Article

Potential Risk to the Superior Gluteal Nerve During the Anterior Approach to the Hip Joint: An Anatomical Study

Article

Potential Risk to the Superior Gluteal Nerve During the Anterior Approach to the Hip Joint: An Anatomical Study

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Abstract

Background: The anterior approach to the hip joint is widely used in pediatric and adult orthopaedic surgery, including hip arthroplasty. Atrophy of the tensor fasciae latae muscle has been observed in some cases, despite the use of this internervous approach. We evaluated the nerve supply to the tensor fasciae latae and its potential risk for injury during the anterior approach to the hip joint. Methods: Cadaveric hemipelves (n = 19) from twelve human specimens were dissected. The course of the nerve branch to the tensor fasciae latae muscle, as it derives from the superior gluteal nerve, was studied in relation to the ascending branch of the lateral circumflex femoral artery where it enters the tensor fasciae latae. Results: The nerve supply to the tensor fasciae latae occurs in its proximal half by divisions of the inferior branch of the superior gluteal nerve. The nerve branches were regularly coursing in the deep surface on the medial border of the tensor fasciae latae muscle. In seventeen of nineteen cases, one or two nerve branches entered the tensor fasciae latae within 10 mm proximal to the entry point of the ascending branch of the lateral circumflex femoral artery. Conclusions: Coagulation of the ascending branch of the lateral circumflex femoral artery and the placement of retractors during the anterior approach to the hip joint carry the potential risk for injury to the motor nerve branches supplying the tensor fasciae latae. Clinical relevance: During the anterior approach, the ligation or coagulation of the ascending branch of the lateral circumflex femoral artery should not be performed too close to the point where it enters the tensor fasciae latae. The nerve branches to the tensor fasciae latae could also be compromised by the extensive use of retractors, broaching of the femur during hip arthroplasty, or the inappropriate proximal extension of the anterior approach.

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... Postoperative atrophy and degeneration of the TFL with a consecutive loss of function can be caused by direct mechanical damage to the muscle or injury to the SGN's terminal branches [16]. Sacred cadaver studies reported that placement of retractors and cauterization of the lateral circumflex femoral artery could, directly and indirectly, lead to injury of the terminal branches of the SGN during DAA THA [13,14]. This can lead to severe functional restrictions that severely affect the patient's everyday life because the TFL is an important thigh abductor, which holds the pelvis horizontal during the stance phase of the gait and balances the body weight and the non-weight-bearing leg when walking [1,8,22]. ...
... In 28 hemipelves, they reported that in 14% the muscular branch entering the TFL was only slightly above the GT. Grob et al [14] reported in 2015 on 19 hemipelves with 2 terminal branches in 74%, 1 terminal branch in 21%, and 3 terminal end branches in 5% of their cases. Likewise, our data also showed a considerable variation of the muscular branch's branching patterns before entering the TFL. ...
... Other authors emphasize specific anatomical circumstances in the region of the DAA to minimize damage to the terminal branch of the SGN: Grob et al [14] showed in their anatomical study the vicinity of the ascending branch of the lateral circumflex femoral artery and the terminal branch of the SGN inserting into the TFL: in 17 of the 19 cases examined, 1 or 2 nerve endings inserted within 10 mm of the vessel's entry point into the TFL. Due to the immediate proximity, cauterization of the ascending branch of the lateral circumflex femoral artery could lead to damage of the terminal branch of the SGN. ...
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Background During primary and revision total hip arthroplasty (THA) lesions of the superior gluteal nerve (SGN) can substantially compromise patient outcome. For the primary direct anterior approach (DAA) and its proximal approach extensions, especially the muscular branch entering the tensor fasciae latae (TFL) muscle is at risk. SGN lesions can result in fatty atrophy and functional loss of the TFL. Therefore, the course and branching pattern of the SGN were examined and related to the DAA and its proximal approach extension. The aim of the study is to describe safe and danger zones for the SGN with regard to the DAA and its proximal extensions. Methods Twenty-five formalin-fixed cadavers with 48 hemipelves were dissected. The course, distribution, and branching pattern of the SGN and its muscular branch inserting into the TFL muscle were investigated with regard to the DAA with the help of anatomical landmarks like the greater trochanter and the iliac tubercle. Results In 72.9% of the specimens the SGN passed the greater sciatic foramen superior to the piriformis muscle with one main trunk. The muscular branch of the SGN supplying the TFL divided from the main branch in 89.6% of the specimens at the level of the greater sciatic foramen. Before entering the TFL muscle the muscular branch showed a variable branching pattern in the interval between the gluteus medius and minimus. A danger zone for the SGN with regard to the DAA was found in the proximal fourth of the skin incision. Conclusion Special care in proximal instrument placement should be taken during the DAA. When extending the DAA proximally manipulations in the proximal, caudal surgical window should be performed with the utmost care.
... In the case of extensile acetabular procedures, we carry the proximal incision up to the ASIS and then laterally along the iliac crest (Fig. 2B). Careful cautery of the perforating lateral femoral circumflex vessels is performed to prevent problematic bleeding while paying attention to avoid injury to the terminal inferior branch of the superior gluteal nerve [19]. This nerve has been found to be in close approximation to the medial border of the tensor fascia lata (TFL), usually within 10 mm proximal to the entry point of the ascending branch of the lateral circumflex femoral artery [19]. ...
... Careful cautery of the perforating lateral femoral circumflex vessels is performed to prevent problematic bleeding while paying attention to avoid injury to the terminal inferior branch of the superior gluteal nerve [19]. This nerve has been found to be in close approximation to the medial border of the tensor fascia lata (TFL), usually within 10 mm proximal to the entry point of the ascending branch of the lateral circumflex femoral artery [19]. Deep proximal dissection explores the interval between the rectus femoris and the gluteus medius (Fig. 2C). ...
... Other concerns of the DAA include maintenance of TFL integrity. In a recent study, Grob et al. [19] reported on a patient with postoperative TFL atrophy after a primary THA through the DAA, and their subsequent cadaver study found that the terminal inferior branch of the superior gluteal nerve regularly coursed along the medial surface of the TFL within 10 mm to the insertion of the ascending branch of the lateral circumflex femoral artery where it is at risk of injury during exposure or cautery. Other studies raise similar concerns including increased damage to the TFL when compared with the posterior approach [16]. ...
Article
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A 74-year-old female patient presented to our clinic with pelvic discontinuity after multiple revision total hip surgeries requiring custom triflange acetabular reconstruction, which we accomplished through a direct anterior approach to the hip. The direct anterior approach to the hip has grown in popularity but still has the reputation of being a minimally invasive approach without the capacity for extensile exposure in the revision setting. We describe the extensile technique and demonstrate through our case the ability to perform the most challenging cases through this approach and discuss the potential benefits of its utilization. Keywords: Direct anterior approach, Triflange, Revision hip arthroplasty, Extensile hip approach, Pelvic discontinuity, Acetabular defect
... The muscle medial, sartorius and rectus femoris, are innervated by branches of the femoral nerve, those lateral, tensor fasciae latae, gluteus medius and minimus are innervated by the superior gluteal nerve. In the anterior approach, access to the hip joint is obtained by passing between the sartorius (femoral nerve) and tensor fasciae latae (superior gluteal nerve) [24]. The gluteal nerve is the only motoric nerve that exits superior to piriformis muscle and then divides into a superior and an inferior branch [25]. ...
... Meneghini et al. reported a muscle damage to the tensor fasciae latae in all cadavers, which underwent total hip arthroplasty involving the direct anterior approach [41]. Grob et al. stated that the tensor fasciae latae surface was mostly damaged in the midsubstance of the muscle after total hip arthroplasty involving the direct anterior approach, which is exactly the area where the superior gluteal nerve enters the tensor fasciae latae [24]. However, damage to the tensor fasciae latae does not automatically imply damage to the nerve branches, but it does endanger the nerve that is very superficial in this area [24]. ...
... Grob et al. stated that the tensor fasciae latae surface was mostly damaged in the midsubstance of the muscle after total hip arthroplasty involving the direct anterior approach, which is exactly the area where the superior gluteal nerve enters the tensor fasciae latae [24]. However, damage to the tensor fasciae latae does not automatically imply damage to the nerve branches, but it does endanger the nerve that is very superficial in this area [24]. Terminal nerve branch lesions of the superior gluteal nerve are probably underdiagnosed because they are not always symptomatic and patients still showed excellent clinical and functional result identical to a modified anterolateral approach [24]. ...
Article
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Introduction: Gluteal insufficiency is of concern with lateral approaches to total hip arthroplasty. Damage to the branches of the superior gluteal nerve may cause degeneration of the innervated muscles. The direct anterior approach exploits the intermuscular and internerval interval between tensor fasciae latae laterally and sartorius and rectus femoris muscle medially. In this study, the distance of the superior gluteal nerve in relation to anatomical landmarks was determined. Materials and methods: Two experienced surgeons implanted trial components in 15 alcohol glycerol fixed cadavers with 30 hips. The trials were removed, and the main branch of the superior gluteal nerve and muscular branches of the nerve were exposed from lateral. Results: No visual damage to the main nerve branches and the location of the nerve in relation to the greater trochanter were noted by an experienced surgeon. The superior gluteal nerve and its muscular branches crossed the muscular interval between the gluteus medius and tensor fasciae latae muscles at a mean distance of 39 mm from the tip of the greater trochanter. Conclusions: The direct anterior approach for total hip arthroplasty minimizes the risk of injuring the superior gluteal nerve, which may result in a gluteal insufficiency. Special care should be paid on avoiding overstretching the tensor fasciae latea muscle using minimum force on retractors during surgery and by taking care of the entrance point of the superior gluteal nerve to the tensor fasciae latae.
... The superior gluteal nerve originates from L4-S1 of the lumbar plexus, passing above the piriformis when exiting the greater sciatic foramen before dividing into superior and inferior branches. 43,51 Two anatomic variants of the division have been described: the spray and transverse neural trunk variants. 52 The superior gluteal nerve innervates the gluteus medius and minimus and the tensor fasciae lata (TFL). ...
... 53 Injury can result in paralysis of these muscles, causing weak abduction and a Trendelenburg gait. 51 Notwithstanding, injury to the terminal branches supplying the TFL can go undiagnosed, because some patients may remain asymptomatic without functional impairment or cosmetic issues, 51 albeit others may experience atrophy and fatty infiltration of the TFL. 54,55 The association between superior gluteal nerve injury and the Hardinge and Watson-Jones approaches have been well described. ...
... 54,55 The association between superior gluteal nerve injury and the Hardinge and Watson-Jones approaches have been well described. 51,56,57 This may occur especially if the gluteus medius is dissected 5 cm proximal to the greater trochanter during the direct lateral or anterolateral approach. 53, 58 Unis and colleagues 56 analyzed MRI scans of patients undergoing THA using an anterolateral approach and noted fatty infiltration of the TFL in 42% of patients at a median of 9.4 months. ...
Article
Nerve injuries following total hip arthroplasty are rare but devastating complications. The most important modifiable risk factor remains the choice of hip approach and surgical technique applied. The risk of nerve injuries is related to technical complexity of the procedure and anatomic variability of the nerves. Surgeons should remain cognizant of inherent risk factors, variations in the course and branching patterns of different nerves, and technical considerations of the surgical approach to mitigate risks. This article reviews the literature on postsurgical nerve injuries following total hip arthroplasty and characterizes the influence of surgical approach on the risk of this complication.
... The severity and the cause of damage to these muscles vary in different reports. For the TFL muscle, these changes were attributed to denervation of the muscle combined with direct damage [17][18][19][20]29]. In the MRI study of Agten and colleagues, the muscle damage was present but low in both anterolateral and direct anterior approaches when compared to direct lateral and posterior approaches [18]. ...
... In another study, Pumberger and colleagues reported significant micro-structural changes in the TFLM in both, the anterolateral and direct lateral approaches [20]. Atrophy of the tensor fasciae latae muscle following anterior hip approach was also attributed to the superior gluteal nerve injury by Grob and colleagues in an anatomic study [29]. They concluded that coagulation of the a-LFCA during anterior hip approach might be accompanied by damage to the terminal branch of the superior gluteal nerve (SGN) which supplies the muscle. ...
