Abstract
Intrapelvic prosthesis migration is a rare but serious complication of bipolar hemiarthroplasty in femoral neck fractures. The external iliac artery is one of the most frequently damaged arteries during the removal of a migrated implant from the pelvic region. This report describes a case in which prophylactic placement of an external iliac artery balloon catheter was performed to reduce blood loss in the event of vascular injury during implant removal surgery in the pelvic region.
Keywords: Implant removal surgery, Bipolar hemiarthroplasty, Intrapelvic prosthesis migration, Femoral neck fracture, External iliac artery
1. Introduction
Bipolar hemiarthroplasty (BHA) is commonly performed in elderly patients with femoral neck fractures as it provides good short-term results for pain relief, allows patients to return to activity, and reduces morbidity. Intrapelvic prosthesis migration is a rare but serious complication of hip arthroplasty.1 An intrapelvic approach is often needed to remove migrated implants.2,3 Tissue injuries, such as arterial injuries, should be considered during surgical removal of migrated prosthesis from the pelvis.4 In this study, we report a case in which successful implant removal surgery was performed using prophylactic placement of a balloon catheter in the external iliac artery (EIA) to control bleeding in the event of vascular injury. Written informed consent was obtained from the patient for publication of this report and all accompanying images.
2. Case report
An 85-year-old Japanese woman presented to our hospital complaining of severe pain in the left groin and a fistula overlying a surgical scar on the left thigh. She had previously undergone BHA for a hip fracture at another hospital 1 year ago. Swelling and redness of the scar had occurred 1 month after operation. Negative pressure wound therapy was performed because the scar had been dissected. After the wound had been closed, she was admitted to a nursing home without further medical examination, although she was unable to walk due to pain in the left hip.
Physical examination revealed shortening and slight external rotation of the left lower limb. The abscess was drained from the fistula overlying the scar on the left thigh (Fig. 1), and Staphylococcus aureus was detected on culturing the drained fluid. The patient's C-reactive protein level was 8.1 mg/dL, which was markedly higher than the upper limit of the reference range (0–0.3 mg/dL). Plain radiography and non-contrast computed tomography (CT) of the pelvis revealed that the prosthesis had migrated through the acetabulum and penetrated the quadrilateral surface of the pelvis (Fig. 2). Further, contrast CT revealed that the left EIA was compressed and shifted medially by the migrated prosthesis (Fig. 3).
Fig. 1.
A skin fistula due to chronic drainage of the abscess.
Fig. 2.
Radiograph (A) and coronal computed tomography (B) of the hip joints and pelvis demonstrating complete migration of the BHA components without disassembly.
Fig. 3.
Contrast computed tomography demonstrating compression and medial shifting of the left external iliac artery by the migrated prosthesis.
A diagnosis of prosthesis migration in the pelvis secondary to chronic infection was made, and implant removal surgery was considered. In order to prepare to vascular injury in the pelvic region, we requested assistance from the Department of Interventional Radiology.
The procedure was performed by a senior interventional radiologist (SM). The patient was transferred to the interventional radiology operating room, and a 5.2 French catheter with a 9 mm balloon (Selecon MP Catheter II, TERUMO Co., Ltd., Tokyo, Japan) was inserted under fluoroscopic guidance through the right common femoral artery under local anaesthesia. The balloon tip was placed in the EIA, proximal to the compressed and shifted portion, which was caused by the migrated prosthesis. The balloon was briefly inflated, and contrast medium was injected to verify the balloon's location and whether it had effectively occluded the artery (Fig. 4). After catheter placement, the patient was transferred to the surgical operating room.
Fig. 4.
Radiograph shows that the balloon was briefly inflated, and contrast medium was injected to verify the balloon's location and whether it had effectively occluded the artery.
In the first stage of implant removal surgery, the patient was positioned in the supine position. A retroperitoneal approach was used to identify the bipolar head. The bipolar head was tapped upward and easily removed from the femoral stem (Fig. 5).
Fig. 5.
Intraoperative image shows the removal of the bipolar head (A, B).
The femoral stem was firmly fixed to the femur and was difficult to remove from the surgical field using the pelvic approach. The wound was closed after confirming that there were no neurovascular complications. The duration of the first stage of removal surgery was 60 min. After the first stage, the patient was placed in the lateral decubitus position, and the direct lateral approach was used to perform the second stage of implant removal surgery. Although the femoral stem was firmly fixed to the femur, it was successfully removed without complications using a chisel. After lavage and debridement of the infected necrotic tissue, antibiotic-containing cement beads were placed in the medullary cavity of the femur and the wound was closed. The duration of the second stage was 121 min. Postoperatively, the patient was transferred to the angiography room and the catheter was removed without any complications. The total operative blood loss was 1138 mL, and the postoperative haemoglobin level was 6.1 g/dL, decreased from the preoperative level of 10.0 g/dL. Therefore, six units of packed red blood cells were transfused. Three weeks following surgery, the patient's course was uneventful without complications and she was transferred to another hospital to wait for revision surgery after the infection had subsided.
