Sciatic Nerve Palsy following Total Hip Replacement: Are Patients Personal Characteristics More Important than Limb Lengthening? A Systematic Review

Mid-term to Long-term Outcomes and Complications of Total Hip Arthroplasty in Patients Who Have Crowe IV Developmental Dysplasia of the Hip: A Systematic Review and Meta-Analysis

BACKGROUND

Severe forms of developmental dysplasia of the hip (DDH) in adulthood often lead to total hip arthroplasty (THA). This study aimed to evaluate the mid-term to long-term outcomes of THA in Crowe type IV DDH cases, which represent a technically challenging and complex patient group.

METHODS

PubMed, EMBASE, Web of Science, and Scopus were searched for observational studies and case series with over 100 months of mean follow-up on adult patients who had Crowe type IV DDH treated with THA. A total of 3,710 records were initially identified, leading to the inclusion of 24 studies in the final analysis. These studies were subjected to quality assessment using the National Institutes of Health (NIH) Quality Assessment tool. Various outcomes including revision rates, leg length discrepancy (LLD), Harris Hip Score (HHS), and complications like periprosthetic joint infections (PJI), dislocations, and nerve injuries were analyzed. A random effects model was employed for statistical analysis, with sensitivity analysis and meta-regression applied in cases of high heterogeneity.

RESULTS

The included studies assessed 1,024 hips with a mean follow-up of 11 years, revealing improvements in HHS and reductions in LLD post-THA. However, notable challenges were noted, including a 10.7% rate of intraoperative fractures, a 1.8% PJI rate, and a 5.8% dislocation rate. Osteolysis and aseptic loosening revisions were observed in 9.1 and 8% of cases, respectively. Heterotopic ossification (HO) occurred in 11.1% of patients. Nerve injury was reported in 4.2% of cases. With the use of meta-regression, some factors for observed heterogeneity were identified.

CONCLUSION

Total hip arthroplasty in Crowe type IV DDH patients presents notable challenges, but can lead to substantial long-term improvements in patient-reported outcomes.

Similar incidence of postoperative sciatic nerve palsy in direct anterior and posterior approach total hip arthroplasty

BACKGROUND

Sciatic nerve palsy is a rare but devastating complication following total hip arthroplasty (THA). While the use of the direct anterior approach is increasing, limited data exist regarding sciatic nerve palsy and surgical approach. The purpose of this study was to determine the factors and outcomes associated with sciatic nerve palsy (SNP) after THA.

METHODS

A retrospective analysis was performed at a single institution of 7 SNP that occurred in 4045 THA via direct anterior approach and 10 SNP in 8854 THA via posterior approach, being operated between 01 January 2017 and 12 December 2021. SNP patients were matched 1:5 to patients without SNP. Medical records were reviewed for demographics including age, gender, body mass index (BMI), comorbidities, and preoperative indication. Additional workup of SNP patients including advanced imaging and reoperation were documented. Recovery grades were assigned to all SNP patients at most recent clinical follow-up.

RESULTS

5 of the SNP were complete and 12 partial. They occurred as frequently with the direct anterior (0.17%) and posterior approach (0.11%, p = 0.5). The presence of femur cables and reoperations were associated with SNP (p = 0.04 and p = 0.002, respecitvely). Age, gender, BMI, comorbidities, and surgical indication had no effect on SNP. 4 of the 17 affected patients had almost complete recovery at latest follow-up.

CONCLUSIONS

The incidence of SNP was similar in direct anterior and posterior approach. Surgeons should counsel patients regarding the risks of SNP regardless of the used approach.

Approaching total hip arthroplasty after Legg-Calvé-Perthes disease: A case series and literature review

Due to femoral head-neck deformities and hip joint incongruence, patients with Legg-Calvé-Perthes Disease (LCPD) commonly require total hip arthroplasty (THA) in the fifth and sixth decades of life. These patients present additional challenges to arthroplasty surgeons not only because of their complicated hip anatomy but also because patients may have undergone prior operative procedures in childhood and thus present with pre-existing proximal femoral deformities. THA in LCPD patients can be associated with peri-operative complications such as fracture or nerve injury, and the rate of reoperation has been reported to be higher in the LCPD population as compared to the general population undergoing THA. Despite this, multiple case reports and studies have shown the relative long-term success of THA in patients with history of LCPD. In particular, uncemented modular stems are a commonly used implant choice in such cases. This article reviews and discusses the technical considerations for THA in patients with LCPD and highlights three such cases.

