HIP

Hip Int 2016; 26 (4): 338-343

DOI: 10.5301/hipint.5000352

ISSN 1120-7000 ORIGINAL ARTICLE

Nerve injuries in total hip arthroplasty with a mini

invasive anterior approach
George A. Macheras1, Panayiotis Christofilopoulos2, Panagiotis Lepetsos1, Andreas O. Leonidou1,
Panagiotis P. Anastasopoulos1, Spyridon P. Galanakos1

 4th Department of Orthopaedics and Trauma, KAT Hospital, Athens - Greece

1

 Department of Surgery, Orthopaedic Surgery and Traumatology of the locomotor System, University Hospitals of Geneva, Geneva - Switzerland
2

Abstract
Purpose: Minimal invasive techniques in total hip arthroplasty (THA) have become increasingly popular during
recent years. Despite much debate over the outcome of several minimal invasive techniques, complications arising
from the use of anterior minimally invasive surgery (AMIS) for THA on a traction table are not well documented. Our
study aims to focus on nerve damage during the AMIS procedure and the possible explanations of these injuries.
Methods: We reviewed all primary THAs performed with the AMIS technique using a traction table, over 5 years
and recorded all intraoperative and postoperative complications up to the latest follow-up. We focused on nerve
injuries and nerve function impairment following the aforementioned technique.
Results: Our study included 1,512 THAs performed with the AMIS technique in 2 major hip reconstruction centres
(KAT General Hospital, Athens, Greece and University Hospital of Geneva, Switzerland), on 1,238 patients (985
women, 253 men; mean age 65.24 years). Mean follow-up was 29.4 months. We observed 51 cases of transient
lateral femoral cutaneous nerve neuropraxia (3.37%), 4 cases of femoral nerve paralysis (3 permanent, 1 transient
[0.26%]) and 1 case of permanent sciatic nerve paralysis (0.06%). No case of obturator or pudendal nerve injury
was noticed. Mean age of these cases was 68.97 years. Sciatic and femoral nerve injuries were confirmed by
electromyography, showing axonotmesis of the damaged nerve.
Conclusions: Neurological injuries are a rare but distinct complication of THAs using the AMIS technique. Possible
explanations for such referred nerve injuries are direct nerve injury, extreme traction, hyperextension, extreme
external rotation of the leg, use of retractors and coexisting spinal deformities. Controlled use of traction in hip
extension, cautious use of retractors and potential use of dynamometers may be useful, so that neurological
damage can be avoided. Further studies are needed to fully elucidate the role of the above factors in AMIS neu-
rological complications.
Keywords: Anterior mini-invasive, Nerve injuries, Total hip arthroplasty

Introduction therefore entail risk and benefit profiles based on the ana-
tomic structures involved (2).
Total hip arthroplasty (THA) is the most successful opera- Anterior mini-invasive surgery (AMIS) for THA, firstly de-
tion in medical history in terms of pain relief and functional scribed as a modified Hueter approach and utilised by Judet
restoration (1). Despite the success that has been reported and Judet in 1950 (3), has recently gained popularity. Because
over multiple decades, there is a constant push to refine the of the intermuscular and internervous approach, it may be
technique to allow improvement in patient outcome, hospital preferable in terms of shorter rehabilitation, decreased post-
stay and complication rates. The main surgical approaches to operative pain, smaller skin scar, less blood loss, shorter hos-
the hip for THA utilise different intervals to the hip joint and pital stay and quicker return to daily activities (4-6). However,
the method has been noted for several complications such as
femoral fractures and perforations, trochanteric and acetabu-
Accepted: December 26, 2015 lar fractures, ankle fractures and neurovascular injuries (7).
Published online: April 13, 2016 Nerve injuries are a potentially devastating complication
of primary THA, with a reported incidence ranging from 0.09%
Corresponding author: to 3.7%. Reported aetiologies include intraoperative direct
George A. Macheras nerve injury, significant leg lengthening, improper retractor
4th Department of Orthopaedics and Trauma
KAT Hospital placement, cement extravasation, cement-related thermal
Nikis 2 damage, patient positioning, intraoperative manoeuvers,
14561 Kifissia Athens, Greece anatomical variations and postoperative haematoma (8). De-
gmacheras@gmail.com spite much debate over the outcomes of the AMIS procedure,

