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Distal extension of the direct anterior approach to the hip poses risk to neurovascular structures: an anatomical study
直接前方入路髋关节的远端延伸对神经血管结构构成风险：一项解剖学研究

Grob, K ; Monahan, R ; Gilbey, H ; Yap, F ; Filgueira, L ; Kuster, M
格罗布, K ; 莫纳汉, R ; 吉尔比, H ; 叶, F ; 菲尔盖拉, L ; 库斯特, M

Posted at the Zurich Open Repository and Archive, University of Zurich
发布于苏黎世大学开放存储库和档案馆
ZORA URL: https://doi.org/10.5167/uzh-121066
Journal Article 期刊文章
Published Version 已发布版本
Originally published at: 最初发布于：
Grob, K; Monahan, R; Gilbey, H; Yap, F; Filgueira, L; Kuster, M (2015). Distal extension of the direct anterior approach to the hip poses risk to neurovascular structures: an anatomical study. Journal of Bone and Joint Surgery. American Volume, 97(2):126-132.
Grob, K; Monahan, R; Gilbey, H; Yap, F; Filgueira, L; Kuster, M (2015)。髋关节直接前入路的远端延伸对神经血管结构构成风险：一项解剖研究。《骨与关节外科杂志》。美国卷，97(2)：126-132。
DOI: https://doi.org/10.2106/JBJS.N. 00551

Distal Extension of the Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures
直接前方入路的远端延伸对髋关节神经血管结构构成风险

An Anatomical Study 解剖学研究

Karl Grob, MD, Rebecca Monahan, MBBS, Helen Gilbey, PhD, Francis Yap, MBBS, Luis Filgueira, PhD, MD, and Markus Kuster, PhD, MD
卡尔·格罗布，医学博士，丽贝卡·莫纳汉，医学学士，海伦·吉尔比，博士，弗朗西斯·亚普，医学学士，路易斯·菲尔盖拉，博士，医学博士，马库斯·库斯特，博士，医学博士Investigation performed at the Department of Anatomy, University of Zurich Irchel, Zurich, Switzerland, and the Department of Anatomy and Human Biology, University of Western Australia, Perth, Australia
在瑞士苏黎世伊尔赫尔苏黎世大学解剖学系和澳大利亚西澳大学解剖学与人类生物学系进行的调查

Abstract 摘要

Background: The anterior approach to the hip gained popularity for total hip arthroplasty in recent years. Distal extension of the anterior approach, sometimes needed intraoperatively, potentially endangers neurovascular structures to the quadriceps. The aim of this study was to determine the anatomical structures placed at risk by distal extension of the anterior approach to the hip. Methods: Seventeen cadaveric hemipelves from twelve human specimens were dissected. The femoral nerve and its branches and the vessels arising from the lateral femoral circumflex artery were assessed in relation to the distal extension of the anterior approach. The damage caused by the introduction of a cerclage cable passer was also investigated.
背景：近年来，前入路在全髋关节置换术中越来越受欢迎。前入路的远端延伸在手术中有时是必要的，但可能会危及到股四头肌的神经血管结构。本研究的目的是确定前入路远端延伸所置于风险的解剖结构。方法：对来自十二具人类标本的十七个尸体半骨盆进行了解剖。评估了股神经及其分支以及来自外侧股旋动脉的血管与前入路远端延伸的关系。还调查了引入缠绕电缆穿线器所造成的损伤。

Results: The area immediately distal to the intertrochanteric line is a common entry point for several nerve branches and is a useful distal landmark for surgeons to use to protect important neurovascular structures. The distal extension of the anterior approach compromises the nerve supply to the anterolateral portions of the quadriceps. Introduction of a cerclage cable passer through the anterior access also jeopardizes nerve branches to the vastus lateralis, lateral parts of the vastus intermedius, and branches of the lateral femoral circumflex artery. Conclusions: Distal extension of the direct anterior approach to the hip is challenging to accomplish without neurovascular injury to anterolateral parts of the quadriceps muscle group. In addition, important neurovascular structures are endangered with the introduction of a cable passer through the anterior approach.
结果：股骨转子间线远端区域是多个神经分支的常见进入点，是外科医生用来保护重要神经血管结构的有用远端标志。前方入路的远端延伸会影响到股四头肌前外侧部分的神经供应。通过前方入路引入缠绕电缆穿线器也会危及到外侧广肌、外侧中间广肌的外侧部分以及外侧股动脉的分支。结论：直接前方入路到髋关节的远端延伸在不造成股四头肌前外侧部分神经血管损伤的情况下是具有挑战性的。此外，通过前方入路引入缠绕电缆穿线器会危及重要的神经血管结构。

Clinical Relevance: Distal extension of the direct anterior approach to the hip beyond the intertrochanteric line may compromise neurovascular structures supplying the quadriceps muscle.
临床相关性：直接前方入路向髋关节的远端延伸超出转子间线可能会损害供应股四头肌的神经血管结构。

