The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 4

Scientific Articles | April 01, 2007

Risk of Superior Gluteal Nerve and Gluteus Medius Muscle Injury During Femoral Nail Insertion

Mehmet Hakan Ozsoy, MD¹; Kerem Basarir, MD²; Alp Bayramoglu, MD³; Bulent Erdemli, MD²; Eray Tuccar, MD²; M. Fatih Eksioglu, MD⁴

¹ 1st Clinic of Orthopedics and Traumatology, Ankara Training and Research Hospital, 06340 Ankara, Turkey. E-mail address: hakanozsoy@rocketmail.com
² Departments of Orthopedics and Traumatology (K.B. and B.E.) and Anatomy (E.T.), Ankara University Faculty of Medicine, 06100 Ankara, Turkey. E-mail address for K. Basarir: basarirkerem@yahoo.com. E-mail address for B. Erdemli: erdemli@dialup.ankara.edu.tr. E-mail address for E. Tuccar: eraytuccar@yahoo.com
³ Department of Anatomy, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey. E-mail address: abayramo@hacettepe.edu.tr
⁴ Department of Orthopedics and Traumatology, Kirikkale University Faculty of Medicine, 71100 Kirikkale, Turkey. E-mail address: mfatiheksioglu@hotmail.com

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Anatomy, Hacettepe University Faculty of Medicine, and the Department of Anatomy, Ankara University Faculty of Medicine, Ankara, Turkey

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Apr 01;89(4):829-834. doi: 10.2106/JBJS.F.00617

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Abstract

Background: Abduction weakness and limping is a well-recognized complication of closed antegrade insertion of femoral nails. Iatrogenic injuries to the superior gluteal nerve and the gluteus medius muscle are the most likely contributing factors. The purpose of this study of cadavers was to assess the risk of nerve and muscle injury with various lower-limb positions used during nail insertion.

Methods: We studied thirteen hips of ten formalin-fixed adult cadavers. With the cadaver in the full lateral position, a 9-mm reamer was introduced in a retrograde fashion from the intercondylar notch and passed through the gluteus medius muscle. The distance between the point of entry of the reamer into the undersurface of this muscle and the inferior main branch of the superior gluteal nerve (the nerve-reamer distance) and the distance between the entry and exit points of the reamer in the gluteus medius muscle (the intramuscle distance) were measured in three different hip positions: 15° of flexion and 15° of adduction (Position 1), 30° of flexion and 30° of adduction (Position 2), and 60° of flexion and 30° of adduction (Position 3).

Results: In Position 1, the average nerve-reamer distance was 7 mm and the average intramuscle distance was 24 mm. In three hips the reamer injured the nerve directly, and in two other hips the distance was =5 mm. In Position 2, the average nerve-reamer distance was 21 mm and the average intramuscle distance was 18 mm. In Position 3, the average nerve-reamer distance was 33 mm and the average intramuscle distance was 11 mm. None of the reamers in this position came closer than 20 mm to the nerve.

Conclusions: The risk of injury to the superior gluteal nerve and the gluteus medius muscle during closed antegrade insertion of a femoral nail is lessened by increasing the amount of hip flexion and adduction.

Clinical Relevance: The risk of injury to both the superior gluteal nerve and the gluteus medius muscle is higher with limited degrees of hip flexion and adduction, such as are possible in the supine position on a fracture table, than it is with greater degrees of hip flexion and adduction, which are possible in the lateral position on a fracture table or in the so-called sloppy lateral position on an ordinary table. Therefore, insertion of a femoral nail with the hip in increased flexion and adduction might help to lower the risk of injuries to the superior gluteal nerve and the gluteus medius muscle.

Figures in this Article

Abductor weakness following antegrade insertion of a femoral nail is a disturbing residual problem that might result from gluteal muscle injury during the approach to and the use of instrumentation in the femoral medullary canal or from injury to the superior gluteal nerve during exposure^1-4. Bain et al.¹ reported that, at a minimum of twenty-four months postoperatively, 41% of thirty-two patients in whom an isolated femoral shaft fracture had been fixed with an intramedullary nail on a fracture table limped. Heterotopic ossification in the trochanteric region secondary to the gluteal muscle injury has also been considered to be a cause of limping and abductor weakness after intramedullary nail fixation of the femur^5-8. Although reported to resolve spontaneously, this abductor weakness might persist for up to two years postoperatively^2-4.