Article
Full-text available
Background The purpose of this cadaveric study was to anatomically demonstrate the contribution of the lateral femoral circumflex artery (LFCA) to the articular and peri-articular hip circulation with an emphasis on the vascularization of hip abductors specially tensor fasciae latae muscle (TFLM). Methods and materials Thirty hips from 26 fresh cadavers were dissected after injection of the aorta or common iliac artery by colored silicon, to study the contribution of the LFCA to the articular and periarticular hip circulation. Furthermore, the aorta was injected in another 18 fresh cadavers after unilaterally ligating the ascending branch of the LFCA (a-LFCA) as the vascular pedicle of the TFLM, to evaluate the collateral circulation to the TFLM, if available. Results In all specimens but one, the a-LFCA was found as the single major vascular pedicle of the TFLM. When ligated, only 4 out of 18 hips demonstrated colored cast vessels in the cut surface of the muscle. The ascending branch had also consistent but variable contribution to the gluteus medius and gluteus minimus muscles in 80% of the hips. Furthermore, the a-LFCA consistently supplied the anterior and anterolateral aspects of the hip capsule. In 35% of hips, the a-LFCA contributed to the femoral head and neck circulation via one or two small anterior retinacular arteries. Conclusion LFCA contribution to the articular and periarticular hip circulation is only delivered by the ascending branch. The TFLM is specially perfused by the a-LFCA; its ligation significantly decreases the muscle perfusion. It is poorly supplied by the collateral circulation.
... Muscle atrophy and damage have been assessed using muscle function tests (e.g. gait analysis and electromyography), which only provide indirect and nonspecific conclusions about specific muscle damage, or through cadaver investigation, which does not reflect the muscle damage due to nerve injury or the regenerative capacity of the muscles [7,8]. Recently, muscle atrophy and damage after THA have successfully been assessed via magnetic resonance imaging (MRI) [7,9,10]. ...
... The modified Watson-Jones approach, as well as other minimally invasive approaches, provides less overview of the surgery and this disadvantage is more prominent in higher BMI cases [1,11,19]. Some anatomical reports have suggested that joint overexposure should be avoided in this approach to prevent SGN injury [1,8,20]. Thus, we consider that overexposure of the joint, which can cause SGN injury, might have been performed in the high BMI cases of our study. ...
Article
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Background Post-operative tensor fascia lata (TFL) muscle atrophy due to superior gluteal nerve (SGN) injury during total hip arthroplasty (THA) can affect patients’ post-operative hip function. This study aimed to determine the incidence of TFL muscle atrophy in THA performed via the modified Watson-Jones anterolateral approach and the risk factors for TFL atrophy. Methods We reviewed pre- and post-operative magnetic resonance imaging (MRI) data of 164 patients who underwent cementless THA via the modified Watson-Jones approach at one institution. TFL atrophy was defined as worsening of ≥ 2 grades in the Goutallier classification or > 40% decrease in the cross-sectional area (CSA) of the TFL on post-operative MRI compared to that on preoperative MRI. Patients’ backgrounds were compared between those with or without TFL atrophy to determine the risk factors of TFL atrophy. Fatty atrophy grade and CSA of the gluteus minimus and medius were also evaluated. Results Thirteen (8.0%) cases of TFL atrophy were detected. The mean body mass index (BMI) in the cases with TFL atrophy was significantly higher than in those without TFL atrophy (p = 0.012). The fatty atrophy grade was worse post-operatively than preoperatively; moreover, the CSA of the gluteus minimus decreased. Conclusions We found a low incidence of TFL atrophy due to SGN injury after THA using the modified Watson-Jones approach. High BMI can be a risk factor for nerve injury. The gluteus minimus can be injured directly during surgery. We suggest that overexposure of the surgical site should be avoided, especially in patients with high BMI.
... Preservation of the TFL is also critical because the muscle works in conjunction with the hip abductors and is essential in maintaining pelvis stability during standing and walking. In a cadaver study, Grob et al 22 found that the terminal inferior branch of the superior gluteal nerve routinely crossed along the medial TFL surface within 10 mm of the ascending branch of the lateral circumflex femoral artery where it is at risk of injury during exposure and ligation. Other studies have also suggested increased TFL damage during DAA when compared with the anterolateral 23 and posterior approach. ...
Article
There has been increased interest and literature on the efficacy of anterior approach (DAA) for total hip arthroplasty (THA). Developments in surgical technique and instrumentation, along with exposure earlier in orthopedic residency training, may augment the adoption of this approach among practicing orthopedic surgeons. With the rising number of primary THA performed through the DAA, understanding the indications and techniques associated with revision THA via the DAA has proved increasingly important. Patient positioning, understanding surgical anatomy and extensile maneuvers, and applying key reconstructive methods are essential for obtaining adequate exposure and fixation. Acetabular exposure can be facilitated through capsular and soft tissue release, along with extensile approaches to the pelvis and acetabulum. Extensile distal extension can be performed for safe access to the femur, including extended femoral osteotomies. The purpose of this review is to describe indications, surgical anatomy, intra-operative tips, clinical outcomes and complications after DAA for revision THA.
... 5,6,7 Se debe tomar en cuenta que este abordaje requiere mayor curva de aprendizaje por la dificultad técnica que puede llevar a posibles complicaciones. 8,9,10,11 Se han hecho varios estudios que comparan estos abordajes. Algunos describen que no hay diferencia entre el posterior y el anterior si se lleva una rehabilitación adecuada. ...
Article
Indroduction: Today, there is insufficient evidence, that determines the best option of the surgical approach for primary total hip replacement. The objective of this study is to compare patient satisfaction results with the HOOS scale between anterior, lateral and posterior surgical access in patients treated with primary hip joint replacement. Material and methods: Satisfaction results were compared with the HOOS scale between the surgical approach anterior, lateral and posterior at 48-hour, monthly, and three-month; the ANOVA statistical test and a Tukey post-hoc test were applied to the results obtained. Results: A higher score on the HOOS scale was obtained with the anterior approach compared to the lateral and posterior. At 48 hour, per month and three months after surgery, with a p-value of 0.012 at 48 hours, 0.014 per month and from 0.047 to three months. Conclusions: It was concluded, that in our study group, there was greater satisfaction of the post-operative patients of primary hip replacement with Anterior approach compared to the lateral and posterior approaches, however this difference decreases over the length of the time, reaching similar satisfaction results with all three approaches at three months.
... Limping and abductor dysfunction are well known complications of hip surgery. The function of the abductor muscles may be compromised after surgery if there is damage to the superior gluteal nerve or the muscle itself [4,5]. ...
Article
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Background The purpose of this cadaveric study was to evaluate the damage to the gluteus medius muscle, tendon and superior gluteal nerve in low BMI patients during the reaming of the greater trochanter tip for proximal femoral nailing.Materials and methodsThe study used 19 femurs of 10 fresh femur intact cadavers [mean BMI: 22.79 (17.60–28.70)]. A guidewire was placed in the tip of greater trochanter under C-arm fluoroscopy, and a 17-mm reamer was advanced over the wire. After the reaming was completed, the hips were dissected and the gluteus medius muscle, tendon and superior gluteal nerve were inspected to evaluate the amount of injury. ResultsBMI was < 18.50 in 3 cadavers. The gluteus medius muscle was injured in all hips. The superior gluteal nerve was intact in all hips, but the thickness of gluteus medius muscle mass that remained intact was thicker in the cadavers with a higher BMI (3.86 mm for low BMI, 9.08 mm for high BMI group). The percentage of the tendon insertion disrupted by the reamer was an average of 36.20% in the low BMI group and an average of 26.93% in the high BMI group. The percentage of the tendon insertion disrupted by the reamer showed a statistically significant difference between low and high BMI cadavers. Conclusion The injury to the gluteus medius muscle and tendon after proximal femoral nailing through the greater trochanter tip may be higher in patients with low BMI. It must be kept in mind that gluteal muscle could be damaged during proximal femoral nailing and this could result in limping.
... 5,6,7 Se debe tomar en cuenta que este abordaje requiere mayor curva de aprendizaje por la dificultad técnica que puede llevar a posibles complicaciones. 8,9,10,11 Se han hecho varios estudios que comparan estos abordajes. Algunos describen que no hay diferencia entre el posterior y el anterior si se lleva una rehabilitación adecuada. ...
Article
Full-text available
Introducción: Hoy en día no se cuenta con evidencia suficiente que determine la mejor opción del abordaje quirúrgico para artroplastía total primaria de cadera. El objetivo de este estudio es comparar los resultados de satisfacción del paciente con la escala de HOOS entre el acceso quirúrgico anterior, lateral y posterior en pacientes tratados mediante reemplazo articular primario de cadera. Material y métodos: Se compararon los resultados de satisfacción con la escala de HOOS entre el abordaje quirúrgico anterior, lateral y posterior a las 48 horas, al mes y a los tres meses; se aplicó la prueba estadística de ANOVA y una prueba post hoc de Tukey a los resultados obtenidos. Resultados: Se obtuvo mayor puntaje en la escala de HOOS con el abordaje anterior en comparación con el abordaje lateral y el posterior a las 48 horas, al mes y a los tres meses del postoperatorio, con un valor p de 0.012 a las 48 horas, de 0.014 al mes y de 0.047 a los tres meses. Conclusiones: Se concluyó que en nuestro grupo de estudio hubo mayor satisfacción de los pacientes postoperados de artroplastía primaria de cadera con abordaje anterior en comparación con los abordajes lateral y posterior; sin embargo, esta diferencia va disminuyendo a lo largo del tiempo, llegando a tener resultados de satisfacción similares a los tres abordajes al cabo de tres meses.
... Several anatomical landmarks have been proposed for the reliable identification of minimally-invasive surgical approaches in total hip arthroplasty [1][2][3]. The correct identification of such landmarks is a conditio sine qua non to avoid complications related to the restricted overview of the surgical situs [4]. ...
Article
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Background The key for successful delivery in minimally-invasive hip replacement lies in the exact knowledge about the surgical anatomy. The minimally-invasive direct anterior approach to the hip joint makes it necessary to clearly identify the tensor fasciae latae muscle in order to enter the Hueter interval without damaging the lateral femoral cutaneous nerve. However, due to the inherently restricted overview in minimally-invasive surgery, this can be difficult even for experienced surgeons. Methods and Surgical Technique In this technical note, we demonstrate for the first time how to use the tensor fasciae latae perforator as anatomical landmark to reliably identify the tensor fasciae latae muscle in orthopaedic surgery. Such perforators are used for flaps in plastic surgery as they are constant and can be found at the lateral third of the tensor fasciae latae muscle in a direct line from the anterior superior iliac spine. Conclusion As demonstrated in this article, a simple knowledge transfer between surgical disciplines can minimize the complication rate associated with minimally-invasive hip replacement.
... In fact, these tendinous attachments and the innervation of the abductor muscles may be damaged as dissection  THE HIP SOCIETY Incidence and treatment of abductor deficiency during total hip arthroplasty using the posterior approach is extended to gain exposure. 10 The lateral approaches that enter the hip through the abductor muscles themselves compromise the muscles and tendons, and also endanger the superior gluteal nerve that innervates the entire abductor muscle group. 11,12 The posterior approach, if done with care, can avoid damaging the abductor muscles and their nerve supply, resulting in better abductor muscle function after THA. ...
Article
Aims: The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. Patients and methods: A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter. Results: Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased. Conclusion: The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116-122.
... Beim vorderen Zugang zum Hüftgelenk können Nerven auf drei Ebenen direkt geschädigt werden [1][2][3]6]. ...
... The most effective action of the TFL is highly dependent on hip joint position and femoral neck angle [5,6,14]. TFL function is abolished by nerve injury during hip surgery, but its function can be compensated by the other hip muscles after rehabilitation [2,10]. However in contrast to the limited muscle function in adults, the fetal TFL plays a role in connecting the gluteus fascia to the vastus fascia. ...
Article
Background: The human tensor fasciae latae muscle (TFL) is inserted into the iliotibial tract and plays a critical role in lateral stabilisation of the hip joint. We previously described a candidate of the initial iliotibial tract that originated from the gluteus maximus muscle and extended distally. Materials and methods: This study extended our observations by examining 30 human embryos and foetuses of gestational age (GA) 7-14 weeks (crown-to-rump length 24-108 mm). At GA 7 weeks, the TFL appeared as a small muscle mass floating in the subcutaneous tissue near the origins of the gluteus medius and rectus femoris muscles. Results: Subsequently, the TFL obtained an iliac origin adjacent to the rectus femoris tendon, but the distal end remained a tiny fibrous mass on the vastus lateralis muscle. Until GA 10 weeks, the TFL muscle fibres were inserted into a vastus lateralis fascia that joined the quadriceps tendon distally. The next stage consisted of the TFL muscle belly "connecting" the vastus fascia and the gluteus fascia, including our previous candidate of the initial iliotibial tract. Until GA 14 weeks, the TFL was sandwiched by two laminae of the connecting fascia. Conclusions: These findings suggested that, when the vastus lateralis fascia separated from the quadriceps tendon to attach to the tibia, possibly after birth, the resulting iliotibial tract would consist of a continuous longitudinal band from the gluteus maximus fascia, via the vastus fascia, to the tibia. Although it is a small muscle, the foetal TFL plays a critical role in the development of the iliotibial tract.