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
同行评审：本文由主编和一位副编辑审阅，并经过两位或更多外部专家的盲审。副编辑审查了文章的每次修订，并在发表前由主编进行了最终审查。最终的修正和澄清是在作者与文稿编辑之间的一次或多次交流中进行的。
The direct anterior approach for total hip arthroplasty has recently gained popularity with good clinical results 1 − 6 1 − 6 ^(1-6){ }^{1-6}. However, there have been reports of intraoperative complications, such as femoral fracture, implant failure, and muscle trauma 7 − 12 7 − 12 ^(7-12){ }^{7-12}, that may require an extension of the surgical approach. Kennon et al. 1 1 ^(1){ }^{1} reported that the direct anterior approach could be safely extended proximally and distally even in complex revisions without clinically relevant
直接前入路全髋关节置换术最近因良好的临床结果而受到欢迎 1 − 6 1 − 6 ^(1-6){ }^{1-6} 。然而，已有报告指出术中并发症，如股骨骨折、植入物失败和肌肉损伤 7 − 12 7 − 12 ^(7-12){ }^{7-12} ，可能需要扩展手术入路。Kennon 等人 1 1 ^(1){ }^{1} 报告称，直接前入路即使在复杂的修复中也可以安全地向近端和远端扩展，而不会产生临床相关的并发症。
nerve injuries. Furthermore, a textbook on surgical exposures describes and recommends this option 13 13 ^(13){ }^{13}.
神经损伤。此外，一本关于外科暴露的教科书描述并推荐了这个选项 13 13 ^(13){ }^{13} 。
While proximal extension with detachment of the tensor fascia femoris and gluteal muscles from the pelvis is part of the Smith-Petersen approach, distal extension could endanger neurovascular structures. The anatomical relationship of nerve branches and blood vessels to the quadriceps with respect to the anterior approach has not been documented, to our knowledge.
虽然在史密斯-彼得森方法中，近端延伸伴随髂筋膜和臀肌从骨盆的分离，但远端延伸可能会危及神经血管结构。根据我们的了解，关于神经分支和血管与股四头肌在前方入路中的解剖关系尚未有文献记录。
The Journal of Bone & Joint Surgery ⋅ ⋅ *\cdot jbjs.org Volume 97-A ⋅ ⋅ *\cdot Number 2 ⋅ ⋅ *\cdot Jandary 21, 2015
骨与关节外科杂志 ⋅ ⋅ *\cdot jbjs.org 第 97 卷-A ⋅ ⋅ *\cdot 第 2 期 ⋅ ⋅ *\cdot 2015 年 1 月 21 日
Distal Extension of Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures
直接前方入路的远端延伸对髋关节神经血管结构构成风险
Fig. 1-A 图 1-A
Fig. 1-B 图 1-B
Fig. 1-A Anterolateral view of the right hip. The anatomy of the anterior approach is presented. The internervous space between the sartorius and the rectus femoris medially and the tensor fascia femoris laterally is widened. The rectus femoris and sartorius are reflected medially. The yellow dotted line indicates the position of the skin incision slightly lateral to the anatomical plane. The yellow arrow indicates the way of access to the hip joint proximal to the nerve branches to the vastus lateralis and intermedius and the branches of the lateral femoral circumflex artery (LFCA). Fig. 1-B Anterolateral view of the right hip region (the same specimen as shown in Figure 1-A). Needles mark the entry points of the femoral nerve branches. Two Hohmann hooks are placed around the neck of the femur medially and laterally. The rectus femoris is reflected medially and the sartorius, proximally. X1 is a line through the middle of the neck of the femur on the level of the intertrochanteric line (red sticker), and X2 is the line through the lower margin of the lesser trochanter (pin, see also radiographic image). The green dotted line ( Y ) ( Y ) (Y)(\mathrm{Y}) corresponds to the midline of the femur in a neutral position of rotation. The yellow dotted line indicates our preferred incision of the joint capsule during the standard anterior approach to the hip joint.
图 1-A 右侧髋关节的前外侧视图。展示了前方入路的解剖结构。缝匠肌和股直肌之间的神经间隙向内侧和外侧的髋肌筋膜张肌之间被扩展。股直肌和缝匠肌向内侧反射。黄色虚线表示皮肤切口的位置，稍微偏离解剖平面。黄色箭头指示了进入髋关节的方式，位于外侧广肌和中间广肌的神经分支及外侧股动脉（LFCA）的分支的近端。图 1-B 右侧髋关节区域的前外侧视图（与图 1-A 中显示的标本相同）。针标记了股神经分支的进入点。两个霍曼钩分别放置在股骨颈的内侧和外侧。股直肌向内侧反射，缝匠肌向近端反射。X1 是通过股骨颈中部的线，位于转子间线的水平（红色贴纸），X2 是通过小转子下缘的线（针，另见放射影像）。 绿色虚线 ( Y ) ( Y ) (Y)(\mathrm{Y}) 对应于股骨在中立旋转位置的中线。黄色虚线表示我们在标准前方入路到髋关节时首选的关节囊切口。
The Journal of Bone & Joint Surgery ⋅ ⋅ *\cdot jbjs.org Volume 97-A ⋅ ⋅ *\cdot Number 2 ⋅ ⋅ *\cdot January 21, 2015
骨与关节外科杂志 ⋅ ⋅ *\cdot jbjs.org 第 97 卷-A ⋅ ⋅ *\cdot 第 2 期 ⋅ ⋅ *\cdot 2015 年 1 月 21 日
Distal Extension of Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures
直接前方入路的远端延伸对髋关节神经血管结构构成风险
The purpose of this cadaver study was to demonstrate the neurovascular structures encountered during the direct anterior approach to the hip joint with special emphasis on potential distal extension or the placement of a cerclage cable passer around the proximal part of the femur.
本尸体研究的目的是展示在直接前方接近髋关节时遇到的神经血管结构，特别强调潜在的远端延伸或在股骨近端放置环形缆线穿线器。

