Distal femoral shortening osteotomy for treatment of sciatic nerve palsy after total hip arthroplasty — a report of 3 cases

Total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH) with associated femoral head dislocation is a challenging procedure, with a high complication rate. These include dislocation, nonunion or malunion of osteotomies, infection, implant loosening, and sciatic nerve injury (Rogers et al. 2012 Rogers B A, Garbedian S, Kuchinad R A, Backstein D, Safir O, Gross AE. Total hip arthroplasty for adult hip dysplasia. J Bone Joint Surg Am 2012; 94-A(19): 1809–21., Sonohata et al. 2016 Sonohata M, Kitajima M, Kawano S, Mawatari M. Nerve palsy after total hip arthroplasty without subtrochanteric femoral shortening osteotomy for a completely dislocated hip joint. Open Orthop J 2016; 10: 785–92.). In severe DDH cases, overlengthening of the lower limb may cause sciatic nerve injury, a devastating complication (De Fine et al. 2017 De Fine M, Romagnoli M, Zaffagnini S, Pignatti G. Sciatic nerve palsy following Total hip replacement: are patients’ personal characteristics more important than limb lengthening? A systematic review. Biomed Res Int 2017; 2017: 8361071.). Secondary neurologic pain and associated muscle weakness may overshadow otherwise excellent arthroplasty reconstruction and lead to patient dissatisfaction. In order to avoid this complication, it has been suggested that a proximal or subtrochanteric femoral osteotomy be performed when lengthening exceeds 4 cm (Cameron et al. 1998 Cameron H U, Eren O T, Solomon M. Nerve injury in the prosthetic management of the dysplastic hip. Orthopedics 1998; 21(9): 980–1.). Other authors have suggested intraoperative monitoring to assess nerve function as a decision tool to determine the maximal or appropriate limb lengthening (Paavilainen 1997 Paavilainen T. Total hip replacement for developmental dysplasia of the hip: how I do it. Acta Orthop Scand 1997; 68(1): 77–84.). When a sciatic nerve injury is identified postoperatively, there is debate over what is the optimal treatment.

In 3 THA cases for DDH (2 patients), we describe an effective surgical technique for treating associated sciatic nerve injuries secondary to excessive nerve tension. A late shortening distal femoral osteotomy was performed as treatment for 2 hips and as a prophylactic procedure for the third case.