Lateral Femoral Cutaneous Nerve Injury Using an Anterior-Based Muscle-Sparing Approach to the Hip: A Clinical and Cadaveric Analysis with Review of Literature

Abstract

The alternative anterior hip approach between the tensor fascia lata and gluteus medius (the modified Watson-Jones approach, Röttinger approach, anterior-based muscle-sparing [ABMS] approach, and ABLE approach) may decrease the risk of lateral femoral cutaneous nerve (LFCN) palsy. A retrospective case study, systematic literature review, and cadaveric study were performed to assess the risk for LFCN palsy with the ABMS compared with the direct anterior (DA) approach. Consecutive patients who underwent total hip arthroplasty (THA) using ABMS were identified and assessed for LFCN palsy. A systematic review of LFCN injury with ABMS and DA approaches was conducted. In four fresh cadavers (eight hips), ABMS and DA approaches were performed and the LFCN identified. The proximity of the LFCN to the fascial incision was measured and compared between ABMS and DA approaches. In 64 consecutive ABMS THA (mean age: 57.3 ± 13.5 years, 42% female, mean body mass index: 30.2 ± 5.3 kg/m²), two hips (3.2%) had an LFCN palsy. In combination with the systematic literature review, the risk of LFCN palsy was less with ABMS (0.3%, 7/2,609 hips) compared with DA (3.1%, 638/20,402 hips, p < 0.001). In eight cadaveric hip dissections, the LFCN was significantly further away from the ABMS fascial incision (mean: 67.6 ± 9.1 mm), compared with the fascial incision of the DA approach (mean: 18.5 ± 3.5 mm, p < 0.0001). The risk of LFCN palsy was found to be 10-fold greater with the DA approach compared with the ABMS approached in this combined retrospective case series and systematic literature review. The anatomic location of the ABMS fascial incision was significantly farther from the LFCN, contributing to the decreased risk of LFCN injury.

Keywords

anterior-based muscle-sparing - ABMS - modified Watson-Jones - lateral femoral cutaneous nerve - direct anterior approach

