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The sensory innervation of the hip joint - An anatomical study

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Typically obturator nerve blockade is used to relieve hip pain. It sometimes only has a minor effect in resolving symptoms. This clinical observation led us to examine comprehensively the sensory nerve innervation of formalin-fixed hip joint capsules. Following macroscopic preparation, the area of the hip joint capsule was inspected with the aid of an operating microscope. We discovered a separation between the anterior and posterior sensory innervation of the hip joint capsule. The anteromedial innervation was determined by the articular branches of the obturator n. Additionally, the anterior hip joint capsule was innervated by sensory articular branches from the femoral n. In the posterior part we found articular branches from the sciatic n., which in addition to the articular branches from the nerves to the quadratus femoris m., innervate the postero-medial section of the hip joint capsule. Moreover, articular branches of the superior gluteal n. were found, which innervate the posterolateral section of the hip joint capsule. This anatomical study demonstrates that the obturator n. block is insufficient for the treatment of hip pain. Further investigations will determine if these nn. can be reached percutaneously. Effective neural blockade of the hip joint must include the femoral n., the sciatic n. and the superior gluteal n.
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Surg Radiol Anat 19: 371-375
© Springer-Verlag France 1997
Original article
The sensory innervation of the hip joint - An anatomical study
K. Birnbaum
1
, A. Prescher
2
, S. Heþler
1
and K.-D. Heller
1
1
Orthopaedic Department, Technical University Aachen, Pauwelsstrasse 30, D-52074 Aachen, Germany
2
Anatomical Institute I, Technical University Aachen, Wendlingweg 2, D-52074 Aachen, Germany
Received February 13, 1997 / Accepted in final form July 16, 1997
K
ey words:
Hip joint - Coxarthrosis - Sensory innervation - Nerve block anesthesia
Correspondence to: K. Birnbaum
Abstract
Typically obturator nerve blockade is used to relieve hip pain. It sometimes only has a minor effect in resolving symptoms. This
clinical observation led us to examine comprehensively the sensory nerve innervation of formalin-fixed hip joint capsules. Following
macroscopic preparation, the area of the hip joint capsule was inspected with the aid of an operating microscope. We discovered a
separation between the anterior and posterior sensory innervation of the hip joint capsule. The anteromedial innervation was
determined by the articular branches of the obturator n. Additionally, the anterior hip joint capsule was innervated by sensory articular
branches from the femoral n. In the posterior part we found articular branches from the sciatic n., which in addition to the articular
branches from the nerves to the quadratus femoris m., innervate the posteromedial section of the hip joint capsule. Moreover, articular
branches of the superior gluteal n. were found, which innervate the posterolateral section of the hip joint capsule. This anatomical
study demonstrates that the obturator n. block is insufficient for the treatment of hip pain. Further investigations will determine if these
nn. can be reached percutaneously. Effective neural blockade of the hip joint must include the femoral n., the sciatic n. and the
superior gluteal n.
Our understanding of the distribution of nerves to the hip joint has remained unchanged for many years. However, an examination of
the reports of various investigators shows considerable differences in opinion. Cruveilhier [4] was the first who stated that the
obturator n. gives a branch to the hip joint and that this branch has the greatest influence on the sensory innervation of the hip joint.
R¸dinger [18] seemed to be the first to do a systematic study of the nerve supply to the hip joint. He stated that the supplying nerves
arise from the femoral, obturator, sciatic and inferior gluteal nn. and that they are small. He also described an articular branch which
arises from the obturator n. before this n. reaches the obturator foramen. Woodburne [22] showed the existence of an accessory
obturator n., which was also described later by Katritsis [12]. Bardeen's [1] and Fick's [7] brief descriptions are similar in most
respects to those in the current manuals of human anatomy. Sadovsky [19] published the first comprehensive study since the time of
R¸dinger [18] and found that the femoral, obturator, sciatic and superior gluteal nerves supply the hip joint. It seems to be generally
agreed that the hip joint is supplied by the femoral n., the obturator n., the sacral plexus via the n. to the quadratus femoris m., and, in
some cases, directly by the sciatic n. There is no agreement whether the superior or the inferior gluteal n. contribute to the innervation
of the hip joint. Based on these investigations Kaiser [10] and Padovani [16] investigated the denervation of the sensory hip joint. In
the beginning this technique seemed to be sucessful, but further investigation showed the rapid development of deformation of the
femoral head, so that the authors abandoned this. Neural blockade had already been described in an investigation published by
Keppler [13]. In the seventies the method of nerve block anesthesia using various local anaesthetics was propagated [12]. According
to Hey [9] the obturator n. block was considered to be an alternative method to intra-articular hip joint injections. Unfortunately, the
obturator n. block for relief of pain in the hip joint was only successful in some cases. Our aim was to analyze the nerve supply of the
hip joint capsule in greater detail. Precise knowledge of the nerve supply of the hip joint is essential to achieve a more effective and
prolonged reduction of pain by injections.
