RESUMO
BACKGROUND: Entrapment or injury of the lateral femoral cutaneous nerve (LFCN) is being recognized with increasing frequency, often requiring a surgical approach to relieve symptoms. The presence of anatomic variations can lead to errors in diagnosis and intraoperative decision-making. METHODS: This study presents the experience of a single surgeon (T.W.T.) in managing 184 patients referred with clinical issues related to the LFCN. A comprehensive review of these cases was conducted to develop a prospective surgical management algorithm. Data on the LFCN's anatomic course, pain relief outcomes, comorbidities, body mass index, and sex were extracted from patients' medical charts and operative notes. Pain relief was assessed subjectively, categorized into "excellent relief" for complete pain resolution, "good" for substantial pain reduction with some residual discomfort, and "failure" for cases with no pain relief necessitating reoperation. RESULTS: The decision tree is dichotomized based on the mechanism of LFCN pathology: compression (requiring neurolysis) versus history of trauma, surgery, and/or obesity (requiring resection). Forty-seven percent of the patients in this series had an anatomic variation. It was found that failure to relieve symptoms of compression often indicated the presence of anatomic variation of the LFCN or intraneural changes consistent with a neuroma, even if adequate decompression was achieved. With respect to pain relief as the outcome measure, recognition of LFCN anatomic variability and use of this algorithm resulted in 75% excellent results, 10% good results, and 15% failures. Twenty-seven of the 36 failures originally had neurolysis as the surgical approach. Twelve of those failures had a second surgery, an LFCN neurectomy, resulting in 10 excellent, 1 good, and 1 persistent failure. CONCLUSION: This article establishes an algorithm for the surgical treatment of MP, incorporating clinical experience and anatomical insights to guide treatment decisions. Criteria for considering neurectomy may include a history of trauma, prior local surgery, anatomical LFCN variations, and severe nerve damage due to chronic compression.
Assuntos
Nervo Femoral , Síndromes de Compressão Nervosa , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Adulto , Síndromes de Compressão Nervosa/cirurgia , Nervo Femoral/cirurgia , Nervo Femoral/lesões , Algoritmos , Neuropatia Femoral/cirurgia , Resultado do Tratamento , Idoso , Descompressão Cirúrgica/métodos , Estudos Retrospectivos , Árvores de Decisões , Traumatismos dos Nervos Periféricos/cirurgia , Medição da Dor , Procedimentos Neurocirúrgicos/métodosRESUMO
The femoral and obturator nerves both arise from the L2, L3, and L4 spinal nerve roots and descend into the pelvis before emerging in the lower limbs. The femoral nerve's primary function is knee extension and hip flexion, along with some sensory innervation to the leg. The obturator nerve's primary function is thigh adduction and sensory innervation to a small area of the medial thigh. Each may be injured by a variety of potential causes, many of them iatrogenic. Here, we review the anatomy of the femoral and obturator nerves and the clinical features and potential etiologies of femoral and obturator neuropathies. Their necessary investigations, including electrodiagnostic studies and imaging, their prognosis, and potential treatments, are discussed in this chapter.
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Nervo Obturador , Doenças do Sistema Nervoso Periférico , Humanos , Nervo Obturador/anatomia & histologia , Doenças do Sistema Nervoso Periférico/diagnóstico , Doenças do Sistema Nervoso Periférico/fisiopatologia , Nervo Femoral/lesões , Nervo Femoral/fisiologia , Neuropatia FemoralRESUMO
Aims: Lateral femoral cutaneous nerve (LFCN) injury is a complication after periacetabular osteo-tomy (PAO) using an anterior approach, which might adversely affect the outcome. However, no prospective study has assessed the incidence and severity of this injury and its effect on the clinical outcomes over a period of time for longer than one year after PAO. The aim of this study was to assess the incidence and severity of the symptoms of LFCN injury for ≥ three years after PAO and report its effect on clinical outcomes. Methods: A total of 40 hips in 40 consecutive patients who underwent PAO between May 2016 and July 2018 were included in the study, as further follow-up of the same patients from a previous study. We prospectively evaluated the incidence, severity, and area of symptoms following LFCN injury. We also recorded the clinical scores at one year and ≥ three years postoperatively using the 36-Item Short Form Health Survey (SF-36) and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) scores. Results: A total of 20 patients (50%) had symptoms of a LFCN injury at one year after PAO. At ≥ three years postoperatively, the symptoms had completely resolved in seven of these patients and 13 (33%) had persistent symptoms. The severity and area of symptoms did not significantly differ between one and ≥ three years postoperatively. The JHEQ showed significant differences in the patient satisfaction and mental scores between those with and those without sypmtoms of LFCN injury at ≥ three years postoperatively, while there was no significant difference in the mean SF-36 scores. Conclusion: The incidence of LFCN injury after PAO using an anterior approach is high. The outcome of PAO, ≥ three years postoperatively, is poorer in patients with persistent symptoms from a perioperative LFCN injury, in that patient satisfaction and mental health scores are adversely affected.
