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Updated: Feb 20 2024

THA Sciatic Nerve Palsy

  • summary
    • THA Sciatic Nerve Palsy is an uncommon, but potentially devastating complication following THA that may lead to persistent foot drop.
    • Diagnosis can be made clinically with post-operative complaints of numbness and paresthesias along the sciatic nerve distribution and weakness of the dorsiflexors of the foot.
    • Treatment is placing the hip in extension and knee in flexion immediately post-operatively. Observation and AFO in the presence of foot drop are recommended to monitor for recovery of the nerve.
  • epidemiology
    • Incidence
      • uncommon (0-3%)
        • most common cause for medical malpractice litigation following THA 
    • Anatomic location
      • peroneal division of sciatic nerve most commonly affected (80%)
        • sciatic nerve travels closest to acetabulum at level of ischium
        • exercise care with posterior acetabular retraction when hip in flexed position
      • less commonly affected nerves include
        • femoral
        • obturator
        • superior gluteal
  • Etiology
    • Causes
      • direct trauma
      • stretch
      • compression due to hematoma
      • heat from polymethylmethacralate polymerization
      • unrecognized lumbar lateral recess stenosis
      • unknown (40%)
    • Risk factors
      • for motor nerve palsies include
        • developmental dysplasia of the hip
        • revision surgery
        • female gender
        • limb lengthening
        • posttraumatic arthritis
        • surgeon self-rated procedure as difficult
        • pre-existing lumbar stenosis 
  • Presentation
    • Post-operative complaints of numbness, paresthesias, or weakness
  • Imaging
    • Post-operative CT
      • may be helpful if hematoma suspected
    • Ultrasound
      • may be helpful if hematoma suspected
  • Studies
    • EMGs
      • may be used post-operatively to confirm level of injury and guide discussion with patient regarding prognosis
  • Treatment
    • Intraoperative
      • adult hip dysplasia undergoing THA
        • subtrochanteric osteotomy
        • downsizing components
    • Immediate postoperative
      • place hip in extension and knee in flexion
        • indications
          • immediate post-operative palsy
        • technique
          • decreases tension along sciatic nerve
      • immediate evacuation in operating room
        • indications
          • post-operative hematoma
    • Persistent foot drop
      • AFO orthosis
        • indications
          • first line of treatment for persistent foot drop
  • Prognosis
    • Only 35% to 40% recover full strength after complete palsy
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