... Injury to the superior gluteal nerve may occur if the gluteus medius is dissected 5 cm proximal to the greater trochanter, 39 and would present with abductor weaknesses and Trendelenburg gait. 10 Violation of this critical area is most common during a direct lateral or anterolateral approach. 40 Also, through experimental cadaveric dissections, Grob et al. 41 proposed that ligation of the ascending branch of the lateral circumflex femoral artery was a potential source of superior gluteal nerve injury. Picado et al. 42 evaluated 40 patients who underwent THA with the direct lateral approach and all had EMGs 4-weeks postoperatively, revealing superior gluteal nerve injuries in 17 patients; however, only 3 of these patients continued to demonstrate injury patterns 6-months postoperatively and at 1-year postoperatively only 1 patient had a positive Trendelenburg sign. ...
Article
Nerve injury is a relatively rare, yet potentially devastating complication of total hip arthroplasty (THA). Incidence of this ranges from 0.6 to 3.7%, and is highest in patients with developmental hip dysplasia and previous hip surgery. Apart from patient and surgeon dissatisfaction, this complication can have medico-legal consequences. Therefore, the purpose of this study was to review the risk factors, etiology, diagnostic options, management strategies, prognosis, and prevention measures of nerve injuries associated with THA. We specifically evaluated the: 1) sciatic nerve; 2) femoral nerve; 3) obturator nerve; 4) superior gluteal nerve; and 5) the lateral femoral cutaneous nerve.
... Insofern ist er relativ sicher. In einer Arbeit von Grob und Mitarbeitern[15] wird der Fall einer Patientin mit Atrophie des M. tensor fasciae latae nach direkt anteriorem Zugang zur Hüfte beschrieben, und als mögliche Ursache beschrieben, dass der Endast des N. gluteus sup. dort in den M. tensor fasciae latae eintritt und diesen versorgt, wo auch der Ramus ascendens der A. circumflexa fem. ...
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Mit dem anterioren Zugang zum Hüftgelenk können Hüftpfanne und periazetabulärer Knochen gut dargestellt werden. Bei einfachen Pfannenrevisionen kann der Zugang klein (minimalinvasiv) gehalten werden, bei ausgedehnten Destruktionen des Azetabulums ist er erweiterbar bis zu einer Darstellung des gesamten Ileums kranial des Azetabulums, des Os pubis und von angrenzenden Strukturen im Beckeninneren. Die für den Zugang genutzte internervale Grenze zwischen Versorgung durch den N. femoralis und den N. gluteus superior erlaubt die Darstellung des Iliums ohne Gefährdung der Nervenversorgung der Glutealmuskulatur.
... Care must be taken as insufficient exposure during broaching may lead to direct damage to the fibers of the tensor fasciae latae muscle including the motor nerve branches (19)(20)(21). Grob et al. performed an anatomical study with cadaveric dissection of the course of the nerve branch to the tensor fasciae latae muscle and found that coagulation of the ascending branch of the lateral circumflex femoral artery and placement of retractors during the DAA carry the potential for injury to its motor branches (22). In this same study, they present a case of post-operative atrophy to the tensor fasciae latae after the DAA. ...
... The terminal branches of the inferior branch of the superior gluteal nerve innervates the tensor fasciae latae being at potential risk during DAA (15). Grob et al. performed an anatomical study with cadaveric dissection of the course of the nerve branch and found that that the nerve is at risk during the placement of retractors and coagulation of the ascending branch of the lateral femoral circumflex femoral artery (16). ...
Article
Background: This study aims to evaluate complications and early postoperative clinical outcomes of direct anterior approach (DAA) in total hip arthroplasty (THA). Methods: Ninety-one consecutive patients who underwent primary elective unilateral THA between January 2013 and December 2019 were identified. Collected data included age of patient, BMI, ASA score, EBL (estimated blood loss), LOS (length of stay), operating time, and intra/postoperative complications. The recorded complications included prolonged wound drainage without infection, superficial and deep infection, dislocation, periprosthetic fracture, aseptic loosening or failure of osteointegration and nervous damage. Any reoperation, with or without prosthetic component revision, was recorded. Results: Fourteen complications (15,4%) and 12 (13,18%) postoperative anemizations were observed in this series. No deep infection was reported. Most common complications were nerve damage (3/91;3,29%), greater trochanter fracture (3/91; 3,29%), and wound trouble (3/91; 3,29%). Two (2,19%) dislocations were reported. One (1,09%) intraoperative periprosthetic fracture was treated with cerclage wiring. One (1,09%) revision was needed for an acetabular mobilization. One patient (1,09%) had severe periprosthetic ectopic ossifications (Brooker 4), needing reintervention because of severe limitations of the range of motion (ROM). Conclusions: Complications rate in this study with THA by DAA is comparable to those reported in literature. DAA is a safe, efficient procedure but it needs a steep learning curve. (www.actabiomedica.it).
... 5,6 TFL muscle is also utilised as a free muscle or a myocutaneous microvascular flap with several advantages and a important anatomical landmark during surgical approaches to the hip joint. 7,8 The present article will review the normal anatomy of the TFL, ITB and emphasize the pathologies affecting TFL which present as other, more commonly associated conditions of the region. An Algorithm to assess patients with suspected pathological conditions affecting Tensor Fasciae Latae muscle is highlighted. ...
Article
Introduction Tensor Fasciae Latae (TFL) and the iliotibial band (ITB) act as a single functional unit in maintaining pelvic stability whilst standing, walking, or running in human beings. The Tensor Fasciae Latae (TFL) muscle acts across the hip and the knee joint. Consequently, though its pathologies traditionally present with lateral hip pain, identifying the precise clinical diagnosis can be a challenge. Patients and methods A retrospective search for the keyword ‘Tensor Fasciae Latae’/iliotibial band (ITB) was performed of our Radiology Information System (RIS) and Picture Archiving and Communication System (PACS) computerised radiology information system (CRIS) at our tertiary orthopaedic referral centre of a for orthopaedic oncology/hospital over a period of 13 years (2007–2020).Data was collected from RIS, oncology database and local histopathology laboratory records. Patient demographics, clinical characteristics, complementary imaging and clinical management outcome were documented. Results We identified 35 patients with a mean age of 66 years (range 19–94 years). There were 18 female and 17 male patients. Lateral hip lump and pain were the most frequent clinical finding/presentation features. A variety of pathologies such as benign and malignant tumours, including vascular and tumour mimic lesions involving the TFL muscle were identified. Atrophy and pseudohypertrophy of TFL was the commonest pathology found; accounting for two thirds of the cases. Conclusion Tensor Fasciae Latae (TFL) can be afflicted with a broad spectrum of pathologies. Radiological imaging especially cross-sectional imaging modality is crucial in guiding appropriate patient management of TFL conditions. Our analysis suggests isolated TFL lesion are more likely to be benign conditions commonly presenting as hip pain and swelling.
... In the aspect of nerve injury, the traditional view is that more attention should be paid to the lateral femoral cutaneous nerve (LFCN) in DAA 45,46 and the superior gluteal nerve (SGN) in LA 47,48 due to the anatomical nerve distribution. However, an anatomical study demonstrated that DAA could also increase the potential risk of SGN injury because of the coagulation of ascending branch of lateral circumflex femoral artery and the placement of hooks 49 . In addition, peroneal nerve and femoral nerve damage were also observed in the patients after THA by using DAA 50,51 , although the cause of that was unclear. ...
Article
Full-text available
The direct anterior approach (DAA) are attracting increasing attention from orthopedic arthroplasty surgeons, due to the less blood loss, mild soft tissue invasion, rapid rehabilitation and shorter length of stay. However, the longer learning curve in DAA can give rise to several complications, such as intraoperative femoral fracture, lateral femoral cutaneous nerve injury, wound-healing problem, premature revision and so on. This meta-analysis was performed to compare the rate of postoperative orthopedic complications between the DAA and the lateral approach (LA). All studies involving the comparison of postoperative orthopedic complications after THA between the DAA and LA group were searched in 7 databases prior to October 2020. The odds ratio (OR) with the 95% confidence intervals (CI) for each outcome was calculated by using the RevMan 5.3. The methodological bias of included studies was evaluated and the potential heterogeneity sources were analyzed. Thirteen comparative studies including a total of 24853 hips (9575 hips in the DAA group and 15278 hips in the LA group) were eligible for this meta-analysis. There was no significant difference in the rate of surgical site infection [2.59% vs 2.14% (OR = 0.98; 95% CI: 0.59-1.61, P = 0.93)], heterotopic ossification [12.16% vs 26.47% (OR = 0.46; 95% CI: 0.20-1.07, P = 0.07)] and reoperation [2.70% and 2.11% respectively (OR = 0.93; 95% CI: 0.68-1.26, P = 0.64)] between the DAA and LA groups. Although a lower rate in prosthesis malposition [36.19% vs 54.86% (OR = 0.50; 95% CI: 0.35-0.73, P = 0.0003)], leg length discrepancy [1.87% vs 2.37% (OR = 2.35; 95% CI: 1.30-4.25, P = 0.005)] and Trendelenburg gait [1.68% vs 4.78% (OR = 0.29; 95% CI: 0.13-0.65, P = 0.003)] was observed in the DAA group, a higher rate in dislocation [0.77% vs 0.18% (OR = 3.73; 95% CI: 2.35-5.94, P< 0.00001)], periprosthetic fracture [1.05% vs 0.41% (OR = 2.38; 95% CI: 1.58-3.58, P< 0.0001)], prosthesis loosening [0.61% vs 0.37% (OR = 1.66; 95% CI: 1.05-2.62, P = 0.03)] and nerve injury [0.95% vs 0% (OR = 7.12; 95% CI: 1.66-30.48, P = 0.008)] was found in the DAA group. This meta-analysis demonstrated several evidences indicating that the DAA exhibited the advantages in the accurate prosthesis placement and less damage of surrounding hip musculature. However, a higher rate in dislocation, periprosthetic fracture, prosthesis loosening and nerve injury in the DAA group should be paid more attention, due to the limited exposure and a longer learning curve, compared to the LA.
... They concluded that while the risk of direct injury to the superior gluteal nerve during DAA THA is low, caution must still be exercised in retraction of the TFL because the superior gluteal nerve enters the TFL in the midsubstance of the muscle, where most of the damage occurs from retraction 58 . Grob et al. performed an anatomic study of the superior gluteal nerve in 19 cadaveric specimens and found that in 17 specimens, 1 or 2 nerve branches entered the TFL within 10 mm of the ascending branch of the lateral femoral circumflex artery 59 . They concluded that coagulation of the ascending branch of the lateral femoral circumflex artery and placement of retractors during DAA THA could place the superior gluteal nerve at risk. ...
Article
While no single approach for total hip arthroplasty (THA) has been proven to be superior to others in terms of patient outcomes, the direct anterior approach (DAA) is becoming increasingly popular. » All of the described techniques for THA carry a small risk of nerve injury. » Identifying risk factors for nerve injury and mitigating these risks where feasible are imperative in order to reduce the incidence of this complication with any approach for THA.
... This approach releases the anterior insertions of the gluteus medius and minimus from the great trochanter of the proximal part of the femur. As a result of surgical trauma, the superior gluteal nerve may be injured, or the primary reattachment and healing of the muscle to the femur may fail [3,4]. Another cause could be the destruction of the femoral bone or the muscle itself due to the degenerative process [5,6]. ...
Article
Full-text available
Gluteus maximus flap transfer (GMT) is a surgical technique used to improve gait kinematics and kinetics, as well as to reduce and ameliorate the functional outcome in patients with hip abductor deficiency following total hip arthroplasty (THA). The purpose of this observational study was to evaluate the gait pre- and postoperatively and examine whether GMT increases the abduction moment. Materials and methods: A gait analysis based on reflective markers and force plates was performed in 15 patients who underwent GMT and were examined using an optical tracking system before and at a minimum of 13 months after the operation. The median follow-up time was 24 (13-60) months. The primary outcome was hip abduction moment (Nm/kg) during gait. The control group consisted of 15 female subjects without any gait pathology. Results: The mean adduction moment was significantly higher compared with controls before the operation (p = 0.02), but this did not apply to the abduction moment (p = 0.60). At the group level, the abduction moment did not improve postoperatively (p = 0.30). Only six of fifteen patients slightly improved their hip abduction moment postoperatively. However, speed (0.74 to 0.80 m/s) and cadence (94 to 105 steps/min) were improved (p < 0.03). Discussion: The results of this study showed no improvement in the hip abduction moment after GMT surgery. In our experience, abduction deficiency following primary THA is still a difficult and unsolved problem.
