This case involves an adult patient with a history of prior right total hip replacement for developmental dysplasia of the hip. The patient later developed left hip pain with functional limitations and underwent a left total hip replacement.
Postoperatively, the patient was found to have a complete femoral nerve palsy, along with a significant leg length discrepancy. Imaging also demonstrated intrapelvic protrusion of the acetabular component, with limited bony purchase of the acetabular screws. Over multiple postoperative visits, the femoral nerve palsy did not improve, and the patient continued to experience difficulty walking and persistent pain.
The patient ultimately sought a second opinion and underwent additional imaging, which showed disruption of the pelvic ring, bony discontinuity of both the anterior and posterior columns, and significant protrusion of the acetabular cup into the pelvis. The patient later underwent revision surgery but continued to require a walker for ambulation and was unable to return to their prior work capacity.
From a legal perspective, this case may turn on whether the acetabular component was properly positioned during the hip replacement and whether postoperative imaging findings were recognized and addressed in a timely manner. The key issues may include surgical technique, implant placement, nerve injury, leg length discrepancy, follow-up care, and whether earlier revision or referral could have reduced the patient’s long-term functional limitations.
Questions to the Hip Surgery expert and their responses
What are some measures that should be taken intraoperatively to prevent inadvertent nerve injury and leg length discrepancy?
Preoperatively, it is important to template the patient to determine the native leg length and hip offset to ensure these are recreated during surgery. Intraoperatively, soft tissue tension, sciatic nerve tension, hip range of motion, and stability are assessed to help confirm that appropriate leg length and offset have been achieved. Care is also taken when placing retractors in or around the area of the sciatic nerve during surgery. In the recovery room, x-rays are obtained to assess appropriate hip component positioning, including leg length and offset, which can be related to nerve stretching. Postoperatively, care is taken to avoid the development of a hematoma near the sciatic nerve, as this can also cause progressive sciatic nerve dysfunction.
About the expert
This highly qualified expert has nearly 15 years of experience in orthopedic surgery, and he specializes in hip surgery. He obtained his BS in economics from Vanderbilt University, before receiving his MD from the University of North Carolina School of Medicine. He then completed a prestigious residency and fellowship in orthopedic surgery and joint preservation, resurfacing, and replacement, respectively, at Washington University in St. Louis, followed by a second traveling fellowship in hip surgery in the United Kingdom through The Hip Society. Today, this expert is board-certified in orthopedic surgery. He is an active member of several professional organizations, including The Hip Society, the American Orthopedic Association, the American Academy of Orthopedic Surgeons, and the American Association of Hip and Knee Surgeons.
E-001219
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Questions to the Orthopedic Surgery expert and their responses
How often do you perform total hip replacement procedures?
I perform total hip replacement procedures approximately 100 times per year.
What are the most pertinent measures that a provider can perform to minimize the incidence of sciatic nerve injury when performing a total hip replacement?
The orthopedic literature indicates that nerve injuries at the hip during joint replacement procedures are exceedingly rare, regardless of surgical approach, occurring in approximately 3 out of every 10,000 hip replacements.
The most pertinent measures an orthopedic surgeon may take to minimize the risk of sciatic nerve injury include maintaining constant awareness of the sciatic nerve’s location during both anterior and posterior approaches to the hip joint. This is especially important when placing retractors around the acetabulum.
Slightly more than half of the rare nerve injuries associated with hip replacement surgery are thought to result from improper retractor placement. The remaining injuries tend to be caused by inadvertent stretching of the nerve or its branches.
About the expert
This expert has over 30 years of experience in the field of orthopedic surgery, focusing on adult reconstructive surgery. He earned his BA from Case Western Reserve University, his MD from the Medical College of Ohio, and later, his MBA in health care management from Columbia Southern University. He completed a residency in orthopedic surgery at Mount Carmel Mercy Hospital and a fellowship in adult total joint reconstruction from Central DuPage Hospital. Today, this expert is board-certified in orthopedic surgery and has special interests in adult reconstruction, arthroscopic reconstruction, general orthopedics, and anterior hip replacements. Currently, he serves as an orthopedic surgeon at a health system in Ohio as well as a residency program advisor at a second health system and the chief of orthopedic surgery at a local hospital. He is also a clinical assistant professor at a college in Michigan.
E-777222
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Questions to the expert and their responses
What are some measures that can be taken perioperatively and/or intraoperatively to prevent nerve injury/foot drop for patients undergoing hip replacement surgery?
Retractor placement is critical. The most commonly injured nerve with an anterior approach is the femoral nerve. The table is also critical to safe surgery. If you are using a HANA table the traction is not released when you drop the leg, everything can get stretched, including the nerves, and you are at risk of femoral fracture. If screws are placed in the acetabulum, you have to be very careful about their placement and length as well. The femoral neck cut is another part of the case where the sciatic nerve could potentially be at risk.
About the expert
This orthopedic surgery expert is clinically active in hip arthroplasty, performing approximately 2–3 anterior hip replacements per week and maintaining proficiency with anterior, anterolateral, and posterior approaches. The expert has specific familiarity with nerve injury risks in hip replacement surgery, including femoral nerve injury in anterior approaches and sciatic nerve injury in other approaches, and can address technical considerations such as retractor placement, table positioning and traction, acetabular screw placement, femoral neck cuts, and the potential mechanisms of intraoperative nerve stretch or injury. The expert has substantial medicolegal experience.
E-468621
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