Header

UZH-Logo

Maintenance Infos

Distal extension of the direct anterior approach to the hip poses risk to neurovascular structures: an anatomical study


Grob, K; Monahan, R; Gilbey, H; Yap, F; Filgueira, L; Kuster, M (2015). Distal extension of the direct anterior approach to the hip poses risk to neurovascular structures: an anatomical study. Journal of Bone and Joint Surgery. American Volume, 97(2):126-132.

Abstract

Background: The anterior approach to the hip gained popularity for total hip arthroplasty in recent years. Distal extension of the anterior approach, sometimes needed intraoperatively, potentially endangers neurovascular structures to the quadriceps. The aim of this study was to determine the anatomical structures placed at risk by distal extension of the anterior approach to the hip.
Methods: Seventeen cadaveric hemipelves from twelve human specimens were dissected. The femoral nerve and its branches and the vessels arising from the lateral femoral circumflex artery were assessed in relation to the distal extension of the anterior approach. The damage caused by the introduction of a cerclage cable passer was also investigated.
Results: The area immediately distal to the intertrochanteric line is a common entry point for several nerve branches and is a useful distal landmark for surgeons to use to protect important neurovascular structures. The distal extension of the anterior approach compromises the nerve supply to the anterolateral portions of the quadriceps. Introduction of a cerclage cable passer through the anterior access also jeopardizes nerve branches to the vastus lateralis, lateral parts of the vastus intermedius, and branches of the lateral femoral circumflex artery.
Conclusions: Distal extension of the direct anterior approach to the hip is challenging to accomplish without neurovascular injury to anterolateral parts of the quadriceps muscle group. In addition, important neurovascular structures are endangered with the introduction of a cable passer through the anterior approach.
Clinical Relevance: Distal extension of the direct anterior approach to the hip beyond the intertrochanteric line may compromise neurovascular structures supplying the quadriceps muscle.
The direct anterior approach for total hip arthroplasty has recently gained popularity with good clinical results. However, there have been reports of intraoperative complications, such as femoral fracture, implant failure, and muscle trauma7-12, that may require an extension of the surgical approach. Kennon et al.1 reported that the direct anterior approach could be safely extended proximally and distally even in complex revisions without clinically relevant nerve injuries. Furthermore, a textbook on surgical exposures describes and recommends this option13.
While proximal extension with detachment of the tensor fascia femoris and gluteal muscles from the pelvis is part of the Smith-Petersen approach, distal extension could endanger neurovascular structures. The anatomical relationship of nerve branches and blood vessels to the quadriceps with respect to the anterior approach has not been documented, to our knowledge.
The purpose of this cadaver study was to demonstrate the neurovascular structures encountered during the direct anterior approach to the hip joint with special emphasis on potential distal extension or the placement of a cerclage cable passer around the proximal part of the femur.

Abstract

Background: The anterior approach to the hip gained popularity for total hip arthroplasty in recent years. Distal extension of the anterior approach, sometimes needed intraoperatively, potentially endangers neurovascular structures to the quadriceps. The aim of this study was to determine the anatomical structures placed at risk by distal extension of the anterior approach to the hip.
Methods: Seventeen cadaveric hemipelves from twelve human specimens were dissected. The femoral nerve and its branches and the vessels arising from the lateral femoral circumflex artery were assessed in relation to the distal extension of the anterior approach. The damage caused by the introduction of a cerclage cable passer was also investigated.
Results: The area immediately distal to the intertrochanteric line is a common entry point for several nerve branches and is a useful distal landmark for surgeons to use to protect important neurovascular structures. The distal extension of the anterior approach compromises the nerve supply to the anterolateral portions of the quadriceps. Introduction of a cerclage cable passer through the anterior access also jeopardizes nerve branches to the vastus lateralis, lateral parts of the vastus intermedius, and branches of the lateral femoral circumflex artery.
Conclusions: Distal extension of the direct anterior approach to the hip is challenging to accomplish without neurovascular injury to anterolateral parts of the quadriceps muscle group. In addition, important neurovascular structures are endangered with the introduction of a cable passer through the anterior approach.
Clinical Relevance: Distal extension of the direct anterior approach to the hip beyond the intertrochanteric line may compromise neurovascular structures supplying the quadriceps muscle.
The direct anterior approach for total hip arthroplasty has recently gained popularity with good clinical results. However, there have been reports of intraoperative complications, such as femoral fracture, implant failure, and muscle trauma7-12, that may require an extension of the surgical approach. Kennon et al.1 reported that the direct anterior approach could be safely extended proximally and distally even in complex revisions without clinically relevant nerve injuries. Furthermore, a textbook on surgical exposures describes and recommends this option13.
While proximal extension with detachment of the tensor fascia femoris and gluteal muscles from the pelvis is part of the Smith-Petersen approach, distal extension could endanger neurovascular structures. The anatomical relationship of nerve branches and blood vessels to the quadriceps with respect to the anterior approach has not been documented, to our knowledge.
The purpose of this cadaver study was to demonstrate the neurovascular structures encountered during the direct anterior approach to the hip joint with special emphasis on potential distal extension or the placement of a cerclage cable passer around the proximal part of the femur.

Statistics

Citations

15 citations in Web of Science®
18 citations in Scopus®
Google Scholar™

Altmetrics

Downloads

17 downloads since deposited on 15 Feb 2016
15 downloads since 12 months
Detailed statistics

Additional indexing

Item Type:Journal Article, refereed, original work
Communities & Collections:04 Faculty of Medicine > Institute of Anatomy
Dewey Decimal Classification:570 Life sciences; biology
610 Medicine & health
Language:English
Date:2015
Deposited On:15 Feb 2016 11:55
Last Modified:08 Dec 2017 18:09
Publisher:Boston, Journal of Bone and Joint Surgery
ISSN:0021-9355
Additional Information:Copyright: Journal of Bone & Joint Surgery
Publisher DOI:https://doi.org/10.2106/JBJS.N.00551

Download

Download PDF  'Distal extension of the direct anterior approach to the hip poses risk to neurovascular structures: an anatomical study'.
Preview
Content: Published Version
Filetype: PDF
Size: 1MB
View at publisher