Common Femoral Artery Intimal Injury Following Total Hip Replacement. a Case Report and Literature Review

Orthopaedics & Traumatology: Surgery & Research (2009) 95, 154—158

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CLINICAL REPORT Common femoral artery intimal injury following total hip replacement. A case report and literature review

G. Riouallon, S. Zilber ∗, J. Allain

Orthopaedics and Traumatology Department, Henri Mondor Hospital, Assistance Publique—Hôpitaux de Paris, Créteil Faculty of Medicine (Paris XII), 51, avenue Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France

Accepted: 4 November 2008

KEYWORDS Summary Vascular injuries diagnosed during the course of total hip arthroplasty (THA) implan- Total hip tations are rare. They must be constantly feared as they sometimes put at risk the vital and arthroplasty; functional prognosis of the operated limb. We report the case of a common femoral artery Vascular injury diagnosed by arteriography within two days of THA replacement in the presence of atyp- complications; ical symptoms. The vascular damage was caused by an arterial lesion resulting from positioning Femoral artery; a retractor on the anterior wall of the acetabulum. A literature review on the topic of vascular Acetabular revision complications arising after THA made us aware of multiple possible mechanisms and clinical presentations relating to such complications while identifying speciﬁc risk factors in THA replacement cases. Acetabular revision constitutes a major risk situation. Most of these vascular complications may be better prevented or more efﬁciently treated by thorough preoperative assessment and careful postoperative monitoring. © 2009 Published by Elsevier Masson SAS.

Introduction influence the functional prognosis of the operated limb, and even put at risk patients’ vital prognosis. In the liter- Acute arterial complications occurring after total hip arthro- ature, we find different types of lesions with various types plasty (THA) are rare, with orthopaedic surgery teams not of mechanisms [1,2,4—6], and their diagnosis is often diffi- reporting more than a few isolated cases over a long time cult considering that the symptoms are not very specific. We period [1—3]. According to Duparc [1], their low incidence report a case of common femoral artery laceration during must be considered an element of severity in itself as such THA replacement. vascular complications are not the first explanation given in difficult surgery cases. They remain serious because they Observation

Born in 1950, this female patient presented with con- ∗ Corresponding author. genital dysplasia of both hips in association with necrotic E-mail address: [email protected] (S. Zilber). avascular remodelling changes. The right hip had been

To achieve good acetabulum exposure (made difficult by major periarticular fibrosis), the femur was reclined forward with an Hohmann retractor hooked on the deficient anterior acetabulum wall, which showed a severe loss of bony substance. The Kerboull’s device appeared stable and in a good position; it was preserved. The femoral stem was loosed and replaced by a new stem with an alumina head. The intervention thus comprised replacement of the polyethylene insert and the femoral implant with an alumina head. In the immediate postoperative period, the patient did not manifest any vasculonervous problems. Three hours after the intervention, a sensory deficit occurred from dysesthesia of the left foot with paralysis of the long extensor muscles of the toes and long extensor muscle of the hallux. Twelve hours after surgery, the clinical picture was completed by a clear motor deficit of the anterior tibial Figure 1 Preoperative anteroposterior pelvic roentgeno- muscle associated with a loss of strength of the triceps and gram: osteolysis signs around the two femoral components. posterior tibial muscle. During the first 12 hours, the posterior tibial pulses and left pedal were felt but more weakly than the right. There was no increase in volume of the hematoma on the thigh or in the scar. After 24 hours, recov- operated on many times (greater trochanter lateralization ery of the motor deficit of the anterior tibial muscle was osteotomy, THA, THA revision). This hip was asymptomatic, apparent. After 48 hours, examination revealed a decrease despite the presence of radiological signs of osteolysis. in warmth of the left toes compared to the contralateral Mobility of the components was not obvious on repeated side. The peripheral distal pulses were thus not felt. Emer- radiographic controls. The left hip had been operated gency arteriography showed a common left femoral artery on three times. A high valgus femoral osteotomy, direc- tear of 4 cm, causing total obstruction (Figs. 3 and 4). tional de-rotation and deflexion with Chiari’s osteotomy Exploration of the common femoral artery by the Scarpa had been performed in 1982 by the double simultaneous approach allowed us to authenticate the 4 cm intimal tear, lateral and anterior approach of Smith-Petersen. This was treated surgically by installation of a prothetic patch. Per- followed by a left THA in 1995 using a Moore’s posterolat- operatively, the anterior side of the cup was visibly in eral approach for secondary coxarthrosis. The polyethylene direct contact with the common femoral vascular pack- cup was cemented in a Kerboull’s reinforcement acetab- age. In the immediate postoperative period, the distal ular device and the femoral head was made of zircon. peripheral pulses were symmetrical. The patient progres- Because of secondary functional degradation associated sively recovered sensitivity and subnormal motricity. At with polyethylene wear and femoral osteolysis, this prothe- one year recall, the hip was mobile and painless, but the sis was revised in 2007 by the posterolateral route of Moore distal pains persisted subsequent to the initial subacute (Figs. 1 and 2). ischemia that responded incompletely to medical treatment.

