THA Complications

Author: Mark Karadsheh

Topic updated on 06/08/13 11:01am

Introduction

Complications following THA include
- nerve palsies (see below)
- limb length discrepancy
- iliopsoas impingement
- heterotopic ossification
- blood transfusion

Nerve Palsies

Introduction
- epidemiology
  - uncommon (0-3%), but potentially devastating complication following THA
  - peroneal division of sciatic nerve most commonly affected (80%)
    - sciatic nerve travels closest to acetabulum at level of ischium
    - must avoid posterior acetabular retraction when hip in flexed position
  - less commonly affected nerves
    include
    - femoral
    - obturator
    - superior gluteal
- causes
  - compression (most common) due to
    - hematoma
    - retraction
    - tight bandages
  - direct trauma
  - heat from polymethylmethacralate polymerization
  - 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
- prognosis
  - only 35% to 40% recover full strength after complete palsy
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
Evaluation
- EMGs
  
  may be used post-operatively to confirm level of injury and guide discussion with patient regarding prognosis
Treatment
- nonoperative
  - place hip in extension and knee in flexion
    - indications
      - immediate post-operative palsy
    - technique
      - decreases tension along sciatic nerve
- operative
  - immediate excavation in operating room
    - indications
      - post-operative hematoma

Limb length discrepancy

Introduction
- most common reason for litigation following total hip arthroplasty
- operative limb lengthening most common
- functional, but transient, limb-length differences are common
  - weak abductors may provide the sensation of a long leg in the absence of true LLD
  - usually resolve within 3-6 months post-operatively
Presentation
- symptoms
  - patient may feel perceived LLD despite anatomic equality
- physical exam
  - post-operative assessment of limb-length discrepancy
    - true limb length
      - measured from anterior superior iliac spine to medial malleolus
    - apparent limb length
      - determined by adding effect of soft-tissue contractures and pelvic obliquity
      - difficult to truly measure
Imaging
- radiographic measurement of leg-length discrepancy
- increasing neck length will increase limb length
- increasing femoral offset will not increase limb length
Treatment
- shoe-lift
  - indications
    - shoe-lift treatment adequate in most cases
    - wait 6 months until treatment to allow adequate relaxation of muscles
Prevention
- pre-operative planning reduces incidence of post-operative discrepancies

Iliopsoas impingement

Introduction
- underrecognized cause of recurrent groin pain after total hip replacement
- may be caused by
  - retained cement
  - malpositioned acetabular component
  - limb length discrepancy
  - excessive length of screws
Presentation
- symptoms
  - groin pain
Evaluation
- diagnostic cortisone injection into iliopsoas sheath is helpful in diagnosis
Treatment
- nonoperative
  - most patients require operative intervention for complete resolution of symptoms
- operative
  - iliopsoas tenotomy or resection
    - indications
      - in cases of normal post-op radiographs
  - acetabular component revision
    - indications
      - in cases of excessive anterior cup overhang

Heterotopic Ossification

Introduction
- frequent complication that may limit functional outcome following hip replacement
- risk factors
  - prolonged surgical time
  - excessive soft tissue handling during procedure
  - hypertrophic osteoarthritis
  - male gender
Treatment
- surgical excision
  - indications
    - severe loss of motion
    - once heterotopic ossification is visible on radiographs, only surgical excision will eradicate
  - technique
    - must wait 6 months after initial procedure to allow for maturation and formation of capsule
    - perioperative prophylaxis with perioperative radiation or NSAIDs
Prophylaxis
- oral indomethacin
- radiation therapy
  - 600-800 Gy administered ideally within 24-48 hours following procedure

Postoperative Transfusions

Low preoperative hemoglobin
- is the best predictor of the need for a blood transfusion postoperatively

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Qbank (12 Questions)

