The Journal of Arthroplasty Vol. 25 No.

8 2010

Sciatic Nerve Injury in Total Hip Resurfacing

A Biomechanical Analysis
Dustin P. Gay, MD, Dana R. Desser, MD, Brent G. Parks, MSc, and
Henry R. Boucher, MD

Abstract: The condition of the gluteal sling was a significant factor in determining the pressure
experienced by the sciatic nerve during acetabular exposure in total hip resurfacing via a posterior
approach. The position of the knee did not play a significant role at this stage of the procedure.
Average pressures were not elevated above a predefined injury level during positioning for
femoral preparation. During hip reduction, knee positioning seemed to play a significant role in
pressures placed on the sciatic nerve. These findings suggest that releasing the gluteal sling during
a posterior approach for total hip resurfacing may help to prevent postoperative sciatic nerve
palsies. Consideration should also be given to at least partially flexing the knee during hip
reduction in this procedure. Keywords: biomechanical, hip, total hip resurfacing, sciatic nerve.
© 2010 Elsevier Inc. All rights reserved.

Nerve palsies are a relatively uncommon but catastroph-
ic complication of total hip arthroplasty [1-3]. Only
approximately 40% [2] of patients have complete
recovery of nerve palsies that result from total hip
arthroplasty. Despite research and intraoperative neu-
romonitoring, approximately 50% of these nerve palsies
are due to unknown causes [1,3]. Therefore, any
intraoperative factors felt to contribute to potential
nerve palsies remain important.
The first new-generation metal-on-metal total hip
resurfacing was recently approved for use in the United
States after use outside the United States for more than
10 years [4,5]. Early US results suggest concern with
complications, including nerve palsy, as compared with
traditional hip arthroplasty. One US study of total hip
resurfacing found a 1.7% incidence of postoperative
nerve palsies at 1-year follow-up [6] as compared with
an incidence of 1% in traditional total hip arthroplasty
[2]. An Australian study found a 2.1% incidence of
postoperative nerve palsies with modern total hip
resurfacing [7]. This higher incidence of nerve palsies
From the Department of Orthopaedic Surgery, The Union Memorial
Hospital, Baltimore, Maryland.
Submitted April 16, 2009; accepted August 26, 2009.
Departmental research funds were received in support of this study.
Financial disclosure: The authors state no potential conflict of
interest with regard to the subject of this study.
Reprint requests: Henry R. Boucher, MD, c/o Lyn Camire, Editor,
Union Memorial Orthopaedics, The Johnston Professional Building,
#400, 3333 North Calvert Street, Baltimore, MD 21218.
© 2010 Elsevier Inc. All rights reserved.
0883-5403/2508-0019$36.00/0
doi:10.1016/j.arth.2009.08.017
may become increasingly important as total hip resurfa-
cing gains in popularity. The problem may be further
exacerbated by use of this procedure in a younger, more
active population in whom nerve palsies will likely result
in even greater loss of function. Younger patients'
heightened sense of dissatisfaction will result from
their desired and expected increased activity level
when compared with older patients.
It is important to discover what aspects of the hip
resurfacing technique might be associated with risk of
nerve injury. Some investigators have suggested that the
gluteal sling plays a role in sciatic nerve palsies in total
hip arthroplasty. The gluteus maximus has a broad
insertion. The upper fibers insert into and blend with the
iliotibial band. The lower fibers, referred to as the gluteal
sling, insert into the gluteal tuberosity of the femur and
the lateral intermuscular septum. This occurs just distal
the insertion of the quadratus femoris. At this level, the
sciatic nerve lies medial and deep to the gluteal sling and
lateral to the ischial tuberosity. Hip flexion and internal
rotation, which occur during hip arthroplasty proce-
dures, result in tightening of the gluteal sling and
potential entrapment of the nerve against the ischial
tuberosity. Hurd et al [8] have stated that an intact
gluteal sling can lead to sciatic nerve compression during
positioning for femoral preparation during hip arthro-
plasty. The position of the knee may also play a role as a
result of its effects on tensioning of the sciatic nerve.