Assuntos
Acetábulo , Osteotomia , Traumatismos dos Nervos Periféricos , Complicações Pós-Operatórias , Humanos , Feminino , Masculino , Incidência , Adulto , Osteotomia/efeitos adversos , Osteotomia/métodos , Acetábulo/cirurgia , Acetábulo/lesões , Estudos Prospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/epidemiologia , Pessoa de Meia-Idade , Nervo Femoral/lesões , Adulto Jovem , Resultado do Tratamento , AdolescenteRESUMO
PURPOSE: To illustrate MRI findings in patients with femoral neuropathy following anterior approach total hip arthroplasty (THA). METHODS: This was a retrospective review of patients who underwent MRI for femoral neuropathy following anterior approach THA between January 1, 2010, and July 1, 2022. Included patients had no preexisting neurologic condition. Clinical and diagnostic data were collected. MRIs were reviewed in consensus by 2 musculoskeletal radiologists. RESULTS: A total of 115 patient records were reviewed, 17 of which were included in the final analysis (mean age 64 years; 11 females). Study subjects presented with weakness with hip flexion and knee extension and pain and numbness in the femoral nerve distribution. In 7 subjects, the femoral nerve appeared normal. In 5 subjects, the femoral nerve was hyperintense on fluid-sensitive fat-suppressed imaging. In 4 patients, mass effect on the femoral nerve by either ill-defined soft tissue edema (n = 2), seroma (n = 1), or heterotopic ossification (n = 1) was detected. Only 1 patient had a nerve transection. Patients were imaged at a median time of 8 months (range: 1 day to 11 years) following arthroplasty placement. Clinical follow-up was available in 8 patients, of whom half had complete symptomatic resolution and half had partial improvement at a mean follow-up time of 39.3 months (SD 51.1). Of these 8, 1 underwent revision arthroplasty, 1 had removal of hardware, and another had excision of heterotopic ossification. CONCLUSION: MRI provides a means to directly evaluate the femoral nerve following anterior approach THA in both the immediate and chronic postoperative periods.
Assuntos
Artroplastia de Quadril , Neuropatia Femoral , Ossificação Heterotópica , Feminino , Humanos , Pessoa de Meia-Idade , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Neuropatia Femoral/diagnóstico por imagem , Neuropatia Femoral/etiologia , Nervo Femoral/diagnóstico por imagem , Nervo Femoral/lesões , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Imageamento por Ressonância Magnética , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Femoral nerve damage, especially in proximal retroperitoneal space, is rare. Therefore, surgical strategy is still unclear for these patients. Various specialists discuss repair with autografts or neurotization by the obturator nerve or its muscular branch. OBJECTIVE: To demonstrate the diagnostic algorithm for proximal femoral nerve injury and favorable outcomes after repair with long autografts. MATERIAL AND METHODS: We assessed movements and sensitivity using a five-point scale, as well as ultrasound, magnetic resonance imaging and electroneuromyography data in a patient with extended iatrogenic femoral nerve damage before and after repair with long autografts (10.5 cm). RESULTS AND DISCUSSION: The patient had complete femoral nerve interruption in proximal retroperitoneal space with 10-cm defect that required repair with five autografts from two sural nerves. Postoperative ultrasound and magnetic resonance imaging revealed signs of graft survival and no neuroma within the nerve suture lines. The first signs of motor recovery occurred after 10 months. After 14 months, strength of quadriceps femoris muscle comprised 4 points, and electroneuromyography confirmed re-innervation. CONCLUSION: Femoral nerve repair with autografts for complete proximal anatomical interruption can provide sufficient restoration of movements and sensitivity. Therefore, this surgical option should be preferred instead of neurotization. Ultrasound, MRI and ENMG are valuable to clarify the diagnosis and state of the autografts.