Material and methods
Eleven formalin-mounted hip joint preparations were examined. Due to the small diameter, the articular branches of the hip joint
capsule were prepared with the aid of an operating microscope. To detect the articular branches responsible for the sensory innervation
of the hip joint capsule, an enlargement factor of 7.5 was selected first. For the final preparation of the articular branches, an
enlargement factor of 12.5 was needed. We distinguished between the anterior and the posterior preparations of the hip joint. For
documentation, we coloured the nerves by hand with an acrylic varnish.
Results
The anterior section of the hip joint capsule (Table 1) was supplied by the articular branches of the femoral n. (Figs. 1-4) and the
obturator n. (Figs. 4-6). The femoral n. (Figs. 1-4) was responsible for the sensory innervation of the anterior and anterolateral region
of the hip joint capsule. One of the two important articular branches entered the iliopsoas m. and gave several branches to muscle. A
side branch passe vertical from this branch down to the m. fibres and innervates the anterior side of the hip joint capsule. The other
articular branch passed at a lateral angle right across the iliopsoas m. and joined the lateral margin of the hip joint capsule or with an
additional branch to the hip joint capsule below the iliopsoas m. To some extent the femoral n. gave articular branches to the hip joint
capsule accompanied by vessels. In three cases we found an accessory femoral n. (Fig. 3) which was also responsible for the sensory
innervation of the anterior region. The obturator n. (Figs. 4-6) supplied the anteromedial section of the hip joint capsule. The articular
branches derived either from the anterior branch, the posterior branch or the trunk of the obturator n. One articular branch from the
obturator n. that innervates the hip joint capsule passed posterolaterally. The posterior branch, passing over the external obturator m.
and running between the adductor brevis and magnus mm., arose from the trunk of the obturator n. In our investigations often a
combined innervation by the femoral and the obturator n. at the anterior section of the hip joint capsule was identified.
Fig. 1
Femoral n. with two articular branches (arrow); 1: V. femoralis, 2: A. femoralis, 3: N. femoralis, 4: hip joint capsule, 5: iliopsoas m.
Fig. 2
Femoral n. with three articular branches (arrow)
Fig. 3
Femoral n. with one articular branch (arrow 1) and the accessory femoral n. (arrow 2), 3: inguinal lig., 4: V. femoralis, 5: A.
femoralis, 6: N. femoralis, 7: R. anterius of the obturator n.
Fig. 4
Femoral n. with articular branch (arrow 1) and the obturator n. with an articular branch for the hip joint capsule (arrow 2); 3: a.
femoralis, 4: n. femoralis, 5: inguinal lig., 6: m. adductor brevis, 7: r. anterior of the obturator n.
Fig. 5
Obturator n. with an articular branch for the hip joint capsule (arrow); 1: canalis obturatorius
Fig. 6
Enlarged section of Fig. 5; 1: canalis obturatorius
The posterior section of the hip joint capsule (Table 1) was supplied by the articular branches from the nerve to quadratus femoris m.
