Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria.
Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria.
J Arthroplasty. 2021 Mar;36(3):1138-1142. doi: 10.1016/j.arth.2020.09.045. Epub 2020 Oct 1.
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.
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.
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.
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.
在初次和翻修全髋关节置换术（THA）中，臀上神经（SGN）的损伤会严重影响患者的预后。对于直接前入路（DAA）及其近端入路的扩展，尤其是进入阔筋膜张肌（TFL）的肌支，存在损伤风险。SGN 损伤可导致 TFL 的脂肪萎缩和功能丧失。因此，我们研究了 SGN 的走行和分支模式，并将其与 DAA 及其近端扩展相关联。本研究的目的是描述 DAA 及其近端扩展与 SGN 之间的安全和危险区域。
对 25 具福尔马林固定的尸体（48 个半骨盆）进行解剖。借助大转子和髂嵴等解剖学标志，研究了 SGN 及其肌支在 DAA 中的走行、分布和分支模式，以及与 DAA 的关系。
在 72.9%的标本中，SGN 穿过梨状肌上方的坐骨大切迹，有一个主干。供应 TFL 的 SGN 肌支在 89.6%的标本中于坐骨大切迹水平发自主干。在进入 TFL 肌肉之前，肌支在臀中肌和臀小肌之间的间隔内呈变异性分支。在 DAA 中，SGN 的危险区域位于皮切口近端的四分之一处。
在 DAA 中，近端器械的放置应特别小心。当近端扩展 DAA 时，应在近端、尾侧手术窗口中进行操作，并格外小心。
