Nerve Injury With Acetabulum Fractures: Incidence and Factors Affecting Recovery

Salvage of Iatrogenic Sciatic Nerve Injury Caused by Operatively Treated Acetabular Fractures: Two Cases and Literature Review

BACKGROUND

While sciatic nerve injury has been described as a complication of acetabular fractures, iatrogenic nerve injury remains sparsely reported. This study aims to assess iatrogenic sciatic nerve injuries occurring during acetabular fracture surgery, tracking their neurological recovery and clinical outcomes, and investigating any correlation between recovery and the severity of neurologic injury to facilitate physicians in providing prediction of prognosis.

CASE PRESENTATION

We present two cases of male patients, aged 56 and 22, who developed sciatic palsy due to iatrogenic nerve injury during acetabular fracture surgery. Iatrogenic sciatic nerve injury resulted from operatively treated acetabular fractures. Surgical exploration, involving internal fixation removal and nerve decompression, successfully alleviated symptoms in both cases postoperatively. At the latest follow-up, one patient achieved full recovery with excellent function, while the other exhibited residual deficits at the L5/S1 root level along with minimal pain.

CONCLUSION

Sciatic nerve injury likely stemmed from reduction techniques and internal fixation procedures for the posterior column, particularly when performed with the hip flexed, thereby placing tension on the sciatic nerve. Our case reports underscore the significance of liberal utilization of electrophysiologic examinations and intraoperative monitoring for the prediction of prognosis. Surgical exploration, encompassing internal fixation removal and nerve decompression, represents an effective intervention for resolving sciatic palsy, encompassing both sensory neuropathy and motor symptoms.

Rejuvenating fecal microbiota transplant enhances peripheral nerve repair in aged mice by modulating endoneurial inflammation

Peripheral nerve injury (PNI) resulting from trauma or neuropathies can cause significant disability, and its prognosis deteriorates with age. Emerging evidence suggests that gut dysbiosis and reduced fecal short-chain fatty acids (SCFAs) contribute to an age-related systemic hyperinflammation (inflammaging), which hinders nerve recovery after injury. This study thus aimed to evaluate the pro-regenerative effects of a rejuvenating fecal microbiota transplant (FMT) in a preclinical PNI model using aged mice. Aged C57BL/6 mice underwent bilateral crush injuries to their sciatic nerves. Subsequently, they either received FMT from young donors at three and four days after the injury or retained their aged gut microbiota. We analyzed gut microbiome composition and SCFA concentrations in fecal samples. The integrity of the ileac mucosal barrier was assessed by immunofluorescence staining of Claudin-1. Flow cytometry was utilized to examine immune cells and cytokine production in the ileum, spleen, and sciatic nerve. Various assessments, including behavioural tests, electrophysiological studies, and morphometrical analyses, were conducted to evaluate peripheral nerve function and repair following injury. Rejuvenating FMT reversed age-related gut dysbiosis by increasing Actinobacteria, especially Bifidobacteriales genera. This intervention also led to an elevation of gut SCFA levels and mitigated age-related ileac mucosal leakiness in aged recipients. Additionally, it augmented the number of T-helper 2 (Th2) and regulatory T (Treg) cells in the ileum and spleen, with the majority being positive for anti-inflammatory interleukin-10 (IL-10). In sciatic nerves, rejuvenating FMT resulted in increased M2 macrophage counts and a higher IL-10 production by IL-10+TNF-α- M2 macrophage subsets. Ultimately, restoring a youthful gut microbiome in aged mice led to improved nerve repair and enhanced functional recovery after PNI. Considering that FMT is already a clinically available technique, exploring novel translational strategies targeting the gut microbiome to enhance nerve repair in the elderly seems promising and warrants further evaluation.

Visualization analysis of research frontiers and trends in the treatment of sciatic nerve injury

Objective

To visualize and analyze the literature related to sciatic nerve injury treatment from January 2019 to December 2023, and summarize the current status, hotspots, and development trends of research in this field.

