Lateral Femoral Cutaneous Nerve Impairment After Direct Anterior Approach for Total Hip Arthroplasty

Abstract

The anterior supine approach for total hip arthroplasty (THA) offers the advantage of operating through a true intravascular and intranervous plane, but it places the lateral femoral cutaneous nerve at risk. The purpose of this study was to identify the incidence of and impairment relating to injury of the lateral femoral cutaneous nerve. We performed a retrospective chart review of 81 hips undergoing anterior supine THA from November 2005 through May 2007 to determine operative time, estimated blood loss, fluoroscopic time, type of anesthesia used, intraoperative complications, and postoperative systemic and wound complications. Postoperative radiographs were evaluated for leg-length discrepancy, acetabular inclination and anteversion, and femoral stem position. Patients were reassessed at 6 weeks, 3 months, 6 months, 1 year, and 2 years. At each visit, patients were questioned about numbness or paresthesias in the distribution of the lateral femoral cutaneous nerve; if present, the patient outlined the area with a marking pen. This area was photographed, and data were collected. No hip had frank numbness; 12 hips (14.8%) had paresthesias. For those 12, symptoms resolved in 4 by 6 months, in 6 by 1 year, and in 10 (83.3%) by 2 years; 2 remained unresolved. No significant difference was found between patients with and without paresthesias or between patients with resolved or unresolved paresthesias. Impaired sensation did not appear to affect functional outcome or Harris Hip Score. Incision position, dissection plane, retractor placement, tension and soft tissue handling, and surgeon experience may affect incidence of injury to the lateral femoral cutaneous nerve.

Skin Crease ‘Bikini’ Incision for Anterior Approach Total Hip Arthroplasty: Surgical Technique and Preliminary Results

“…We found an incidence of subjective LCFN dysesthesia in approximately 20% and objective hypoesthesia in approximately 60% of the patients. These values compare favorably with those reported previously [1,6], and according to Bhargava et al [1], symptoms in many of these patients improve with time. We believe that LCFN problems mainly are related to a reversible neurapraxia of the LCFN as a result of traction caused by the retractors rather than to an irreversible dissection injury.…”

The Anatomical Course of the Lateral Femoral Cutaneous Nerve with Special Attention to the Anterior Approach to the Hip Joint

“…This variation may be explained by different interpretations or lack of recognition of LFCN injury, or the diversity of skin incisions chosen for the anterior approach 2,16,33,34,38 . While some authors observed that most symptoms of LFCN paresthesia resolved after 6 to 24 months 12 , others reported only a small number of patients with complete resolution 13 . The present study showed that 2 parameters influence the potential risk of LFCN injury: the individual distribution pattern of the LFCN in the proximal aspect of the thigh, and the technique and skin incision used for the anterior approach.…”

“…The anterior approach to the hip joint takes advantage of the internervous plane between the sartorius muscle (femoral nerve) and the tensor fasciae latae muscle (superior gluteal nerve). Despite the soft tissue-preserving nature of the anterior approach, there is a great danger of damaging the lateral femoral cutaneous nerve (LFCN) [12][13][14] ; the literature shows diverse rates of injury to the LFCN of between 0.1% and 81% 13,[15][16][17] . Although injury to the LFCN does not represent a major neurological complication, patients may report numbness or a burning sensation in the anterolateral region of the thigh and, in the worst cases, dysesthesia.…”

Basic Anatomy of Direct Anterior Approach for Mini-Invasive Hip Surgery

“…[8] A study of Barghava et al in 81 hips undergoing THA through DAA found that paresthesia was observed in only 12 cases (14.8%), of which 4 were resolved within 6 months, 6 were resolved by 1 year and 2 cases remained unresolved. [9] According to this study, frank numbness in the affected limb was not observed. [9] Kennon et al reported incidence of LFCN injury in only 5 out of 2,132 cases (<0.01%) with a curved transverse incision or short straight incision.…”

“…[9] According to this study, frank numbness in the affected limb was not observed. [9] Kennon et al reported incidence of LFCN injury in only 5 out of 2,132 cases (<0.01%) with a curved transverse incision or short straight incision. [10] One multicenter observational study found neurological impairment in 13 out of 1,152 patients who underwent THA through DAA: seven cases of palsy of the LFCN, five cases of numbness in the lateral aspect of the thigh and one case of anterolateral thigh paresthesia.…”