Anatomical and CT angiographic study of superior gluteal neurovascular pedicle: implications for hip surgery
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ORIGINAL ARTICLE
Anatomical and CT angiographic study of superior gluteal neurovascular pedicle: implications for hip surgery Carla Stecco • Veronica Macchi • Luca Baggio • Andrea Porzionato • A. Berizzi • Roberto Aldegheri Raffaele De Caro
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Received: 5 June 2012 / Accepted: 28 August 2012 / Published online: 16 September 2012 Springer-Verlag 2012
Abstract Purpose To identify the site of incision with the lowest risk of injury of the superior gluteal neurovascular pedicle in the total hip arthroplasty with Hardinge’s direct lateral approach. Methods Eight fresh donated bodies were dissected and the branches of the superior gluteal nerve (SGN) and superior gluteal artery (SGA) were dissected. The distance between the SGA and the apex of greater trochanter (GT) was also evaluated in vivo in 29 patients by CT angiography. Results We observed 12 spray pattern and 4 transverse neural trunk pattern of the SGN. In all cases the nerve runs inferiorly to the artery, with a mean distance of 0.5 cm. At the CT angiography the average distance between the main branch of SGA and the GT was 5.2 cm, indicating a mean distance of 4.7 cm from the SGN to the GT. Terminal branches of SGA are found until 2.7 cm from GT. Conclusions This study analyzed the relationships between superior gluteal neurovascular pedicle and the GT in vivo (considering also the muscular tone), showing that during direct lateral access a safe area of 4.7 cm exists from the GT to the SGN and of 3.5 cm to its lower rami. C. Stecco V. Macchi A. Porzionato R. De Caro Section of Anatomy, Department of Molecular Medicine, University of Padova, Padua, Italy C. Stecco (&) Section of Anatomy, Department of Human Anatomy and Physiology, University of Padova, via A Gabelli 65, 35127 Padua, Italy e-mail: [email protected] L. Baggio A. Berizzi R. Aldegheri Clinic of Orthopaedic Surgery, Department of Surgery, University of Padova, Padua, Italy
Keywords Superior gluteal nerve Superior gluteal artery Gluteus medius muscle Hip surgery Hardinge’s direct lateral approach
Introduction Hardinge’s direct lateral, or transgluteal, access to the hip [6, 12] is one of the most commonly used surgical approaches for hip arthroplasty. It gives excellent exposure of the hip joint and a clear operating field with a low rate of postoperative dislocation. However, there is a risk of damaging superior gluteal nerve (SGN), with the potential consequence of denervation of the anterior part of the gluteus medius and tensor fascia latae [25], which causes abductor weakness [16, 23], pain, and limping. The clinical effects of SGN damage may be ascertained by a positive Trendelenburg test or may remain subclinical [4, 12, 13, 15, 23, 26, 27]. The exact incidence of permanent damage to the SGN is not known, but according to the study of Khan and Knowles [17], the inferior division of the SGN is damaged in 6.8 % of cases. On the contrary Abitbol et al. [1], investigating the incidence of injury to the SGN by EMG, report subclinical damage to the SGN in up to 77 % of cas
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