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Scientific Articles   |    
Risk of Sciatic Nerve Traction Injury During Hip Arthroscopy—Is It the Amount or Duration?An Intraoperative Nerve Monitoring Study
Jessica J.M. Telleria, MD1; Marc R. Safran, MD2; John N. Gardi, PhD, D.ABNM, F.ASNM3; Alex H.S. Harris, PhD2; James M. Glick, MD4
1 Department of Orthopaedics and Sports Medicine, University of Washington, 1959 N.E. Pacific Street, Seattle, WA 98102. E-mail address: telleria@uw.edu
2 Department of Orthopaedic Surgery, Stanford University, 450 Broadway, M/C 6342, Redwood City, CA 94063
3 California Neuromonitoring Services, Inc., 199 Knockash Hill, San Francisco, CA 94127
4 2705 Ralston Avenue, Hillsborough, CA 94115
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Investigation performed at the Stanford University Department of Orthopaedic Surgery, Redwood City, California, the University of California-San Francisco/Mount Zion Medical Center, San Francisco, California, and the Healthsouth Surgery Center, San Francisco, California

This article was chosen to appear electronically on October 10, 2012, in advance of publication in a regularly scheduled issue.

A commentary by Patrick Birmingham, MD, is linked to the online version of this article at jbjs.org.



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Nov 21;94(22):2025-2032. doi: 10.2106/JBJS.K.01597
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Abstract

Background: 

Using intraoperative nerve monitoring we prospectively studied the prevalence, pattern, and predisposing factors for sciatic nerve traction injury during hip arthroscopy.

Methods: 

The transcranial motor (tcMEP) and/or somatosensory (SSEP) evoked potentials of seventy-six patients undergoing hip arthroscopy in the lateral position were recorded. Changes in the posterior tibial and common peroneal nerves were evaluated to assess the effects of the amount and duration of traction on nerve function. Sixteen subjects were excluded because of incomplete data. Nerve dysfunction was defined as a 50% reduction in the amplitude of SSEPs or tcMEPs or a 10% increase in the latency of the SSEPs; nerve injury was defined as a clinically apparent sensory or motor deficit. Traction time and weight were continuously monitored with use of a custom foot-plate tensiometer.

Results: 

Of sixty patients (thirty-one female and twenty-nine male, with a mean age of thirty-seven years [range, sixteen to sixty-one years]), thirty-five (58%) had intraoperative nerve dysfunction and four (7%) sustained a clinical nerve injury. The average maximum traction weight (and standard deviation) for patients who did and those who did not have nerve dysfunction or injury was 38.1 ± 7.8 kg (range, 22.7 to 56.7 kg) and 32.9 ± 7.9 kg (range, 22.7 to 45.4 kg), respectively. The odds of a nerve event increased 4% with every 0.45-kg (1-lb) increase in the traction amount (age/sex-adjusted; p = 0.043; odds ratio, 1.04; 95% confidence interval, 1.01 to 1.08). The average total traction time for patients who did and those who did not have nerve dysfunction was 95.9 ± 41.9 minutes (range, forty-two to 240 minutes) and 82.3 ± 35.4 minutes (range, thirty-eight to 160 minutes), respectively, and an increase in traction time did not increase the odds of a nerve event (p = 0.201). Age and sex were not significant risk factors.

Conclusions: 

The prevalence of nerve changes seen with monitoring of SSEPs and tcMEPs is greater than what is clinically identified. The maximum traction weight, not the total traction time, is the greatest risk factor for sciatic nerve dysfunction during hip arthroscopy. This study did not identify a discrete threshold of traction weight or traction time that increased the odds of nerve dysfunction.

Clinical Relevance: 

Surgeons should attempt to minimize traction weight and time during hip arthroscopy.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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