An anatomic consideration of the femoral nerve during direct anterior hip approach: A cadaveric study.

PURPOSE: This study aimed to investigate the distance and correlation between the anatomy of the anterior side of the hip joint and the femoral nerve. METHODS: Using ten fresh-frozen cadavers with twenty hip joints. We dissected and marked the femoral nerve in the inguinal area. Employing the direct anterior approach, we identified and marked study points, including the superior and inferior points of the anterior rim of the acetabulum, » point, half point, and ¾ point along an imagined line connecting the formers, the inferomedial and mid aspect of the femoral neck, and the soft spot. Coronal plane measurements gauged the distance between these points and the femoral nerve. The collected data were analyzed to assess the distance and correlation. RESULTS: In the coronal plane, the median distance between the inferior point of the anterior rim of the acetabulum and the femoral nerve was 0 millimeters (interquartile range [IQR] 0-0). Likewise, the median distance between the mid aspect of the medial side of the femoral neck and the femoral nerve was 0 millimeters (IQR 0-0). Additionally, the mean distance between the soft spot and the femoral nerve was 1.18 cm (SD 0.63). CONCLUSION: Surgeons approaching the hip joint via the direct anterior approach should be cautious at the inferior point of the anterior rim of the acetabulum and the mid aspect of the femoral neck. The soft spot at the anterior rim of the acetabulum remains safe from direct injury when surgeons use the correct technique during anterior retractor insertion.

Anatomical basis for the selective block of the nerve to quadratus femoris by way of percutaneous techniques / Bases anatómicas para el bloque selectivo del nervio del músculo cuadrado femoral a través de técnicas percutáneas

SUMMARY: Hip joint chronic pain can severely compromise patients' life quality. Peripheral nerve blocks play an important role as diagnostic and therapeutic procedures. The aim of this work is to study the anatomy of the nerve to quadratus femoris (NQF) in view of the possibility of its percutaneous selective block. Forty-three gluteal cadaveric regions fixed in formaldehyde solution were dissected. The quadratus femoris, the obturator internus and superior and inferior gemellus were freed from their lateral insertion, exposing thus the posterior aspect of the hip joint. The NQF was identified, and the horizontal distance to the posterior edge of the greater trochanter at its upper, middle and lower thirds was registered. The number of the articular branches of the NQF was identified. Likewise, the horizontal distance to the posterior edge of the greater trochanter and the longitudinal distance to the line through the distal end of the posterior edge of the greater trochanter were measured. The distance between the NQF and the greater trochanter posterior edge at upper, middle and lower thirds was 46 mm, 41 mm and 35 mm, respectively. In most cases (85 %) the NQF presented one or two articular branches. The longitudinal distances between the line through the distal end of the posterior edge of the greater trochanter and the origin of the first, second and third articular branches of the NQF were 14.7 mm (-19.4 - 40), 16.4 mm (-9.3-42) and 27 mm (0-46), respectively. The distances to the posterior edge of the greater trochanter were 43.1 mm (16.3-66), 37.7 mm (6.5-53) and 39.8 mm (26-52), for the first, second and third articular branches, respectively. In conclusion, the articular branches of the nerve to quadratus femoris have a constant and predictable distribution. Our findings allow for generating a coordinate system for the selective block of the NQF by way of percutaneous techniques.

