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      Avascular Necrosis of Acetabulum: The Hidden Culprit of Resistant Deep Wound Infection and Failed Fixation of Fracture Acetabulum – A Case Report

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          Abstract

          Introduction:

          Chances of avascular necrosis of acetabulum are rare as it enjoys a rich blood supply. But cases of post - traumatic avascular necrosis of acetabulum following fracture of posterior column have been well documented. Importance of identifying and suspecting the avascular necrosis of acetabulum is essential in cases of failed fixation of fracture acetabulum, previously operated using extensile approach to acetabulum; either extended anterior ilio - femoral or tri - radiate approach. Such patients usually present with repeated deep bone infection or with early failure of fixation with aseptic loosening and migration of its components. We present a similar case.

          Case Presentation:

          40 years female presented with inadequately managed transverse fracture of left acetabulum done by anterior extended ilio-inguinal approach. The fixation failed. She presented 6 months later with painful hip. Cemented total hip replacement was performed with reconstruction of acetabulum by posterior column plating. Six months postoperatively patient presented with dislodgement of cup, pelvic discontinuity and sinus in the thigh. Two stage revision surgery was planned. First implant, removal; debridement and antibiotic spacer surgery was performed. At second stage of revision total hip replacement, patient had Paprosky grade IIIb defect in acetabulum. Spacer was removed through the posterior approach. Anterior approach was taken for anterior plating. Intra-operatively external iliac pulsations were found to be absent so procedure was abandoned after expert opinion.

          Postoperatively digital subtraction angiography demonstrated a chronic block in the external iliac artery and corona mortis was the only patent vascular channel providing vascular to the left lower limb. Thus, peripheral limb was stealing blood supply from the acetabulum to maintain perfusion. Patient was ultimately left with pelvic discontinuity, excision arthroplasty and pseudoarthrosis of the left hip.

          Conclusions:

          Avascular necrosis of acetabulum is a rare entity & often not recognized. One should be suspicious about diagnosis of avascular necrosis of acetabulum in select cases of failed acetabular fixation, previously operated via extensile anterior ilio - inguinal approach. Angiographic evaluation is essential in revision cases of failed acetabular fixation. Corona mortis (crown or circle of death) can sometimes act as a savior of limb.

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          Most cited references 10

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          Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum.

          The "corona mortis" is an anatomical variant, an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (range 40-96 mm). The name "corona mortis" or crown of death testifies to the importance of this feature, as significant hemorrhage may occur if accidentally cut and it is difficult to achieve subsequent hemostasis. It constitutes a hazard for orthopedic surgeons especially in the anterior approach to the acetabulum. We carried out forty cadaver dissections (80 hemi-pelvises) through the ilioinguinal approach. A vascular anastomosis was found in 83% of specimens. Of these, 60% had a large diameter (>3 mm) channel along the posterior aspect of the superior pubic ramus. In clinical practice, however, 492 anterior approaches (to the best of our knowledge the largest series described) have been carried out over the last 15 years by the senior author (MB) and only five of these problematic vessels were discovered, and in only two cases was there troublesome bleeding. This study confirms a paradox: in anatomical dissections a large vessel was identified behind the superior pubic ramus, whereas in clinical practice this vessel does not seem to be as great a threat as initially perceived. Orthopedic surgeons planning an anterior approach to the acetabulum, such as the ilioinguinal or the intrapelvic approach (modified Stoppa), have to be cautious when dissecting near the superior pubic ramus. Despite the high prevalence of these large retropubic vessels in the dissecting room, surgeons should exercise caution but not alter their surgical approach for fear of excessive hemorrhage.
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            Corona mortis: Incidence and location

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              Fractures of the acetabulum

               E Letournel,  R Judet (1993)
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                Author and article information

                Journal
                J Orthop Case Reports
                J Orthop Case Reports
                Journal of Orthopaedic Case Reports
                Indian Orthopaedic Research Group (India )
                2321-3817
                Oct-Dec 2015
                : 5
                : 4
                : 36-39
                Affiliations
                [1 ]Department of Orthopaedics, Seth G. S. Medical College and K. E. M. Hospital. Mumbai. India
                Author notes
                Address of Correspondence Dr. Vikram K. Kandhari Plot No. 5/5a, Pande Layout, Behind Gulmohor Hall, Khamla, Nagpur – 440025. Email – dr.vikramkandhari@ 123456gmail.com .
                Article
                JOCR-5-36
                10.13107/jocr.2250-0685.341
                4845453
                27299095
                Copyright: © Indian Orthopaedic Research Group

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc-sa/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Case Report

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