The Advantages of Using Intraoperative Neurophysiological Monitoring in Hip Surgeries: A Meta-Analysis


  • Ayyoub Sam Department of Neuroscience, School of Behavioral & Brain Sciences, The University of Texas at Dallas, Richardson, Texas, USA
  • Rishab Parapperi Department of Neuroscience, School of Behavioral & Brain Sciences, The University of Texas at Dallas, Richardson, Texas, USA
  • Ubayd Isa Department of Neuroscience, School of Behavioral & Brain Sciences, The University of Texas at Dallas, Richardson, Texas, USA
  • Mahek Mumtaz Department of Neuroscience, School of Behavioral & Brain Sciences, The University of Texas at Dallas, Richardson, Texas, USA
  • Faisal R Jahangiri Department of Neuroscience, School of Behavioral & Brain Sciences, The University of Texas at Dallas, Richardson, Texas, USA; Global Innervation LLC, Dallas, Texas, USA; Labouré College of Healthcare, Milton, Massachusetts, USA



Sciatic nerve, palsy, hip, neuromonitoring, neurophysiology, pelvis, IONM, femoral nerve, saphenous nerve, tibial nerve, EMG, MEP, TOF


Various hip surgeries place peripheral nerves at risk of injury, such as those occurring during total hip arthroplasty, arthroscopic hip repair, and periacetabular osteotomy. In total hip arthroplasty, intraoperative neurophysiological monitoring (IONM) is focused on the sciatic nerve, which is particularly vulnerable due to its proximity to the surgical site. During arthroscopic hip repair, careful attention is paid to monitoring the femoral and lateral femoral cutaneous nerves to prevent traction and compression injuries. In periacetabular osteotomy, which involves cutting and realigning the hip socket, the primary focus of monitoring is on the sciatic and obturator nerves to minimize the risk of bone repositioning and fixation damage. 

The use of IONM in hip surgeries is becoming increasingly popular to prevent neurological deficits associated with procedures such as total hip replacements and hip dysplasia corrections. This meta-analysis draws on data from 18 studies involving 522 patients, adhering to PRISMA guidelines, and utilizing techniques such as somatosensory evoked potentials (SEP), motor evoked potentials (MEP), electromyography (EMG), and train of four stimulation (TOF). The findings suggest that using multiple IONM techniques resulted in an alert rate of 61%, compared to 54% in single-modality IONM treatments. The results demonstrate that multimodal IONM improves the detection and prevention of nerve injuries, with combined modalities providing higher sensitivity and specificity than single-modality monitoring.


Maradit Kremers, H., Larson, D. R., Crowson, C. S., Kremers, W. K., Washington, R. E., Steiner, C. A., Jiranek, W. A., & Berry, D. J. (2015). Prevalence of total hip and knee replacement in the United States. The Journal of Bone and Joint Surgery-American Volume, 97(17), 1386–1397.

Zusmanovich, M., Haselman, W., Serrano, B., & Banffy, M. (2022). The incidence of hip arthroscopy in patients with femoroacetabular impingement syndrome and labral pathology increased by 85% between 2011 and 2018 in the United States. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 38(1), 82–87.

Climent, A., de Meo, F., Ribas, M., Coscujuela, A., Agullo, J. L., Ulkatan, S., & Deletis, V. (2020). An intraoperative neurophysiological monitoring method for testing functional integrity of the low extremity peripheral nerves during hip surgery. In Neurophysiology in Neurosurgery (pp. 431–440). Elsevier.

Kong, X., Chai, W., Chen, J., Yan, C., Shi, L., & Wang, Y. (2019). Intraoperative monitoring of the femoral and sciatic nerves in total hip arthroplasty with high-riding developmental dysplasia. The Bone & Joint Journal, 101-B(11), 1438–1446.

Page, M.J., McKenzie, J.E., Bossuyt, P.M. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev 10, 89 (2021).

Overzet, K., Mora, D., Faust, E., Krisko, L., Welch, D., & Jahangiri, F. R. (2021). Distal stimulation site at the medial tibia for saphenous nerve somatosensory evoked potentials (DSN-sseps) in lateral lumbar spine procedures. The Neurodiagnostic Journal, 61(2), 72–85.

Overzet, K., Kazewych, M., & Jahangiri, F. R. (2018a). Multimodality intraoperative neurophysiological monitoring (IONM) in anterior hip arthroscopic repair surgeries. Cureus.

Somatosensory evoked potentials (Ssep). Somatosensory Evoked Potentials (SSEP) - NeurophysPedia. (n.d.).

Kim, S.-M., Kim, S. H., Seo, D.-W., & Lee, K.-W. (2013). Intraoperative neurophysiologic monitoring: Basic principles and recent update. Journal of Korean Medical Science, 28(9), 1261.

