Lateral Femoral Cutaneous Nerve Injury Using an Anterior-Based Muscle-Sparing Approach to the Hip: A Clinical and Cadaveric Analysis with Review of Literature

Abstract

The alternative anterior hip approach between the tensor fascia lata and gluteus medius (the modified Watson-Jones approach, Röttinger approach, anterior-based muscle-sparing [ABMS] approach, and ABLE approach) may decrease the risk of lateral femoral cutaneous nerve (LFCN) palsy. A retrospective case study, systematic literature review, and cadaveric study were performed to assess the risk for LFCN palsy with the ABMS compared with the direct anterior (DA) approach. Consecutive patients who underwent total hip arthroplasty (THA) using ABMS were identified and assessed for LFCN palsy. A systematic review of LFCN injury with ABMS and DA approaches was conducted. In four fresh cadavers (eight hips), ABMS and DA approaches were performed and the LFCN identified. The proximity of the LFCN to the fascial incision was measured and compared between ABMS and DA approaches. In 64 consecutive ABMS THA (mean age: 57.3 ± 13.5 years, 42% female, mean body mass index: 30.2 ± 5.3 kg/m2), two hips (3.2%) had an LFCN palsy. In combination with the systematic literature review, the risk of LFCN palsy was less with ABMS (0.3%, 7/2,609 hips) compared with DA (3.1%, 638/20,402 hips, p < 0.001). In eight cadaveric hip dissections, the LFCN was significantly further away from the ABMS fascial incision (mean: 67.6 ± 9.1 mm), compared with the fascial incision of the DA approach (mean: 18.5 ± 3.5 mm, p < 0.0001). The risk of LFCN palsy was found to be 10-fold greater with the DA approach compared with the ABMS approached in this combined retrospective case series and systematic literature review. The anatomic location of the ABMS fascial incision was significantly farther from the LFCN, contributing to the decreased risk of LFCN injury.