Abstract
Purpose
The direct anterior approach for primary total hip arthroplasty (THA) has become increasingly popular in recent years. Nerve compression or traction with a retractor is a common cause of nerve injury in this approach. The purpose of this cadaveric study was to evaluate the anatomic relationship of the femoral neurovascular bundle to the anterior acetabular retractor during direct anterior approach THA.
Methods
Eleven fresh-frozen cadavers underwent a standard direct anterior THA, with placement of an anterior acetabular retractor in the usual fashion between the iliopsoas and acetabulum for visualization during acetabular preparation. Careful dissection of the femoral triangle was performed, and the distances from the anterior retractor tip to the femoral nerve, artery, and vein were recorded and analyzed as mean distance ± standard deviation.
Results
In all 11 cadavers, the retractor tip was medial to the femoral nerve. The mean distance from retractor tip to femoral artery and vein was 5.9 mm (SD = 5.5, range 0–20) and 12.6 mm (SD 0.7, range 0–35), respectively.
Conclusions
Surgeons should be aware of the proximity of the neurovascular structures in relation to the anterior acetabular retractor in the direct anterior approach, taking care to avoid perforating the iliopsoas muscle during retractor insertion and limit excessive traction to prevent nerve injury.
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References
Barrett WP, Turner SE, Leopold JP (2013) Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. J Arthroplasty 28:1634–1638. https://doi.org/10.1016/j.arth.2013.01.034
Parvizi J, Restrepo C, Maltenfort MG (2016) Total hip arthroplasty performed through direct anterior approach provides superior early outcome: results of a randomized, prospective study. Orthop Clin North Am 47:497–504. https://doi.org/10.1016/j.ocl.2016.03.003
Brown GD, Swanson EA, Nercessian OA (2008) Neurologic injuries after total hip arthroplasty. Am J Orthop Belle Mead NJ 37:191–197
Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89:780–785. https://doi.org/10.2106/JBJS.F.00222
Macheras GA, Christofilopoulos P, Lepetsos P, Leonidou AO, Anastasopoulos PP, Galanakos SP (2016) Nerve injuries in total hip arthroplasty with a mini invasive anterior approach. Hip Int 26:338–343. https://doi.org/10.5301/hipint.5000352
Dietze S, Perka C, Baecker H (2014) Blood vessel and nerve damage in total hip arthroplasty. Orthopade 43:64–69. https://doi.org/10.1007/s00132-013-2126-9
Lee G-C, Marconi D (2015) Complications following direct anterior hip procedures: costs to both patients and surgeons. J Arthroplasty 30:98–101. https://doi.org/10.1016/j.arth.2015.03.043
Fleischman AN, Rothman RH, Parvizi J (2018) Femoral nerve palsy following total hip arthroplasty: incidence and course of recovery. J Arthroplasty 33:1194–1199. https://doi.org/10.1016/j.arth.2017.10.050
Shubert D, Madoff S, Milillo R, Nandi S (2015) Neurovascular structure proximity to acetabular retractors in total hip arthroplasty. J Arthroplasty 30:145–148. https://doi.org/10.1016/j.arth.2014.08.024
Wang T-I, Chen H-Y, Tsai C-H, Hsu H-C, Lin T-L (2016) Distances between bony landmarks and adjacent nerves: anatomical factors that may influence retractor placement in total hip replacement surgery. J Orthop Surg Res 11:31. https://doi.org/10.1186/s13018-016-0365-2
Weale AE, Newman P, Ferguson IT, Bannister GC (1996) Nerve injury after posterior and direct lateral approaches for hip replacement. A clinical and electrophysiological study. J Bone Joint Surg Br 78:899–902
Slater N, Singh R, Senasinghe N, Gore R, Goroszeniuk T, James D (2000) Pressure monitoring of the femoral nerve during total hip replacement: an explanation for iatropathic palsy. J R Coll Surg Edinb 45:231–233
McConaghie FA, Payne AP, Kinninmonth AWG (2014) The role of retraction in direct nerve injury in total hip replacement: an anatomical study. Bone Joint Res 3:212–216. https://doi.org/10.1302/2046-3758.36.2000255
Cohen EM, Vaughn JJ, Ritterman SA, Eisenson DL, Rubin LE (2017) Intraoperative femur fracture risk during primary direct anterior approach cementless total hip arthroplasty with and without a fracture table. J Arthroplasty 32:2847–2851. https://doi.org/10.1016/j.arth.2017.04.020
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Stubbs, T., Moon, A.S., Dahlgren, N. et al. Anterior acetabular retractors and the femoral neurovascular bundle in anterior total hip arthroplasty: a cadaveric study. Eur J Orthop Surg Traumatol 30, 617–620 (2020). https://doi.org/10.1007/s00590-019-02611-3
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DOI: https://doi.org/10.1007/s00590-019-02611-3