Although the exact pressure required to injure a
peripheral nerve in humans is not known, investigators
have found endoneural edema indicating nerve injury
with compressive pressures as low as 400 mm Hg in as

1295
1296 The Journal of Arthroplasty Vol. 25 No. 8 December 2010
little as 15 minutes using a rabbit tibial nerve model [9].
Although some portions of the total hip resurfacing
procedure are transient, such as hip reduction, other
portions of the procedure, such as acetabular exposure
and preparation and femoral preparation, can take
longer than 15 minutes. Using a pressure of 400 mm
Hg or greater as an indicator of nerve injury could
provide preliminary understanding of potential causes of
sciatic nerve injury in humans.
We hypothesized that an intact gluteal sling and an
extended knee position would result in higher pressures
on the sciatic nerve during acetabular exposure,
positioning for femoral preparation, and hip reduction
in total hip resurfacing in a cadaver model. Our purpose
was to compare pressure in the sciatic nerve at these
technique stages with the gluteal sling in intact and
released condition and with the knee in both full
extension and 90 degrees of flexion, with the posterior
approach used in total hip resurfacing.
Materials and Methods
Ten hips from 5 fresh cadaveric lower torso specimens
harvested through the thoracolumbar spine were used.
There were 4 male and 1 female specimens aged 71.6
years (range, 63-85 years). Each specimen was checked
for previous surgical scars around the hip to ensure that
no prior hip procedures had been performed. Each
specimen was positioned on a peg board in a standard
lateral position, and stability of the setup was confirmed
by placing the operative leg through a range of motion.
Fig. 1. Illustration shows anatomic detail including the gluteal sling and ischial tuberosity.
A standard posterior hip incision was made in a
curvilinear fashion over the posterior tip of the greater
trochanter. Dissection was carried down through the
tensor fascia lata and gluteus maximus in a standard
fashion. The greater trochanteric bursa was then
resected, and the sciatic nerve was identified.
The sciatic nerve was then carefully exposed both
proximally and distally (Fig. 1) while leaving the short
external rotators intact. The dissection was carried
distally to just below the level of the gluteal sling
insertion. Next, a 3- to 4-cm incision was made proximal
and perpendicular to the previous incision. This incision
was used to pass a calibrated 6-panel 6900 I-Scan sensor
(Tekscan, Inc, South Boston, Mass). The final sensor was
constructed by using 6 sensor panels, each measuring 1
× 1 cm, from two 4-panel 6900 I-Scan sensors. Each
6900 I-Scan sensor has 4 fingers with a 1 × 1-cm sensor
panel on the end. These 4-sensor panels and 2-sensor
panels from a second 6900 I-Scan Sensor were glued
together to construct a 6-panel sensor. The 6-panel
sensor covered the nerve from the ischial tuberosity to
below the gluteal sling insertion. This includes the area
of sciatic nerve compression injury described by Hurd et
al [8] from magnetic resonance imaging evaluations.
The sciatic nerve was instrumented (Fig. 2) with the I-
Scan sensor. The sensor was attached to the sciatic nerve
with a thin layer of glue, and secure fixation was
confirmed. The interval between the abductors and
external rotators was identified. The external rotators
were released, and a capsulotomy was performed while
 Total Hip Resurfacing Sciatic Nerve Injury  Gay et al
Fig. 2. Photograph shows placement of sensor on sciatic nerve.
The ischial tuberosity is located beneath the sciatic nerve and
is covered by soft tissue in the cephalad portion of the wound.
leaving the gluteal sling insertion intact. The I-Scan
sensor was then attached to its base unit, which was
connected to a computer with Tekscan software to
collect pressure data.
The hip was then dislocated posteriorly with traction and
internal rotation. A pocket was created anterior and
superior to the acetabulum to allow translation of the
femoral head for acetabular exposure. A retractor was
placed anterior to the acetabulum and used to translate the
femur and femoral head anteriorly to expose the
acetabulum. A second retractor was placed posteriorly.
Whereas gentle retraction was performed, a small episiot-
omy was made inferiorly just through the capsule to allow
better exposure. Completion of the acetabular exposure
including labral resection was performed. All exposures
were performed by the first author, who was blinded to
pressure recordings throughout each procedure.
