Foot Drop After Hip Replacement: Case Illustration of Iatrogenic Peroneal Nerve Injury and Review of Literature

Bridging the gap: A technique to avoid limb length discrepancy in arthroplasty for femoral neck fracture – a case report

Introduction: Femoral neck fractures (FNFs) in young adults are relatively uncommon but pose significant clinical and surgical challenges. Hip arthroplasty is rarely used as a treatment option in this population but has seen rising use over the previous decade. This study seeks to compare hip arthroplasty outcomes among young adult patients in the United States admitted with FNF by evaluating hip hemiarthroplasty (HHA) and total hip arthroplasty (THA). Materials and Methods: Using the National Inpatient Sample (NIS) data, adult patients less than 50 years old who underwent HHA or THA from 2016 to 2020 were analyzed. Both groups' postoperative length of stay (pLOS), total hospital charges, and prosthesis-related complications (PRCs), including mechanical loosening (ML), prosthesis dislocation (PD), and periprosthetic fracture (PPF), were analyzed and compared. Results: Out of 174,776,205 hospitalizations between 2016 and 2020, 15,590 young adult patients had FNF, and 2970 patients (2.18%) underwent hip arthroplasty (1195 HHAs and 1775 THAs). After controlling for demographic, clinical and hospital characteristics, HHA was associated with a 22.4% longer pLOS compared to THA [rate ratio: 1.224, 95% CI: 1.183 to 1.266; p < 0.001]. Patients in the HHA group also had higher odds of PPF (aOR: 9.06, 95% CI: 4.21, 19.48; p < 0.001). Conversely, patients in the THA group had higher odds of PD (aOR: 6.00, 95% CI: 1.78, 20.24; p=0.004). There was no statistically significant difference in total hospital charges between the groups [cost ratio: 1.03, 95% CI: 0.995 to 1.075; p=0.092]. Conclusion: Among young adults with FNF undergoing hip arthroplasty, HHA is associated with a longer postoperative hospital stay and higher risk of PPF as a major early complication, while THA is associated with a higher risk of PD. Financial burden is comparable for both procedure groups. When hip arthroplasty is a preferred treatment for FNFs, individual patient factors are important considerations that should guide the choice of procedure.

Objective: This study aimed to assess the necessity of routine pathological examination of femoral heads in detecting incidental metastatic bone disease in patients undergoing elective and emergency hip arthroplasty. Methods: A retrospective review was conducted on medical records, operative notes, and histopathology reports of patients who underwent hip arthroplasty between 2016 and 2024. Patients without pathological evaluation or with known metastases were excluded. The study included patients with hip osteoarthritis undergoing total hip arthroplasty and those with femoral neck fractures undergoing bipolar hemiarthroplasty. Preoperative diagnoses, comorbidities, and operative and histopathological findings were analyzed. Results: The study included 193 patients with femoral neck fractures (mean age: 76.8 years, age range=60 – 98 years) and 257 with osteoarthritis (mean age: 60.4 years, age range= 23 – 88). After excluding 22 femoral neck fracture and 90 osteoarthritis patients, 36 patients in the fracture group and 18 in the osteoarthritis group had a history of malignancy, with 10 and 2 patients, respectively, having known metastases. Incidental metastatic bone disease was identified in four femoral neck fracture patients, while no neoplastic findings were detected in the osteoarthritis group. Conclusion: Routine pathological examination of femoral heads is particularly relevant in femoral neck fracture cases, where the risk of detecting metastatic disease is higher. While thorough preoperative assessments and meticulous intraoperative evaluations aid diagnosis, the decision to submit specimens for pathology should be guided by the surgeon’s clinical judgment and patient-specific factors. Cite this article as: Birsel O, Aslan L, Eren !, Deveci MA, "im#ek A. Routine histopathological examination of femoral heads and incidental metastatic bone disease in hip arthroplasty. Acta Orthop Traumatol Turc., 2025;59(1):58-62.

