The rate of total hip arthroplasty (THA) surgery continues to dramatically rise in the United States, with over 300,000 procedures performed in 2010. Although a relatively safe procedure, THA is not without complications. These complications include acetabular fracture, heterotopic ossification, implant failure, and nerve palsy to name a few. The rates of neurologic injury for a primary THA are reported as 0.7–3.5%. These rates increase to 7.6% for revision THA. The direct anterior total hip arthroplasty (DATHA) is gaining popularity amongst orthopedic surgeons. Many of these surgeons elect to use the Hana® table during this procedure for optimal positioning capability. Although intraoperative mobility and positioning of the hip joint during DATHA improves operative access, select positions of the limb put certain neurologic structures at risk. The most commonly reported neurologic injuries in this regard are to the sciatic and femoral nerves. To our knowledge, the use of neuromonitoring during DATHA, especially those using the Hana® table, has not been described in the literature. The patient was a 60-year-old male with long standing osteoarthritis of the right hip and prior left THA. Somatosensory evoked potential (SSEP) leads were placed bilaterally into the hand (ulnar nerve) as well as the popliteal fossae (posterior tibial nerve). Unilateral electromyography leads were placed into the vastus medialis obliquus, biceps femoris, gastrocnemius, tibialis anterior, and abductor hallucis of the operative limb (Fig. 1). Once the patient was sterilely draped, a direct anterior Smith-Peterson approach to the hip was used.Introduction
Methods
Analysis of orthopaedic malpractice claims has shown that highest impact allegations (highest payment dollars per claim) were those that were related to failure to protect anatomic structures in surgical fields. The prevalence of subclinical peripheral neurologic deficit following reverse and anatomic shoulder arthroplasty has been reported to be 47% and 4%, respectively. We propose the following five rules in order to avoid neurovascular injury during shoulder arthroplasty cases:. Pre-operative planning would assure a smooth operation without intra-operative difficulties. Adequate planning would include appropriate imaging, obtaining previous operative reports, complete pre-operative neurovascular examination and requesting the necessary operative equipment. Tug test: It is crucial to palpate the axillary nerve and be aware of its location. The tug test is a systematic technique for locating and protecting the axillary nerve.
