r e v b r a s o r t o p . 2017;52(3):359–362
SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Case
report
Late
screw
perforation
of
external
iliac
artery
following
acetabular
revision.
A
simple
solution
for
a
rare
complication
夽
André
Sá
Rodrigues
∗,
Joana
Freitas,
Isabel
Pinto,
Sérgio
Sampaio,
Rui
Pinto
CentroHospitalarSãoJoão,Porto,Portugal
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received17April2016
Accepted2May2016
Availableonline25July2016
Keywords:
Arthroplasty Replacement Hip
Bonescrews
Vascularsysteminjuries
Endovascularprocedures
a
b
s
t
r
a
c
t
Vascularlesions,althoughquiterare,areoneofthemostdevastatingcomplicationsinthe
contextofahipprosthesis.Therefore,thecorrectdiagnosisiscrucialtopreventirreversible
damagetothepatient.
Theauthorspresentthecaseofa70-year-oldCaucasianwomanwithanischemiclower
limbasconsequenceofalateperforationofexternaliliacarteryduetoanacetabularscrew.
Theissuewasresolvedbysimplycuttingpartofthescrew,avoidingothersurgicaloptions
thatwouldbemuchmoreaggressiveforthepatient.
Carefulclinicalevaluationallowedforacorrectdiagnosisandatimelycreativetreatment,
preventingfurtherconsequencestothepatient.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Perfurac¸ão
tardia
da
artéria
ilíaca
externa
após
cirurgia
de
revisão
acetabular:
uma
soluc¸ão
simples
para
uma
complicac¸ão
rara
Palavras-chave:
Artroplastiadequadril
Parafusosósseos
Lesõesdosistemavascular
Procedimentosendovasculares
r
e
s
u
m
o
Aslesõesvasculares,emboramuitoraras,sãoumadascomplicac¸õesmaisdevastadorasno
contextodeumaprótesedoquadril,peloqueoseudiagnósticocorretoéfundamentalpara
evitardanosirreversíveisaopaciente.
Apresentamosocasodeumamulhercaucasianade70anosdeidadecomummembro
inferiorisquêmicocausadoporumaperfurac¸ãotardiadaartériailíacaexternadevidoaum
parafusoacetabular.
夽
StudyconductedattheCentroHospitalarSãoJoão,Porto,Portugal.
∗ Correspondingauthor.
E-mail:[email protected](A.S.Rodrigues).
http://dx.doi.org/10.1016/j.rboe.2016.05.004
2255-4971/©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle
360
rev bras ortop.2017;52(3):359–362Oproblemafoiresolvidosimplesmentecortandopartedoparafuso,evitandooutrasopc¸ões
cirúrgicasquepoderiamsermuitomaisagressivasparaopaciente.
Aavaliac¸ãoclínicacuidadosapermitiuumdiagnósticocorretoeumtratamentocriativo
atempodepreveniroutrasconsequênciasparaopaciente.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier
EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Totalhiparthroplasty(THA)hasalowcomplicationrateand
theincidenceofvascularinjuryisevenlower.1–3Thelatercan
havedevastatingeffectsthatifnotimmediatelyrecognized
andcaneventuallyleadtoamputationorevendead.3,4 We
presentacaseofanacetabularscrewthatresultedininjury
andcompressionofleftexternaliliacarteryandischemiaof
theleftlowerlimb.
Case
report
A70year-oldwomanattendedtheemergencyclinicfor
eval-uationofanincreasingswollenleftlowerlimbsinceshehad
wokenupwithassociatedabdominalandleftlowerlimbpain.
She denied dyspnea or other symptoms. She also had no
traumahistoryoranddidnothadunusualphysicalexercise
inthedaysbefore.
In2007sheunderwent anuncementedtotalhip
arthro-plastyastreatmenttoherhiposteoarthritis.Followingapain
freeintervalofsixyearsshestartedtohavegroin painfor
whichshewasinvestigated.Shewasdiagnosedwithaseptic
acetabularlooseningandsoshehadanacetabularrevision
surgeryin2014(threemonthsbeforeshecometoour
emer-gencyservice).Post-opunderwentwithawoundinfectionthat
waspromptlytreatedwithlargespectrumantibioticsand
sur-gicaldebriding.Both surgerieswererecorded asuneventful
andthepatientdidwellforthefollowingthreemonths
retur-ningtoherfullemploymentandweight-bearing.Shehadno
otherrelevantmedicalhistory.
When she entered our hospital, medical examination
showed apainful and paleleft lower limbwithnumbness
and diminished pulses.She was hypotenseand laboratory
exams showeda hemoglobinof4.9withno other relevant
alterations.PelvicCTscanshowedabulkyhematomanearby
leftilio-psoasuntilsuperiorfemorallevelleadingtoanalmost
completeocclusionoftheilio-femoralvascularaxis(Fig.1).
Herhipprosthesislookedwellpositioneddespiteassessment
difficultiescausedbyimageartifacts(Fig.2).Oneofacetabular
screwspiercedtheinternalcorticalwithintrapelvicextension
(Fig.3).
Thevascular surgeons suggested that her left ischemic
memberwasduetoableedingarteryofiliac-femoralaxis
com-binedwithacompressivehematoma.Shewasimmediately
proposedtosurgerybyvascularsurgery.
Aretroperitonealapproachoftheleftiliacfossawasused.