RESUMEN: El dolor crónico de la articulación coxal puede comprometer severamente la calidad de vida de los pacientes. Los bloqueos nerviosos periféricos juegan un papel importante como procedimientos diagnósticos y terapéuticos. El objetivo de este trabajo es estudiar la anatomía del nervio del músculo cuadrado femoral (NCF) en vista de la posibilidad de su bloqueo selectivo percutáneo. Se utilizaron 22 cadáveres fijados en solución de formaldehído. Fueron disecadas en total 43 regiones glúteas. Los músculos cuadrado femoral, obturador interno y los gemelos superior e inferior fueron liberados de su inserción lateral, exponiendo así la cara posterior de la articulación coxal. Se identificó el NCF y se registró la distancia horizontal al margen posterior del trocánter mayor en sus tercios superior, medio e inferior. Se identificó el número de ramas articulares del NQF. Asimismo, se midió la distancia horizontal al margen posterior del trocánter mayor y la distancia longitudinal a la línea que pasa por el extremo distal del margen posterior del trocánter mayor. La distancia entre el NCF y el margen posterior del trocánter mayor en los tercios superior, medio e inferior fue de 46 mm, 41 mm y 35 mm, respectivamente. En la mayoría de los casos (85 %) el NCF presentó una o dos ramas articulares. Las distancias longitudinales entre la línea que pasa por el extremo distal del margen posterior del trocánter mayor y el origen de la primera, segunda y tercera ramas articulares del NQF fueron 14,7 mm (-19,4 - 40), 16,4 mm (-9,3-42) y 27 mm (0-46), respectivamente. Las distancias al margen posterior del trocánter mayor fueron 43,1 mm (16,3-66), 37,7 mm (6,5-53) y 39,8 mm (26-52), para la primera, segunda y tercera ramas articulares, respectivamente. En conclusión, las ramas articulares del nervio al cuadrado femoral tienen una distribución constante y predecible. Nuestros hallazgos permiten generar un sistema de coordenadas para el bloqueo selectivo del NCF por medio de técnicas percutáneas.

Minimally Invasive Therapies for Osteoarthritic Hip Pain: a Comprehensive Review.

PURPOSE OF REVIEW: Osteoarthritis (OA) is a highly prevalent cause of chronic hip pain, affecting 27% of adults aged over 45 years and 42% of adults aged over 75 years. Though OA has traditionally been described as a disorder of "wear-and-tear," recent studies have expanded on this understanding to include a possible inflammatory etiology as well, damage to articular cartilage produces debris in the joint that is phagocytosed by synovial cells which leads to inflammation. RECENT FINDINGS: Patients with OA of the hip frequently have decreased quality of life due to pain and limited mobility though additional comorbidities of diabetes, cardiovascular disease, poor sleep quality, and obesity have been correlated. Initial treatment with conservative medical management can provide effective symptomatic relief. Physical therapy and exercise are important components of a multimodal approach to osteoarthritic hip pain. Patients with persistent pain may benefit from minimally invasive therapeutic approaches prior to consideration of undergoing total hip arthroplasty. The objective of this review is to provide an update of current minimally invasive therapies for the treatment of pain stemming from hip osteoarthritis; these include intra-articular injection of medication, regenerative therapies, and radiofrequency ablation.

Fascia and soft tissues innervation in the human hip and their possible role in post-surgical pain.

Persistent symptoms, most commonly pain, may remain after otherwise successful hip replacement surgery. Innervation of fascia and soft tissues has become increasingly important in etiopathogenesis of pain, but the relative importance of the various anatomical structures in the hip region is still not known. Innervation of skin, superficial adipose tissue, superficial fascia, deep adipose tissue, deep fascia, muscles, capsule, capsule ligament, ligamentum teres, and tendon in the human hip from 11 patients and 2 cadavers were quantified by staining with anti-S100 antibody for myelin-forming Schwann cells, to obtain the percentage of antibody positivity, density and mean diameter of the nerve fibers. The skin was the most highly innervated (0.73% ± 0.37% of positive area in patients; 0.80% ± 0.28% in cadavers); the tendon was the least innervated (0.07% ± 0.01% in patients, 0.07% ± 0.007% in cadavers). The muscles (vasto-lateral and gluteus medius) were the second most innervated structure according the percentage (0.31% ± 0.13% in living humans, 0.30% ± 0.07% in cadavers), but with only a few nerves, with large diameters (mean diameter 36.4 ± 13.4 µm). Instead, the superficial fasciae showed 0.22% ± 0.06% and 0.26% ± 0.05% of positive areas in living humans and cadavers, respectively. Fasciae were invaded by networks of small nerve fibers, revealing a possible role in pain. The superficial fascia was the second most highly innervated tissue after the skin, with a density of 33.0 ± 2.5/cm2 , and a mean nerve sizes of 19.1 ± 7.2 µm. Lastly, the capsule turned out to be poorly innervated (0.09%), showing that its removal does not necessarily lead to painful consequences. Statement of clinical significance: Deeper knowledge about the innervation of the soft tissue in the human hip joint will enhance study and understanding of the best surgical procedures to follow during hip arthroplasty to reduce post-operative pain.

Applications and critical evaluation of fascia iliaca compartment block and quadratus lumborum block for orthopedic procedures.

