Nerve Injuries with the Direct Anterior Approach to Total Hip Arthroplasty

Vajapey, Sravya P.; Morris, Jesse H.; Lynch, Daniel; Spitzer, Andrew I.; Li, Mengnai; Glassman, Andrew H.

doi:10.2106/jbjs.rvw.19.00109

Cited by 28 publications

(36 citation statements)

References 59 publications

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“…However, a patient's anxiety is due to lateral femoral cutaneous nerve (LFCN) injury that results in hypesthesia, dysesthesia or pain in the anterolateral aspect of the thigh [10][11][12]. This is the main complaint of the patients after DAA and causes a low satisfaction rate despite the high score of the hip function.…”

Section: Introductionmentioning

confidence: 99%

“…Compared to other approaches, such as direct lateral, anterolateral and posterior approach, patients after DAA THA had improved early ambulation capacity, fewer reoperations, enhanced functional recovery and a low dislocation rate [5][6][7][8][9]. However, a patient's anxiety is due to lateral femoral cutaneous nerve (LFCN) injury that results in hypesthesia, dysesthesia or pain in the anterolateral aspect of the thigh [10][11][12]. This is the main complaint of the patients after DAA and causes a low satisfaction rate despite the high score of the hip function.…”

Section: Introductionmentioning

confidence: 99%

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Preoperative Ultrasound to Map the Three-Dimensional Anatomical Distribution of the Lateral Femoral Cutaneous Nerve in Direct Anterior Approach for Total Hip Arthroplasty

Yao

Wang

Zhuang

et al. 2021

Preprint

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Background：The postoperative complaints of hypoaesthesia or a burning sensation due to lateral femoral cutaneous nerve (LFCN) injury in patients is not yet solved. The present study aimed to identify the three-dimensional (3D) distribution of LFCN using preoperative ultrasound and evaluate the rate of injury in direct anterior approach for total hip arthroplasty. Methods： A total of 59 patients were allocated to the ultrasound group and 58 patients were in the control group. Surgeons received the data of 3D distribution of LFCN only in the ultrasound group before surgery with respect to the direction, the depth on the skin, and the length to tensor fasciae latae (TFL). The anatomical characteristics of LFCN in the surgical region were summarized. At 1 and 3 months post-surgery, the rate of LFCN injury and abnormal sensitive area were evaluated in both groups. Results： Based on the data from the ultrasound group, over 90% of patients had one or two branches of LFCN. LFCN always courses in the fascia layer, the depth ranged from 6.8±2.6 (3.0 ~12.0) mm to 11.1±3.4 (4.0 ~17.0) mm and depended on the thickness of the subcutaneous fat, and length was 3.3±4.6 (-5.0 ~10.0) mm at proximal part and -2.7±4.7 (-10.0 ~8.0) at distal end to the medial edge of TFL. Both the rate of LFCN injury and abnormal sensory area in the ultrasound group were significantly lower than those in the control group (3.4% VS 25.9%, P=0.001, χ21=11.893, at 1 month; 3.4% VS 22.4%, P=0.005, χ21=9.471, at 3 months).Conclusions： LFCN mostly courses along the medial border of TFL in the fascia layer. The 3D distribution of LFCN could help the surgeons to evaluate the risk of injury preoperatively and decrease the rate of injury during the operation. However, some branch injuries, especially for the fan type LFCN, could not be avoided.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Preoperative Ultrasound to Map the Three-Dimensional Anatomical Distribution of the Lateral Femoral Cutaneous Nerve in Direct Anterior Approach for Total Hip Arthroplasty

Yao

Wang

Zhuang

et al. 2021

Preprint

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“…There are several surgical approaches for THA; in particular, an intermuscular and internervous approach known as direct anterior approach (DAA) causes less harm to the soft tissue compared with other approaches. Thus, DAA is associated with a lower risk of dislocation and rapid recovery of muscular strength after the procedure (3)(4)(5)(6)). However, it can result in injury to the lateral femoral cutaneous nerve (LFCN) (5,(7)(8)(9)(10).…”

Section: Introductionmentioning

confidence: 99%

“…Thus, DAA is associated with a lower risk of dislocation and rapid recovery of muscular strength after the procedure (3)(4)(5)(6)). However, it can result in injury to the lateral femoral cutaneous nerve (LFCN) (5,(7)(8)(9)(10). LFCN is a pure sensory nerve that controls the anterolateral aspect of the thighs, and LFCN injury leads to hypesthesia and dysesthesia.…”

Section: Introductionmentioning

confidence: 99%

Lateral versus conventional fasciotomy for prevention of lateral femoral cutaneous nerve injury in total hip arthroplasty with direct anterior approach: a study protocol for dual-center, single-blind, randomized controlled trial