Materials and Methods 材料与方法

eventeen cadaveric hemipelves (ten paired and seven unpaired) from twelve Specimens (eight male and four female) were investigated.
对来自十二个标本（八个男性和四个女性）的十七个尸体半骨盆（十对和七个单独的）进行了研究。
Seven limbs were “Thiel-fixed” 14 14 ^(14){ }^{14} and ten were embalmed in a formalinbased solution. None of the cadavers showed any evidence of previous trauma or surgery to the femur or hip joint. The dissection protocol began with each lower limb being placed supine on a dissection table and the hip joint approached anteriorly. For improved visualization, a 25 − cm 25 − cm 25-cm25-\mathrm{cm} long incision following the anterior half of the iliac crest to the anterior superior iliac spine was made. From there, the incision was curved downward, aiming toward the fibular head. The superficial skin and subcutaneous tissue were removed. The fascia of the tensor fascia femoris muscle was incised laterally. Staying lateral to
七肢被“蒂尔固定”，十肢则浸泡在基于福尔马林的溶液中。没有尸体显示出股骨或髋关节之前有任何创伤或手术的迹象。解剖协议开始时，每条下肢被平放在解剖台上，髋关节从前方接近。为了更好地观察，沿着髂骨脊的前半部分到前上髂棘做了一个长切口。从那里，切口向下弯曲，目标指向腓骨头。去除了表层皮肤和皮下组织。髂筋膜张肌的筋膜在外侧被切开。保持在外侧。
the sartorius and rectus femoris muscles allowed us to identify the ascending branch of the lateral femoral circumflex artery where it entered the tensor fascia femoris muscle and trace it medially to its origin (Fig. 1-A). After resection of the joint capsule, the proximal margin of the muscle bellies of the vastus lateralis and vastus intermedius were localized at the intertrochanteric line. The femoral nerve was dissected proximal to the inguinal ligament, and its course was traced distally. The anterior approach to the hip joint was then extended distally along the anterior margin of the tensor muscle, while remaining lateral to the rectus femoris. All nerve branches to the vastus lateralis and vastus intermedius, the rectus, and the sartorius as well as the vessels arising from the lateral femoral circumflex artery were dissected carefully. To improve visualization of the neurovascular structures, the rectus femoris and the sartorius were transected distally and elevated medially and proximally. The tensor was mobilized from the underlying vastus lateralis. The entry point of each nerve branch into its specific muscle belly was recorded (Fig. 1-B), and the distances to two reference lines-X1 and X2, with distance X1 to X2 being 100%-were measured. X1 was the horizontal line through the middle of the neck of the femur just proximal to the intertrochanteric line, and X 2 was the horizontal line through the lower margin of the lesser trochanter.
缝匠肌和股直肌使我们能够识别外侧股旋动动脉的上升支进入髂筋膜肌的位置，并向内追踪到其起源（图 1-A）。在切除关节囊后，外侧广肌和中间广肌的肌腹近端边缘定位于转子间线。股神经在腹股沟韧带近端被解剖，并向远端追踪。然后，髋关节的前方入路沿着髂肌的前缘向远端延伸，同时保持在股直肌的外侧。所有通往外侧广肌、中间广肌、股直肌和缝匠肌的神经分支，以及来自外侧股旋动动脉的血管都被仔细解剖。为了改善神经血管结构的可视化，股直肌和缝匠肌在远端被切断并向内和近端抬起。髂肌从下方的外侧广肌中游离出来。每个神经分支进入其特定肌腹的切入点被记录下来（图。 1-B)，并测量了到两条参考线-X1 和 X2 的距离，其中 X1 到 X2 的距离为 100%。X1 是通过股骨颈中部的水平线，位于转子间线的近端，而 X2 是通过小转子下缘的水平线。
Fig. 2 图 2
The entry points (as a percentage of the distance from X1 to X2) of nerve branches into the lateral part of the vastus lateralis (VL lat), the medial part of vastus lateralis (VL med), the lateral part of the vastus intermedius (VI lat), the medial part of the vastus intermedius (VI med), the rectus femoris, and the sartorius in relation to lines X1 and X2. Ascendens, transverse, and descendens refer to the areas where the ascending, transverse, and descending branches of the lateral femoral circumflex artery cross the midline of the femur. For better visualization, some nerve branches are marked with black paper. X1 corresponds to the horizontal line through the middle of the neck of the femur just proximal to the intertrochanteric line, and X2 corresponds to the horizontal line through the lower margin of the lesser trochanter (distance X1 to X2 is 100%). Red double arrow = the shortest measured distance between the horizontal line X1 and the first entrance of a nerve branch, black dots in the centers of the double black arrows = the average distance, and black double arrows = 95% confidence limits.
神经分支进入外侧阔筋膜肌（VL lat）、内侧阔筋膜肌（VL med）、外侧中间阔筋膜肌（VI lat）、内侧中间阔筋膜肌（VI med）、直肌和缝匠肌相对于 X1 和 X2 线的入口点（以 X1 到 X2 的距离百分比表示）。Ascendens、transverse 和 descendens 指的是外侧股动脉环绕支的上升、横向和下降分支穿过股骨中线的区域。为了更好地可视化，某些神经分支用黑纸标记。X1 对应于通过股骨颈中部的水平线，位于转子间线的近端，X2 对应于通过小转子下缘的水平线（X1 到 X2 的距离为 100%）。红色双箭头 = 水平线 X1 与神经分支第一次进入点之间测得的最短距离，黑色双箭头中心的黑点 = 平均距离，黑色双箭头 = 95%置信区间。
The Journal of Bone & Joint Surgery ⋅ ⋅ *\cdot jbjs.org Volume 97-A ⋅ ⋅ *\cdot Number 2 ⋅ ⋅ *\cdot January 21, 2015
骨与关节外科杂志 ⋅ ⋅ *\cdot jbjs.org 第 97 卷-A ⋅ ⋅ *\cdot 第 2 期 ⋅ ⋅ *\cdot 2015 年 1 月 21 日
Distal Extension of Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures
直接前方入路的远端延伸对髋关节神经血管结构构成风险

