Peripheral neuropathies following total hip arthroplasty

doi:10.1016/0883-5403(94)90119-8

The Journal of Arthroplasty

Volume 9, Issue 6, December 1994, Pages 645-651

https://doi.org/10.1016/0883-5403(94)90119-8 Get rights and content

Abstract

The authors reviewed the complication records following total hip arthroplasty at their institution between January 1976 and July 1989. Forty-two patients (12 men and 30 women) with 45 neurologic complications were identified following 7,133 consecutive total hip arthroplasties; an incidence rate of 0.63%. The average age of these patients was 58 years (range, 27–81 years). Thirty-four nerve injuries were noted in the lower extremity (0.48% incidence rate) and 11 in the upper extremity (0.15% incidence rate). The majority of patients (64%) with neurologic injury to the upper extremity had the diagnosis of inflammatory arthritis. The common peroneal was most often involved in the lower extremity. The ulnar nerve was most commonly involved in the upper extremity. The pathogenetic factors leading to neurologic injury in the majority of patients were not clearly established. Leg lengthening did not seem to be a major cause. The prognosis of patients with nerve palsy of the upper extremity is favorable compared with injury to the lower extremity. Similarly, the percentage of patients with a permanent neurologic deficit was lower in the primary surgery group (27%) compared with the revision/reoperation group (43%). The overall percentage of permanent nerve palsy was 33%. Female patients, for unclear reasons, appear to have a higher risk for neurologic injury. Also, the risk of neurologic injury following total hip arthroplasty appears to be higher with revisions/reoperations and with an inexperienced surgeon.

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Cited by (84)

