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| CASE REPORT |
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| Year : 2022 | Volume
: 19
| Issue : 2 | Page : 95-98 |
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Delayed vascular complication after total hip replacement
Vijaya Mohan, V Shyam Gopal
Department of Orthopaedics, Aster Medcity, Kochi, Kerala, India
| Date of Submission | 18-Jun-2022 |
| Date of Acceptance | 20-Jun-2022 |
| Date of Web Publication | 09-Feb-2023 |
Correspondence Address:
V Shyam Gopal
Department of Orthopaedics, Aster Medcity, Kochi, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joasis.joasis_23_22
Vascular injuries following an arthroplasty are a nightmare for both patient and surgeon. When the presentation is delayed and atypical, it is of major concern. We present a case of late presentation of pseudoaneurysm of common femoral artery left hip following total hip replacement. A 54-year-old male presented with complaints of weakness and numbness left knee, following total hip arthroplasty, which was performed 4 months earlier at an outside institution for secondary osteoarthritis of the left hip. on evaluation was found to have pseudoaneurysm of Femoral artery. Due to the co morbid condition of the patient (CKD, DM, Obsity) elevated creatinine values non surgical method of embolization of the pseudoaneurysm via one coil and Gelfoam was deferred and was decided to manage the psuedoaneurysm surgically with repair and PTFE graft. High suspicion in the setting of unresolving postoperative pain, paralysis, or need for blood transfusions may allow for earlier diagnosis and avoidance of serious limb-threatening complications. Care during the procedure for accurate retractor placement and careful manipulation may help avoid serious complications.
Keywords: Delayed complication, Total Hip Replacement, vascular
How to cite this article:
Mohan V, Gopal V S. Delayed vascular complication after total hip replacement. J Orthop Assoc South Indian States 2022;19:95-8 |
| Introduction | |  |
Total hip arthroplasty (THA) is one of the most commonly performed orthopedic procedures, which have consistently relieved pain and improved function in patients with osteoarthritis of the hip. Vascular injuries are a rare complication of these surgeries. Even if such an event occurs, usually it presents acutely. Delayed presentation of vascular injuries or its complications is even rarer. Vascular injuries occur at a reported rate of 0.25% of all complications following hip surgeries.[1] Pseudoaneurysms are a very rare complication in the subset of vascular injuries.
We present a case of late presentation of pseudoaneurysm of common femoral artery left hip following total hip replacement
| Case Report | | |
A 54-year-old male presented with complaints of weakness and numbness left knee, following THA, which was performed 4 months earlier at an outside institution for secondary osteoarthritis of the left hip. As per the operative report, there were no complications encountered with the surgery, intraoperatively; however, on postoperative day 10, he developed respiratory distress and was diagnosed to have pulmonary embolism which was managed symptomatically and improved. He was discharged with oral anticoagulants. He is a known case of morbid obesity, diabetes mellitus, and chronic kidney disease (CKD). He had undergone appropriate rehabilitation following the index procedure. Upon arrival at our institution, he was evaluated in detail:
Left hip there was healed scar lateral aspect with no deformity or scar tenderness or local rise in temperature, Passive range of movement was full painless with no limb length discrepencies no tenderness localized swelling over left thigh no instability rom normalquadriceps gr 3 power. Femoral pulse palpable.distal pulses were palpable.
Radiological evaluation
Initial radiographs at our practice show well-aligned femoral and acetabular components [Figure 1] without obvious evidence of loosening. Magnetic resonance imaging evaluation of the hip was done which showed a well-circumscribed oval lesion with mixed signals on T1 and T2 sequences noted along the left inguinal region, closely abutting the common femoral artery. The lesion pushes femoral vessels anteromedially [Figure 2]. Approximate dimensions are 10 cm × 6.5 cm × 7 cm. Ultrasonography correlation done shows color flow filling the lesion on Doppler suggesting pseudoaneurysm. | Figure 2: MRI showing a well-circumscribed oval lesion. MRI: Magnetic resonance imaging
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Magnetic resonance (MR) angiogram showed an 8.3 cm × 8.5 cm pseudoaneurysm anterior to the left hip joint. The sac displaced the left common femoral artery medially given the position; this was likely compressing the left femoral nerve [Figure 3].
The neck of the sac was difficult to delineate but appeared to be from the juxta-ostial segment of the left profunda femoris.
Although blood investigation showed increased total leukocyte count, all investigations for infective foci over the left hip were negative including hip joint aspirate culture and sensitivity.
Management
Due to the co morbid condition of the patient (CKD,DM,Obsity) elevated creatinine values embolization of the pseudoaneurysm via one coil and Gelfoam was deferred and was decided to manage the psuedoaneurysm surgically.
After optimizing the patient and getting anesthesia fitness, he underwent pseudoaneurysm repair left common femoral artery using 8-mm ringed polytetrafluoroethylene (PTFE) graft. Intraoperatively, left common femoral pseudoaneurysm was found with a rent of size 8 mm in the posterolateral aspect at the junction of the common femoral profunda bifurcation. The hip joint was aspirated which showed no features of infection. The left external iliac artery was exposed and looped. The distal superficial femoral artery was looped. The left profunda femoris was looped. Left pseudoaneurym was opened [Figure 4]. Segment of common femoral artery and bifurcation resected PTFE interposition grafting done [Figure 5] and wound closed over drain. Post operative MR Angio was done which showed normal flow in the vessels [Figure 6] and he improved clinically. | Figure 5: PTFE graft after repair of aneurysm. PTFE: Polytetrafluoroethylene
Click here to view |
| Discussion | | |
Despite being a rare complication, delayed or undetected vascular injuries following any procedure may be significant. Complications from vascular injuries include intraoperative or perioperative bleeding, critical limb ischemia, pain, pulsating mass or swelling, and hematoma development. The relationship between hematoma and early infection after THA has been well documented.[2]
Vascular injuries in total hip replacements are rare. As per studies[3] the causes of vascular injuries has been enlisted in [Table 1].