Figure 2 Postoperative anteroposterior pelvic roentgeno- gram after the last left total hip prosthesis replacement: the polyethylene cup and the femoral stem were changed. The zir- Figure 3 Arteriography: occlusion of the common femoral con head was replaced by an alumina head. artery. 156 G. Riouallon et al.

revision remained the most serious situation. Muscle wast- ing and scar alteration could lead to anatomical changes [1]. Acetabular implantation could provoke vascular lesions, especially in case of local adherences. Sometimes difficult dislocation of the prothetic head may be at the origin of traction mechanisms not tolerated by the vessels. Recon- struction is also risky. According to Shoenfeld et al. [9], re-intervention for THA represents 39% of situations at risk. To Jonsson et al. [10], fibrosis and/or metallosis favor join- ing of the vessels and implants during prothetic unsealing. In parallel, Calligaro et al. [3] did not find the risk to be signif- icantly higher in replacement surgery than in first-intention surgery in a series of 9,581 THA with 1,769 revisions (eight cases of acute arterial complications, seven after first- intention THA and 1 after revision), whereas they reported a rate of acute arterial complications six times higher in total knee prothesis replacements than in THA replacements (0.36 versus 0.06). This may be explained by the low incidence of Figure 4 Distal vascularization is partly maintained by a col- these complications. For the same reasons, it is less likely lateral artery. that feminine predominance and left hips among arthroplas- ties complicated by vascular attack, as reported by Bergqvist Discussion et al. [7], have real predictive value. Infection, a logical predisposing factor (local infiltration by inflammatory tis- Introduction: epidemiology sue with the disappearance of planes and spaces), has been proposed by many authors [10,12]. Thus, the patient that we are reporting was at high risk of vascular complications, Vascular complications in the course of prothetic hip surgery given her medical history. are extremely rare [1]. Different series in the literature have reported an average frequency of 0.2 to 0.3% [2,3,5,7,8]. Extremes varied from 0.08% [3] — for a single group of hip Causes of arterial lesions protheses (this study at times included hip and knee protheses) — to 0.67% [7]. These complications may be delayed, as Duparc [1] divided the lesional mechanisms into three in the case of pseudo-aneurysms and arteriovenous fistulas groups: [6], or immediate: hemorrhage (sometimes with compres- sive hematomas) and/or ischemia from arterial injury, • traumas of the elongation or vascular torsion type which traumatic arterial tearing or mobilisation of atheromatous may be produced during dislocation and reduction maneu- plaque. Shoenfeld et al. [9] reported vascular lacerations vers; in 18 patients in a review of 68 vascular trauma cases. • traumas from persistent pressure due usually to the tip of Four isolated ruptures of the intima leading to thrombosis an Hohmann type retractor placed on the anterior acetab- have been described in the literature: Jonsson et al. [10] ulum wall; observed intimal rupture and thrombosis after THA replace- • and, finally, cutting or penetrating traumas are the ment. Nachbur et al. [5] reported two cases in a series lesional mechanisms of iliac vessels most frequently of 15 arterial complications: intimal rupture and thrombo- incriminated in acetabular revision: perforations of the sis of the superficial femoral artery or external iliac artery acetabulum by a pin, during drilling or during the implan- after THA and THA replacement. In a review of 14 vascular tation of an acetabular screw, have been reported to be complications, Beguin et al. [4] reported one case of intimal responsible for vascular lesions [4,5]. rupture of the initial portion of the femoral artery complicated by thrombosis after THA by the posterolateral route, The dilaceration of vessels during reaming [13] and the which comprised reconstruction of a dysplastic acetabulum vascular complications secondary to an exothermic reac- with 3 cm lowering. tion during cement polymerisation [14] have also been reported. Extraction of the acetabular anchoring cement Risk factors for arterial lesions plugs may finally be the cause of vascular wounds. Shoen- feld et al. [9], who studied 68 vascular complications of THA, Beguin et al. [4] defined the vascular risk factors associated found: with a more significant risk of vascular complications during THA. Except for vascular history (arteriopathy, bypass, • 30 cases (44%) of incorporation of iliac vessels in cement; alcohol and tobacco use) and bone anomalies (rheumatoid • 12 cases (18%) related to a misplaced Hohmann retractor; polyarthritis, Paget’s disease, osteoporosis, osteitis, cor- • seven cases (10%) secondary to excessive traction on the ticotherapy, X-irradiation), anatomic abnormalities, such vessels; as acetabular dysplasia, congenital dislocation, acetabular • five cases (7%) deriving from intrapelvic migration of an protrusion [11] and acetabulum or pelvic fractures, consti- acetabular component; tuted known risk factors. However, for them, acetabular • two cases (3%) caused by excessive reaming; Common femoral artery intimal injury following total hip replacement 157

