Sensory Innervation of the Hip Joint

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Surg Radiol Anat 19: 371-375 Springer-Verlag France 1997

Original article

The sensory innervation of the hip joint - An anatomical study

K. Birnbaum1, A. Prescher 2, S. Heler 1 and K.-D. Heller 1

1 Orthopaedic Department, Technical University Aachen, Pauwelsstrasse 30, D-52074 Aachen, Germany2 Anatomical Institute I, Technical University Aachen, Wendlingweg 2, D-52074 Aachen, Germany

Received February 13, 1997 / Accepted in final form July 16, 1997

Key words: Hip joint - Coxarthrosis - Sensory innervation - Nerve block anesthesia

Correspondence to: K. Birnbaum

Abstract

Typically obturator nerve blockade is used to relieve hip pain. It sometimes only has a minor effect in resolving symptoms. clinical observation led us to examine comprehensively the sensory nerve innervation of formalin-fixed hip joint capsules. Fmacroscopic preparation, the area of the hip joint capsule was inspected with the aid of an operating microscope. We discovseparation between the anterior and posterior sensory innervation of the hip joint capsule. The anteromedial innervation wasdetermined by the articular branches of the obturator n. Additionally, the anterior hip joint capsule was innervated by sensor branches from the femoral n. In the posterior part we found articular branches from the sciatic n., which in addition to the ar branches from the nerves to the quadratus femoris m., innervate the posteromedial section of the hip joint capsule. Moreove branches of the superior gluteal n. were found, which innervate the posterolateral section of the hip joint capsule. This anatostudy demonstrates that the obturator n. block is insufficient for the treatment of hip pain. Further investigations will determnn. can be reached percutaneously. Effective neural blockade of the hip joint must include the femoral n., the sciatic n. and tsuperior gluteal n.

Our understanding of the distribution of nerves to the hip joint has remained unchanged for many years. However, an examithe reports of various investigators shows considerable differences in opinion. Cruveilhier [4] was the first who stated that thobturator n. gives a branch to the hip joint and that this branch has the greatest influence on the sensory innervation of the hiRdinger [18] seemed to be the first to do a systematic study of the nerve supply to the hip joint. He stated that the supplyingarise from the femoral, obturator, sciatic and inferior gluteal nn. and that they are small. He also described an articular brancarises from the obturator n. before this n. reaches the obturator foramen. Woodburne [22] showed the existence of an accessobturator n., which was also described later by Katritsis [12]. Bardeen's [1] and Fick's [7] brief descriptions are similar in mrespects to those in the current manuals of human anatomy. Sadovsky [19] published the first comprehensive study since theRdinger [18] and found that the femoral, obturator, sciatic and superior gluteal nerves supply the hip joint. It seems to be geagreed that the hip joint is supplied by the femoral n., the obturator n., the sacral plexus via the n. to the quadratus femoris msome cases, directly by the sciatic n. There is no agreement whether the superior or the inferior gluteal n. contribute to the inof the hip joint. Based on these investigations Kaiser [10] and Padovani [16] investigated the denervation of the sensory hipthe beginning this technique seemed to be sucessful, but further investigation showed the rapid development of deformation

femoral head, so that the authors abandoned this. Neural blockade had already been described in an investigation published Keppler [13]. In the seventies the method of nerve block anesthesia using various local anaesthetics was propagated [12]. Ato Hey [9] the obturator n. block was considered to be an alternative method to intra-articular hip joint injections. Unfortunaobturator n. block for relief of pain in the hip joint was only successful in some cases. Our aim was to analyze the nerve suphip joint capsule in greater detail. Precise knowledge of the nerve supply of the hip joint is essential to achieve a more effec prolonged reduction of pain by injections.

Material and methods

Eleven formalin-mounted hip joint preparations were examined. Due to the small diameter, the articular branches of the hipcapsule were prepared with the aid of an operating microscope. To detect the articular branches responsible for the sensory iof the hip joint capsule, an enlargement factor of 7.5 was selected first. For the final preparation of the articular branches, anenlargement factor of 12.5 was needed. We distinguished between the anterior and the posterior preparations of the hip joint


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documentation, we coloured the nerves by hand with an acrylic varnish.

