• A L A Kerver, M S Leliveld, D den Hartog, M H J Verhofstad, and G J Kleinrensink.
• Department of Neuroscience and Anatomy (A.L.A.K. and G.J.K.), and Trauma Research Unit, Department of Surgery (M.H.J.V. and D.d.H.), Erasmus MC, University Medical Center Rotterdam, Postbus 2040, Room Number 1485, 3000 CA, Rotterdam, The Netherlands. E-mail address for A.L.A. Kerver: antonkerver@gmail.com.
• J Bone Joint Surg Am. 2013 Dec 4;95(23):2119-25.

BackgroundIatrogenic injury to the infrapatellar branch of the saphenous nerve is a common complication of surgical approaches to the anteromedial side of the knee. A detailed description of the relative anatomic course of the nerve is important to define clinical guidelines and minimize iatrogenic damage during anterior knee surgery.MethodsIn twenty embalmed knees, the infrapatellar branch of the saphenous nerve was dissected. With use of a computer-assisted surgical anatomy mapping tool, safe and risk zones, as well as the location-dependent direction of the nerve, were calculated.ResultsThe location of the infrapatellar branch of the saphenous nerve is highly variable, and no definite safe zone could be identified. The infrapatellar branch runs in neither a purely horizontal nor a vertical course. The course of the branch is location-dependent. Medially, it runs a nearly vertical course; medial to the patellar tendon, it has a -45° distal-lateral course; and on the patella and patellar tendon, it runs a close to horizontal-lateral course. Three low risk zones for iatrogenic nerve injury were identified: one is on the medial side of the knee, at the level of the tibial tuberosity, where a -45° oblique incision is least prone to damage the nerves, and two zones are located medial to the patellar apex (cranial and caudal), where close to horizontal incisions are least prone to damage the nerves.ConclusionsThe infrapatellar branch of the saphenous nerve is at risk for iatrogenic damage in anteromedial knee surgery, especially when longitudinal incisions are made. There are three low risk zones for a safer anterior approach to the knee. The direction of the infrapatellar branch of the saphenous nerve is location-dependent. To minimize iatrogenic damage to the nerve, the direction of incisions should be parallel to the direction of the nerve when technically possible.Clinical RelevanceThese findings suggest that iatrogenic damage of the infrapatellar branch of the saphenous nerve can be minimized in anteromedial knee surgery when both the location and the location-dependent direction of the nerve are considered when making the skin incision.

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