Motor Nerve Palsy After Direct Anterior Versus Posterior Total Hip Arthroplasty: Incidence, Risk Factors, and Recovery
2023, Journal of Arthroplasty
There is limited literature on motor nerve palsy in modern total hip arthroplasty (THA). The purpose of this study was to establish the incidence of nerve palsy following THA using the direct anterior (DA) and postero-lateral (PL) approaches, identify risk factors, and describe the extent of recovery.
Using our institutional database, we examined 10,047 primary THAs performed between 2009 and 2021 using the DA (6,592; 65.6%) or PL (3,455; 34.4%) approach. Postoperative femoral (FNP) and sciatic/peroneal nerve palsies (PNP) were identified. Incidence and time to recovery was calculated, and association between surgical and patient risk factors and nerve palsy were evaluated using Chi-square tests.
The overall rate of nerve palsy was 0.34% (34/10,047) and was lower with the DA approach (0.24%) than the PL approach (0.52%), P = .02. The rate of FNPs in the DA group (0.20%) was 4.3 times more than the rate of PNPs (0.05%), while in the PL group the rate of PNPs (0.46%) was 8 times more than that of FNPs (0.06%). Higher rates of nerve palsy were observed with women, shorter patients, and nonosteoarthritis preoperative diagnoses. Full recovery of motor strength occurred in 60% of cases with FNP and 58% of cases with PNP.
Nerve palsy is rare after contemporary THA through the PL and DA approaches. The PL approach was associated with a higher rate of PNP, whereas the DA approach was associated with a higher rate of FNP. Femoral and sciatic/peroneal palsies had similar rates of complete recovery.
Short stature and short distance between the anterior acetabular rim to the femoral nerve are risk factors for femoral nerve palsy following primary total hip arthroplasty using the modified Watson-Jones approach
2022, Orthopaedics and Traumatology: Surgery and Research
Nerve palsy following total hip arthroplasty (THA) critically impacts patient clinical function. However, few studies have focused on femoral nerve palsy (FNP) following THA via the modified Watson-Jones approach. Previous reports have suggested that THA, regardless of the approach, is associated with several FNP risk factors, including female gender, hip dysplasia, revision surgery, and short stature. Magnetic resonance imaging (MRI) has suggested that a shorter distance between the femoral nerve and the anterior acetabular edge (dFN) is related to FNP after THA. The purposes of this study were: 1) to determine the presumed risk factors through a retrospective investigation of FNP clinical courses, and 2) to identify the relationships between FNP occurrence and the short dFN following primary THA via the modified Watson-Jones approach.
Short stature is a risk factor for femoral nerve palsy following THA. i.e. a significant difference in dFN exists between patients with and without FNP.
This retrospective case-control study was performed at a single university hospital. From January 2016 to December 2020, 676 THAs were performed via the modified Watson-Jones approach at our institution. These included 495 THAs performed in the supine position and 181 in the lateral position. In this study, FNP was defined as weakness of the quadriceps femoris (manual muscle test < grade 3) with or without sensory disturbance over the anteromedial aspect of the thigh. The incidence of FNP was calculated. Patient background factors (age, sex, preoperative diagnosis, surgical position, height, weight, body mass index, surgeon experience, type of components, the method of anesthesia, leg lengthening during the surgery, and operation time) were compared between the FNP group and a non-FNP control group. The dFN was measured in T1-weighted MRI axial images at the level of the hip center. The distance between the femoral nerve and the anterior acetabular edges, where retractors are commonly placed during surgery, was also measured and compared between the FNP group and the non-FNP control group. The FNP group and non-FNP control group were extracted by 1:4 matching of patient height and weight. All data were statistically evaluated using the Mann-Whitney U test, and p values less than 0.05 were considered statistically significant.
FNP occurred in 6 out of 676 joints (0.88%) following primary THA via the modified Watson-Jones approach. In all 6 cases, the motor deficit recovered completely within a year. Patient height was significantly shorter in the FNP group than in the non-FNP control group (148.4 ± 3.3 cm vs. 155.4 ± 8.1 cm [p = 0.01]). The dFN was significantly shorter in the FNP group (16.3 ± 4.1 mm vs. 21.5 ± 4.0 mm [p = 0.034]).
Short stature and short dFN are risk factors for FNP after THA using the modified Watson-Jones approach.
III, case-control study.
Nerve Injuries Following Total Hip Arthroplasty: The Influence of Surgical Approach
2022, Orthopedic Clinics of North America
Citation Excerpt :
Some authors have suggested that most postoperative nerve injuries never fully recover, regardless of whether they were incomplete or complete injuries.10,77 Nercessian and colleagues77 found that nerve injuries in 27% of primary cases and 43% of revision cases were permanent. However, femoral nerve injuries, in general, have a more favorable prognosis and predictable recovery compared with that of sciatic nerve injuries.5,32
Treatment approach to isolated common peroneal nerve palsy by mechanism of injury: Systematic review and meta-analysis of individual participants’ data
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Following title/abstract screening, 483 articles were eligible for full-text review, of which 144 published from 1985 through 2020 included 1284 patients (Figure 1). Patients with isolated CPN palsies were treated with primary neurorrhaphy (studies=13, patients=28),17,21-32 neurolysis (studies=72, patients=450),17,19,24,26-28,30,33-97 nerve grafts (studies=28, patients=301),17,19,22-27,29,30,32,44,57,61,71,83,84,89,98-107 partial nerve transfer (studies=9, patients=42),79,108-115 neuromusculotendinous transfer (studies=5, patients=23),16,28,113,116,117 tendon transfer (studies=41, patients=325),17,18,21,23,26,40,57,77,80,83,89,98-100,102,105,111,118-141 AFO (studies=28, patients=112),49,57,77,80,98,99,121,123,136,142-160, or arthrodesis (studies=3, patients=3).21,124,161 Study characteristics, interventions, injury characteristics, muscle strengths on MRC, functional results, and follow-ups were summarized for patients (Table 1, Supplemental Digital Content 3).