Assuntos
Nervo Femoral , Transferência de Nervo , Humanos , Nervo Femoral/diagnóstico por imagem , Nervo Femoral/cirurgia , Nervo Femoral/lesões , Autoenxertos , Espaço Retroperitoneal , Procedimentos Neurocirúrgicos , Transferência de Nervo/métodosRESUMO
Aims: Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury. Methods: In this trial, 134 patients were randomized into a lateral fasciotomy (n = 67) or a conventional fasciotomy (n = 67) group. This study was a dual-centre, double-blind, prospective randomized controlled two-arm trial with parallel group design and a 1:1 allocation ratio. The primary endpoint was the presence of LFCN injury, which was determined by the presence of numbness, decreased sensation, tingling, jolt-like sensation, or pain over the lateral aspect of the thigh, excluding the surgical scar, using a patient-based questionnaire. The secondary endpoints were patient-reported outcome measures (PROMs) using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), and the Forgotten Joint Score-12 (FJS-12). Assessments were obtained three months after surgery. Results: The incidence of LFCN injury tended to be lower in the lateral fasciotomy group (p = 0.089). In the lateral fasciotomy group, there were no significant differences in the mean PROM scores between patients with and without LFCN injury (FJS-12: 54.42 (SD 15.77) vs 65.06 (SD 26.14); p = 0.074; JHEQ: 55.21 (SD 12.10) vs 59.72 (SD 16.50); p = 0.288; WOMAC: 82.45 (SD 6.84) vs 84.40 (SD 17.91); p = 0.728). In the conventional fasciotomy group, there were significant differences in FJS-12 and JHEQ between patients with and without LFCN injury (FJS-12: 43.21 (SD 23.08) vs 67.28 (SD 20.47); p < 0.001; JHEQ: 49.52 (SD 13.97) vs 59.59 (SD 15.18); p = 0.012); however, there was no significant difference in WOMAC (76.63 (SD 16.81) vs 84.16 (SD 15.94); p = 0.107). Conclusion: The incidence of LFCN injury at three months after THA was comparable between the lateral and conventional fasciotomy groups. Further studies are needed to assess the long-term effects of these approaches.
Assuntos
Artroplastia de Quadril , Coxa da Perna , Humanos , Antivirais , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Fasciotomia , Nervo Femoral/lesões , Estudos Prospectivos , Coxa da Perna/inervação , Resultado do TratamentoRESUMO
Postoperative femoral nerve palsy (FNP) is a rare complication associated with urologic surgery. Inappropriate use of retractors, use of lithotomy position, and prolonged surgery that lead to the femoral nerve compression have been reported as risk factors for FNP. Here, we report two cases of FNP after pelvic surgery. Case 1: A 47-year-old woman underwent ureterocystoneostomy for a giant ureterocele. On the first postoperative day, she developed muscle weakness and paresthesia in the left lower leg. An orthopedic surgeon diagnosed her with FNP associated with the surgery. Case 2: An 82-year-old woman underwent radical cystectomy for invasive bladder cancer. On the second postoperative day, she developed extension deficit in the left lower leg and was diagnosed with an iatrogenic FNP. Although this complication is infrequent, at onset, it leads to difficulty in walking and gait disturbance in the patient. As a result, it greatly reduces the patient's postoperative quality of life. Therefore, preventive measures should be taken to reduce the risk of this postsurgical nerve injury, such as appropriate placement of retractors and proper patient positioning during the operation.
Assuntos
Nervo Femoral , Neuropatia Femoral , Feminino , Humanos , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Nervo Femoral/lesões , Qualidade de Vida , Neuropatia Femoral/etiologia , Pelve , Paralisia/complicaçõesRESUMO
BACKGROUND: An incision for total hip arthroplasty (THA) via the direct anterior approach (DAA) is generally made outside of the space between the sartorius and tensor fasciae latae muscles to prevent lateral femoral cutaneous nerve (LFCN) injury. Anatomical studies have revealed that the LFCN courses between the sartorius and tensor fasciae latae muscles. When the LFCN branches radially while distributing in the transverse direction from the sartorius muscle to the tensor fasciae latae muscle, it is called the fan type. Studies suggest that damage to the fan type LFCN is unavoidable during conventional fasciotomy. We previously demonstrated that injury to non-fan variation LFCN occurred in 28.6% of patients who underwent THA by fasciotomy performed 2 cm away from the intermuscular space. This suggests that the conventional approach also poses a risk of LFCN injury to non-fan variation LFCN. LFCN injury is rarely reported in the anterolateral approach, which involves incision of fascia further away than the DAA. The purpose of this study is to investigate how the position of fasciotomy in DAA affects the risk of LFCN injury. METHODS: We will conduct a prospective, randomized, controlled study. All patients will be divided into a fan variation and a non-fan variation group using ultrasonography before surgery. Patients with non-fan variation LFCN will receive conventional fasciotomy and lateral fasciotomy in the order specified in the allocation table created in advance by our clinical trial center. The primary endpoint will be the presence of LFCN injury during an outpatient visit using a patient-based questionnaire. The secondary endpoints will be assessed based on patient-reported outcomes at 3 months after surgery in an outpatient setting using the Western Ontario and McMaster Universities Osteoarthritis Index, the Japanese Orthopaedic Association Hip-disease Evaluation Questionnaire, and the Forgotten-Joint Score-12. DISCUSSION: We hypothesize that the incidence of LFCN injury due to DAA-THA is reduced by making the incision further away from where it is typically made in conventional fasciotomy. If our hypothesis is confirmed, it will reduce the disadvantages of DAA and improve patient satisfaction. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000035945 . Registered on 20 February, 2019.
