Background: Sciatic nerve injuries following total hip arthroplasty are disabling complications. Although degrees of injury are variable from neuropraxia to neurotmesis, mechanical irritation of sciatic nerve might be occurred by protruding hardware. This case shows endoscopic decompression for protruded acetabular screw irritating sciatic nerve, the techniques described herein may permit broader arthroscopic/endoscopic applications for management of complications after reconstructive hip surgery. Case presentation: An 80-year-old man complained of severe pain and paresthesias following acetabular component revision surgery. Physical findings included right buttock pain with radiating pain to lower extremity. Radiographs and computed tomography imaging showed that the sharp end of protruded screw invaded greater sciatic foramen anterior to posterior and distal to proximal direction at sciatic notch level. A protruding tip of the acetabular screw at the sciatic notch was decompressed by use of techniques gained from experience performing endoscopic sciatic nerve decompression. The pre-operative pain and paresthesias resolved post-operatively after recovering from anesthesia. Conclusions: This case report describes the first documented endoscopic resection of the tip of the acetabular screw irritating sciatic nerve after total hip arthroplasty. If endoscopic resection of an offending acetabular screw can be performed in a safe and minimally invasive manner, one can envision a future expansion of the role of hip arthroscopic surgery in several complications management after total hip arthroplasty. Keywords: Endoscopic sciatic nerve decompression, Sciatic nerve neuropathy, Acetabular dome screw, Total hip arthroplasty Background This is the first documented case of completely endo- Sciatic nerve irritation due to an acetabular screw fol- scopic treatment of sciatic nerve irritation by a pro- lowing total hip arthroplasty (THA) is rare; the few re- truded acetabular dome screw following THA. ported were treated with revision procedure to remove an acetabular screw . Recent reports of the ortho- Case presentation paedic literature document the use of endoscopic de- An 80-year-old man complained of severe pain and par- compression of sciatic nerve entrapment syndrome/deep esthesias following acetabular component revision sur- gluteal syndrome treatment . Endoscopy allows for gery via the original posterolateral approach. The patient complete extrapelvic sciatic nerve visualization and safe subsequently complained of right leg pain and paresthe- nerve decompression in the deep gluteal space [3, 4]. sias. The symptoms were exaggerated during initial hip flexion and internal rotation that limited ambulation. Physical findings included right buttock pain with radiat- * Correspondence: firstname.lastname@example.org Department of Orthopedic Surgery, Research Institute of clinical medicine of ing pain to the ipsilateral lower extremity. Radiographs Chonbuk National University, Biomedical Research Institute of Chonbuk and computed tomography imaging (Figs. 1, 2, 3, and 4) National University Hospital, 54907 Gunji-Ro 20, Dukjin-Gu, Chonbuk, Jeonju, showed an acetabular screw tip protruding into the South Korea Full list of author information is available at the end of the article greater sciatic foramen in an anterior to posterior and © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Yoon et al. BMC Musculoskeletal Disorders (2018) 19:184 Page 2 of 6 Fig. 1 Preoperative hip radiographs (anteroposterior view; Left, iliac oblique view; Right) with protruded dome screw (arrowhead) into sciatic notch distal to proximal direction at the level of the sciatic utilizing the radiofrequency probe. Fluid pressure was notch. The screw was 30 mm in length and positioned set to 60 mmHg with intermittent pressure increases up at posterior-inferior acetabular quadrant. Magnetic res- 80 mmHg. After endoscopic greater trochanteric bur- onance imaging demonstrated tenting of the right piri- sectomy, the repaired piriformis from previous revision formis muscle tented by the end of screw. Mechanical surgery was well visualized (Fig. 5). Endoscopic irritation of the sciatic nerve screw was suspected. visualization of the sciatic nerve revealed a hypo vascular Eight months after the aforementioned surgery, the appearance, with entrapped by repaired the piriformis patient underwent supine hip arthroscopy without dis- muscle and adjacent fibrous tissue. Endoscopic