Methods

Using CiteSpace and VOSviewer software, we searched the Web of Science database for literature related to the treatment of sciatic nerve injury. Then we analyzed and plotted visualization maps to show the number of publications, countries, institutions, authors, keywords, references, and journals.

Results

A total of 2,653 articles were included in the English database. The annual number of publications exceeded 230, and the citation frequency increased yearly. The United States and China were identified as high-influence nations in this field. Nantong University was the leading institution in terms of close cooperation among institutions. The authors Wang Yu had the highest number of publications and were highly influential in this field. Keyword analysis and reference Burst revealed a research focus on nerve regeneration and neuropathic pain, which involve regenerative medicine and neural tissue engineering. Chronic pain resulting from sciatic nerve injury often manifests alongside anxiety, depression, cognitive-behavioral disorders, and other issues. Interventions such as stem cells, electrical stimulation, electroacupuncture, total joint replacement, pharmacological interventions, gene therapy, nerve conduits, chitosan scaffolds, and exercise promote nerve repair and alleviate pain. Schwann cells have been the focus of much attention in nerve repair and regeneration. Improving the outcome of sciatic nerve injury is a current research challenge and focus in this field. Based on keyword Burst, nerve conduits and grafts may become a potential research hotspot in the treatment of sciatic nerve injury.

Conclusion

This visual analysis summarizes research trends and developments of sciatic nerve injury treatment and predicts potential research frontiers and hot directions.

Incidence, risk factors, and prognosis of sciatic nerve injury in acetabular fractures: a retrospective cross-sectional study

PURPOSE

This study aimed to investigate the incidence, risk factors of the sciatic nerve injury in patients with acetabulum fractures and assess its prognosis.

METHODS

A retrospective cross-sectional review was conducted on 273 patients with acetabulum fractures who were treated between January 1st, 2017, and December 30th, 2019. The medical records and radiographs of these patients were analyzed.

RESULTS

The overall nerve injury rate was 7.7% (21 of 273 cases), with 3.1% (8 of 273 cases) occurring because of the initial injury and 12.8% (13 of 101 cases) as post-operative complications. Among those with nerve injuries, 95.2% (20 of 21 cases) were males and the average age of the patients was 31.5 (SD 9.5) years. The most common mechanism of injury was motor vehicle collisions with 55.7% (152 of 273 cases), and the most common fracture pattern associated with nerve injury was posterior column and posterior wall fracture with 31.6% (6 of 21 cases). Hip dislocation was found in 16.5% (14 of 21 cases) of patients with nerve injury. The Kocher Langenbeck approach was the most common approach used for patients with post-operative nerve injury, and the prone position was significantly associated with sciatic nerve injury during the operation. Of all patients with nerve injury, 52% (11 of 21 cases) had fully recovered, 29% (6 of 21 cases) had partially recovered, and 19% (4 of 21 cases) had no improvement. The average follow-up was 15 months.

CONCLUSION

This study emphasizes the incidence of sciatic nerve injuries in individuals with acetabulum fractures and highlights key risk factors, including hip dislocation, posterior column, and posterior wall fractures. It is noteworthy that the Kocher Langenbeck approach and the prone position may contribute to iatrogenic nerve injuries. Encouragingly, over half of the patients who suffered nerve injuries achieved full recovery, while nearly one-third experienced partial recovery. These findings underscore the vital significance of recognizing and addressing these risk factors in clinical practice.

Developing a trans-multisynaptic tracer to map the neural circuit of recovered sciatic nerve after treatment with nerve growth factor

Nerve growth factor (NGF) has been shown to support the survival and differentiation of neurons. In this study, we first developed a retrograde trans-multisynaptic tracer PRV580 expressing the mCherry fluorescent protein based on pseudorabies virus Bartha strain to map the neural circuit of sciatic nerve. Secondly, the newly developed PRV580 was used to map the neural circuit of the recovering sciatic nerve upon treatment with NGF. Our results showed that red signals from PRV580 were observed in various brain regions. Among these regions, many areas of the pyramidal system and the extra-pyramidal system had been mapped, accounting for as much as 56.8 % of the total inputs. Furthermore, we found that NGF could significantly increase the ratio of total input (29.05 %) compared to PBS (3.65 %), indicating that NGF indeed can aid in the repair of injured sciatic nerve. These findings indicated that NGF has therapeutic ability for the treatment of peripheral nerve injuries and virus-based tracers can be used to monitor the recovery.

