05 The size of the IPFP, particularly the posterior part, decreased more in the resection group than that in the preserved group at 6 months after surgery.

11 Clinical evaluation resection group preservation group P Kujula score (3M) 74.3 ± ± kujula score (6M) 90.2 ± ± IKDC(1Y) 93.5 ± ± KOOS(1Y) 96.6 ± ± Mann Whitney U test, P<0.05 No cases had more than a 10-degree loss of knee extension compared to the healthy side at 6 months postoperatively. One patient in the resection group had AKP and required a hyaluronic acid injection up to 22 months after the surgery. There was no significant difference in clinical evaluations between the resection group and the preservation group.

12 Conclusions IPFP resection around the intercondylar area to better visualize ACL had no effect in the early postoperative period.

13 References 1. Scapinelli R. Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat 1997;10(3): Dragoo JL, Johnson C, McConnell J. Evaluation and treatment of disorders of the infrapatellar fat pad. Sports Med 2012;42: Ushiyama T, Chano T, Inoue K, Matsusue Y. Cytokine production in the infrapatellar fat pad: another source of cytokines in knee synovial fluids. Ann Rheum Dis 2003;62(2): Liu YP, Li SZ, Yuan F, Xia J, Yu X, Liu X, Yu GR. Infrapatellar fat pad may be with tendon repairing ability and closely related with the developing process of patella baja. Med Hypotheses 2011;77(4): Scapinelli R. Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat 1997;10(3): Bohnsack M, Hurschler C, Demirtas T, Ruhmann O, Stukenborg- Colsman C, Wirth CJ. Infrapatellar fat pad pressure and volume changes of the anterior compartment during knee motion: possible clinical consequences to the anterior knee pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2005;13(2):