Case Report
European Journal of Trauma and Emergency Surgery
Iatrogenic Sciatic Nerve Palsy Following Hemiarthroplasty of the Hip Toby J. Colegate-Stone, Saj Hussain1
Abstract We report a rare complication following insertion of an uncemented hip prosthesis that resulted in posterior perforation of the femoral stem and a sciatic nerve palsy. To our knowledge, sciatic nerve palsy due to the femoral stem perforating the cortex has not been previously described. Key Words Sciatic nerve Æ Palsy Æ Hemiarthroplasty Æ Hip fracture Æ Nerves Eur J Trauma Emerg Surg 2008;34:171–2 DOI 10.1007/s00068-007-6214-6
Background Accurate reaming down the shaft of the femur, prior to femoral stem insertion during hip arthroplasty, is essential to prevent a femoral cortical defect from occurring and possible subsequent misplacement of the femoral stem. We present a rare complication of an uncemented hip prosthesis that resulted in posterior perforation of the femoral stem and a sciatic nerve palsy.
Case Report An 88-year-old woman, previously living independently and mobilising with one stick, was admitted to hospital following a fall. She had no past medical history of note. Clinical examination revealed a painful and shortened left hip, with an inability to straight leg raise. Radiographic examination revealed a displaced intracapsular proximal femoral fracture. An uncemented hemiarthroplasty was performed and osteoporotic bone was noted at the time of surgery.
1
Post-operatively she complained of significant radicular pain in the posterior aspect of the thigh and leg on the operated side. Nerve conduction studies demonstrated a deep lesion of the sciatic nerve with sensory loss in the distribution of the common peroneal nerve. Radiographic examination demonstrated misplacement of the femoral prosthesis with posterior protrusion through a perforation in the femoral shaft. After discussion with the regional peripheral nerve injury unit, it was advised that the prosthesis be promptly revised by removal of the femoral stem under direct vision following dissection of the sciatic nerve. She was subsequently taken to theatre where a revision procedure was performed through a posterior approach. At revision, the sciatic nerve was seen to be tented over the tip of the femoral prosthesis (Figure 1) but was macroscopically intact. However, some nerve bruising was noted near the tip of the stem. As the cortical perforation was small, a cemented bi-polar revision was performed with the plugging of the defect during cement pressurisation to prevent extravasation. Post-operatively, the patient was fitted with a foot ankle orthosis. The patient’s pain improved almost immediately. The paresthesia disappeared over a period of 2 weeks following surgery. Active dorsiflexion of the ankle was almost normal at 8 weeks following surgery. At this time the patient was discharged home, mobilising with the aid of one stick.
Discussion Nerve palsies following total hip arthroplasty are well documented, with an overall prevalence of less than 1% [1, 2]. In this case, the prompt timing of the second operation ensured that the sciatic nerve lesion was still
Department Trauma and Orthopaedic Surgery, Maidstone Hospital, Hermitage Lane, Maidstone, Kent, ME16 9QQ, UK.
Received: March 19, 2007; revision accepted: April 16, 2007; Published Online: July 11, 2007
Eur J Trauma Emerg Surg 2008 Æ No. 2 Ó URBAN & VOGEL
171
Colegate-Stone T.J, Hussain S. Iatrogenic Sciatic Nerve Palsy
femoral cortex and creation of a false passage. This may lead to subsequent misplacement of the femoral stem, and damage to the sciatic nerve. Sciatic nerve palsy following stem protrusion is a rare complication of hemiarthroplasty. Early operation is advised in order to prevent the conduction block in the nerve progressing to a deeper lesion and a less favourable prognosis.