Recordings were taken of the pressure experienced by
the sciatic nerve with the described standard acetabular
exposure necessary to prepare for acetabular reaming.
Data were collected first with the knee at 90 degrees of
flexion and then with the knee at 0 degree of flexion.
Each position was held for approximately 5 seconds,
whereas a pressure recording was taken by another
investigator and the primary investigator holding the
leg remained blinded to the pressure readings. The
retractors were then removed. The leg was positioned
for femoral preparation with hip flexion and internal
rotation to center the femoral head within the wound,
followed by application of axial femoral loading to
deliver the femoral head out of the wound. Pressures
placed on the sciatic nerve were again recorded with
the knee at both 90 and 0 degrees of flexion. Pressure
data were again collected by the coinvestigator, main-
taining blinding of the primary investigator. The hip
was then reduced with the knee in 90 degrees of
flexion, followed by reduction with the knee in 0
1297
degree of flexion using traction and external rotation.
The reduction was performed in a standard fashion
with gentle posterior soft-tissue retraction to prevent
entrapment within the acetabulum. Again, pressure
experienced by the sciatic nerve was recorded as was
done previously by the coinvestigator maintaining
blinding of the primary investigator.
The gluteal sling insertion was then sharply released,
and the hip was again posteriorly dislocated. Then the
entire process of acetabular exposure, positioning for
femoral preparation, and reduction was repeated as
described above with consistent retractor placement.
Pressure recordings were again obtained in a blinded
fashion. After completion of data collection, the
pressure sensor was examined to ensure that its
position had remained unchanged throughout the
data collection process.
Statistical Analysis
Power analysis of the first 4 specimens determined that
10 hips were needed to obtain a 75% ability to detect a
significant pressure difference on the sciatic nerve
during acetabular exposure at a significance level of
.05. Two-way repeated-measures analysis of variance
testing was used to compare the data. Significance was
set at P ≤ .05.
Results
During acetabular exposure with the gluteal sling
intact, the average pressure experienced by the sciatic
nerve was 851.7 ± 275.5 mm Hg (mean ± SD) when the
2 knee position groups were combined. The average
pressure with the sling intact and knee fully extended
was 926.9 ± 310.6 mm Hg, compared with 776.4 ± 226.3
mm Hg with the knee in 90 degrees of flexion. This
difference was not significant (P = .29). The average
pressure in both groups exceeded the established critical
value of 400 mm Hg. During acetabular exposure with
the gluteal sling released, the average pressure exerted
on the sciatic nerve, when combining the 2 knee
position groups, was 263.9 ± 392.4 mm Hg. The average
pressure with the knee fully extended was 314.3 ± 412.5
mm Hg, compared with 213.5 ± 386.5 mm Hg with the
knee flexed 90 degrees (P = .44; Fig. 3).
When the entire sling intact group including the knee
at 0- and at 90-degree flexion was compared with the
entire sling released group, the difference was significant
(P = .001). When the sling intact knee at 0-degree group
was compared with the sling released knee at 0-degree
group, the difference was significant (P = .002). When
the sling intact knee at 90-degree group was compared
with the sling released knee at 90-degree group, the
difference was significant (P = .003). Thus, the condition
of the gluteal sling was a significant factor in determining
the pressure experienced by the sciatic nerve during
acetabular exposure. The position of the knee did not
play a significant role.
1298 The Journal of Arthroplasty Vol. 25 No. 8 December 2010

Fig. 3. Graph showing comparisons during acetabular expo-
sure. Horizontal line at 400 mm Hg shows predetermined
pressure level at which nerve injury was considered possible.
AE indicates acetabular exposure; SI, sling intact; SR, sling
reduced; 0, knee at 0 degree of flexion; 90, knee at 90 degrees
of flexion. Error bars show SD.
Fig. 4. Graph showing comparisons during femoral position-
ing. Horizontal line at 400 mm Hg shows predetermined
pressure level at which nerve injury was considered possible.
FP indicates femoral positioning; SI, sling intact; SR, sling
reduced; 0, knee at 0 degree of flexion; 90, knee at 90 degrees
of flexion. Error bars show SD.