... However, they defined TFL atrophy as a deterioration of two or more steps in the Goutallier classification or a decrease in the crosssectional area of the TFL by 40% or more, which seems to be an underestimation because the criteria for atrophic change are too strict. Grob et al. [13] stated that the diagnosis of SGN terminal branch lesions may be delayed because they are not always accompanied by symptoms. They reported that a patient who underwent THA via an anterior approach had a depressed TFL that was visibly atrophic from the outside but had exactly the same good clinical and functional results as the contralateral side. ...
Article
Full-text available
Background and Objectives: We performed anterolateral total hip arthroplasty (ALS THA) with the purpose of complete muscle-tendon preservation without muscle-tendon dissection. This study aimed to evaluate muscle damage in the periprosthetic hip joint muscles of patients undergoing ALS THA at 1-year post-operative hip magnetic resonance imaging (MRI). Materials and Methods: We evaluated changes in the muscle cross-sectional area (M-CSA) and fatty atrophy of the periprosthetic muscles. We also assessed the Harris hip score on pre-operative and 12-month post-operative MRI in 66 patients who underwent ALS THA. The grade of M-CSA atrophy was classified into no atrophy, slight atrophy, moderate atrophy, and severe atrophy. Fatty atrophy was classified as improved, no change, and worsened using the Goutallier classification. Results: More than 90% of patients’ M-CSA had no atrophy in the obturator internus (Oi), obturator externus (Oe), gluteus medius (Gmed), and gluteus minimus (Gmin), and some improvement was observed in terms of fatty atrophy. In contrast, M-CSA of the tensor fascia latae (TFL) muscle was clearly decreased, and there was no improvement in the TFL fatty atrophy. However, the presence or absence of TFL atrophy did not affect clinical outcome. Conclusions: We performed the complete muscle preserving procedure, ALS THA, with attention to preserving the Oi and Oe by direct visual confirmation and gentle treatment of the Gmed and Gmin with effective retraction. Post-operative M-CSA atrophy evaluation on MRI showed that the Oi, Oe, Gmed, and Gmin were satisfactorily preserved; however, the TFL was clearly atrophic. In the ALS approach, where entry is made between Gmed and TFL, atrophy of the TFL due to superior gluteal nerve injury must be tolerated to some extent.
... Prevention of iatrogenic damage to the nerve is much more important in light of the fact that a high proportion of patients do not recover completely even after several months of the surgery [8,14]. The distance of SGN with respect to the surrounding bony landmarks like greater trochanter, PSIS, ASIS, AIIS and superior rim of the acetabulum has been measured previously (Table 2) [15,16,17,18]. With this data, a safe zone has been defined by some authors, operating within which would not damage the nerve. ...
Article
Full-text available
Introduction: The superior gluteal nerve (SGN) is a branch of sacral plexus with root value of L4, L5 and S1. It leaves pelvic cavity through greater sciatic foramen along with superior gluteal artery above piriformis. This neurovascular bundle lies in close proximity to superior acetabular rim. Iatrogenic damage to SGN is common during hip arthroplasties and may be primarily attributed to inappropriate placement of retractors. Alarmingly high percentage of affected individuals are stuck with persistent irreversible damage to SGN. Vascular injuries are not as common but pose a challenging scenario to surgeons. Hence in both situations prevention is of supreme importance. Precise knowledge of course and relation of superior gluteal neurovascular bundle (SGNVB) to clinically useful landmarks such as the superior rim of acetabulum is desired. With an aim to provide baseline data for the Indian population we conducted this study. Material and methods: 200 dry adult Indian hip bones {Left side -109(male:66, female:43); Right side-91(male:66, female:43)} were photographed in anatomical position. Two lines- line A and line B were drawn. Line A corresponded to a horizontal passing through the anterior inferior iliac spine (AIIS) and roof of GSN while line B passed tangentially through the highest point on the acetabular rim parallel to line A. The vertical distance (white line) between the 2 lines was measured (Fig.2) was measured using Image J software. Results: The mean distance calculated was 0.62 ± 0.16 cm (0.68 ± 0.38 cm in right hip bones and 0.60 ± 0.30 cm in left side hip bones). The difference between the two sides and the two genders were compared and found to be statistically non- significant. Conclusion: A safe zone of 0.5 to 0.7 cm beyond the superior acetabular rim should be considered during surgeries around hip joint. The safe zone can be easily measured by the surgeons intraoperatively and be used as a guide to careful positioning of the retractors while performing surgeries around the hip joint. Better localization of SGNVB using the anatomic landmark defined in this study may be used to decrease surgical morbidity. KEY WORDS: Superior Gluteal, Acetabulum, Hip Joint, Total hip arthroplasty, Safe Zone.
Article
Case: A patient with Aitken type A proximal focal femoral deficiency (PFFD) and significant limb length discrepancy managed with total hip arthroplasty making use of a novel technique that features a direct anterior approach (DAA) and a subtrochanteric shortening osteotomy. Conclusion: Although the current description of the shortening osteotomy is for PFFD, it is versatile enough to allow its application in other hip pathologies requiring subtrochanteric shortening in the setting of total hip arthroplasty. The authors believe that the description of this case report and surgical technique may be an option for the experienced DAA surgeon.
Chapter
Recovery after anterior-based muscle-sparing (ABMS) total hip arthroplasty (THA) is accelerated compared with historic and contemporary non-muscle-sparing approaches, leading to earlier discharge home, quicker return to driving and work, and a higher level of patient satisfaction. Successful rehabilitation starts with presurgical considerations and depends on meticulous perioperative pain, nausea, and hemodynamic management and then a stepwise, measured approach to mobilization through the healing process. In this chapter, we will discuss a process to support accelerated recovery from ABMS THA with a goal of the least chance of postoperative complications. We will offer an example of one protocol used at a successful ABMS program. Finally, we will discuss physical therapy methods to overcome some common challenges in patients recovering from ABMS surgery.
Article
Abductor deficiency after total arthroplasty is rare and challenging problem facing reconstructions surgeons today. The etiologies are vast. Herein we review the relevant anatomy of the abductor mechanism, as well as the course and potential sites of injury for the superior gluteal nerve. The diagnosis can be challenging, but a focus on history and physical examination are the most important diagnostic tools. Supplemental modalities include plain radiographs, arthrography, ultrasound, EMG, and MRI. A variety of treatment exist for symptomatic abductor deficiency. We review potential modalities ranging from soft tissue transfers, trochanter fixation and osteotomy with a slide, as well as potential revision components.
Article
Objectives: Iliosacral (IS) and transsacral (TS) screws are popular techniques to repair complicated injuries to the pelvis. The anatomy of the superior gluteal neurovasculature (SG NV bundle) is well described as running along the posterior ilium, providing innervation and perfusion to important abductor muscles. The method of pelvis fixation least likely to injure the SG NV bundle is unknown. Methods: Twenty uninjured patients with a contrasted computed tomogram of the pelvis and lower extremities (CTA) were evaluated. Starting points for an S1 IS screw, and S1 and S2 TS screws were estimated on the "ghost" lateral CTA image for those pelvi with safe corridors (>9mm diameter). The distance from the projected screw to the SG artery was measured. A distance of <3.65mm (half of a 7.3mm screw's diameter) was considered likely for NV bundle injury. Results: Of forty pelvi CTA's (single sides), 10 pelvi (25%) were determined to be inappropriate for a S1 TS screw. The average distances from the screw starting point and the artery were 25.3mm (±9.2) for S1 IS, 12.4mm (±9.0) for S1 TS, and 23.5mm (±10.7) for S2 TS screws, respectively. Ten S1 TS screws (25%) and no S1 IS or S2 TS screws were projected to have caused injury to the SG NV bundle (P<0.001). Conclusions: Inserting S1 IS and S2 TS screws put the SG NV anatomy at significantly less risk than S1 TS screws. This information may aid in choosing the "best" fixation option for patients with pelvic ring trauma requiring surgery. Level of evidence: Therapeutic level III.
Article
Introduction: Minimally invasive approaches (direct anterior approach: DAA; minimally invasive anterolateral: MIAL; piriformis-sparing posterior approach: PSPA) are widely used for total hip arthroplasty (THA), with a muscle-sparing objective. There are no published comparative studies of muscle damage secondary to these approaches. The aim of the present study was to compare fatty infiltration (FI) on MRI induced by DAA, MIAL and PSPA in THA 1) in the tensor fasciae latae (TFL) and sartorius muscles, 2) in the gluteal muscles, and 3) in the pelvitrochanteric muscles. Hypothesis: Greater FI is induced by DAA in anterior muscles, by MIAL in gluteal muscles and by PSPA in pelvitrochanteric muscles. Materials and Methods: Three continuous prospective series of THA by DAA, MIAL and PSPA included 25 patients each. MRI was performed preoperatively and at 1 year postoperatively. FI was graded on the Goutallier classification in all periarticular hip muscles. Muscles showing ≥2 grade aggravation at 1 year were considered damaged. Results: Nine patients whose preoperative MRI was uninterpretable were excluded. In all, 66 patients (21 DAA, 24 MIAL and 21 PSPA) with 132 MRI scans were analyzed. TFL was damaged in 2/21 DAA patients (9.5%), 1/24 MIAL patients (4.2%) and 0/21 PSPA patients (0%). There were no sartorius lesions. The anterior third of the gluteus medius was damaged in 8/24 MIAL patients (33.3%) and the gluteus minimus in 10/24 (41.7%), compared to 1/21 DAA patients (4.8%) and 0/21 PSPA patients (0%). The mid and posterior thirds of the gluteus medius and the gluteus maximus were never damaged. The piriformis muscle was damaged in 3/21 DAA patients (14.3%), 2/24 MIAL patients (8.3%) and 2/21 PSPA patients (9.5%). The obturator internus was damaged in 4/21 DAA patients (19%), 1/24 MIAL patients (4.2%) and 16/21 PSPA patients (76.2%). The obturator externus and quadratus femoris were mainly damaged in PSPA patients: respectively, 5/21 (23.8%) and 4/21 patients (19%)). Conclusion: The muscle-sparing properties of minimally invasive hip approaches are only theoretical. In the present series, there were rare TFL lesions with DAA and MIAL. Gluteus medius and minimus lesions were frequent in MIAL. Pelvitrochanteric muscles lesions were more frequent in PSPA, but found in all 3 approaches. These findings should help guide surgeons in their choice of approach and in informing patients about the damage these minimally invasive approaches can cause. Level of evidence: III, prospective comparative study
Article
Objective: To retrospectively compare the mid-term effectiveness between by direct anterior approach (DAA) and by posterolateral approach in total hip arthroplasty (THA). Methods: Between January 2009 and December 2010, 110 patients (110 hips) treated with THA and followed up more than 5 years were chosen in the study. THA was performed on 55 patients by DAA (DAA group), and on 55 patients by posterolateral approach (PL group). There was no significant difference in gender, age, body mass index, types of hip joint disease, and preoperative Harris score between 2 groups ( P>0.05). The operation time, amount of bleeding, length of hospital stay, postoperative complications, and the Harris scores were recorded and compared. Results: There was no significant difference in operation time and length of hospital stay between 2 groups ( t=0.145, P=0.876; t=1.305, P=0.093). The amount of bleeding was significantly less in DAA group than in PL group ( t=2.314, P=0.032). All patients were followed up 5-7 years (mean, 5.97 years). Complications happened in 5 cases (9.1%) of DAA group and in 3 cases (5.5%) of PL group, and there was no significant difference in the incidence of complications between 2 groups ( χ2=0.539, P=0.463). There was significant difference in Harris scores at 6 months after operation between 2 groups ( t=2.296, P=0.014), but no significant difference was found in Harris score at 1 year and 5 years between 2 groups ( t=1.375, P=0.130; t=0.905, P=0.087). Further analysis, at 6 months after operation, the joint function score in DAA group was significantly higher than that in PL group ( t=1.087, P=0.034), while there was no significant difference in the pain score and range of motion score between 2 groups ( t=1.872, P=0.760; t=1.059, P=0.091). Conclusion: THA by DAA has the advantages of less bleeding and faster recovery. The short-term effectiveness is superior to the THA by traditional posterolateral approach, but there is no obvious advantage in the mid-term effectiveness.