Anterior section of the hip joint capsule is innervated by femoral nerve and obturator nerve, and posterior section is innervated by the nerve to quadratus femoris muscle and occasionally by the superior gluteal (posterolateral region) and sciatic nerve (posterosuperior region). One of the regional anesthesia options for hip surgery is the fascia iliaca compartment block (FICB) that affects nerves important for hip innervation and sensory innervation of the thigh - femoral, obturator and lateral femoral cutaneous nerve. FICB can be easily performed and is often a good solution for management of hip fractures in emergency departments. Its use reduces morphine pre-operative requirement for patients with femoral neck fractures and can also be indicated for hip arthroplasty, hip arthroscopy and burn management of the region. Quadratus lumborum block (QLB) is a block of the posterior abdominal wall performed exclusively under ultrasound guidance, with still unclarified mechanism of action. When considering hip surgery and postoperative management, the anterior QLB has shown to reduce lengthy hospital stay and opioid use, it improves perioperative analgesia in patients undergoing hip and proximal femoral surgery compared to standard intravenous analgesia regimen, provides early and rapid pain relief and allows early ambulation, thus preventing deep vein thrombosis and thromboembolic complications etc. However, some nerve branches responsible for innervation of the hip joint are not affected by QLB, which has to be taken into consideration. QLB has shown potential for use in hip surgery and perioperative pain management, but still needs to be validated as a reliable treatment approach.

Pudendal nerve injury is a relatively common but transient complication of hip arthroscopy.

PURPOSE: Hip arthroscopy is emerging as the standard of care for conditions involving the hip, and has a unique set of complications. The purpose of this review was to identify (1) the crude rate of pudendal nerve injury following hip arthroscopy and (2) the specific factors leading to pudendal nerve injury. METHODS: MEDLINE, EMBASE, and PubMed were searched from database inception to October 2016. Patient demographics, indications, surgical technique, complication rates, treatment approaches, and rehabilitation strategies were extracted. RESULTS: Twenty-four studies (n = 3405) were included, with the majority (66%) of studies being level IV evidence. The mean age was 33.9 ± 9.7 years (range 12-78) and 48.2% were males. Average follow-up was 30.2 ± 19.1 months. 62 patients were reported to have sustained pudendal nerve injury (1.8%) post-operatively, and all resolved within 6 weeks to 3 months. Of the seven studies that reported using a perineal post, 20 patients were diagnosed with pudendal nerve injury (4.3%), in contrast to two studies (189 patients) reporting only 0.5% pudendal nerve injury without the use of perineal post. Two studies commented on time of traction during surgical intervention with mean times of 98 and 68 min with complication rates of 10% and 6.6%, respectively. CONCLUSIONS: Pudendal nerve injury is not uncommon following hip arthroscopy, with a reported rate found in this review of 1.8%. Potential risk factors may include the use of a perineal post and long traction times. All reported cases resolved within 3 months. Patients should be informed of complications related to pudendal nerve injury, which include sexual and urinary dysfunction. LEVEL OF EVIDENCE: Level IV, systematic review of level I-IV studies.

Acetabular labrum of hip joint in osteoarthritis: A qualitative original study and short review of the literature.

PURPOSE: Histological architecture of normal acetabular labrum regarding free nerve endings (FNEs) and mechanoreceptors (MRs) has been satisfactorily described in the literature. However, the presence of FNEs and MRs in acetabular labrum of hip joint has been analyzed only once in patients with osteoarthritis (OA). Aim of this article is to report histological distribution pattern of FNEs and MRs in acetabular labrum of patients with severe OA, at the same time conducting a comparison with normal acetabular labrum described in the literature. METHODS: Seven patients with severe hip OA were enrolled in this study. Patient selection was assisted by the utilization of specific clinical scales delineated by the American College of Rheumatology. After successful total hip arthroplasty, tissue samples of acetabular labra of seven patients were histologically processed and stained with the gold standard chloride method, which was subsequently examined under a compound microscope. RESULTS: FNEs and MRs constituted the major histological structures. Identified MRs included Pacini corpuscles, Ruffini corpuscles, and Golgi-Mazzoni corpuscles. The presence of FNEs was predominant in the middle part of the acetabular labrum, featuring a remarkable decrease in peripheral parts. In contrast, MRs were detected basically in peripheral parts and less in the middle part. CONCLUSIONS: Differentiation of the distribution pattern of MRs and FNEs in acetabular labrum of hip joint is remarkable between normal patients and patients with severe OA. The abundance of FNEs in the middle part of the pathologic labrum is mainly responsible for the observed discrimination. A "conversion" of MRs to FNEs may occur during OA progression, modulating therefore this pattern as well as the upcoming clinical manifestations.