Abstract 摘要

The distances from the point where the vessels of the lateral femoral circumflex artery crossed the midline of the femur (Y) in a neutral position of rotation were also recorded. Nerve branches to the vastus lateralis and vastus intermedius were traced intramuscularly, and their courses deep into the muscle surface were studied. Finally, a cerclage cable passer (Stryker, Selzach, Switzerland) was placed around the shaft of the femur just distal to the lesser trochanter, and its proximity to the neurovascular structures was recorded. The cerclage cable passer was inserted once through the extended anterior approach and once through a separate lateral subvastus approach. Both passing methods were investigated as they were performed from medial to lateral and from lateral to medial.
从侧股旋 circumflex 动脉的血管交叉股骨中线（Y）的位置在中立旋转位置的距离也被记录下来。对外侧广肌和中间广肌的神经分支进行了肌内追踪，并研究了它们深入肌肉表面的路径。最后，一个缠绕电缆穿线器（Stryker，Selzach，瑞士）被放置在股骨干的部位，正好在小转子下方，并记录了它与神经血管结构的接近程度。缠绕电缆穿线器通过扩展的前方入路插入一次，并通过单独的外侧下广肌入路插入一次。两种穿线方法都进行了研究，因为它们是从内侧到外侧和从外侧到内侧进行的。

