A total of 13,252 patients underwent 19,058 elective TKA procedures during the 20-yr study period. Assessment of predisposing and prognostic factors. Patel NK, Johns W, Vedi V, Langstaff RJ, Golladay GJ. Search for other works by this author on: Warner MA, Martin JT, Schroeder DR, Offord KP, Chute CG: Lower-extremity motor neuropathy associated with surgery performed on patients in a lithotomy position. It is possible that transient neurologic events (i.e ., short-term deficits) may have been underreported within the current study as well. Surg Radiol Anat. Relatively high rates of persistent hypoesthesia (3%), weakness (2.2%), and persistent paresthesia (1.5%) were identified. presentation after injury. Privacy, Help This site needs JavaScript to work properly. Finally, the multicenter study design may have once again introduced a lack of standardization in anesthesia and surgical practices, both of which are limitations not seen within a single-center study design. After multivariable logistic regression, age (OR, 0.70 [per decade]; P < 0.001) and tourniquet time (OR, 1.28 [per 30-min increment]; P = 0.003) were found to be associated with risk for PNI (table 2). 8600 Rockville Pike Here we report 2 cases of femoral neuropathy immediately following pelvic surgery. However, patients with peripheral nerve injury were less likely to recover completely if they had received peripheral nerve blockade. The femoral nerve itself mainly controls the thigh muscles. Reda W, ElGuindy AMF, Zahry G, Faggal MS, Karim MA. By using a homogeneous surgical population (i .e ., TKA) with extended postoperative follow-up, we assessed the interaction between the risk for PNI imposed by RA techniques and that imposed by the surgery itself. Therefore, even trained abstractors will not be able to identify those events that were either clinically present and not documented by the surgeon or anesthesiologist or documented more than 3 months after surgery but occurring during the immediate postoperative period. Although we found that the use of RA techniques (neuraxial anesthesia or peripheral nerve blockade) did not increase PNI risk, we cannot speculate whether an association exists between RA and PNI in those cases that developed a postoperative neurologic deficit and underwent RA. There are 2 nerves that run through that area that could have been damaged during the operation. 2016 Sep;24(9):2948-2952. doi: 10.1007/s00167-015-3582-z. We report a case of tourniquet-related permanent femoral nerve palsy after knee surgery. Twelve months after surgery, an additional 28 patients (29%) achieved maximal neurologic recovery, with 17 reporting complete recovery. Tourniquet-induced nerve injuries have been reported in the literature, but even if electromyography abnormalities in knee surgery are frequent, only two cases of permanent Both cases had neither previous vascular nor peripheral nerve disease. We report a case of tourniquet-related permanent femoral nerve palsy after knee surgery. Patient demographics (sex, date of birth, height, weight), date of surgery, side of surgery (right, left, bilateral), surgeon, total tourniquet time, and type of surgery (primary, revision) were recorded from the Mayo Clinic Total Joint Registry. Sensorimotor deficits were defined as the presence of any new subjective or objective weakness, nerve palsy, or neurapraxia with an associated sensory deficit in the same anatomic distribution. Case description See a physical medicine and rehab doc or a neurologist for an emg to assess the damage. Adam K. Jacob, Carlos B. Mantilla, Hans P. Sviggum, Darrell R. Schroeder, Mark W. Pagnano, James R. Hebl; Perioperative Nerve Injury after Total Knee Arthroplasty: Regional Anesthesia Risk during a 20-Year Cohort Study. Papalia R, Zampogna B, Franceschi F, Torre G, Maffulli N, Denaro V. Br Med Bull. Postoperative femoral neuropathy is an uncommon complication occurring after pelvic surgery. Overall, 69.7% of TKA surgical procedures were unilateral primary; 15.5%, unilateral revision; and 14.8%, bilateral. We report a case of a 58-year-old woman who underwent surgical treatment of a patella fracture. Femoral neuropathy is an infrequent complication after surgeries or obstetric procedures and is most commonly reported after direct trauma ( 1, 2 ). Although most experts agree that the overall incidence of neurologic complications is quite low, estimated rates of nerve injury should be interpreted in the context of a study's limitations. J Bone Joint Surg 2005; 87:63–70, Feibel RJ, Dervin GF, Kim PR, Beaulé PE: Major complications associated with femoral nerve catheters for knee arthroplasty: A word of caution. Previous studies examining PNI have included patients undergoing a wide range of surgical procedures or they have collected data from numerous institutions with varying surgical practices.2,4,16,17,20This variation in study methodology may confound the interpretation of surgical, anesthetic, and patient-related risk factors for PNI. Anesthesiology 1994; 81:6–12, Warner MA, Warner ME, Martin JT: Ulnar neuropathy. Fertil Steril . It is important to recognize the limitations of the current study. Lastly, data capture methods that rely on patient referral to neurology or pain medicine specialists run the risk of identifying only those patients with several neurologic deficits. Eight patients (32%) had a neurologic deficit in a distribution unrelated to the peripheral nerve block (e.g ., peroneal nerve injury after femoral nerve blockade). 