Salvage of Iatrogenic Sciatic Nerve Injury Caused by Operatively Treated Acetabular Fractures: Two Cases and Literature Review

Abstract

Background: While sciatic nerve injury has been described as a complication of acetabular fractures, iatrogenic nerve injury remains sparsely reported. This study aims to assess iatrogenic sciatic nerve injuries occurring during acetabular fracture surgery, tracking their neurological recovery and clinical outcomes, and investigating any correlation between recovery and the severity of neurologic injury to facilitate physicians in providing prediction of prognosis.

Case Presentation: We present two cases of male patients, aged 56 and 22, who developed sciatic palsy due to iatrogenic nerve injury during acetabular fracture surgery. Iatrogenic sciatic nerve injury resulted from operatively treated acetabular fractures. Surgical exploration, involving internal fixation removal and nerve decompression, successfully alleviated symptoms in both cases postoperatively. At the latest follow-up, one patient achieved full recovery with excellent function, while the other exhibited residual deficits at the L5/S1 root level along with minimal pain.

Conclusion: Sciatic nerve injury likely stemmed from reduction techniques and internal fixation procedures for the posterior column, particularly when performed with the hip flexed, thereby placing tension on the sciatic nerve. Our case reports underscore the significance of liberal utilization of electrophysiologic examinations and intraoperative monitoring for the prediction of prognosis. Surgical exploration, encompassing internal fixation removal and nerve decompression, represents an effective intervention for resolving sciatic palsy, encompassing both sensory neuropathy and motor symptoms.

Keywords

Acetabular fractures / Electromyography / Iatrogenic sciatic nerve injury / Magnetic resonance imaging / Open reduction and internal fixation

References

[1] Liu Z, Fu B, Xu W, Liu F, Dong J, Li L, et al. Incidence of traumatic sciatic nerve injury in association with acetabular fracture: a retrospective observational single-center study. Int J Gen Med. 2022; 15: 7417–7425.

[2] Liu Z, Tao F, Xu W, Liu F, Dong J, Li L, et al. Incidence of traumatic sciatic nerve injury in patients with acetabular fractures and factors affecting recovery: a retrospective study. J Orthop Surg Res. 2023; 18(1): 35.

[3] Simske NM, Krebs JC, Heimke IM, Scarcella NR, Vallier HA. Nerve injury with acetabulum fractures: incidence and factors affecting recovery. J Orthop Trauma. 2019; 33(12): 628–634.

[4] Ahmed M, Abuodeh Y, Alhammoud A, Salameh M, Hasan K, Ahmed G. Epidemiology of acetabular fractures in Qatar. Int Orthop. 2018; 42(9): 2211–2217.

[5] Fassler PR, Swiontkowski MF, Kilroy AW, Routt ML Jr. Injury of the sciatic nerve associated with acetabular fracture. J Bone Jt Surg Am. 1993; 75(8): 1157–1166.

[6] Lehmann W, Hoffmann M, Fensky F, Nüchtern J, Groβterlinden L, Aghayev E, et al. What is the frequency of nerve injuries associated with acetabular fractures? Clin Orthop Relat Res. 2014; 472(11): 3395–3403.

[7] Kanawati AJ, Narulla RS, Lorentzos P, Facchetti G, Smith A, Stewart F. The change in position of the sciatic nerve during the posterior approach to the hip. Bone Jt J. 2015; 97(8): 1056–1062.

[8] Isin Y, Hapa O, Kara YS, Kilic AI, Balci A. A CT study of the femoral and sciatic nerve periacetabular moving in different hip positions. J Orthop Surg Res. 2020; 15(1): 404.

[9] Lu S, Liu F, Xu W, Zhou X, Li L, Zhou D, et al. Management of Open Tile C Pelvic Fractures and Their Outcomes: a retrospective study of 30 cases. Ther Clin Risk Manage. 2022; 18: 929–937.

[10] Zhao X, Lu S, Wang B, Zhou X, Liu F, Xu W, et al. Fracture types influence the likelihood of lower urinary tract injuries in patients with pelvic fractures. J Clin Med. 2023; 12(8): 2967.