Results

The anterior section of the hip joint capsule (Table 1) was supplied by the articular branches of the femoral n. (Figs. 1-4) anobturator n. (Figs. 4-6). The femoral n. (Figs. 1-4) was responsible for the sensory innervation of the anterior and anterolateof the hip joint capsule. One of the two important articular branches entered the iliopsoas m. and gave several branches to mside branch passe vertical from this branch down to the m. fibres and innervates the anterior side of the hip joint capsule. Tharticular branch passed at a lateral angle right across the iliopsoas m. and joined the lateral margin of the hip joint capsule oradditional branch to the hip joint capsule below the iliopsoas m. To some extent the femoral n. gave articular branches to thecapsule accompanied by vessels. In three cases we found an accessory femoral n. (Fig. 3) which was also responsible for theinnervation of the anterior region. The obturator n. (Figs. 4-6) supplied the anteromedial section of the hip joint capsule. Th branches derived either from the anterior branch, the posterior branch or the trunk of the obturator n. One articular branch frobturator n. that innervates the hip joint capsule passed posterolaterally. The posterior branch, passing over the external obtuand running between the adductor brevis and magnus mm., arose from the trunk of the obturator n. In our investigations oftcombined innervation by the femoral and the obturator n. at the anterior section of the hip joint capsule was identified.

Fig. 1 Femoral n. with two articular branches (arrow ); 1: V. femoralis,2: A. femoralis,3: N. femoralis,4: hip joint capsule,5: iliopsoas m.


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Fig. 2 Femoral n. with three articular branches (arrow )


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Fig. 3 Femoral n. with one articular branch (arrow 1 ) and the accessory femoral n. (arrow 2 ), 3: inguinal lig.,4: V. femoralis,5: A.

femoralis,6: N. femoralis,7: R. anterius of the obturator n.

Fig. 4 Femoral n. with articular branch (arrow 1 ) and the obturator n. with an articular branch for the hip joint capsule (arrow 2 ); 3: a.femoralis,4: n. femoralis,5: inguinal lig.,6: m. adductor brevis,7: r. anterior of the obturator n.


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Fig. 5 Obturator n. with an articular branch for the hip joint capsule (arrow ); 1: canalis obturatorius


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Fig. 6 Enlarged section of Fig. 5;1: canalis obturatorius

The posterior section of the hip joint capsule (Table 1) was supplied by the articular branches from the nerve to quadratus fe(Figs. 7-9), as well as by articular branches from the superior gluteal n. (Figs. 7-9) and directly by the sciatic n. The nerve tofemoris m. (Figs. 7-9) with the articular branch for the hip joint passed out of the sciatic n. immediately after penetration thrinfrapiriformis foramen. At the same level an articular branch from the sciatic n. existed which passed through the lesser sci below the sacrotuberous lig. and innervated the internal obturator m. There was a ramification into two articular branches; o posteroinferiorly, and the other posterolaterally. The n. to quadratus femoris m. innervated the posteroinferior section of thecapsule. The number of articular branches from the n. to quadratus femoris m., which had its origin in the sciatic n., varied bone and five. In four cases we found an innervation of the hip joint by articular branches from the superior gluteal n. (Figs. 7superior gluteal n. innervated the posterolateral capsule of the hip joint. In one case we found an articular branch direct fromsciatic n., supplying the posterosuperior region of the hip joint capsule.


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Fig. 7 Superior gluteal n. with an articular branch for the hip joint capsule (arrow 1 ) and the n. for the quadratus femoris m. from the scian. with an articular branch for the hip joint capsule (arrow 2 ); 3: trochanter major,4: gluteus medius m.

Fig. 8 Enlarged section of Fig. 7


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Fig. 9

Articular branch of the hip joint capsule from the superior gluteal n. (arrow 1 ) and an articular of the hip joint capsule from the n. the quadratus femoris m. (arrow 2 )

Discussion

An analysis of the literature concerning the sensory innervation of the hip joint showed various conflicting findings.

With the exception of the results of Sadovsky [19], Gardner [8] and Polacek [17], the prevalent opinion hitherto has been thventral hip joint capsule is innervated in the first place by articular branches of the obturator n. We mainly found an innervaanterior hip joint capsule by articular branches from the femoral n. The accessory obturator n., which occurs according to lit10-30% [14-17] and which is said to have a significant role in the innervation of the hip joint, was not found in our study. It that these articular branches passing through the iliac m. were misunderstood as motor n. fibers of the iliac m.

