Transient simultaneous sciatic and femoral nerve palsy secondary to iliacus and gluteal hematomas following heparinization for pulmonary embolus in a patient with posterior hip dislocation

Sciatic nerve palsy as a result of a posterior hip dislocation has been reported in the literature. Femoral nerve palsy as a result of a iliacus hematoma has also been documented. However, a simultaneous sciatic and femoral nerve palsy occurring after heparinization for a pulmonary embolus in a patient with a posterior hip dislocation has not been reported. This combined nerve palsy was found in a 64-year-old white woman who had been involved in a motor vehicle accident and sustained a posterior hip dislocation. This patient subsequently had a pulmonary embolism, was heparinized, and then developed a large iliacus and gluteal hematoma, resulting in a simultaneous sciatic and femoral nerve palsy. Without treatment, the patient regained motor and sensory of the sciatic nerve in a few days, and a gradual improvement of function of her femoral nerve was evident over several months.     

Femoral nerve palsy due to iliacus hematoma occurred after primary total hip arthroplasty

The perforation of the medial acetabular wall during total hip arthroplasty due to drilling is not uncommon. But, it has rarely been associated with serious adverse events. Here, we present a case report describing an iliacus hematoma with subsequent femoral nerve palsy after primary total hip arthroplasty in a 67-year-old woman who underwent primary total hip arthroplasty due to painful hip osteoarthritis. The diagnosis was made by pelvic magnetic resonance imaging. Conservative treatment was employed and the symptoms were resolved within 3 months. It should be borne in mind that femoral nerve palsy may occur after total hip arthroplasty. It may be due to a treatable cause, such as iliacus hematoma. So, pelvic MRI is recommended in such a condition, rather than just observation.     

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.     

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.     

Double-chevron subtrochanteric shortening derotational femoral osteotomy combined with total hip arthroplasty for the treatment of complete congenital dislocation of the hip in the adult: Preliminary report and description of a new surgical technique

Total hip arthroplasty for the treatment of complete congenital dislocation of the hip in the adult has been associated with high rates of complications, including acetabular component loosening, femoral or sciatic nerve palsy, and prosthetic dislocation. Placement of the acetabular component in the true acetabulum has yielded the most durable results, but leads to significant limb lengthening, which is associated with sciatic and femoral nerve palsy. Femoral shortening with a transverse osteotomy tends to be torsionally unstable. Increased femoral anteversion complicates femoral component placement and, if not corrected, can lead to postoperative anterior instability and component dislocation. A new surgical technique that combines total hip arthroplasty with a femoral subtrochanteric shortening derotational double-chevron osteotomy in complete congenital hip dislocation using standard components is described. This procedure has been successfully performed in seven hips.     

Post-surgical neuropathy after total hip arthroplasty: Causality and avoidance

Nerve palsy is an uncommon but distressing complication after total hip arthroplasty. Because motor function can be affected, weakness of the lower limb is a common manifestation, causing difficulty with walking and the planned rehabilitation for the hip. As such, significant disability is imparted to the affected patient. The proposed etiologies of nerve palsy include compression and tension during the course of the operation, or a collection of blood postoperatively. In the literature, hip dysplasia, lengthening of the leg, use of an uncemented femoral component, and female sex are associated with a greater risk of nerve palsy. If a compressive hematoma is found, surgical evacuation may be beneficial. As palsies are slow to recover, supportive care such as bracing, therapy, and reassurance are the mainstays of treatment.     

Early complications of hip resurfacing

There has been a rapid increase in the number of hip resurfacing procedures for the treatment of symptomatic osteoarthritis over the last decade. We examine our early complications associated with this procedure. Eight hundred forty consecutive hip resurfacing procedures by 1 surgeon using 1 prosthesis were assessed. The complications seen within the first 12-month postoperative period were analyzed. Specific patient selection criteria were used. Complications such as loosening, femoral neck notching, femoral neck fracture, deep vein thrombosis, stress fracture, nerve palsy, and infection were noted. Complications linked with loosening were categorized to either the femoral or acetabular component. A total of 86 early complications were observed in the 840 resurfacings. Twenty-three (2.7%) required operative intervention, and 10 (1.2%) were converted to stemmed hip arthroplasties. Of these 86 complications, the most common complication was deep vein thrombosis, 19 instances (2.26% occurrence in 840), followed by femoral neck fracture, 11 (1.31%); infection, 10 (1.19%); femoral notching, 10 (1.19%); transient nerve palsy, 8 (0.95%); acetabular loosening, 6 (0.71%); hematoma, 5 (0.60%); and stress fracture, 4 (0.48%). The fractures occurred mostly in patients older than 60 years.     