dynamic traction on a fracture table (Hana®, Mizuho OSI). The testing demonstrated sciatic nerve hypomobility with operating table was tilted right side upward to increase limited excursion during hip flexion and extension in in- accessibility of ipsilateral buttock. An anterolateral view- ternal and external rotation. The repaired piriformis ten- ing portal and poster lateral working portal were devel- don was tenotomized and more adjacent scar tissue was oped without incident. For deep gluteal space observed. Endoscopic resection of fibrovascular bands visualization, a 70-degree high definition long arthro- and adhesions between the piriformis muscle and pos- scope with adjustable length cannulas were utilized. The terior acetabular wall was performed without incident, cannula was opened to maintain the fluid flow when allowing visualization of the protruding screw tip pene- trated through the piriformis muscle (Fig. 6). Endoscopic piriformis muscle dissection and adhesiolysis was per- formed, improving visualization of the screw tip adjacent to the supero-lateral aspect of the sciatic nerve. No sciatic nerve intra-substance splitting or tearing was ob- served, supporting the diagnosis of sciatic nerve irritation without direct nerve injury. Via endoscopic and intermit- tent multiplanar fluoroscopic visualization, further dissec- tion was performed proximally and distally to prevent inadvertent injuries to the sciatic nerve and the superior gluteal neurovascular bundle. Partial osteoplasty of the sciatic notch with a motorized burr performed under endoscopic guidance. Endoscopic resection of the offend- ing screw tip was performed with a 5.5 mm motorized round burr (Fig. 7). The adjustable cannula protected the adjacent superior gluteal vessels from iatrogenic harm. The screw was scored from the superolateral direction to minimize the risk of unexpected injury by the burr after decorticating the sciatic notch. The protruded screw tip Fig. 2 Oblique 3-dimensional computed tomography reconstruction was completely resected and subsequently recontoured to showing an acetabular screw protruded into sciatic a smooth surface. The screw tip was removed enbloc with notch (arrowhead) an arthroscopic grasper (Fig. 8). Generated metallic debris Yoon et al. BMC Musculoskeletal Disorders (2018) 19:184 Page 3 of 6 Fig. 3 Coronal and computed tomography views of right hip showing sciatic notch area occupied by an acetabular screw (arrow). The protruded screw was placed superiorly than piriformis muscle (P) were removed via suction through the burr cannula. All negative active and passive piriformis test and he visible metallic debris was removed. Dynamic arthroscopic remained pleased with the outcome. Postoperative im- and fluoroscopic examinations confirmed successful de- aging included radiographs and computed tomography compression of the acetabular screw with an immediate scans with 3-dimensional reconstruction demonstrating visible improvement in sciatic nerve vascularity and excur- complete resection of the offending portion of the ace- sion. Key procedural steps of this arthroscopic procedure tabular screw. are shown as Additional file 1: Endoscopic technique. After this endoscopic surgery, immediate hip range of motion was begun with a continuous passive motion Discussion machine. The pre-operative pain and paresthesias re- Nerve lesions following total hip arthroplasty (THA) are solved post-operatively after recovering from anesthesia. disabling complications occurring in 0.06 to 2.2% of The patient advanced to household ambulation without arthroplasties [5, 6]. Hardware-induced sciatic nerve upper extremity aids at 1 postoperative week despite neuropathies are rarely reported [1, 6]. If placed in the recommendations for 2 weeks of ambulation using crutches. By 3 months postoperatively, he had returned to full activities. At 6 months postoperatively, he had a Fig. 5 Endoscopic view from anterolateral portal of right hip (supine, upward tilt ipsilateral hip) showing repaired piriformis in previous Fig. 4 T2 turbo spin echo magnetic resonance image displaying a surgery (arrow). Sciatic nerve (SN) is pale and loss of perineural fat. It is screw protrusion (arrowhead) and irritated piriformis muscle (arrow) better visualized in the accompanying video Yoon et al. BMC Musculoskeletal Disorders (2018) 19:184 Page 4 of 6 Fig. 6 Endoscopic view from anterolateral portal of right hip (supine, ipsilateral upward tilt) showing screw tip (arrow) protruding from posterior column into sciatic notch being irritated sciatic nerve (SN) posterior superior quadrant, the screws may be directed endoscopic fluid pressure minimized risk of iatrogenic toward the sciatic nerve . Mechanical irritation should fluid extravasation into the intra-abdominal and/or be suspected in cases of any sign of sciatic neuropathy retroperitoneal spaces. after THA. The treatment of nerve injuries is tailored its An expandable cannula facilitated safe resection of the causation. In most cases, the cause is unknown and protruding screw tip while avoiding injury to the adja- treatment is directed toward managing symptoms rather cent superior gluteal nerve and sciatic nerve. Circulating than reversing the nerve injury . Open sciatic nerve endoscopy fluid might decrease thermogenesis during exploration with dissection of nerve bundle and metal-on-metal burring of the offending screw. In burr-decompression of the screw has been reported . addition, generated metallic debris is removed immedi- A protruding acetabular screw can tether the sciatic ately through suction system attached burr and cannula nerve, restricting its excursion. Endoscopic resection of to minimize bodily retention with possible adverse an offending acetabular screw has now been described. consequences. Indeed, had this protruded screw not been resectable by The decision to remove rather than try to preserve the endoscopic means, open exploration and screw removal piriformis muscle was influenced by the surgeon’s ex- or resection may have been required. Some advantages perience with deep gluteal space exploration often per- of deep gluteal space endoscopy as a minimally invasive formed for sciatic nerve decompression. procedure are demonstrated in this case report. Decreas- Relevant suggestions and pearls are summarized in ing morbidity with minimal blood loss while avoiding Table 1. re-revision surgery with hip dislocation was facilitated. For this patient, resection of offending screw tip using Moreover, early joint mobilization, relatively rapid post- endoscopy was considered first, because the acetabular operative rehabilitation, and outstanding cosmesis were component implanted revision surgery had bony in- realized. Surgical skills gained from experience with growth without evidence of loosening. Although sciatic endoscopic technique for deep gluteal syndrome explor- nerve irritation from a protruding acetabular screw is ation and comfort with the 70 degree arthroscope aided rare and its described treatment even rarer, the endo- the performance of this surgery. Careful management of scopic techniques described herein may have broader Fig. 7 Endoscopic view from anterolateral portal of right hip (supine) showing an acetabular screw being cut proximally by arthroscopic burr Yoon et al. BMC Musculoskeletal Disorders (2018) 19:184 Page 5 of 6 Fig. 8 Postoperative radiography and 3-dimensional computed tomography reconstruction showing the resected acetabular screw at sciatic notch level applications. Recent interest in hip arthroscopy along Conclusion with more advanced techniques gained from the en- A protruding acetabular screw at the sciatic notch was doscopic management of sciatic nerve entrapment decompressed by use of techniques gained from experi- syndrome/deep gluteal syndrome have allowed the ap- ence performing endoscopic sciatic nerve decompres- plication of minimally invasive hip surgery for condi- sion. Expandable cannula was used to protect superior tions once thought treatable only by open sciatic nerve gluteal neurovascular bundle proximally and sciatic exploration, screw resection and/or revision hip arthro- nerve distally, followed by exposure of screw using an plasty. The endoscopic exploration and screw resection arthroscopic shaver. described herein enables less invasive surgery permit- ting early joint motion, accelerated rehabilitation, and Additional file potential outpatient management. Beyond iliopsoas ten- Additional file 1: Endoscopic section of acetabular screw tip to otomy, endoscopic treatment may expand to other decompress sciatic nerve. Via endoscopic and intermittent multiplanar complication of THA including protruding screws fluoroscopic visualization, further dissection was performed proximally causing adjacent neurovascular compromise. and distally to prevent inadvertent injuries to the sciatic nerve and the superior gluteal neurovascular bundle. Partial osteoplasty of the sciatic notch