The Anatomical Course of the Lateral Femoral Cutaneous Nerve with Special Attention to the Anterior Approach to the Hip Joint

ALDI (Anterior Lateral Decubitus Intermuscular) approach to the hip: Comprehensive description of the surgical technique with operative video

The direct anterior approach to the hip is judged to be difficult and even after many solutions, such as special operating tables, have been proposed to perform it, in some reports the complication rate remains high. The complications reported are nerve lesions, dislocation, muscles damages, intraoperative fractures. We describe a modification of the anterior approach, undertaken keeping the patient in lateral decubitus, in order to gain a better range of leg movement and a significant reduction of the force applied to the retractors, the technique was named ALDI (anterior lateral decubitus intermuscular) approach. The surgeon starts behind the patient as in all the other traditional approaches, to maintain unchanged the acetabular view and the dexterity in cup implantation. For the femoral preparation, he moves in front of the patient to have a better visualization. In a series of 150 patients, with a mean operative time of 51.38minutes (range, 40-112), we had no intraoperative fractures, one (0.6%) lateral femoral cutaneous nerve temporary neurapraxia, one (0.8%) posttraumatic dislocation four years after the operation and, no revisions for aseptic loosening or infection. At the 5 years follow-up, the mean Oxford Hip score was 45.2 (range, 38-48; SD 2.6), the mean Harris Hip Score was 96,7 (range, 76-100; SD 2.8), and the mean UCLA score was 7 (range, 5-10; SD 1.4). The possibility to always obtain the optimal position of the surgical window with reduced tension on the muscles, and the unchanged initial surgeon position, could make the ALDI approach the ideal technique for the surgeons that decide to perform an anterior approach.

Effects of lateral circumflex femoral artery ligation on blood flow to the surrounding muscles in the direct anterior approach

BACKGROUND

The direct anterior approach to the hip joint enables the identification and ligation of the lateral circumflex femoral artery. However, the effect of lateral circumflex femoral artery ligation on blood flow to the muscles surrounding the hip remains unknown. This study clarified the changes in blood flow to the surrounding muscles following ascending branch ligation of this artery.

METHODS

We included 36 consecutive patients (8 male and 28 female) who underwent total hip arthroplasty via the direct anterior approach for hip osteoarthritis between April 2015 and July 2016. The intraoperative blood flow to the tensor fascia latae (TFL), vastus lateralis (VL), rectus femoris (RF), and subcutaneous tissue (control) was measured using a laser Doppler blood flow meter. Measurements were repeated after artery ligation and at the end of surgery. We compared the means (±SD) of these measurements at each location and time point.

RESULTS

The patients' mean age was 64.2 ± 9.0 years, systolic and diastolic blood pressures were 92.8 ± 13.6 and 54.9 ± 9.1 mmHg, respectively, and body mass index was 23.1 ± 3.9 kg/m². Hypertension was noted in 35.9% patients and dyslipidemia in 27.8%. The mean surgical duration was 101 (70-158) min. The preligation blood flow in TFL, VL, RF, and subcutaneous tissue was 3.91 ± 1.93, 5.15 ± 2.19, 4.51 ± 2.24, and 3.03 ± 0.99 mL/min/100 g, respectively.

CONCLUSIONS

Blood flow to TFL significantly decreased post ligation and at the end of surgery. However, there was no change in blood flow to VL and RF.

Natural history of lateral femoral cutaneous nerve neuropraxia after anterior approach total hip arthroplasty

AIM:

The aim of this study was to examine the natural history of lateral femoral cutaneous nerve (LFCN) neuropraxia in a previously reported cohort of individuals after direct anterior approach (DAA).

METHODS:

99 patients (107 hips) with LFCN neuropraxia were identified, out of which 82 patients (87 hips) (83.1%) completed functional outcomes questionnaires at mean follow-up of 5.5 years (4.4-6.9 years). 5 patients were excluded from the study due to intra-articular source of pain and/or revision surgery. The total sample was composed of 77 patients (31 total hip replacements and 51 hip resurfacings) and functional outcomes scores were obtained for all patients.