We reviewed the individual participant data of patients who sustained isolated common peroneal nerve (CPN) injuries resulting in foot drop. Functional results were compared between eight interventions for CPN palsies to determine step-wise treatment approaches for the underlying mechanisms of nerve injury.
PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were searched. PRISMA-IPD and Cochrane guidelines were followed in the data search. Eligible patients sustained isolated CPN injuries resulting in their foot drop. Patients were stratified by mechanisms of nerve injury, ages, duration of motor symptoms, and nerve defect/zone of injury sizes, and were compared by functional results (poor = 0, fair = 1, good = 2, excellent = 3), using meta-regression between interventions. Interventions evaluated were primary neurorrhaphy, neurolysis, nerve grafts, partial nerve transfer, neuromusculotendinous transfer, tendon transfer, ankle-foot orthosis (AFO), and arthrodesis.
One hundred and forty-four studies included 1284 patients published from 1985 through 2020. Transection/Cut: Excellent functional results following tendon transfer (OR: 126, 95%CI: 6.9, 2279.7, p=0.001), compared to AFO. Rupture/Avulsion: Excellent functional results following tendon transfer (OR: 73985359, 95%CI: 73985359, 73985359, p<0.001), nerve graft (OR: 4465917, 95%CI: 1288542, 15478276, p<0.001), and neuromusculotendinous transfer (OR: 42277348, 95%CI: 3001397, 595514030, p<0.001), compared to AFO. Traction/Stretch: Good functional results following tendon transfer (OR: 4.1, 95%CI: 1.17, 14.38, p=0.028), compared to AFO. Entrapment: Excellent functional results following neurolysis (OR: 4.6, 95%CI: 1.3, 16.6, p=0.019), compared to AFO.
Functional results may be optimized for treatments by the mechanism of nerve injury. Transection/Cut and Traction/Stretch had the best functional results following tendon transfer. Rupture/Avulsion had the best functional results following tendon transfer, nerve graft, or neuromusculotendinous transfer. Entrapment had the best functional results following neurolysis.
What Actions Can Be Used to Prevent Peripheral Nerve Injury?
2022, Evidence-Based Practice of Anesthesiology
Perioperative peripheral nerve injury is a significant source of morbidity for patients and a frequent cause of professional liability for anesthesiologists. The etiology of perioperative nerve injury is largely unknown and multifactorial, and insults interact with the patient’s underlying neuronal reserve. There are few prospective studies on the genesis or prevention of perioperative neuropathy. This chapter summarizes the evidence related to the etiology and incidence of perioperative upper and lower extremity peripheral nerve injury. It also summarizes evidence related to nerve injury after peripheral nerve blockade. Because of the absence of randomized controlled trials and a paucity of epidemiologic studies, the evidence on which practice patterns for prevention of perioperative peripheral neuropathy are based is largely consensus opinion. The chapter summarizes the recommendations from the 2018 American Society of Anesthesiologists (ASA) Task Force on Prevention of Perioperative Peripheral Neuropathies concerning perioperative positioning of the patient, use of protective padding, and avoidance of contact with hard surfaces or supports to reduce perioperative neuropathies.
Bilateral Total Hip Arthroplasty in the Setting of Developmental Dysplasia of the Hip and Extreme Hip Flexion Requirements due to Phocomelia
2021, Arthroplasty Today
Citation Excerpt :
However, with her increased medical comorbidities, a staged bilateral THA was selected for this patient taking into account the risks for systemic complications [34]. Moreover, with lower extremity nerve injury being attributed to leg lengthening at a threshold as low as 0.5 cm during THA, there was concern for tension on the sciatic nerve and development of a foot drop in our patient [35]. Therefore, a staged bilateral THA was offered to this patient to allow her adequate rehabilitation while minimizing the risks of neuropraxia and falls.
Phocomelia is a rare congenital birth defect marked by hypoplastic or markedly absent limbs. Developmental dysplasia of the hip (DDH) is a congenital disorder with a failure of the native acetabulum to provide complete coverage over the femoral head. The secondary osteoarthritis that develops from DDH is technically challenging for orthopedic surgeons because of distorted anatomy. The present case describes the diagnosis of Crowe 3 DDH in a phocomelia patient with hyperflexion requirements who successfully underwent staged bilateral total hip arthroplasty via a direct anterior approach. It highlights the utility of preoperative computerized tomography and intraoperative computer navigation to assist in implant placement. Recognizing difficult arthroplasty cases in advance is imperative as these cases may require great expertise and more extensive surgical planning.

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Original articlePeripheral neuropathies following total hip arthroplasty

Abstract

Orthop Clin North Am

Clin Orthop

Total hip arthroplasty: a review of three hundred and thirty-three cases with long follow-up

J Bone Joint Surg

Results of the total hip prosthesis design “St. George”

Clin Orthop

The long-term results of low-friction arthroplasty of the hip performed as a primary intervention

J Bone Joint Surg

Cemented total hip replacement in patients who are less than fifty years old

J Bone Joint Surg

2012 total hip arthroplasties: a study of postoperative course and early complications

J Bone Joint Surg

Experience with low-friction arthroplasty: a statistical review of early results and complications

Clin Orthop

Revision arthroplasty using Charnley low friction arthroplasty technic: with reference to specifics of technique and comparison of results with primary low friction arthroplasty

Clin Orthop

Systemic and local complications following low-friction arthroplasty of the hip joint: a study of 800 consecutive operations

Arch Surg

Interim results of Charnley-Muller total hip arthroplasty

Clin Orthop

A ten-year follow-up study of our first one hundred consecutive Charnley total hip replacements

J Bone Joint Surg

Original article
Peripheral neuropathies following total hip arthroplasty