External Iliac Artery Laceration Caused by Hip Prosthesis Migration
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Abstract

Hip arthroplasty is a common and safe intervention in orthopedic surgery. However, the proximity of this joint to large vessels makes the occurrence of vascular injury a rare but serious and possibly lethal complication of this surgical technique. Acute vascular injuries in the context of a hip arthroplasty have variable etiologies and clinical presentations, and are more common in revision surgeries and in situations of medial intrapelvic migration and of chronic infection of the hip prosthesis. In the present article, the authors present a case of acute and late major vascular complication in the context of hip arthroplasty revision. The patient developed an acute laceration of the external iliac artery caused by chronic and progressive medial intrapelvic acetabular migration of the hip prosthesis associated with chronic infection.

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Most cited references 11

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Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty.

I. L. Cooperstein, Colin Krüger, H Rubash … (1990)

An anatomical and radiographic study was undertaken to determine the safest zones in the acetabulum for the transacetabular placement of screws during uncemented acetabular arthroplasty. To avoid injury to intrapelvic structures, which are not visible to the surgeon during placement of the screws, cadavera were studied to define the location of these structures with respect to fixed points of reference within the acetabulum. Four clinically useful acetabular quadrants were delineated. The quadrants are formed by drawing a line from the anterior superior iliac spine through the center of the acetabulum to the posterior fovea, forming acetabular halves. A second line is then drawn perpendicular to the first at the mid-point of the acetabulum, forming four quadrants. The posterior superior and posterior inferior acetabular quadrants contain the best available bone stock and are relatively safe for the transacetabular placement of screws. The anterior superior and anterior inferior quandrants should be avoided whenever possible, because screws placed improperly in these quadrants may endanger the external iliac artery and vein, as well as the obturator nerve, artery, and vein. The acetabular-quadrant system provides the surgeon with a simple intraoperative guide to the safe transacetabular placement of screws during primary and revision acetabular arthroplasty.

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The mechanisms of severe arterial injury in surgery of the hip joint.

N Zürcher, B. Nachbur, Charles Meyer … (1979)

Vascular accidents occurring in the course of hip surgery may reach potentially catastrophic dimensions by posing an immediate and sudden threat to life and limb. This is a report of 15 cases with severe arterial injury representing 0.2--0.3% of all reconstructive hip operations performed during an 8 year period. In 6 cases perforation of either the external iliac artery, the common femoral artery of main branches of the lateral and medial circumflex femoral artery were caused by the tip of a narrow-pointed Hohmann retractor used to expose the hip joint. Other mechanisms were: intimal tear with appositional thrombosis, probably caused by mechanical strain imposed on atherosclerotic arteries, giving rise to complete limb ischemia (2 cases); the dangers associated with the entry of bone cement through a defective acetabulum into the pelvis causing thrombotic occlusion due to polymerization heat (one case) or intimate adhesion of artificial bone to the external iliac artery subsequently being ripped open during replacement of the cup (one case); the increased hazards of replacing firmly embedded hip prosthesis (3 cases of direct arterial injury with chisel, knife and cutting edge of protruding bone); and the complications associated with the development of a false aneurysm (2 cases). Fourteen of the 15 extremities were salvaged. Above-knee amputation was unavoidable in one case owing to delay of vascular repair. There was no immediate operative mortality. Knowledge of the causative mechanisms prevents arterial injury during hip surgery. The relatively low rate of vascular complications in spite of vicinity of main vessels gives credit to the well standardized technique of hip surgery, especially hip replacement. However, it is suggested that the surgeon should be sufficiently acquainted with the exposure of the main vessels above and below the groin to be able to control life threatening hemorrhage at all times. A McBurney incision with retroperitoneal exposure and clamping of the external iliac artery will suffice to diminish bleeding considerably. Thereupon careful dissection and placement of snares around the common femoral artery, the arteria profunda femoris, and whenever necessary, the lateral or medial circumflex femoral artery will enable closure of the lacerated artery. For hemorrhage resulting during replacement of firmly embedded hip prosthesis it might become necessary to ligate the internal iliac artery. Reconstruction of obliterated arteries should call for the cooperation of the vascular surgeon for eventual angioplasty. Angiologic examination of the lower extremities is mandatory whenever severe arterial trauma has occurred in the course of hip surgery and is best performed by measuring the ankle blood pressure with a Doppler ultrasound probe.

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The management of vascular injuries associated with total hip arthroplasty.

Norman A. Shoenfeld, Steven Stuchin, Richard H Pearl … (1990)

Approximately 100,000 total hip reconstructions are done annually in the United States. The nature of the surgical technique in a field close to the iliac and femoral vessels makes the occurrence of vascular injury an occasional but serious complications. We have reviewed retrospectively our experience of five cases of vascular injuries with total hip replacement and an additional 63 cases in the literature to identify those patients at risk and to define the management of these injuries. For the entire group of 68 patients, most injuries were sustained on the left side (66%), and 39% were seen in revisions. Complications were related to cement incorporation of the iliac vessels (44%), aggressive medial retraction (17%), excessive traction on atherosclerotic vessels (10%), and improper technique in preparation of the acetabulum. The most commonly injured vessels were the external iliac artery (36), common femoral artery (17), and external iliac vein (6). Twenty-seven of these injuries required emergent surgery, most for hemorrhage (66%). Injuries consisted of thromboembolic complications leading to distal ischemia (46%), vessel lacerations (26%), pseudoaneurysms (25%), and arteriovenous fistulas (3%). Vascular repair was individualized and included suture repair, thrombectomy and patch angioplasty, embolectomy, and arterial and venous bypass procedures. There was an overall 7% mortality and a 15% incidence of limb loss. Risk factors include (1) revision procedures, (2) left-sided procedures, and (3) intrapelvic migration of the acetabular component of the hip prosthesis. Elective vascular workup and preliminary retroperitoneal exposure of the iliac vessels at time of hip arthroplasty is recommended for patients at risk.

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Journal

Journal ID (nlm-ta): Rev Bras Ortop (Sao Paulo)

Journal ID (iso-abbrev): Rev Bras Ortop (Sao Paulo)

Journal ID (doi): 10.1055/s-00042410

Title: Revista Brasileira de Ortopedia

Publisher: Sociedade Brasileira de Ortopedia e Traumatologia. Published by Thieme Revnter Publicações Ltda (Rio de Janeiro, Brazil )

ISSN (Print): 0102-3616

ISSN (Electronic): 1982-4378

Publication date (Print): September 2019

Publication date (Electronic): 27 August 2019

Volume: 54

Issue: 5

Pages: 597-600

Affiliations

[1 ]Serviço de Ortopedia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

[2 ]Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

[3 ]Serviço de Imagem Médica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

Author notes

Endereço para correspondência Diogo Lino Moura Serviço de Ortopedia, Hospitais da Universidade de Coimbra, Praceta Prof. Mota Pinto 3000-075, CoimbraPortugal dflmoura@ 123456gmail.com

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Diogo Lino Moura http://orcid.org/0000-0003-4037-2442

Article

Publisher ID: 170250pt

DOI: 10.1016/j.rbo.2017.09.020

PMC ID: 6819160

SO-VID: 8e6206a2-f33e-42aa-b9e8-420bf2d85e97

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This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

External Iliac Artery Laceration Caused by Hip Prosthesis Migration *

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Most cited references 11

Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty.

The mechanisms of severe arterial injury in surgery of the hip joint.

The management of vascular injuries associated with total hip arthroplasty.

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