Neurovascular Traction Injury

Neuropraxia due to traction has been reported, most commonly involving the sciatic nerve. Glick was the first to report four such cases, which he attributed to his early technique for performing the procedure.3 Later, Sampson reported on a larger series from this same center, observing that all neuropraxias were associated with prolonged traction times.6 He advocates that the traction time should be kept under 2 hours

TABLE 16.1. Complications Associated with 1491 Arthroscopic Hip Procedures (Number in Parentheses).

Transient pudendal nerve neuropraxia (5)

Permanent pudendal nerve neuropraxia (1)

Transient sciatic nerve neuropraxia (4)

Intraabdominal fluid extravasation (3)

Partial lateral femoral cutaneous nerve neuropraxia (2)

Laceration of the lateral femoral cutaneous nerve (1)

Scrotal skin necrosis (1)

Femoral nerve palsy (1)

Instrument breakage (1)

Heterotopic ossification (1)

and, if more prolonged surgery is necessary, the traction should be intermittently released. Additionally, the amount of traction should be gauged to the laxity of the individual. Excessive traction on a loose joint can result in hyperelongation of the extremity and greater risk of neuropraxia. Villar has also reported three sciatic neuropraxias.5 All three occurred on the same day, and he thought that this was probably due to a technical error in application of the traction. Villar and Sampson have each reported one femoral neu-ropraxia as well.

All reported traction neuropraxias were transient and the recovery was complete. However, this author is anecdotally aware of two cases by different surgeons in which the patients demonstrated evidence of sciatic nerve damage that only partially recovered. In both cases, the traction time was well under 2 hours, indicating that other factors may be involved in addition to the duration of traction. Sufficient traction force is necessary to ensure adequate joint space separation. Otherwise, there is greater risk of damage from the instruments entering the joint. However, care should be taken to use the least amount of traction force necessary to achieve adequate distraction.

This author has not experienced any traction neuropraxias. The greatest risk seems to be to the sciatic nerve. Some authors advocate hip flexion to relax the capsule, making distraction easier. However, this may place the sciatic nerve under greater stretch, increasing the risk of injury. We deliberately maintain the hip in extension or perhaps with only a few degrees (<10 degrees) of flexion. This practice may explain why we have not observed any sciatic neuropraxias.

It is worthy to note, when considering the amount of distraction of the hip (approximately 1 cm), that this proportionately represents a small change relative to the overall length of the sciatic and femoral nerves. Perhaps some nerves are simply more at risk for injury. However, currently there are no parameters by which to define this circumstance. Some patients with hip joint pathology may have coexistent radicular or neurologic-type pain. For these patients, it is especially prudent to offer coun seling on the uncertain risk of exacerbating neurologic symptoms.

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