Duza [6] described an articular branch of the femoral n. that "perforates the m. fibres of the iliopsoas m.". He described twarticular branches from the lumbar plexus with a close relation to the psoas m. and communicating branches to the femoral obturator nn. Tavernier and Truchet [20] mentioned in their investigations an innervation of the hip joint capsule ventrally b branches of the obturator and femoral nn. They noticed that the posterior branch of the obturator n. played a decisive role ininnervation of the ventral hip joint capsule. The explanation they gave for the unsatisfactory results of the neurotomies perfoan "abnormity of the neural distribution" and the concomitant incomplete denervation. They postulated an additional dorsalinnervation - which was confirmed by our investigations. We found an innervation of the posterior hip joint capsule by artic branches of the superior gluteal n., the sciatic n. and the n. to quadratus femoris m. Tavernier and Pellanda [21] mentioned aof additional denervation of the articular branches of the femoral n. However this was only carried out in cases of postoperain the anterolateral region of the thigh. If pain was persisting despite this greater degree of neurotomy, they assumed fine art branches that accompany the vessels to the joint capsule to be responsible. According to their work, the radiation of pain wicoxarthrosis provides information of the origin of articular branches. In the papers of Gardner [8] and Polacek [17] the medcapsule was described to be the most sensitive part of the joint capsule. According to Gardner the articular branches ramificeven finer branches in the anteromedial region of the hip joint capsule. It is likely that many of the nerve fibres supply blood


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the capsule and neighboring bone. Yet, the different types of nerve ending are not described sufficiently. The concentration the anteromedial region of the capsule is due to proprioceptive endings in this region, but nevertheless Polacek [17] was unaany greater numbers of proprioceptors there. With respect to the topography of pain in coxarthrosis, it should be noticed thaauthors [2, 10] who attribute the radiation of pain to the knee joint not to the main branches of the obturator n., but rather to saphenous n. Chandelux [3] considered pain in the hip joint region to be a reflex phenomenon, e.g. a neuritis of the whole nsystem, including the cutaneous branches of the femoral n. On the other hand Kaplan [11], deemed it more likely that a comof the articular branch of the femoral n. is responsible for the symptoms. On account of the symptoms and pain described bywith coxarthrosis, it was considered to preserve the articular branches of the hip joint capsule at operation. Tavernier and Pa[16, 20, 21] were the first who postulated a preservation of the branches as a therapy for painful coxarthrosis. Luzuy [15] resuccess of the neurotomies not only as a result of preservation of the sensory nerves in the joint, but also as an improvement painful contraction of the adductors. The method of obturator n. neurotomy was further developed by Tavernier et al. [20, 2considered the posterior branch of the obturator n. to be the decisive branch concerning the pain symptoms in coxarthrosis. agreed that the posterior articular branch of the obturator n. is of considerable significance for the sensory hip joint capsuleinnervation. In his investigations he additionally preserved the articular branches of the femoral n. Padovani [16] postuled thexistence of an accessory obturator n. to be responsible for the high failure rate of denervations of the hip joint capsule. Mordescribed in his work certain individual cases of denervation of the obturator n. and the n. to quadratus femoris m. in which anterolateral region of the hip joint capsule remained. In accordance with our investigations, this region corresponds to the iarea of the articular branches of the femoral n. In individual cases the partial denervation of the hip joint capsule led to a lostransmission. This results in an excessive and unphysiological pressure on the joint and leads to its destruction. As known, tradiological picture is similar to the findings that can be obtained with tabes dorsalis or syringomyelia. The acetabulum becoenlarged and the head becomes necrotic, so that the patient acquires a Charcot's joint with a lack of stability. The accessory n., which is occasionally thought to be responsible for the failure rate with neurotomies, was impossible to find in our examhip joints. Chandelux [3] was the first to describe this nerve and named it on account of its importance for hip joint capsuleinnervation, the "nerf de larticulation coxo-fmorale". One reason for the divergent opinion concerning the accessory obtuthe fact that the authors were not able to distinguish exactly enough between the accessory obturator n. and the accessory fewhich we founded in several cases in our investigations. The accessory femoral n. has the same origin as the femoral n. In oinvestigations we identified articular branches of the superior gluteal n. and the n. to quadratus femoris m. This correspondsfindings of Dee, Gardner and Sadovsky [5, 8, 19]. In four cases we found articular branches of the superior gluteal n. In addinformation hitherto on hip joint capsule innervation, we found a great number of articular branches from the n. to quadratum., which derives from the sciatic n. In some cases up to five articular branches of the n. to quadratus femoris m. could be f