Cemented fixation in arthroplasty to treat hip fractures is now widely recommended, but it is not universally used. Some surgeons may feel that the risk of bone cement implantation syndrome and its cardiopulmonary sequalae are too high, in part, because the evidence provides little detail on postoperative myocardial injury and other medical complications after cement use. We aimed to use data from the HIP ATTACK trial (an RCT in which patients with a hip fracture were randomized to accelerated time to surgery versus normal timing of surgery) for a secondary analysis to answer the following questions on arthroplasty for patients with hip fractures: (1) Are patients who undergo cemented hip arthroplasty for hip fractures more likely to experience cardiopulmonary events than patients who undergo uncemented hip arthroplasty? (2) Are patients who undergo cemented hip arthroplasty for hip fractures more likely to experience myocardial injury, identified by elevated troponin levels, than patients who undergo uncemented hip arthroplasty? We performed a post hoc analysis of the HIP ATTACK trial for a subset of patients who were treated with THA or hemiarthroplasty for a femoral neck fracture because the trial collected postoperative troponin levels to allow us to identify myocardial injury. The HIP ATTACK trial consisted of 2970 patients. We limited our source cohort to the 1049 patients who underwent hip arthroplasty and were not lost to follow-up (four patients who had undergone arthroplasty were lost to follow-up). We excluded two patients with unknown fixation and six patients with "other arthroplasty." We limited our analysis to femoral neck fractures, which excluded 75 more patients. Of the 966 patients who received hip arthroplasty, 61% (593) had cemented fixation. Patients with cemented fixation were older than patients with cementless fixation (median [IQR] 82 (74 to 88) versus 79 (71 to 86); p = 0.003). Race was self-reported by patients and differed between patients with cemented and cementless fixation. A higher proportion of patients who received cementless fixation had undergone THA (compared with hemiarthroplasty) than patients in the cemented fixation group (24% [91] versus 11% [66]; p < 0.001). We used logistic regression to estimate the association between cement use and a composite outcome consisting of all-cause mortality and various cardiopulmonary outcomes. We included cardiopulmonary outcomes possibly associated with bone cement implantation syndrome; there were only a small number of patients who had only nonsevere outcomes. We had 80% power to detect an OR of ≥ 1.6. We adjusted for all baseline differences between both groups except for anesthesia (as it was not associated with the outcome) and duration of surgery (as it is a function of cement use). After controlling for age, sex, race, and relevant comorbidity, we found that cement use was not associated with differences in the composite outcome at 90 days (OR 1.0 [95% confidence interval (CI) 0.7 to 1.4]; p = 0.99) or 1 year (OR 1.0 [95% CI 0.7 to 1.4]; p = 0.95) or with postoperative elevated troponin (OR 1.4 [95% CI 1.0 to 1.9]; p = 0.06) on Day 1. There was no difference in cardiopulmonary outcomes among patients with arthroplasty to treat their hip fracture by fixation method. These findings further support the recommendations to use cemented femoral fixation in THA and hemiarthroplasty for patients with hip fractures. Surgeons with limited experience with cemented femoral fixation should familiarize themselves with these skills. Future studies should assess what barriers to cemented fixation exist and how they can be mitigated. Level III, therapeutic study.

Iatrogenic Peripheral Nerve Injuries-Surgical Treatment and Outcome: 10 Years' Experience.

This study aimed to assess the necessity of routine pathological examination of femoral heads in detecting incidental metastatic bone disease in patients undergoing elective and emergency hip arthroplasty. A retrospective review was conducted on medical records, operative notes, and histopathology reports of patients who underwent hip arthroplasty between 2016 and 2024. Patients without pathological evaluation or with known metastases were excluded. The study included patients with hip osteoarthritis undergoing total hip arthroplasty and those with femoral neck fractures undergoing bipolar hemiarthroplasty. Preoperative diagnoses, comorbidities, and operative and histopathological findings were analyzed. The study included 193 patients with femoral neck fractures (mean age: 76.8 years, age range=60 - 98 years) and 257 with osteoarthritis (mean age: 60.4 years, age range= 23 - 88). After excluding 22 femoral neck fracture and 90 osteoarthritis patients, 36 patients in the fracture group and 18 in the osteoarthritis group had a history of malignancy, with 10 and 2 patients, respectively, having known metastases. Incidental metastatic bone disease was identified in four femoral neck fracture patients, while no neoplastic findings were detected in the osteoarthritis group. Routine pathological examination of femoral heads is particularly relevant in femoral neck fracture cases, where the risk of detecting metastatic disease is higher. While thorough preoperative assessments and meticulous intraoperative evaluations aid diagnosis, the decision to submit specimens for pathology should be guided by the surgeon's clinical judgment and patient-specific factors. Level III, Diagnostic Study.