Placement of Standard Sized Acetabular Cup Between True and False Acetabulum in Patients with Crowe III/IV Dysplasia: A Safe Option in THA Without Femoral Osteotomy

Introduction

There is no consensus in literature on the surgical treatment of patients with Crowe type III/IV patients. Each arthroplasty procedure has its own advantages and disadvantages. In this study by placing the acetabular cup between the true and false acetabulum, we aimed to share our experience about criteria of patient selection, surgical technique, and mid-term results of THA (total hip arthroplasty) in which the risk of dislocation was minimized using a standard-sized acetabular cup.

Materials and Methods

We reviewed the clinical and radiographic data of the patients with Crowe type III/IV treated by cementless THA without femoral shortening osteotomy from January 2015 to January 2020. The clinical (Harris hip score, Trendelenburg sign, limb lengths) and radiographic (AP/L hip X-ray, 3D CT) examinations before surgery; 1, 3 months and 1 year after the surgery were evaluated. All postsurgical complications were noted.

Results

Among all, 268 patients met the inclusion criteria. Thirty-two patients (11.9%) were male and 236 (88.1%) were female. Mean age was 46.8 years. Mean follow-up duration was 42.4 (26-57) months. Mean Harris Hip score (HHS) was 49.7 and Trendelenburg sign was positive in all patients preoperatively. In the final evaluation, mean HHS significantly improved to 80.2 (p < 0.005) and none of the patients had Trendelenburg sign. Mean lengthening of the operated leg was 4.3 cm.

Conclusion

Total hip arthroplasty with placement of acetabular cup between true and false acetabulum can be successfully preferred in selected patients with Crowe III/IV dysplasia.

Total hip arthroplasty with monobloc press-fit acetabular components and large-diameter bearings for atypical acetabula is safe: a consecutive case series of 125 hips with mean follow-up of 9 years

BACKGROUND

Large-diameter head (LDH) total hip arthroplasty (THA) with a monobloc acetabular component improves hip stability. However, obtaining initial press-fit stability is quite challenging in atypical acetabula. The purpose of this study was to assess primary and secondary fixation of monobloc cups in atypical acetabula.

METHODS

In this consecutive case series, the local arthroplasty database was used to retrospectively identify patients with secondary osteoarthritis who underwent primary hip replacement with press-fit only LDH monobloc acetabular components between 2005 and 2018 and who had a minimum of 2 years of follow-up. Radiographic evaluation was performed at last follow-up, and patient-reported outcome measures (PROMs) were assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Forgotten Joint Score (FJS), and the Patient's Joint Perception (PJP) question.

RESULTS

One hundred and six LDH THAs and 19 hip resurfacings were included in the study. Preoperative diagnoses included hip dysplasia (36.8%), Legg-Calve-Perthes disease (32.0%), osteoarthritis with acetabular deficiency (17.6%), periacetabular osteotomy (8.0%), arthrodesis (4.0%), and osteopetrosis (1.6%). After a mean follow-up of 9.2 years, no aseptic loosening of the acetabular component was recorded nor observed on radiologic review. There were 13 (10.4%) revisions unrelated to the acetabular component fixation. The mean WOMAC and FJS scores were 9.2 and 80.9, respectively. In response to the PJP question, 49.4% of the patients perceived their hip as natural, 19.1% as an artificial joint with no restriction, 31.5% as an artificial joint with restriction, and none as a non-functional joint.

CONCLUSION

Primary press-fit fixation of monobloc acetabular components with LDH implanted in atypical acetabula led to secondary fixation in all cases with low revision and complication rates and great functional outcomes. With careful surgical technique and experience, systematic use of supplemental screw fixation is not essential in THA with atypical acetabula.

Perforator Mapping and Clinical Experience with the Superthin Profunda Artery Perforator Flap for Reconstruction in the Upper and Lower Extremity

INTRODUCTION

Thin skin flaps have gained popularity for extremity reconstruction. However, the use of the profunda artery perforator (PAP) flap has not been explored as much. With its concealed donor site on the medial thigh and bulk, the PAP has become popular for reconstruction in the breast, head, and neck. The thickness of the subfascial PAP flap is decreased through elevation on the thin or superthin plane, making it more suitable for extremity reconstruction.

METHODS

A consecutive series of 28 patients with 29 flaps who received a thin or superthin single perforator PAP flap for upper or lower extremity reconstruction was reviewed. Our technique for preoperative localization of the dominant perforator using computed tomography angiography (CTA) and color duplex ultrasonography (CDU) is described.

RESULTS

Flap success rate was 93.1%. Mean flap artery diameter, vein diameter, area, and thickness were 1.7 + 0.4 mm, 2.2 + 0.4 mm, 157.3 + 52.1 cm², and 0.7 + 0.2 cm, respectively. Skin thickness at the suprafascial bifurcation point of a dominant "T" perforator measured on preoperative CTA correlated with actual intraoperative flap thickness. Patient body mass index did not correlate with flap thickness.