TAG

(OBQ11.167) A 62-year-old female has persistent activity related anterior groin pain 10 months after total hip arthroplasty (THA). Infection workup is negative. Radiographs are provided in figures A and B. Pain is temoporarily relieved following an injection of lidocaine and cortisone into the iliopsoas tendon sheath. What is the next appropriate treatment option? Topic

Review Topic

FIGURES: A

1. Indefinite activity modification
2. Iliopsoas tendon release
3. Femoral component revision
4. Acetabular component revision
5. Femoral and acetabular component revision

PREFERRED RESPONSE ▶

DISCUSSION: After diagnosis of iliopsoas impingement, iliopsoas muscle tenotomy or resection is the treatment of choice if radiographs are within normal limits. In contrast, if imaging shows anterior acetabular overhang (as shown in Illustration A), then acetabular revision would be the next appropriate step in management.

Lachiewicz et al provide a great review on iliopsoas impingement after THA. Anterior iliopsoas impingement can cause functional disability after total hip arthroplasty. The diagnosis may be confirmed by one or more imaging studies, including a cross-table lateral radiograph, computed tomography, magnetic resonance imaging, and ultrasonography, in combination with a confirmatory diagnostic injection into the iliopsoas sheath. Treatment, consisting of release or resection of the iliopsoas tendon, alone or in combination with acetabular revision for an anterior overhanging component, usually provides permanent pain relief.

Trousdale et al also reviewed cases of iliopsoas impingment after THA. They studied two cases of iliopsoas tendinitis following THA due to a malpositioned, uncemented, metal-backed acetabular component. In cases of anterior acetabular overhang, acetabular revision to reduce anterior impingement is the appropriate management.

Illustration A shows an example of anterior acetabular overhang which would require acetabular revision if symptomatic.

Illustrations: A

REFERENCES:

1. Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis after total hip arthroplasty. J Am Acad Orthop Surg. 2009 Jun;17(6):337-44. PMID:19474443 (Link to Abstract)

2. Trousdale RT, Cabanela ME, Berry DJ. Anterior iliopsoas impingement after total hip arthroplasty. J Arthroplasty. 1995 Aug;10(4):546-9. PMID:8523018 (Link to Abstract)

Question Authors:

David Abbasi MD, John Badylak MD, Dave Marcu MD, Stephen Incavo MD,

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(OBQ11.208) A 65-year-old female with a history of developmental dysplasia of the hip (DDH) undergoes a total hip arthroplasty (THA) utlizing a posterior approach. Following THA, she notices an inability to dorsiflex then ankle of her operative extremity. Her pre-operative and post-operative radiographs are seen in figues A and B. Which of the following intra-operative techniques could have avoided this complication in this patient? Topic

Review Topic

FIGURES: A

1. Utilization of an anterior approach
2. Modular components
3. Use of a larger femoral head
4. Femoral shortening osteotomy
5. Acetabular osteotomy

PREFERRED RESPONSE ▶

DISCUSSION: Patients with DDH undergoing THA are at risk for post-operative sciatic nerve palsy due to intra-operative limb lengthening which increases tension on the sciatic nerve. Appropriate management after discovering a sciatic nerve palsy after surgery should include immediate knee flexion and hip extension to decrease tension on the sciatic nerve. Sciatic nerve palsy following THA most commonly only effects the common peroneal nerve branch, and spares the tibial nerve and can present as an inability to dorsiflex and evert the ankle.

Farrell et al retrospectively looked at the risk factors for motor nerve palsy after THA. They found while motor nerve palsy is uncommon following primary THA, it can be a devastating complication. Some risk factors include: preoperative diagnosis of developmental dysplasia of the hip, posttraumatic arthritis, the use of a posterior approach, lengthening of the extremity, and use of an uncemented femoral implant. In their review, many of the motor nerve deficits did not fully resolve.

Barrack et al reviewed neurovascular complications following THA. They stated that sciatic nerve injury is the most common nerve injury following THA utilizing a posterior approach. In comparison, femoral nerve injury is much less common and is usually from an anterior approach.

