Meralgia Paresthetica-An Approach Specific Neurological Complication in Patients Undergoing DAA Total Hip Replacement: Anatomical and Clinical Considerations

Introduction: Mini-invasive surgical (MIS) approaches to total hip replacement (THR) are becoming more popular and increasingly adapted into practice. THR via the direct anterior approach (MIS DAA) has become a rather controversial topic in hip arthroplasty literature in the last decades. Our retrospective observational study focuses on the prevalence of one approach-specific complication-lateral femoral cutaneous nerve (LFCN) iatrogenic lesion-and tries to clarify the possible pathogenesis of this injury. Methods: This is a retrospective single-cohort observational single-center and single-surgeon study. Our patient records were searched for the period from 2015 to 2017-after a safe period of time after the learning curve for MIS DAA. All intra- and post-operative lesions of the LFCN were recorded. Lesion of the LFCN was confirmed by a neurological examination. Minimum patient follow-up was 2 years. Results: This study involved 417 patients undergoing single-side THR via MIS DAA. Patients were examined on follow-up visits at 6 weeks, 6 months, 1 year, and 2 years after surgery. There were 17 cases of LCFN injury at the 6 weeks early follow-up visit (4.1%). All cases of clinically presenting LFCN injury resolved at the 2-year follow-up ad integrum. Discussion: Possible explanations of such neurological complications are direct iatrogenic injury, vigorous traction, hyperextension, or extreme external rotation of the operated limb. Use of a traction table or concomitant spinal pathology and deformity also play a role. Prevention involves stepwise adaptation of the approach during the learning curve period by attending cadaver lab courses, rational use of traction and hyperextension, and careful surgical technique in the superficial and deep fascial layers. Dynamometers could be used to visualise the limits of manipulation of the operated limb. Conclusions: Neurological complications are not as rare but questionably significant in patients undergoing THR via the DAA. Incidental finding of LFCN injury has no effect on the functional outcome of the artificial joint. It can lead to lower subjective satisfaction of patients with the operation, which can be avoided with careful education and management of expectations of the patients.