Near-Complete Transection of the Sciatic Nerve After Closed Reduction Attempt of a Dislocated Total Hip Arthroplasty

Sciatic nerve injuries are rare and devastating complications that can occur following total hip dislocations. These injuries are even more uncommon when resulting from a closed reduction attempt. In the literature, only one other case of sciatic nerve palsy secondary to sciatic nerve laceration has been reported. Conducting a careful neurovascular examination following a closed reduction procedure is crucial in determining the presence of sciatic nerve injury. We present a case of sciatic nerve palsy following a closed reduction attempt of a dislocated total hip arthroplasty (THA). Surgical exploration revealed a near-complete sciatic nerve laceration. The patient subsequently underwent neurolysis and nerve repair. This case highlights the importance of thorough neuromuscular examination following closed reduction of THA, with consideration for surgical exploration when necessary.

Acetabular fractures in elderly patients are associated with high rates of complications during the initial admission

Background

Acetabular fractures among the elderly are common. Identification of risk factors predisposing elderly patients to in-hospital complications is critical to mitigating morbidity and mortality.

Methods

A retrospective cohort study was performed including 195 patients ≥60 years old who sustained acetabulum fractures treated at a single level 1 trauma center. Operative (n=110, 56.4%) or non-operative management was undertaken, and complications during the index hospitalization were defined.

Results

Seventy-three patients (37%) developed a complication during their hospitalization. Most common complications were acute respiratory failure: 13.3%, pneumonia: 10.3%, urinary tract infection: 10.3%, cardiac dysrhythmia: 9.7%, and acute kidney injury: 6.2%. On multivariable analysis, factors associated with in-hospital complications were increased age (adjusted OR (AOR): 1.06, 95% CI: 1.01 to 1.11, p=0.013), more comorbidities (AOR: 1.69, 95% CI: 1.07 to 2.65, p=0.024), operative management (AOR: 0.3, 95% CI: 0.12 to 0.76, p=0.011), and increased length of stay (AOR: 1.34, 95% CI: 1.2 to 1.51, p<0.001).

Conclusions

Acetabular fractures in the elderly are associated with high rates of in-hospital complications. Advanced age, more medical comorbidities and longer lengths of stay predicted higher risk of developing complications. Whereas operative management was associated with lower risk of developing complications during the initial admission, it is important to note the selection bias in which healthier patients with improved baseline functionality may be more likely to undergo operative management.

Level of evidence

Level III therapeutic.

Posterior Hip Dislocation in Association With Anterior Column Acetabular Fracture, Femoral Head Fracture, and Sciatic Nerve Injury: A Case Report

CASE

Posterior hip dislocations are classically associated with posterior acetabular wall fractures. We report the case of a 29-year-old man presented after a motorcycle accident with an unusual combination of injuries that included posterior hip dislocation, anterior column acetabulum fracture, femoral head fracture, and sciatic nerve injury. At the final follow-up, excellent outcomes were obtained with complete recovery of the sciatic nerve injury.

CONCLUSION

A favorable outcome may be achieved in young patients who sustain this unusual compilation of ipsilateral anterior acetabulum fracture, posterior hip dislocation, femoral head fracture, and sciatic nerve injury with meticulous preoperative surgical planning and tailored patient management.

Risk of Postoperative Sciatic Nerve Palsy After Posterior Acetabular Fracture Fixation: Does Patient Position Matter?