REFERENCES:

1. Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Dec;87(12):2619-25. PMID:16322610 (Link to Abstract)

2. Barrack RL, Butler RA. Avoidance and management of neurovascular injuries in total hip arthroplasty. Instr Course Lect. 2003;52:267-74. PMID:12690854 (Link to Abstract)

Question Authors:

David Abbasi MD, John Badylak MD, Dave Marcu MD,

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(OBQ11.238) A 66-year-old female underwent a surgical procedure 6 weeks ago, and video A demonstrates her gait during ambulation. Based on her gait pattern, which reconstructive procedure did the patient most likely have? Topic

Review Topic

FIGURES: V

1. Right total hip arthroplasty through Smith-Petersen approach
2. Left total hip arthroplasty through Smith-Petersen approach
3. Left total hip arthroplasty through modified Hardinge approach
4. Right total hip arthroplasty through modified Hardinge approach
5. Left L2-L3 decompression foraminotomy

PREFERRED RESPONSE ▶

DISCUSSION: The video demonstrates a left sided Trendelenberg gait resulting from left sided gluteus medius weakness. Left-sided abductor muscle weakness is most likely found in the setting of a left total hip arthroplasty performed through a lateral approach, of the options listed.

Abductor weakness will lead to an apparent leg length discrepancy with the left side feeling longer to the patient.

Maloney and Keeney note that most leg length discrepancies that are less than 1 centimeter are well tolerated by the patient. However, they also discuss that patient dissatisfaction with leg-length discrepancies after THA is the most common reason for litigation against orthopaedic surgeon.

Clark et al present a Level 5 review describing the differences between true and apparent leg length discrepancies. Increasing femoral neck length and not fully seating the femoral stem will lead to a true leg lengthening on the operative side.

REFERENCES:

1. Maloney WJ, Keeney JA. Leg length discrepancy after total hip arthroplasty. J Arthroplasty. 2004 Jun;19(4 Suppl 1):108-10. Review. PMID:15190563 (Link to Abstract)

2. Clark CR, Huddleston HD, Schoch EP 3rd, Thomas BJ. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg. 2006 Jan;14(1):38-45. Erratum in: J Am Acad Orthop Surg. 2006 May;14(5):35A. PMID:16394166 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD, Ben Taylor MD,

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TAG

(OBQ10.160) All of the following intra-operative techniques may result in lengthening of the operative leg during total hip arthroplasty EXCEPT: Topic

Review Topic

1. Increasing the femoral neck offset
2. Increasing the femoral neck length
3. Incomplete insertion of a cemented femoral stem
4. Making a high femoral neck cut just below the femoral head
5. Bone grafting superior to the acetabulum to seat the cup more inferior

PREFERRED RESPONSE ▶

DISCUSSION: Limb length discrepancy, especially operative limb lengthening, is a common complication following THA that can lead to patient dissatisfaction. Extending the femoral neck offset does not lengthen the limb. Rather it increases the horizontal distance of the stem away from the femoral head. This increases abductor tension improving stability. It should be noted that weakness of the abductors can result in patient sensation of leg lengthening in the absence of any true LLD.

Bhave et al reviewed 78 patients who complained of poor function 3 months following THA. The patients were evaluated by physical exam, 3-D gait analysis, and isokinetic strength testing. Muscle weakness, muscle tightness, limb-length discrepancies, and limb malalignment were the most common findings.

Maloney et al reviewed the etiologies, complications, and proper management of limb length discrepancy following THA. Careful pre-operative physical exam and pre-operative templating can be useful in mitigating post-operative leg length discrepancy.

Illustration A demonstrates an example of extended femoral neck offset.