Source of Funding 资金来源

No external funding was used in this study.
本研究未使用外部资金。

Results 结果

The distance from X1 and X2 to the points where the branches of the lateral femoral circumflex artery intersected the Y line and the distance from X 1 and X 2 to the points where the muscle branches of the femoral nerve entered the specific muscle belly are shown in Figure 2 as percentages (with the distance from X1 to X2 being 100%). The lateral femoral circumflex artery diverged into the ascending, transverse, and descending branches between the horizontal reference lines X1 and X 2 in all cases. The ascending branch always progressed directly above the middle of the femoral neck, the transverse branch was always between reference lines X1 and X2, and the descending branch was below the reference lines.
X1 和 X2 到外侧股动脉分支与 Y 线交点的距离，以及 X1 和 X2 到股神经肌肉分支进入特定肌肉腹的距离如图 2 所示，以百分比表示（X1 到 X2 的距离为 100%）。在所有情况下，外侧股动脉在水平参考线 X1 和 X2 之间分为上行、横行和下行分支。上行分支始终位于股骨颈中部正上方，横行分支始终位于参考线 X1 和 X2 之间，下行分支位于参考线下方。
The mean distance (and standard deviation) between X1 and the proximal nerve branches of the vastus lateralis or vastus intermedius was 34 ± 14.5 mm 34 ± 14.5 mm 34+-14.5mm34 \pm 14.5 \mathrm{~mm} (range, 9 to 75 mm ). In eight of the seventeen lower limbs, one or more nerve branches pierced
X1 与外侧广肌或中间广肌的近端神经分支之间的平均距离（和标准差）为 34 ± 14.5 mm 34 ± 14.5 mm 34+-14.5mm34 \pm 14.5 \mathrm{~mm} （范围，9 到 75 毫米）。在十七条下肢中的八条中，一个或多个神经分支穿透了
the vastus lateralis or vastus intermedius < 20 mm < 20 mm < 20mm<20 \mathrm{~mm} distal to Xl . The shortest measured distance in millimeters between the horizontal line X1 and the first entry point of a nerve branch of either the vastus lateralis or the vastus intermedius was 9 mm .
外侧广肌或中间广肌 < 20 mm < 20 mm < 20mm<20 \mathrm{~mm} 位于 Xl 的远端。测得的水平线 X1 与外侧广肌或中间广肌的神经分支第一个进入点之间的最短距离为 9 毫米。
A vascular and nerve web of the lateral femoral circumflex artery and muscle branches of the femoral nerve coursed toward the muscle fibers of the vastus lateralis and vastus intermedius (Fig. 3). We found separate proximal-medial and distal-lateral muscle bellies of the vastus lateralis. These two muscle bellies, together with lateral portions of the vastus intermedius, were supplied by nerve branches from the same lateral division of the femoral nerve. The main nerve branch to the lateral part of the vastus lateralis coursed regularly together with the descending branch of the lateral femoral circumflex artery and vein. Additional neural supply was provided from the proximal aspect of the femoral nerve.
股外侧旋动脉及股神经肌肉分支的血管和神经网络向外侧广肌和中间广肌的肌纤维延伸（图 3）。我们发现外侧广肌有两个独立的近端内侧和远端外侧肌腹。这两个肌腹与外侧中间肌的外侧部分由来自股神经同一外侧分支的神经分支供给。供给外侧广肌的主要神经分支与外侧股旋动脉和静脉的降支一起规律地走行。额外的神经供给来自股神经的近端部分。
The blood supply to the vastus lateralis and vastus intermedius proximally was either via the transverse branch or ramifications of the ascending branch of the lateral femoral circumflex artery. The lateral part of the vastus intermedius received nerve branches from the same division of the femoral nerve that supplied the vastus lateralis. The medial part of the vastus intermedius was supplied by medial branches of the femoral nerve. Those branches supplied deep layers of the vastus intermedius, which served the articularis genus in the distal aspect. The rectus femoris and the sartorius were innervated by separate arcade-like branches of the femoral nerve that were more superficial and at a greater distance from the anterior border of the femur. Figure 2 shows the distribution pattern of the points of entry of nerves in relation to the anatomical reference lines X1 and X2.
股外侧肌和股中间肌近端的血液供应来自股外侧旋动动脉的横支或上升支的分支。股中间肌的外侧部分接受来自同一股神经分支的神经支配，该分支也供应股外侧肌。股中间肌的内侧部分由股神经的内侧分支供应。这些分支供应股中间肌的深层，服务于远端的关节肌。直肌和缝匠肌由股神经的独立弓状分支支配，这些分支更表浅，距离股骨前缘更远。图 2 显示了神经进入点的分布模式与解剖参考线 X1 和 X2 的关系。
Fig. 3 图 3
Anterior view to the proximal part of the right thigh and the right hip joint. The sartorius (not visible) and rectus muscles are lifted proximally. For better visualization, some nerve branches (yellow arrows) are marked with black paper. The ascending branch of the lateral femoral circumflex artery and the joint capsule were partially removed. The green dotted line indicates the distal extension of the anterior approach to the hip joint. Neurovascular structures lateral to the incision are endangered, with the vastus lateralis and lateral portions of the vastus intermedius affected.
右大腿近端和右髋关节的前视图。缝匠肌（不可见）和直肌被向近端抬起。为了更好地可视化，一些神经分支（黄色箭头）用黑纸标记。外侧股动脉的上升支和关节囊部分被切除。绿色虚线表示髋关节前方入路的远端延伸。切口外侧的神经血管结构受到威胁，外侧广肌和外侧中间广肌的部分受到影响。
The Journal of Bone & Joint Surgery ⋅ ⋅ *\cdot jbjs.org Volume 97-A ⋅ ⋅ *\cdot Number 2 ⋅ ⋅ *\cdot January 21, 2015
骨与关节外科杂志 ⋅ ⋅ *\cdot jbjs.org 第 97 卷-A ⋅ ⋅ *\cdot 第 2 期 ⋅ ⋅ *\cdot 2015 年 1 月 21 日