The average pressure during positioning for femoral degree flexed group. The average pressures experienced
preparation with the gluteal sling intact, when the 0- by the sciatic nerve in each group were as follows: sling
and 90-degree flexion groups were combined was intact knee 0 degree flexed, 610.4 ± 412.5 mm Hg; sling
263.4 ± 450.7 mm Hg, compared with 0.0 ± 0 mm Hg intact knee 90 degrees flexed, 223.9 ± 347.8 mm Hg;
with the gluteal sling released (P = .09). The average sling released knee 0 degree flexed, 569.4 ± 439.0 mm
pressure for the sling intact group was 321.4 ± 480.1 Hg; and sling released knee 90 degrees flexed, 55.3 ±
mm Hg with the knee at 0 degree of flexion, compared 157.4 mm Hg (Fig. 5). A significant difference in the
with 205.4 ± 437.0 mm Hg with the knee 90 degrees pressure experienced by the sciatic nerve during hip
flexed (P = .07). The average pressure for the sling reduction was present when isolating the variable of
released group was 0.0 ± 0 mm Hg with the knee at 0 knee positioning (0 degree versus 90 degrees flexed; P =
degree of flexion and 0.0 ± 0 mm Hg with the knee 90 .002), with the higher pressure occurring when the
degrees flexed (P = 1.0). There was a significant knee was 0 degree flexed. Knee positioning was also
difference in pressure placed on the sciatic nerve found to be a significant variable in determining pressure
during positioning for femoral preparation between
the sling intact knee 0-degree flexed group and the
sling released knee 0-degree flexed group (P = .05).
There was no significant difference when the same
comparison was made with the knee 90-degree flexed
groups (P = .19). Therefore, during positioning for
femoral preparation, only a combination of knee
positioning and condition of the gluteal sling made a
significant difference in the pressure experienced by
the sciatic nerve. The pressures during positioning for
femoral preparation did not reach the predefined
critical level of 400 mm Hg (Fig. 4).
Pressures experienced by the sciatic nerve during hip
reduction were also recorded with the gluteal sling intact
and released with the knee in 0 and 90 degrees of
flexion. The average pressure in the combined (knee 0
and 90 degrees flexed) sling intact group was 417.2 ±
Fig. 5. Graph showing comparisons during reduction with
420.2 mm Hg, compared with 312.4 ± 426.8 mm Hg in gentle retraction of the nerve. Horizontal line at 400 mm Hg
the combined (knee 0 and 90 degrees flexed) sling shows predetermined pressure level at which nerve injury was
released group (P = .29). Although the pressure in the considered possible. RED indicates hip reduction; SI, sling
combined sling intact group did exceed the predefined intact; SR, sling reduced; 0, knee at 0 degree of flexion; 90,
critical value, this is due to the inclusion of the knee 0- knee at 90 degrees of flexion. Error bars show SD.
 Total Hip Resurfacing Sciatic Nerve Injury  Gay et al
experienced by the sciatic nerve within both the sling
intact (P = .05) and the sling released (P = .01) groups.
When the condition of the sling (intact versus released)
was isolated at both knee positions, it was not found to be
a significant variable in determining pressure experi-
enced by the sciatic nerve (P = .81 and P = .34). Thus,
knee positioning and not the condition of the gluteal
sling seems to play a significant role in pressures placed
on the sciatic nerve during hip reduction.
Discussion
Since the approval for use in the United States in 2006,
new-generation metal-on-metal total hip resurfacing
has been an alternative to total hip arthroplasty. Recent
early data have shown that the rate of nerve injury in
modern total hip resurfacing is between 1.7% and 2.1%
[6,7], compared with an incidence of approximately 1%
in conventional total hip arthroplasty [2]. Modern total
hip resurfacing has been indicated for use in a younger
more active population, which means the dramatic
impact of nerve injuries will be further increased as
younger patients face the loss of function associated with
nerve injury.