RESULTS:

At average 5.46-year follow-up, 55 patients (60 hips 73%) still reported symptoms of LFCN neuropraxia but their Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were not inferior to those who had resolution for pain, function and stiffness: p values of 0.716, 0.171, and 0.238, respectively. The mean score on visual analogue scale decreased from 2.32 (SD 2.11) to 1.76 (SD 1.99). 1 patient (1.2%) reported his activities were limited by his symptoms.

CONCLUSION:

Although the majority of patients still report symptoms related to LFCN neuropraxia, symptoms do improve over time and there are no functional limitations. Even if LFCN neuropraxia following DAA does not lead to functional limitations, all patients should be made aware in order to alleviate any long-term functional concerns.

Prospective evaluation of lateral femoral cutaneous nerve injuries during periacetabular osteotomy

Periacetabular osteotomies (PAOs) are used to treat acetabular dysplasia in younger patients, but are not without morbidity. Lateral femoral cutaneous nerve (LFCN) injuries are commonly associated with the approach for PAOs, but the true incidence and rate of resolution is not known. The purpose of this prospective study was to determine the incidence of LFCN injuries after PAO using an innovative nerve conduction study (NCS) and to report the patient-reported outcomes. We prospectively enrolled 23 patients (24 hips) undergoing PAOs to have pre- and post-operative NCSs at a mean of 12 weeks post-operative. Patients were followed prospectively. Patients were contacted 3 years post-operatively via phone to determine the presence and severity of symptoms. Patient-reported outcome scores were also correlated with patient symptoms. Patients (91%) reported one or more LFCN symptoms post-operatively. The most common symptoms were numbness (91%), tingling (36%), pain (18%) and burning (9%). Patients (67%) had evidence of LFCN injury based on NCSs. Symptoms (40%) resolved 4 months post-operatively. Two-thirds of patients had continued symptoms at 3 years. Only 1 patient required treatment. The incidence of LFCN injury after PAO is 90%, two-thirds of which can be identified objectively by NCS. Numbness is the most common symptom. LFCN symptoms (40%) resolve by 4 months, but two-thirds of patients may continue to have thigh numbness up to 3 years after surgery. Fortunately, symptoms are not clearly associated with outcome score and treatment for this complication is rare.

Cutaneous anaesthesia of hip surgery incisions with iliohypogastric and subcostal nerve blockade: A randomised trial

BACKGROUND

Cutaneous nerve blockade may improve analgesia after hip surgery. Anaesthesia after the lateral femoral cutaneous (LFC) nerve block is too distal for complete coverage of most hip surgery incisions, which requires additional anaesthesia of the adjacent, proximal area. The transversalis fascia plane (TFP) block potentially anaesthetises the iliohypogastric and subcostal nerves. The primary aim of the present study was to investigate, if the TFP block provides cutaneous anaesthesia adjacent to the LFC nerve block.

METHODS

Active vs placebo TFP blocks were compared in a paired randomised controlled trial (RCT) in 20 volunteers, who all had bilateral LFC nerve blocks. The day preceding the RCT, the area anaesthetised by a novel selective ultrasound guided subcostal nerve block was identified bilaterally in order to assess the contribution of the subcostal nerve to the area anaesthesia by the TFP block.

RESULTS

Anaesthesia of the lateral hip region after TFP block was 80%. The cutaneous anaesthesia after active TFP block was in continuity with the LFC nerve block in 65%. Combined TFP and LFC nerve blockade significantly increased the coverage of hip surgery incisions compared to LFC nerve block alone. The success rate of blocking the subcostal nerve was 50% with the TFP block.

CONCLUSION

The TFP block anaesthetises the skin proximal to the LFC nerve block by anaesthetising the iliohypogastric and subcostal nerves. TFP block as a supplement to LFC nerve block improves the coverage of the proximal surgical incisions used for hip surgery.

Ultrasound Intervention of the Lower Extremity/Pelvis

Musculoskeletal (MSK) conditions are growing in prevalence. Ultrasound (US) is increasingly used for managing MSK conditions due to its low cost and ability to provide real-time image guidance during therapeutic interventions. As MSK US becomes more widespread, familiarity and comfort with US-guided interventions will become increasingly important. This article focuses on general concepts regarding therapeutic US-guided injections of corticosteroids and platelet-rich plasma and highlights several of the US-guided procedures commonly performed, involving the pelvis and lower extremity.

