Iatrogenic Sciatic Nerve Injury in Posterior Acetabular Surgery: Surgeon More Predictive Than Position

OBJECTIVES: Identify factors that contribute to iatrogenic sciatic nerve palsy during acetabular surgery through a Kocher-Langenbeck (KL) approach, and to evaluate if variation among individual surgeons exists. METHODS: Design : Retrospective cohort Setting: Level I trauma center Patient Selection Criteria: Adults undergoing fixation of acetabular fractures (AO/OTA 62) through a posterior approach by 9 orthopaedic traumatologists between November 2010 and November 2022. Outcome Measures and Comparisons: Prevalence of iatrogenic sciatic nerve palsy and comparison of the prevalence and risk of palsy between prone and lateral positions before and after adjusting for individual surgeon and presence of transverse fracture patterns in logistic regression. Comparison of the prevalence of palsy between high- (>1 case/month) and low-volume surgeons. RESULTS: A total of 644 acetabular fractures repaired through a posterior approach were included (median age 39, 72% male). Twenty of 644 surgeries (3.1%) resulted in iatrogenic sciatic nerve palsy with no significant difference between the prone (3.1%, 95% CI: 1.9% – 4.9%) and lateral (3.3%, 95% CI: 1.3% – 8.1%) positions (p = 0.64). Logistic regression adjusting for surgeon and transverse fracture pattern demonstrated no significant effect for position (OR 1.0, 95% CI: 0.3 – 3.9). Transverse fracture pattern was associated with increased palsy risk (OR 3.0, 95% CI: 1.1 – 7.9). Individual surgeon was significantly associated with iatrogenic palsy (p < 0.02). CONCLUSIONS: Surgeon and presence of a transverse fracture line predicted iatrogenic nerve palsy after posterior approach to the acetabulum in this single-center cohort. Surgeons should perform the KL approach for acetabular fixation in the position they deem most appropriate, as position was not associated rate of iatrogenic palsy in this series. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.