Technical success of the ultrasound-guided supra-inguinal fascia iliaca compartment block in older children and adolescents for hip arthroscopy.

BACKGROUND: Hip arthroscopic surgery is performed on older pediatric patients. Fascia iliaca compartment block has proven efficacy in providing analgesia following hip surgery and can be performed with target location of local anesthetic below or above the inguinal ligament. The reported success of ultrasound-guided infra-inguinal fascia iliaca compartment block is lower when compared to traditional landmark technique, while the reliability of supra-inguinal fascia iliaca compartment block is unreported. AIM: The primary aim was to report the results in obtaining sensory changes in the distribution of the femoral and lateral femoral cutaneous nerves following supra-inguinal fascia iliaca compartment block in patients undergoing arthroscopic hip surgery. Secondary outcomes are the ability to find echogenic landmarks and to report pain scores and opioid consumption. METHODS: We reviewed the electronic medical record and regional anesthesia database of patients receiving ultrasound-guided fascia iliaca compartment block for arthroscopic hip surgery. Sensory changes to the femoral and lateral femoral cutaneous nerves were determined. Identification of echogenic landmarks was quantified. Pain scores and opioid consumption were determined. RESULTS: Seventeen patients of mean age 15.4 years old (SD 1.3; range 13-17 years) were included. Sensory changes to both the femoral and lateral femoral cutaneous nerves occurred in 94% of patients (95% CI: 82%-100%). The average volume of ropivacaine 0.2% was 0.53 mL/Kg (SD 0.11 mL/Kg). Echogenic landmarks were identified in all patients. Pain scores and opioid consumption were generally low. CONCLUSION: A supra-inguinal location for the deposition of local anesthetic when performing fascia iliaca nerve block for hip surgery is reliable in anesthetizing the femoral and lateral femoral cutaneous nerves and should encourage investigation into the clinical efficacy.

[Nerve distribution and density in the canine hip joint capsule. Comparison of healthy and dysplastic hip joints]. / Nervenverteilung und -verteilungsdichte in der Hüftgelenkskapsel des Hundes. Vergleichende Untersuchung gesunder und dysplastischer Hüftgelenke.

OBJECTIVE: The hip-joint capsule is exposed to increased tension forces during canine hip dysplasia, resulting in inflammation of the capsular tissue. It has been postulated that inflammation is associated with an increased nerve-distribution density. Therefore, it could be supposed that the nerve-distribution density in the hip-joint capsule is higher in dogs with dysplastic hip compared to healthy dogs. MATERIAL AND METHODS: In 16 Labrador Retriever dogs that had been euthanised due to unrelated reasons, the hip joints were classified as normoplastic (group 1, n = 18) or dysplastic (group 2, n = 14) based on radiography. Following staining of the capsular nerve fibres by the Sihler method, histological specimens of the hip-joint capsules were scanned. By subdividing each specimen into 10 quadrants numbered from dorsomedial (Q01) to craniodorsolateral (Q10), the ratio of black to white pixels was calculated digitally for each specimen and each quadrant by using a semiautomatic image analysis. Statistical analysis was performed using an independent t-test. RESULTS: Comparison of the mean values of each quadrant showed a significantly higher (p < 0.03) nerve distribution density for the craniodorsolateral quadrant (Q10) in group 2 when compared to group 1. Mean nerve-distribution density for all quadrants combined was not significantly different between the two groups. CONCLUSION: The increase in nerve-distribution density of the craniodorsal region of the hip-joint capsule in dogs with dysplastic hip could be the result of increased tension forces on this area following hip-joint dysplasia. The craniodorsal region of the hip-joint capsule is an important origin of pain and coxarthrosis in canine hip dysplasia. CLINICAL RELEVANCE: The results provide the pathophysiological basis for the efficacy of hip-joint denervation. Denervation of the cranial region of the acetabular rim is essential to reduce capsular inflammation and joint-related pain in canine hip dysplasia.