Intramedullary nail fixation of the femur can be performed with the patient on a fracture table or on a radiolucent table and with use of different hip positions. It was hypothesized that, with the hip flexed, the abductors could be retracted anteriorly and that such an abductor-retracting approach might prevent injury to the superior gluteal nerve and to the abductor muscles during femoral reaming and insertion of the nail¹. However, we are not aware of any reported study in which this concept was evaluated. We performed a cadaver study to investigate the risks of superior gluteal nerve injury and the extent of gluteus medius muscle injury during femoral preparation and nail placement with use of three different hip positions.

Materials and Methods

Materials and Methods | Results | Discussion | References

Thirteen lower extremities of ten formalin-fixed adult cadavers (six male and four female) with mobile hip joints that allowed up to 60° of hip flexion and without any visible scars indicating former hip surgery were dissected. The gluteus maximus muscle was detached from the outer border of the iliac crest. With the cadaver in the side-lying position, a long semiflexible hand reamer with a 9-mm-diameter cutting tip was introduced in a retrograde fashion from the intercondylar notch halfway between the medial and lateral margins of the articular surfaces of the femoral condyles and then was advanced to exit through the gluteus medius muscle. This procedure was performed with the hip held in three different positions, in each of which the lower extremity distal to the hip joint was brought into different degrees of adduction and flexion with reference to the body axis. The angles were measured with a goniometer, and the extremity was held by an assistant throughout the procedure. Position 1 was 15° of flexion and 15° of adduction; Position 2, 30° of flexion and 30° of adduction; and Position 3, 60° of flexion and 30° of adduction. In all three positions of the hip, the reamer was advanced until it penetrated the gluteus medius muscle. The point of muscle penetration was marked with a pin, and the reamer was then withdrawn. The pin was introduced into the reaming path while the reamer was being withdrawn. The hip position was then sequentially changed, and the reamer was readvanced until it had penetrated the gluteus medius muscle.

The distance between the exit point on the outer surface of the gluteus medius muscle and the most prominent palpable part of the greater trochanter (the trochanter-reamer distance) was measured and recorded.

The gluteus medius was then detached from the posterior iliac crest, and the intermuscular plane between the gluteus medius and the gluteus minimus was exposed to identify the course of the superior gluteal nerve and its relationship to the reaming path in the three different hip positions. The entrance points of the reamer into the undersurface of the gluteus medius muscle were also identified.

The superior gluteal nerve and its branches were dissected. The extremity was then brought into Position 1, and the reamer was reintroduced with the guidance of the first pin. The distance between the inferior main branch of the superior gluteal nerve and the entrance point of the reamer into the undersurface of the gluteus medius muscle (the nerve-reamer distance) was measured and recorded, as was the distance between the entrance and exit points of the reamer in the gluteus medius muscle (the intramuscle distance). Then the hip position was changed, and the reamer was reintroduced with the guidance of the previously introduced pins and the same measurements were made in Position 2 and Position 3.

Differences among the measurements (trochanter-reamer distance, nerve-reamer distance, and intramuscle distance) made in the three different hip positions were evaluated with Friedman two-way analysis of variance by ranks. When the p value derived with the Friedman test was significant, the Bonferroni-corrected Wilcoxon signed rank test was applied to determine which measurement differed from the others. The Statistical Package for Social Sciences (version 11.5.0; SPSS, Chicago, Illinois) was used for statistical analyses, and a p value of 0.05 was considered to be significant.

Results

Materials and Methods | Results | Discussion | References

The superior gluteal nerve exited the pelvis through the supra-piriformis foramen in all specimens. Twelve of the thirteen hips had a spray-pattern course of the superior gluteal nerve, with the nerve dividing into branches within 2 cm of the superior border of the piriformis muscle and fanning out between the gluteus medius and minimus muscles. In one hip, the nerve was observed to have a neural-trunk-pattern course, with distal branching and short branches to the muscles. The most vulnerable part of the superior gluteal nerve during reaming was found to be its inferior main branch. Therefore, distances were measured with reference to this branch of the superior gluteal nerve.

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Figs. 1-A and 1-B: Reamer entrance points into the gluteus medius muscle (GMM) in a right hip and their relationship with the inferior main branch of the superior gluteal nerve (SGN) (arrowhead) in (1) Position 1, (2) Position 2, and (3) Position 3. The asterisk denotes the piriformis muscle.