Illustrations: A

REFERENCES:

1. Bhave A, Marker DR, Seyler TM, Ulrich SD, Plate JF, Mont MA. Functional problems and treatment solutions after total hip arthroplasty. J Arthroplasty. 2007 Sep;22(6 Suppl 2):116-24. Epub 2007 Jul 26. PMID:17823029 (Link to Abstract)

2. Maloney WJ, Keeney JA. Leg length discrepancy after total hip arthroplasty. J Arthroplasty. 2004 Jun;19(4 Suppl 1):108-10. PMID:15190563 (Link to Abstract)

Question Authors:

John Badylak MD, Michael Hughes MD,

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TAG

(OBQ09.155) A 67-year-old woman undergoes a total hip arthroplasty. Postoperatively, she develops a complete peroneal palsy that does not improve with flexion of the knee and removal of compressive dressings. All of the following are associated with a post-operative nerve palsy EXCEPT: Topic

Review Topic

1. Developmental dysplasia of the hip
2. Lengthening of the extremity
3. Surgeon self-rating the procedure as being a difficult intervention
4. Avascular necrosis of the femoral head
5. Posttraumatic arthritis

PREFERRED RESPONSE ▶

DISCUSSION: This patient has a motor and sensory (complete) peroneal nerve palsy. The incidence of postoperative nerve injury ranges from 0% to 3% and most often affects the peroneal branch of the sciatic nerve. Eggli et al reviewed 370 patients following total hip arthroplasty and found the only factor that correlated to nerve palsy was the surgeon self-rating the procedure as difficult potentially leading to direct or indirect mechanical trauma. Farrell et al reviewed 27,004 total hip arthroplasties and found that developmental dysplasia, extremity lengthening, posterior approach, posttraumatic arthritis, and uncemented femoral component increased the odds ratio of a nerve palsy. They found less than a 50% rate of nerve recovery.

REFERENCES:

1. Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Dec;87(12):2619-25 PMID:16322610 (Link to Abstract)

2. Eggli S, Hankemayer S, Müller ME. Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. J Bone Joint Surg Br. 1999 Sep;81(5):843-5. PMID:10530847 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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(OBQ08.189) A 65-year-old female scheduled to undergo a total hip replacement is concerned about the need of a blood transfusion. The surgeon should explain that which factor is the best predictor of the need for a blood transfusion? Topic

Review Topic

1. Shorter height
2. Lower body weight
3. Previous total hip replacement on the contralateral side
4. Lower preoperative hemoglobin
5. Female gender

PREFERRED RESPONSE ▶

DISCUSSION: Bierbaum et al in 1999 prospectively evaluated the post operative course of 9482 patients undergoing hip or knee replacement. They found low hemoglobin level < 130g/L preoperatively, revision hip, and bilateral knee to be associated with increased frequency of transfusion post op. In a retrospective study of 296 hip and knee replacement patients by Salido et al in 2002, only preoperative hemoglobin levels and weight of the patient were found to be significant factors in determining need for transfusion post operatively. Gender, height, and surgical duration were not found to be signficant factors in the multivariate analysis. Guerin et al in a prospective study of 162 consecutive THA and TKA found preoperative hemoglobin to be the only predictive factor for need of a transfusion. Weight and age were not significant when assessed by multivariate analysis. Thus, all three cited studies agree that the preoperative hemoglobin predicts need for transfusion.

REFERENCES:

1. Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors. J Bone Joint Surg Am. 2002 Feb;84-A(2):216-20. PMID:11861727 (Link to Abstract)

2. Guerin S, Collins C, Kapoor H, McClean I, Collins D. Blood transfusion requirement prediction in patients undergoing primary total hip and knee arthroplasty. Transfus Med. 2007 Feb;17(1):37-43. PMID:17266702 (Link to Abstract)

3. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999 Jan;81(1):2-10. PMID:9973048 (Link to Abstract)

Question Authors:

Doug Nowak MD, Derek Moore,

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TAG

(OBQ08.224) What percentage of patients with complete peroneal nerve palsy after total hip arthroplasty will never recover full strength? Topic

Review Topic

1. 90% to 95%
2. 60% to 65%
3. 40% to 45%
4. 20% to 25%
5. 0% to 5%

PREFERRED RESPONSE ▶

DISCUSSION: The likelihood of complete functional recovery to preoperative strength levels is 35% to 40%.