Distal Extension of Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures
直接前方入路的远端延伸对髋关节神经血管结构构成风险
Fig. 4 图 4
Anterior view to the proximal part of the right thigh and the right hipjoint (same specimen as shown in Figure 3). The sartorius (not visible) and rectus muscles are reflected proximally. The nerve branches (yellow arrows) extend between the individual muscle lamellae in a spiral-shaped manner around the femur distally and are then divided further dorsally into terminal branches. LFCA = lateral femoral circumflex artery.
右大腿近端和右髋关节的前视图（与图 3 中所示的标本相同）。缝匠肌（不可见）和直肌向近端反射。神经分支（黄色箭头）在股骨远端以螺旋形方式延伸于各个肌肉层之间，然后进一步向背侧分为末端分支。LFCA = 外侧股动脉。
Muscular portions of the vastus lateralis and vastus intermedius always joined dorsally in the direction of the linea aspera. In the deeper aspect, the nerve branches were divided; some extended to adjacent muscles. Further distally, terminal branches to the vastus intermedius also extended laterally, innervating the vastus lateralis dorsally. The intramuscular courses of the muscle branches had a specific pattern. The main branches extended between the individual muscle lamellae in a spiral-shaped manner around the femur distally, and they divided further dorsally into terminal branches (Fig. 4). The entry of nerve branches into muscles was always from the medial side in the anterior and superficial aspect of the muscles.
股外侧肌和股中间肌的肌肉部分总是从背侧沿着粗线相连。在更深的层面上，神经分支被分开；一些延伸到相邻的肌肉。进一步远端，股中间肌的末端分支也向外侧延伸，背侧支配股外侧肌。肌肉分支的肌内走向具有特定的模式。主要分支在股骨远端以螺旋形的方式延伸于各个肌肉层之间，并在背侧进一步分为末端分支（图 4）。神经分支进入肌肉的方式总是从肌肉的前内侧和表面进入。
The introduction of a cerclage cable passer anteriorly, either from medial to lateral or vice versa, causes direct trauma to nerve branches supplying the vastus lateralis and the lateral portions of the vastus intermedius as well as to branches of the lateral femoral circumflex artery. It was impossible to introduce the cerclage cable passer around the femur without causing some damage to surrounding muscles. Introduction of the cable passer also jeopardized the deep femoral artery, the first perforating artery of the profunda femoris artery, and the lateral femoral circumflex artery. Intramuscular nerve branches to the vastus intermedius and the articularis genus were invariably injured. There was no damage to the nerves to the medial portions of the vastus intermedius or to the vastus medialis, rectus femoris, or sartorius.
在前方引入缠绕电缆穿线器，无论是从内侧到外侧还是反之，都会对供应外侧广阔肌和外侧中间广阔肌的神经分支以及外侧股旋动动脉的分支造成直接损伤。无法在不对周围肌肉造成一定损伤的情况下将缠绕电缆穿线器引入股骨。引入电缆穿线器还危及深股动脉、深股动脉的第一穿通动脉以及外侧股旋动脉。通往外侧中间广阔肌和关节肌的肌内神经分支不可避免地受到损伤。内侧中间广阔肌、内侧广阔肌、股直肌或缝匠肌的神经没有受到损伤。
When we introduced the cerclage cable passer through a lateral subvastus access, either from medial to lateral or vice versa, it was always possible to guide it close to the femur and protect important structures. No superficial nerves or large vessels were damaged. However, some nerve branches to deeper parts of the vastus intermedius, including the nerve branch to the articularis genus, were stretched by the instrument.
当我们通过侧面股内侧的途径引入缠绕缆线时，无论是从内侧到外侧还是反之，总是可以将其引导靠近股骨并保护重要结构。没有损伤到表层神经或大血管。然而，一些深层股中肌的神经分支，包括支配关节肌的神经分支，被器械拉伸了。
In all cases, extension of the anterior approach to the femur interrupted the nerve supply to the anterolateral por-
在所有情况下，前方接近股骨的延伸中断了对前外侧部分的神经供应
tions of the quadriceps muscle group (green dotted line on Figs. 3 and 5). Internally rotating the femur made it possible to turn some lateral nerve entry points away from the endangered
股四头肌群的作用（图 3 和图 5 中的绿色虚线）。内旋股骨使得一些侧面神经进入点能够远离受威胁的区域。
Fig. 5 图 5
Drawing illustrating the consequences of approaching the femur through an anterior approach (green arrow) compared with a lateral subvastus approach (red arrow). Extension of the anterior approach to the femur interrupts the nerve supply to the anterolateral portions of the quadriceps muscle group. When the lateral subvastus approach is used, the muscles and their anterior and superficial entering nerves can be protected. FI and Fm = lateral and medial divisions of the femoral nerve, 1 and 1 ′ = 1 ′ = 1^(')=1^{\prime}= lateral and medial parts of the vastus lateralis, and 2 and 2 ′ = 2 ′ = 2^(')=2^{\prime}= lateral and medial parts of the vastus intermedius.
图示说明了通过前方入路（绿色箭头）接近股骨与通过外侧股内侧入路（红色箭头）所带来的后果。前方入路延伸至股骨会中断对股四头肌前外侧部分的神经供应。当使用外侧股内侧入路时，肌肉及其前方和表面进入的神经可以得到保护。FI 和 Fm = 股神经的外侧和内侧分支，1 和 1 ′ = 1 ′ = 1^(')=1^{\prime}= 为外侧广阔肌的外侧和内侧部分，2 和 2 ′ = 2 ′ = 2^(')=2^{\prime}= 为中间广阔肌的外侧和内侧部分。
zone. Vessels leading to and away from the femur were also injured by the extension of the direct anterior approach. Further mobilization of the incised muscles would have strained deep muscular nerve branches and vessels.
区域。通往和离开股骨的血管也因直接前方入路的扩展而受损。进一步的切开肌肉的活动将会拉紧深层肌肉神经分支和血管。