(Figs. 7-9), as well as by articular branches from the superior gluteal n. (Figs. 7-9) and directly by the sciatic n. The nerve to quadratus
femoris m. (Figs. 7-9) with the articular branch for the hip joint passed out of the sciatic n. immediately after penetration through the
infrapiriformis foramen. At the same level an articular branch from the sciatic n. existed which passed through the lesser sciatic notch
below the sacrotuberous lig. and innervated the internal obturator m. There was a ramification into two articular branches; one passed
posteroinferiorly, and the other posterolaterally. The n. to quadratus femoris m. innervated the posteroinferior section of the hip joint
capsule. The number of articular branches from the n. to quadratus femoris m., which had its origin in the sciatic n., varied between
one and five. In four cases we found an innervation of the hip joint by articular branches from the superior gluteal n. (Figs. 7-9). The
superior gluteal n. innervated the posterolateral capsule of the hip joint. In one case we found an articular branch direct from the
sciatic n., supplying the posterosuperior region of the hip joint capsule.
Fig. 7
Superior gluteal n. with an articular branch for the hip joint capsule (arrow 1) and the n. for the quadratus femoris m. from the sciatic
n. with an articular branch for the hip joint capsule (arrow 2); 3: trochanter major, 4: gluteus medius m.
Fig. 8
Enlarged section of Fig. 7
Fig. 9
Articular branch of the hip joint capsule from the superior gluteal n. (arrow 1) and an articular of the hip joint capsule from the n. for
the quadratus femoris m. (arrow 2)
Discussion
An analysis of the literature concerning the sensory innervation of the hip joint showed various conflicting findings.
With the exception of the results of Sadovsky [19], Gardner [8] and Polacek [17], the prevalent opinion hitherto has been that the
ventral hip joint capsule is innervated in the first place by articular branches of the obturator n. We mainly found an innervation of the
anterior hip joint capsule by articular branches from the femoral n. The accessory obturator n., which occurs according to literature in
10-30% [14-17] and which is said to have a significant role in the innervation of the hip joint, was not found in our study. It is possible
that these articular branches passing through the iliac m. were misunderstood as motor n. fibers of the iliac m.
DuzÈa [6] described an articular branch of the femoral n. that "perforates the m. fibres of the iliopsoas m.". He described two further
articular branches from the lumbar plexus with a close relation to the psoas m. and communicating branches to the femoral and
obturator nn. Tavernier and Truchet [20] mentioned in their investigations an innervation of the hip joint capsule ventrally by articular
branches of the obturator and femoral nn. They noticed that the posterior branch of the obturator n. played a decisive role in the
innervation of the ventral hip joint capsule. The explanation they gave for the unsatisfactory results of the neurotomies performed was
an "abnormity of the neural distribution" and the concomitant incomplete denervation. They postulated an additional dorsal
innervation - which was confirmed by our investigations. We found an innervation of the posterior hip joint capsule by articular
branches of the superior gluteal n., the sciatic n. and the n. to quadratus femoris m. Tavernier and Pellanda [21] mentioned a technique
of additional denervation of the articular branches of the femoral n. However this was only carried out in cases of postoperative pain
in the anterolateral region of the thigh. If pain was persisting despite this greater degree of neurotomy, they assumed fine articular
branches that accompany the vessels to the joint capsule to be responsible. According to their work, the radiation of pain with
coxarthrosis provides information of the origin of articular branches. In the papers of Gardner [8] and Polacek [17] the medial hip joint
capsule was described to be the most sensitive part of the joint capsule. According to Gardner the articular branches ramificate into
even finer branches in the anteromedial region of the hip joint capsule. It is likely that many of the nerve fibres supply blood vessels in
the capsule and neighboring bone. Yet, the different types of nerve ending are not described sufficiently. The concentration of fibres in
the anteromedial region of the capsule is due to proprioceptive endings in this region, but nevertheless Polacek [17] was unable to find