Publication History

Received: 15 August 2021

Accepted: 07 June 2022

Article published online:
08 September 2022

• References

• 1 Bertin KC, Röttinger H. Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach. Clin Orthop Relat Res 2004; (429) 248-255
• 2 Hansen BJ, Hallows RK, Kelley SS. The Rottinger approach for total hip arthroplasty: technique and review of the literature. Curr Rev Musculoskelet Med 2011; 4 (03) 132-138
• 3 Civinini R, Cozzi Lepri A, Carulli C, Matassi F, Villano M, Innocenti M. The anterior-based muscle-sparing approach to the hip: the “other” anterior approach to the hip. Int Orthop 2019; 43 (01) 47-53
• 4 Jergesen F, Abbott LC. A comprehensive exposure of the hip joint. J Bone Joint Surg Am 1955; 37-A [phone]
• 5 Jones R. Observations on fractures of the neck of the femur. BMJ 1931; 1 (3670): 781-785
• 6 Burwell HN, Scott D. A lateral intermuscular approach to the hip joint for replacement of the femoral head by a prosthesis. J Bone Joint Surg Br 1954; 36-B [phone]
• 7 Müller ME. Total hip prostheses. Clin Orthop Relat Res 1970; 72 (72) 46-68
• 8 McKee GK, Watson-Farrar J. Replacement of arthritic hips by the McKee-Farrar prosthesis. J Bone Joint Surg Br 1966; 48 (02) 245-259
• 9 Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005; 441 (441) 115-124
• 10 Goulding K, Beaulé PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res 2010; 468 (09) 2397-2404
• 11 Vajapey SP, Morris J, Lynch D, Spitzer A, Li M, Glassman AH. Nerve injuries with the direct anterior approach to total hip arthroplasty. JBJS Rev 2020; 8 (02) e0109
• 12 Delanois RE, Sultan AA, Albayar AA. et al. The Röttinger approach for total hip arthroplasty: technique, comparison to the direct lateral approach and review of literature. Ann Transl Med 2017; 5 (Suppl. 03) S31
• 13 Homma Y, Baba T, Sano K. et al. Lateral femoral cutaneous nerve injury with the direct anterior approach for total hip arthroplasty. Int Orthop 2016; 40 (08) 1587-1593
• 14 Patton RS, Runner RP, Lyons RJ, Bradbury TL. Clinical outcomes of patients with lateral femoral cutaneous nerve injury after direct anterior total hip arthroplasty. J Arthroplasty 2018; 33 (09) 2919-2926.e1
• 15 Ozaki Y, Homma Y, Baba T, Sano K, Desroches A, Kaneko K. Spontaneous healing of lateral femoral cutaneous nerve injury and improved quality of life after total hip arthroplasty via a direct anterior approach. J Orthop Surg (Hong Kong) 2017; 25 (01) 2309499016684750
• 16 Rudin D, Manestar M, Ullrich O, Erhardt J, Grob K. The anatomical course of the lateral femoral cutaneous nerve with special attention to the anterior approach to the hip joint. J Bone Joint Surg Am 2016; 98 (07) 561-567
• 17 Sugano M, Nakamura J, Hagiwara S. et al. Anatomical course of the lateral femoral cutaneous nerve with special reference to the direct anterior approach to total hip arthroplasty. Mod Rheumatol 2020; 30 (04) 752-757
• 18 Thaler M, Dammerer D, Hechenberger F, Hörmann R, Van Beeck A, Stofferin H. The anatomical course of the lateral femoral cutaneous nerve in relation to various skin incisions used for primary and revision total hip arthroplasty with the direct anterior approach. J Arthroplasty 2021; 36 (01) 368-373
• 19 Kagan RP, Greber EM, Richards SM, Erickson JA, Anderson MB, Peters CL. Advantages of an anterior-based muscle-sparing approach in transitioning from a posterior approach for total hip arthroplasty: minimizing the learning curve. J Arthroplasty 2019; 34 (12) 2962-2967
• 20 Chulsomlee K, Sa-Ngasoongsong P, Kulachote N. et al. Hip muscle power recovery after hip replacement using anterior-based muscle-sparing approach in elderly femoral neck fracture: a prospective study in 40 patients. Orthop Res Rev 2018; 10: 31-39
• 21 D'Arrigo C, Speranza A, Monaco E, Carcangiu A, Ferretti A. Learning curve in tissue sparing total hip replacement: comparison between different approaches. J Orthop Traumatol 2009; 10 (01) 47-54
• 22 Fleischman AN, Rothman RH, Parvizi J. Femoral nerve palsy following total hip arthroplasty: incidence and course of recovery. J Arthroplasty 2018; 33 (04) 1194-1199
• 23 Laffosse JM, Chiron P, Accadbled F, Molinier F, Tricoire JL, Puget J. Learning curve for a modified Watson-Jones minimally invasive approach in primary total hip replacement: analysis of complications and early results versus the standard-incision posterior approach. Acta Orthop Belg 2006; 72 (06) 693-701