© 2016 Wichtig Publishing

Macheras et al 339

reports of neurological complications deriving from the use TABLE I - Characteristics of the study population
of the minimally invasive anterior approaches for THA on a
fracture table are scarce. THAs (n) 1512
Female (%) 79.6
Materials and methods
Mean age (years) 65.24 ± 10.86 (range 51-87)
We prospectively collected data from a series of 1,512 Mean follow-up (months) 29.4
THAs performed with the AMIS method, in 2 high-volume hip Mean BMI (kg/m ) 2
28.82 ± 5.42 (range 22.1-32.8)
reconstruction centres (KAT General Hospital, Athens, Greece
and University Hospital of Geneva, Switzerland). All of the op- Mean surgical time (minutes) 82.01 ± 15.43 (range 61-123)
erations were performed by the 2 senior authors in a period Mean hospitalisation (days) 5.9 ± 1.8 (range 3-14)
between March 2011 and May 2014 using a mini-invasive
Reason for THA 95% Primary hip osteoarthritis
direct anterior approach with a positioning table. Preop-
erative clinical examination in all patients showed no sign of 4% Rheumatoid arthritis
peripheral nerve damage. The severity of osteoarthritis was 1% Femoral head osteonecrosis
evaluated according to the Kellgren and Lawrence radiologi-
cal scale (9).
The procedure was performed, under epidural anaes- TABLE II - Incidence of nerve injuries
thesia, through an anterior minimal invasive approach as
described by Laude (10), with the patient in a supine posi- Nerve injured Number of cases Incidence
tion on an orthopaedic traction table (AMIS Mobile Leg po-
sitioned, Medacta). An anterior incision 6 to 10 cm in length LFCN 51 (transient) 3.37%
was centred on the apex of the great trochanter, parallel
Femoral nerve 4 (1 permanent, 3 transient) 0.26%
to a line joining the anterosuperior iliac crest to the fibula
head. The interval between the tensor fascia lata (TFL) and Sciatic/peroneal nerve 1 (permanent) 0.06%
the sartorius and rectus femoris muscles was used to expose Obturator nerve 0 0%
the hip joint capsule. The lateral femoral cutaneous nerve
(LFCN) was protected by the anterior part of the superficial Pudendal nerve 0 0%
aponeurosis. After the capsule was opened, the femoral neck
was osteotomised with the aid of gentle traction and exter-
nal rotation and the femoral head was removed with the use latest follow-up. We mainly focused on nerve injuries (LFCN,
of a corkscrew. A Charnley frame was placed on the capsule. femoral, sciatic, obturator and pudendal nerves).
Fluoroscopy was used to assess adequate acetabular reaming Statistical analysis was performed using the PASW 18
and depth of the socket and to determine correct acetabu- (SPSS release 18.0; SPSS Inc.). The baseline characteristics
lar component positioning and orientation. The femur was for categorical variables were expressed in number and per-
prepared by exposing the femoral neck after surgical release centage. The continuous variables were expressed as mean ±
of the capsule, whereas the leg was positioned by rotating standard deviation (SD).
the leg with the fracture table to 90° of external rotation at
the knee level and placing the hip into hyperextension and Results
adduction. Traction was released automatically during hy-
perextension in order to protect the femoral nerve. During As shown in Table I, our study included 1,512 THAs
femoral preparation, 2 Hohmann retractors were placed in performed with the AMIS technique in 2 major hip recon-
the neck area and under the greater trochanter in order to struction centres, on 1,238 patients (985 women, 253 men;
facilitate the elevation of the femur. At the time of hip reduc- mean age 65.24 years). Mean follow-up was 29.4 months.
tion, traction was used and adduction, hyperextension and Mean body mass index (BMI) of patients was 28.82. The av-
external rotation were released. All acetabular components erage surgical time was 82 minutes and mean hospitalisa-
were press-fit, uncemented porous-types, with screw fixation tion period was 5.9 days. We identified 1,436 patients with
in case of initial instability and all femoral components were a diagnosis of primary hip osteoarthritis, 60 patients with
cementless. All femoral heads were ceramic with a diameter rheumatoid arthritis and 16 patients with osteonecrosis.
of either 28 mm or 32 mm. 35% of cases had a Kellgren-Lawrence score of 3, while 65%
All patients received oral antithrombotic prophylaxis had a score of 4 (9).
(10 mg of rivaroxaban) for 5 weeks after the operation. Reha- Postoperatively, we observed 4 cases of femoral nerve
bilitation started on the first postoperative day and patients paralysis (3 permanent, 1 transient; incidence 0.26%), 1
were allowed to progress with weight-bearing as tolerated. case of permanent sciatic nerve paralysis (incidence 0.06%)
There were no specific precautions against dislocation. In and 51 cases of transient lateral femoral cutaneous nerve
case of no complication, the patients were discharged from (LFCN) neuropraxia (3.37%) (Tab. II). The mean age of these
the hospital on the third day after surgery. Postoperatively, cases was 68.97 years. There was no case of obturator or
visits were scheduled at 4 weeks, 3 months, 6 months, pudendal nerve damage. The clinical symptoms of femoral
12 months after surgery and annually thereafter. All intraop- nerve damage were weakness of ipsilateral hip flexion, knee
erative and postoperative complications were recorded up to extension, and numbness over the anteromedial aspect of