IntroductionThe early rehabilitation and mobilization after hip arthroplasty (HA) in elderly femoral neck fracture (FNF) patients significantly reduces the postoperative morbidity and mortality. The direct anterior approach (DAA) without the muscle detachment has been shown to improve the early postoperative functional outcomes in coxarthrosis patients. However, the application of DAA on elderly FNF and the most suitable surgical technique have rarely been investigated. This study aimed to report the short-term outcome after our anterior-based muscle-sparing approach (ABMS) in elderly FNF.Materials and methodsA prospective study, in 40 elderly unilateral FNF patients who underwent HA with ABMS, was conducted. The primary outcomes were hip flexion and abduction power at each follow-up period. The contralateral muscle power, measured at 3 and 6 months, was used as the control value. The perioperative data and complications were recorded.ResultsThirty-two patients underwent bipolar hemiarthroplasty (BHA), while eight other patients received total hip arthroplasty (THA). The hip abduction power returned to control value at 6 weeks (99.0%±6.1%; 95% CI: 86.1–111.8). The hip flexion power returned to control at 3 months (108.5%±5.6%, 95% CI: 96.8–120.2). No iatrogenic nerve injury was found. The intraoperative femoral fracture (IFF) was found in 7 patients (17.5%), and was significantly related to the early period of learning skill (first 11 cases; p<0.01). BHA had nonsignificant higher IFF than THA (8 vs. 0; p=0.31).ConclusionAfter ABMS, the hip muscle could recover to the baseline value within 3 months without iatrogenic nerve injury. The ABMS-related complication, which was IFF, could be significantly improved with the learning skill. The adequate posterior soft tissue release and gentle manipulation of the hip joint might play important roles for IFF prevention. BHA might relate to higher risk of IFF because of difficult reduction from large femoral head diameter.

Background: Most peroneal nerve injuries resulting in foot drop are secondary to trauma or iatrogenic. Foot drop can occur due to potential complications from the hip, lumbosacral spine, and knee surgeries, which are critical to diagnose and manage.Methods: We reviewed our foot drop patients’ data to determine the incidence and iatrogenic causes of the injury and managed surgically by neurolysis of the peroneal nerve and transfer of functional fascicles of either the superficial peroneal or the tibial nerve to the deep peroneal nerve.Results: We found 28 iatrogenic foot drop patients who have had surgery and postoperative follow-up evaluations with us. Before the onset of foot drop, all except one (27 of 28) patient have had surgeries in other clinics before presenting to our institution. Foot drop in one patient was due to infection and hip wound after he was intubated and stayed in ICU for 4 weeks. Thirteen of the 28 patients have had lumbosacral (L3-4, L4-L5, and L5-S1) fusion or laminectomy, eight have had hip surgery, and five have had knee surgery. One patient had a fasciotomy due to compartment syndrome and another patient had two previous surgeries for posterior tibial entrapment and tarsal tunnel syndrome at other institutions. NCS and EMG reports showed that these patients had injuries to the peroneal or tibial nerve after their prior surgeries. One patient had a femoral nerve injury. Preoperatively, 10 patients had severe foot drop with muscle weakness and a functional grade of 0/5; 16 patients had grades ranging from 1 to 2/5; and two patients had 3/5. Overall, 23 of the 28 patients (83%) had improvement in their ankle dorsiflexion with anti-gravity and regained a healthier gait after the decompression, neurolysis, and nerve transfer at our clinic.Conclusion: Twenty-three of the 28 (83%) iatrogenic foot drop patients in this report regained a healthier gait with improved ankle dorsiflexion and anti-gravity after the neurolysis, and nerve transfer of the peroneal or tibial nerve and transfer of functional fascicles of either the superficial peroneal or the tibial nerve to the deep peroneal nerve at our clinic.