• 24 Mandereau C, Brzakala V, Matsoukis J. Functional recovery, complications and CT positioning of total hip replacement performed through a Röttinger anterolateral mini-incision. Review of a continuous series of 103 cases. Orthop Traumatol Surg Res 2012; 98 (01) 8-16
• 25 Martin R, Clayson PE, Troussel S, Fraser BP, Docquier PL. Anterolateral minimally invasive total hip arthroplasty: a prospective randomized controlled study with a follow-up of 1 year. J Arthroplasty 2011; 26 (08) 1362-1372
• 26 Nakai T, Liu N, Fudo K, Mohri T, Kakiuchi M. Early complications of primary total hip arthroplasty in the supine position with a modified Watson-Jones anterolateral approach. J Orthop 2014; 11 (04) 166-169
• 27 Rottinger H. Minimally invasive anterolateral surgical approach for total hip arthroplasty: early clinical results. Hip Int 2006; 16 (Suppl. 04) 42-47
• 28 Alecci V, Valente M, Crucil M, Minerva M, Pellegrino CM, Sabbadini DD. Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthop Traumatol 2011; 12 (03) 123-129
• 29 Alexandrov T, Ahlmann ER, Menendez LR. Early clinical and radiographic results of minimally invasive anterior approach hip arthroplasty. Adv Orthop 2014; 2014: 954208
• 30 Bal BS, Vallurupalli S. Minimally invasive total hip arthroplasty with the anterior approach. Indian J Orthop 2008; 42 (03) 301-308
• 31 Barnett SL, Peters DJ, Hamilton WG, Ziran NM, Gorab RS, Matta JM. Is the anterior approach safe? early complication rate associated with 5090 consecutive primary total hip arthroplasty procedures performed using the anterior approach. J Arthroplasty 2016; 31 (10) 2291-2294
• 32 Barrett WP, Turner SE, Leopold JP. Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. J Arthroplasty 2013; 28 (09) 1634-1638
• 33 Berend KR, Lombardi Jr. AV, Seng BE, Adams JB. Enhanced early outcomes with the anterior supine intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg Am 2009; 91 (Suppl. 06) 107-120
• 34 Bergin PF, Doppelt JD, Kephart CJ. et al. Comparison of minimally invasive direct anterior versus posterior total hip arthroplasty based on inflammation and muscle damage markers. J Bone Joint Surg Am 2011; 93 (15) 1392-1398
• 35 Bhandari M, Matta JM, Dodgin D. et al; Anterior Total Hip Arthroplasty Collaborative Investigators. Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study. Orthop Clin North Am 2009; 40 (03) 329-342
• 36 Bhargava T, Goytia RN, Jones LC, Hungerford MW. Lateral femoral cutaneous nerve impairment after direct anterior approach for total hip arthroplasty. Orthopedics 2010; 33 (07) 472
• 37 Chen M, Luo Z, Ji X, Cheng P, Tang G, Shang X. Direct anterior approach for total hip arthroplasty in the lateral decubitus position: our experiences and early results. J Arthroplasty 2017; 32 (01) 131-138
• 38 Cheng TE, Wallis JA, Taylor NF. et al. A prospective randomized clinical trial in total hip arthroplasty-comparing early results between the direct anterior approach and the posterior approach. J Arthroplasty 2017; 32 (03) 883-890
• 39 De Geest T, Vansintjan P, De Loore G. Direct anterior total hip arthroplasty: complications and early outcome in a series of 300 cases. Acta Orthop Belg 2013; 79 (02) 166-173
• 40 Foissey C, Fauvernier M, Fary C, Servien E, Lustig S, Batailler C. Total hip arthroplasty performed by direct anterior approach - does experience influence the learning curve?. SICOT J 2020; 6: 15
• 41 Gebel P, Oszwald M, Ishaque B. et al. Process optimized minimally invasive total hip replacement. Orthop Rev (Pavia) 2012; 4 (01) e3
• 42 Hallert O, Li Y, Brismar H, Lindgren U. The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty. J Orthop Surg Res 2012; 7: 17
• 43 Hartford JM, Bellino MJ. The learning curve for the direct anterior approach for total hip arthroplasty: a single surgeon's first 500 cases. Hip Int 2017; 27 (05) 483-488
• 44 Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 2011; 469 (02) 503-507
• 45 Kreuzer S, Leffers K, Kumar S. Direct anterior approach for hip resurfacing: surgical technique and complications. Clin Orthop Relat Res 2011; 469 (06) 1574-1581
• 46 Langlois J, Delambre J, Klouche S, Faivre B, Hardy P. Direct anterior Hueter approach is a safe and effective approach to perform a bipolar hemiarthroplasty for femoral neck fracture: outcome in 82 patients. Acta Orthop 2015; 86 (03) 358-362