Article
Objective: To compare the short-term effectiveness of staged bilateral total hip arthroplasty via different approaches. Methods: Thirty-two patients (64 hips) with bilateral hip disease were treated with total hip arthroplasty between January 2012 and December 2014. There were 20 males and 12 females with the mean age of 45.3 years (range, 30-67 years). There were avascular necrosis of femoral head in 14 cases, developmental dislocation of the hip in 12 cases, ankylosing spondylitis in 4 cases, osteoarthritis in 2 cases. All patients were treated with total hip arthroplasty; and the direct anterior approach (DAA) or direct lateral approach (DLA) was chosen for the unilateral hip randomly. The length of incision, operation time, total blood loss volume, the time of first postoperative activity, and the acetabular anteversion angle were compared. The Harris score, visual analogue scale (VAS) score, and incidence of complication were compared between 2 groups. Results: All incisions healed at stage Ⅰ. All patients were followed up 20-53 months (mean, 39.6 months). The length of incision, total blood loss volume, the time of first postoperative activity were significantly shorter in DAA group than in DLA group ( P<0.05). The operation time was significantly longer in DAA group than in DLA group ( P<0.05). There was no significant difference in acetabular anteversion angle between 2 groups ( t=1.122, P=0.266). The incidence of complication were 25.00% and 15.63% in DAA group and DLA group, respectively, showing no significant difference ( χ2=0.869, P=0.536). The Harris score in DAA group significantly increased at 3 and 9 months after operation than in DLA group ( P<0.05); there was no significant difference at 18 months after operation between 2 groups ( P>0.05). The VAS score was significantly lower in DAA group than in DLA group at 1 day, 3 days, and 1 week after operation ( P<0.05); there was no significant difference at 4 and 8 weeks between 2 groups ( P>0.05). The prosthesis did not loosen and sink during the follow-up. Conclusion: Total hip arthroplasty via DAA can reduce operation related complication and speed up the recovery of hip function at the early stage after operation. However, the lateral cutaneous nerve injury is the most common complication.
Article
Although superior gluteal nerve (SGN) injury can have significant morbidity, to date, surgical strategies for its repair are scant in the literature. Specifically, neurotization options have not been explored. To address this deficiency in the literature, the current cadaveric feasibility study was performed. Via a transgluteal approach on 16 cadaveric sides, the proximal sciatic nerve and the entrance of the SGN into the gluteus medius and minimus were identified. Additionally, branches from the sciatic nerve to the hamstring muscles were traced proximally to confirm their position in relation to the sciatic nerve as a whole. These branches were cut at the level of the ischial tuberosity and teased away from the sciatic nerve proximally to the greater sciatic foramen and transferred superolateral to the SGN. The diameter of each nerve branch was measured as well as its available length for reaching the SGN. All branches of the sciatic nerve to the hamstring muscles arose from the anteromedial part of the nerve. The mean diameters of the branches to the semimembranosus, semitendinosus, and biceps femoris muscles were 2.1 mm, 1.9 mm, and 1.5mm, respectively. The mean diameter of the SGN was 3.1 mm and the mean distance from this entrance point to the ischial spine was 7.2 cm. The mean length of the donor nerve was 8.5 cm. Based on our study, use of a tibial-innervated hamstring branch as a donor for nerve transfer to the SGN is feasible. This article is protected by copyright. All rights reserved.
Chapter
The incidence of nerve injury ranges from 0.17% to 3.7% during primary hip arthroplasty and is reported to be as high as 7.5% in revision surgery. It is an often serious complication arising from this frequently performed surgical procedure. There is a wide range of severity of nerve injury, with more severe injuries having a notable impact on the patient’s overall functional outcome. In describing the pathophysiology and risk factors for nerve injury during total hip arthroplasty, the authors will delineate preventative measures and appropriate steps for referral and subsequent management.
Article
Abductor deficiency following total hip arthroplasty is a rare and complex problem facing reconstructive surgeons today. The appropriate management is contingent on a thorough knowledge of the clinical anatomy of the abductor mechanism and its potential pathology during and after total hip arthroplasty. Throughout this review we will highlight the relevant clinical anatomy, diagnostic modalities, and various surgical options to aid in the appropriate management of this difficult problem.
Article
* While no single approach for total hip arthroplasty (THA) has been proven to be superior to others in terms of patient outcomes, the direct anterior approach (DAA) is becoming increasingly popular. * All of the described techniques for THA carry a small risk of nerve injury. * Identifying risk factors for nerve injury and mitigating these risks where feasible are imperative in order to reduce the incidence of this complication with any approach for THA.
Chapter
This chapter will discuss the lateral thigh perforator (LTP) flap for the use in breast reconstructive surgery. The LTP is an alternative flap for those patients in whom the first choice donor site, the abdomen, is not suitable as a do nor site. The history of the LTP flap, also known as the septocutaneous perforator tensor fasciae latae (TFL) flap, is described. Knowledge of the topographical and functional anatomy of the thigh is crucial for a surgeon when harvesting the LTP flap. Preoperative radiological imaging is essential in selecting suitable patients and planning the surgical procedure, which is systematically explained in the paragraph “Surgical Technique.” The authors share their experience and provide the reader with tips to perform a LTP flap breast reconstruction.
Article
In total hip arthroplasty, the advantages of the direct anterior approach (DAA) compared with the direct lateral and posterior approaches include a true intermuscular approach that spares the abductor musculature, protects the soft tissues surrounding the hip, and thus maintains hip joint stability. The disadvantages of the DAA compared with the direct lateral and posterior approaches include a steep learning curve; intraoperative radiation exposure; injury to the nerves, vessels, and muscles; and intraoperative and early postoperative complications including blood loss, wound-healing problems, increased time under anesthesia, proximal femoral fractures and dislocations, complex femoral exposure and bone preparation, and sagittal malalignment of the stem leading to loosening and an increased revision rate. Stem implantation in flexed sagittal position and early femoral-stem failures are more common with the DAA compared with the direct lateral and posterior approaches.
Article
Iatrogenic nerve injury is a rare but potentially devastating complication in total joint arthroplasty of the hip and the knee. Multiple previous studies have evaluated the incidence, mechanisms of injury, recovery, and potential treatments for this complication. Injury in total hip arthroplasty generally involves direct injury of sensory nerves from the incision, direct or traction injury of during exposure, or limb lengthening. Injury in total knee arthroplasty generally involves direct injury of sensory nerves from incision, injury due to errant placement of retractors, during balancing, or from traction because of deformity correction. Treatment of iatrogenic nerve injuries has ranged from observation, intraoperative prevention by nerve monitoring, limb shortening postoperatively, medications, and decompression. The orthopaedic surgeon should be versed in these etiologies to advise their patients on the incidence of injury, to prevent occurrence by understanding risky intraoperative maneuvers, and to select appropriate interventions when nerve injuries occur.
Article
Purpose This study aims to reveal the exact course of the superior gluteal nerve (SGN) branch innervating the tensor fascia lata (TFL) and show how it can be protected in the direct anterior approach (DAA) and anterolateral approach (ALA). Methods The anterolateral regions of 22 thighs from formalin-fixed cadavers were dissected. 3 anatomical points were determined. Point A, B, C indicates where the SGN enters the gluteus minimus (GMin) fibres, the SGN leaves the gluteal muscles, the SGN enters the TFL, respectively. Measurements were made on 3 separate lines. Results On the anterior superior iliac spine (ASIS) and the head of the fibula line (Line 1), the horizontal–vertical distances from point B and C to the ASIS were 7.99 ± 3.65 mm–40.40 ± 11.50 mm and 11.74 ± 6.61 mm–70.35 ± 14.11 mm respectively. The horizontal-vertical distances from point A, B, C to the greater trochanter (GT) were 32.41 ± 9.97 mm–55.28 ± 12.25 mm; 67.70 ± 8.54 mm–17.76 ± 13.57 mm; 63.92 ± 9.96 mm–13.00 ± 7.92 mm on the GT and the head of the fibula line (Line 2), respectively. The horizontal-vertical distances from point A, B, C to the GT were 24.58 ± 9.83 mm–42.54 ± 12.86 mm; 9.45 ± 7.92 mm–36.25 ± 9.06 mm; 26.18 ± 11.12 mm–64.05 ± 11.67 mm on the ASIS and the GT line (Line 3). Conclusions In the DAA, the increased risk of damaging the branch of the SGN that innervates the TFL must be kept in mind. The protection of this branch can be ensured with easy and applicable rules.
Article
Résumé Introduction Les abords mini-invasifs (voies antérieures mini-invasives (VAMI), voies antérolatérales mini-invasives (VALMI) et abords postérieurs épargnant le piriforme (APEP)) utilisés pour l’implantation d’arthroplasties totales de hanche (ATH) sont largement utilisés en orthopédie et prônent une théorique épargne musculaire. Aucune étude comparative des dommages musculaires secondaires à ces abords n’est disponible dans la littérature. L’objectif de notre étude était de comparer via IRM, l’infiltration graisseuse (IG) induite par les VAMI, VALMI et APEP dans le cadre d’ATH au niveau : (1) des muscles tenseur du fascia lata (TFL) et sartorius (2) des muscles glutéaux (3) et des muscles pelvitrochantériens. Hypothèse Nous avons émis l’hypothèse que les VAMI engendreraient comparativement davantage d’IG au niveau des muscles antérieurs, les VALMI au niveau des muscles glutéaux et les APEP au niveau des muscles pelvitrochantériens. Matériels et méthodes Trois séries prospectives continues d’ATH par VAMI, VALMI et APEP, comprenant chacune 25 patients, ont été réalisées. Des IRM ont été réalisées en préopératoire, puis à 1 an de la chirurgie. L’analyse de l’IG selon la classification de Goutallier était réalisée sur l’ensemble des muscles périarticulaires de hanche. Les muscles qui présentaient une augmentation d’au moins 2 stades d’IG entre l’IRM préopératoire et l’IRM à 1 an étaient considérés comme lésés. Résultats Les IRM préopératoires de 9 patients n’étaient pas interprétables. Ces patients ont été exclus de l’analyse. Au total 66 patients (21 VAMI, 24 VALMI et 21 APEP) et 132 IRM ont été analysés. Le TFL de 2/21 patients (9,5 %) était lésé dans les VAMI, contre 1/24 patient (4,2 %) dans les VALMI et 0/21 patients (0 %) dans les APEP. Aucun sartorius ne présentait de lésions. Le tiers antérieur du moyen glutéal de 8/24 patients (33,3 %) et le petit glutéal de 10/24 patients (41,7 %) étaient lésés dans les VALMI, contre 1/21 (4,8 %) patient dans les VAMI et 0/21 (0 %) patient dans les APEP. Les tiers moyen et postérieur du moyen glutéal ainsi que le grand glutéal n’étaient pas lésés. Le piriforme de 3/21 patients (14,3 %) était lésé dans les VAMI contre 2/24 patients (8,3 %) dans les VALMI et 2/21 patients (9,5 %) dans les APEP. L’obturateur interne de 4/21 patients (19 %) était lésé dans les VAMI contre 1/24 patient (4,2 %) dans les VALMI et 16/21 patients (76,2 %) dans les APEP. L’obturateur externe et le carré fémoral étaient majoritairement lésés dans les APEP (respectivement 5/21 patients [23,8 %] et 4/21 patients [19 %]). Conclusion L’épargne musculaire des abords mini-invasifs de hanche dans les ATH est uniquement théorique. Dans notre étude, de rares lésions du muscle TFL étaient constatées dans les VAMI et les VALMI. De fréquentes lésions des muscles moyen et petit glutéaux étaient présentes dans les VALMI. Enfin, des lésions des muscles pelvitrochantériens, bien que plus fréquentes dans les APEP, étaient constatées dans ces trois abords chirurgicaux. Ces résultats doivent permettre aux chirurgiens d’orienter le choix de leur abord chirurgical ainsi que d’informer loyalement les patients sur les dommages causés par ces abords mini-invasifs. Niveau de preuve III, étude prospective comparative.
Article
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We have carried out a blind, prospective study of 50 consecutive patients undergoing replacement arthroplasty of the hip using two different approaches. Clinical assessment, including the Harris hip score and a modified Trendelenberg test, and electrophysiological examination of the abductor muscles of the hip were undertaken before and three months after surgery. We found that 48% of patients had preoperative evidence of chronic injury to the superior gluteal nerve. Perioperative injury to the nerve occurred commonly with both approaches to the hip. We did not find a significant correlation between injury to the superior gluteal nerve and clinical problems.