Tanabe¹,

Baba²,

Ozaki³

et al. 2021

Preprint

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Background; An incision for total hip arthroplasty (THA) via the direct anterior approach (DAA) is generally made outside of the space between sartorius and tensor fasciae lataea muscles to prevent lateral femoral cutaneous nerve (LFCN) injury. Recent anatomical studies have revealed that the LFCN not only courses between the sartorius and tensor fasciae latae muscles, but it also branches radially while distributing in the transverse direction from the sartorius muscle to the tensor fasciae latae muscle. The latter is called the fan type, and studies suggest that damage to the fan type LFCN is unavoidable by conventional fasciotomy. We previously demonstrated that injury to non-fan type LFCN occurred in 28.6% of patients who underwent THA by fasciotomy performed 2 cm away from the intermuscular space. This suggests that the conventional approach also poses a risk of LFCN injury for non-fan type LFCN. LFCN injury is rarely reported in the anterolateral approach (ALA), which involves incision of fascia further away than DAA. The purpose of this study is to investigate how the position of fasciotomy in DAA affects the risk of LFCN injury. Methods; This is a prospective, randomized, controlled study. All patients are divided into the fan type and non-fan type using ultrasonography before surgery. Patients with the non-fan type LFCN will be performed by the conventional fasciotomy and the lateral fasciotomy in the order specified in the allocation table created in advance by our clinical trial center. The primary endpoint is the presence of LFCN injury. The secondary endpoints will be assessed based on patient-reported outcomes (PROs) at 3 months after surgery in an outpatient setting using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), and the Forgotten-Joint Score-12 (FJS-12). Discussion; We hypothesize that the incidence of LFCN injury due to DAA-THA can be reduced by making the incision further away from where it is typically made in conventional fasciotomy. If our hypothesis is confirmed, it will reduce the disadvantages of DAA, improve patient satisfaction. Trial registration; UMIN Clinical Trials Registry, UMIN000035945.Registered on 20 Feburary 2019.

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“…As the DAA enables preservation of the soft tissue, the hip joint function can be restored rapidly after THA and a low dislocation rate is achieved. Accordingly, a good postoperative outcome can be expected (3)(4)(5). On the other hand, lateral femoral cutaneous nerve (LFCN) injury is one of the complications speci c to the DAA (6)(7)(8)(9).…”

Section: Introductionmentioning

confidence: 99%

Medial Versus Conventional Approach for Prevention of Lateral Cutaneous Nerve Injury in Total hip Arthroplasty with Direct Anterior Approach: A Study for Dual-center, Single-blind, Randomized Controlled Trial

Tanabe¹,

Baba²,

Ozaki³

et al. 2020

Preprint

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Background; Lateral cutaneous nerve (LFCN) injury is one of the complication specific to total hip arthroplasty via the direct anterior approach. Recent anatomical studies have revealed that the LFCN not only courses between the sartorius and tensor fasciae latae muscles, but it also branches radially while distributing in the transverse direction from the sartorius muscle to the tensor fasciae latae muscle. The latter is called the fan type, in which injury of the LFCN is almost unavoidable using the conventional site for incision of the fascia. In order to reduce LFCN injury in the fan type, we devised a new approach of incising the fascia at a side 2 cm medial from the conventional site of incision. The purpose of this study is to examine how the site of incision of the fascia influences LFCN injury.Methods; This is a prospective, randomized, controlled study. All patients are divided into the fan type and non-fan type using ultrasonography before surgery. Patients with the fan type LFCN will be performed by the conventional approach and the medial approach in the order specified in the allocation table created in advance by our clinical trial center. The conventional approach involves incision of the skin, followed by incision of the fascia just below the site of skin incision. The medial approach proceeds medially from the site of skin incision, and involves incision of the fascia at a site 2 cm medial from the conventional site of incision. The primary endpoint is the presence of LFCN injury. The secondary endpoints will be assessed based on PROs at 3 months after surgery in an outpatient setting using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), and the Forgotten-Joint Score-12 (FJS-12).Discussion; We hypothesize that the fan type LFCN can be protected from injury by incising the fascia at a more medial site than conventional site. If the usefulness of this surgical procedure is confirmed, the disadvantages of the DAA will be eliminated, potentially being highly beneficial to patients.Trial registration; UMIN Clinical Trials Registry, UMIN000035944.Registered on 20 Feburary 2019.

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Nerve Injuries with the Direct Anterior Approach to Total Hip Arthroplasty

Cited by 28 publications

References 59 publications

Preoperative Ultrasound to Map the Three-Dimensional Anatomical Distribution of the Lateral Femoral Cutaneous Nerve in Direct Anterior Approach for Total Hip Arthroplasty

Preoperative Ultrasound to Map the Three-Dimensional Anatomical Distribution of the Lateral Femoral Cutaneous Nerve in Direct Anterior Approach for Total Hip Arthroplasty

Lateral versus conventional fasciotomy for prevention of lateral femoral cutaneous nerve injury in total hip arthroplasty with direct anterior approach: a study protocol for dual-center, single-blind, randomized controlled trial

Medial Versus Conventional Approach for Prevention of Lateral Cutaneous Nerve Injury in Total hip Arthroplasty with Direct Anterior Approach: A Study for Dual-center, Single-blind, Randomized Controlled Trial

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Nerve Injuries with the Direct Anterior Approach to Total Hip Arthroplasty

Cited by 28 publications

References 59 publications

Preoperative Ultrasound to Map the Three-Dimensional Anatomical Distribution of the Lateral Femoral Cutaneous Nerve in Direct Anterior Approach for Total Hip Arthroplasty

Preoperative Ultrasound to Map the Three-Dimensional Anatomical Distribution of the Lateral Femoral Cutaneous Nerve in Direct Anterior Approach for Total Hip Arthroplasty

Lateral versus conventional fasciotomy&nbsp;for prevention of&nbsp;lateral femoral cutaneous nerve injury&nbsp;in total hip arthroplasty with direct anterior approach: a study protocol for dual-center, single-blind, randomized controlled trial

Medial Versus Conventional Approach for Prevention of Lateral Cutaneous Nerve Injury in Total hip Arthroplasty with Direct Anterior Approach: A Study for Dual-center, Single-blind, Randomized Controlled Trial

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Lateral versus conventional fasciotomy for prevention of lateral femoral cutaneous nerve injury in total hip arthroplasty with direct anterior approach: a study protocol for dual-center, single-blind, randomized controlled trial