Nerve palsy is an uncommon but acknowledged complication of total hip replacement. The overall prevalence is approximately 1%. The sciatic nerve, or the peroneal division of the sciatic nerve, is involved in nearly 80% of cases. The risk of nerve palsy in association with total hip replacement is increased for female compared with male patients, with a diagnosis of developmental dysplasia, and with patients undergoing revision surgery. A preoperative diagnosis of developmental dysplasia of the hip or posttraumatic arthritis, the use of a posterior approach, lengthening of the extremity, and use of an uncemented femoral implant increased the odds ratio of sustaining a motor nerve palsy (in Farrell study). In the majority of cases, the origin of the palsy is unknown. Because peripheral nerves are sensitive to compression, unrecognized compression may play a role in these cases.

Farrell performed a retrospective review of 27,004 primary THA’s done at Mayo. There was a 0.17% incidence rate of postoperative motor nerve dysfunction (29 pts with complete palsy, 18 with incomplete palsy). Of the twenty-eight patients with a complete palsy who were available for follow-up, only ten (36%) had complete recovery of motor strength, which took an average of 21.1 months.

Another study by Schmalzried et. al states a prevalence of 1%, with the sciatic nerve involved in 80% of those palsies. Complete, or essentially complete, recovery occurs in approximately 41% and another 44% have only a mild deficit. Patients with some motor function immediately after the operation and those who recover some motor function within approximately 2 weeks of surgery have a good prognosis for recovery.

REFERENCES:

1. Farrell CM, Springer BD, Haidukewych GJ, et al: Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am 2005;87:2619-2625 PMID:16322610 (Link to Abstract)

2. Schmalzried TP, Noordin S, Amstutz HC: Update on nerve palsy associated with total hip replacement. Clin Orthop Relat Res 1997;344:188-206 PMID:9372771 (Link to Abstract)

Question Authors:

David Abbasi MD, Patrick McCulloch MD, Michael Hughes MD,

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(OBQ08.267) Risk factors for a motor nerve palsy following primary total hip arthroplasty include all of the following EXCEPT? Topic

Review Topic

1. Developmental dysplasia of the hip
2. Limb lengthening
3. Posttraumatic arthritis
4. Obesity
5. Posterior approach

PREFERRED RESPONSE ▶

DISCUSSION: Certain pre-operative risk factors may place patients at increased risk for the development of nerve injury during primary total hip arthroplasty (THA). These include a history of developmental dysplasia of the hip (DDH), limb lengthening, posttraumatic arthritis, cementless femoral fixation, and the posterior approach.

Farrell et al. reviewed more than 27,000 patients who underwent THA between 1970 and 2000. Forty-seven patients developed a nerve palsy (0.17%) with 29 complete palsies and 18 incomplete palsies. DDH, post-traumatic arthritis, posterior approach, use of a cementless femoral implant, and limb-lengthening were all found to have an increased risk of nerve palsy. Body-mass index (BMI) was not associated with increased risk of nerve palsy.

Of note, the average time to maximal recovery for both incomplete and complete nerve palsies was approximately 2 years. Patient should be counseled regarding this complication especially if one of the above risk factors is present.

REFERENCES:

1. Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Dec;87(12):2619-25.: Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am 2005;87:2619-2625 PMID:16322610 (Link to Abstract)

Question Authors:

Anay Patel MD, Jan Szatkowski MD, John Badylak MD,

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(OBQ07.110) All of the following are risk factors for developing a sciatic nerve palsy following total hip arthroplasty EXCEPT: Topic

Review Topic

1. Female gender
2. Developmental dysplasia of the hip
3. Revision surgery
4. Rheumatoid arthritis
5. Lengthening of the extremity

PREFERRED RESPONSE ▶

DISCUSSION: Female gender, DDH, Revision surgery, and extremity lengthening are all risk factor for the development of a post-operative sciatic nerve palsy following total hip arthroplasty. Rheumatoid arthritis is not a risk factor.

