Histological assessment of the resected segment of the nerve demonstrated complete loss of axons with marked fibrosis involving the endoneurium, perineurium, and epineurium. Loss of nerve continuity was confirmed by immunohistochemical staining.
Postoperatively, the patient reported immediate and complete resolution of the persistent burning pain in the leg and foot for a period of eight days. Since that time, however, at a recent evaluation performed twenty-five months following the nerve injury, the patient noted intermittent episodes of mild-to-moderate pain at the lateral and plantar aspects of the foot. She needed narcotic analgesics occasionally (approximately once every three days) and continued to take gabapentin, as recommended previously by a neurologist. Serial examinations demonstrated distal progression of the Tinel sign, elicited with percussion over the popliteal fossa. The patient noted that paresthesias radiated over the lateral aspect of the foot. No improvement in motor function was noted at the time of the most recent examination.
In contrast to nerve injuries that are the direct result of hip dislocation, the neuropathy in this patient was a result of a joint reduction. The proximity of the sciatic nerve to the posterior structures of the hip places it at risk of tension injury because of the distortion of local soft-tissue structures9 and because of compression injury with circumduction motion of the femoral head during reduction maneuvers10. To our knowledge, only one case of a patient with sciatic nerve palsy following reduction of a dislocated hip prosthesis has been reported. Lazansky, in a review of postoperative complications after 501 total hip arthroplasties, reported that one patient had a partial sciatic nerve injury following manipulative reduction of a dislocated hip prosthesis1. Full neurological recovery occurred without operative intervention.
A review of the reports on nerve injury following a fracture or joint manipulation suggested that a distinction should be made between partial and complete nerve palsy following reduction of displaced fracture fragments or a dislocated joint11-23. Most authors have recommended that nerve injuries that are both partial and secondary be treated with an initial period of observation for four to six months, as 70% to 100% of the injured nerves improve spontaneously13,17,19,21,24. Conversely, substantial evidence supports early operative exploration if the neuropathy is complete and has occurred immediately after bone or joint manipulation13,14,17,19,21. The concept holds that immediate and complete nerve loss implies nerve entrapment within a fracture site or a joint11-13,15,16,18-20.
Authors of clinical reviews on the treatment of dislocation of a prosthesis following total hip arthroplasty have suggested that a limited number of attempts at closed reduction be carried out, as prolonged manipulation may place surrounding soft-tissue structures at risk of injury4,9,25. When attempts at closed reduction with use of intravenous sedation are unsuccessful, conversion to a general anesthetic is indicated, as conscious sedation may be ineffective in overcoming excessive muscular tension. If a closed reduction with the patient under general anesthesia is difficult, open exploration and reduction is indicated26-28.
In our patient, a difficult reduction of a total hip prosthesis following posterior dislocation was associated with a new onset of complete sciatic nerve palsy that was evidenced by loss of all motor function distal to the motor branch of the semitendinosus muscle. While joint asymmetry was not evident on the postreduction radiographs of our patient, previous reports have indicated that plain radiographs or other imaging modalities, such as computed tomography and magnetic resonance imaging, may be effective for assessing the adequacy of joint reduction and delineating the extent of soft-tissue interposition4,6,24,25 or nerve injury29,30. The findings of preoperative clinical examination and intraoperative nerve assessment were consistent with the histological findings of gross fibrotic changes throughout the resected nerve segment, a neuromatous mass, and a loss of nerve continuity.
The case of our patient emphasizes two factors that should be considered during closed reduction of a displaced fracture or a dislocated joint. First, during difficult or prolonged attempts at closed reduction, excessive force to the surrounding soft tissues places neurological structures at risk for injury; therefore, open reduction is indicated after a limited number of attempts at closed reduction have been carried out. Second, our findings support the conclusion made by previous authors that immediate operative exploration is indicated when complete nerve loss occurs following closed manipulation of displaced fracture fragments or a dislocated joint.
Investigation performed at the Department of Orthopaedic Surgery, Barnes-Jewish Hospital at Washington University School of Medicine, St. Louis, Missouri
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
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