Preoperative ultrasound to identify distribution of the lateral femoral cutaneous nerve in total hip arthroplasty using the direct anterior approach

Introduction: Recently, the branching pattern of the lateral femoral cutaneous nerve (LFCN) named Fan type has been reported that LFCN injury cannot be avoided in surgical dissections that use the direct anterior approach to the hip joint in the cadaveric study. We hypothesized that the Fan type can be identified by ultrasound The aim of this study was to investigate whether LFCN injury occurs in DAA-THA in cases identified as the Fan type based on preoperative ultrasound of the proximal femur.

Methods: Ultrasonography of the proximal femur on the surgical side was performed before surgery and the LFCN distribution was judged as the Fan type or Non-Fan type. A self-reported questionnaire was sent to the patients at two months after surgery, and the presence or absence of LFCN injury was prospectively surveyed.

Results: After application of exclusion criteria, 45 hips were included. LFCN injury was observed after surgery in 9 of the 10 patients judged as the Fan type based on the ultrasound of the proximal femur (positive predictive value: 90%), and no LFCN disorder was actually observed in 25 of the 26 patients judged as Non-Fan type (specificity: 96.2%).

Conclusions: To prevent injury of the LFCN in patients judged as the Fan type on the ultrasound test before surgery, the risk of direct injury of the LFCN may be reduced through the approach in which an incision is made in the fascia which is opposite to the radial spreading, i.e., between the sartorius and tensor fasciae latae muscles or slightly medial from it.

Clinical Outcomes of Patients With Lateral Femoral Cutaneous Nerve Injury After Direct Anterior Total Hip Arthroplasty

BACKGROUND

Direct anterior total hip arthroplasty (THA) is an increasingly utilized and patient-requested approach for arthroplasty carrying a unique set of complications. Injury to the lateral femoral cutaneous nerve (LFCN) can have a wide range of clinical symptoms ranging from hypesthesia to painful paresthesia. Long-term effects of this injury have not been well studied. We describe duration and severity of these symptoms and correlate their relationship with hip functional scores.

METHODS

Between January 2009 and January 2016, 1665 patients with 1871 hips who underwent direct anterior THA by a single surgeon were surveyed for reported outcomes including Douleur Neuropathique 4-Interview (DN4-I), Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR), and Patient-Reported Outcomes Measurement Information System Short Form Global Health Assessment. The DN4-I was considered positive if 3 (or more) of 7 neuropathic pain symptoms were affirmed at present in the distribution of the LFCN of the affected leg.

RESULTS

Six hundred eighty patients accounting for 778 hips completed the survey. Overall, 16% of responders had positive DN4-I scores for continued neuropathic symptoms with a mean time since surgery of 3.9 years at assessment. Twenty-four percent of those responding within 2 years of surgery had positive scores compared with 15% from 2 to 4 years, 14% from 4 to 6 years, and 11% positive from 6 to 8 years after surgery. Of those with positive DN4-I scores, the most commonly affirmed neuropathic symptom was "numbness", reported in 37% of patients. The overall average interval HOOS, JR score was 89.8. There were no differences in HOOS, JR or Patient-Reported Outcomes Measurement Information System scores for patients further out from surgery.

CONCLUSION

The most commonly experienced neuropathic symptom in the distribution of the LFCN following direct anterior THA is "numbness" that occurred in 37% of patients with a positive DN4-I score. Neuropathic symptoms improved in patients further out from surgery with pain reported in 11% of patients from 6 to 8 years postoperatively. Neuropathic symptoms significantly improve with time and appear to be independent of hip function scores.

Direct anterior versus anterolateral approach in one-stage supine total hip arthroplasty. Focused on nerve injury: A prospective, randomized, controlled trial

BACKGROUND

The difference in clinical results between the direct anterior approach (DAA) and the anterolateral approach (ALA) for total hip arthroplasty (THA) is still unclear. The purpose of this study was to compare clinical results, including nerve injuries, between DAA and ALA in one-stage bilateral THA in a prospective, randomized controlled trial.

