title: Iatrogenic nerve injury in acetabular fracture surgery: a comparison of monitored and unmonitored procedures.
abstract: OBJECTIVE
  To review our experience with iatrogenic nerve injuries and to evaluate the efficacy of intraoperative monitoring in a large consecutive series of operatively treated acetabular fractures.
  
  
  METHODS
  Retrospective, nonrandomized.
  
  
  METHODS
  Level I Trauma Center, January 1, 1992 through December 31, 1998.
  
  
  METHODS
  A total of 256 consecutive acetabular fractures were operatively treated at our institution; 140 unmonitored procedures and 112 monitored procedures were available for review. The decision to use monitoring was at the discretion of the treating surgeon.
  
  
  METHODS
  Open reduction and internal fixation of the acetabular fracture.
  
  
  METHODS
  Preoperative and postoperative neurologic examinations, fracture type, use of traction, dislocation, operative approach, and complications were analyzed. Motor strength, sensation, the need for gait aids, orthoses, and extent of recovery were evaluated.
  
  
  RESULTS
  Traumatic nerve palsies were present in eleven of 140 (7.9 percent) unmonitored and thirteen of 112 (11.6 percent) monitored fractures (p = 0.314). There were fourteen iatrogenic sciatic nerve palsies in 252 cases (5.6 percent). There were four iatrogenic sciatic palsies (2.9 percent) in the unmonitored group and ten iatrogenic palsies (8.9 percent) in the monitored group (p = 0.037). In the unmonitored group one of eighty-one Kocher-Langenbeck approaches (1.2 percent), two of fifty-two ilioinguinal (3.9 percent), and one of three extended iliofemoral approaches developed a sciatic palsy. In the monitored group six of seventy-seven Kocher-Langenbeck approaches (7.8 percent), three of twenty-five ilioinguinal (12 percent), and one of six combined approaches (16.7 percent) developed a sciatic palsy. In seven of the ten iatrogenic palsies in the monitored group, the intraoperative monitoring was normal. Seventy-six patients were monitored with somatosensory evoked potential alone, and nine had iatrogenic injuries (11.8 percent). Thirty-six patients were monitored with somatosensory evoked potential and electromyography, and one had an iatrogenic injury (2.8 percent) (p = 0.164). Clinical follow-up was available for three of the four patients with iatrogenic injuries in the unmonitored group, with a mean follow-up of twenty-seven months (range 8 to 60 months). Two patients had full motor recovery at a mean of six months, and one had no recovery at fourteen months.
  
  
  CONCLUSIONS
  The use of intraoperative monitoring did not decrease the rate of iatrogenic sciatic palsy. Further study involving larger prospective, randomized methodology appears warranted. Sciatic nerve injury was more common in ilioinguinal approaches in both groups, likely due to reduction techniques for the posterior column performed with the hip flexed, placing the sciatic nerve under tension.
authors.affiliation: Orthopedic Trauma Service, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, MN 55905, USA..
authors.forename: George John
authors.initials: GJ
authors.lastname: Haidukewych
authors.forename: Julia
authors.initials: J
authors.lastname: Scaduto
authors.forename: Dolfi
authors.initials: D
authors.lastname: Herscovici
authors.forename: Roy W
authors.initials: RW
authors.lastname: Sanders
authors.forename: Thomas
authors.initials: T
authors.lastname: DiPasquale
mesh_terms: D000077:Acetabulum / Q000293:injuries* / Q000601:surgery; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D016001:Confidence Intervals; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects* / Q000379:methods; D017102:Fracture Healing / Q000502:physiology; D050723:Fractures, Bone / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007049:Iatrogenic Disease; D007431:Intraoperative Complications / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D011336:Probability; D011859:Radiography; D012016:Reference Values; D012189:Retrospective Studies; D018570:Risk Assessment; D012584:Sciatic Nerve / Q000293:injuries*