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Nerve palsy 'a vexing complication' in total hip replacement

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LAHAINA, Hawaii — While the overall incidence of nerve palsy resulting from total hip replacement remains low, patients undergoing revision surgery have a threefold risk for nerve injury, and women are at a higher risk than men.

Thomas P. Schmalzried, MD, of St. Vincent Medical Center in Los Angeles, said that in an analysis he conducted with colleagues S. Noordin, MD, and Harlan C. Amstutz, MD, of more than 34,000 total hip replacements (primary and revision), there were 359 nerve palsies — a 1% overall prevalence. However, the incidence among revision surgeries escalated to 2.5%, (0.9% for primary cases), and patients with developmental dysplasia of the hip (DDH) demonstrated a 5% risk for nerve palsy.

Even more alarming: nerve palsy occurred in women nearly twice as much as men, he said.

"What this all says to me is that anatomy plays a role," he told attendees at Orthopedics Today Hawaii 2008, here. "Nerve palsy is a vexing complication. You might be doing what you usually do, but because of the variances in anatomy — if the nerve isn't where it usually is or if it takes a course around the hip joint different from where it usually goes — indirect injury may be the result."

He said the sciatic nerve is the most frequently injured nerve in THR, accounting for 79% of all nerve palsies. Injury to the sciatic nerve or the peroneal division of the sciatic nerve typically occurs proximally at the level of the hip joint.

Electromyography has demonstrated evidence of nerve injury in 70% of extremities following THR, he added.

"In our research, femoral nerve injuries tend to be more frequent when we use an anterolateral approach to THR," he said. This is because the femoral nerve is close to the anterior aspect of the hip joint and, consequently, to the anterior acetabular retractors.

Schmalzried said that if neuropathy is suspected in a THR patient, the orthopedic surgeon should consult with the neurologist.

"Be nice to your neurologist," he said. "He can help you validate your findings and identify the exact source or location of the nerve injury."

For more information:

• Schmalzried TP. Nerve and vascular injuries associated with total hip arthroplasty. Presented at Orthopedics Today Hawaii 2008. Jan. 13-16, 2008. Lahaina, Maui, Hawaii.