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Minimally invasive surgery (MIS) for hip replacement is thought to minimize soft tissue damage. We determined the damage caused by 4 different MIS approaches as compared to a conventional lateral transgluteal approach. 5 surgeons each performed a total hip arthroplasty on 5 fresh frozen cadaver hips, using either a MIS anterior, MIS anterolateral, MIS 2-incision, MIS posterior, or lateral transgluteal approach. Postoperatively, the hips were dissected and muscle damage color-stained. We measured proportional muscle damage relative to the midsubstance cross-sectional surface area (MCSA) using computerized color detection. The integrity of external rotator muscles, nerves, and ligaments was assessed by direct observation. None of the other MIS approaches resulted in less gluteus medius muscle damage than the lateral transgluteal approach. However, the MIS anterior approach completely preserved the gluteus medius muscle in 4 cases while partial damage occurred in 1 case. Furthermore, the superior gluteal nerve was transected in 4 cases after a MIS anterolateral approach and in 1 after the lateral transgluteal approach. The lateral femoral cutaneous nerve was transected once after both the MIS anterior approach and the MIS 2-incision approach. The MIS anterior approach may preserve the gluteus medius muscle during total hip arthroplasty, but with a risk of damaging the lateral femoral cutaneous nerve.
Article
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The influence of surgical trauma on gluteus minimus muscle in total hip arthroplasty (THA) and the impact on functional outcome has been hardly investigated up to now. Potential risks of minimus damage during the approach or femoral preparation is due to its attachment to the anterior facet of the greater trochanter. Possible trauma-associated functional deficits of minimus muscle may result in reduced abduction force or in an unstable hip joint. The aim of the present study was to assess the pre- and post-operative gluteus minimus muscle (tendon defects and fatty atrophy) in patient with anterolateral minimally invasive and modified lateral approach by means of magnetic resonance imaging (MRI) and to investigate the associated impact on functional outcome. Thirty-eight patients [average age, 64 years (35-80); BMI, 28 kg/m(2) (19-35)] with primary coxarthrosis were prospectively enrolled in the study. A cementless hip prosthesis was implanted either via a minimally invasive anterolateral or a modified direct lateral approach. Patients were clinically and radiologically (MRI) examined preoperatively, 3, and 12 months postoperatively. Additionally, the Harris hip score, a pain score (NRS 0-10) and a satisfaction score (1-6) were recorded. To test the function of the abductor muscles the Trendelenburg's sign and the abductor muscle strength were evaluated. MRI evaluation includes the assessment of tendon defects and fatty atrophy of the minimus muscle. Tendon defects and fatty atrophy were seen in nearly 50% of the patients after THA. Harris hip-, pain-, and satisfaction scores did not correlate with the MR findings. There was also no impact on the abduction strength or the Trendelenburg's sign. Furthermore, the frequency of minimus damage was neither influenced by age, gender, BMI nor by the applied approach. Muscle atrophy and tendon defects of the minimus muscle appear frequently after THA without any favored relation to the lateral or anterolateral approach. The extent of injured minimus muscle has a minor impact on the clinical outcome particularly not on the abduction strength within the first postoperative year. The main function of the gluteus minimus is rather the centralization of the femoral head in the joint during the gait cycle than hip abduction and stabilization of the pelvis. The use of a straight stem with the associated need for lateral femoral preparation may be a risk factor for minimus tendon damage. Therefore, the surgeon should pay special attention to the prevention of surgical trauma to the gluteus minimus muscle during femoral preparation.
Article
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To prospectively evaluate magnetic resonance (MR) imaging findings of abductor tendons and muscles in asymptomatic and symptomatic patients after lateral transgluteal total hip arthroplasty (THA). The institutional review board approved the study, and all patients provided informed consent. Two musculoskeletal radiologists blinded to clinical information analyzed triplanar MR images of the greater trochanter obtained in 25 patients without and 39 patients with trochanteric pain and abductor weakness after THA. Tendon defects, diameter, signal intensity, and ossification; fatty atrophy; and bursal fluid collections were assessed. In 14 symptomatic patients, MR imaging and surgical findings were correlated. Differences in the frequencies of findings between the two groups were tested for significance by using chi2 analysis. Tendon defects were uncommon in asymptomatic patients and significantly more frequent in symptomatic patients: Two asymptomatic versus 22 symptomatic patients had gluteus minimus defects (P < .001); four asymptomatic versus 24 symptomatic patients, lateral gluteus medius defects (P < .001); and no asymptomatic versus seven symptomatic patients, posterior gluteus medius defects (P = .025). In both patient groups, tendon signal intensity changes were frequent, with the exception of those in the posterior gluteus medius tendon, which demonstrated these changes more frequently in symptomatic patients (in 23 vs five asymptomatic patients, P = .002). Tendon diameter changes were frequent in both groups but significantly (P = .001 to P = .009) more frequent in symptomatic patients (all tendon parts). Fatty atrophy was evident in the anterior two-thirds of the gluteus minimus muscle in both groups, without significant differences. In the posterosuperior third of the gluteus minimus muscle, however, differences in fatty atrophy between the two groups were significant (P = .026). Fatty atrophy of the gluteus medius muscle was present in symptomatic patients only, with significant differences among all muscle parts. Bursal fluid collections were more frequent in symptomatic patients (n = 24) than in asymptomatic patients (n = 8, P = .021). The MR imaging-based diagnosis was confirmed in all 14 patients who underwent revision surgery. Abductor tendon defects and fatty atrophy of the gluteus medius muscle and the posterior part of the gluteus minimus muscle are uncommon in asymptomatic patients after THA.
Book
Part of the highly regarded Master Techniques in Orthopaedic Surgery series, Relevant Surgical Exposures, Second Edition, is a concise, lavishly illustrated reference designed to assist today’s orthopaedic surgeons in a crucial task: choosing and executing the exposure necessary for a given procedure. It presents successful, widely used exposures for hand and wrist, forearm, elbow, humerus, shoulder, pelvis, hip and acetabulum, femur, knee, tibia and fibula, foot and ankle, and spine, all in step-by-step detail. Fully revised with new exposures, anatomic dissections, and illustrations throughout, as well as a section on preferred exposures for trauma, this Second Edition is ideal for orthopaedic surgeons at all levels of experience. • Presents approximately 100 preferred exposure techniques of surgical masters, illustrated with full-color, sequential, surgeon’s-eye view photographs, as well as superb drawings by noted medical illustrators. • Virtually every chapter is enhanced by exceptional anatomic dissections of unexcelled quality. • Includes substantial additions to the shoulder, hip and acetabulum, knee and leg, as well as many more exposures for minimally invasive procedures in all areas. • Features enhanced and expanded full-color drawings throughout. • Provides the up-to-date guidance you need to master both well-established exposures and recent exposures for minimally invasive procedures. • Contains practical guidance, pearls, and tips from Dr. Bernard Morrey and his son, Dr. Matthew Morrey, as well as other leading orthopaedic surgeons.
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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. 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. 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. 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. Distal extension of the direct anterior approach to the hip beyond the intertrochanteric line may compromise neurovascular structures supplying the quadriceps muscle. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
Article
Der muskuläre Weichteilschaden nach primärer Hüftprothesenimplantation unter Verwendung eines minimal-invasiven anterioren Zugangs wurde mit Hilfe der MRT bei 25 Patienten prä- und 6 Monate postoperativ untersucht. Als Untersuchungsparameter wurden die fettige Infiltration sowie die Veränderung des Muskelquerschnitts als Ausdruck einer Atrophie gemessen. MR-tomographisch können sowohl präoperativ bestehende als auch zugangsbedingte Muskelschäden durch Bestimmung der Muskelquerschnittsfläche und der fettigen Infiltration gefunden werden. Bereits präoperativ wurden aufgrund der Koxarthrose eine vermehrte Atrophie und fettige Infiltration der periartikulären Hüftmuskulatur nachgewiesen. Für den minimal-invasiven vorderen Zugang zeigten sich postoperativ sowohl für den M. tensor fasciae latae als auch für den M. glutaeus minimus ein signifikanter Muskelschaden und eine signifikant ansteigende fettige Infiltration. Dagegen waren für den M. glutaeus medius keine signifikanten Veränderungen feststellbar.
Article
The authors present a study of the intrinsic anatomy of the gluteus medius m. and of its innervation through the caudal branch of the superior gluteal n. The existence of an intramuscular tendon in the thickness of the gluteus medius was constantly prooved in 40 muscles. The relations of the intrinsic fibrous structure of the muscle and its innervation were studied. The authors deduce from that the topography of a gluteus medius incision, with respect to a safety area towards its innervation, which leads to an exposure of the acetabulum that is satisfying and gives opportunities of a sound repair after the surgery of the hip joint through the transgluteal approach. They propose the “anterior hemimyotomy of the gluteus medius m” designation.
Article
The modified Watson-Jones approach to the hip has been described as a minimally invasive approach with the potential for fewer postoperative complications than the traditional approach. Because the approach relies on an intermuscular rather than an internervous plane, there is potential for injury to the superior gluteal nerve. The aim of this study was to evaluate incidence of tensor fascia lata (TFL) denervation in patients undergoing this approach. Twenty-six patients underwent total hip arthroplasty (THA) using a modified anterolateral approach. Postoperative MRIs were analyzed for signs of muscle denervation including atrophy, hypertrophy and fat replacement. At a median follow-up of 9.3months, 74% of patients exhibited either atrophy or hypertrophy of the TFL and 42% exhibited fat replacement on MRI.
Article
Muscle trauma in minimally invasive hip arthroplasty using a direct anterior approach was assessed by magnetic resonance imaging (MRI) in 25 patients preoperatively, as well as 6 months after total hip replacement. The MRI evaluation included the measurement of changes in muscle cross-sectional area (CSA = atrophy) and fatty infiltration of the muscles. Using MRI, preoperatively existing and operatively caused muscle tissue damage could be detected by assessing changes in muscle CSA and fatty infiltration. Even preoperatively, a muscular atrophy and fatty infiltration could be demonstrated in the diseased hip. Using the minimally invasive direct anterior approach, a postoperative significantly reduced CSA and significantly increased fatty degeneration was detected for the M. tensor fasciae latae and the M. glutaeus minimus. No increased damage of the M. glutaeus medius could be detected.
Article
The gluteus medius and minimus muscle-tendon complex is crucial for gait and stability in the hip joint. There are three clinical presentations of abductor tendon tears. Degenerative or traumatic tears of the hip abductor tendons, so-called rotator cuff tears of the hip, are seen in older patients with intractable lateral hip pain and weakness but without arthritis of the hip joint. The second type of tear may be relatively asymptomatic. It is often seen in patients undergoing arthroplasty for femoral neck fracture or elective total hip arthroplasty (THA) for osteoarthritis. The third type of abductor tendon dysfunction occurs with avulsion or failure of repair following THA performed through the anterolateral approach. Abductor tendon tear should be confirmed on MRI. When nonsurgical management is unsuccessful, open repair of the tendons with transosseous sutures is recommended. Good pain relief has been reported following endoscopic repair. Abductor tendon repair has had inconsistent results in persons with avulsion following THA. Reconstruction with a gluteus maximus muscle flap or Achilles tendon allograft has provided promising short-term results in small series.
Article
The direct anterior approach in total hip replacement anatomically offers the chance to minimise soft-tissue trauma because an intermuscular and internervous plane is explored. This motivated us to abandon our previously used transgluteal approach and to adopt the direct anterior approach for total hip replacement. Using MRI, we performed a retrospective comparative study of the direct anterior approach with the transgluteal approach. There were 25 patients in each group. At one year post-operatively all the patients underwent MRI of their replaced hips. A radiologist graded the changes in the soft-tissue signals in the abductor muscles. The groups were similar in terms of age, gender, body mass index, complexity of the reconstruction and absence of symptoms. Detachment of the abductor insertion, partial tears and tendonitis of gluteus medius and minimus, the presence of peri-trochanteric bursal fluid and fatty atrophy of gluteus medius and minimus were significantly less pronounced and less frequent when the direct anterior approach was used. There was no significant difference in the findings regarding tensor fascia lata between the two approaches. We conclude that use of the direct anterior approach results in a better soft-tissue response as assessed by MRI after total hip replacement. However, the impact on outcome needs to be evaluated further.