• 47 Leunig M, Faas M, von Knoch F, Naal FD. Skin crease ‘bikini’ incision for anterior approach total hip arthroplasty: surgical technique and preliminary results. Clin Orthop Relat Res 2013; 471 (07) 2245-2252
• 48 Luo ZL, Chen M, Shang XF. et al. Direct anterior approach versus posterolateral approach for total hip arthroplasty in the lateral decubitus position [in Chinese]. Zhonghua Yi Xue Za Zhi 2016; 96 (35) 2807-2812
• 49 Macheras GA, Christofilopoulos P, Lepetsos P, Leonidou AO, Anastasopoulos PP, Galanakos SP. Nerve injuries in total hip arthroplasty with a mini invasive anterior approach. Hip Int 2016; 26 (04) 338-343
• 50 Martin CT, Pugely AJ, Gao Y, Clark CR. A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. J Arthroplasty 2013; 28 (05) 849-854
• 51 Masonis J, Thompson C, Odum S. Safe and accurate: learning the direct anterior total hip arthroplasty. Orthopedics 2008; 31 (12, Suppl 2): 31
• 52 Mjaaland KE, Kivle K, Svenningsen S, Nordsletten L. Do postoperative results differ in a randomized trial between a direct anterior and a direct lateral approach in THA?. Clin Orthop Relat Res 2019; 477 (01) 145-155
• 53 Nakata K, Nishikawa M, Yamamoto K, Hirota S, Yoshikawa H. A clinical comparative study of the direct anterior with mini-posterior approach: two consecutive series. J Arthroplasty 2009; 24 (05) 698-704
• 54 Neyisci C, Erdem Y, Bilekli AB, Bek D. Direct anterior approach versus posterolateral approach for hemiarthroplasty in the treatment of displaced femoral neck fractures in geriatric patients. Med Sci Monit 2020; 26: e919993
• 55 Nöth U, Nedopil A, Holzapfel BM. et al. Minimally invasive anterior approach [in German]. Orthopade 2012; 41 (05) 390-398
• 56 Ozaki Y, Baba T, Homma Y. et al. Preoperative ultrasound to identify distribution of the lateral femoral cutaneous nerve in total hip arthroplasty using the direct anterior approach. SICOT J 2018; 4: 42
• 57 Rachbauer F. Minimally invasive total hip arthroplasty via direct anterior approach [in German]. Orthopade 2005; 34 (11) 1103-1104 , 1106–1108, 1110
• 58 Restrepo C, Parvizi J, Pour AE, Hozack WJ. Prospective randomized study of two surgical approaches for total hip arthroplasty. J Arthroplasty 2010; 25 (05) 671-9.e1
• 59 Rodriguez JA, Deshmukh AJ, Rathod PA. et al. Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach?. Clin Orthop Relat Res 2014; 472 (02) 455-463
• 60 Sang W, Zhu L, Ma J, Lu H, Wang C. The influence of body mass index and hip anatomy on direct anterior approach total hip replacement. Med Princ Pract 2016; 25 (06) 555-560
• 61 Schweppe ML, Seyler TM, Plate JF, Swenson RD, Lang JE. Does surgical approach in total hip arthroplasty affect rehabilitation, discharge disposition, and readmission rate?. Surg Technol Int 2013; 23: 219-227
• 62 Spaans AJ, van den Hout JA, Bolder SB. High complication rate in the early experience of minimally invasive total hip arthroplasty by the direct anterior approach. Acta Orthop 2012; 83 (04) 342-346
• 63 Takada R, Jinno T, Miyatake K. et al. Direct anterior versus anterolateral approach in one-stage supine total hip arthroplasty. Focused on nerve injury: a prospective, randomized, controlled trial. J Orthop Sci 2018; 23 (05) 783-787
• 64 Vasantharao P, Fenbury D, Khan R. et al. Anterior approach to hip replacement and associated complications: an independent review. Hip Int 2022; 32 (03) 312-317
• 65 Wayne N, Stoewe R. Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach. Orthop Rev (Pavia) 2009; 1 (02) e27
• 66 Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthroplasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty 2009; 24 (07) 999-1005
• 67 Yi C, Agudelo JF, Dayton MR, Morgan SJ. Early complications of anterior supine intermuscular total hip arthroplasty. Orthopedics 2013; 36 (03) e276-e281
• 68 York PJ, Logterman SL, Hak DJ, Mavrogenis A, Mauffrey C. Orthopaedic trauma surgeons and direct anterior total hip arthroplasty: evaluation of learning curve at a level I academic institution. Eur J Orthop Surg Traumatol 2017; 27 (03) 421-424
• 69 Yuasa T, Maezawa K, Sato H, Maruyama Y, Kaneko K. Safely transitioning to the direct anterior from posterior approach for total hip arthroplasty. J Orthop 2018; 15 (02) 420-423