Assuntos
Artroplastia de Quadril , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Fasciotomia , Nervo Femoral/diagnóstico por imagem , Nervo Femoral/lesões , Humanos , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Coxa da Perna/inervaçãoRESUMO
BACKGROUND: Lateral femoral cutaneous nerve (LFCN) injury after total hip arthroplasty causes patient dissatisfaction. This cadaveric study aimed to assess the risk for LFCN injury after the direct anterior approach (DAA) and anterolateral supine approach (ALS) with a focus on the anatomical variations of the LFCN. METHODS: Thirty-seven hemipelves from 20 formalin-preserved cadavers (10 males and 10 females) were dissected to identify the LFCN, evaluate variations, and measure the distance from the LFCN to each approach. The LFCN was classified as classical, late, multi trunk, or primary femoral. RESULTS: There were no significant variations in the LFCN between the sexes. The distance from the LFCN to DAA incision (10 [0-17.8] mm) was significantly less than that from the LFCN to ALS incision (27 [0-40] mm); moreover, 64.9% of DAA incisions crossed the LFCN. The classical type LFCN was closest to the DAA incision. The DAA incision most frequently crossed the LFCN at the proximal third, and the frequency of intersection of the LFCN and DAA incisions decreased by 25% by a 10-mm shortening of the DAA proximal incision. In contrast, 27% of ALS incisions crossed the LFCN. Multi trunk type LFCN was closest to the ALS incision. There were no significant differences between each approach and LFCN variations, and the frequency of intersection of the LFCN and ALS incisions decreased by 20% by a 10-mm shortening of the ALS proximal incision. CONCLUSIONS: The intersection rates between the LFCN and the DAA and between the LFCN and the ALS were approximately 65 and 30%, respectively. Approximately 20-25% of these injuries may be avoidable by a 10-mm shortening of the proximal incision.
Assuntos
Artroplastia de Quadril , Artroplastia de Quadril/efeitos adversos , Feminino , Nervo Femoral/lesões , Fêmur , Humanos , Masculino , Coxa da PernaRESUMO
AIMS: This study aimed to use intraoperative free electromyography to examine how the placement of a retractor at different positions along the anterior acetabular wall may affect the femoral nerve during total hip arthroplasty (THA) when undertaken using the direct anterior approach (THA-DAA). METHODS: Intraoperative free electromyography was performed during primary THA-DAA in 82 patients (94 hips). The highest position of the anterior acetabular wall was defined as the "12 o'clock" position (middle position) when the patient was in supine position. After exposure of the acetabulum, a retractor was sequentially placed at the ten, 11, 12, one, and two o'clock positions (right hip; from superior to inferior positions). Action potentials in the femoral nerve were monitored with each placement, and the incidence of positive reactions (defined as explosive, frequent, or continuous action potentials, indicating that the nerve was being compressed) were recorded as the primary outcome. Secondary outcomes included the incidence of positive reactions caused by removing the femoral head, and by placing a retractor during femoral exposure; and the incidence of femoral nerve palsy, as detected using manual testing of the strength of the quadriceps muscle. RESULTS: Positive reactions were significantly less frequent when the retractor was placed at the ten (15/94; 16.0%), 11 (12/94; 12.8%), or 12 o'clock positions (19/94; 20.2%), than at the one (37/94; 39.4%) or two o'clock positions (39/94; 41.5%) (p < 0.050). Positive reactions also occurred when the femoral head was removed (28/94; 29.8%), and when a retractor was placed around the proximal femur (34/94; 36.2%) or medial femur (27/94; 28.7%) during femoral exposure. After surgery, no patient had reduced strength in the quadriceps muscle. CONCLUSION: Placing the anterior acetabular retractor at the one or two o'clock positions (right hip; inferior positions) during THA-DAA can increase the rate of electromyographic signal changes in the femoral nerve. Thus, placing a retractor in these positions may increased the risk of the development of a femoral nerve palsy. Cite this article: Bone Joint J 2022;104-B(2):193-199.