Acknowledgment We are grateful to Professor Rolfe Birch of the Royal National Orthopaedic Hospital, Stanmore, UK for reading the manuscript and offering valuable advice. Figure 1. Sciatic nerve tented over the tip of the femoral prosthesis. Arrow indicates femoral prosthesis.
in the conduction block stage. A delay may have resulted in more advanced lesion with a less favourable prognosis (Rolfe Birch, personal communication). The sciatic nerve, or its peroneal division, is the most frequently injured nerve accounting for 79% of all nerve palsies [1]. Palsies affecting the femoral, obturator, peroneal and superior gluteal nerves have also been described [1, 2]. Published reports of sciatic nerve damage have mainly documented problems arising from trauma during the operative approach [3, 4], the effects of lengthening the lower extremity [5] or compression secondary to cement extrusion, haematoma formation, broken trochanteric wires, the gluteus maximus tendon or a protruding acetabular reinforcement ring [6–10]. To our knowledge, sciatic nerve palsy due to the femoral stem perforating the cortex has not been described previously. The prognosis for neurological recovery is related to the severity of nerve damage. Complete or essentially complete recovery occurs in approximately 41% of cases and another 44% have only a mild deficit [1]. Patients who either recover some motor function immediately post-operatively or within 2 weeks of surgery have a good prognosis for recovery [1, 2]. In most reports of sciatic nerve injury, the common peroneal division is relatively tethered at the sciatic notch, and tolerates acute stretching less favourably, as occurred in this case. Further, the lateral position of the nerve in gluteal region may make it more susceptible to direct injury [11]. Due care must be taken when preparing the femoral shaft prior to prosthesis insertion. The entry point of the initial reamer must be chosen carefully, so as to ensure that subsequent reaming occurs in the line of the femoral shaft. Too anterior an entry point, as occurred in this case, may result in the perforation of the
172
References 1.
Schmalzried TP, Noordin S, Amstutz HC. Update on nerve palsy associated with total hip replacement. Clin Orthop Relat Res 1997;344:188–206. 2. Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am 2005;87:2619–25. 3. Navarro RA, Schmalzried TP, Amstutz HC, Dorey FJ. Surgical approach and nerve palsy in total hip arthroplasty. J Arthroplasty 1995;10:1–5. 4. Schmalzried TP, Amstutz HC, Dorey FJ. Nerve palsy associated with total hip replacement. Risk factors and prognosis. J Bone Joint Surg Am 1991;73:1074–80. 5. Silbey MB, Callaghan JJ. Sciatic nerve palsy after total hip arthroplasty: treatment by modular neck shortening. Orthopedics 1991;14:351–52. 6. Birch R, Wilkinson MC, Vijayan KP, Gschmeissner S. Cement burn of the sciatic nerve. J Bone Joint Surg Br 1992;74:731–33. 7. Johanson NA, Pellicci PM, Tsairis P, Salvati EA. Nerve injury in total hip arthroplasty. Clin Orthop Relat Res 1983;179:214–22. 8. Asnis SE, Hanley S, Shelton PD. Sciatic neuropathy secondary to migration of trochanteric wire following total hip arthroplasty. Clin Orthop Relat Res. 1985;196:226–28. 9. Hurd JL, Potter HG, Dua V, Ranawat CS. Sciatic nerve palsy after primary total hip arthroplasty: a new perspective. J Arthroplasty 2006;21:796–802; Epub 2006 June 8. 10. Bader R, Mittelmeier W, Zeiler G, Tokar I, Steinhauser E, Schuh A. Pitfalls in the use of acetabular reinforcement rings in total hip revision. Arch Orthop Trauma Surg. 2005;125:558–63; Epub 2005 October 22. 11. Sunderland S. Nerves and nerve injuries. Churchill Livingstone, Edinburgh, 1978.