Chemical Coding of Sensory Neurons Supplying the Hip Joint Capsule in the Sheep.

Immunohistochemical properties of nerve fibres supplying the joint capsule were previously described in many mammalian species, but the localization of sensory neurons supplying this structure was studied only in laboratory animals, the rat and rabbit. However, there is no comprehensive data on the chemical coding of sensory neurons projecting to the hip joint capsule (HJC). The aim of this study was to establish immunohistochemical properties of sensory neurons supplying HJC in the sheep. The study was carried out on 10 sheep, weighing about 30-40 kg. The animals were injected with a retrograde neural tracer Fast Blue (FB) into HJC. Sections of the spinal ganglia (SpG) with FB-positive (FB+) neurons were stained using antibodies against calcitonin gene-related peptide (CGRP) substance P (SP), pituitary adenylate cyclase-activating peptide (PACAP), nitric oxide synthase (n-NOS), neuropeptide Y (NPY), vasoactive intestinal polypeptide (VIP), Leu-5-enkephalin (Leu-Enk), galanin (GAL) and vesicular acetylcholine transporter (VACHT). The vast majority of FB+ neurons supplying HJC was found in the ganglia from the 5th lumbar to the 2nd sacral. Immunohistochemistry revealed that most of these neurons were immunoreactive to CGRP or SP (80.7 ± 8.0% or 56.4 ± 4.8%, respectively) and many of them stained for PACAP or GAL (52.9 ± 2.9% or 50.6 ± 19.7%, respectively). Other populations of FB+ neurons were those immunoreactive to n-NOS (37.8 ± 9.7%), NPY (34.6 ± 6.7%), VIP (28.7 ± 4.8%), Leu-Enk (27.1 ± 14.6) and VACHT (16.7 ± 9.6).

Inflammatory pain-related traits of sensory DRG neurons innervating the hip joints.

BACKGROUND: Hip pain is transmitted to the dorsal horn of the spinal cord via the dorsal root ganglion (DRG), which contains two types of neurons with differential sensitivity to neurotrophic factors. If either type predominantly innervates the hip joint, it may represent a good target for hip joint pain treatment. METHODS: Inflammation was induced in the left hip joint of rats (n = 10) by using complete Freund's adjuvant. Fluoro-Gold (FG) was applied to the hip joint after 7 days, and T12-L6 DRGs were double-stained for calcitonin gene-related peptide (CGRP) and isolection-IB4 1 week later. RESULTS: FG-labeled neurons in the control group were distributed throughout the left DRG from T13 to L5, primarily in L2 to L4, and CGRP-positive neurons were significantly more frequent than IB4-binding neurons. In the inflammatory group, FG-labeled neurons were similarly distributed, primarily at L3 and L4, and CGRP-positive neurons were significantly more frequent than IB4-binding neurons. The percentage of CGRP-positive neurons was significantly greater in the inflammatory group (P < 0.05). CONCLUSIONS: Most small neurons innervating the hip joint express CGRP. Furthermore, hip joint inflammation caused an increase in CGRP-positive neurons, but not in IB4-binding neurons. Our results suggest that CGRP-expressing nerve growth factor-dependent neurons are primarily responsible for hip joint pain and may represent therapeutic targets.

A Randomized, Double-Blind, Placebo-Controlled Study of Neuromuscular Electrical Stimulation (NMES) use for Recovery after Elective Total Hip Replacement Surgery.

Early physical activity has been proven to accelerate functional recovery after total hip replacement (THR). Weightbearing intolerance secondary to postoperative pain inhibits participation in physical therapy and limits the achievement of functional independence. Neuromuscular electrical stimulation (NMES) has been shown to improve pain and accelerate recovery. This study focused on the effects of NMES on weightbearing pain. The primary objective of this study was to compare the efficacy of NMES versus placebo in the reduction of pain and the use of opiate medications in the treatment of patients during weightbearing exercises after THR. A secondary objective was to assess the use of NMES during weightbearing exercise and its effects on function, hospital length of stay, and disposition planning. This was a randomized, doubleblinded, placebo-controlled study performed with subjects obtained from an outpatient orthopaedic service. Subject underwent elective THR. The NMES device was provided to all subjects; active and a control group were assigned different intensity levels of stimulation. Twenty-nine subjects participated in the study: 15 in the active and 14 in the control group. Data, including pain assessment, opiates use, function, hospital length of stay in days, and disposition was recorded and analyzed. Both control and active groups showed no significant difference on the pain visual analog scale at various postoperative time intervals, length of inpatient hospital stay, and days on opiate medications.

