Unaddressed arterial injuries in revision total hip arthroplasty: mortality outcomes of a low-prevalence complication

Delayed Femoral Nerve Palsy Due to Femoral Artery Pseudo-Aneurysm After a Total Hip Replacement Through an Anterolateral Approach

We present a rare case of delayed femoral nerve palsy resulting from a pseudo-aneurysm presenting as excruciating anterior thigh pain 2 months after an uneventful total hip arthroplasty through a Watson Jones approach. The large pseudo-aneurysm of the posterior wall of the femoral artery was treated with open exploration and artery repair since the anatomy of the lesion precluded an embolization. Although pain resolved immediately, the recovery of the femoral nerve started after 3 months, while full quadriceps function was restored by the 6th month. Positioning a Hohmann retractor along the inferior part of the anterior acetabulum rim may place the femoral artery branches under significant stretch. Preserving the capsule and keeping the retractor tension as low as possible may avoid this complication.

The Anatomical Course of the Superior Gluteal Vessel Bundle with Regard to Different Approaches in Total Hip Arthroplasty

BACKGROUND

Iatrogenic vascular injury during total hip arthroplasty (THA) is rare, reported at rates of 0.05 to 0.3%, but a potentially limb-threatening and life-threatening complication. We aimed to describe safe and danger zones for the superior gluteal vessel bundle (SGV bundle) with reference to different THA approaches.

METHODS

There were 27 formalin-fixed cadavers with 49 hemipelves dissected. The course and distribution of the SGV bundle were investigated with the help of anatomical landmarks like the greater trochanter, the iliac tubercle (IT), and the ischial tuberosity.

RESULTS

We found and exposed the SGV bundle in all 49 specimens with no sex-specific differences. No SGV bundle was encountered up to 28 mm from the greater trochanter and up to 16 mm below the IT. The zone with the highest probability of finding the vessels was 25 to 65 mm below the IT in 39 (80%) cases - defining a danger zone (in relation to the skin incision) in the proximal fourth for the direct anterior approach, in the proximal half for the antero-lateral approach, in the proximal fifth for the direct lateral approach, and almost no danger zone for the posterior approach.

CONCLUSIONS

Special care in proximal instrument placement should be taken during THA. When extending one of the surgical approaches, manipulations in the proximal, cranial surgical window should be performed with the utmost care to avoid SGV bundle injury.

Endovascular Management of Iatrogenic Arterial Injuries after Orthopedic Surgery of the Lower Limb

PURPOSE

To evaluate the safety and effectiveness of embolization, and to identify the contributory factors of failures in patients treated for iatrogenic arterial injuries after orthopedic surgery of the lower limb.

MATERIALS AND METHODS

In this retrospective study, data from patients treated from December 2008 to March 2022 for an arterial injury due to orthopedic surgery of the lower limb were analyzed from a single center. Demographic, clinical, and procedure-related data were collected. Perioperative and 30-day mortalities were estimated. Odds ratios and hazard ratios were calculated for several potential risk factors: age of >75 years, atherosclerosis, preexisting infection, urgency of surgery (trauma vs elective), previous surgery, multiple distant injuries, and multiple vascular supplies to the same injury.

RESULTS

Eighty-six procedures performed on 78 patients were included in the study. The rates of technical and clinical success were 100% and 92.3%, respectively. Six (7.7%) patients were retreated because of persistent bleeding. The perioperative mortality was 1.3%, and the 30-day mortality rate was 7.7%. The presence of multiple arterial supplies, multiple injuries, previous surgery, presence of atherosclerosis, or a preexisting musculoskeletal infection resulted in a higher risk of retreatment.

CONCLUSIONS

Embolization is safe and effective in the management of iatrogenic arterial injuries after orthopedic surgery. The number of involved vascular territories was the most critical factor in determining technical failure.

Pseudoaneurysm following Two-Stage Hip Revision with Fasciotomy

In the setting of total hip arthroplasty (THA), pseudoaneurysms are extremely rare and can be difficult to diagnose, as clinical symptoms can mimic symptoms of other more common complications, such as periprosthetic joint infection, hematoma, and nerve damage. We present a case of a 69-year-old male with a history of slipped capital femoral epiphysis 56 years prior and subsequent right THA. The right hip primary arthroplasty was subsequently complicated by multiple dislocations and recurrent prosthetic joint infections. The most recent infection was treated with debridement, antibiotics, and implant retention (DAIR) in 2017. The patient later presented in 2019 with right thigh pain. Upon further analysis, he was diagnosed with Streptococcus bovis positive periprosthetic joint infection. The patient underwent a two-stage revision of the hip using an antibiotic spacer. Two weeks following the second stage, he presented with a sudden onset of uncontrolled atrial fibrillation with rapid ventricular response and a low hemoglobin. The computed tomography scan revealed a large hematoma involving both the anterior and posterior thigh compartments with lab markers that were questionable for infection. An operation to remove the hematoma revealed no purulence, and a large pulsatile pseudoaneurysm on the posterolateral aspect at the mid femur was found. A sharp bone fragment was noted next to the pseudoaneurysm. The pseudoaneurysm was repaired by a vascular surgeon, and the bone fragment was removed. Following this procedure, the patient developed a subsequent periprosthetic joint infection requiring a double DAIR procedure six weeks following the pseudoaneurysm repair and is now on chronic antibiotic suppression. Orthopedic surgeons should be aware of the potential for pseudoaneurysm in the setting of total joint arthroplasty when treating a postsurgical hematoma of sudden onset.

Progress of gelatin-based microspheres (GMSs) as delivery vehicles of drug and cell

Gelatin has various attractive features as biomedical materials, for instance, biocompatibility, low immunogenicity, biodegradability, and ease of manipulation. In recent years, various gelatin-based microspheres (GMSs) have been fabricated with innovative technologies to serve as sustained delivery vehicles of drugs and genetic materials as well as beneficial bacteria. Moreover, GMSs have exhibited promising potentials to act as both cell carriers and 3D scaffold components in tissue engineering and regenerative medicine, which not only exhibit excellent injectability but also could be integrated into a macroscale construct with the laden cells. Herein, we aim to thoroughly summarize the recent progress in the preparations and biomedical applications of GMSs and then to point out the research direction in future. First, various methods for the fabrication of GMSs will be described. Second, the recent use of GMSs in tumor embolization and in the delivery of cells, drugs, and genetic material as well as bacteria will be presented. Finally, several key factors that may enhance the improvement of GMSs were suggested as delivery vehicles.