CONCLUSIONS

The thin and superthin PAP flap has multiple favorable characteristics, making it suitable for extremity reconstruction, and it has become the workhorse skin flap in our institution. Conventional low-frequency CDU together with CTA can be used effectively to map the dominant perforator preoperatively, allowing accurate flap design and rapid flap harvest.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Common Peroneal Nerve Palsy at the Level of Proximal Fibula After Total Hip Arthroplasty: A Case Report

Sciatic nerve injury is a well-known devastating complication and is the most commonly involved nerve after total hip arthroplasty (THA). Most of these injuries occur at the level of the hip and surgery site rather than a distal location. In this case report, a 62-year-old male presented with common peroneal nerve (CPN) palsy at the level of the knee immediately after undergoing left THA via posterior hip approach. This likely occurred due to direct compression during the surgical positioning or intraoperative leg manipulation. It was associated with excruciating uncontrolled neuropathic pain around the ipsilateral lateral leg and foot and absence of motor function. The patient's THA was performed elsewhere, seven weeks prior to his presentation to us. His clinical examination and electromyographic (EMG) findings confirmed focal peroneal nerve entrapment around the neck of the fibula. An urgent distal peroneal nerve decompression was performed followed by a dramatic improvement in the pain. Consequently, the patient discontinued all pain medications within three days after the decompression. On follow up, he demonstrated remarkable improvement in his motor and sensory functions. In conclusion, direct or indirect CPN injury at the level of the knee is extremely rare after THA. Early distal peroneal nerve decompression after THA can be beneficial in selected patients based on the clinical presentation and EMG findings.

Common peroneal nerve palsy after primary total hip arthroplasty

PURPOSE

The study wants to evaluate the incidence, the clinical evolution, and treatment of common peroneal nerve (CPN) palsy after primary total hip arthroplasty.

METHODS

Our clinical prospective study was made between January 2016 and December 2020. The study group comprised 1240 total hip replacements over a period of five years. Six cases were diagnosed with CPN palsy (0.48%). Five were women and one man, aged from 52 to 71 years old. The common peroneal nerve lesion was diagnosed clinically and by electromyography.

RESULTS

The follow-up period was at least 24 months post-operatively. In all six cases, there was a complete common peroneal nerve palsy, documented by electromyography. The poorest results were obtained in the older patients and those who had the highest body mass index, which at two years post-operatively achieved only a partial sensory rehabilitation, with complete motor deficit. All patients can walk unassisted, without support, with one case having complete rehabilitation achieved 18 months postoperatively and three with partial rehabilitation.

CONCLUSION

CPN palsy after primary THA is a very serious complication with poor functional outcome. There is no consensus regarding the treatment. The age and the intensity of the rehabilitation program are the only significant factors for the medical rehabilitation after this debilitating post-operative complication.

Total Hip Arthroplasty: Direct Anterior Approach Versus Posterior Approach in the First Year of Practice

Background

The direct anterior approach (DAA) for total hip arthroplasty (THA) has been popularized as a less invasive technique, however outcomes within the first year of practice after fellowship have not been investigated. The primary aim was to determine differences in complications and outcomes between DAA and posterior approach (PA) in the first year of practice. The secondary aim was to determine if there was a learning curve factor in DAA and PA after fellowship training.

Methods

THA cases performed by two surgeons during their first year of practice were reviewed. Overall, 181 THAs (91 DAA, 90 PA) in 168 patients, were performed. Intraoperative differences (blood loss, operative time), hospital stay, complications, reoperations, and revisions were compared.

Results

Overall surgical complications were similar between DAA and PA (11% vs. 9%, p=0.64), but complication profiles were different: dislocation (1% vs. 4%, p=0.17), intraoperative femoral fracture (2% vs. 1%, p=0.32), postoperative periprosthetic fractures (2% vs. 3%, p=0.64). neuropraxia (3% vs. 0%, p=0.08). There was no difference in rate of reoperation (1% vs. 3%, p=0.31). There was a difference in rate of revision at final follow-up (0% vs. 6%, p=0.02). DAA consisted of longer operative time (111 vs. 99 minutes; p<0.001), however was only significant in the first 50 cases (p<0.001), while the subsequent cases were similar (p=0.31). There was no difference in the first 50 cases compared to the subsequent cases for either approach regarding blood loss, complications, reoperations, or revisions.

Conclusion

DAA and PA for THA performed within the first year of practice exhibit similarly low complication rates, but complication profiles are different. In our series, PA did demonstrate a higher risk of revision at final follow-up. A learning curve is not unique to the DAA. Both DAA and PA THA exhibited a learning curve in the first 50 cases performed at the start of a surgeon's practice. Level of Evidence: III.