Nerve palsy is an uncommon but devastating injury following total hip arthroplasty. Common causes include compression from hematoma or tight dressings, direct injury, and excess heat from polymethylmethacralate polymerization. Initial management in the post-operative period is to place the hip in extension and the knee in flexion to take tension off the sciatic nerve. If a hematoma is thought to be the cause, excavation in the operating room is the preferred treatment.

Schmalzried et al in CORR 1997 found the risk for post-operative palsy increased in females, those with a diagnosis of developmental dysplasia, and patients undergoing revision surgery. Obesity, RA, Perthes, and SCFE were not associated with nerve palsy following THA.

Farrell et al in a retrospective analysis of 27,000 primary THA found a 0.17% incidence of nerve plasy. Risk factors included preoperative diagnosis of DDH or posttraumatic arthritis, the use of a posterior approach, lengthening of the extremity, and cementless femoral fixation. Only 10 of the 28 patients at final follow-up had complete resolution of symptoms.

Illustration A shows an excellent representation of the sciatic nerve as it courses beneath the piriformis.

Illustrations: A

REFERENCES:

1. Schmalzried TP, Noordin S, Amstutz HC. Update on nerve palsy associated with total hip replacement. Clin Orthop Relat Res. 1997 Nov;(344):188-206. PMID:9372771 (Link to Abstract)

2. Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Dec;87(12):2619-25. PMID:16322610 (Link to Abstract)

Question Authors:

Mark Karadsheh MD, Derek Moore, John Badylak MD,

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(OBQ06.141) The preoperative pelvic radiograph of a 63-year-old female with osteoarthritis is shown in Figure A. She undergoes an uncomplicated total hip replacement. Six weeks post-operatively she complains that her right leg is longer than her left, and an AP pelvic radiograph is obtained which is shown in Figure B. Physical exam shows normal post-operative range of motion and strength in both hips. What is the most likely etiology for this patients gait impairment?? Topic

Review Topic

FIGURES: A

1. Hip flexion contracture
2. Excessive medialization of the acetabular component
3. Patient's perceived leg length discrepancy
4. Hip adduction contracture
5. Malpositioning of the femoral component

PREFERRED RESPONSE ▶

DISCUSSION: Unilateral osteoarthritis normally causes a leg length discrepancy because of cartilage loss and bone deformity. Post-operatively, some patients take months to adjust to this apparent lengthening, even though they have been made equal to the non-operative side. Figure B shows leg lengths to be equal based on the presence of symmetric teardrops, femoral head heights, and lesser trochanter levels. Konyves et al evaluated leg length discrepancy (LLD) and hip function in 90 patients undergoing primary total hip arthroplasty before surgery and at three and 12 months post-operatively. Of the limbs that were over-lengthened (mean 9mm), LLD was perceived in only 43% of the patients after three months and by 33% after 12 months. Lengthening occurred in the femoral component in 98% of the patients with LLD. There was a strong correlation with perceived LLD and poorer function in the Oxford Hip Score. Hip flexion or adduction contractures would functionally shorten the limb so the longer leg would be perceived on the opposite side. Medialization of the acetabular component would not affect limb length, and Figure B does not represent malpositioning of the femoral component.