Assuntos
Artroplastia de Quadril/métodos , Eletromiografia/métodos , Nervo Femoral/fisiopatologia , Complicações Intraoperatórias/prevenção & controle , Monitorização Neurofisiológica Intraoperatória/métodos , Traumatismos dos Nervos Periféricos/prevenção & controle , Acetábulo/cirurgia , Adulto , Idoso , Artroplastia de Quadril/instrumentação , Feminino , Nervo Femoral/lesões , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Traumatismos dos Nervos Periféricos/etiologia , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND CONTEXT: The transpsoas lateral lumbar interbody fusion (LLIF) technique is an effective alternative to traditional anterior and posterior approaches to the lumbar spine; however, nerve injuries are the most reported postoperative complication. Commonly used strategies to avoid nerve injury (eg, limiting retraction duration) have not been effective in detecting or preventing femoral nerve injuries. PURPOSE: To evaluate the efficacy of emerging intraoperative femoral nerve monitoring techniques and the importance of employing prompt surgical countermeasures when degraded femoral nerve function is detected. STUDY DESIGN/SETTING: We present the results from a retrospective analysis of a multi-center study conducted over the course of 3 years. PATIENT SAMPLE: One hundred and seventy-two lateral lumbar interbody fusion procedures were reviewed. OUTCOME MEASURES: Intraoperative femoral nerve monitoring data was correlated to immediate postoperative neurologic examinations. METHODS: Femoral nerve evoked potentials (FNEP) including saphenous nerve somatosensory evoked potentials (snSSEP) and motor evoked potentials with quadriceps recordings were used to detect evidence of degraded femoral nerve function during the time of surgical retraction. RESULTS: In 89% (n=153) of the surgeries, there were no surgeon alerts as the FNEP response amplitudes remained relatively unchanged throughout the surgery (negative group). The positive group included 11% of the cases (n=19) where the surgeon was alerted to a deterioration of the FNEP amplitudes during surgical retraction. Prompt surgical countermeasures to an FNEP alert included loosening, adjusting, or removing surgical retraction, and/or requesting an increase in blood pressure from the anesthesiologist. All the cases where prompt surgical countermeasures were employed resulted in recovery of the degraded FNEP amplitudes and no postoperative femoral nerve injuries. In two cases, the surgeons were given verbal alerts of degraded FNEPs but did not employ prompt surgical countermeasures. In both cases, the degraded FNEP amplitudes did not recover by the time of surgical closure, and both patients exhibited postoperative signs of sensorimotor femoral nerve injury including anterior thigh numbness and weakened knee extension. CONCLUSIONS: Multimodal femoral nerve monitoring can provide surgeons with a timely alert to hyperacute femoral nerve conduction failure, enabling prompt surgical countermeasures to be employed that can mitigate or avoid femoral nerve injury. Our data also suggests that the common strategy of limiting retraction duration may not be effective in preventing iatrogenic femoral nerve injuries.
Assuntos
Nervo Femoral , Fusão Vertebral , Potencial Evocado Motor/fisiologia , Nervo Femoral/lesões , Humanos , Vértebras Lombares/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodosAssuntos
Cateterismo Periférico/efeitos adversos , Oxigenação por Membrana Extracorpórea , Nervo Femoral/lesões , Traumatismos dos Nervos Periféricos/terapia , Nervo Radial/lesões , Estimulação Elétrica Nervosa Transcutânea/métodos , Adulto , Humanos , Masculino , Traumatismos dos Nervos Periféricos/etiologiaRESUMO
INTRODUCTION: Advances in the care of soft-tissue tumors, including imaging capabilities and adjuvant radiation therapy, have broadened the indications and opportunities to pursue surgical limb salvage. However, peripheral nerve involvement and femoral nerve resection can still result in devastating functional outcomes. Nerve transfers offer a versatile solution to restore nerve function following tumor resection. METHODS: Two cases were identified by retrospective review. Patient and disease characteristics were gathered. Preoperative and postoperative motor function were assessed using the Medical Research Council Muscle Scale. Patient-reported pain levels were assessed using the numeric rating scale. RESULTS: Nerve transfers from the obturator and sciatic nerve were employed to restore knee extension. Follow up for Case 1 was 24 months, 8 months for Case 2. In both patients, knee extension and stabilization of gait without bracing was restored. Patient also demonstrated 0/10 pain (an average improvement of 5 points) with decreased neuromodulator and pain medication use. CONCLUSION: Nerve transfers can restore function and provide pain control benefits and ideally are performed at the time of tumor extirpation. This collaboration between oncologic and nerve surgeons will ultimately result in improved functional recovery and patient outcomes.
