66yo female
Prior to May 2024 Patient had a known diagnosis of avascular necrosis (AVN) of the right femoral head, causing progressive hip pain and functional decline.
No documented prior sciatic nerve dysfunction.
May 28, 2024 – Primary Right Total Hip Arthroplasty. Direct anterior approach performed for end-stage avascular necrosis. Intraoperative complication: Posterior acetabular wall fracture occurred during component placement. (OP NOTE ATTACHED)
Immediate stability issues noted during the procedure, but no sciatic nerve injury documented at this time.
May 30, 2024 – Acute Revision Surgery. Patient returned to the operating room for acute revision due to acetabular fracture. A posterior buttress augment was placed to stabilize the acetabular component.
During surgery: Significant soft tissue trauma was noted around the sciatic nerve region. Surgeon acknowledged concern for sciatic nerve injury intraoperatively.
(OP NOTE ATTACHED)
Postoperative course: Foot drop and numbness in the right lower extremity were first clinically documented.
June 11, 2024 – Second Revision: Femur Fracture Repair Patient sustained a mechanical fall during transfer at a rehabilitation facility. Diagnosed with a periprosthetic femur fracture.
Underwent revision of the femoral component and open reduction and internal fixation (ORIF) of the fracture. Pre-operative note documented pre-existing right foot drop, confirming sciatic nerve injury was present before this event.
June 28, 2024 – Closed Reduction of Hip Dislocation Patient experienced a dislocation of the right hip prosthesis. Required closed reduction under anesthesia.
Reduction was achieved, but instability raised concerns about implant positioning.
July 2024 – Second Dislocation and Additional Reduction Patient suffered a second dislocation. Underwent another closed reduction attempt, successfully realigned but soft tissue status remained compromised.
August–September 2024 Imaging (CT) obtained: Showed posterior displacement of the acetabular component. Mass effect directly observed against the sciatic nerve.
October 23, 2024 – EMG/NCS Testing
EMG demonstrated: Severe chronic right sciatic nerve injury. Complete absence of motor and sensory nerve conduction in the right lower extremity. Moderate fibrillation potentials in multiple muscles supplied by the sciatic nerve.
Findings consistent with subacute to chronic sciatic neuropathy and no significant recovery.
November 21, 2024 – Orthopedic Follow-up Patient continued to report: Severe pain in the right hip and buttock. Complete foot drop with wheelchair dependence.
Very slow rehabilitation progress.
Plan involved pain management and avoiding further surgery unless prosthetic instability worsened.
Pre-existing avascular necrosis necessitated the original hip replacement but ensuring it did not directly contribute to the sciatic nerve injury?
Sciatic nerve palsy developed immediately after the revision surgery for the posterior acetabular fracture on May 30, 2024, is that the culprit surgery? Known complication?
Looking for opinion relating to the initial 2 surgeries and her subsequent findings during surgery # 2 on technique and etiology of nerve injury..
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Do you believe there might have been medical error?
The cause of the posterior wall fracture and need for second surgery is concerning. It suggests improper reaming of the acetabulum. Would need to see imaging to confirm.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Second surgery, probably unnecessary had improper reaming not have occurred, would have prevented injury to the sciatic nerve.
What makes you a good expert for this case?
I am not a good expert for this case.
How often do you encounter cases similar to this one in your practice?
I do not encounter this is my practice.
Do you believe there might have been medical error?
I believe the sciatic nerve was injured at the time of acetabular revision surgery and also by the malpositioned acetabular component putting pressure on the sciatic nerve.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I believe the sciatic nerve was injured during revision surgery based on the operating report, postop CT scan and EMG.
What makes you a good expert for this case?
I have been doing expert medicolegal work for approximately 8 years and am a full time practicing orthopedic surgeon who frequently treats patients with foot drop..
How often do you encounter cases similar to this one in your practice?
I see cases like this approximately 5-10 times per year.
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