Distal Extension of the Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures

Grob, Karl; Monahan, Rebecca; Gilbey, Helen; Yap, Francis H.X.; Filgueira, Luis; Kuster, Markus S.

doi:10.2106/jbjs.n.00551

Cited by 70 publications

(30 citation statements)

References 15 publications

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“…The upper aspect of this approach provides visualization of the entire ilium and hip joint. The distal extension is limited by multiple nerve branches that supply anterolateral parts of the quadriceps muscle group 36 . The initial technique involved partial removal of the tensor fasciae latae from the anterolateral aspect of the iliac crest and the release of the reflected head of the rectus femoris.…”

Section: Fan-typementioning

confidence: 99%

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

Rudin

Manestar

Ullrich

et al. 2016

The Journal of Bone and Joint Surgery

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111

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BACKGROUND: Injury to the lateral femoral cutaneous nerve (LFCN) is a risk during the operative anterior approach to the hip joint. Although several anatomical studies have described the proximal course of the nerve in relation to the anterior superior iliac spine (ASIS) and the inguinal ligament, the distal course of the LFCN in the proximal aspect of the thigh has not been sufficiently studied. The aim of this cadaveric study was to examine the branching pattern of the nerve, with special consideration to the anterior approach to the hip joint. METHODS: Twenty-eight cadaveric hemipelves from 18 donors (10 paired and 8 unpaired specimens) were dissected. The LFCN branches were localized proximal to the inguinal ligament and traced distally into the area of the proximal aspect of the thigh. Distribution patterns of the nerve with respect to its relationship to the ASIS and the internervous plane of the anterior approach to the hip joint were recorded. RESULTS: We found 3 different branching patterns of the LFCN: sartorius-type (in 36% of the specimens), characterized by a dominant anterior nerve branch coursing along the lateral border of the sartorius muscle with no, or only a thin, posterior branch; posterior-type (in 32%), characterized by a strong posterior nerve branch; and fan-type (in 32%), characterized by multiple spreading nerve branches of equal thickness. In 50% of the specimens, the LFCN divided into 2 branches superior to the inguinal ligament. Sixty-two percent of the LFCN branches entered the proximal aspect of the thigh medial to the ASIS; 27%, above; and 11%, lateral to the ASIS. The LFCN consistently coursed within the deep layer of the subcutaneous fat tissue. CONCLUSIONS: Injury to branches of the LFCN cannot be avoided in approximately one-third of surgical dissections that use the anterior approach to the hip joint. To protect the anterior branch of the LFCN, the skin incision should be as lateral as possible. The posterior branch of the LFCN is most vulnerable in the proximal aspect of the anterior approach to the hip joint, where it can be expected to course within the deep layer of the subcutaneous tissue. Background: Injury to the lateral femoral cutaneous nerve (LFCN) is a risk during the operative anterior approach to the

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Section: Fan-typementioning

confidence: 99%

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

Rudin

Manestar

Ullrich

et al. 2016

The Journal of Bone and Joint Surgery

Self Cite

111

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“…It is supplied by several muscle branches of the femoral nerve, which in turn can be divided into two parts (Patil et al, ; Becker et al, ). According to recently published anatomical observations, the proximal‐ventral aspects of the bellies of the VL and VI are supplied by numerous muscle branches of the femoral nerve (F), and by branches of the lateral circumflex femoral artery and vein (LCFA and LCFV) (Grob et al, ). This creates the impression that the TVI belongs to the VL.…”

Section: Introductionmentioning

confidence: 99%

A newly discovered muscle: The tensor of the vastus intermedius

et al. 2016

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The quadriceps femoris is traditionally described as a muscle group composed of the rectus femoris and the three vasti. However, clinical experience and investigations of anatomical specimens are not consistent with the textbook description. We have found a second tensor-like muscle between the vastus lateralis (VL) and the vastus intermedius (VI), hereafter named the tensor VI (TVI). The aim of this study was to clarify whether this intervening muscle was a variation of the VL or the VI, or a separate head of the extensor apparatus. Twenty-six cadaveric lower limbs were investigated. The architecture of the quadriceps femoris was examined with special attention to innervation and vascularization patterns. All muscle components were traced from origin to insertion and their affiliations were determined. A TVI was found in all dissections. It was supplied by independent muscular and vascular branches of the femoral nerve and lateral circumflex femoral artery. Further distally, the TVI combined with an aponeurosis merging separately into the quadriceps tendon and inserting on the medial aspect of the patella. Four morphological types of TVI were distinguished: Independent-type (11/26), VI-type (6/26), VL-type (5/26), and Common-type (4/26). This study demonstrated that the quadriceps femoris is architecturally different from previous descriptions: there is an additional muscle belly between the VI and VL, which cannot be clearly assigned to the former or the latter. Distal exposure shows that this muscle belly becomes its own aponeurosis, which continues distally as part of the quadriceps tendon.