METHODS

Thirty patients were recruited for primary bilateral THAs from 2014 to 2016. The left and right hips of each patient were randomly assigned to DAA and the others to ALA. We prospectively compared the clinical results, incidence of lateral femoral cutaneous nerve (LFCN) injury, and tensor fascia lata (TFL) atrophy considered to be related to superior gluteal nerve injury between both approaches.

RESULTS

No significant difference was found in the clinical results between both sides at postoperative 1 year. Temporary symptom of LFCN injury was observed only in DAA sides (7/30, 23.3%). The ratio of 3-month postoperative to preoperative cross-sectional area of TFL on computed tomography was significantly lower on the side subjected to DAA (DAA side, 78.8 ± 22.8%) than on the side subjected to ALA (ALA side, 90.7 ± 17.7%) (p < 0.01). In magnetic resonance imaging at postoperative 1 year, the mean grade of fatty atrophy of TFL by Goutalier classification was significantly higher in DAA sides (2.00 ± 1.6) than in ALA sides (1.1 ± 1.3) (p = 0.03).

CONCLUSIONS

Excellent clinical results for both DAA and ALA were achieved. LFCN injury was found only in DAA sides. Although TFL atrophy was found in both approaches, it was found significantly more in DAA sides. Our study suggested that ALA should be used rather than DAA in terms of the risk of nerve injuries.

Skin crease ‘bikini’ incision for the direct anterior approach in total hip arthroplasty

Aims

The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease ‘bikini’ when the DAA is used for total hip arthroplasty (THA).

Patients and Methods

A total of 964 patients (51% female; 59% longitudinal, 41% ‘bikini’) completed a follow-up questionnaire between two and four years postoperatively, including the Oxford Hip Score (OHS), the University of North Carolina ‘4P’ scar scale (UNC4P) and two items for assessing the aesthetic appearance of the scar and symptoms of numbness. The positioning of the components, rates of heterotopic ossification (HO) and rates of revision were assessed.

Results

The mean OHS was similar in both groups (p = 0.41). The mean UNC4P total score was slightly better (p = 0.01) and the proportion of patients who were very satisfied with the cosmetic aspects of the scar was higher in the ‘bikini’ group (p < 0.001). The proportion of patients reporting numbness in the scar was higher in the longitudinal group (14.5% vs 7.5%, respectively, p < 0.001). The abduction angle of the acetabular component, the position of the stem and rates of HO did not differ between the groups. There were no differences in the revision rates of both groups, being 2.3% in the longitudinal and 1.5% in the ‘bikini’ group (p = 0.911).

Conclusion

We found that a short oblique ‘bikini’ skin crease incision is safe when used for the DAA at THA, without compromising the positioning of the components or increasing the rate of lateral femoral cutaneous nerve dysaesthesia. Although it leads to a superior scar satisfaction, as it is less extensile, it should be used after having gained experience with the classic longitudinal incision. Cite this article: Bone Joint J 2018;100-B:853–61.

What Is the Risk Posed to the Lateral Femoral Cutaneous Nerve During the Use of the Anterior Portal of Supine Hip Arthroscopy and the Minimally Invasive Anterior Approach for Total Hip Arthroplasty?

PURPOSE

To determine: (1) What is the proximity of the lateral femoral cutaneous nerve (LFCN) to the anterior portal (AP) used in supine hip arthroscopy? (2) What is the proximity of the LCFN to the incision in the minimally invasive anterior approach (MIAA) for total hip arthroplasty? (3) What effect does lateralizing the AP have on the likelihood of nerve injury? (4) What branching patterns are observable in the LFCN?

METHODS

Forty-five hemipelves were dissected. The LFCN was identified and its path dissected. The positions of the nerve in relation to the AP and the MIAA incision were measured.

RESULTS

The AP intersected with 38% of nerves. In the remainder, the LFCN was located 5.7 ± 4.5 mm from the portal's edge. In addition, 44% of nerves crossed the incision of the MIAA. Of those that did not, the average minimum distance from the incision was 14.4 ± 7.0 mm. We found a significant reduction in risk if the AP is moved medially by 5 mm or laterally by 15 mm (P = .0054 and P = .0002). The LFCN showed considerable variation with 4 branching variants.

