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Nerve Injuries in THR

- See: Total Hip Replacement Menu:
            - arterial injuries: in THR 
            - nerve injury 
            - nerve palsy from TKR

- Discussion:
    - incidence of sciatic (tibial and/or peroneal) &/or femoral palsies after THR ranges from 1-3%;
    - incidence of nerve palsy is 1-2% of primary total hip replacement, 3-4% after revision, and 5-6% in THR for
             congenitally dislocated hips; 
    - majority of these nerve deficits are partial, & many will resolve; 
             - references:
                       - Neurovascular injury: avoiding catastrophe
                       - Recovery of sciatic nerve injuries in association with total hip arthroplasty in 27 patients.
                       - Nerve Palsy Associated with Total Hip Arthroplasty
                       - The frequency, prognosis and significance of nerve injuries in total hip arthroplasty

    - females seem to be at significantly higher risk;
    - sciatic and superior gluteal nerve and vessels course opposite the posterior superior quadrant, and the inferior gluteal
            and pudendal structures are opposite postero-inferior quadrant;
            - w/ EMG evaluation, there is > 75% incidence of subclinical injury to superior and inferior gluteal innervated muscles
                      with use of posterior and lateral approaches;
    - diff dx:
          - revision total hip replacement;
          - limb lengthening;
          - female gender;
          - anticoagulation;
          - broken trochanteric osteotomy wires;
          - vascular insufficiency;
          - ref: Delayed transient sciatic nerve palsy after total hip arthroplasty.
    - prognosis:
          - recovery from mild injury that consists of transient conduction block may occur in days to wks;
          - if injury is severe enough to cause axonal damage, recovery may not occur at all or may be incomplete after 1 to 2 yrs;
          - consider electromyography;
          - referenences:
                 - Long-term prognosis of nerve palsy after total hip arthroplasty: results of two-year-follow-ups and long-term results after a mean time of 8 years.
                 - Nerve palsy associated with total hip replacement. Risk factors and prognosis.

- Management:
    - if limb has been lengthened, & there is no other cause of injury, knee may be flexed to relieve stretch of sciatic nerve; 
    - hematoma: early ultrasound of the hip to evaluate for hematoma around the sciatic nerve;
           - ref: Sciatic nerve palsy secondary to postoperative haematoma in primary total hip replacement. 
    - prevention of decubiti
    - EMG studies 
    - decompression / neurolysis:
           - note the variant of the relationship between the sciatic nerve and the piriformis muscle;
           - lateral part of the nerve penetrated the muscle and the medial half passes distal to it
           - when the piriformis retracts after an external rotator tenotomy, the nerve will be stretced.
           - treatment is to resect / release that part of tendon/ muscle compressing the nerve while the remainder of the nerve is
                     dissected from scar tissue;
            - peroneal palsy:
                    - consideration of peroneal nerve decompression;
            - references:
                    - Postarthroplasty "palsy" and systemic neuropathy: a peripheral-nerve management algorithm
                    - Isolated deep peroneal (fibular) nerve palsy in association with primary total hip arthroplasty.
                    - Sciatic neurostenalgia: caused by total hip arthroplasty, cured by late neurolysis
                    - Patient outcome after common peroneal nerve decompression
                    - Decompression of the Common Peroneal Nerve: Experience with 20 Consecutive Cases
                    - Exploration and neurolysis for the treatment of neuropathic pain in patients with a sciatic nerve palsy after total hip replacement.
                    - Sciatic nerve palsy after total hip replacement
                    - Sciatic nerve palsy after primary total hip arthroplasty: a new perspective
                    - Neurolysis for the treatment of sciatic nerve palsy associated with total hip arthroplasty
                    - Nerve Decompression Surgery After Total Hip Arthroplasty: What Are the Outcomes?

- References:

Sciatic nerve palsy after total hip arthroplasty: treatment by modular neck shortening.

Contributory factors and etiology of sciatic nerve palsy in total hip arthroplasty.

Sciatic neuropathy secondary to intrapelvic migration of an acetabular cup. A case report

Neural and vascular injury in total hip arthroplasty.  

Peripheral neuropathies associated with total hip arthroplasty.  

Motor Nerve Palsy Following Primary Total Hip Arthroplasty.

Sciatic Nerve Palsy After Primary Total Hip Arthroplasty: a New Perspective.

Neurovascular Injuries in Acetabular Reconstruction Cage Surgery: an Anatomical Study.

Delayed, transient sciatic nerve palsy after primary cementless hip arthroplasty: a report of two cases.

Femoral Nerve Palsy Associated with Iliacus Hematoma Following Pseudoaneurysm After Revision Hip Arthroplasty

Incidence of sciatic nerve palsy after revision hip arthroplasty through a posterior approach

Motor nerve palsy following primary total hip arthroplasty.

Sciatic nerve palsy after primary total hip arthroplasty: a new perspective

Common Peroneal Nerve Palsy Following Total Hip Arthroplasty: Prognostic Factors for Recovery