any greater numbers of proprioceptors there. With respect to the topography of pain in coxarthrosis, it should be noticed that there are
authors [2, 10] who attribute the radiation of pain to the knee joint not to the main branches of the obturator n., but rather to the
saphenous n. Chandelux [3] considered pain in the hip joint region to be a reflex phenomenon, e.g. a neuritis of the whole nervous
system, including the cutaneous branches of the femoral n. On the other hand Kaplan [11], deemed it more likely that a compression
of the articular branch of the femoral n. is responsible for the symptoms. On account of the symptoms and pain described by patients
with coxarthrosis, it was considered to preserve the articular branches of the hip joint capsule at operation. Tavernier and Padovani
[16, 20, 21] were the first who postulated a preservation of the branches as a therapy for painful coxarthrosis. Luzuy [15] regarded the
success of the neurotomies not only as a result of preservation of the sensory nerves in the joint, but also as an improvement of the
painful contraction of the adductors. The method of obturator n. neurotomy was further developed by Tavernier et al. [20, 21]. They
considered the posterior branch of the obturator n. to be the decisive branch concerning the pain symptoms in coxarthrosis. Billet [2]
agreed that the posterior articular branch of the obturator n. is of considerable significance for the sensory hip joint capsule
innervation. In his investigations he additionally preserved the articular branches of the femoral n. Padovani [16] postuled the
existence of an accessory obturator n. to be responsible for the high failure rate of denervations of the hip joint capsule. Moreover, he
described in his work certain individual cases of denervation of the obturator n. and the n. to quadratus femoris m. in which pain in the
anterolateral region of the hip joint capsule remained. In accordance with our investigations, this region corresponds to the innervation
area of the articular branches of the femoral n. In individual cases the partial denervation of the hip joint capsule led to a loss of pain
transmission. This results in an excessive and unphysiological pressure on the joint and leads to its destruction. As known, the
radiological picture is similar to the findings that can be obtained with tabes dorsalis or syringomyelia. The acetabulum becomes
enlarged and the head becomes necrotic, so that the patient acquires a Charcot's joint with a lack of stability. The accessory obturator
n., which is occasionally thought to be responsible for the failure rate with neurotomies, was impossible to find in our examinations of
hip joints. Chandelux [3] was the first to describe this nerve and named it on account of its importance for hip joint capsule
innervation, the "nerf de l¥articulation coxo-fÈmorale". One reason for the divergent opinion concerning the accessory obturator n. is
the fact that the authors were not able to distinguish exactly enough between the accessory obturator n. and the accessory femoral n. -
which we founded in several cases in our investigations. The accessory femoral n. has the same origin as the femoral n. In our
investigations we identified articular branches of the superior gluteal n. and the n. to quadratus femoris m. This corresponds to the
findings of Dee, Gardner and Sadovsky [5, 8, 19]. In four cases we found articular branches of the superior gluteal n. In addition to the
information hitherto on hip joint capsule innervation, we found a great number of articular branches from the n. to quadratus femoris
m., which derives from the sciatic n. In some cases up to five articular branches of the n. to quadratus femoris m. could be found.
Conclusion
Our investigations clearly show why the symptoms and pain in connection with inflammatory or degenerative processes in the area of
the hip joint can vary so often. The femoral n. has a greater influence on the innervation of the hip joint capsule than assumed in
former investigations. Blockade of the obturator n. on its own is doomed to failure. Given a suitable choice of local anaesthetic,
however, and an additional infiltration in the region of the articular branches of the femoral, superior gluteal and sciatic nn., it is
conceivable that the signs and symptoms of pain attendant upon coxarthrosis could be reduced for some days or weeks. Further
clinical investigations have to determine that these nerves are reachable percutaneously.