Conclusion

Our investigations clearly show why the symptoms and pain in connection with inflammatory or degenerative processes in tthe hip joint can vary so often. The femoral n. has a greater influence on the innervation of the hip joint capsule than assumeformer investigations. Blockade of the obturator n. on its own is doomed to failure. Given a suitable choice of local anaesthhowever, and an additional infiltration in the region of the articular branches of the femoral, superior gluteal and sciatic nn.,conceivable that the signs and symptoms of pain attendant upon coxarthrosis could be reduced for some days or weeks. Furclinical investigations have to determine that these nerves are reachable percutaneously.

References

1. Bardeen CR (1901) The accessory obturator nerve. Anat Anz 19: 209

2. Billet H, Vincent G, Gaudefroy M (1947) Les nerfs de la hanche. CR Ass Anat 34: 42-47

3. Chandelux A (1886) Note sur les nerfs de l'articulation coxo-fmorale. Lyon Med 51: 551-554

4. Cruveilhier J (1844) The anatomy of the human body. The first american from the last Paris edition. Pattison GS (ed) HarBros, New York

5. Dee R (1969) Structure and function of hip joint innervation. Ann R Coll Surg Engl 44: 357-3746. Duza R (1886) Note sur les nerfs de l'articulation coxo-fmorale. Lyon Med 52: 35-38

7. Fick R (1904) In: Bardeleben von K (ed) Handbuch der Anatomie des Menschen, Vol 2, pt 1, sect 1. Gustav Fischer Verl

8. Gardner E ( 1948) The innervation of the hip joint. Anat Rec 101: 353-371

9. Hey W, Fahr J, Henche HR (1985) Die Obturatoriusblockade als Alternative zur Hftgelenksinjektion bei schmerzhafterCoxarthrose. Orthopdische Praxis 2: 102-105

10. Kaiser RA (1949) Obturator neurectomy for coxalgia - An anatomical study of the obturator and accessory obturator neBone Joint Surg [Am] 31-A: 815-819


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11. Kaplan EB (1948) Resection of the obturator nerve for relief of pain in arthritis of the hip joint. J Bone Joint Surg [Br] 3216

12. Katritsis E (1980) Anatomical observations on the accessory obturator nerve. Anat Anz 148: 440-445

13. Keppler W (1913) Die Ansthesie der unteren Extremitten mittels Injektionen auf die groen Nervenstmme. LangenbKlin Chir 100: 794

14. Larochelle JL (1949) Anatomical research on the innervation of the hip joint. Anat Rec 103: 480-481

15. Luzuy M (1945) Rsultats du traitement de 14 cas de coxarthrites par section des nerfs sensitifs de l'articulation. MmoChir 71: 221-225

16. Padovani P (1947) L'nervation totale de la hanche (Notes de technique chirurgicale). Presse Medicale 55: 225

17. Polacek P (1963) Die Nervenversorgung des Hft- und Kniegelenkes und ihre Besonder-heiten. Anat Anz 11: 243-256

18. Rdinger N (1857) Die Gelenknerven des menschlichen Krpers. Enke, Stuttgart

19. Sadovsky DM (1933) Innervation of the capsule of the hip joint. Vestn Khir 31: 100-103

20. Tavernier L, Truchet P (1942) La section des branches articulaires du nerf obturateur dans le traitement de l'arthrite chrola hanche. Revue d'Orthopedie 18: 62

21. Tavernier L, Pellanda C (1949) Les nerfs articulaires de la hanche. CR Ass Anat 36: 662-671

22. Woodburne RT (1960) The accessory obturator nerve and the innervation of the pectineus muscle. Anat Rec 136: 367

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Sensory Innervation of the Hip Joint