The lower extremity vasculature around the hip is complex, with many branches crossing the surgical field. The common femoral artery enters the leg through the femoral triangle, where it divides into the profunda femoris and superficial femoral arteries (SFA). The SFA gives off further five branches (superficial circumflex iliac, superficial epigastric, superficial external pudendal, deep external pudendal, and descending genicular artery). The profunda femoris artery runs between the pectineus and the posterior side of the adductor longus. It gives off the lateral femoral circumflex artery, medial femoral circumflex artery (MFCA), and adductor perforating arteries as it traverses the thigh.[4] The MFCA gives off further five branches (superficial, ascending, acetabular, descending, and deep arteries) that provide the majority of the blood supply to the femoral head
Different causes of pseudoaneurysm of all vessels following THA have been reported in the literature [Table 1] including retractor placement,[5],[6] screw encroachment,[7] drill encroachment,[5] reduction techniques,[6] removal of hardware,[7] and cement exothermic reactions.[6] Retractor-induced injuries can be caused to the common femoral artery that lies directly anterior and medial to the hip joint. The iliopsoas and rectus femoris muscles afford a degree of protection to the common femoral artery from the effect of the narrow bone lever used anterior to the acetabular rim. However, this protection may be overcome by excessive force used in flexed, adducted, and rotated limb. This can be a possible cause, especially in our case as with patients with higher body mass index. Excessive joint manipulations for joint dislocation and relocation can also produce longitudinal stress on femoral vessels causing intimal tears and later to pseudoaneurysms.[8]
Nachbur et al.[9] described several causes and mechanisms of vascular injuries. Four mechanisms were distinguished: perforation of a major artery with a Hohmann retractor, overextension of atherosclerotic arteries with subsequent thrombus formation, laceration of a major artery during replacement of a total hip prosthesis, and thrombotic occlusion of a major artery due to extensive heat of polymerization
We believe in late presenting cases of pseudo aneurysm, the cause described by Nachbur et al is unlikely but as described by Rossi et al chance of vascular injuries due to useof electrocautery is morelikely.[3] In our case, this could also be a possibility due to the delay in presentation. Our case presented with a neurological symptom due to the compression on the femoral nerve, which is a rare occurrence. The prolonged anticoagulant therapy given as part of the treatment of pulmonary thromboembolism might have added to the increase in size of the pseudoaneurysm and cause compressive symptoms.
As per studies, the average time for diagnosis of the pseudoaneurysms was 29 months.[8] In our case, it was diagnosed 4 months after the surgery, and its early detection was possible due to the presentation as a neurological weakness. Often, these are missed and they present as infected hematoma or with bleeding as a complication of rupture of the aneurysms.
| Conclusion | | |
Although pseudoaneurysms are a rare complication after total hip replacement, it should be a differential diagnosis for persistent pain or weakness or persistent anemia following total hip replacement. These can be potentially dangerous as they pose the chance of imminent rupture. Prevention of vascular complications in total hip replacement is the most important aspect of treatment. Interventional radiological procedures offer less cumbersome modality of treatment of such complication; however, when such procedures are contraindicated, open repair is warranted High suspicion in the setting of unresolving postoperative pain or need for blood transfusions may allow for earlier diagnosis and avoidance of serious limb-threatening complications. Care during the procedure for accurate retractor placement and careful manipulation may help avoid serious complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Rengsen P, Abbas A, Choon S, Tai C. Pseudoaneurysm of external iliac artery following septic loosening of total hip arthroplasty. Malays Orthop J 2007;1:42-4.  |
| 2. | Fitzgerald RH Jr. Infected total hip arthroplasty: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:249-62. |
| 3. | Rossi FH, Izukawa NM, Silva DG, Chen J, Prakasan AK, Zamorano MM, et al. Effects of electrocautery to provoke endovascular thermal injury. Acta Cir Bras 2011;26:329-32. |
| 4. | Dixit DP, Mehta LA, Kothari ML. Variations in the origin and course of profunda femoris. J Anat Soc India 2001;50:6-7. |
| 5. | Cowley A, Williams D, Butler M, Edwards A, Parsons S. Pseudo-aneurysm of the profunda femoris artery as a late complication of hip fracture in a patient with myelodysplasia. Ann R Coll Surg Engl 2007;89:W4-6. |
| 6. | Hall C, Khan WS, Ahmed SI, Sochart DH. A rare case of arterial avulsion presenting with occult blood loss following total hip arthroplasty: A case report. J Med Case Rep 2009;3:9320. |
| 7. | Bergqvist D, Carlsson AS, Ericsson BF. Vascular complications after total hip arthroplasty. Acta Orthop Scand 1983;54:157-63. |
| 8. | Shoenfeld NA, Stuchin SA, Pearl R, Haveson S. The management of vascular injuries associated with total hip arthroplasty. J Vasc Surg 1990;11:549-55. |
| 9. | Nachbur B, Meyer RP, Verkkala K, Zürcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res 1979. p. 122-33. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1]
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