全髋关节置换及翻修术后坐骨神经损伤的原因探讨

目的 通过对655例行全髋关节置换及翻修术患者的回顾性分析，探讨术后出现坐骨神经损伤的原因并提出相应的预防措施。方法 1998年1月～2001年12月，对655倒髋关节病变的患者行手术治疗．其中全髋关节置换术587例，全髋关节翻修术68例，术后有9例出现坐骨神经损伤．发生率为1.37％。其中8例发生在全髋关节置换术后，1例发生在全髋关节翻修术后，9例患者中，男3例，女6例；年龄35～67岁，平均51岁，9例患者中4例因股骨头缺血性坏死、2例因先天性髋臼发育不良合并髋关节骨关节炎、1例因强直性脊柱炎合并髋部病变、1例因类风湿关节炎合并髋部病变、1例因全髋关节假体松动而行全髋关节置换术。非骨水泥固定8例，骨水泥固定1例。9例坐骨神经损伤的患者中．7例因肢体不等长而同时行下肢延长术．2例因髋部强直而同时行松解术，结果 9例术后出现坐骨神经损伤的患者．8例为单纯腓总神经损伤．临床表现为足不能背伸；1例为腓总神经和胫神经联合损伤．临床表现为足不能背伸和跖屈。术后随访6～48个月，平均31个月.其中8例患者术后半年坐骨神经功能全部恢复；1例患者术后半年坐骨神经功能仍未恢复．遂行切开探查松解术．探查术后1年坐骨神经功能部分恢复。结论 全髋关节置换及翻修术后坐骨神经损伤．多由下肢过度延长或机械性压迫所致，大多数不完全损伤可以恢复.     

Sciatic nerve palsy after total hip arthroplasty in a patient receiving continuous lumbar plexus block

We report a case of late-onset postoperative sciatic palsy after total hip arthroplasty in a 30-yr-old man with congenital hip dysplasia. The patient was receiving continuous lumbar plexus blockade and had received low-molecular-weight heparin 3 h before the onset of symptoms. Anatomic distinction between the nerve block and the sciatic palsy facilitated rapid diagnosis and treatment of a periarticular hematoma, with resulting neurologic recovery. This case illustrates that, with the expanded role of regional anesthetic techniques in acute pain management, the finding of a new postoperative deficit must be jointly investigated by both anesthesiologists and surgeons. Timely and open communication between services is critical because rapid intervention may be essential to achieving full recovery of an affected nerve. IMPLICATIONS: A case is presented of sciatic palsy developing after total hip arthroplasty in a patient receiving a continuous lumbar plexus block. The case highlights various issues in the use of continuous peripheral nerve blocks for postoperative analgesia.     

Late sciatic nerve palsy caused by hematoma after primary total hip arthroplasty

A case of late sciatic nerve palsy caused by subfascial hematoma after uncemented right total hip arthroplasty is reported. The patient developed respiratory distress 13 days postoperatively and was admitted to another institution, where she was diagnosed with pulmonary embolism and was subsequently therapeutically anticoagulated with heparin. The patient complained of right-leg numbness and tingling 18 days' postoperatively, which progressed to complete sciatic nerve palsy over several hours.     

Iliacus hematoma and femoral nerve palsy after revision hip arthroplasty: a case report

Femoral nerve palsy occurred in a 65-year-old man after he had undergone a revision total hip arthroplasty using cementless components. The magnetic resonance imaging scan showed a mass in the iliacus muscle. The mass showed increased signal intensity on T1-weighted and T2-weighted spin-echo images and contained linear septa and a nodule. The gadolinium-enhanced T1-weighted image showed a rim of significant enhancement in the nodule. The findings of magnetic resonance images were suggestive of iliacus hematoma and of liposarcoma. The patient underwent surgery, and the mass was identified as an iliacus hematoma. The femoral nerve was stretched by the hematoma. After removal of the hematoma, the nerve palsy was improved completely. Iliacus hematoma may occur after total hip arthroplasty, even without anticoagulant therapy. The hematoma might appear to be a liposarcoma on magnetic resonance imaging scans.     

