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Z Orthop Unfall 2020; 158(05): 535-555
DOI: 10.1055/a-0915-9272
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Iatrogene Nervenläsionen in der Hüft- und Knieendoprothetik

Nerve Injuries in Hip and Knee Arthroplasty – Risk Factors, Diagnostic and Therapeutic Approaches
Claude Léonie Weynandt
,
Alexander Kowski
,
Carsten Perka
,
Anastasia Rakow
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Zusammenfassung

Iatrogene Verletzungen motorischer Nerven gehören zu den Majorkomplikationen der Hüft- und Knieendoprothetik. Entsprechende Risikofaktoren und das Vorgehen bei solchen Schädigungen sollten den behandelnden Ärzten vertraut sein.

Abstract

Iatrogenic nerve injuries are rare complications of total hip and knee arthroplasty, which may cause chronic pain and loss of function, severely affecting the patientʼs daily activities and quality of life. Nerves “at risk” include the sciatic nerve, the femoral nerve, the lateral femoral cutaneous nerve and the superior gluteal nerve during total hip arthroplasty, and the infrapatellar branch of the saphenous nerve as well as the peroneal nerve during total knee arthroplasty. Multiple procedure-related and patient-related factors have been identified to modify the risk of nerve injury in the course of lower limb joint replacement surgery. These include the surgeonʼs skills, the surgical approach, the type of implant fixation, the intraoperative positioning of the patient, as well as pre-existing scars, the patientʼs sex, age and comorbidities. Diagnostic and therapeutic approaches should be based on the aetiology of the lesion: iatrogenic nerve lesions can result from direct (compression or transection) and/or indirect (traction, ischemia) trauma. The majority of nerve injuries encountered in hip or knee arthroplasty has been referred to as “minor” nerve lesions, which generally respond very well to non-operative treatment. “Major” nerve lesions, such as complete motor nerve transection, may result in lifelong impairment. Any perioperatively encountered neurological deficit requires a meticulous diagnostic work-up and an individually tailored treatment strategy, respecting aetiology and anatomic site of the nerve lesion as well as the individual patientʼs needs and comorbidities.

Kernaussagen

  • Iatrogene Nervenläsionen sind seltene Komplikationen der Hüft- und der Knieendoprothetik. Angesichts global steigender Implantationszahlen von Hüft- und Kniegelenksendoprothesen ist jedoch von einer steigenden absoluten Anzahl solcher adversen Ereignisse auszugehen.

  • Postoperativ neu auftretende periphere motorische Defizite sind in der Hüftendoprothetik am häufigsten durch Läsionen des N. ischiadicus und in der Knieendoprothetik am häufigsten durch Verletzungen des N. peroneus communis bedingt.

  • Für die Primärprävention perioperativer Nervenverletzungen sind eine gründliche Anamneseerhebung und präoperative Untersuchung des Patienten, fundierte Anatomiekenntnisse, der bedachte Einsatz von Retraktoren, stets sorgfältiges Präparieren und die schonende Lagerung des Patienten essenziell.

  • Nach der Feststellung postoperativ neu aufgetretener peripherer neurologischer Defizite ist die sofortige Einleitung der Diagnostik obligat. Standard ist die Kombination aus neurologischer Untersuchung und bildgebenden Modalitäten, welche die Beurteilung der periimplantären Weichteile erlauben.

  • Ist eine mechanische Ursache identifiziert, so ist die rasche Initiierung der zielgerichteten Therapie für das klinische Outcome perioperativer Nervenläsionen in der Hüft- und Knieendoprothetik entscheidend.

  • In bis zu > 50% der nach hüftendoprothetischen Eingriffen apparent werdenden neurologischen Defizite bleibt die Ursache der Nervenläsion(en) unbekannt [11], [16], [17], [18], [19].

  • Unter medikolegalen Aspekten sind die dem elektiven Setting der Endoprothetik angemessene Ausführlichkeit der präoperativen Risikoaufklärung des Patienten und die präzise Erhebung und Dokumentation des motorischen Status sowie des Sensibilitätsstatus von großer Bedeutung.

Schlüsselwörter

Nervenläsion - Endoprothetik - Hüftgelenk - Kniegelenk - postoperative Komplikationen

Key words

postoperative neurological deficit - arthroplasty - hip joint - knee joint - perioperative complications


Publication History

Article published online:
09 July 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Stuttgart · New York

 

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