Farmer, S. F., Gibbs, J., Halliday, D. M., Harrison, L. M., James, L. M., Mayston, M. J., & Stephens, J. A. (2007). Changes in EMG coherence between long and short thumb abductor muscles during human development. The Journal of Physiology, 579(2), 389–402.

Jahangiri F R, Jahangiri R H, Asad H, et al. (October 05, 2022) Scoliosis Corrective Surgery with Continuous Intraoperative Neurophysiological Monitoring (IONM). Cureus 14(10): e29958. doi:10.7759/cureus.29958.

Jahangiri, F. (2018). Train of Four (TOF) Monitoring: Are We Doing It The Right Way? AXIS Neuromonitoring. 2024,

Agustina D Saenz, M. (2023, December 20). Peripheral nerve stimulator - train of four monitoring. Overview, Periprocedural Care, Technique.

Motor evoked potentials (MEP). Motor Evoked Potentials (MEP) - NeurophysPedia. (n.d.).

Bayram, S., Akgül, T., Özmen, E., Kendirci, A. Ş., Demirel, M., & Kılıçoğlu, Ö. İ. (2020). Critical limit of lower-extremity lengthening in total hip arthroplasty. Journal of Bone and Joint Surgery, 102(8), 664–673.

Yalınay Dikmen, P., Ozden, V. E., Dikmen, G., Aydınlar, E. I., & Tozun, I. R. (2018). Intraoperative neuromonitoring of anterior root muscle response during hip surgery under Spinal Anesthesia. Journal of Clinical Monitoring and Computing, 33(4), 695–702.

Gundogdu, E. C., Kale, A., Mercan, M., Yayla, V., Ozcan, U. E., Usta, T., & Keles, E. (2023). Integration of intraoperative neurophysiological monitoring into laparoscopic pelvic nerve decompression surgery: A novel technique for protecting pelvic nerves. Clinical and Experimental Obstetrics & Gynecology, 50(9), 198.

Hesper, T., Scalone, B., Bittersohl, B., Karlsson, S., Keenan, J., & Hosalkar, H. S. (2017). Multimodal neuromonitoring during safe surgical dislocation of the hip for joint preservation: Feasibility, safety, and intraoperative observations. JAAOS: Global Research and Reviews, 1(7).

Novais, E. N., Heare, T., Kestel, L., Oliver, P., Boucharel, W., Koerner, J., & Strupp, K. (2017). Multimodal nerve monitoring during periacetabular osteotomy identifies surgical steps associated with risk of injury. International Orthopaedics, 41(8), 1543–1551.

Ochs BC, Herzka A, Yaylali I. Intraoperative neurophysiological monitoring of somatosensory evoked potentials during hip arthroscopy surgery. Neurodiagn J. 2012 Dec;52(4):312-9. Erratum in: Neurodiagn J. 2013 Mar;53(1):84. PMID: 23301281.

Porat, M., Orozco, F., Goyal, N., Post, Z., & Ong, A. (2013). Neurophysiologic monitoring can predict iatrogenic injury during acetabular and pelvic fracture fixation. HSS Journal ®, 9(3), 218–222.

Shelton, T. J., Patel, A., Agatstein, L., & Haus, B. M. (2019). What neuromonitoring changes can be expected during hip arthroscopy in the pediatric population? The American Journal of Sports Medicine, 48(2), 409–414.

Shemesh, S. S., Robinson, J., Overley, S., Bronson, M. J., Moucha, C. S., & Chen, D. (2017). Novel technique for intraoperative sciatic nerve assessment in complex primary total HIP Arthroplasty: A pilot study. HIP International, 28(2), 210–217.

Turan, K., Kezer, M., Çamurcu, Y., Uysal, Y., Kızılay, Y. O., Ucpunar, H., & Temiz, A. (2023). Intraoperative neurophysiological monitoring in total hip arthroplasty for Crowe types 3 and 4 hips. Clinics in Orthopedic Surgery, 15(5), 711.

Charalampidis, A., Jiang, F., Wilson, J. R., Badhiwala, J. H., Brodke, D. S., & Fehlings, M. G. (2020). The use of intraoperative neurophysiological monitoring in spine surgery. Global Spine Journal, 10(1_suppl).

Murena, L., Colin, G., Dussi, M., & Canton, G. (2021). Is intraoperative neuromonitoring effective in hip and pelvis orthopedic and trauma surgery? A systematic review. Journal of Orthopaedics and Traumatology, 22(1).




How to Cite

Sam, A., Parapperi, R., Isa, U., Mumtaz, M., & Jahangiri, F. R. (2024). The Advantages of Using Intraoperative Neurophysiological Monitoring in Hip Surgeries: A Meta-Analysis. J of Neurophysiological Monitoring, 2(2), 46–59.