In Position 1, the trochanter-reamer distance was 72 ± 9.3 mm, the nerve-reamer distance was 7 ± 5.7 mm, and the intramuscle distance was 24 ± 3.9 mm (Table I). In three hips the reamer injured the nerve directly, and in two other hips the distance was =5 mm (Figs. 1-A and 1-B). In Position 2, the trochanter-reamer distance was 55 ± 11.5 mm, the nerve-reamer distance was 21 ± 5.5 mm, and the intramuscle distance was 18 ± 3.1 mm. In Position 3, the trochanter-reamer distance was 38 ± 9.5 mm, the nerve-reamer distance was 33 ± 8.1 mm, and the intramuscle distance was 11 ± 2.2 mm. None of the reamers in this position came closer than 20 mm to the nerve.

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TABLE I Measured Distances in the Three Different Hip Positions

Hip Position	Trochanter-Reamer Distance	Nerve-Reamer Distance	Intramuscle Distance
1*	72 ± 9.3 (60-95)	7 ± 5.7 (0-17)	24 ± 3.9 (18-31)
2*	55 ± 11.5 (38-80)	21 ± 5.5 (11-28)	18 ± 3.1 (13-23)
3*	38 ± 9.5 (29-65)	33 ± 8.1 (20-50)	11 ± 2.2 (8-14)
	p < 0.001	p < 0.001	p < 0.001

The values are given, in millimeters, as the mean and standard deviation, with the range in parentheses.

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TABLE I Measured Distances in the Three Different Hip Positions

Hip Position	Trochanter-Reamer Distance	Nerve-Reamer Distance	Intramuscle Distance
1*	72 ± 9.3 (60-95)	7 ± 5.7 (0-17)	24 ± 3.9 (18-31)
2*	55 ± 11.5 (38-80)	21 ± 5.5 (11-28)	18 ± 3.1 (13-23)
3*	38 ± 9.5 (29-65)	33 ± 8.1 (20-50)	11 ± 2.2 (8-14)
	p < 0.001	p < 0.001	p < 0.001

The values are given, in millimeters, as the mean and standard deviation, with the range in parentheses.

All three measurements (trochanter-reamer distance, nerve-reamer distance, and intramuscle distance) showed a strong, significant difference among the three hip positions (p < 0.001). Additionally, in all three measurements the measured value in each hip position was significantly different from each of the others (p = 0.01 for each measurement). The reamer exit merged closer to the greater trochanter and the distance between the reamer and the nerve increased with increasing hip flexion and adduction. In addition, the distance traveled by the reamer in the muscle mass decreased with increases in the amounts of hip flexion and adduction.

Discussion

Materials and Methods | Results | Discussion | References

Antegrade intramedullary nail fixation has been recognized as a reliable method for the treatment of femoral shaft fractures^9,10. Although the piriformis fossa is the most commonly used entry point and is in line with the medullary canal, gaining access through this structure is technically demanding, and some complications, including iatrogenic fractures of the femoral neck, comminution of the proximal part of the femur, osteonecrosis of the femoral head, and residual symptoms such as thigh and hip pain, limping, and limited walking distance have been reported^1,3,6,11,12. Heterotopic ossification around the area of nail entrance and abductor weakness have been proposed as common causes of these symptoms^1,2,6.

The superior gluteal nerve, the gluteal muscles, and even the tendons of the hip external rotators are at risk during antegrade insertion of a femoral nail through the piriformis fossa¹³. Injury to these structures may account for the abductor weakness that has been reported to persist for up to two years after the operation^2-4. Both Winquist et al.¹⁰ and Danckwardt-Lilliestrom and Sjogren² found that the hip abductors were severely affected following femoral nail fixation. Bain et al.¹ also reported marked abductor weakness in comparison with the strength in normal individuals and concluded that this weakness might have resulted from injury to the superior gluteal nerve and the hip abductor muscles.

We noticed a higher risk of injury to the inferior main branch of the superior gluteal nerve when the reaming was performed with the hip in 15° of flexion and 15° of adduction. In three of the thirteen hips the reamer injured the nerve directly, and in two other hips the nerve-reamer distance was =5 mm. However, the distance between the nerve and the reamer increased with increasing hip flexion and adduction, substantially decreasing the risk of nerve injury.

Similarly, Moein et al.¹³ inserted a femoral nail in an antegrade fashion in ten cadavers in the supine position and reported that, in two of them, the inferior branch of the superior gluteal nerve was in danger of injury, with a distance of <5 mm measured from that branch to the surgical lesion in the gluteus medius.

The inferior main branch of the superior gluteal nerve is the main trunk of the nerve and the main neural supply of the gluteus medius muscle¹⁴. It also innervates the gluteus minimus and the tensor fasciae latae muscles. The most inferior branch of the superior gluteal nerve is a continuation of its inferior main branch or is a separate branch, which is found at an average of 1 cm distal and anterior to the inferior main branch of the superior gluteal nerve¹⁴. The most inferior branch is in danger when the Hardinge approach or its modifications are used during hip arthroplasty^14-16. However, the inferior main branch of the superior gluteal nerve is in greater danger when a more proximally and posteriorly placed gluteal-splitting approach is used for nail placement.