2006;102(3):950–955. Type of intraoperative anesthesia was also not associated with PNI (OR, 1.10 [neuraxial vs . Changes in walking patterns or difficulty in walking properly is also amongst the symptoms of nerve damage. The clinical course of each PNI was recorded, including: (1) date of onset, (2) terminology used to describe the deficit (numbness, weakness, neuropathy, neurapraxia, nerve palsy, nerve injury, paresthesia, foot drop, other), (3) presence of neurologic deficit at hospital discharge, (4) diagnostic evaluation by neurology consultation and/or electromyography study, (5) date of neurologic recovery, (6) date of last follow-up, (7) time to recovery (less than 1 month, 1–3, 3–6, 6–12 months, or more than 12 months), and (8) degree of neurologic recovery (complete [returned to baseline neurologic status], partial [deficit improved, but symptoms still exist], or none [deficit unchanged from initial description]). A doctor may check a patient's knee jerk reflex to determine if there is femoral nerve damage. After surgery, patient complained about paralysis of the quadriceps femoris with inability to extend the knee. This page was updated by Dr Barrie Lewis on 29th October, 2018. Compound muscle action potential showing a marked amplitude reduction (0.7 mV). Femoral nerve lesions are uncommon. Although the data collection methods of the Mayo Clinic Total Joint Registry have been previously validated,21additional validation was performed to confirm the reliability of the registry to capture PNI. Several studies have attempted to quantify the incidence of PNI after orthopedic surgery. Epub 2015 Mar 19. Femoral nerve The femoral nerve originates from nerve roots L2–L4. Accessibility Anesthesiology 2011; 114:311–317 doi: https://doi.org/10.1097/ALN.0b013e3182039f5d. Pathological spontaneous activity (fibrillation potentials, fasciculations). J Bone Joint Surg 2005; 87:1487–97, Horlocker TT, Cabanela ME, Wedel DJ: Does postoperative epidural analgesia increase the risk of peroneal nerve palsy after total knee arthroplasty? Femoral nerve block (FNB) is an analgesic technique that blocks sensation to the knee to reduce pain following surgery. In summary, the use of RA techniques (neuraxial anesthesia or peripheral nerve blockade) does not increase the risk for PNI. It supplies the back of the thigh, side of the lower leg and much of the foot. Six months after surgery, 5 patients (25%) achieved maximal neurologic recovery, all having reported complete recovery. Arch Phys Med Rehabil. “The good news is that if we’re able to identify patients experiencing postsurgical inflammatory neuropathy, rather than damage caused by a mechanical process, we may be able to provide treatment immediately to mitigate pain and improve overall … J Arthroplasty 2009; 24:132–7, Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier FJ, Bouaziz H, Samii K, Mercier F: Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Injury to the infrapatellar branch of the saphenous nerve (IPS) is not uncommon after knee surgeries and trauma, yet the diagnosis and treatment of IPS neuralgia is not usually taught in pain training programs. Bethesda, MD 20894, Copyright While we cannot make any formal conclusions about the association of PNI severity and peripheral nerve blockade, it is possible that complete recovery may be less likely when a neurologic deficit develops in the setting of peripheral nerve blockade. The overall incidence of PNI after TKA was 0.79% (95% CI, 0.64–0.96%). In the remaining 68% of patients, the peripheral nerve block was in an anatomic distribution that was congruent with the location of the nerve injury. The neurological lesion after hip surgery is one of the most horrible complications for both surgeon and patient ( 3 ). Assessment is made of the effectiveness of femoral nerve block, administered either before or after surgery, in supplementing postoperative analgesia for knee joint (anterior cruciate) reconstruction surgery. 