Background The incidence of femoral neck fractures in the elderly is increasing due to global population aging, posing a significant public health challenge. The optimal timing for surgical intervention remains controversial. To determine if early surgical intervention reduces complications and enhances therapeutic efficacy in elderly patients with femoral neck fractures undergoing hip arthroplasty. Objective To compare the effects of surgery performed ≤48 h (early) versus &amp;gt;48 h (late) after injury on 30-day complications and 1-year integrated somatic-psychosocial recovery. Methods A retrospective cohort study enrolled 168 consecutive patients aged ≥65 years with Garden-IV femoral neck fracture who underwent hip arthroplasty between January 2023 and December 2024. 77 patients were operated on within 48 h and 91 after 48 h. The primary endpoint was the 30-day composite complication rate; secondary endpoints included length of stay (LOS), haemoglobin drop, inflammatory biomarkers, Harris Hip Score (HHS), Forgotten Joint Score (FJS), 15-item Geriatric Depression Scale (GDS-15) and Lawton Instrumental Activities of Daily Living (IADL) scale. Results Early surgery reduced the 30-day composite complication rate to 29.9% versus 60.4% in the late group (χ 2 = 15.670, p &amp;lt; 0.001, ARR = 30.5, 95%CI:(16.2 to 44.9%)), driven by lower incidences of hypoalbuminaemia (3.9% vs. 24.2%, χ 2 = 13.542, p &amp;lt; 0.001, ARR = 20.3, 95%CI:(10.5 to 30.1%)) and joint pain (1.3% vs. 11.0%, χ 2 = 6.401, p = 0.012, ARR = 9.7, 95%CI:(2.8 to 16.6%)). LOS was shortened by 4.6 days (t = −9.969, p &amp;lt; 0.001) and post-operative haemoglobin decline (115.43 ± 15.03 vs. 98.04 ± 18.48 g/L, t = 6.609, p &amp;lt; 0.001). At 1 month, the early group achieved 10.9 points higher HHS (79.12 ± 4.37 vs. 68.24 ± 8.06, t = 11.090, p &amp;lt; 0.001) and 13.3 points higher FJS (68.74 ± 7.10 vs. 55.46 ± 9.56, t = 10.308, p &amp;lt; 0.001); the advantage persisted at 3 months but disappeared at 6 months. GDS-15 scores were 2.2, 2.7 and 2.0 points lower at 1, 3 and 6 months (1 month: 5.40 ± 3.77 vs. 7.62 ± 2.49, t = −4.546, p &amp;lt; 0.001; 3 months: 2.99 ± 2.57 vs. 5.64 ± 1.74, t = −7.682, p &amp;lt; 0.001; 6 months: 1.95 ± 1.44 vs. 3.97 ± 2.21, t = −7.114, p &amp;lt; 0.001). Lawton-Brody IADL Scores (1 month: 26.29 ± 11.39 vs. 34.37 ± 3.75, t = −5.962, p &amp;lt; 0.001; 3 months: 23.27 ± 9.86 vs. 32.47 ± 4.17, t = −7.630, p &amp;lt; 0.001; 6 months: 20.84 ± 6.37 vs. 29.27 ± 8.06, t = −77.571, p &amp;lt; 0.001). No differences were observed in intra-operative blood loss, operative time, 90-day readmission or 1-year mortality. Conclusion Hip arthroplasty performed within 48 h after femoral neck fracture in the elderly significantly decreases early complications, shortens hospitalisation, accelerates functional recovery and sustains better mood and daily activity without increasing intra-operative risk or late mortality.

The Association of Postoperative Osteoporosis Therapy With Periprosthetic Fracture Risk in Patients Undergoing Arthroplasty for Femoral Neck Fractures