Nerve Injuries Following Total Hip Arthroplasty: The Influence of Surgical Approach

Nerve injuries following total hip arthroplasty are rare but devastating complications. The most important modifiable risk factor remains the choice of hip approach and surgical technique applied. The risk of nerve injuries is related to technical complexity of the procedure and anatomic variability of the nerves. Surgeons should remain cognizant of inherent risk factors, variations in the course and branching patterns of different nerves, and technical considerations of the surgical approach to mitigate risks. This article reviews the literature on postsurgical nerve injuries following total hip arthroplasty and characterizes the influence of surgical approach on the risk of this complication.

Is intraoperative neuromonitoring effective in hip and pelvis orthopedic and trauma surgery? A systematic review

INTRODUCTION

Sciatic nerve injury is an uncommon but potentially devastating complication in hip and pelvis surgery. Intraoperative nerve monitoring (IONM) was applied since the seventies in neurosurgery and spine surgery. Nowadays, IONM has gained popularity in other surgical specialities including orthopaedic and trauma surgery. Aim of this systematic review is to resume the literature evidences about the effectiveness of intraoperative monitoring of sciatic nerve during pelvic and hip surgery.

METHODS

Two reviewers (GC and MD) independently identified studies by a systematic search of PubMed and Google Scholar from inception of database to 10 January 2021. Inclusion criteria were: (a) English written papers, (b) use of any type of intraoperative nerve monitoring during traumatic or elective pelvic and hip surgery, (c) comparison of the outcomes between patients who underwent nerve monitoring and patient who underwent standard procedures, (d) all study types including case reports. The present review was conducted in accordance with the 2009 PRISMA statement.

RESULTS

The literature search produced 224 papers from PubMed and 594 from Google Scholar, with a total amount of 818 papers. The two reviewer excluded 683 papers by title or duplicates. Of the 135 remaining, 72 were excluded after reading the abstract, and 31 by reading the full text. Thus, 32 papers were finally included in the review.

CONCLUSIONS

The use of IONM during hip and pelvis surgery is debated. The review results are insufficient to support the routine use of IONM in hip and pelvis surgery. The different IONM techniques have peculiar advantages and disadvantages and differences in sensitivity and specificity without clear evidence of superiority for any. Results from different studies and different interventions are often in contrast. However, there is general agreement in recognizing a role for IONM to define the critical maneuvers, positions or pathologies that could lead to sciatic nerve intraoperative damage.

LEVEL OF EVIDENCE

Level 2.

Incidence, Injury Mechanisms, and Recovery of Iatrogenic Nerve Injuries During Hip and Knee Arthroplasty

Iatrogenic nerve injury is a rare but potentially devastating complication in total joint arthroplasty of the hip and the knee. Multiple previous studies have evaluated the incidence, mechanisms of injury, recovery, and potential treatments for this complication. Injury in total hip arthroplasty generally involves direct injury of sensory nerves from the incision, direct or traction injury of during exposure, or limb lengthening. Injury in total knee arthroplasty generally involves direct injury of sensory nerves from incision, injury due to errant placement of retractors, during balancing, or from traction because of deformity correction. Treatment of iatrogenic nerve injuries has ranged from observation, intraoperative prevention by nerve monitoring, limb shortening postoperatively, medications, and decompression. The orthopaedic surgeon should be versed in these etiologies to advise their patients on the incidence of injury, to prevent occurrence by understanding risky intraoperative maneuvers, and to select appropriate interventions when nerve injuries occur.

Review of complications, functional outcome, and long-term survival following conversion of hip fusion to total hip arthroplasty

AIMS

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

METHODS

A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed.

RESULTS

At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint.

CONCLUSION

The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129-134.

Nerve palsy, dislocation and revision rate among the approaches for total hip arthroplasty: a Bayesian network meta-analysis

BACKGROUND

Total hip arthroplasty (THA) is one of the most performed intervention in orthopaedics surgery. Currently, there is no unanimous approval concerning the best approach for THA in terms of nerve palsies, dislocations and further revisions. Hence, a Bayesian network meta-analysis was conducted.

METHODS

The present study was conducted according to the PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of healthcare interventions. The literature search was performed in September 2019. The NMA was performed through the STATA Software/MP routine for Bayesian hierarchical random-effects model analysis.

RESULTS

Data from 10,675 THA were collected. The mean follow-up was 10 months. The anterior approach reported the lowest risk to incur a post-operative dislocation (overall inconsistency P = 0.99). The posterolateral approach reported the lowest risk to incur a nerve palsy (overall inconsistency P = 0.77). The funnel plot revealed a low risk of publication bias. The lateral approach was found to have the lowest risk of resulting in a revision surgery (overall inconsistency P = 0.90).

CONCLUSION

According to our network comparisons, the posterolateral approach for THA represent the favourable exposure with regards to nerve palsy, further dislocations and revision surgeries.