1). FNB is given as a single injection or as continuous infusion of numbing medication in the groin area. 2011 Oct;33(8):649-58. doi: 10.1007/s00276-011-0791-0. In a review of more than 12,000 total knee arthroplasty patients during 20 yr, use of peripheral nerve blockade was not associated with peripheral nerve injury. The incidence of PNI was significantly higher among patients undergoing bilateral procedures (1.70%; 95% CI, 1.15–2.41%) compared with those undergoing unilateral primary (0.65%; 95% CI, 0.49–0.85%) or unilateral revision surgical procedures (0.52%; 95% CI, 0.25–0.96%). There were no sex differences in the incidence of PNI (OR, 1.11 [female vs . The majority (56%) of patients undergoing TKA were female. Epub 2011 Feb 17. The remaining 24 cases (25%) of PNI were limited to sensory deficits without associated motor dysfunction. Patients frequently experience severe chronic pain following knee operations. Furthermore, the lack of a standardized definition for PNI and the restricted time frame in which many studies assess PNI (i.e ., short follow-up periods) limit the widespread application of these findings to the general population.4,16,17Therefore, the objective of this single-institution, large scale, single procedural cohort study was to test the hypothesis that risk for PNI differs among patients during elective TKA based on RA status. Furthermore, they found that the use of general or epidural anesthesia increased the risk of postoperative neuropathy. Most cases of PNI (73 [75%] of 97) were combined sensorimotor deficits. Tourniquet-Related Iatrogenic Femoral Nerve Palsy after Knee Surgery: Case Report and Review of the Literature JuanMingo-Robinet, 1 CarlosCastañeda-Cabrero, 2 VicenteAlvarez, 3 However, patients with an isolated sensory deficit were more likely to have complete neurologic recovery compared with patients with sensorimotor deficits (73 vs . They reported the overall incidence of PNI at 0.03%, including a 0.05% incidence among orthopedic patients. male]). 52 cases were iatrogenic, 19 were due to hip or pelvic fractures, 10 to gunshot wounds and 8 to lacerations. Intraoperative anesthesia included general anesthesia in 44%, neuraxial anesthesia in 45%, and combined neuraxial/general anesthesia in 8% of patients. Many times nerve issues after surgery are temporary, for example, many patients have nerve problems after surgery that only last for a few weeks to months (2,3). Because the use of peripheral nerve blockade has become more common during the past decade, the 20-yr study period was divided into quartiles to assess the incidence of PNI over time (fig. Roots of Post-Surgical Knee Nerve Damage Uncovered. Purpose. Specifically, neurologic complications were coded as either a “nerve-related complication” or a “peroneal/sciatic nerve palsy” based on documentation by the surgical service, the Department of Anesthesiology, or the Acute Pain Service within the medical record. Each of the above variables was independently associated with risk for PNI. Kornbluth ID, Freedman MK, Sher L, Frederick RW. Although regional anesthesia (RA) techniques reduce pain and improve functional outcomes after TKA, they may also contribute to PNI. 17-4, B). 2003 Jun;84(6):909-11. doi: 10.1016/s0003-9993(02)04809-8. Femoral nerve block (FNB) has been proposed for pain control following anterior cruciate ligament (ACL) reconstruction. Mean patient age was 69 ± 10 yr. The clinician first passively extends the patient's hip and then passively flexes the knee. Tourniquet injuries: pathogenesis and modalities for attenuation. Scand J Rheumatol 1983; 12:201–5, Nercessian OA, Ugwonali OF, Park S: Peroneal nerve palsy after total knee arthroplasty. Vastus medialis. -, Aho K, Sainio K, Kianta M, Varpanen E. Pneumatic tourniquet paralysis. Overall incidence of PNI was 0.79% (95% CI, 0.64-0.96%). In contrast, only 5 (21%) of 24 patients experiencing isolated sensory deficits had documentation of the neurologic deficit before hospital dismissal. It is responsible for hip bending and knee extension. Peripheral nerve blockade was performed in 3,883 patients (31%) for supplemental postoperative analgesia. All cases of PNI were observed until complete resolution or the date of last documented follow-up. Femoral nerve damage causes severe pain in the buttock and upper anterior thigh and lower inner leg pain. 1983;65(4):441–443. Transient femoral neuropathy after knee ligament reconstruction and nerve stimulator‐guided continuous femoral nerve block: a case series. Peripheral nerve blockade was performed in 0.5, 0.2, 19.8, and 82.5% of TKA patients during the designated time periods, respectively, 1988–1992, 1993–1997, 1998–2002, and 2003–2007 (P < 0.001). doi: 10.1097/GOX.0000000000001204. The primary outcome variable was the presence of a new PNI documented within 3 months of the procedural date. Incidence, outcome, and risk factors in sedated or anesthetized patients. 