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Revision total hip arthroplasty through the direct anterior approach is technically challenging but offers some advantages in exposure of the acetabulum. This study presents a retrospectively reviewed consecutive series of fifty-one patients who underwent revision total hip arthroplasty through the anterior approach utilizing various extensions of this technique. The anatomic approach is discussed as well as problems as encountered in our series. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. Copyright
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Iatrogenic femoral nerve injury is a recognized complication of abdominal and pelvic surgery. It causes distress and disability and may lead to permanent motor and/or sensory sequelae. The aim of this systematic review was to explore the contemporary spectrum of this injury reported in the literature. A systematic review of iatrogenic femoral nerve injuries reported between 2000 and October 2010 was undertaken using the electronic databases Medline, PubMed, Cochrane Library, and Google Scholar. The context, frequency, mechanism of injury, and outcome were recorded. Relevant clinical and anatomical literature was reviewed to provide an overview of the surgical anatomy. Iatrogenic femoral nerve injury is not rare, occurring as a complication of common abdominal, pelvic, and orthopedic operations and after femoral nerve blocks and femoral artery puncture. Mechanisms of injury are diverse and include direct trauma and ischemia from retraction or stretching of the nerve. Variant anatomy is very rarely the source of the problem. Although the prognosis in most cases is good some affected patients require nerve repair or grafting and some are left with permanent residual neurologic deficits. A wider awareness of this complication, particularly the context in which it may occur, together with an appropriate understanding of the anatomy of the femoral nerve may help to reduce the frequency of this distressing and disabling iatrogenic complication.
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A variety of surgical techniques have been introduced for the treatment of femoroacetabular impingement, but clinical outcome studies of less-invasive treatment with a minimum duration of follow-up of two years are limited. The purpose of this study was to evaluate the early clinical and radiographic outcomes of combined hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction for the treatment of cam femoroacetabular impingement. We performed a retrospective review of our first thirty-five patients (thirty-five hips) in whom cam femoroacetabular impingement had been treated with combined hip arthroscopy and limited open osteochondroplasty. Thirty-five patients (twenty-eight men and seven women) with an average age of thirty-four years and a minimum duration of follow-up of two years were analyzed. The modified Harris hip score was utilized to assess hip function. The Tönnis osteoarthritis grade and the alpha angle were determined to assess osteoarthritis progression and deformity correction, respectively. The average modified Harris hip score improved from 63.8 points preoperatively to 87.4 points at the time of the last follow-up. Twenty-nine (83%) of the thirty-five patients had at least a 10-point improvement in the Harris hip score, and 71% had a score of >80 points. The average alpha angle was reduced from 58.6 degrees preoperatively to 37.1 degrees at the time of follow-up when measured on cross-table lateral radiographs, from 63.9 degrees to 37.8 degrees when measured on frog-leg lateral radiographs, and from 63.1 degrees to 44.8 degrees when measured on anteroposterior radiographs. Two patients had osteoarthritis progression from Tönnis grade 0 to grade 1. Minor complications included one superficial wound infection, one deep vein thrombosis, and four cases of asymptomatic Brooker grade-I heterotopic ossification. There were no femoral neck fractures or cases of femoral head osteonecrosis, and no hip was converted to an arthroplasty. Early results indicate that combined hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction is a safe and effective treatment for femoroacetabular impingement. In our small series, most patients had symptomatic relief, improved hip function, and enhanced activity after two years of follow-up.
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The anterior approach is a safe, reliable, and feasible technique for total hip arthroplasty, permitting optimal soft tissue preservation. Since Hueter first described this interval, many surgeons have approached the hip anteriorly to perform a myriad of surgical procedures. The anterior approach allows optimal muscle preservation, and it is a truly internervous approach to the hip. An understanding of the evolution of the anterior approach to the hip will help the orthopedic community understand these advantages and why so many have used this approach in the treatment of hip pathology and for the implantation total hip arthroplasty.
Article
Femoroacetabular impingement (FAI) may be considered as an important cause of hip pain among young patients. A new surgical technique using a mini open anterior Hueter approach with arthroscopic assistance was developed in our department in 1999. The goal of our study was to evaluate the midterm clinical results and the quality of life after cam resection, rim trimming, and labrum refixation using this technique. The first 100 hips operated on using this technique were evaluated with the Nonarthritic Hip Score (NAHS) at a mean follow-up of 54 months. The mean age of the patients was 33.4 years, with 50 men and 47 women. At the last follow-up, the mean NAHS score increased significantly from 54.5±12 by 29.6 points to 84.3±16 (p<0.001). The clinical result was very good in 40 cases, good in 38 cases, fair in 8 cases, and poor in 14 patients. Eleven hips developed osteoarthrosis and finally had a total hip replacement. One patient had a femoral neck fracture at 3 weeks postoperatively. The best results were obtained in patients under 40 years of age (53 patients) and with a Tönnis osteoarthrosis grade of 0, 90% of whom had a very good or good result at a mean follow-up of 55 months. Refixation of the labrum was not significantly correlated with a higher NAHS (87±11 versus 82±19, p=0.13) at the last follow-up. Resection of cam FAI of the femoral head-neck junction using a mini anterior Hueter approach with arthroscopic assistance is a safe and effective technique in treating young adults with femoroacetabular impingement. This technique offers direct visualization of the anterior femoral head-neck junction and is less invasive than the surgical dislocation approach.
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Cutaneous branches from the superior gluteal nerve were studied in 39 half pelves (18 right, 21 left) of 23 adult Japanese cadavers. A detailed description of the branches is not currently available in the literature. Most of these branches perforated tensor fascia lata and were distributed to the centre of the lateral gluteal region.
Article
Injuries to the peroneal or tobial divisions of the sciatic nerve occur in approximately 0.7-7.6% of patients undergoing total hip arthroplasty. No prior studies have investigated the incidence of injury to the superior or inferior gluteal nerves during hip surgery. This study evaluates the incidence of injury to the superior and inferior gluteal nerves in 55 patients undergoing total hip arthroplasty using a newly devised EMG scoring system. Subclinical gluteal nerve injury was documented in over 77% of patients, whether a posterior or a lateral approach to the hip was used.
Article
The postoperative integrity of the conjoined aponeurosis of the gluteus medius and vastus lateralis was studied in 97 consecutive total hip arthroplasties in 95 patients performed via a transgluteal approach. Metal markers were placed in the gluteal/vastus aponeurosis, one on each side of the suture line, and the integrity of the repair was assessed on radiographs taken immediately after surgery and 2 weeks, 2 months, and 1 year after operation. Separation between the markers occurred in about half of the patients, but gross separations were rare. Since most separations showed a progressive increment, elongation of the sutured aponeurosis might be a more common mechanism than perioperative injury to the neurovascular pedicle. Moreover, the degree of separation did not correlate with pain, and Trendelenburg gait was significantly increased only in the group of patients with a separation greater than 2.5 cm, indicating that a moderate gluteal elongation may be readily compensated for.
Article
The more accurate description of the anatomy of the glutei and the new biomechanical theory that has been presented describe the abductor mechanism as a system in which the tensor fasciae latae has the primary function of balancing the weight of the body and the non-weight-bearing leg during walking. Gluteus medius with its three parts and phasic functions is responsible for the stabilisation of the hip joint in the initial phase of the gait cycle. It is important also in initiating the major gait determinant of pelvic rotation. Gluteus minimus functions as a primary hip stabiliser during the mid- and late phase of the gait cycle.
Article
The recently described Hardinge approach is currently widely used for implanting total hip prostheses. It is characterized by a dissociation of the fibers of the mid-gluteal, of which the anterior fibers remain continuous with the vastus lateralis. To assess the functional impact, a series of 63 prostheses implanted with the Hardinge approach was compared with an identical series performed with the posterior approach. Results show a lower frequency of dislocation with the Hardinge approach, but also a 33 p. cent residual functional deficiency of the mid-gluteal at one year, compared with 17 p. cent with the posterior approach. A modification of the technique is proposed to limit this phenomenon.
Article
The superior gluteal nerve and its branches were dissected bilaterally in ten cadavera. The patterns of branching and the distribution of the branches were identified. The reference point for measurements was the mid-point of the superior border of the greater trochanter. Two patterns of neural branching were thus established. The points of termination of all branches formed an arcuate pattern along the middle one-third of the deep surface of the gluteus medius muscle. The so-called safe area of the gluteus medius muscle was found to be as much as five centimeters adjacent to the greater trochanter. If this distance is not exceeded by the intramuscular incision, the risk to the superior gluteal nerve and its branches will be minimum.
Article
Electromyographic and clinical studies were performed on patients undergoing total hip replacement by the modified direct lateral (29 hips), the direct lateral (29 hips) and the posterior approaches (21 hips). Assessments were made three months after operation. The Trendelenburg test was positive (Grade II) in eight cases operated upon by the direct lateral route, but in only one of each of the other two groups. Denervation occurred in only five of the 28 hips with abductor weakness without statistical difference between the groups. In the modified direct lateral group, radiological evidence of union of the trochanteric sliver was associated with significantly better abductor function than in those with malunion or non-union.
Article
A new periacetabular osteotomy of the pelvis has been used for the treatment of residual hip dysplasias in adolescents and adults. The identification of the joint capsule is performed through a Smith-Petersen approach, which also permits all osteotomies to be performed about the acetabulum. This osteotomy does not change the diameter of the true pelvis, but allows an extensive acetabular reorientation including medial and lateral displacement. Preparations and injections of the vessels of the hip joint on cadavers have shown that the osteotomized fragment perfusion after correction is sufficient. Because the posterior pillar stays mechanically intact the acetabular fragment can be stabilized sufficiently using two screws. This stability allows patients to partially bear weight after osteotomy without immobilization. Since 1984, 75 periacetabular osteotomies of the hip have been performed. The corrections are 31 degrees for the vertical center-edge (VCE) angle of Wiberg and 26 degrees for the corresponding angle of Lequesne and de Seze in the sagittal plane. Complications have included two intraarticular osteotomies, a femoral nerve palsy that resolved, one nonunion, and ectopic bone formation in four patients prior to the prophylactic use of indomethacin. Thirteen patients required screw removal. There was no evidence of vascular impairment of the osteotomized fragment.
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The application of innominate osteotomy (IO) to persistent subluxation of the hip in adults is limited. Indeed, a relatively small percentage of such adults, particularly those in the fourth and fifth decades of life, meet the precise indications and essential prerequisites for IO. Nevertheless, in most carefully selected young adults in up to and including the fifth decade of life, IO has proved successful. The objective of IO is to prevent degenerative processes in adults with only potential arthritis, seeking arrest or even reversal of the progression of degenerative disease. IO is applicable only to adults who have arthritis in its earliest stages. Achievement of these objectives is dependent on adherence to the exact indications, prerequisites, and contraindications as well as to the details of the surgical technique as described.
Article
A direct lateral approach to the hip is described which allows adequate access for orientation of the implant, for the insertion of the cement and for the correction of discrepancy in leg length. An anatomical observation was made that the gluteus medius muscle is inserted into the greater trochanter by a tendon and that the axis of the shaft of the femur lies anterior to the main bulk of the muscle which was left undisturbed.
Article
Forty-six patients who had undergone excision of one or more well defined hip and/or thigh muscles because of a soft-tissue tumor or a tumoriform lesion were investigated with respect to the function of the operated limb and the isometric and isokinetic strength of the affected motion or motions, relative to the non-operated side (percentage). Hip flexion: Loss of the iliopsoas caused slight impairment of function. The flexion strength decreased with increasing flexion of the hip joint. Loss of the rectus femoris reduced the isometric strength by 37 and the isokinetic strength by 17 per cent. Hip abduction: The strength reduction was only about 50 per cent and the impairment of function only slight or moderate even in patients with extensive loss of abductor muscles. Hip adduction: Removal of all three prime adductors (longus, brevis, magnus) caused a strength reduction of about 70 per cent but the impairment of function was only slight or moderate. Hip extension: Loss of the gluteus maximus caused only a small strength reduction and no impairment or only slight impairment of function. Significant strength reduction was only seen when all hamstrings had been removed. Knee extension: Loss of one, two, and three of the quadriceps muscles reduced the isometric strength by 22, 33, and 55 per cent, respectively. The isokinetic strength was reduced somewhat more. The strength reduction usually had to exceed 50 per cent to cause more than slight impairment of function. Knee flexion: Loss of the semitendinosus, the biceps femoris, and all the hamstrings reduced the isometric strength by 24, 28, and 67 per cent, respectively. The isokinetic strength was reduced somewhat less. Loss of one of the hamstrings usually caused no impairment of function whereas loss of all three resulted in moderate impairment of function.