3. Discussion
Intrapelvic prosthesis migration is a rare but serious complication of hip arthroplasty.1 The major risk factor of intrapelvic prosthesis migration is chronic infection. In a literature review, Stiehl reported that 11 of 16 prosthetic protrusion cases had chronic sepsis, and presence of chronic infection should be suspected when intrapelvic prosthetic migration occurs after hip arthroplasty.5 In our case, Staph. aureus was detected in the abscess culture, which suggests that the cause of pelvic prosthesis migration is chronic infection.
Intrapelvic prosthesis migration is challenging to manage surgically because it poses a risk of injury to adjacent intrapelvic structures, such as the intrapelvic vessels, urogenital tract, intestinal tract, and nervous system, during implant removal surgery.4
The EIA is the most frequently injured artery owing to its proximity to the acetabular roof.2,4 Damage to the EIA may lead to severe complications such as the loss of limbs and even death.6 To reduce the risk of these complications, we performed prophylactic placement of an EIA balloon catheter in our patient. Similar techniques are commonly performed in gynaecological surgery, such as insertion of internal iliac artery balloon catheter to manage haemorrhage during caesarean section in women with placenta accreta7 or abnormal placental implantation.8 However, to the best of our knowledge, the use of this technique in orthopaedic surgery has not yet been reported in the literature; thus, our study is the first case report in this area.
During a procedure, intervention of a vascular surgeon is essential in the event of vascular injuries.9 An advantage of prophylactic EIA balloon catheter placement is that it can reduce the amount of bleeding before the arrival of the vascular surgeon and allow them to visually identify the damaged parts of blood vessels more easily. However, there is a potential disadvantage of prophylactic balloon catheter placement in arteries, such as damage to endothelial cells due to prolonged compression by inflated balloons. Future studies should consider the indications for this procedure.
In conclusion, prophylactic placement of an EIA balloon catheter was performed to reduce blood loss in the event of vascular injury during the management of intrapelvic prosthetic migration after BHA. Interventional radiological assistance should be sought to manage bleeding due to vascular injuries in intrapelvic implant removal surgeries.
Declaration of competing interest
The authors declare that they have no competing interest.
References
- 1.Lim J.B., Ang C.L., Pang H.N. Acetabular prosthetic protrusio after bipolar hemi-arthroplasty of the hip: case report and review of the literature. J Orthop Case Rep. 2016;6(3):28–31. doi: 10.13107/jocr.2250-0685.448. Jul-Aug. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Girard J., Blairon A., Wavreille G., Migaud H., Senneville E. Total hip arthroplasty revision in case of intra-pelvic cup migration: designing a surgical strategy. Orthop Traumatol Surg Res. 2011;97(2):191–200. doi: 10.1016/j.otsr.2010.10.003. Apr. [DOI] [PubMed] [Google Scholar]
- 3.Eftekhar N.S., Nercessian O. Intrapelvic migration of total hip prostheses. Operative treatment. J Bone Joint Surg Am. 1989;71(10):1480–1486. Dec. [PubMed] [Google Scholar]
- 4.Bach C.M., Steingruber I.E., Ogon M., Maurer H., Nogler M., Wimmer C. Intrapelvic complications after total hip arthroplasty failure. Am J Surg. 2002;183(1):75–79. doi: 10.1016/s0002-9610(01)00845-5. Jan. [DOI] [PubMed] [Google Scholar]
- 5.Stiehl J.B. Acetabular prosthetic protrusion and sepsis: case report and review of the literature. J Arthroplasty. 2007;22(2):283–288. doi: 10.1016/j.arth.2006.02.170. Feb. [DOI] [PubMed] [Google Scholar]
- 6.Chen J.L., Yang T.Y., Chuang P.Y., Huang T.W., Huang K.C. Pseudoaneurysm rupture with hemorrhagic shock in a patient with periprosthetic hip joint infection: a case report. Medicine (Baltim) 2018;97(26) doi: 10.1097/MD.0000000000011028. Jun. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Feng S., Liao Z., Huang H. Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study. Anaesthesia. 2017;72(7):853–858. doi: 10.1111/anae.13895. Jul. [DOI] [PubMed] [Google Scholar]
- 8.Nicholson P.J., O'Connor O., Buckley J., Spence L.D., Greene R.A., Tuite D.J. Prophylactic placement of internal iliac balloons in patients with abnormal placental implantation: maternal and foetal outcomes. Cardiovasc Intervent Radiol. 2018;41(10):1488–1493. doi: 10.1007/s00270-018-1983-3. Oct. [DOI] [PubMed] [Google Scholar]
- 9.Wera G.D., Ting N.T., Della Valle C.J., Sporer S.M. External iliac artery injury complicating prosthetic hip resection for infection. J Arthroplasty. 2010;25(4) doi: 10.1016/j.arth.2009.03.006. Jun. 660.e1-660.e4. [DOI] [PubMed] [Google Scholar]