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

Delayed sciatic nerve palsy is uncommon after primary hip replacement. Two kinds of sciatic palsy have been reported with regard to the time of onset: early palsy related to wound haematoma or lumbosacral nerve elongation which occurs between surgery and 18 days, is more frequent than delayed palsy, occurring between 10 and 32 months, which is usually caused by cement extrusion or heat produced by cement polymerisation. We present two cases of delayed, transient sciatic nerve palsy arising at three weeks and four months after primary cementless arthroplasty, respectively, without haematoma and with a normal lumbar spine. These palsies were possibly caused by excessive tension from minor limb lengthening of 2 cm to 4 cm required to achieve leg-length equality. As the initial symptoms were limited to calf pain and mild numbness in the foot, surgeons should be aware of this mode of onset, particularly when it is delayed after hip replacement. Both patients recovered fully by 12 months after surgery so we did not undertake surgical exploration of the nerve in either patient.     

复杂全髋关节置换术中应用体感诱发电位监测的初步报告

目的：利用体感诱发电位在复杂全髋关节置换手术中进行监测，以预防坐骨神经损伤。方法：自2002年8月～2003年4月对12例复杂全髓关节置换手术患者术前清醒状态下行体感诱发电位检查．术中麻醉后行体感诱发电位监测。均采用全身麻醉．麻醉药品的使用和单位体重的用药剂量尽量相同。本组复杂全髋关节置换手术患者选择的标准是下肢短缩在4cm以上的初次手术和短缩3cm以上的翻修手术者，术中判断诱发电位异常标准是波幅峰值下降50％并持续10min以上和(或)潜伏期延长10％。重点监测时段为手术中坐骨神经周围暴露和关节复位后。结果：与术前清醒状态下比较，麻醉后患者的体感诱发电位波幅峰值和潜伏期均有不同程度的改变；而与麻醉后体感诱发电位的波幅峰值和潜伏期比较，12例患者术中监测的结果也发生改变、但是两者改变程度均未超过体感诱发电位异常的判断标准。术后下肢延长最短3cm，最长6cm，平均3．9cm，除1例手术前就有腓总神经损伤的患者外，其余患者术后均未出现下肢神经损伤症状.结论:体感诱发电位监测对颈防全髋关节置换术中坐骨抻经损伤有一定帮助．尤其对下肢短缩或翻修病例．术中体感诱发电位监测更有价值。     

Sciatic neuropathy secondary to total hip arthroplasty wear debris.

Sciatic neuropathy after total hip arthroplasty can result from several causes. We present a case in which a large cystic mass developed around a failed total hip arthroplasty. The lesion extended through the greater sciatic notch and into the pelvis producing sciatic nerve compression. The diagnosis was delayed, and the patient underwent a laminectomy without relief of symptoms before an abdominopelvic computed tomography (CT) scan revealed the mass. After revision of the components and excision of the accessible portion of the lesion, the symptoms improved. Resolution of the intrapelvic portion of the mass was demonstrated on follow-up CT scan, suggesting that retroperitoneal resection of this type of lesion may not be required at the time of revision of the components.     

Traumatic bilateral hip dislocation with bilateral sciatic nerve palsy

Bilateral hip dislocation rarely occurs. In this paper, a case of bilateral hip dislocation associated with bilateral sciatic nerve palsy resulted from a road traffic accident is reported. Both hips were emergently reduced under general anaesthesia. Acetabular reconstruction was done bilaterally due to the unstable hips. The patient subsequently developed heterotopic ossification and avascular necrosis on the left hip and underwent total hip arthroplasty. The sciatic nerve on the right side achieved complete recovery but that on the left side only partly recovered and was augmented by tendon transfer. Such injuries are serious and one should be aware of the complications because they can resurface and so patients should be followed up for a long time. To the best of our knowledge, this kind of injury has not been reported in the English .language literature.     