Address for Correspondence Dr. Toby J. Colegate-Stone Department Trauma and Orthopaedic Surgery Maidstone Hospital Beech Cottage, Orestan Lane Effingham, Surrey KT24 5SP UK Phone (+44/7977) 531559 e-mail: [email protected]
Eur J Trauma Emerg Surg 2008 Æ No. 2 Ó URBAN & VOGEL
European Journal of Trauma and Emergency Surgery
Iatrogenic Sciatic Nerve Palsy Following Hemiarthroplasty of the Hip Toby J. Colegate-Stone, Saj Hussain1
Abstract We report a rare complication following insertion of an uncemented hip prosthesis that resulted in posterior perforation of the femoral stem and a sciatic nerve palsy. To our knowledge, sciatic nerve palsy due to the femoral stem perforating the cortex has not been previously described. Key Words Sciatic nerve Æ Palsy Æ Hemiarthroplasty Æ Hip fracture Æ Nerves Eur J Trauma Emerg Surg 2008;34:171–2 DOI 10.1007/s00068-007-6214-6
Background Accurate reaming down the shaft of the femur, prior to femoral stem insertion during hip arthroplasty, is essential to prevent a femoral cortical defect from occurring and possible subsequent misplacement of the femoral stem. We present a rare complication of an uncemented hip prosthesis that resulted in posterior perforation of the femoral stem and a sciatic nerve palsy.
Case Report An 88-year-old woman, previously living independently and mobilising with one stick, was admitted to hospital following a fall. She had no past medical history of note. Clinical examination revealed a painful and shortened left hip, with an inability to straight leg raise. Radiographic examination revealed a displaced intracapsular proximal femoral fracture. An uncemented hemiarthroplasty was performed and osteoporotic bone was noted at the time of surgery.
1
Post-operatively she complained of significant radicular pain in the posterior aspect of the thigh and leg on the operated side. Nerve conduction studies demonstrated a deep lesion of the sciatic nerve with sensory loss in the distribution of the common peroneal nerve. Radiographic examination demonstrated misplacement of the femoral prosthesis with posterior protrusion through a perforation in the femoral shaft. After discussion with the regional peripheral nerve injury unit, it was advised that the prosthesis be promptly revised by removal of the femoral stem under direct vision following dissection of the sciatic nerve. She was subsequently taken to theatre where a revision procedure was performed through a posterior approach. At revision, the sciatic nerve was seen to be tented over the tip of the femoral prosthesis (Figure 1) but was macroscopically intact. However, some nerve bruising was noted near the tip of the stem. As the cortical perforation was small, a cemented bi-polar revision was performed with the plugging of the defect during cement pressurisation to prevent extravasation. Post-operatively, the patient was fitted with a foot ankle orthosis. The patient’s pain improved almost immediately. The paresthesia disappeared over a period of 2 weeks following surgery. Active dorsiflexion of the ankle was almost normal at 8 weeks following surgery. At this time the patient was discharged home, mobilising with the aid of one stick.
Discussion Nerve palsies following total hip arthroplasty are well documented, with an overall prevalence of less than 1% [1, 2]. In this case, the prompt timing of the second operation ensured that the sciatic nerve lesion was still
Department Trauma and Orthopaedic Surgery, Maidstone Hospital, Hermitage Lane, Maidstone, Kent, ME16 9QQ, UK.
Received: March 19, 2007; revision accepted: April 16, 2007; Published Online: July 11, 2007
Eur J Trauma Emerg Surg 2008 Æ No. 2 Ó URBAN & VOGEL
171
Colegate-Stone T.J, Hussain S. Iatrogenic Sciatic Nerve Palsy
femoral cortex and creation of a false passage. This may lead to subsequent misplacement of the femoral stem, and damage to the sciatic nerve. Sciatic nerve palsy following stem protrusion is a rare complication of hemiarthroplasty. Early operation is advised in order to prevent the conduction block in the nerve progressing to a deeper lesion and a less favourable prognosis.