Muscle damage and heterotopic ossification are other possible causes of abductor weakness^5,6. Brumback et al.⁵ found that heterotopic ossification had developed in 60% of their patients treated with antegrade insertion of an intramedullary nail, and it was moderate to severe in 26%. They noted the importance of minimizing muscle damage during reaming in order to decrease the soft-tissue healing response, which may stimulate the formation of heterotopic bone. Our results showed that the extent of muscle injury might be decreased by changing the hip position. When the hip was in less flexion and adduction, the reamer was more parallel to the gluteus medius muscle and the distance traveled by the reamer in the muscle mass was more pronounced. Thus, the least amount of muscle damage was observed in Position 3.

A patient can be in either the supine or the lateral decubitus position when treated on a fracture table. Although the supine position is more common, it allows only restricted degrees of adduction and flexion of the extremity and, thus, creation of an entry point can be difficult¹⁷. In our study, Position 1 (15° of hip flexion and 15° of adduction) was used to simulate the supine position on the fracture table. We observed a higher risk of injuries to the inferior main branch of the superior gluteal nerve and to the gluteus medius muscle when the procedure had been done in Position 1 than when it had been done in either of the other two hip positions. In contrast, the lateral decubitus position on the fracture table allows up to 30° of both flexion and adduction, thus facilitating access to the correct entry point¹⁷. Furthermore, McFerran and Johnson¹⁸, Sirkin et al.¹⁹, Stephen et al.²⁰, and Baumgaertel et al.²¹ all reported excellent results without using a fracture table. Sirkin et al. reported intramedullary nail fixation with use of manual traction and the patient in the so-called sloppy lateral position, in which the affected hip was elevated with a bolster placed beneath the buttock, which allowed hip adduction up to 45°. We used Position 2 (30° of hip flexion and 30° of adduction) to simulate the lateral position on a fracture table or the sloppy lateral (free-leg) position on an ordinary radiolucent table. We found the risk of nerve and muscle injury to be lower in Position 2 than in Position 1.

Position 3 (60° of flexion and 30° of adduction of the hip) can rarely be achieved clinically during closed antegrade nail placement. However, it is possible to flex the hip up to 60° during open intramedullary nail fixation when the medullary canal is reamed in a retrograde fashion from the fracture site.

We used a 9-mm reamer in our study; however, as the nail diameters used in adult surgery range between 12 and 16 mm, muscle and nerve injuries during such procedures can be expected to be even more extensive than those reported here.

We chose to pass the reamer in a retrograde rather than an antegrade fashion to minimize the extraneous soft-tissue injury that might occur from the dissection and the introduction of the awl or guidewire. Another reason why we used the retrograde technique was to determine the most appropriate entry site in the proximal part of the femur that was in line with the medullary canal and to standardize the entry-point variable.

Although the risk of injury to the superior gluteal nerve may be reduced by changing the hip position, it is not possible to totally eliminate this risk because of anatomical variations of this nerve^14-16,22. While careful dissection and the use of protectors may also decrease the risk, the superior gluteal nerve is difficult to locate and protect because of its position beneath the gluteus medius muscle mass and its anatomical variations. Thus, there is potential for an injury to the superior gluteal nerve no matter what technique is used. It is also possible to reduce the risk of muscle injury by changing the hip position, but the risk cannot be totally eliminated because the reamer or nail still must pass through the abductor musculature.

The limitations of our study include the difference in tissue fragility and mobility, which might have been lessened with use of fresh cadaver samples. Furthermore, the fact that the leg was held by an assistant throughout the procedure and the measurements were made with a goniometer created an opportunity for error. It is also difficult to evaluate variations in muscle and nerve mobility under traction. Thus, additional clinical studies are required in order to make definite conclusions regarding the effect of hip position on the risk of nerve and muscle injury during femoral nail fixation.

In summary, the risk of injury to the inferior main branch of the superior gluteal nerve and the gluteus medius muscle is greater when preparation of the femoral canal and placement of a femoral nail are performed through the piriformis fossa with the hip in lower degrees of flexion and adduction, as are achievable with the patient in the supine position on the fracture table. With the hip in higher degrees of flexion and adduction, as is possible with the patient in the lateral position on a fracture table or in the sloppy lateral position on a radiolucent table, the superior gluteal nerve moves superiorly and anteriorly and thus is at less risk of injury. Additionally, the reaming path distance in the gluteus medius muscle decreases since the reamer traverses the muscle at a more vertical angle. Thus, the risk of muscle injury is also lower with the hip in higher degrees of flexion and adduction. In conclusion, the risk of injury to the superior gluteal nerve and the gluteus medius muscle is lessened when closed antegrade placement of a femoral nail is performed with the hip in an increased amount of flexion and adduction. ?

