Updated: 3/3/2019

THA Sciatic Nerve Palsy

Topic
Review Topic
0
0
Questions
11
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0
Evidence
3
0
0
Introduction
  • illustrationIntroduction
    • 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 
        • exercise care with posterior acetabular retraction when hip in flexed position 
      • less commonly affected nerves 
        include
        • femoral
        • obturator
        • superior gluteal
    • causes
      • direct trauma
      • stretch
      • compression due to hematoma
      • 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
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 excavation in operating room    
      • indications
        • post-operative hematoma
  • Persistent foot drop
    • AFO orthosis  
      • indications
        • first line of treatment for persistent foot drop
 

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Questions (11)

(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 the 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?

Review Topic

QID: 3631
FIGURES:
1

Utilization of an anterior approach

4%

(120/3365)

2

Modular components

1%

(39/3365)

3

Use of a larger femoral head

1%

(19/3365)

4

Femoral shortening osteotomy

93%

(3142/3365)

5

Acetabular osteotomy

1%

(40/3365)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ13.30) After total hip arthroplasty (THA) for osteoarthritis a patient is unable to dorsiflex her ankle or extend her great toe. She is treated conservatively with an orthosis and after 3 months on physical therapy she ambulates with a "slapping gait." What is the most appropriate next treatment option? Review Topic

QID: 4665
1

MRI of her spine

5%

(244/4473)

2

Ankle Fusion

1%

(44/4473)

3

Continue Ankle-Foot Orthosis

89%

(3995/4473)

4

Revision total hip arthroplasty

1%

(41/4473)

5

Sural nerve grafting

3%

(128/4473)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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(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: Review Topic

QID: 2968
1

Developmental dysplasia of the hip

1%

(22/1813)

2

Lengthening of the extremity

0%

(4/1813)

3

Surgeon self-rating the procedure as being a difficult intervention

9%

(162/1813)

4

Avascular necrosis of the femoral head

66%

(1193/1813)

5

Posttraumatic arthritis

23%

(426/1813)

ML 3

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PREFERRED RESPONSE 4
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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? Review Topic

QID: 1354
1

Provide traction to the leg

0%

(4/2121)

2

Pulsatile irrigation in the wound to remove blood clots

0%

(2/2121)

3

Flex the hip

5%

(101/2121)

4

Extend the hip

94%

(2003/2121)

5

Extend the knee

0%

(4/2121)

ML 1

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PREFERRED RESPONSE 4
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(OBQ08.267) Risk factors for a motor nerve palsy following primary total hip arthroplasty include all of the following EXCEPT? Review Topic

QID: 653
1

Developmental dysplasia of the hip

3%

(27/906)

2

Limb lengthening

1%

(8/906)

3

Posttraumatic arthritis

26%

(235/906)

4

Obesity

45%

(408/906)

5

Posterior approach

25%

(225/906)

ML 4

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PREFERRED RESPONSE 4

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

QID: 610
1

90% to 95%

7%

(99/1323)

2

60% to 65%

43%

(566/1323)

3

40% to 45%

18%

(234/1323)

4

20% to 25%

24%

(319/1323)

5

0% to 5%

7%

(98/1323)

ML 4

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PREFERRED RESPONSE 2

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

QID: 771
1

Female gender

39%

(743/1923)

2

Developmental dysplasia of the hip

2%

(31/1923)

3

Revision surgery

1%

(18/1923)

4

Rheumatoid arthritis

58%

(1123/1923)

5

Lengthening of the extremity

0%

(4/1923)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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