with a motorized burr performed under endoscopic guidance. Endoscopic resection of the offending screw tip was performed with a Table 1 Pearls for endoscopic resection of protruded acetabular 5.5 mm motorized round burr. (MP4 4460 kb) screw irritating sciatic nerve Perform preoperative assessment of feasibility approaching the location Abbreviation of screw. THA: Total hip arthroplasty Perform accurate preoperative self-assessment of surgical experience and arthroscopic skills. Funding Consider patient position (supine or lateral) allowing for manual This paper was supported by Fund of Biomedical Research Institute, manipulation of the lower limb at the knee and hip joints for the full Chonbuk National University Hospital. assessment of sciatic nerve excursion Lateral position may facilitate ease of conversion to open surgery Availability of data and materials Prepare for possible open resection of screw or revision total hip Data are contained within the manuscript. arthroplasty (rather than endoscopic resection) if endoscopic method fails. Authors’ contributions Consider fluoroscopic guidance to identify and confirm resection of the SY wrote the manuscript including the literature review. MP is an protruding screw. experienced hip surgeon with an interest in the sciatic nerve injury, and had Mobilize and development of soft tissue around sciatic notch. made substantial contributions to conception and design. DM had been Consider sciatic notch osteoplasty to expose proper cutting level of the involved in revising the manuscript critically. YC guided the literature search screw. and anatomic considerations. All authors have read and approved the final Pay careful attention to safe position of burr to prevent superior gluteal manuscript. neurovascular bundle and sciatic nerve injury (may require several accessory portals). Ethics approval and consent to participate Circulating fluid during burr resection of screw may minimize Not applicable. thermogenesis and metallic debris retention. Confirm adequate resection and smooth recontour of the screw by Consent for publication arthroscopic dynamic testing while envisioning the sciatic nerve Written informed consent was obtained from the patient for publication of Allow early mobilization of hip commensurate with symptomatic this Case report and any accompanying images. A copy of the written improvement. consent is available for review by the Editor of this journal. Yoon et al. BMC Musculoskeletal Disorders (2018) 19:184 Page 6 of 6 Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Department of Orthopedic Surgery, Research Institute of clinical medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, 54907 Gunji-Ro 20, Dukjin-Gu, Chonbuk, Jeonju, South Korea. DISC Sports and Spine Center, Marina del Rey, CA, USA. Department of Anatomy, Medical School, Institute for Medical Sciences, Chonbuk National University, Jeonju 561-180, South Korea. Received: 30 January 2018 Accepted: 15 May 2018 References 1. Park JH, Hozack B, Kim P, Norton R, Mandel S, Restrepo C, et al. Common peroneal nerve palsy following total hip arthroplasty: prognostic factors for recovery. J Bone Joint Surg Am. 2013;95:e55. 2. Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ. The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2011; 27:172–81. 3. Martin HD, Reddy M, Gómez-Hoyos J. Deep gluteal syndrome. J Hip Preserv Surg. 2015;2:99–107. 4. Park M, Yoon S-J, Jung S, Kim S-H. Clinical results of endoscopic sciatic nerve decompression for deep gluteal syndrome: mean 2-year follow-up. BMC Musculoskelet Disord. 2016;17:218. 5. Brown GD, Swanson EA, Nercessian OA. Neurologic injuries after total hip arthroplasty. Am J Orthop Belle Mead NJ. 2008;37:191–7. 6. Vastamäki M, Ylinen P, Puusa A, Paavilainen T. Late hardware-induced sciatic nerve lesions after acetabular revision. Clin Orthop. 2008;466:1193–7. 7. Wasielewski RC, Cooperstein LA, Kruger MP, Rubash HE. Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am. 1990;72:501–8. 8. Schmalzried TP, Noordin S, Amstutz HC. Update on nerve palsy associated with total hip replacement. Clin Orthop. 1997;344:188–206. 9. Xu LW, Veeravagu A, Azad TD, Harraher C, Ratliff JK. Delayed presentation of sciatic nerve injury after Total hip arthroplasty: neurosurgical considerations, diagnosis, and management. J Neurol Surg Rep. 2016;77(3):e134–8.
BMC Musculoskeletal Disorders – Springer Journals
Published: Jun 4, 2018
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