[11] Li P, Liu F, Li Q, Zhou D, Dong J, Wang D. Role of pelvic packing in the first attention given to hemodynamically unstable pelvic fracture patients: a meta-analysis. J Orthop Traumatol. 2022; 23(1): 29.

[12] Sun Y, Fu Y, Liu F, Zhang W, Ma H, Li Q, et al. Biomechanical tests and finite element analyses of pelvic stability using bilateral single iliac screws with different channels in lumbo-iliac fixation. Front Surg. 2022; 9: 1035614.

[13] Scheib J, Höke A. Advances in peripheral nerve regeneration. Nat Rev Neurol. 2023; 9(12): 668–676.

[14] Benga A, Zor F, Korkmaz A, Marinescu B, Gorantla V. The neurochemistry of peripheral nerve regeneration. Indian J Plast Surg. 2017; 50(1): 5.

[15] Park C-w, Cho W-c, Soncorresponding B-c. Iatrogenic injury to the sciatic nerve due to intramuscular injection: a case report. Korean J Neurotrauma. 2019; 15(1): 61–66.

[16] Foulk DM, Mullis BH. Hip dislocation: evaluation and management. J Am Acad Orthop Surg. 2010; 18(4): 199–209.

[17] Issack PS, Helfet DL. Sciatic nerve injury associated with acetabular fractures. HSS J. 2009; 5(1): 12–18.

[18] Issack PS, Toro JB, Buly RL, Helfet DL. Sciatic nerve release following fracture or reconstructive surgery of the acetabulum. J Bone Jt Surg Am. 2007; 89(7): 1432–1437.

[19] Meccariello L, Razzano C, De Dominicis C, et al. A new prognostic pelvic injury outcome score. Med Glas. 2021; 18(1): 299–308.

[20] Kreder HJ, Rozen N, Borkhoff CM, Laflamme YG, McKee MD, Schemitsch EH, et al. Determinants of functional outcome after simple and complex acetabular fractures involving the posterior wall. J Bone Jt Surg Br. 2006; 88(6): 776–782.

[21] Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop Relat Res. 2003; 407: 173–186.

[22] Bage T, Power DM. Iatrogenic peripheral nerve injury: a guide to management for the orthopaedic limb surgeon. EFORT Open Rev. 2021; 6(8): 607–617.

[23] Juodzbalys G, Wang HL, Sabalys G. Injury of the inferior alveolar nerve during implant placement: a literature review. J Oral Maxillofac Res. 2011; 2(1): e1.

[24] Hinz N, Fuchs S, Frosch KH, Hartel MJ. Neurogenic gluteus medius and minimus muscle atrophy with Trendelenburg’s sign after a displaced acetabular fracture of the posterior column—a case report. Trauma Case Rep. 2022; 42: 100741.

[25] Wang Z, Chen W, Jia H, Hu F, Wang B, Yang Y, et al. Application of preoperative ultrasonography in the percutaneous minimally invasive repair of acute closed Achilles tendon rupture. Biomed Res Int. 2023; 2023: 8956803.

[26] Urbanek H, van der Smagt P. iEMG: imaging electromyography. J Electromyogr Kinesiol. 2016; 27: 1–9.

[27] Bhandari PS. Management of peripheral nerve injury. J Clin Orthop Trauma. 2019; 10(5): 862–866.

[28] Bhalodia VM, Schwartz DM, Sestokas AK, Bloomgarden G, Arkins T, Tomak P, et al. Efficacy of intraoperative monitoring of transcranial electrical stimulation-induced motor evoked potentials and spontaneous electromyography activity to identify acute-versus delayed-onset C-5 nerve root palsy during cervical spine surgery: clinical article. J Neurosurg Spine. 2013; 19(4): 395–402.

[29] Frew N, Foster P, Maury A. Femoral nerve palsy following traumatic posterior dislocation of the native hip. Injury. 2013; 44(2): 261–262.

RIGHTS & PERMISSIONS

2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.