REFERENCES:

1. Konyves A, Bannister GC. The importance of leg length discrepancy after total hip arthroplasty. J Bone Joint Surg Br. 2005 Feb;87(2):155-7. PMID:15736733 (Link to Abstract)

Question Authors:

Joshua Blomberg MD,

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(OBQ05.109) All of the following interventions help restore anatomic limb length following total hip arthroplasty EXCEPT: Topic

Review Topic

1. Preoperative templating
2. Use of an arthroplasty system incorporating variable neck lengths
3. Intraoperative assessment of limb length
4. Use of a modular arthroplasty system that allows variable femoral offset
5. Clinical and radiographic preoperative assessment for limb length discrepancy

PREFERRED RESPONSE ▶

DISCUSSION: Femoral offset can be decreased following total hip arthroplasty compared to the preoperative anatomy. A decrease in femoral offset moves the femur closer to the pelvis, which can result in impingement at the extremes of movement. Moving the femur medially also results in soft tissue laxity. Both of these problems can cause instability and possible dislocation. Increasing femoral offset, which moves the femur laterally, will decrease impingement and improve soft tissue tension resulting in better stability without lengthening the leg.

Bourne et al review techniques to restore femoral offset during total hip arthroplasty. Pre-operative templating, intra-operative assessment of limb length, and high offset femoral necks are helpful to replicate femoral offset.

Suh et al reviewed a series of THA's to evaluate how well preoperative templating corresponded with postoperative limb lengthening and femoral offset. They reported both parameters were on average within 2 mm of the preoperative template.

Line A in Illustration A demonstrates femoral offset. Illustration B compares neck length and femoral offset affect on limb length.

Illustrations: A

REFERENCES:

1. Bourne RB, Rorabeck CH. Soft tissue balancing: the hip. J Arthroplasty. 2002Jun;17(4 Suppl 1):17-22. PMID:12068397 (Link to Abstract)

2. Suh KT, Cheon SJ, Kim DW. Comparison of preoperative templating withpostoperative assessment in cementless total hip arthroplasty. Acta Orthop Scand.2004 Feb;75(1):40-4. PMID:15022804 (Link to Abstract)

Question Authors:

John Badylak MD, Michael Hughes MD,

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(OBQ04.249) During revision total hip arthroplasty (THA), adjunctive motor-evoked potentials (MEPs) and electromyography (EMG) are utilized to monitor the sciatic and peroneal nerves. During the procedure, a conduction abnormality arises in the sciatic nerve. Which of the following actions would decrease tension on the sciatic nerve? Topic

Review Topic

1. Provide traction to the leg
2. Pulsatile irrigation in the wound to remove blood clots
3. Flex the hip
4. Extend the hip
5. Extend the knee

PREFERRED RESPONSE ▶

DISCUSSION: The only answer choice that would decrease tension on the sciatic nerve is hip extension. Satcher et al used motor-evoked potentials (MEPs) and electromyography (EMG) monitoring during 27 consecutive total hip revision cases to identify intraoperative events that caused conduction abnormalities of the sciatic and peroneal nerves. Leg positioning was the most commonly associated factor that increased sciatic nerve pressure, causing changes in monitored parameters in 4 patients. The position that caused the most conduction abnormality was hip flexion during posterior acetabular retraction in these patients. During hip flexion, the nerve can impinge on the acetabular retractor. Providing traction to the leg, pulsatile irrigation, hip flexion, and knee extension would all increase sciatic nerve pressure.

REFERENCES:

1. Satcher RL, Noss RS, Yingling CD, Ressler J, Ries M. The use of motor-evoked potentials to monitor sciatic nerve status during revision total hip arthroplasty. J Arthroplasty. 2003 Apr;18(3):329-32. PMID:12728425 (Link to Abstract)

Question Authors:

David Abbasi MD, John Badylak MD,

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Posts

Motor Nerve Palsy Following Primary Total Hip Arthroplasty. Includes Poll

Farrell CM, Springer BD, Haidukewych GJ, Morrey BF
J Bone Joint Surg Am. 2005 Dec;87(12):2619-25. PMID: 16322610 (Link to Pubmed)