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Fig. 1 - Lateral femoral cutaneous nerve exposure during AMIS.
the thigh as well as hyperaesthesia and pain. The symptoms
of sciatic nerve damage were loss of foot dorsiflexion and
numbness of the dorsal, plantar and lateral aspects of the
foot. Femoral and sciatic nerve injuries were confirmed by
electromyography, showing axonotmesis of the damaged
nerve. The patient with sciatic nerve palsy was treated
with a foot-drop splint. LFCN neuropraxia was diagnosed by
clinical examination, as these patients complained of numb-
ness and a burning sensation along the anterolateral thigh.
All cases of LCFN neuropraxia gradually resolved within
6 months postoperatively.
Possible causes of LCFN injury include direct trauma to the
nerve during the approach Figure 1. The femoral nerve may
be injured by the retractors used during acetabular prepara-
tion Figure 2. We hypothesise that the sciatic nerve is injured
because of traction at the time of hip reduction as the nerve
is compressed by the intact external hip rotators.
Discussion
Nerve palsy following hip replacement can be a devastat-
ing complication that is likely to face all orthopaedic surgeons
at some stage. The incidence of nerve palsies in primary THA
ranges from 0.09% to 3.7% (8). The aim of the present study
was to evaluate neurological complications from the use of
the minimally invasive anterior approach for THA with the aid
of a fracture table.
The literature on nerve injuries following THA is scarce.
Most studies agree that there is no relation between nerve
injury and surgical approach and in many cases the precise
cause of the palsies remains unknown (11). In a recent sys-
tematic review by Lee and Marconi (12), intraoperative and
early postoperative complications were analysed in 11,810
hip procedures. The authors found 250 LFCN injuries (2.1%);
11 femoral nerve palsies (0.09%); and 8 peroneal nerve dys-
Nerve injuries in AMIS THAs
Fig. 2 - Femoral nerve may be injured by the retractors.
functions (0.07%). Common causes of nerve palsy after THA
include traction or compression upon the nerve, direct op-
erative trauma, haematoma formation, thermal lesions from
extraneous cement, use of epidural anaesthetics and under-
lying spinal stenosis (11). Risk factors include developmental
dysplasia of the hip, female sex, anatomical variations, previ-
ous hip surgery, posttraumatic arthritis, and revision surgery.
However, no single risk factor has been consistently reported
to be significant, and many patients with no known risk fac-
tors incur neurologic injuries (13).
Our study has several advantages and limitations. It is the
largest multicentre study that has investigated the outcome
of AMIS method to date, focusing on neurological complica-
tions, with the longest follow-up time. All operations were
performed by the 2 senior authors, who had overcome the
learning curve of the method, thus minimising potential com-
plication risk. However, there was no control group to compare
the rate of nerve injuries of THAs with different approaches.
The diagnosis of nerve damage depended on clinical examina-
tion and was confirmed by EMG. Even though clinical exami-
nation underestimates the incidence of neurologic injury after
THA, we chose not to routinely perform postoperative EMGs
in all THA patients as it is known that 70% of THA patients have
subclinical sciatic nerve injury (13, 14).
Table III shows the results of all studies that have reported
nerve injuries after THA with a mini-invasive direct anterior
approach; however, there are several studies that do not
mention nerve injuries in the complications of the method
(15-19). The only study that focused on nerve injuries in THAs
with mini-invasive direct anterior approach was published by
Bhargava et al, in 2010 (20). The reported incidence of LFCN
injury was 14.8%, among 81 THAs (10 transient, 2 permanent
damage). However, the sample size of the study was much
smaller than in the current study and the authors did not
mention details of other nerve injuries. Moreover, it is known
that the AMIS method has a prolonged learning curve and
the surgeon’s level of experience with this approach directly
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TABLE III - Rate of nerve injuries in AMIS studies