Article
The purpose of this clinical and radiographic study is to determine whether the surgeon can remain within the 5 cm "safe zone" while using the direct lateral approach during total hip arthroplasty (THA) without endangering the superior gluteal nerve. The direct lateral approach was used in a prospective, consecutive series of 36 primary THAs in 31 patients performed by one surgeon. At the time of closure of the abductor muscle layer, a small metallic clip was placed at the superior extent of the incision into the gluteus medius. After surgery, the patients were mobilized on crutches with protected weight bearing for either a 6-week (hybrid THA) or 12-week (uncemented THA) period. Before surgery, and at 3, 6, and 12 months after surgery, abductor strength and the Trendelenburg sign were measured by the same physical therapist. The vertical distance from the superior pole of the greater trochanter to the base of the clip was measured on all radiographs of the pelvis and corrected for magnification. Before surgery, only 25 of the 36 hips demonstrated abduction strength of 4/5 or greater. Three months after surgery, 34 hips had a grade of 4/5 or greater for abductor strength. The Trendelenburg sign was positive in 24 of 34 hips before surgery, in 5 hips at 3 months, in 1 hip at 6 months, but negative in all hips by 12 months. The clip was located 3.2 +/- 1.3 cm (mean +/- SD) vertically from the superior pole of the greater trochanter. In 34 of 36 hips (95%), the 5 cm safe zone was respected.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
In view of the increasing popularity of the direct lateral approach to the hip joint for hemi- or total hip arthroplasty, the location of the superior gluteal nerve (SGN) was studied. This nerve is in danger when using a transgluteal incision. In 20 embalmed specimens the relation of the SGN to the tip of the greater trochanter (TT) was studied as well as the relation to the iliac crest. For this purpose macroscopy, microscopy and CT were used. In 13 hips a so-called most inferior branch was found at an average of 1 cm distal to the inferior branch, the main trunk of the nerve. There was substantial variation in the course of both the inferior and the most inferior branch of the SGN. In order to prevent nerve damage, proximal extension of the transgluteal incision should be limited to 3 cm cranial to TT. Furthermore the incision has to be confined to the distal one third of the distance TT-iliac crest. In tall people extra care should be taken.
Article
The Transgluteal approach (TGa) to the hip, proposed by BAUER, and often used for total arthroplasties, could be responsible, according to some authors for bad clinical results, due to injury of the nervus gluteus superius (NGS). The aim of this study was to verify the nerve's anatomical condition and evaluate the risks of injury during TGa. Thirty three dissections of fresh corpses in the lateral position (preceded by a TGa) permitted the estimation of the risk and the measurement of the distances between the nerve and the trochanter major (TM). The NGS was sought in the area of the foramen ischiaticum at the proximal side of the piriformis muscle after cutting the vessels and the fat. It was possible to follow it's branches to the end, but we had to lift the m. gluteus medius (mGM), or to cut it transversally. Many anatomical variations were found concerning the point of the nerve's division into 2 branches, nearer or farther from the foramen ischiaticum. The upper branch followed the proximal side of the gluteus minimus (GMin) then innervated the GM and the m. tensor fasciae latae (TFL). the lower branch showed a variable distribution of the strings to the three muscles (GM, GMin and TFL). The TFL's branch ended at upper side of the TM. A safe area, over the TM, without any nerve branches could be determined 7 cm above and behind the TM, 5 cm above it's posterior angle and 3 cm above it's anterior angle. During anterior TGa we noted that the coxofemoral dislocation could tear the GM's proximal fibers and threatened the "inter" or intramuscular nerve filaments. The acetabular exposition by retractors, could compress the more frontal branches. On the contrary using the posterior TGa, neither the dislocation nor the exposition seemed to threaten the nerve, which was farther away and more posterior. In this study we confirmed the existence of numerous anatomical variations of the NGS and classified them into 4 categories which include those already described in previous publications, of which the first category seems to be the most common. Our distances measured from the nerve to the TM are similar to those previously published, but our safe area is more restrictive than that proposed by Jacobs and Buxton. Respecting the limits of this area reduces the risk of nerve injuries. During the anterior TGa, the nerve is nearer to the TM and more exposed. The muscular mass innervated is large and the functional consequences of frontal injury must not be neglected. During acetabular exposition, the retractors should exert moderate muscular pressure, to avoid crushing them. The respect of the GMin, ensures adequate protection for the nerves situated between the muscles. To avoid muscular tearing during the anterior dislocation it is better to cut the collum femoris in place. The posterior approach seemed to be less dangerous for the nerves and muscles which are farther away. Strictly remaining within the limits of the safe area and carefully separating the muscles, should allow to decrease the risk of NGS injuries during TGa which seems to be more important in the anterior than in the posterior approaches.
Article
Several reports describe methods of treatment for avascular necrosis of the femoral head (ANFH) involving 0 to 2 mm of collapse. Some cases of ANFH have good prognoses, requiring only non-weight-bearing treatment. Other cases rapidly progress to collapse and complete destruction with enlargement of the necrotic area. The progression of the necrotic area is related to the activity of the original disease, steroid treatment, and the size and location of the necrotic area in the early stages of the disorder. In this report, a vascularized pedicle bone graft was used to treat ANFH, particularly those cases identified as Stage II on the system established by the Japanese Investigation Committee. Surgery involved curettage of necrotic bone, implantation of spongy bone, and application of a vascularized pedicle bone graft. Grafts were taken from the ilium and included the superficial circumflex iliac artery (SCIA). A bony canal was made in the anterior femoral neck, from which the necrotic bone was curetted and to which the bone graft was applied. The deep circumflex iliac artery (DCIA) was also used in combination with the SCIA. The postoperative weight-bearing period was six months. Follow-up periods lasted one to six years. Seventeen of 23 Stage II joints (19 cases) achieved satisfactory results at a mean of three years after surgery. Three Stage II joints and three Stage III joints continue to have significant problems. One of these six has been converted to a dual-bearing type endoprosthesis. The unsuccessful results generally occurred in patients who were treated with steroids. This operation is indicated only for cases identified as Stage II and Type I-C and possibly for cases that have an extensive necrotic area and in which anterior rotational osteotomy of the femoral head is not indicated. (C) Lippincott-Raven Publishers.
Article
Cemented total hip arthroplasties (THAs) were performed through a Charnley transtrochanteric approach in 1162 patients from 1970 through 1986. Trochanteric separations numbered 58 (5%). Rate of nonunion was related to gender, preoperative diagnosis, and prior THA or endoprosthesis. Nonunion patients had lower mean Charnley pain and function mean scores than union patients at the 45- and 49-month examinations, respectively. A Trendelenberg gait was noted in 17% of nonunions compared with 6% of united patients. Revision rates were nearly three times higher in nonunion patients. These results indicate there is a quantifiable risk for a surgeon who chooses to use a trochanteric osteotomy.
Article
We studied prospectively 81 consecutive patients undergoing hip surgery using the Hardinge (1982) approach. The abductor muscles of the hip in these patients were assessed electrophysiologically and clinically by the modified Trendelenburg test. Power was measured using a force plate. We performed assessment at two weeks, and at three and nine months after operation. At two weeks we found that 19 patients (23%) showed evidence of damage to the superior gluteal nerve. By three months, five of these had recovered. The nine patients with complete denervation at three months showed no signs of recovery when reassessed at nine months. Persistent damage to the nerve was associated with a positive Trendelenburg test.
Article
A new technique to achieve a reliable fusion of the hip joint through an anterior approach with use of a ventral low contact dynamic compression plate and a lateral 6.5 mm lag screw is presented in detail. The advantages of this technique are that the approach does not jeopardize the vascularity of the femoral head, that the fixation on the pelvic side uses the strong bone stock of the sciatic buttress, and that the hip abductor muscles and greater trochanter are preserved. The authors also present the indications and the results of their experience with 12 patients. The followup period averaged 24.8 months (range, 10-42 months). Ten patients (83%) achieved a solid fusion by radiologic and clinical criteria. Although a moderately symptomatic nonunion developed in 1 patient, another patient went on to a painful nonunion to whom another attempt for fusion has been recommended. According to the hip score of Merle d'Aubigné and Postel, the average figures for pain and ambulation increased from 3.2 points to 5.0 points and from 2.7 points to 4.5 points, respectively, after surgery. Six of the 12 patients regained the ability to work in their former jobs or in new occupations. Eight patients felt no or minor restrictions in doing their former sports activities. Patient satisfaction was high with a majority reporting minor discomfort mainly around the fused hip.
Article
The authors present a study of the intrinsic anatomy of the gluteus medius m, and of its innervation through the caudal branch of the superior gluteal n. The existence of an intramuscular tendon in the thickness of the gluteus medius was constantly prooved in 40 muscles. The relations of the intrinsic fibrous structure of the muscle and its innervation were studied. The authors deduce from that the topography of a gluteus medius incision, with respect to a safety area towards its innervation, which leads to an exposure of the acetabulum that is satisfying and gives opportunities of a sound repair after the surgery of the hip joint through the transgluteal approach. They propose the "anterior hemimyotomy of the gluteus medius m" designation.
Article
The purpose of this study was to evaluate the incidence of intraoperative superior gluteal nerve irritation and to identify specific surgical maneuvers that may harm the nerve. Continuous intraoperative electromyography (EMG) monitoring of the superior gluteal nerve-innervated muscles (gluteus medius and tensor fascia lata muscles) was performed in 12 patients undergoing total hip arthroplasty. A modified lateral approach was used, including a partial anterior osteotomy of the greater trochanter with splitting of the gluteus medius and vastus lateralis muscles. All patients had a clinical follow-up examination 1 year postoperatively to evaluate abductor muscle function. Irritation of the nerve occurred first during splitting of the gluteus medius muscle, then with increased gluteus medius retraction for exposure of the acetabulum, and finally during positioning of the leg for preparation of the femur. The detected EMG alterations were important because they were found in a single patient with persistent abductor muscle weakness.
Article
The authors investigated the reliability of the safe area, which previously was defined to prevent injury to the superior gluteal nerve during the lateral approach to the hip, and its relation to body height. The distance between the point of entry of the superior gluteal nerve into the gluteus medius muscle and the greater trochanter, in the regions which were defined as the anterior and posterior halves of the muscle, were measured in 23 cadaveric hips. There was a significant correlation between the height of the cadavers and the distance in the anterior and posterior regions. In all of the anterior regions and 78% of the posterior regions of the hips, the superior gluteal nerve as found to be in the safe area. The current study showed that the average distance between the innervation point of the gluteus medius muscle and the greater trochanter might change as a function of body height. The risk of damage to the superior gluteal nerve may be higher if the direct lateral approach to the hip is used. These data show that it is possible that the safe area is not always safe.
Article
Injuries to the superior gluteal nerve are very bad complications in hip surgery. An exact knowledge of its course may be helpful in avoiding such problems. Nineteen half pelvises from ten male and female adult cadavers were dissected. Dissections revealed that the nerve divided into two (89.48%) or three (10.52%) branches after leaving the pelvis. The more caudal branch was responsible for innervation of tensor fascia latae. The distance and the angle from the entry points of all branches of the superior gluteal nerve into the deep surface of the gluteus medium and minimus muscles to the mid-point of the superior border of the greater trochanter were measured. The branch that innerved the tensor fascia latae was also followed. These data were subjected to several statistical tests. Based on these findings, and in order to prevent nerve damage, we propose to define a 2-3 cm safe area above the great trochanter.
Article
Correct positioning of the prosthetic components in total hip replacements is important to prevent dislocations. Correct positioning is made easier by extensive approaches, but it also is possible using the mini-incision approach. The mini-incision used to facilitate early rehabilitation should not produce a higher dislocation rate than that of the more conventional approaches. The anterior surgical approach we describe allows for good exposure, despite the reduced size of the skin incision. Its length is 5-10 cm and usually 6-8 cm for patients with normal corpulence. Our mini-incision anterior approach using intermuscular planes allows a surgical approach to the hip and implantation of a total prosthesis with no muscle, tendon, or trochanteric section, even partially. This is not possible with any other surgical approach. A series of 1037 primary total hip replacements done between June 1993 and June 2000 was studied retrospectively. The dislocation rate was 0.96% (10 of 1037 hips). The mini-incision approach allows for adequate positioning of the two prosthetic components. Preserving the muscular potential also may contribute to dynamic stabilization of the hip.
Article
There remains uncertainty about the most effective surgical approach in the treatment of complex fractures of the acetabulum. We have reviewed the experience of a single surgeon using the extended iliofemoral approach, as described by Letournel. A review of the database of such fractures identified 106 patients operated on using this approach with a minimum follow-up of two years. All data were collected prospectively. The fractures involved both columns in 64 (60%). Operation was undertaken in less than 21 days after injury in 71 patients (67%) and in 35 (33%) the procedure was carried out later than this. The reduction of the fracture was measured on plain radiographs taken after operation and defined as anatomical (0 to 1 mm of displacement); imperfect (2 to 3 mm) or poor (> 3 mm). The functional outcome was measured by the modified Merle d’Aubigné and Postel score. The mean follow-up was for 6.3 years (2 to 17). All patients achieved union of the fractures. The reduction was graded as anatomical in 76 (72%) of the patients, imperfect in 23 (22%), and poor in six (6%). The mean Merle d’Aubigné and Postel score was