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Eggli S, Hankemayer S, Müller ME. Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. J Bone Joint Surg Br. 1999 Sep;81(5):843-5. PMID:10530847 (Link to Abstract)
Farrell CM, Springer BD, Haidukewych GJ, et al: Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am 2005;87:2619-2625 PMID:16322610 (Link to Abstract)
Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Dec;87(12):2619-25 PMID:16322610 (Link to Abstract)
Satcher RL, Noss RS, Yingling CD, Ressler J, Ries M. The use of motor-evoked potentials to monitor sciatic nerve status during revision total hip arthroplasty. J Arthroplasty. 2003 Apr;18(3):329-32. PMID:12728425 (Link to Abstract)
Schmalzried TP, Noordin S, Amstutz HC: Update on nerve palsy associated with total hip replacement. Clin Orthop Relat Res 1997;344:188-206 PMID:9372771 (Link to Abstract)
Suh KT, Cheon SJ, Kim DW. Comparison of preoperative templating withpostoperative assessment in cementless total hip arthroplasty. Acta Orthop Scand.2004 Feb;75(1):40-4. PMID:15022804 (Link to Abstract)
Trousdale RT, Cabanela ME, Berry DJ. Anterior iliopsoas impingement after total hip arthroplasty. J Arthroplasty. 1995 Aug;10(4):546-9. PMID:8523018 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Bourne RB, Rorabeck CH. Soft tissue balancing: the hip. J Arthroplasty. 2002Jun;17(4 Suppl 1):17-22. PMID:12068397 (Link to Abstract)
Clark CR, Huddleston HD, Schoch EP 3rd, Thomas BJ. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg. 2006 Jan;14(1):38-45. Erratum in: J Am Acad Orthop Surg. 2006 May;14(5):35A. PMID:16394166 (Link to Abstract)
Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis after total hip arthroplasty. J Am Acad Orthop Surg. 2009 Jun;17(6):337-44. PMID:19474443 (Link to Abstract)
Maloney WJ, Keeney JA. Leg length discrepancy after total hip arthroplasty. J Arthroplasty. 2004 Jun;19(4 Suppl 1):108-10. Review. PMID:15190563 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Barrack RL, Butler RA. Avoidance and management of neurovascular injuries in total hip arthroplasty. Instr Course Lect. 2003;52:267-74. PMID:12690854 (Link to Abstract)
Bhave A, Marker DR, Seyler TM, Ulrich SD, Plate JF, Mont MA. Functional problems and treatment solutions after total hip arthroplasty. J Arthroplasty. 2007 Sep;22(6 Suppl 2):116-24. Epub 2007 Jul 26. PMID:17823029 (Link to Abstract)
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999 Jan;81(1):2-10. PMID:9973048 (Link to Abstract)
Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Dec;87(12):2619-25. PMID:16322610 (Link to Abstract)
Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Dec;87(12):2619-25. PMID:16322610 (Link to Abstract)
Farrell CM, Springer BD, Haidukewych GJ, Morrey BF. Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am. 2005 Dec;87(12):2619-25.: Motor nerve palsy following primary total hip arthroplasty. J Bone Joint Surg Am 2005;87:2619-2625 PMID:16322610 (Link to Abstract)
Guerin S, Collins C, Kapoor H, McClean I, Collins D. Blood transfusion requirement prediction in patients undergoing primary total hip and knee arthroplasty. Transfus Med. 2007 Feb;17(1):37-43. PMID:17266702 (Link to Abstract)
Konyves A, Bannister GC. The importance of leg length discrepancy after total hip arthroplasty. J Bone Joint Surg Br. 2005 Feb;87(2):155-7. PMID:15736733 (Link to Abstract)
Maloney WJ, Keeney JA. Leg length discrepancy after total hip arthroplasty. J Arthroplasty. 2004 Jun;19(4 Suppl 1):108-10. PMID:15190563 (Link to Abstract)
Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors. J Bone Joint Surg Am. 2002 Feb;84-A(2):216-20. PMID:11861727 (Link to Abstract)
Schmalzried TP, Noordin S, Amstutz HC. Update on nerve palsy associated with total hip replacement. Clin Orthop Relat Res. 1997 Nov;(344):188-206. PMID:9372771 (Link to Abstract)

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