2009 Feb. 91(2):622-3. After manual chart review, 76 of these cases did not meet inclusion criteria for PNI. The incidence of neurologic complications after RA for lower extremity procedures is estimated at 0.03–1.5%,15–19with central neuraxial techniques having a lower estimated risk than peripheral techniques.4,18. All data pertaining to the patient's anesthetic care were collected from the Mayo Clinic Department of Anesthesiology Quality Database. Therefore, the known functional and clinical benefits of RA for patients undergoing TKA14can be achieved without increasing the risk of neurologic injury. Unless otherwise indicated, data are presented as mean ± SD for continuous variables and frequency percentages for categorical variables. Rev Chir Orthop Reparatrice Appar Mot. However, there was no difference with the use of peripheral nerve blockade. If they last longer than a few months, then they’re placed into the permanent nerve damage category … Study 2 (9 months). J Arthroplasty 2001; 16:1048–54, Yacub JN, Rice JB, Dillingham TR: Nerve injury in patients after hip and knee arthroplasties and knee arthroscopy. Data collection was limited to 5 days postoperatively with the exception of those patients in whom a prolonged neurologic deficit was already documented. You need to get him to a neurologist for examination immediately. Reg Anesth Pain Med 2009; 34:534–41, Asp JP, Rand JA: Peroneal nerve palsy after total knee arthroplasty. 2005;71(6):635–645. There are two basic kinds of health care professional mistakes that can lead to nerve damage during surgery: a physical error by a surgeon or assisting staff, and an error during administration of anesthesia. There was no difference in the time to resolution of sensory neurologic deficits compared to the resolution of sensorimotor deficits. Left vastus medialis. [Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 14 cases]. Tourniquet and tranexamic acid use in total knee arthroplasty. Patients who denied research authorization were excluded according to state government statute (Minnesota). Tourniquet was inflated to 310 mmHg for 45 minutes. [Medline] . However, in 32% of PNI cases that underwent a peripheral nerve block, the neurologic deficit was in a distribution anatomically unrelated to the block. Anesth Analg 2006; 102:950–5, Neal JM, Bernards CM, Hadzic A, Hebl JR, Hogan QH, Horlocker TT, Lee LA, Rathmell JP, Sorenson EJ, Suresh S, Wedel DJ: ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine. The use of supplemental peripheral nerve blockade was also documented and categorized as (1) femoral nerve blockade, (2) psoas compartment blockade, (3) fascia iliaca blockade, (4) sciatic nerve blockade, (5) combined femoral/sciatic nerve blockade, or (6) combined psoas compartment/sciatic nerve blockade. Finally, while a single center study design may strengthen internal validity, external validity may be limited compared to a multicenter design. Because the use of prolonged (i.e ., more than 48 hours) postoperative continuous RA techniques may obscure symptoms of PNI, this study design may have also increased the risk of underreporting overall PNI frequency. Most folk have heard of sciatica, and the nerve which comes from the lower lumbar spine. Patients were also excluded if they were younger than 18 yr, underwent a “staged” bilateral procedure (i.e ., right and left TKA performed during the same hospitalization but on different dates), or if a matched anesthesia record (name, date of birth, surgical date) was not identified within the Mayo Clinic Department of Anesthesiology Quality Database. J Bone Joint Surg Am 1982; 64:347–51, Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA: Nerve injury after primary total knee arthroplasty. In all cases, two-tailed P  values less than or equal to 0.05 were considered statistically significant. TKA is one of the most commonly performed orthopedic procedures in the United States, representing the greatest single Medicare procedural expenditure.22,23Despite these surgical volumes, the American Academy of Orthopedic Surgeons estimates that the number of TKAs will continue to increase by 300% per year through the year 2030. “Neuropathy after surgery can significantly affect postsurgical outcomes,” says Nathan Staff, M.D., Ph.D., Mayo Clinic neurologist. Potential cases of PNI were identified using a comprehensive list of complications documented within the Mayo Clinic Total Joint Registry. Study…, Vastus medialis. Nerve damage shown to be cause of unexplained chronic pain following knee operations. The primary outcome variable was the presence of a new sensory or sensorimotor deficit documented within 3 months of the surgical date. However, in rare situations when PNI occurs, complete recovery may be less likely if it develops after peripheral nerve blockade. After excluding 923 patients who denied research authorization or met one or more exclusion criteria, the first TKA of 12,329 patients was included for study analysis. Twenty-five patients undergoing peripheral nerve blockade had PNI. Tourniquet-induced nerve injuries have been reported in the literature, but even if electromyography abnormalities in knee surgery are frequent, only two cases of permanent femoral nerve palsies have been reported, both after prolonged tourniquet time. Age, sex, body mass index, type of procedure, tourniquet time, type of anesthesia, and use of peripheral nerve blockade were evaluated as potential risk factors for PNI using multivariable logistic regression. 