CONCLUSIONS

These results show that the LFCN is at high risk during supine hip arthroscopy and the MIAA, emphasizing the need for meticulous dissection. We suggest that relocation of the AP 5 mm medially or 15 mm laterally will reduce the risk to the LFCN.

CLINICAL RELEVANCE

These findings should aid surgeons in minimizing the risk to the LCFN during hip arthroscopy and the minimally invasive anterior approach to the hip.

Nerve injuries associated with total hip arthroplasty

Nerve injury is a relatively rare, yet potentially devastating complication of total hip arthroplasty (THA). Incidence of this ranges from 0.6 to 3.7%, and is highest in patients with developmental hip dysplasia and previous hip surgery. Apart from patient and surgeon dissatisfaction, this complication can have medico-legal consequences. Therefore, the purpose of this study was to review the risk factors, etiology, diagnostic options, management strategies, prognosis, and prevention measures of nerve injuries associated with THA. We specifically evaluated the: 1) sciatic nerve; 2) femoral nerve; 3) obturator nerve; 4) superior gluteal nerve; and 5) the lateral femoral cutaneous nerve.

A retrospective study of SPECT/CT scans using SUV measurement of the normal pelvis with Tc-99m methylene diphosphonate

OBJECTIVE

To perform quantitative measurement based on the standardized uptake value (SUV) of Tc-99m methylene diphosphonate (MDP) in the normal pelvis using a single-photon emission tomography (SPECT)/computed tomography (CT) scanner.

MATERIAL AND METHODS

This retrospective study was performed on 31 patients with cancer undergoing bone SPECT/CT scans with 99mTc-MDP. SUVmax and SUVmean of the normal pelvis were calculated based on the body weight. SUVmax and SUVmean of the bilateral anterior superior iliac spine, posterior superior iliac spine, facies auricularis ossis ilii, ischial tuberosity, and sacrum were also calculated. Furthermore, the correlation of SUVmax and SUVmean of all parts of pelvis with weight, height, and CT was assessed.

RESULTS

The data for 31 patients (20 women and 11 men; mean age 58.97±9.12 years; age range 37-87 years) were collected. SUVmax and SUVmean changed from 1.65±0.40 to 3.8±1.0 and from 1.15±0.25 to 2.07±0.58, respectively. The coefficient of variation of SUVmax and SUVmean ranged from 0.22 to 0.31. SUVmax and SUVmean had no statistically significant difference between men and women. SUVmax and SUVmean also showed no significant correlation with weight and height. However, part of SUVmax and SUVmean showed a significant correlation with CT. In addition, SUVmax and SUVmean of the bilateral ischial tuberosity showed a significant correlation with CT values.

CONCLUSIONS

Determination of the SUV value of the normal pelvis with 99m Tc-MDP SPECT/CT is feasible and highly reproducible. SUVs of the normal pelvis showed a relatively large variability. As a quantitative imaging biomarker, SUVs might require standardization with adequate reference data for the participant to minimize variability.

[Mid-term effectiveness of total hip arthroplasty by direct anterior approach]

Objective

To retrospectively compare the mid-term effectiveness between by direct anterior approach (DAA) and by posterolateral approach in total hip arthroplasty (THA).

Methods

Between January 2009 and December 2010, 110 patients (110 hips) treated with THA and followed up more than 5 years were chosen in the study. THA was performed on 55 patients by DAA (DAA group), and on 55 patients by posterolateral approach (PL group). There was no significant difference in gender, age, body mass index, types of hip joint disease, and preoperative Harris score between 2 groups ( P>0.05). The operation time, amount of bleeding, length of hospital stay, postoperative complications, and the Harris scores were recorded and compared.