Discussion 讨论

The direct anterior approach is a true internervous approach to the hip and has been used successfully by many authors 1 − 6 1 − 6 ^(1-6){ }^{1-6}. However, some have reported increased complication rates 7 , 11 , 12 , 15 7 , 11 , 12 , 15 ^(7,11,12,15)^{7,11,12,15}, such as intraoperative trochanteric fractures, femoral fractures, and perforations of the femur. Such complications may require distal extension of the approach, which also may be required with arthroplasty revision surgery. Extension of the anterior approach by splitting the interval between the rectus femoris and the vastus lateralis has been described 1 , 13 , 16 1 , 13 , 16 ^(1,13,16){ }^{1,13,16}. The present study shows that carrying out this extension without substantially damaging the lateral portions of the quadriceps muscles is challenging. Neurovascular structures lateral to the incision are endangered directly, affecting the vastus lateralis and lateral portions of the vastus intermedius. Deeper muscle branches and vessels are strained indirectly due to mobilization of muscles when the surgeon accesses the femur.
直接前方入路是一种真正的神经间入路，已被许多作者成功使用 1 − 6 1 − 6 ^(1-6){ }^{1-6} 。然而，一些人报告了并发症发生率的增加 7 , 11 , 12 , 15 7 , 11 , 12 , 15 ^(7,11,12,15)^{7,11,12,15} ，例如术中大转子骨折、股骨骨折和股骨穿孔。这些并发症可能需要对入路进行远端延伸，这在关节置换修复手术中也可能是必要的。通过分开股直肌和外侧广肌之间的间隙来扩展前方入路已被描述 1 , 13 , 16 1 , 13 , 16 ^(1,13,16){ }^{1,13,16} 。本研究表明，在不显著损伤股四头肌外侧部分的情况下进行这种扩展是具有挑战性的。切口外侧的神经血管结构直接受到威胁，影响外侧广肌和外侧中间广肌的部分。由于外科医生在接触股骨时对肌肉的动员，深层肌肉分支和血管也受到间接拉伸。
Patil et al. investigated the innervation pattern of the vastus lateralis muscle 17 17 ^(17){ }^{17}, and their findings were in agreement with those of the present study. Splitting the vastus lateralis in the mid-lateral line of the femur resulted in denervation of the posterior half of the muscle. Splitting the underlying vastus intermedius in the same plane caused damage to the nerve supplying the vastus intermedius in most cases 17 17 ^(17){ }^{17}. The vastus lateralis is the largest of the four quadriceps muscles, so damage to the vastus lateralis and the vastus intermedius theoretically reduces maximal quadriceps strength. However, Kennon et al. routinely used the direct anterior approach for revision surgery and suggested that this approach could be readily extended proximally and distally in complex revision cases, including stem revisions and even total femoral replacement 1 1 ^(1){ }^{1}. In a series of 468 consecutive revision total hip arthroplasties with distal extension, they split the vastus lateralis longitudinally in line with the skin incision and used a subperiosteal dissection to access the entire femoral shaft. They reported no clinically relevant nerve injuries. This may well be due to the fact that the distal portions of the vastus lateralis are supplied by nerve branches from the vastus intermedius and are not affected by extension to the proximal part of the femur. Furthermore, loss of some function of the vastus lateralis and the lateral part of the vastus intermedius can possibly be compensated for by the remaining portions of the quadriceps in low-demand patients. The present study shows that distal extension of the direct anterior approach is difficult to perform without causing neural damage to the proximal portions of the vastus lateralis and vastus intermedius. Alternative approaches for complex stem revisions should be considered.
Patil 等人研究了外侧广肌的神经支配模式 17 17 ^(17){ }^{17} ，他们的发现与本研究的结果一致。在股骨的中外侧线分开外侧广肌导致肌肉后半部分的去神经支配。在同一平面上分开下方的中间广肌在大多数情况下会损伤供应中间广肌的神经 17 17 ^(17){ }^{17} 。外侧广肌是四个股四头肌中最大的，因此，外侧广肌和中间广肌的损伤理论上会降低最大股四头肌的力量。然而，Kennon 等人常规使用直接前方入路进行修复手术，并建议这种方法可以在复杂的修复案例中方便地向近端和远端延伸，包括干修复甚至全股骨置换 1 1 ^(1){ }^{1} 。在一系列 468 例连续的修复全髋关节置换术中，他们在皮肤切口的线条上纵向分开外侧广肌，并使用骨膜下解剖来进入整个股骨干。他们报告没有临床相关的神经损伤。 这可能是由于阔筋膜外侧肌的远端部分由阔筋膜中间肌的神经分支供给，并且不受股骨近端伸展的影响。此外，阔筋膜外侧肌和阔筋膜中间肌外侧部分的某些功能丧失可能会被低需求患者的股四头肌剩余部分所补偿。本研究表明，直接前方入路的远端扩展在不造成阔筋膜外侧肌和阔筋膜中间肌近端部分神经损伤的情况下是很难进行的。应考虑复杂干修复的替代方法。
The anterior access is also not ideal for the introduction of a cerclage cable passer at the proximal part of the femur for treatment of an intraoperative fissure or fracture. In this situation, a lateral subvastus approach seems more suitable and less damaging
前方入路对于在股骨近端引入环扎缆线穿导器以治疗术中裂缝或骨折也并不理想。在这种情况下，侧面股内侧入路似乎更合适且损伤更小。
to muscle. Whether this requires a separate skin incision depends on the selection and extension of the primary incision.
到肌肉。这是否需要单独的皮肤切口取决于主切口的选择和延伸。
The present study highlights that the zone immediately distal to the intertrochanteric line is crucial. The first entries of nerve branches into muscles occur as close as 9 mm distal to the intertrochanteric line. The zone defines an anatomical barrier and should not be crossed distally unnecessarily.
本研究强调，股骨转子间线远端的区域至关重要。神经分支首次进入肌肉的距离可近至股骨转子间线下方 9 毫米。该区域定义了一个解剖屏障，不应不必要地向远端穿越。
The ascending branch of the lateral femoral circumflex artery consistently lies at the level of the midpart of the femoral neck, which is an important consideration in open or arthroscopic surgery in the anterior aspect of the hip joint. The branches of the lateral femoral circumflex artery are substantially involved in the vascularization of the proximal quadriceps muscle group.
外侧股旋转动脉的上升支始终位于股骨颈中部的水平，这是在髋关节前侧进行开放或关节镜手术时的重要考虑因素。外侧股旋转动脉的分支在股四头肌近端的血管化中起着重要作用。
In conclusion, the present cadaver study indicated that distal extension of the direct anterior approach to the hip joint is difficult to perform without causing neurovascular injury to anterolateral parts of the quadriceps muscle group. The direct anterior approach to the hip joint is best suited for interventions proximal to the intertrochanteric line, such as primary hip replacement, treatment of femoral head fractures, revisions of the acetabulum, and simple femoral stem revisions. An alternative approach to the hip or an extended trochanteric osteotomy should be considered for complex stem revisions necessitating distal extension. When the direct anterior approach must be extended distally, a lateral subvastus access seems more advantageous.
总之，目前的尸体研究表明，髋关节的直接前方入路的远端延伸在不造成股四头肌前外侧部分神经血管损伤的情况下是很难进行的。髋关节的直接前方入路最适合用于股骨转子间线近端的干预，例如初次髋关节置换、股骨头骨折的治疗、髋关节盂的修复以及简单的股骨干修复。对于需要远端延伸的复杂干预，应考虑采用替代的髋关节入路或扩展的转子截骨术。当必须向远端延伸直接前方入路时，侧面股外侧肌的入路似乎更具优势。
The Journal of Bone & Joint Surgery ⋅ ⋅ *\cdot jbjs.org Volume 97-A ⋅ ⋅ *\cdot Number 2 ⋅ ⋅ *\cdot January 21, 2015
骨与关节外科杂志 ⋅ ⋅ *\cdot jbjs.org 第 97 卷-A ⋅ ⋅ *\cdot 第 2 期 ⋅ ⋅ *\cdot 2015 年 1 月 21 日
Distal Extension of Direct Anterior Approach to the Hip Poses Risk to Neurovascular Structures
直接前方入路的远端延伸对髋关节神经血管结构构成风险