Afterthehematomadrainageitwasnoticedthatanacetabular
Fig.1–CTscanshowingintrapelvichemotoma.
Fig.2–Acetabularcomponentwithnolooseningsigns.
screwwasinacloserelationshipwiththeleftexternaliliac
artery(Fig.4).Orthopedicsurgeonswereaskedtotakeover.
GiventheurgencyofthesurgerytheOrthopedicTeam
sim-plycuttheprominentscrewwithabarcutusuallyusedin
spine surgeries sothe screwcould bein theinner cortical
boundaryoftheacetabulum(Fig.5).Afterthat,vascular
sur-geonsarrangedtorepairthearterywithnoneedofabypass.
Therewerenosignsofapseudoaneurysm.
Post-opunderwentwellwithimprovementofedemaand
rev bras ortop.2017;52(3):359–362
361
Fig.3–Intrapelvicacetabularscrew.
Fig.4–Acetabularscrewinclosecontactwiththeartery.
good ambulation assisted by a crutch with the prosthesis
remaininginthepreviousorientation.
Discussion
Vascularinjuriesassociatedtoprimaryor revisionhip
sur-gerieshavebeendescribedbutitsincidenceislessthan1%
off all THA cases.3–7 Themost usual causes are injury to
the common femoralartery due to misplaced retractor or
froma cerclagewireplacement.8–12 Therehavebeen some
otherunusualreportsofvascularinjuriessuchaslesionof
externaliliacarteryaftercomplicatedremovalorchronically
infectedTHA,development ofexternaliliac andsuperficial
femoralpseudoaneurysmorevenalatedirectexternaliliac
vesselinjuryfromaspikeofamediallydisplacedacetabular
implant.9–14
Fig.5–Portionofthescrewthathasbeencut.
However,tothebestofourknowledgethisisthefirsttime
thatalateperforationofleft externaliliacarteryduetoan
acetabularscrewisreportedwithoutlooseningofacetabular
componentsandnoformationofpseudoaneurysm.
Duringtherevisionsurgerythatthepatientsustainedone
oftheacetabularscrewsstayedmisguidedandneartotheleft
externaliliacartery.Itisbelievedthatthisproximityleadtoa
repeatedly,butyetsoftinjuryoftheartery.Thefactthatthe
patientstartedhersymptomsjustthreemonthsafterthelast
surgerysuggeststhatitmightbeafirstperiodofan
inflamma-toryresponseinthesurroundingsofthearterythatmayhad
controlledmoreconcerningsymptoms.Theinfectionthatthe
patienthadmayalsohadcontributetothisfirstperiod.
How-everoncetheinflammatoryphasefadedawayandthepatient
started todo morephysical activity the anticipated artery
fragilityleadedtoitsrupture. Hopkinsetal.15 alsobelieved
thatinfection hadacrucialroleasapredisposingfactorto
anarteryruptureafterTHRoncethat,initsabsence,aspike
injurywouldproducefibrosisofthearterialwallwith
conse-quentconstrainorthrombosis.
Other authors also previously showed the relationship
betweenpseudoaneurysmand ruptureofthe externaliliac
arteryandinfectionafteraTHA.15–18Nevertheless,inthiscase
noproofofpseudoaneurysmwasfound.Thismaybedueto
theprompttreatmentatanearlystageoftheinfectionandso
therearestilldoubtsaboutthatrelationship.
Inthiskind ofclinicalsituationsspeed indiagnosis and
treatment are crucial. Clinical presentation with pain and
swellingoftheleftlowerlimbmaymisleadingsuggestdeep
vein thrombosis. However,hemoglobin dropand pelvic CT
scanshowingabulkyhematomawithconsequentocclusion
oftheilio-femoralvascularaxisishighlysuggestiveofa
vas-cular rupture. Thisshows that althoughthe initial clinical
presentationcansometimesbesimilar,etiologyand
362
rev bras ortop.2017;52(3):359–362Kongetal.19 showed adelayed presentationoftheiliac
arteryinjury byanacetabularscrewdetectedina revision
surgery,10 years afterthefirst procedure. Inthat casethe
screwthatwasmisguidedwasnotchangedandvascularteam
didabypassgrafting.Inourcase,theoptionwastocutthepart
ofthescrewthatwasoutofbonedespitenorecordsofsimilar
reports.Thiswasasimpleprocedure,whichsolvedthe
prob-lemquickly,avoidingtheneedforamoreaggressivesurgery,
asitwouldbeanewhiprevision.
Thepresenceofa swelling and painful lower limbin a
patientwithhistoryofhipprosthesisshouldalwaysbe
evalu-atedassoonaspossible,bearinginmindthatnotallsituations
aredeepveinthrombosis.Other vascularcomplicationsare
alreadylistedandshouldbetakenintoaccountinthe
evalu-ationofthesepatients.Inthisstudyalatecomplicationofa
poorlyorientedacetabularscrewthatledtoaruptureofthe
externaliliacarteryispresented.Carefulclinicalevaluation
allowedacorrectdiagnosisandappropriatetreatmentintime
preventingfurtherconsequencestothepatient.
Inthisreportweshowedanunusualpresentationofalate
perforationofleftexternaliliacarteryduetoanacetabular
screwwithout looseningofacetabularcomponents andno
associatedpseudoaneurysm.Theissuewasresolvedby
sim-plycuttingpartofthescrewavoidingothersurgicaloptions
thatshouldbemuchmoreaggressiveforthepatient.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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