Assuntos
Nervo Femoral/lesões , Lipossarcoma/cirurgia , Transferência de Nervo/métodos , Neurilemoma/cirurgia , Traumatismos dos Nervos Periféricos/cirurgia , Neoplasias de Tecidos Moles/cirurgia , Adulto , Idoso , Feminino , Humanos , Lipossarcoma/patologia , Masculino , Neurilemoma/patologia , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/patologia , Estudos Retrospectivos , Neoplasias de Tecidos Moles/patologiaRESUMO
AIMS: Injury to the lateral femoral cutaneous nerve (LFCN) is one of the known complications after periacetabular osteotomy (PAO) performed using the anterior approach, reported to occur in between 1.5% and 65% of cases. In this study, we performed a prospective study on the incidence of LFCN injury as well as its clinical outcomes based on the Harris Hip Score (HHS), Short-Form 36 Health Survey (SF-36), and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ). METHODS: The study included 42 consecutive hips in 42 patients (three male and 39 female) who underwent PAO from May 2016 to July 2018. We prospectively evaluated the incidence of LFCN injury at ten days, three months, six months, and one year postoperatively. We also evaluated the clinical scores, including the HHS, SF-36, and JHEQ scores, at one year postoperatively. RESULTS: LFCN injury was observed in 31 of 42 (74%) patients at ten days, of which 11 resolved completely by one year. Incidence decreased gradually, to 25 of 42 (60%) patients at three months, 24 of 42 patients (57%) at six months, and 20 of 42 (48%) patients at one year postoperatively. There was no significant difference in the HHS between patients with and without LFCN injury at one year postoperatively. Regarding the SF-36 and JHEQ, a significant difference in the mental score was recognized between patients with and without LFCN injury, but there were no significant differences in the other clinical scores. CONCLUSION: The incidence of LFCN injury was 74% at ten days after PAO, and subsequently decreased to 48% at one year. LFCN injury did not influence the hip function as assessed by the HHS, but had a negative impact on mental health at one year. Cite this article: Bone Joint J 2021;103-B(4):659-664.
Assuntos
Acetábulo/cirurgia , Displasia do Desenvolvimento do Quadril/cirurgia , Nervo Femoral/lesões , Osteotomia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Feminino , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Inquéritos e QuestionáriosRESUMO
Arthroplasty is a surgical procedure to restore the function of the joint of patient suffering from knee osteoarthritis. However, postoperative functional deficits are reported even after a rehabilitation program. In order to determine the origin of functional deficits of patient suffering from knee osteoarthritis and total knee arthroplasty, we developed a rodent model including a chemically-induced-osteoarthritis and designed a knee prosthesis (Ti6Al4V/PEEK) biomechanically and anatomically adapted to rat knee joint. Dynamic Weight-Bearing, gait kinematics, H-reflex from vastus medialis muscle and activities from metabosensitive III and IV afferent fibers in femoral nerve were assessed at 1 and 3 months post-surgery. Results indicate that knee osteoarthritis altered considerably the responses of afferent fibers to their known activators (i.e., lactic acid and potassium chloride) and consequently their ability to modulate the spinal sensorimotor loop, although, paradoxically, motor deficits seemed relatively light. On the contrary, results indicate that, after the total knee arthroplasty, the afferent responses and the sensorimotor function were slightly altered but that motor deficits were more severe. We conclude that neural changes attested by the recovery of the metabosensitive afferent activity and the sensorimotor loop were induced when a total knee replacement was performed and that these changes may disrupt or delay the locomotor recovery.