• one case (1%) during osteotomy; In risky situations, paraclinical assessment should com- • 11 other cases (16%) of unknown origin. prise, besides the usual radiography, arteriography and phlebography or angioscan to define the anatomical rap- The presumed mechanism of all these arterial tears was port between the prothetic elements and vascular structures excessive traction on the vessels during dislocation and [1,11]. According to Gasiunas et al. [16], angio CT-scan is the reduction maneuvers with the prothesis. reference examination in this context and should be comple- In the report that we are presenting, several arguments mented as needed by urinary or digestive opacification. The favour a lesion caused by the tip of Hohmann retractor: risk of intrapelvic complications whatever they may be is, in fact, important, notably in cases of collapse of the acetab- • a major bone defect of the anterior acetabulum wall; ular line [6]. This preoperative exploration, in collaboration • surgical difficulty in translating the femur forward to with vascular surgeons, should allow us to precisely identify obtain satisfactory acetabulum exposure, requiring the more suitable ways: needing or not needing retroperitoneal placement of an Hohmann retractor on the anterior arm access to first control the iliac vessels, external and internal, of Kerboull’s acetabular device used previously; to limit the risk of vascular injuries and their consequences. • the absence of a muscular floor or of all other interposing For actual access to the hip, we should discuss the advantage tissues between the femoral artery and the anterior edge of an approach leading to dislocation of the hip prothesis of the cup, confirmed during replacement for vascular in flexion, for relaxed positioning of the common vascular lesion repairs. femoral axis. The mechanisms of traction during these dislocation or reduction maneuvers in scar tissue appear, in Diagnosis of arterial lesions fact, to be particularly incriminated in arterial tearing [9]. Beguin et al. [4] have defined a precise decisional tree that permits codified management of THA revision. According Different articles in the literature do not always mention the to them, all acetabular revisions represent severity crite- diagnostic strategy used. Nevertheless, we can differentiate ria (protrusion without a bone barrier, foreign intrapelvic two major situations: the first is that of an acute vascular bodies, intrapelvic cup dislocation) that should benefit from accident occurring during the intervention or immediately arteriography and preoperative phlebography. In case of postoperatively. The clinical picture does not leave any room calibre or vessel trajectory anomalies or false aneurysms, for doubts in the diagnosis. In this case, the lesion is assessed they recommended the retroperitoneal approach. In case during surgical replacement, which is undertaken urgently of intrapelvic cup dislocation, the retroperitoneal approach without previous paraclinical examination. At the most, we should, according to them, be obligatory whatever the arte- can conduct an echo-Doppler study to confirm the diagnosis riography results. These recommendations were helpful in before re-intervention, without postponing it. The other sit- the case reported by Gasiunas et al. [16] since they justified uation comprises complications occurring at a distance from the direct release of vessels before the ablation of acetabu- the intervention and when patients present a more insidi- lar material. They recalled different possible approaches to ous clinical picture. In all these cases, the slightest doubt prevent various intrapelvic complications during THA abla- calls for exploration with urgent vascular opacification [1]. tion in protrusion situations: the Mears route reported by That is what makes the diagnosis certain and leads to rapid Stiehl et al. [17], which seems to be especially adapted surgical replacement. In fact, the absence of peroperative to bone reconstruction attempts without allowing real con- wounds incriminating a local hematoma does not necessar- trol of noble organs, the transperitoneal route [18], the ily eliminate an eventual vascular complication: the case retroperitoneal route [15,19—21] and, finally, the combined that we are presenting here fits in the second category of route recommended simultaneously by Augereau et al. [22] patients: the slow evolution several hours after the inter- and Petrera et al. [21]. According to Tazawa et al. [18], vention favored an arterial tear; the initial intimal lesions the choice between the retroperitoneal or transabdominal spread further,detaching the arterial intima-media and end- approach depends on iliopsoas muscle state: if it is intact, ing in distal hypoperfusion. The clinical expression of such the retroperitoneal approach is possible. In contrast, with a subacute ischemic picture thus took the form of a distal the components in contact with the peritoneum, laparotomy neuromuscular deficit, which mimicked sciatic nerve attack is preferred. during the early hours in the present case and erroneously delayed the hypothesis of a vascular problem. Conclusion Preoperative prevention methods An arterial tear may translate into a picture of acute or sub- At first, at-risk patients have to be identified according to acute, atypical ischemia. The signs may be unclear because predefined criteria. In the preoperative stage, pelvic exami- of progressive hypoperfusion, as in the case presented here. nation may allow us to evaluate the site and size of elements This instance of diagnosis obtained through close postop- protruding in the lesser pelvis [15]. If the patient has an arte- erative follow-up suggests to confirm the need for actively riopathic or vascular surgery history, he or she should consult searching a vascular complication in presence of any unusual a vascular surgeon [11]. On the other hand, installation on distal vascular compromise symptom following hip prothe- the operating table and the set-up of supports would be pru- sis surgery. This is even more true when there are other dent for patients with vascular bypass. Preoperative arterial risk factors that should be have been preoperatively recog- Doppler on the table, with the patient installed, may help nised. 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