References
1. Bardeen CR (1901) The accessory obturator nerve. Anat Anz 19: 209
2. Billet H, Vincent G, Gaudefroy M (1947) Les nerfs de la hanche. CR Ass Anat 34: 42-47
3. Chandelux A (1886) Note sur les nerfs de l'articulation coxo-fÈmorale. Lyon Med 51: 551-554
4. Cruveilhier J (1844) The anatomy of the human body. The first american from the last Paris edition. Pattison GS (ed) Harper and
Bros, New York
5. Dee R (1969) Structure and function of hip joint innervation. Ann R Coll Surg Engl 44: 357-374
6. DuzÈa R (1886) Note sur les nerfs de l'articulation coxo-fÈmorale. Lyon Med 52: 35-38
7. Fick R (1904) In: Bardeleben von K (ed) Handbuch der Anatomie des Menschen, Vol 2, pt 1, sect 1. Gustav Fischer Verlag, Jena
8. Gardner E ( 1948) The innervation of the hip joint. Anat Rec 101: 353-371
9. Hey W, Fahr J, Henche HR (1985) Die Obturatoriusblockade als Alternative zur H¸ftgelenksinjektion bei schmerzhafter
Coxarthrose. Orthop”dische Praxis 2: 102-105
10. Kaiser RA (1949) Obturator neurectomy for coxalgia - An anatomical study of the obturator and accessory obturator nerves. J
Bone Joint Surg [Am] 31-A: 815-819
11. Kaplan EB (1948) Resection of the obturator nerve for relief of pain in arthritis of the hip joint. J Bone Joint Surg [Br] 31-B: 213-
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12. Katritsis E (1980) Anatomical observations on the accessory obturator nerve. Anat Anz 148: 440-445
13. Keppler W (1913) Die An”sthesie der unteren Extremit”ten mittels Injektionen auf die groþen Nervenst”mme. Langenbecks Arch
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14. Larochelle JL (1949) Anatomical research on the innervation of the hip joint. Anat Rec 103: 480-481
15. Luzuy M (1945) RÈsultats du traitement de 14 cas de coxarthrites par section des nerfs sensitifs de l'articulation. MÈmoires Acad
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17. Polacek P (1963) Die Nervenversorgung des H¸ft- und Kniegelenkes und ihre Besonder-heiten. Anat Anz 11: 243-256
18. R¸dinger N (1857) Die Gelenknerven des menschlichen K–rpers. Enke, Stuttgart
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22. Woodburne RT (1960) The accessory obturator nerve and the innervation of the pectineus muscle. Anat Rec 136: 367
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Background Hip fracture and surgery are associated with moderate to severe pain, which hampers early mobilization and extends the hospital stay. Femoral nerve block and fascia iliaca compartment block could provide effective postoperative pain relief. Unfortunately, they could weaken the strength of the quadriceps muscle and increase the risk of falls. Iliopsoas plane block (IPB) is a novel motor-sparing regional technique, which targets the sensory branches of the hip joint originating from the femoral nerve. However, the analgesic effect of IPB has not been confirmed yet. Case presentation In the present case series, IPB and lateral femoral cutaneous nerve block were implemented under the guidance of ultrasound for eight patients with hip fractures. The median (IQR) visual analog scale (VAS) score (0–10; 0: no pain, 10: worst pain) decreased from 1.5 (0.25–2) before IPB to 0 (0–0) 0.5h after IPB at rest. The median (IQR) VAS score decreased from 8 (7–8) before IPB to 2 (1–2) 0.5h after IPB during flexion of hip 30°. Pain score was no more than one at rest and three during flexion of the hip 30° within 48h after surgery. Furthermore, the MMT grades of quadriceps strength were no less than four after IPB. Conclusions Our case series firstly highlights that IPB might be an effective analgesic technique for hip fracture and surgery, while retaining motor function.
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This study compared the effects of the pericapsular nerve group (PENG) block and supra-inguinal fascia iliaca compartment block (FICB) on postoperative analgesia and quadriceps strength following total hip arthroplasty under general anesthesia. A total of 58 patients were randomized to receive either PENG block (PENG group) or supra-inguinal FICB (FICB group) following anesthetic induction. The primary outcomes were the postoperative pain scores. Patients were randomized to receive either PENG block or supra-inguinal FICB following anesthetic induction. Pain scores at rest and with movement were assessed preoperatively, at the postanesthesia care unit (only at rest), and at 6, 24, 36, and 48 h postoperatively. Opioid consumption was also assessed for 48 h postoperatively. Quadriceps strength measurements were performed preoperatively, at 6, 24, and 36 h postoperatively. In total, 54 patients completed the study: 27 in the PENG group and 27 in the FICB group. Despite lower pain scores at rest in the PENG group at postoperative 6 and 24 h, there were no significant differences in the pain scores at rest and during movement between the two groups during postoperative 48 h in the linear mixed model analysis (p = 0.079 and p = 0.323, respectively). Cumulative opioid consumption up to postoperative 48 h was also similar in the two groups (p = 0.265). The changes in quadriceps strength measurements in the operative leg and the nonoperative leg were not significantly different between the groups (p = 0.513 and p = 0.523, respectively). The PENG block may have similar analgesic efficacy to the supra-inguinal FICB. No difference was detected in the quadriceps strength between the patients receiving these two blocks.
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