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  1. Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
    披露：作者没有直接或间接（即通过其机构）从第三方获得任何支持本工作的付款或服务。在提交本工作的三十六个月内，作者之一或其机构与生物医学领域的某个实体有过财务关系，这可能被认为会影响或有潜在影响本工作的内容。没有任何作者有其他关系或参与其他活动，这可能被认为会影响或有潜在影响本工作的内容。作者提交的潜在利益冲突的完整披露信息始终与文章的在线版本一起提供。
  2. Karl Grob, MD 卡尔·格罗布，医学博士
    Department of Orthopaedic Surgery, Kantonsspital St. Gallen,
    圣加仑州立医院骨科手术部
    Rorschacher Strasse 95, 罗尔沙赫街 95 号，
    St. Gallen CH-9007, Switzerland.
    圣加仑 CH-9007，瑞士。
    E-mail address: karl.grob@kssg.ch
    电子邮件地址：karl.grob@kssg.ch
    Rebecca Monahan, MBBS 丽贝卡·莫纳汉，医学学士
    Francis Yap, MBBS 弗朗西斯·叶，医学士
    University of Western Australia, 35 Stirling Highway,
    西澳大利亚大学，斯特林公路 35 号，
    Crawley WA 6009, 克劳利 WA 6009，
    Perth, Australia. 澳大利亚珀斯。
    E-mail address for R. Monahan: 20256562@student.uwa.edu.au.
    R. Monahan 的电子邮件地址：20256562@student.uwa.edu.au。
    E-mail address for F. Yap: 10994138@student.uwa.edu.au
    F. Yap 的电子邮件地址：10994138@student.uwa.edu.au
    Helen Gilbey, PhD 海伦·吉尔比，博士
    Hollywood Functional Rehabilitation Clinic, Perth, Western Australia, Australia.
    好莱坞功能康复诊所，澳大利亚西澳大利亚州珀斯。
    E-mail address: hgilbey29@gmail.com
    电子邮件地址：hgilbey29@gmail.com
    Luis Filgueira, PhD , MD
    路易斯·菲尔盖拉，博士，医学博士
    Department of Anatomy, 解剖学系，
    University of Fribourg, Switzerland.
    瑞士弗里堡大学。
    E-mail address: luis.filgueira@unifr.ch.
    电子邮件地址：luis.filgueira@unifr.ch。
    Markus Kuster, PhD, MD 马库斯·库斯特，博士，医学博士
    Royal Perth Hospital, 皇家珀斯医院
    Western Australia, Australia.
    西澳大利亚，澳大利亚。
    E-mail address: family.kuster@bluewin.ch
    电子邮件地址：family.kuster@bluewin.ch