Acknowledgment We are grateful to Professor Rolfe Birch of the Royal National Orthopaedic Hospital, Stanmore, UK for reading the manuscript and offering valuable advice. Figure 1. Sciatic nerve tented over the tip of the femoral prosthesis. Arrow indicates femoral prosthesis.
in the conduction block stage. A delay may have resulted in more advanced lesion with a less favourable prognosis (Rolfe Birch, personal communication). The sciatic nerve, or its peroneal division, is the most frequently injured nerve accounting for 79% of all nerve palsies [1]. Palsies affecting the femoral, obturator, peroneal and superior gluteal nerves have also been described [1, 2]. Published reports of sciatic nerve damage have mainly documented problems arising from trauma during the operative approach [3, 4], the effects of lengthening the lower extremity [5] or compression secondary to cement extrusion, haematoma formation, broken trochanteric wires, the gluteus maximus tendon or a protruding acetabular reinforcement ring [6–10]. To our knowledge, sciatic nerve palsy due to the femoral stem perforating the cortex has not been described previously. The prognosis for neurological recovery is related to the severity of nerve damage. Complete or essentially complete recovery occurs in approximately 41% of cases and another 44% have only a mild deficit [1]. Patients who either recover some motor function immediately post-operatively or within 2 weeks of surgery have a good prognosis for recovery [1, 2]. In most reports of sciatic nerve injury, the common peroneal division is relatively tethered at the sciatic notch, and tolerates acute stretching less favourably, as occurred in this case. Further, the lateral position of the nerve in gluteal region may make it more susceptible to direct injury [11]. Due care must be taken when preparing the femoral shaft prior to prosthesis insertion. The entry point of the initial reamer must be chosen carefully, so as to ensure that subsequent reaming occurs in the line of the femoral shaft. Too anterior an entry point, as occurred in this case, may result in the perforation of the
172
References 1.
Schmalzried TP, Noordin S, Amstutz HC. Update on nerve palsy associated with total hip replacement. Clin Orthop Relat Res 1997;344:188–206. 2. Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am 2005;87:2619–25. 3. Navarro RA, Schmalzried TP, Amstutz HC, Dorey FJ. Surgical approach and nerve palsy in total hip arthroplasty. J Arthroplasty 1995;10:1–5. 4. Schmalzried TP, Amstutz HC, Dorey FJ. Nerve palsy associated with total hip replacement. Risk factors and prognosis. J Bone Joint Surg Am 1991;73:1074–80. 5. Silbey MB, Callaghan JJ. Sciatic nerve palsy after total hip arthroplasty: treatment by modular neck shortening. Orthopedics 1991;14:351–52. 6. Birch R, Wilkinson MC, Vijayan KP, Gschmeissner S. Cement burn of the sciatic nerve. J Bone Joint Surg Br 1992;74:731–33. 7. Johanson NA, Pellicci PM, Tsairis P, Salvati EA. Nerve injury in total hip arthroplasty. Clin Orthop Relat Res 1983;179:214–22. 8. Asnis SE, Hanley S, Shelton PD. Sciatic neuropathy secondary to migration of trochanteric wire following total hip arthroplasty. Clin Orthop Relat Res. 1985;196:226–28. 9. Hurd JL, Potter HG, Dua V, Ranawat CS. Sciatic nerve palsy after primary total hip arthroplasty: a new perspective. J Arthroplasty 2006;21:796–802; Epub 2006 June 8. 10. Bader R, Mittelmeier W, Zeiler G, Tokar I, Steinhauser E, Schuh A. Pitfalls in the use of acetabular reinforcement rings in total hip revision. Arch Orthop Trauma Surg. 2005;125:558–63; Epub 2005 October 22. 11. Sunderland S. Nerves and nerve injuries. Churchill Livingstone, Edinburgh, 1978.
Address for Correspondence Dr. Toby J. Colegate-Stone Department Trauma and Orthopaedic Surgery Maidstone Hospital Beech Cottage, Orestan Lane Effingham, Surrey KT24 5SP UK Phone (+44/7977) 531559 e-mail: [email protected]
Eur J Trauma Emerg Surg 2008 Æ No. 2 Ó URBAN & VOGEL