1. 2014 Sep 1;11(1):63-76. doi: 10.1093/bmb/ldu012. However, patients undergoing peripheral nerve blockade and experiencing PNI may be less likely to have complete neurologic recovery than patients not undergoing RA. During the 7-year period from 2008 to 2016, 1756 patients underwent primary THA with a direct anterior approach by a single senior surgeon for end-stage osteoarthritis. Study 3 (18 months). Adv Data 2006; 371:1–19, Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M: Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. Wang HY, Yuan MC, Pei FX, Zhou ZK, Liao R. J Orthop Surg Res. Cox EM, Cohen ER, Mellecker CJ, Raw RM, Fraser AI, Williams GN, Albright JP. The Mayo Clinic Total Joint Registry is a previously validated21and comprehensive repository of data collected for each joint replacement surgery performed at Mayo Clinic since 1969. Tourniquet application during anesthesia: "What we need to know?". !4 weeks post surgery, i am beginning to have some return of the quadriceps which keeps the knee from buckling. Please enable it to take advantage of the complete set of features! Furthermore, because of the assumed low complication rate, large numbers of patients are needed to capture the true incidence reliably. Type of anesthesia, specifically neuraxial anesthesia or peripheral nerve blockade, was not associated with PNI in patients undergoing TKA. Complete neurologic recovery may be less likely in patients that underwent peripheral nerve blockade (OR, 0.37; 95% CI, 0.15–0.94; P = 0.03). Anesthesiology 2009; 111:490–7, Horlocker TT, Hebl JR, Gali B, Jankowski CJ, Burkle CM, Berry DJ, Zepeda FA, Stevens SR, Schroeder DR: Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Of the 25 patients that had PNI after peripheral nerve blockade, 11 (44%) had complete neurologic recovery, and 14 (56%) had partial recovery. The names and medical record numbers of 40 patients with known PNI after joint replacement surgery were prospectively collected during the past 10 yr by one of the authors (J.R.H.). Knee Surg Sports Traumatol Arthrosc. Patients frequently experience severe chronic pain following knee operations. https://www.healthline.com/health/femoral-nerve-dysfunction J Bone Joint Surg Am 1996; 78:177–84, Knutson K, Leden I, Sturfelt G, Rosén I, Lidgren L: Nerve palsy after knee arthroplasty in patients with rheumatoid arthritis. Purpose. Patient and surgical characteristics and the incidence of PNI within patient subgroups (sex, age, type of anesthesia, peripheral nerve blockade) are listed in table 1. Although regional anesthesia (RA) techniques reduce pain and improve functional outcomes after TKA, they may also contribute to PNI. Anesth Analg 2007; 104:965–74, Sirinan C, Akavipat P, Srisawasdi S, Tanudsintum S, Weerawatganon T: The Thai Anesthesia Incidents Study (THAI Study) on nerve injury associated with anesthesia. Even if it is not a serious injury, it still takes a long time. Anesth Analg 1994; 79:495–500, Barrington MJ, Watts SA, Gledhill SR, Thomas RD, Said SA, Snyder GL, Tay VS, Jamrozik K: Preliminary results of the Australasian Regional Anaesthesia Collaboration: A prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. After Mayo Clinic Institutional Review Board approval and written informed consent were obtained, all patients aged at least 18 yr who underwent elective TKA at Mayo Clinic from January 1, 1988, to July 1, 2007, were retrospectively identified using the Mayo Clinic Total Joint Registry. Pneumatic tourniquets in extremity surgery. Discussion. -, Wakai A, Winter DC, Street JT, Redmond PH. Bonnevialle P, Chaufour X, Loustau O, Mansat P, Pidhorz L, Mansat M. Rev Chir Orthop Reparatrice Appar Mot. Symptoms of femoral nerve damage range from a feeling of general weakness in the leg to prickly sensations. Nevertheless, subtle clinical lesions of the femoral nerve or even subclinical lesions only detectable by nerve conduction and EMG activity are frequent, so persistent neurologic dysfunction, even if rare, may be an underreported complication of tourniquet application. J Arthroplasty 2005; 20:1068–73, Rose HA, Hood RW, Otis JC, Ranawat CS, Insall JN: Peroneal-nerve palsy following total knee arthroplasty.