Early US results suggest concerns about risk of nerve
palsies in total hip resurfacing as compared with
traditional hip arthroplasty. In a US study of 537 initial
patients undergoing this procedure, Della Valle et al [6]
reported a 1.7% incidence of postoperative nerve palsies
at 1-year follow-up as compared with an incidence of
1% in traditional total hip arthroplasty [2]. An Austra-
lian study of 230 hips and mean 5-year follow-up found
a 2.1% incidence of postoperative nerve palsies with
modern total hip resurfacing [7]. Our findings suggest
areas of potential risk of sciatic nerve injury in the
standard total hip resurfacing technique done through a
posterior approach.
The highest pressures experienced by the sciatic nerve
occurred during acetabular exposure, which is required
for reaming and cup placement in total hip resurfacing.
Of potential concern, in terms of the predefined pressure
and duration representing nerve injury, is that reaming
and inserting the acetabular cup clinically may require
15 minutes or more. The condition of the gluteal sling
was the most significant variable in determining the
pressure experienced by the sciatic nerve during
acetabular exposure and preparation. Regardless of the
position of the knee (0 or 90 degrees flexed), an intact
gluteal sling resulted in pressures exceeding the critical
value. Although fully extending the knee with the sling
intact further increased the pressure placed on the sciatic
nerve, it did not make a significant difference. Once the
gluteal sling was released, the average pressures during
acetabular exposure dropped below the critical value.
Fully extending the knee raised the pressure placed on
the nerve, but the difference was not significant. These
findings suggest that releasing the gluteal sling during
1299
exposure may help to prevent postoperative sciatic
nerve palsies.
During positioning for femoral preparation, no
variable resulted in a significant difference in the
pressure placed on the sciatic nerve. Pressure on the
nerve was significantly increased with the gluteal sling
intact and the knee fully extended, but pressure did
not exceed the predefined critical value. In contrast,
position of the knee was a significant factor affecting
pressure on the nerve during hip reduction. With the
gluteal sling intact or released, a fully extended knee
significantly increased the pressure placed on the
sciatic nerve to raise the defined critical level during
hip reduction, whereas pressure fell below the critical
level when the knee was flexed 90 degrees. Although
reduction of the hip with an extended knee alone
probably does not cause a postoperative nerve palsy
due to the transient nature of the pressure placed on
the nerve, it may play a role if the nerve has been
stressed in some manner earlier in the procedure. This
potential for additional injury may be further exacer-
bated by multiple reductions if trailing is performed.
These findings suggest the possible benefit of at
least partially flexing the knee during hip reduction
in this technique.
There are several limitations within our study. There
were large SDs in the pressure readings in several
instances. Although the SDs shown in the graphs at
times cross over the described critical pressure level,
we believe the trends seen in the average pressures
remain important. All procedures and all retractor
positioning were done by the primary investigator,
and blinding of this investigator with regard to
pressure readings was maintained. We speculate that
subtle differences in retractor positioning and varied
patient anatomy may have played a role in the wide
variations observed. In future studies with this model,
the primary investigator could be notified of unusually
high pressures allowing for a through examination of
the relationship of the retractor to the nerve. We were
also limited by a lack of information on the amount of
pressure needed to cause a sciatic nerve injury, which
required the use of presumed pressure levels and
pressure duration based on an animal model [9].
Pressure level and duration associated with injury in
humans may be higher or lower than that assumed in
the current study, but the findings provide a useful
relative comparison. Furthermore, cadaveric specimens
may differ in their tissue compliance and nerve
excursion with respect to living tissue. By using fresh
(not frozen or embalmed) specimens, we feel that we
have set up the best possible model to accurately
reflect healthy living tissue. Finally, pressures during
hip reduction were recorded with the native head and
acetabulum with no implants inserted. The implants
used in this technique clinically may change the
1300 The Journal of Arthroplasty Vol. 25 No. 8 December 2010
values obtained, but properly fitted implants should
not change the findings substantially during hip
reduction. These findings cannot be extrapolated to
traditional total hip arthroplasty because the model
was designed with an intact femoral head and neck
replicating total hip resurfacing.
In conclusion, the current findings suggest that
releasing the gluteal sling during exposure with a
posterior approach in total hip resurfacing may help to
prevent postoperative sciatic nerve palsies. Consider-
ation should also be given to partially flexing the knee
during hip reduction in this procedure.
Acknowledgment
The authors thank Lyn Camire, ELS, of our depart-
ment for editorial assistance.
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