References

Materials and Methods | Results | Discussion | References

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Danckwardt-Lilliestrom G, Sjogren S. Postoperative restoration of muscle strength after intramedullary nailing of fractures of the femoral shaft. Acta Orthop Scand. 1976;47: 101-7.47101 1976 [PubMed][CrossRef]

Kempf I, Grosse A, Beck G. Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J Bone Joint Surg Am. 1985;67: 709-20.67709 1985 [PubMed]

Winquist RA. Closed intramedullary osteotomies of the femur. Clin Orthop Relat Res. 1986;212: 155-64.212155 1986 [PubMed]

Brumback RJ, Wells JD, Lakatos R, Poka A, Bathon GH, Burgess AR. Heterotopic ossification about the hip after intramedullary nailing for fractures of the femur. J Bone Joint Surg Am. 1990;72: 1067-73.721067 1990

Dodenhoff RM, Dainton JN, Hutchins PM. Proximal thigh pain after femoral nailing. Causes and treatment. J Bone Joint Surg Br. 1997;79: 738-41.79738 1997 [CrossRef]

Marks PH, Paley D, Kellam JF. Heterotopic ossification around the hip with intramedullary nailing of the femur. J Trauma. 1988;28: 1207-13.281207 1988 [PubMed][CrossRef]

Biyani A, Jones DA, Daniel CL, Bishay M. Assessment of hip abductor function in relation to peritrochanteric heterotopic ossification after closed femoral nailing. Injury. 1993;24: 97-100.2497 1993 [PubMed][CrossRef]

Bick EM. The intramedullary nailing of fractures by G. Kuntscher. Translation of article in Archiv fur Klinische Chirurgie, 200:443, 1940. Clin Orthop Relat Res. 1968;60: 5-12.605 1968 [PubMed]

Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am. 1984;66: 529-39.66529 1984 [PubMed]

Buford D Jr, Christensen K, Weatherall P. Intramedullary nailing of femoral fractures in adolescents. Clin Orthop Relat Res. 1998;350: 85-9.35085 1998

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Moein CM, Verhofstad MH, Bleys RL, van der Werken C. Soft tissue injury related to choice of entry point in antegrade femoral nailing: piriform fossa or greater trochanter tip. Injury. 2005;36: 1337-42.361337 2005 [PubMed][CrossRef]

Bos JC, Stoeckart R, Klooswijk AI, van Linge B, Bahadoer R. The surgical anatomy of the superior gluteal nerve and anatomical radiologic bases of the direct lateral approach to the hip. Surg Radiol Anat. 1994;16: 253-8.16253 1994 [PubMed][CrossRef]

Eksioglu F, Uslu M, Gudemez E, Atik OS, Tekdemir I. Reliability of the safe area for the superior gluteal nerve. Clin Orthop Relat Res. 2003;412: 111-6.412111 2003 [PubMed][CrossRef]

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McFerran MA, Johnson KD. Intramedullary nailing of acute femoral shaft fractures without a fracture table: technique of using a femoral distractor. J Orthop Trauma. 1992;6: 271-8.6271 1992 [PubMed][CrossRef]

Sirkin MS, Behrens F, McCracken K, Aurori K, Aurori B, Schenk R. Femoral nailing without a fracture table. Clin Orthop Relat Res. 1996;332: 119-25.332119 1996 [PubMed][CrossRef]

Stephen DJ, Kreder HJ, Schemitsch EH, Conlan LB, Wild L, McKee MD. Femoral intramedullary nailing: comparison of fracture-table and manual traction. A prospective, randomized study. J Bone Joint Surg Am. 2002;84: 1514-21.841514 2002

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Topics

fracture ; asthenia ; bone nails ; cadaver ; femur ; hip joint ; nails ; neurons ; muscle injury ; gluteus medius muscle

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Mehmet Hakan Ozsoy, Kerem Basarir, Alp Bayramoglu, Bulent Erdemli, Eray Tuccar, M. Fatih Eksioglu; Risk of Superior Gluteal Nerve and Gluteus Medius Muscle Injury During Femoral Nail Insertion. The Journal of Bone & Joint Surgery. 2007 Apr;89(4):829-834.

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