Author THAs Mean age Mean follow-up LFCN injury Femoral nerve Sciatic/peroneal
(months) injury nerve injury

Siguier 2004 (32) 1037 67.8 >12 NM 0.2% NM

Matta 2006 (5) 494 64 NM 0% 0.2% NM
Nakata 2009 (26) 99 62.9 6 1% 0% 0%
Woolson 2009 (37) 247 67.7 8 NM 0% 0.8%
Seng 2009 (22) 182 NM >12 1.09% 0% NM
Bhandari 2009 (21) 1277 65 36 1.02% NM NM
Goulding 2010 (23) 55 55.5 13.4 67% NM NM
Bhargava 2010 (20) 81 57.8 24 14.8% NM NM
Sendtner 2011 (24) 74 68.1 12 4.1% 0% NM
Jewett 2011 (25) 800 62.5 20 0.12% 0% NM
Hallert 2012 (38) 200 67.4 NM 0.5% 0.5% 0.5%
De Geest 2013 (7) 300 69.8 12 5.33% NM NM
Yi 2013 (27) 61 55.6 13.1 1.6% 0% NM
Alexandrov 2014 (33) 43 62 16.8 0% 5% 0%
Homma 2015 (28) 122 66.3 12.8 31.9 % NM NM
Our study 1512 65.2 29.4 3.37% 0.26% 0.06%
NM = not mentioned.