OBJECTIVES

To determine whether the prone or lateral position is associated with postoperative sciatic nerve palsy in posterior acetabular fracture fixation.

DESIGN

Retrospective cohort study.

SETTING

Three Level I trauma centers.

PATIENTS

Patients with acetabular fractures treated with a posterior approach (n = 1045).

INTERVENTION

Posterior acetabular fixation in the prone or lateral positions.

OUTCOME MEASUREMENTS

The primary outcome was the prevalence of postoperative sciatic nerve palsy by position. Secondary outcomes were risk factors for nerve palsy, using multiple regression analysis and propensity scoring.

RESULTS

The rate of postoperative sciatic nerve palsy was 9.5% (43/455) in the prone position and 1.5% (9/590) in the lateral position ( P < 0.001). Intraoperative blood loss and surgical duration were significantly higher for patients who developed a postoperative sciatic nerve palsy. Subgroup analysis showed that position did not influence palsy prevalence in posterior wall fractures. For other fracture patterns, propensity score analysis demonstrated a significantly increased odds ratio of palsy in the prone position [aOR 7.14 (2.22-23.00); P = 0.001].

CONCLUSIONS

With the exception of posterior wall fracture patterns, the results of this study suggest that factors associated with increased risk for postoperative sciatic nerve palsy after a posterior approach are fractures treated in the prone position, increased blood loss, and prolonged operative duration. These risks should be considered alongside the other goals (eg, reduction quality) of acetabular fracture surgery when choosing surgical positioning.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Incidence of traumatic sciatic nerve injury in patients with acetabular fractures and factors affecting recovery: a retrospective study

BACKGROUND

Reports on traumatic sciatic nerve injury associated with acetabular fracture are rare. In this study, we investigated the demographics of these injuries, their clinical characteristics, management, and factors potentially influencing neurological recovery.

METHODS

We retrospectively reviewed all patients diagnosed to have acetabular fracture at our trauma center between January 2014 and June 2021. Data on patient demographics, characteristics of sciatic nerve injury, neurological recovery, factors potentially influencing neurological recovery were analyzed.

RESULTS

Eighteen patients (bilateral in one case) met the diagnostic criteria. All these injuries involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Four of the 19 sides with traumatic sciatic nerve injury involved the common peroneal nerve division and 15 involved both the common peroneal and tibial nerve divisions. Seventeen patients (18 sides) underwent intraoperative nerve exploration, which revealed abnormalities in 7 sides and no obvious abnormality in 11 sides. At the last follow-up, 10 sides (52.6%) had complete recovery and 9 (47.4%) had partial recovery; the difference was statistically significant between those with or without abnormal nerve damage during exploration (P = 0.046). Linear regression analysis showed that a nerve abnormality detected intraoperatively was a predictor of nerve recovery (P = 0.009). The mean recovery time was significantly longer for partial recovery than for complete recovery (13.78 months vs. 6.70 months; P = 0.001).

CONCLUSIONS

All the injuries in this series involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Damage to the common peroneal nerve division was more severe than that to the tibial nerve division preoperatively. However, the degree of recovery of the common peroneal division was not worse than that of the tibial division. There was a relationship between the degree of neurological recovery and whether there was an abnormality at the time of intraoperative nerve exploration. Patients with partial recovery took longer to recover.

Incidence of Traumatic Sciatic Nerve Injury in Association with Acetabular Fracture: A Retrospective Observational Single-Center Study

Purpose

Patients and Methods

Results

Conclusion

Traumatic Hip Dislocations in Major Trauma Patients: Epidemiology, Injury Mechanisms, and Concomitant Injuries