AimHip fracture fixation surgeries are one of the most common surgeries that every trauma unit does regularly. Surgical training and expertise to fix these fractures properly are quite crucial for every orthopaedic surgeon. Therefore, orthopaedic training programmes all over the world consider significant focus on this and teach trainee surgeons expectantly to manage these fractures independently. Surgical fixation of hip fractures often requires fluoroscopy assistance in the operating theatre with associated hazards from ionising radiation. Moreover, hip fractures can be sometimes quite complex and may require relatively more fluoroscopy usage even with the higher grade of the operating surgeons. Therefore, training need for hip fracture fixation surgery is imperative and there is also a need for intraoperative radiation safety. This study has tried to find a balance between intraoperative fluoroscopic radiation exposure, surgical training requirement, and hip fracture complexity.MethodologyThis single centre study has collected retrospective peri-operative data over a period of two years including hip fractures that required fluoroscopy-guided surgical fixation. Femoral head fractures, subtrochanteric fractures, diaphyseal fractures, and trochanteric fractures with associated pelvic fractures were excluded from the study. We collected data on demographic parameters, fracture complexity and grading (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] Classification), intraoperative ionising radiation exposure (centi-Gray/cm2), and grade of the operating surgeon in order to find any relation between these factors.ResultsTotal 268 patients were included in the study with a mean age of 81.8 years (SD 9.3) comprising of 83 (31%) male patients and 185 (69%) female patients. The study population was further stratified into three groups depending upon the operating grade of the surgeon: ‘Junior Trainee’ (<five years of experience; 77 cases [29%]); ‘Senior Trainee’ (>five years of experience; 148 cases [55%]); and ‘Consultant’ (fully trained to practice independently; 43 cases [16%]). There was no statistically significant difference among these three sub-groups with regards to the age (p = 0.79), gender (p = 0.73), body mass index (p = 0.46), and fracture pattern (p = 0.96) of the patients. However, consultants tend to operate more on the higher American Society of Anesthesiologists (ASA) grade patients (p = 0.049) with more comorbidities. There was statistically significant higher fluoroscopic radiation exposure while junior trainee surgeons (p = 0.005) were operating and during the higher complex grade of hip fracture (p = <0.001) fixation.ConclusionIn conclusion, the quantity of intra-operative radiation dose utilised in the surgical fixation of hip fractures is significantly associated with the grade and level of training of the operating surgeon and fracture complexity type. The results of this study emphasise and support the importance of comprehensive, supervised, and structured orthopaedic training for in-theatre radiation safety. It is recommended to have a safe balance between teaching, learning, and prevention of ionising radiation hazards in order to optimally achieve trainee’s professional development with successful patient outcomes.

Objective To observe the effect of alpha lipoic acid on quality of life in patients with type 2 diabetic peripheral neuropathy. Methods 76 cases diagnosed with type 2 diabetic peripheral neuropathy,in accordance with the random number table,were divided into the control group(37cases) and treatment group(39cases).All the patients received diabetic diet,exercise guidance and blood glucose control.The control group was treated with methycobal 500μg muscle injection once a day for 2 weeks.The treatment group was treated besides above treatment with intravenous drip alpha lipoic acid 600mg once a day was added for 2 weeks.Then,the changes of motor nerve conduction velocity,sensory nerve conduction velocity and quality of life(QoL) score(somatic symptoms,cognitive function, health happy feeling,social participation,emotional state,work performance,life satisfaction and total score)of the two groups after treatment were observed. Results After treatment,the motor nerve conduction velocity of the control group were as follows:median nerve(40.7±4.5)cm/s,common peroneal nerves(41.3±4.9)cm/s,The sensory nerve conduction velocity of the control group were as follows:median nerve(38.6±4.3)cm/s,common peroneal nerves (38.3±4.5)cm/s.After treatment,the motor nerve conduction velocity of the treatment group were as follows:Median nerve(45.4±5.7)cm/s,common peroneal nerves(44.9±6.4)cm/s,The sensory nerve conduction velocity of the treatment group were as follows:Median nerve(45.0±2.0)cm/s,common peroneal nerves(43.6 ±3.2)cm/s.Both the two groups' motor nerve conduction velocity and sensory nerve conduction velocity were significantly increased after treatment(P< 0.05).Compared with control group,the motor nerve conduction velocity and sensory nerve conduction velocity in the treatment group were significantly improved after treatment,which had statistically significance,(t= 2.63,2.51,2.85,2.79,all P< 0.05).After treatment,the somatic symptoms,cognitive function,health happy feeling,job performance,social participation,emotional state,life satisfaction and the total score of control group were(52.4±9.6)points,(27.0±7.8) points,(35.7±10.3) points,(19.6±7.3) points,(17.4±3.1) points,(16.5±3.9) points,(185.4±40.7)points,respectively.After treatment,the somatic symptoms,cognitive function,health happy feeling,job performance,social participation,emotional state,life satisfaction and total score of treatment group were(41.9±7.4) points,(24.1±8.6) points,(28.3±9.2) points,(14.5±5.5) points,(12.6±5.6) points,(11.9±4.7)points,(135.0±38.7)points,respectively.The quality of life score of the treatment group was obviously lower than the control group,which had statistically significance,(t= 5.14,2.54,2.96,2.87,2.69,3.05,6.25, all P<0.05). Conclusion Alpha lipoic acid can improve the nerve conduction function of patients with type 2 diabetes peripheral neuropathy,and improve the quality of life. Key words: Diabetic neuropathies; Quality of life; Alpha lipoic acid