correlates with complication rates until reaching a plateau af-
ter the first 40-100 cases (21, 22).
Damage to the LFCN is a commonly described complica-
tion associated with the direct anterior approach and the re-
ported incidence ranges widely from 0.1% to as high as 67%
(23). The distal branches of the LFCN are at risk with distal
extension of the incision. In a recent series of 300 THAs per-
formed with the AMIS technique, De Geest et al (7) reported
a 5.33% incidence of transient LFCN injury, while in another
study, Sendtner et al (24) observed 3 cases of LCFN injury
among 74 THAs (incidence 4.1%). A large study, conducted
by Jewett et al (25), which focused on the complication rate
with anterior THAs on a fracture table, reported only 1 case
of transient LFCN injuries among 800 cases, while there was
no femoral nerve damage. In 2009, Nakata et al (26) reported
only 1 case of transient LFCN damage, in a series of 99 THAs
performed with minimally invasive direct anterior approach.
Similar results were shown in a small study by Yi et al (27),
who reported 1 case of transient LCFN damage among 61
THAs using anterior supine intermuscular approach. Seng
et al (22) reported only 2 (1.09%) cases of transient LFCN par-
aesthesia in 182 patients after anterior THA, both of which
resolved. Recently, Homma et al (28) found that LFCN inju-
ry was seen at a percentage of 31.9 % after direct anterior
approach for THA and they concluded that the incidence of
LFCN injury decreased quality of life but not hip function after
direct anterior approach for THA. The large variation appears
to depend on how aggressively surgeons interrogate patients
postoperatively about LFCN symptoms. Most paraesthesias
largely resolve, and few patients report functional limitation.
Although injury to the LFCN does not represent a major neu-
rologic complication as compared with the potentially cata-
strophic outcomes of sciatic and femoral nerve palsies, this
complication can be distressing to the patient and should be
discussed extensively as part of informed consent (17). In
our study, the incidence of transient LFCN injury was 3.37%,
which is in accordance with the literature.
The location of LFCN and the number of its branches can
widely vary among patients (29-31). In the study by Grothaus
et al (29) as many as 5 branches of the LFCN were found, and
Chen et al (30) noted that the LFCN divided into the anterior
and posterior branches, and then subdivided into the medial,
middle, and lateral branches. In our cases the lateral branch
of the LFCN was accidentally damaged as our approach is
lateral over the belly of the TFL muscle. Only a small area
around the skin incision, corresponding to the lateral branch
of the LFCN injury, was affected in all our cases but 2 where a
larger area in the lateral aspect of the femur was affected. We
had no case of meralgia paraesthetica.
Our approach is located much more laterally than the site
of the incision in the original Smith-Petersen. It is located over
the belly of the TFL. After the skin incision and the underline
fat separation, the aponeurosis of the TFL muscle is opened
at a distance of 2 cm lateral to the TFL-sartorius interval and
it is separated from the muscle fibres in a parallel fashion to
the muscle fibres. Using a finger, we carefully separate the
sartorius and TFL. The muscular belly remains laterally and
the aponeurosis is retracted medially. Then the part of the
aponeurosis underneath the TFL is opened to approach the
joint capsule. In this way the LFCN is left medially. The main
branches of the LFCN are located medially to and at the level
of the ASIS.
In all large studies, the reported incidence of femoral
nerve damage associated with THA is 0.01% to 2.3% (13). The