Femoral nerve palsy associated with iliacus hematoma following pseudoaneurysm after revision hip arthroplasty

Iliacus hematoma associated with femoral nerve palsy is a very rare but considerable complication of hip arthroplasty. A 76-year-old woman had femoral nerve palsy 6 months after revision hip arthroplasty using a reinforcement plate. Computed tomography and selective angiography revealed the pseudoaneurysm on an extension of one of the screws fixing the hardware. Transcatheter arterial embolization proximal to the aneurysm was performed to resolve the aneurysm and to prevent further bleeding. Surgical removal of the hematoma was successfully achieved, as was full functional recovery. This case report describes our diagnosis and treatment of this rare condition and also the therapeutic usefulness of the radiologic intervention to control further bleeding before and after surgical removal of the hematoma.     

Motor nerve palsy following primary total hip arthroplasty

BACKGROUND: Nerve palsy is a potentially devastating complication following total hip arthroplasty. The purpose of this study was to retrospectively identify risk factors for, and the prognosis associated with, a motor nerve palsy following primary total hip arthroplasty. METHODS: Between 1970 and 2000, 27,004 primary total hip arthroplasties were performed at our institution. Forty-seven patients (0.17%) with postoperative motor nerve dysfunction were identified by a review of the complications log of a total joint database. The medical record of each patient provided the data for this study. The average age of the patients was fifty-seven years at the time of surgery. The patients had serial clinical examinations for a minimum of two years, or until neurologic recovery or death. The nerve palsies were classified as complete or incomplete, and only patients with objective motor weakness were included in the study. The limb lengths were measured on preoperative and postoperative radiographs, and those data were then compared with the limb lengths in a matched cohort of patients who had not sustained a nerve injury after a primary total hip arthroplasty. The extent of neurologic recovery, the need for braces or walking aids, and the use of medications for neurogenic pain were evaluated. RESULTS: There were twenty-nine complete motor nerve palsies (sixteen peroneal, eleven sciatic, and two femoral) and eighteen incomplete motor nerve palsies (fourteen peroneal, three sciatic, and one femoral). A preoperative diagnosis of developmental dysplasia of the hip (p = 0.0004) or posttraumatic arthritis (p = 0.01), the use of a posterior approach (p = 0.032), lengthening of the extremity (p < 0.01), and cementless femoral fixation (p = 0.03) were associated with a significantly increased odds ratio for the development of a postoperative motor nerve palsy. Of the twenty-eight patients with a complete palsy who were available for follow-up, only ten (36%) had complete recovery of motor strength, which took an average of 21.1 months. Seven of the eighteen patients with an incomplete palsy fully recovered their preoperative strength. Twenty-one patients required walking aids, and fifteen required permanent use of an ankle-foot orthosis. Five patients required daily medication for chronic neurogenic pain. CONCLUSIONS: Motor nerve palsy is uncommon following primary total hip arthroplasty. A preoperative diagnosis of developmental dysplasia of the hip or posttraumatic arthritis, the use of a posterior approach, lengthening of the extremity, and use of an uncemented femoral implant increased the odds ratio of sustaining a motor nerve palsy. The majority of the motor nerve deficits in our series, whether complete or incomplete, did not fully resolve.     

Femoral nerve palsy as a complication of anterior iliac crest bone harvest: Report of two cases and review of the literature

There are many documented neurological complications of anterior iliac crest bone harvest. Until now, these have included injuries to the iliohypogastric, subcostal and lateral femoral cutaneous nerves. Femoral nerve palsy as a direct surgical complication of anterior iliac crest bone harvest has never been cited in any surgical literature, although it has been reported in deep pelvic and abdominal surgeries in which improper retraction and/or prolonged hyperextension of the hip may have caused a nerve compression syndrome. In addition, surgical patients on antithrombolytic therapy have experienced hemorrhage within the iliacus and iliopsoas muscles, resulting in hematoma and secondary femoral nerve compression. The classic motor and sensory deficits reported in femoral nerve palsies are reduced or absent patellar reflex, weak hip flexion, quadriceps muscle weakness, and anesthesia of the anterior thigh and medial aspect of the leg. Two cases of femoral nerve palsy with different etiologies are presented.     

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.     

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     

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.     

Vermeidung, Diagnostik und Therapie von Nervenl?sionen nach H��ftendoprothesenimplantation

Nerve palsy following total hip arthroplasty is a rare complication. Developmental dysplasia of the hip, previous fracture treatment and medical comorbidities are characteristic risk factors. By accurate preparation of the patient and a careful operative technique nerve palsy can be avoided in most cases. Nerve palsy following poor patient positioning during the perioperative period should be avoided by close cooperation with anesthesiologists.In cases of postoperative nerve palsy correct diagnostics should be carried out immediately. Further treatment options should be considered to minimize the damage. For patients with definite nerve palsy, devices such as a foot drop splint are often necessary and should be carried out as soon as possible.     