Sciatic nerve palsy after cementless total hip arthroplasty. Treatment by modular neck and calcar shortening: a case report

 This is a case report of sciatic nerve palsy after total hip arthroplasty. Although the patient's symptoms became worse postoperatively, full recovery occurred after shortening of the calcar and femoral neck length. For acute sciatic nerve palsy patients with worsening of symptoms in the postoperative course in spite of hip and knee flexion, reexposure for early recognition of the sciatic nerve condition and reoperation by shortening the femoral neck may be an option. Received: July 6, 2001 / Accepted: December 19, 2001     

Acute sciatic neuritis following total hip arthroplasty: a case report

Nerve injuries after total hip arthroplasty are relatively uncommon, but a higher prevalence has been reported in revision arthroplasties, in women and in patients with dysplastic hips. We report a case of a patient who had a painful neuritis of the sciatic nerve after primary arthroplasty, without any objective evidence of motor or sensory deficit and had complete relief of pain after the limb lengths were matched to the contra-lateral side after revision arthroplasty.     

Postarthroplasty "palsy" and systemic neuropathy: a peripheral-nerve management algorithm

Postarthroplasty palsy, occurrence of dysfunction of the sciatic or peroneal nerve after total joint replacement of the hip or knee, is a complication that remains poorly understood. Characteristics of a series of 24 patients with postarthroplasty palsy are reviewed, with the finding that, overall, 58.4% of the patients had an underlying peripheral neuropathy. The role of this neuropathy predisposing the arthroplasty patient to stretch/traction injury is discussed and should be emphasized as a risk factor prior to surgery and should influence the surgeon's intraoperative use of force during the arthroplasty procedure. This clinical problem is addressed from the perspective of peripheral nerve surgery, with an algorithm suggested for its management. The algorithm suggests that if a peroneal palsy is still present at 3 months after an arthroplasty and neurosensory testing fails to demonstrate a sensory reinnervation pattern in the territories of the deep or superficial peroneal nerve, then surgical neurolysis of the common peroneal nerve is indicated.     

Myositis ossificans of the hip joint causing sciatic nerve palsy following Guillain-barré syndrome: A case report

Introduction and importanceMyositis ossificans of the hip is a rare entity caused by trauma and neurological conditions which lead to lamellar bone formation around the joint.Case presentationWe present a 47 years old patient with myositis ossificans of the left and the piriformis muscle following Guillain Barré syndrome causing sciatic nerve palsy (Piriformis syndrome).Clinical discussionClinical assessment revealed global limitation of the left hip movements and palpable bony mass on the lateral aspect of the left hip. Radiographs and computed tomography showed extensive myositis ossificans of the left hip and non-bridging calcification noted on the asymptomatic right side. During initial medical management and physiotherapy patient developed sciatic nerve palsy due to piriformis syndrome and ankylosis of the hip on the left side. Surgical exploration of the sciatic nerve and debridement of the hip. The left hip was found ankylosed and not salvageable. Uncemented total hip arthroplasty was carried out in the session. The patient recovered completely from sciatic nerve palsy and regained the range of motion of the hip. He is under follow-up for the recurrence of myositis ossificans.ConclusionGuillain-barré syndrome causing piriformis syndrome is a rare entity. Extensive myositis ossificans causing sciatic nerve palsy is even rarer. An awareness of this entity, early detection, and intervention of this condition may help to preserve the native hip.     

Rare case of sciatic nerve palsy in a modular total hip arthroplasty

A rare case of sciatic nerve palsy in an uncemented modular hip arthroplasty is described. We believe that a delay in recognizing liner dissociation causing granuloma was responsible for the nerve palsy. Delay in diagnosis can be avoided by a careful inspection of prereduction and postreduction radiographs.     

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

Twenty-three peroneal and sciatic nerve palsies occurred in 21 patients following hip arthroplasty. Apparent risk factors included revision operations, being female, and significant lengthening of the extremity. The amount of lengthening was correlated with the development of either a peroneal palsy or sciatic nerve palsy. In cases of peroneal palsy the average lengthening was 2.7 cm (1.9 cm-3.7 cm) in comparison with 4.4 cm (4.0 cm-5.1 cm) for sciatic nerve palsies. Seven of these nerve palsies occurred among 614 consecutive patients treated at one institution during the period 1983-1985. This corresponded to an overall incidence of 1.1%. Electromyography demonstrated that peroneal stretch palsies originated primarily at the level of the neck of the fibula with some diffuse but lesser involvement along the proximal course of the peroneal division of the sciatic nerve.     