Introduction: Traumatic hip dislocations (THDs) are severe injuries associated with considerable morbidity. Delayed recognition of fracture dislocations and neurovascular deficits have been proposed to cause deleterious long-term clinical outcomes. Therefore, in this study, we aimed to identify characteristics of epidemiology, injury mechanisms, and associated injuries to identify patients at risk. Methods: For this study based on the TraumaRegister DGU^® (January 2002–December 2017), the inclusion criterion was an Injury Severity Score (ISS) ≥9 points. Exclusion criteria were an isolated head injury and early transfer to another hospital. The THD group was compared to a control group without hip dislocation. The ISS and New ISS were used for injury severity and the Abbreviated Injury Scale for associated injuries classification. Univariate and logistic regression analyses were performed. Results: The final study cohort comprised n = 170,934 major trauma patients. We identified 1359 individuals (0.8%) with THD; 12 patients had sustained bilateral hip dislocations. Patients with THD were predominantly male (79.5%, mean age 43 years, mean ISS 22.4 points). Aortic injuries (2.1% vs. 0.9%, p ≤ 0.001) were observed more frequently in the THD group. Among the predictors for THDs were specific injury mechanisms, including motor vehicle accidents (odds ratio (OR) 2.98, 95% confidence interval (CI) 2.57–3.45, p ≤ 0.001), motorcycle accidents (OR 1.99, 95% CI 1.66–2.39, p ≤ 0.001), and suicide attempts (OR 1.36, 95% CI 1.06–1.75, p = 0.016). Despite a lower rate of head injuries and a comparable level of care measured by trauma center admission, both intensive care unit and total hospital stay were prolonged in patients with THD. Conclusions: Since early diagnosis, as well as timely and sufficient treatment, of THDs are of high relevance for long-term outcomes of severely injured individuals, knowledge of patients at risk for this injury pattern is of utmost importance. THDs are frequently related to high-energy mechanisms and associated with severe concomitant injuries in major trauma patients.

Hamstring branches of the sciatic nerve as donors for neurotization of the superior gluteal nerve: A cadaveric feasibility study

Although superior gluteal nerve (SGN) injury can have significant morbidity, to date, surgical strategies for its repair are scant in the literature. Specifically, neurotization options have not been explored. To address this deficiency in the literature, the current cadaveric feasibility study was performed. Via a transgluteal approach on 16 cadaveric sides, the proximal sciatic nerve and the entrance of the SGN into the gluteus medius and minimus were identified. Additionally, branches from the sciatic nerve to the hamstring muscles were traced proximally to confirm their position in relation to the sciatic nerve as a whole. These branches were cut at the level of the ischial tuberosity and teased away from the sciatic nerve proximally to the greater sciatic foramen and transferred superolateral to the SGN. The diameter of each nerve branch was measured as well as its available length for reaching the SGN. All branches of the sciatic nerve to the hamstring muscles arose from the anteromedial part of the nerve. The mean diameters of the branches to the semimembranosus, semitendinosus, and biceps femoris muscles were 2.1, 1.9, and 1.5 mm, respectively. The mean diameter of the SGN was 3.1 mm and the mean distance from this entrance point to the ischial spine was 7.2 cm. The mean length of the donor nerve was 8.5 cm. Based on our study, use of a tibial-innervated hamstring branch as a donor for nerve transfer to the SGN is feasible.

The horizontal shear fracture of the pelvis

PURPOSE

Various classification systems describe fractures of the acetabulum and pelvis separately. Horizontal shear fractures involve the pelvic ring and both acetabula and have not been previously described. The aim of this study is to describe the horizontal shear fracture of the pelvis.

METHODS

At a level 1 trauma centre over 10 years from December 2008 to December 2018, 1242 patients had pelvic and acetabular fractures. Six patients had horizontal shear fractures, comprising 0.5% of all pelvic and acetabular fractures. Demographic, clinical and radiological data was collected. Clinical outcomes were pain and mobility level, sciatic nerve symptoms, further acetabular or pelvic surgery, or total hip arthroplasty. Radiological outcomes included fracture displacement, implant migration, femoral head osteonecrosis, and post-traumatic arthritis. Outcomes were assessed at a minimum 12 month follow-up.