Intraneural hematoma after nerve stimulation-guided femoral block in a patient with factor XI deficiency: case report

Intraneural hematoma after a peripheral nerve block is a theoretical cause of postoperative nerve injury that has not been previously documented in humans. We report an intraneural hematoma after nerve stimulation-guided femoral block, which occurred in a patient with undiagnosed factor XI deficiency and a slightly prolonged activated partial thromboplastin time. Onset of paralysis several days after surgery prompted early surgical exploration and removal of an intraneural hematoma at the femoral nerve. Improvement in motor function was noted after epineurolysis of the femoral nerve. Early nerve decompression contributed to a satisfactory outcome.     

Tomakulöse Neuropathie (HNPP) als Ursache einer verzögerten Parese des N. femoralis nach Hüfttotalendoprothesenimplantation

Delayed lesions of the femoral or sciatic nerve are a rare complication after total hip arthroplasty. Several cases in association with cement edges, scar tissue, broken cerclages, deep hematoma, or reinforcement rings have been published. We report about a 62-year-old female who developed a pure motor paresis of the quadriceps muscle 2 weeks after total hip arthroplasty. After electrophysiological evaluation had revealed an isolated femoral nerve lesion, revision of the femoral nerve was performed. During operative revision no pathologic findings could be seen. One week later the patient developed paralysis of the left wrist and finger extensors after using crutches. Electrophysiological evaluation revealed several nerve conduction blocks in physiological entrapments and the diagnosis of hereditary neuropathy with liability to pressure palsies (HNPP) was established. Hereditary neuropathy with liability to pressure palsies (HNPP) is a rare disease with increased vulnerability of the peripheral nerve system with mostly reversible sensorimotor deficits. It should be taken into consideration in cases of atypical findings of compression syndromes of peripheral nerves or delayed neuropathy, e. g., after total hip arthroplasty.     

Surgical treatment of obturator nerve palsy resulting from extrapelvic extrusion of cement during total hip arthroplasty

A female patient was successfully treated surgically for obturator nerve palsy resulting from extrapelvic extrusion of cement during total hip arthroplasty. Obturator nerve palsy developed because of the extrapelvic extrusion of cement medially in the anterior part of the incisura acetabuli in the zone of the extrapelvic exit of the obturator tunnel. Compression of the obturator nerve was confirmed by electromyography. After surgical removal of a piece of cement, 2.5 cm in length, which was done 11 months after total hip arthroplasty, and after 6 months of intensive postoperative rehabilitation, the patient was able to return to everyday activities and normal working habits. After 1 year, clinical and electromyography results were almost completely normal. A review of current knowledge regarding obturator nerve injuries resulting from total hip arthroplasty is presented.     

Femoral artery and nerve compression by bulk allograft used for acetabular reconstruction: An unreported complication

Absent pulses in the ipsilateral limb and a femoral nerve palsy occurred after revision total hip arthroplasty. Emergent arteriogram revealed an occlusion of the femoral artery inferior to the inguinal ligament. The femoral artery was found to be compressed by the bulk allograft bone used for reconstruction of an anterior segmental acetabular defect. No laceration or thrombosis of the artery was present. A high-speed burr was used to remove the anterior portion of the offending allograft. Pulses were immediately restored and the patient had no long-term vascular sequelae. The femoral nerve palsy has slowly resolved over 2 years.     

Femoral nerve palsy secondary to traumatic pseudoaneurysm and iliacus hematoma

The authors report a case of traumatic femoral nerve palsy caused by a pseudoaneurysm of the iliolumbar artery and a iliacus muscle hematoma. This case report details not only the classic history and physical findings seen in patients such as this one, but also illustrates an unusual source of the hematoma and a discussion of its treatment. A 20-year-old man was assaulted and presented to the authors's institution with a 1-week history of severe pain in the left anterior thigh and groin, weakness in the left quadriceps muscle, and numbness in the anterior thigh and medial distal leg. Imaging studies demonstrated a large, 9.4 x 6.4 x 5.2-cm iliacus hematoma as well as a pseudoaneurysm originating from the left iliolumbar artery. The patient underwent angiographic embolization of the pseudoaneurysm followed by surgical evacuation of the hematoma. The embolization was performed before surgery to prevent any possible rebleeding from the pseudoaneurysm during evacuation of the hematoma. Femoral nerve palsy caused by traumatic iliacus hematoma is an infrequent diagnosis often missed because of its insidious presentation. In this case, embolization of the iliolumbar artery pseudoaneurysm followed by surgical evacuation of the hematoma resulted in a nearly full recovery of the femoral nerve as of the last follow-up examination.     

Leg-length discrepancy after total hip arthroplasty

Leg-length discrepancy after total hip arthroplasty can pose a substantial problem for the orthopaedic surgeon. Such discrepancy has been associated with complications including nerve palsy, low back pain, and abnormal gait. Careful preoperative measurement and assessment, as well as preoperative and postoperative patient education, are important factors in achieving an acceptable result. However, after total hip arthroplasty, equal leg length should not be guaranteed. Rather, the patient should be given a realistic assessment of what can reasonably be expected.