Clinical application of sensory protection of denervated muscle

Following proximal peripheral nerve injury, motor recovery is often poor due to prolonged muscle denervation and loss of regenerative potential. The transfer of a sensory nerve to denervated muscle results in improved functional recovery in experimental models. The authors here report the first clinical case of sensory protection. Following a total hip arthroplasty, this patient experienced a complete sciatic nerve palsy with no recovery at 3 months postsurgery and profound denervation confirmed electrodiagnostically. He underwent simultaneous neurolysis of the sciatic nerve and saphenous nerve transfers to the tibialis anterior branch of the peroneal nerve and gastrocnemius branch from the tibial nerve. He noted an early proprioceptive response. Electromyography demonstrated initially selective amelioration of denervation potentials followed by improved motor recovery in sensory protected muscles only. The patient reported clinically significant functional improvements in activities of daily living. The authors hypothesize that the presence of a sensory nerve during muscle denervation can improve functional motor recovery.     

Acute Postoperative Herpes Zoster With a Sciatic Nerve Distribution After Total Joint Arthroplasty of the Ipsilateral Hip and Contralateral Knee

The differential diagnosis of a patient with acute onset of hip pain during the postoperative recovery period after total hip arthroplasty includes sciatic nerve injury, infection, incisional pain, hardware, or simply muscular issues related to overactivity. Moreover, because the rash of herpes zoster develops after 4 or 5 days of pain, it is difficult to diagnose herpes zoster during the early period. A number of reports have been issued on herpes zoster after surgery or trauma, but no report is available on herpes zoster development with a sciatic nerve distribution after ipsilateral total hip arthroplasty. The authors report the case of 75-year-old woman with herpes zoster with a sciatic nerve distribution after 2 primary total joint arthroplasties of a hip and knee.     

Total Hip Arthroplasty Followed by Traction and Delayed Reduction for Crowe IV Developmental Dysplasia of the Hip

Hip dislocation secondary to developmental dysplasia of the hip is a debilitating condition. Total hip arthroplasty has proven successful in improving pain, restoring joint function, and correcting leg length discrepancies in this select population. Various techniques have been developed to address the increased complexity inherent to the reconstruction of the severely dysplastic hip. Despite this, femoral and/or sciatic nerve palsy remains a potential catastrophic complication after surgery, with reported rates up to five times that in the general population. We present three cases using a previously unreported technique for performing primary total hip arthroplasty via an anterior approach for Crowe IV hip dysplasia. The goal of this technique is to minimize the risk of postoperative nerve palsy following reconstruction of the severely dysplastic hip. A brief discussion of our technique and the topic of nerve dysfunction after total hip arthroplasty for developmental dysplasia of the hip follows.     

Intraosseous radial nerve entrapment complicating total elbow revision

A 43-year-old man underwent revision of a loose total elbow arthroplasty in 1995. The arthroplasty had been implanted 20 years previously for post-traumatic osteoarthritis after a gunshot wound complicated by permanent ulnar nerve palsy. The patient suffered a minimally displaced periprosthetic fracture 4 years after implantation that was treated closed. The patient subsequently developed severe loosening with bony dilation. During revision surgery, while grasping and removing the periprosthetic membrane from within the humeral medullary canal with a Kerrison rongeur, dorsiflexion of the wrist and hand occurred. Close inspection of the membrane revealed that the radial nerve was encased inside the bone. Although not divided, the traction and contusion of the nerve caused a radial nerve palsy that partially resolved by 4 years of follow-up.     

Delayed transient sciatic nerve palsy after total hip arthroplasty

Sciatic nerve palsy after total hip arthroplasty is a well-known complication, but delayed sciatic nerve palsy is rare. We report such a case with profound clinical manifestations and well-documented electrophysiologic changes. We found no helpful guidance to managing delayed palsy in the literature. We also are unaware of any previous cases reported in which nearly full recovery has occurred.