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incidence of femoral nerve injury, in our study, was 0.26%, in
accordance with the results of the largest studies concerning
AMIS complications (5, 32). Matta et al (5) studied a series of
494 single-incision anterior approach hip arthroplasties using
similar fixation technique and postoperative rehabilitation
protocols (cementless fixation and full weight bearing with-
out dislocation precautions) and reported 1 case of transient
femoral nerve palsy, without mentioning any possible expla-
nation. Siguier et al (32) reported 2 femoral nerve palsies
among 1037 THAs using the anterior supine intermuscular
approach on an orthopaedic table, attributing the femoral
nerve damage to the use of retractors. In a recent small se-
ries of 43 THAs performed through an anterior muscle spar-
ing minimally invasive approach, 2 cases of transient femoral
nerve palsy were reported (incidence 5%). The authors stated
that the femoral nerve damage occurred because of the hip
hyperextension during femoral canal preparation (33).
Slater et al (34) found that the only step that consistently
raises pressure adjacent to the femoral nerve is caused by
retractors on the anterior acetabular lip. The femoral nerve
is susceptible to traction injury during this time if the hip
is placed in excessive extension. Kuo et al (35) have shown
that extensive hip abduction and external rotation may also
be associated with femoral nerve traction injury. In the AMIS
technique, both risk factors are involved. A Charnley retrac-
tor is placed on the anterior acetabular lip and two Hohmann
retractors are placed around the femoral neck and behind the
greater trochanter to facilitate the reaming the femoral canal.
Adduction of the femur in AMIS procedure does not press the
femoral nerve while excessive extension and external rota-
tion are part of the technique and cannot be avoided. Femo-
ral nerve injury seems to have a good prognosis and should
resolve completely within a few months.
The sciatic nerve is the most commonly injured nerve fol-
lowing THA, with a reported incidence ranging from 0.05% to
1.9% (8). 50% of sciatic nerve palsies are of unknown aetiol-
ogy (36). Several studies have shown that sciatic nerve palsy
after hip replacement is not correlated to surgical approach.
This reflects the fact that traction is probably the most com-
mon cause of sciatic nerve palsy, which is possible with all ap-
proaches, according to Unwin et al (11). However, the specific
cause of injury has never been clarified.
Few data concerning sciatic nerve palsy after THA with the
AMIS method are available and most studies do not mention
this kind of complication, as shown in Table III. Woolson et al
(37) reported 2 cases of peroneal nerve injuries among 247
AMIS THAs (incidence 0.8%) without mentioning possible ex-
planations. Hallert et al (38), in a series of 200 THAs with min-
imally invasive direct anterior approach, reported 1 case of
LFCN damage, 1 case with decreased peroneal nerve function
and 1 case with postoperative complete loss of femoral nerve
function treated with orthosis. All 3 cases had completely re-
solved within 6 months. The authors attributed femoral nerve
damage to compression caused by the retractors. However,
no possible explanation was given for the peroneal nerve in-
jury (38).
During the AMIS technique, traction is applied through
the fracture table in certain steps of the approach, thus mak-
ing damage of the sciatic nerve more likely. However, traction
cannot fully explain the mechanism of injury, because leg
Nerve injuries in AMIS THAs
positioning during an anterior approach (extension, adduction
and external rotation) reduces tension on the sciatic nerve.
We believe that the sciatic nerve damage during the AMIS
procedure takes place during trial and final hip reduction,
as the nerve is possibly compressed or strangled by the intact
external hip rotators. However, the possibility of coexisting
degenerative spine changes and spinal stenosis that could
possibly trigger sciatic nerve palsy should not be omitted.
The incidence of pudendal nerve palsy in operations
with the use of a traction table has been reported to range
from 1.9% to 27.6% due to excessive and/or prolonged trac-
tion against the perineal post (39). Pudendal nerve palsy has
not been reported in any series of direct anterior approach
for THA (40). The reported incidence of obturator nerve
injury in THAs is 0.01% while obturator nerve palsy during
AMIS procedure has not been reported in the literature (8).
In accordance with most studies, we did not find a case of
obturator or pudendal nerve palsy after THA with the AMIS
method.
Prevention is the best treatment for nerve complications
following THA. In the literature, the intraoperative use of so-
matosensory-evoked potentials (SSEP) for routine primary
THAs is debatable (8). Neurological monitoring with the aid
of spontaneously elicit electromyography (sEMG) and nerve
action potentials (NAPs) has mainly been studied in revi-
sion THAs (41, 42). We believe that the intraoperative use of
EMG and SSEPs could be useful, since the AMIS technique
has not been used for more than 15 years and its complica-
tions are currently under investigation. Moreover, the force
of traction that is applied to the leg through the fracture
table in some steps of the procedure is measurable, and
therefore can be monitored with the aid of force gauges, so
that we could fully investigate the role of traction in AMIS
complications.
Conclusions
Nerve injuries are rare but existing complications of THAs
using the AMIS technique. Permanent injuries are rare, as
most of them recover within 6 months. Surgeons’ aware-
ness and meticulous operative technique have been shown
to reduce the risk. Controlled traction during hip reduction,
avoidance of extreme positions, careful use of retractors and
gentle manoeuvers could prevent neurologic damage. Future
use of EMG and SSEPs could be useful, so that the role of trac-
tion in AMIS complications could be fully elucidated.
Disclosures
Financial support: None.
Conflict of interest: None.
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