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“…En las muestras analizadas, en ocasiones, los ramos primarios inervaron tanto al mVlat como mVint, en otras, tanto al mVm como al mVint. Esta inervación compartida se corresponde con lo observado por D' Arpa et al (2016) y Grob et al (2015a), quienes describieron la inervación del mVint a partir de la división medial del ramo dirigido al mVlat y también a partir de la división lateral del ramo dirigido hacia el mVm.…”

Section: Discussionunclassified

“…En su recorrido, distal al ligamento inguinal, emite 4 ramos destinados a cada una de las porciones del músculo cuádriceps femoral (mCF), los cuales nacen de forma aislada o bien, a partir de troncos comunes (Testut & Latarjet, 1972;Rouvière & Delmas, 2005). La comprensión detallada de la distribución del NF en el mCF, permite al cirujano disminuir los riesgos, asociados a diferentes intervenciones quirúrgicas llevadas a cabo en la zona anterior del muslo (Grob et al, 2015a;Ghijselings et al, 2017), así como también mejorar la eficacia de las inyecciones destinadas a disminuir la espasticidad en diferentes trastornos neurológicos que afecten la zona (Sung et al, 2003). Además es relevante a la hora de realizar inter-venciones que utilizan injertos nerviosos, para recuperar la función en pacientes con daño neurológico (Barbe et al, 2011;Goubier et al, 2012;Tung et al, 2012;Brown et al, 2013).…”

Section: Introductionunclassified

Ramos de Inervación y Distribución del Nervio Femoral en el Músculo Cuádriceps Femoral de Individuos Brasileños

2019

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de inervación y distribución del nervio femoral en el músculo cuádriceps femoral de individuos brasileños. Int. J. Morphol., 37(2):712-718, 2019. RESUMEN:El nervio femoral (NF) se describe originándose desde el plexo lumbar (L2, L3 y L4) y en su recorrido emite ramos destinados a cada una de las porciones del músculo cuádriceps femoral (mCF), los cuales nacen de forma aislada o bien, a partir de troncos comunes. El detalle de la distribución del NF en el mCF, permite disminuir riesgos asociados a diferentes intervenciones quirúrgicas llevadas a cabo en la zona anterior del muslo. Con el propósito describir la distribución del NF en los componentes del mCf. Se utilizaron 15 miembros inferiores formolizados, 10 del lado izquierdo y 5 del lado derecho, de individuos adultos, Brasileños, localizados en los Laboratorios de Anatomía de la Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, Brasil. El NF se clasificó en cuatro tipos de acuerdo a su ramificación y distribución. El Tipo II se subdividió en 3 subtipos y se presentó en 60 % de las muestras y el tipo III en 20 %. El NF se dividió de medial a lateral hasta en 5 ramos (R1,R2,R3,R4,R5), donde el R1 fue el más medial. El R1 dio origen en promedio a 2,47 ramos secundarios (Rs) y a 2,58 ramos terciarios (Rt), en 13,3 % el R1 no emitió Rs. En 73,3 % inervó a sólo a un componente del mCF; el R2 dio origen en promedio a 3,93 Rs y a 3,58 Rt. En 26,7 % inervó a sólo a un componente del mCF; el R3 dio origen en promedio a 3,33 Rs y a 2,0 Rt. En 80 % inervó a sólo a un componente del mCF. La distribución de R4 y R5 se muestran en el texto. Resultados biométricos de origen, diámetro y longitud de los ramos mencionados son mostrados en tablas. Los datos obtenidos en esta investigación complementan el conocimiento de la anatomía regional, pudiendo ser utilizados por la clínica quirúrgica y para efectuar tratamientos que mejoren trastornos neurológicos que afectan a la región.

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Distal Extension of the Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures

Abstract: Distal extension of the direct anterior approach to the hip beyond the intertrochanteric line may compromise neurovascular structures supplying the quadriceps muscle.

Cited by 70 publications

References 15 publications

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

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

A newly discovered muscle: The tensor of the vastus intermedius

Ramos de Inervación y Distribución del Nervio Femoral en el Músculo Cuádriceps Femoral de Individuos Brasileños

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