Review Question - QID 214111

The ascending branch of the lateral femoral circumflex artery is encountered when approaching the hip using the interval between the tensor fasciae latae (TFL) and sartorius muscles. This artery should be identified and ligated during the superficial dissection of the direct anterior approach.

The lateral femoral circumflex artery most commonly arises from the deep (profundus) femoral artery but may arise from the common femoral artery or as a common trunk with the deep femoral artery. Three branches (ascending, transverse, and descending) arise from the lateral femoral circumflex artery. The ascending branch is found within the internervous interval used for the direct anterior (Smith-Peterson) approach. Superficially this interval is between the Sartorius (femoral nerve) and Tensor Fasciae Latae (TFL; superior gluteal nerve). Deep the interval is between the rectus femoris (femoral nerve) and gluteus medius (superior gluteal nerve).

Lovell et al. described the single-incision direct anterior approach for total hip arthroplasty (THA). The authors describe the use of Myerding retractors placed within the intramuscular interval to expose the deep fascia. They note that the ascending branches of the lateral femoral circumflex artery, which are variable in size and number, can be found along this deep fascial layer.

Bender et al. also described the surgical technique of the single-incision direct anterior approach. The authors note the ascending branches vary in number and must be identified. Each branch is cauterized, sutured, or clipped prior to incising the fascial layer between the rectus femoris and TFL. They conclude this approach has significant advantages, including minimal soft tissue trauma; faster postoperative mobilization and rehabilitation; and improved cosmesis.

Light et al. described the use of the direct anterior approach for THA in eighty-five patients. Of all eighty-five patients, one returned to the operating room for excessive blood loss requiring ligation of the lateral femoral circumflex artery. No further complications regarding this vessel were noted. The authors conclude this approach is safe and effective with limited morbidity.

Illustration A demonstrates the origin of the lateral femoral circumflex artery from the deep femoral artery, including the ascending, transverse, and descending branches.

Incorrect Answers
Answer 1: The gluteus maximus is split during the posterior (Moore, Southern) approach to the hip. This dissection crosses a vascular plane created by the inferior and superior gluteal arteries. The ascending branch of the lateral femoral circumflex is not encountered during this approach.
Answer 2:The interval between the adductor longus and gracilis is utilized during the medial approach to the hip. The main vascular risk is the medial femoral circumflex artery.
Answer 3: The interval between the TFL and gluteus medius is utilized during the anterolateral (Watson-Jones) approach. Well described dangers during this approach include the femoral neurovascular bundle and the profunda femoris artery, which can be injured by retractor placement. The ascending branch of the lateral femoral circumflex artery is not classically encountered.
Answer 5: The interval between the vastus lateralis and biceps femoris can be used to approach the posterior femur. The sciatic nerve must be protected during this approach.