Results

There was no significant difference in operation time and length of hospital stay between 2 groups ( t=0.145， P=0.876; t=1.305, P=0.093). The amount of bleeding was significantly less in DAA group than in PL group ( t=2.314, P=0.032). All patients were followed up 5-7 years (mean, 5.97 years). Complications happened in 5 cases (9.1%) of DAA group and in 3 cases (5.5%) of PL group, and there was no significant difference in the incidence of complications between 2 groups ( χ²=0.539， P=0.463). There was significant difference in Harris scores at 6 months after operation between 2 groups ( t=2.296, P=0.014), but no significant difference was found in Harris score at 1 year and 5 years between 2 groups ( t=1.375, P=0.130; t=0.905, P=0.087). Further analysis, at 6 months after operation, the joint function score in DAA group was significantly higher than that in PL group ( t=1.087, P=0.034), while there was no significant difference in the pain score and range of motion score between 2 groups ( t=1.872, P=0.760; t=1.059, P=0.091).

Conclusion

THA by DAA has the advantages of less bleeding and faster recovery. The short-term effectiveness is superior to the THA by traditional posterolateral approach, but there is no obvious advantage in the mid-term effectiveness.

Bikini versus traditional incision direct anterior approach: is there any difference in soft tissue damage?

INTRODUCTION

The direct anterior approach for total hip replacements has reported advantages of improved early function and muscle preservation. In an effort to improve healing and cosmesis, a change in the orientation of the incision has been proposed. Traditionally, the skin incision is in-line with the tensor fasciae latae muscle belly. The bikini incision is orthogonal to this orientation. The hypothesis was that muscle damage would be increased by using the bikini incision.

METHODS

A traditional or bikini incision was performed on 18 cadaveric hips. On each of the 9 specimens, the traditional incision was performed on 1 side, and a bikini incision on the contralateral hip, with an even distribution of right or left side. Blinded anatomists performed the hip dissections, and assessed for muscle damage as well as for damage to the lateral femoral cutaneous nerve.

RESULTS

No difference in muscle damage was identified in the tensor fasciae latae between muscle groups. Muscle damage was very minimal to the gluteus medius and minimus. Damage to the lateral femoral cutaneous nerve occurred equally for both the bikini and traditional skin incisions.

CONCLUSIONS

The bikini incision for the direct anterior approach to the hip can be performed safely, with no increase in muscle damage or damage to the lateral femoral cutaneous nerve compared to the traditional incision.

Applied Anatomy of the Direct Anterior Approach for Femoral Mobilization

INTRODUCTION

Study of the anterior anatomy of the hip reveals specific aspects that are crucial to success in performing both the surgical approach to the hip and mobilization of the femur. In this article, we present the relevant anatomy and our operative technique.

INDICATIONS & CONTRAINDICATIONS

STEP 1 THE ANTERIOR ANATOMY OF THE HIP VIDEO 1

Review the anatomy of the hip as it relates to the surgical technique as doing so is essential to understanding the surgical technique6.

STEP 2 APPROACH TO THE ANTERIOR ASPECT OF THE HIP VIDEO 2

Review the surgical approach to the hip.

STEP 3 RELEASE OF THE CAPSULE VIDEO 3

In the first step of femoral mobilization, release the superior-posterior capsule.

STEP 4 RELEASE OF THE CONJOINED TENDON AND PIRIFORMIS FLIP VIDEO 4

If sufficient elevation of the femur is not achieved with release of the capsule, perform rotator visualization and serial release.

RESULTS

Our prospective, nonrandomized study compared DAA THA using our technique for femoral mobilization with the posterior approach THA12.

PITFALLS & CHALLENGES

Differentiating Radiculopathy from Lower Extremity Arthropathy

Low back and lower extremity pain are among the most common complaints encountered by physicians. Distinguishing pain due to primary extremity pathology versus lumbar radiculopathy can be challenging. Careful physical examination and appropriate imaging with plain radiographs and advanced studies as needed are important in determining the cause of lower extremity complaints. Over-utilization of advanced imaging may reveal otherwise asymptomatic spinal pathology and can lead to an incorrect diagnosis. In patients in whom surgical intervention is being considered by a spine or arthroplasty surgeon, intra-articular or epidural steroid injections may help to reveal the underlying cause of pain via short-term symptomatic relief. Additionally, patients presenting with vague lower extremity pain after recent or distant joint arthroplasty should be considered for potential failure or infection of their implant before assuming the symptoms are coming from the lumbar spine.