Fascia iliaca block associated only with deep sedation in high-risk patients, taking P2Y12 receptor inhibitors, for intramedullary femoral fixation in intertrochanteric hip fracture: a series of 3 cases.

OBJECTIVE: We present a series of 3 cases in which the impact in outcome was, first of all, related to the capacity to offer early and safer treatment to some hip fracture high-risk patients using a fascia iliaca block (FIB; ropivacaine 0,5% 20 cc and mepivacaine 1,3% 15 cc, given 30 minutes before incision) associated only with deep sedation, contributing to better practice and outcome. CASE REPORTS: All elderly patients were American Society of Anesthesiologists IV patients, under P2Y12 receptor inhibitors, suffering from an intertrochanteric fracture, and purposed for intramedullary femoral fixation (IMF). All patients have been managed successfully through a deep sedation using a low-dose infusion of propofol and bolus of fentanyl without face mask ventilation, supraglottic device placement, or endotracheal intubation after an FIB. Bispectral index was always greater than 75, and no CO2 retention or respiratory depression was present. No signs of pain or hemodynamic instability were observed. CONCLUSIONS: In these cases, surgery would be postponed if the choice was neuroaxial anesthesia, particularly because of P2Y12 receptor inhibitors' effect. FIB puncture site is distal to the fracture and incision site, but proximal local anesthetic migration through the interfascial planes allows for constant block of femoral nerve and lateral cutaneous of femur nerve and, less constantly, block of obturator. FIB may reduce the risk of perineural hematoma associated with several injections in nerve vicinity of different lumbar plexus branches. Frequently, indications for extramedullary or IMF are overlapping, but IMF is associated with less blood loss and may be managed using a low anesthetic depth if an FIB is done, increasing safety. This way, these less invasive surgical techniques combined with an adjusted anesthetic technique may have a crucial role in high-risk patients, particularly if taking P2Y12 receptor inhibitors. In these cases of IMF, surgical manipulation of sciatic and/or inferior subcostal nerves territories was managed with systemic analgesia and deep sedation.

Effects of denervation of the hip joint on results of clinical observations and instrumented gait analysis in dogs with sodium urate crystal-induced synovitis.

OBJECTIVE To evaluate the effects of selective hip joint denervation on gait abnormalities and signs of hip joint pain in dogs. ANIMALS 6 healthy adult hound-type dogs. PROCEDURES Minimally invasive denervation was performed on the right hip joint of each dog. Two weeks later, sodium urate was injected into the right hip joint to induce synovitis. Dogs were evaluated clinically and by use of instrumented gait analysis before and 2 weeks after minimally invasive denervation and 4, 8, and 24 hours after induction of synovitis. Dogs were euthanized, and necropsy and histologic examination were performed. RESULTS No kinetic or kinematic gait modifications were detected 2 weeks after minimally invasive denervation. Denervation did not eliminate signs of pain and lameness associated with sodium urate-induced synovitis. Results of histologic examination confirmed that denervation was an effective method for transecting the innervation of the craniolateral and caudolateral aspects of the hip joint capsule. CONCLUSIONS AND CLINICAL RELEVANCE In this study, minimally invasive denervation did not result in gait modifications in dogs. Denervation did not abolish the signs of pain and lameness associated with generalized induced synovitis of the hip joint. Further studies are required before conclusions can be drawn regarding the clinical usefulness of hip joint denervation for dogs with hip dysplasia.