Assuntos
Artroplastia do Joelho/instrumentação , Cetonas , Prótese do Joelho , Osteoartrite do Joelho/cirurgia , Polietilenoglicóis , Titânio , Vias Aferentes/fisiologia , Ligas , Animais , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Benzofenonas , Modelos Animais de Doenças , Nervo Femoral/lesões , Nervo Femoral/fisiopatologia , Marcha , Transtornos Neurológicos da Marcha/etiologia , Transtornos Neurológicos da Marcha/fisiopatologia , Reflexo H , Ácido Iodoacético/toxicidade , Masculino , Músculo Esquelético/fisiopatologia , Osteoartrite do Joelho/induzido quimicamente , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/fisiopatologia , Polímeros , Complicações Pós-Operatórias/etiologia , Distribuição Aleatória , Ratos , Recuperação de Função Fisiológica , Suporte de CargaRESUMO
BACKGROUND: A great extent of knowledge on peripheral nerve regeneration has been gathered using the rat sciatic nerve model. The femoral nerve model of the rat offers an interesting alternative, as it lacks disadvantageous features such as automutilation. For the analysis of locomotor behavior in rats after sciatic nerve injury, the CatWalk™ XT Gait Analysis System is often used. However, lesions of the femoral nerve in the rat have yet remained unstudied with this method. MATERIAL AND METHODS: Ten male Sprague Dawley rats were evaluated with the CatWalk XT to study their gait after a 6-mm resection of the right femoral nerve and reconstruction with an autologous nerve graft. Animals were observed for 10 weeks after surgery. RESULTS: Print Area, Print Length, Swing Speed, and Duty Cycle decreased to a minimum of 40% of baseline 2 weeks after surgery. Swing Time was elevated more than twofold at this time point. However, all these parameters recovered back to >90% of baseline values at 10 weeks after surgery. This degree of functional recovery has not been reported after sciatic nerve resection and autograft repair. Base of support varied minimally postoperatively in contrast to a strong decrement after sciatic nerve resection and repair. CONCLUSION: We hereby provide a comprehensive in-depth analysis of how to study functional recovery after injury of the femoral nerve in the rat via the CatWalk XT. We place special emphasis on highlighting the differences between the femoral nerve and sciatic nerve injury model in this context.
Assuntos
Nervo Femoral/fisiopatologia , Locomoção/fisiologia , Regeneração Nervosa/fisiologia , Traumatismos dos Nervos Periféricos/fisiopatologia , Recuperação de Função Fisiológica/fisiologia , Animais , Autoenxertos/fisiopatologia , Nervo Femoral/lesões , Marcha/fisiologia , Masculino , Transferência de Nervo/métodos , Ratos , Ratos Sprague-DawleyRESUMO
Postoperative femoral nerve palsy with nerve division is a potentially devastating complication with a poor prognosis, especially when there is a delay in diagnosis. We present a novel 'belt and braces' approach for managing this unusual injury, using a modification of a nerve transfer, which has only been previously reported in the literature three times to our knowledge.
Assuntos
Nervo Femoral/lesões , Herniorrafia/efeitos adversos , Transferência de Nervo/métodos , Nervo Obturador/cirurgia , Feminino , Hérnia Inguinal/cirurgia , Humanos , Pessoa de Meia-Idade , Paralisia/etiologia , Paralisia/cirurgiaRESUMO
BACKGROUND: As its indications have evolved, hip arthroscopy is now performed more frequently in pediatric patients. However, despite this increase, there is a lack of evidence in the literature about its safety in this population in regard to traction injury of the nerves of the lower extremity. PURPOSE: To determine neuromonitoring changes of the sciatic, femoral, and obturator nerves during hip arthroscopy in the pediatric population and determine the rate of and risk factors for clinical neurapraxia. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review was performed of all pediatric patients who underwent hip arthroscopy with neuromonitoring from December 2013 to October 2018. Neuromonitoring included somatosensory evoked potentials (SSEPs) in the peroneal and posterior tibial nerves and electromyography (EMG) signal for the obturator, femoral, and peroneal and posterior tibial nerves. Traction was applied using a radiolucent traction table. We recorded total traction time, surgery time, SSEP changes >50% after traction application, and EMG activity. We also recorded whether there was a clinical neurapraxia and when nerve function returned, and analyzed surgical and patient characteristic data for risk factors for neurapraxia. RESULTS: A total of 89 patients had hip arthroscopy (median traction time, 69 minutes). SSEP changes >50% occurred in 78% of patients in the peroneal nerve and 73% in the posterior tibial nerve. EMG activity was observed in 9% of patients in the obturator nerve, 8% in the femoral nerve, 12% in the peroneal nerve, and 8% in the posterior tibial nerve. Clinical neurapraxia was seen in 19% of patients in either the peroneal nerve or posterior tibial nerve but resolved by 2 days postoperatively. Those who sustained a neurapraxia had a 32-minute longer surgery and 6-minute longer traction time. The clinical rate of neurapraxia of the pudendal nerve was 0%. CONCLUSION: Neuromonitoring changes are common during hip arthroscopy and nearly 1 in 5 pediatric patients will have some decreased sensation in either the peroneal or the posterior tibial nerve that resolves within 1 to 2 days after surgery. In pediatric patients, longer surgery and traction times during hip arthroscopy are associated with a higher rate of neurapraxia than that reported for adults.