RESULTS

The median patient age was 35 years. Five of six shear fractures were due to motorcycle crashes. No mortalities occurred. At follow-up, three patients reported pain, two patients had difficulty mobilising associated with traumatic sciatic nerve injury, and one patient underwent total hip arthroplasty for femoral head osteonecrosis. No fracture displacement or implant migration occurred. The Matta arthritis grade was excellent or good in all except one hip. Median follow-up time was 1.8 (range 1.1-7.8) years.

CONCLUSION

The horizontal shear fracture of the pelvis is a high-energy injury characterised by separation of the anterior and posterior pelvic ring through the acetabula. Good outcomes can be achieved with open reduction and internal fixation of displaced fractures.

Prognostic factors in patients who underwent surgery for common peroneal nerve injury: a nest case-control study

Background

Common peroneal nerve (CPN) injury is one of the most common nerve injuries in the lower extremities and the motor functional recovery of injured common peroneal nerve (CPN) was often unsatisfactory, the mechanism of which is still controversial. The purpose of this retrospective study was to determine the prognostic factors in patients who underwent surgery for CPN injury and provide a tool for clinicians to assess the patients’ prognosis.

Methods

This is a retrospective cohort study of all patients who underwent neural exploration for injured CPN from 2009 to 2019. A total of 387 patients with postoperative follow-up more than 12 months were included in the final analysis. We used univariate logistics regression analyses to explore explanatory variables which were associated with recovery of neurological function. By applying multivariable logistic regression analysis, we determined variables incorporated into clinical prediction model, developed a nomogram by the selected variables, and then assessed discrimination of the model by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

Results

The case group included 67 patients and the control group 320 patients. Multivariate logistic regression analysis showed that area (urban vs rural, OR = 3.35), occupation(“blue trouser” worker vs “white-trouser” worker, OR = 4.39), diabetes (OR = 11.68), cardiovascular disease (OR = 51.35), knee joint dislocation (OR = 14.91), proximal fibula fracture (OR = 3.32), tibial plateau fracture (OR = 9.21), vascular injury (OR = 5.37) and hip arthroplasty (OR = 75.96) injury increased the risk of poor motor functional recovery of injured CPN, while high preoperative muscle strength (OR = 0.18) and postoperative knee joint immobilization (OR = 0.11) decreased this risk of injured CPN. AUC of the nomogram was 0.904 and 95% CI was 0.863–0.946.

Conclusions

Area, occupation, diabetes, cardiovascular disease, knee joint dislocation, proximal fibula fracture, tibial plateau fracture, vascular injury and hip arthroplasty injury are independent risk factors of motor functional recovery of injured CPN, while high preoperative muscle strength and postoperative knee joint immobilization are protective factors of motor functional recovery of injured CPN. The prediction nomogram can provide a tool for clinicians to assess the prognosis of injured CPN.

The role of patient positioning on the outcome of acetabular fractures fixation through the Kocher-Langenbeck approach

BACKGROUND

Open reduction and internal fixation through the Kocher-Langenbeck approach is the treatment of choice for selected acetabular fracture patterns. Patient positioning (lateral vs prone) can affect the outcome and post-operative complications.

METHODS

A retrospective cohort of seventy-three adult patients' with acetabular fractures treated with open reduction and internal fixation through the Kocher-Langenbeck approach in either prone or lateral position. Primary outcome was the quality of radiographic fracture reduction; secondary outcomes included operative time, intra-operative estimated blood loss and pre-operative complications.

RESULTS

The demographics and fracture type were similar between the two groups. There was no difference in the quality of reduction using the Matta radiographic grading. Laterally positioned group demonstrated significant shorter surgical time and lower incidence of iatrogenic sciatic nerve injury. There was no difference in estimated blood loss, heterotopic ossification or infection.

CONCLUSION

This study showed no difference in the quality of fracture reduction, intraoperative blood loss, post-operative infection and heterotopic ossification between both groups. Hence, patients' condition, surgeon experience and preference are important factors for deciding patient positioning in the Kocher-Langenbeck approach for acetabulum fracture fixation.