Although literature exists regarding surgery after hip screw/side plate devices, we are unaware of any reports of hip arthroplasty after intramedullary devices. This is a retrospectively reviewed case series. Tertiary care medical center. A consecutive unselected series. Hip arthroplasty surgery after failed hip fracture fixation surgery using an intramedullary nail device. Twenty cases of conversion surgery after intramedullary fixation for hip fractures were retrospectively reviewed. The indications for hip arthroplasty were nonunion with failed fixation in 15, avascular necrosis with secondary hip arthritis in three, and progression of hip arthritis in four. Average operative time and blood loss were 166 minutes and 621 mL, respectively. Of note, nine of 20 patients ultimately developed a nonunion of the greater trochanter after hip arthroplasty. In only one of these cases of nonunion was the greater trochanter refractured intraoperatively and this as part of a trochanteric osteotomy. Patients undergoing hip arthroplasty after failed hip fracture fixation using an intramedullary nail device are at high risk for greater trochanteric fracture and nonunion. The average operative time and blood loss for these procedures were greater than reported for primary but less than for revision arthroplasty. We now consider treating these cases with a trochanteric plate with or without a trochanteric slide osteotomy to minimize fracture of the remaining, damaged trochanteric bone. Therapeutic Level IV. See page 128 for a complete description of levels of evidence.

Objective To evaluate the short-term follow-up results of stemless hip arthroplasty and discuss its security, feasibility and validity in clinical application. Methods From February 2002 to March 2007, 51 patients (56 hips) underwent hip arthroplasty using stemless prostheses, including 31 males (34 hips) and 20 females (22 hips) with an average age of 56.2 years (range, 25 to 87 years). The mean preoper-ative Harris hip score was 72.4 ±8.4. There were fresh femoral neck fractures occurring in 6 patients (6 hips), avascular necrosis of femoral head after femoral neck fractures in 4 (4 hips), aseptic necrosis of femoral head (Ficat ID -IV) in 34 (37 hips), ankylosing spondylitis in 2 (3 hips), rheumatoid arthritis in 2 (3 hips) and hip tuberculosis in 3 (3 hips). Total hip arthroplasty were taken in 50 hips and femoral head replacement in 6 hips. The clinical effects were evaluated basing on Harris score and radiographic analysis according to Amstutz's zoning method for the stem and cup implant. Results All the patients were followed up, with a mean period of 4.8 years (range, 2 to 7 years). According to the Harris hip scoring system, the mean score was 92.8±3.2 after operation. There were 44 hips rated as excellent, 7 as good, 4 as fair, and 1 as poor. The excellent-good rate was 91%. Two patients dislocated at 2 and 3 days after operation, respectively, and who both gained manual reduction successfully. One patient got infected at 40 days after operation, and was cured by focal cleaning and continuous lavage of the joint cavity. Hip pain occurred in 1 case after operation and relieved after revision using femoral prosthesis with stem. X-ray showed no prosthesis loosening, disloca-tion or breakage of screws in these cases during follow-up. Conclusion Stemless hip arthroplasty is charac-terized by preservation of femoral neck, less surgical trauma, less blood loss, less complications and fitting f or revision. It is especially suitable for the old and weak cases or the young who need hip replacement. The follow-up results of 2 to 7 years showed its reliable effect, and the long-term outcomes need further e-valuation. Key words: Arthroplasty, replacement, hip; Prosthesis design; Treatment outcome

Displaced Versus Nondisplaced Femoral Neck Fractures: Is Arthroplasty the Answer for Both?