Assuntos
Artroscopia/métodos , Articulação do Quadril/cirurgia , Traumatismos dos Nervos Periféricos/epidemiologia , Adolescente , Artroscopia/efeitos adversos , Criança , Eletromiografia , Feminino , Nervo Femoral/lesões , Humanos , Masculino , Duração da Cirurgia , Estudos Retrospectivos , Fatores de Risco , TraçãoRESUMO
PURPOSE: The direct anterior approach for primary total hip arthroplasty (THA) has become increasingly popular in recent years. Nerve compression or traction with a retractor is a common cause of nerve injury in this approach. The purpose of this cadaveric study was to evaluate the anatomic relationship of the femoral neurovascular bundle to the anterior acetabular retractor during direct anterior approach THA. METHODS: Eleven fresh-frozen cadavers underwent a standard direct anterior THA, with placement of an anterior acetabular retractor in the usual fashion between the iliopsoas and acetabulum for visualization during acetabular preparation. Careful dissection of the femoral triangle was performed, and the distances from the anterior retractor tip to the femoral nerve, artery, and vein were recorded and analyzed as mean distance ± standard deviation. RESULTS: In all 11 cadavers, the retractor tip was medial to the femoral nerve. The mean distance from retractor tip to femoral artery and vein was 5.9 mm (SD = 5.5, range 0-20) and 12.6 mm (SD 0.7, range 0-35), respectively. CONCLUSIONS: Surgeons should be aware of the proximity of the neurovascular structures in relation to the anterior acetabular retractor in the direct anterior approach, taking care to avoid perforating the iliopsoas muscle during retractor insertion and limit excessive traction to prevent nerve injury.
Assuntos
Acetábulo , Artroplastia de Quadril , Artéria Femoral , Nervo Femoral , Veia Femoral , Complicações Intraoperatórias , Traumatismos dos Nervos Periféricos , Lesões do Sistema Vascular , Acetábulo/irrigação sanguínea , Acetábulo/inervação , Acetábulo/cirurgia , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/instrumentação , Artroplastia de Quadril/métodos , Cadáver , Artéria Femoral/anatomia & histologia , Artéria Femoral/lesões , Nervo Femoral/anatomia & histologia , Nervo Femoral/lesões , Veia Femoral/anatomia & histologia , Veia Femoral/lesões , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Modelos Anatômicos , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/prevenção & controle , Instrumentos Cirúrgicos/efeitos adversos , Tração/efeitos adversos , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/prevenção & controleRESUMO
BACKGROUND: Femoral nerve palsy is a serious neurological complication following total hip arthroplasty (THA) via a direct anterior approach. One hypothesis is that the nerve injury is caused by malpositioning of retractors over the anterior wall of the acetabulum. The purpose of this cadaveric study was to clarify the anatomical features of the femoral nerve around the anterior acetabular rim and the potential risk of nerve injury during a direct anterior approach to THA. METHODS: We dissected 84 cadaveric hips from 44 formalin-embalmed cadavers. When the cadavers were supine, the iliopsoas muscle and the femoral nerve were exposed and the anterior joint capsule and labrum were resected. The measurement points were determined along the acetabular rim every 30°, and a reference line was drawn from the anterior superior iliac spine to the center of the acetabulum, with the intersection of the rim at 0°. The minimum distance to the femoral nerve margin was measured from 0° to 150° (6 points). Other anatomical structures were measured to determine their association with the distance of the shortest measurement points. RESULTS: The mean minimum distances to the femoral nerve were 33.2 mm at 0°, 24.4 mm at 30°, 18.4 mm at 60°, 16.6 mm at 90°, 17.9 mm at 120°, and 23.2 mm at 150°, showing that the distance at 90° was the shortest (p < 0.001). The thickness of the iliopsoas muscle and the femoral length were positively associated with the distance to the femoral nerve at 90°. CONCLUSIONS: In this cadaveric study, the femoral nerve was within 16.6 to 33.2 mm of the acetabular rim at points from 0° to 150° of a line drawn from the anterior superior iliac spine. The nerve was closest to the rim at 90°, indicating that this is an area of high risk during retractor placement. CLINICAL RELEVANCE: Retractor placement at 90° to the anterior acetabular rim should be avoided to reduce the risk of femoral nerve injury.