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

BACKGROUND: Injury to the lateral femoral cutaneous nerve (LFCN) is a risk during the operative anterior approach to the hip joint. Although several anatomical studies have described the proximal course of the nerve in relation to the anterior superior iliac spine (ASIS) and the inguinal ligament, the distal course of the LFCN in the proximal aspect of the thigh has not been sufficiently studied. The aim of this cadaveric study was to examine the branching pattern of the nerve, with special consideration to the anterior approach to the hip joint. METHODS: Twenty-eight cadaveric hemipelves from 18 donors (10 paired and 8 unpaired specimens) were dissected. The LFCN branches were localized proximal to the inguinal ligament and traced distally into the area of the proximal aspect of the thigh. Distribution patterns of the nerve with respect to its relationship to the ASIS and the internervous plane of the anterior approach to the hip joint were recorded. RESULTS: We found 3 different branching patterns of the LFCN: sartorius-type (in 36% of the specimens), characterized by a dominant anterior nerve branch coursing along the lateral border of the sartorius muscle with no, or only a thin, posterior branch; posterior-type (in 32%), characterized by a strong posterior nerve branch; and fan-type (in 32%), characterized by multiple spreading nerve branches of equal thickness. In 50% of the specimens, the LFCN divided into ≥2 branches superior to the inguinal ligament. Sixty-two percent of the LFCN branches entered the proximal aspect of the thigh medial to the ASIS; 27%, above; and 11%, lateral to the ASIS. The LFCN consistently coursed within the deep layer of the subcutaneous fat tissue. CONCLUSIONS: Injury to branches of the LFCN cannot be avoided in approximately one-third of surgical dissections that use the anterior approach to the hip joint. To protect the anterior branch of the LFCN, the skin incision should be as lateral as possible. The posterior branch of the LFCN is most vulnerable in the proximal aspect of the anterior approach to the hip joint, where it can be expected to course within the deep layer of the subcutaneous tissue.

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

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.

Radiofrequency denervation of the hip joint for pain management: case report and literature review.

BACKGROUND: A 55-year-old male presented with severe pain and functional limitations as a result of left hip osteoarthritis. He had failed multiple treatments while waiting for a hip arthroplasty, including physical therapy, medications, and various intra-articular injections. Thermal radiofrequency lesioning of the obturator and femoral articular branches to the hip joint was offered in the interim. OBJECTIVES: To our knowledge, this is the first report to describe an inferior-lateral approach for lesioning the obturator branch, the clinical application of successive lesions to increase denervation area, and outcomes in a patient receiving a second treatment with previously good results. METHODS: To discuss relevant and technical factors for this specific case, we reviewed previous literature on hip joint radiofrequency and critically evaluated previous anatomic studies in the context of radiofrequency. RESULTS: The first treatment provided significant benefit for a period of 6 months. A second treatment was employed providing only mild to moderate benefit until his joint replacement surgery 4 months later. Literature review revealed studies of low quality secondary to small sample sizes, patient selection methodology, inclusion of patients with heterogenous etiologies for pain, variable needle placement techniques, and lack of measurement of functional outcomes. LIMITATIONS: Case report and low quality studies in existing literature. CONCLUSIONS: Hip joint radiofrequency denervation is a promising avenue for adjunctive treatment of hip pain. Further cadaveric studies are required to clarify a multitude of technical parameters. Once these are well defined, future clinical studies should consider pain, functional, and economic outcomes in their design.

Hip joint pain in children with cerebral palsy and developmental dysplasia of the hip: why are the differences so huge?

BACKGROUNDS: Non-traumatic hip dislocation in children is most often observed in the course of developmental dysplasia of the hip (DDH) and infantile cerebral palsy. The risk of pain sensations from dislocated hip joint differentiates the discussed groups of patients. Will every painless hip joint in children with cerebral palsy painful in the future? METHODS: Material included 34 samples of joint capsule and 34 femoral head ligaments, collected during open hip joint reduction from 19 children with CP, GMFCS level V and from 15 children with DDH and unilateral hip dislocation. All the children were surgically treated.The density of nociceptive fibres was compared between the children with CP and DDH, using S-100 and substance P monoclonal antibodies. RESULTS: More frequent positive immunohistochemical reaction to S-100 protein concerned structures of the femoral head ligaments in children with CP and cartilage losses on the femoral head, when compared to the same structures in children with DDH (p = 0.010). More frequent were found positive immunohistochemical reactions for S-100 protein in the joint capsules of children with cartilage losses (p = 0.031) and pain ailments vs. the children with DDH (p = 0.027). More frequent positive reaction to substance P concerned in femoral head ligaments in CP children and cartilage lesions (p = 0.002) or with pain ailments (p = 0.001) vs. the DDH children. CONCLUSIONS: Surgical treatment of hip joint dislocation should be regarded as a prophylactics of pain sensations, induced by tissue sensitisation, inflammatory process development or articular cartilage defects.