Femoral nerve palsy due to iliacus hematoma occurred after primary total hip arthroplasty

The epidemiology and management of iliopsoas hematoma with femoral nerve palsy: A descriptive systematic review of 174 cases

INTRODUCTION

Iliopsoas hematoma with femoral nerve palsy is a rare phenomenon with no consensus treatment algorithm. The objective of this study was to perform a systematic review of all reported cases of femoral nerve palsy secondary to iliopsoas hematoma to better elucidate it's optimal treatment.

MATERIALS AND METHODS

Queries of the PubMed, Embase, and Cochrane databases were performed for reports available in English of femoral nerve palsy secondary to iliopsoas, psoas, or iliacus hematoma. 1491 articles were identified. After removal of duplicated publications and review of abstract titles via a majority reviewer consensus, 217 articles remained for consideration. Dedicated review of the remaining articles (including their reference sections) yielded 122 articles representing 174 distinct cases. Clinical data including patient age, sex, medical history, use of pharmacologic anticoagulation, sensory and motor examination at presentation and follow-up, hematoma etiology and location, time to intervention, and type of intervention were collected. Descriptive statistics were generated for each variable.

RESULTS

Femoral nerve palsy secondary to iliopsoas hematoma occurred at a mean age of 44.5 years old. A majority of patients (60%) were male, and a majority of hematomas (54%) occurred due to pharmacologic anticoagulation. Most hematomas (57%) were treated conservatively, and almost half (49%) - regardless of treatment modality - resulted in persistent motor deficits at final follow-up. A minority of patients treated surgically (34%) had residual motor deficit at final follow-up, while 66% of those treated medically had resultant motor deficits, although no direct statistical comparison was able to be performed.

DISCUSSION AND CONCLUSIONS

The disparate available data on iliopsoas hematoma with femoral nerve palsy precludes the completion of a true metanalysis, and therefore any conclusions on an optimal treatment algorithm. Based on review of the literature, small to moderate hematomas are often treated conservatively, while larger hematomas with progressive neurological symptoms are usually managed with a percutaneous decompression or surgery.

LEVEL OF EVIDENCE

IV.

Iatrogenic femoral nerve injuries: Analysis of medico-legal issues through a scoping review approach

Purpose

Accidental femoral nerve injury is a well-known iatrogenic complication of orthopaedic, abdominal, and pelvic surgery. Because of the largely transitory nature of the symptoms associated with nerve damage, its true incidence is in all likelihood underestimated. This work aims to illustrate the surgical contexts within which this nerve injury is reported, based on the evidence obtained from a Scoping Review of the literature of the last 20 years, with specific reference to the underlying etiopathogenetic mechanisms and prognostic outcomes, to highlight the evaluation issues of medico-legal interest related to this pathology.

Methods

We conducted a Scoping Review of iatrogenic femoral nerve injuries reported between 2000 and 2021 by searching the electronic databases Pubmed, Scopus, Ovid Medline, Ovid Emcare, and Web of Science.We conducted the review according to the five-step methodology outlined by Arksey and O'Malley.

Results

The literature search identified 104 papers, including case reports, case series, and retrospective studies. Surgical contexts within which iatrogenic femoral nerve injuries were reported include orthopaedic, abdominal, gynaecological, urological, vascular, and plastic surgery, as well as locoregional anaesthesiological procedures. The long-term prognosis was generally favourable.

Conclusions

Because of its frequent iatrogenic genesis, femoral nerve injury is a topic of intense medico-legal interest. From the perspective of estimating the patient's disability, the mostly favourable nature of the prognosis makes the medico-legal assessment, in some respects, complex, thus requiring a precise evaluation methodology.

Iliacus hematoma syndrome: A systematic review of recent literature and case report

BACKGROUND

Femoral nerve palsy caused by iliacus hematoma is an infrequent diagnosis often missed because of its insidious presentation. However, due to potentially devastating outcomes, prompt recognition and management are essential.

OBJECTIVES

The aim with this study was to better characterize clinical presentation, diagnosis, treatment, and prognosis of iliacus hematoma.

METHODS

We performed a systematic review of recent literature regarding femoral neuropathy secondary to an iliacus hematoma. A structured literature review of multiple databases ((PubMed, Web of Science, EMBASE, and Cochrane library) referenced articles from 2000 to 2019.

RESULTS

A total of 25 patients from 25 published studies were identified. The average age of the patients was forty years (range, 12 to 85 years). There were 16 male patients and 9 female patients. The single most important predisposing cause of iliacus hematoma was trauma (14/25), with a pooled percentage of 56%. All patients with spontaneous hematoma were taking antiplatelet medications. Thirteen patients (52%) were treated conservatively with analgesia. Surgical decompression was performed in 10 patients (40%). At the final follow-up, complete resolution of symptoms was achieved in 12 patients (48%).

CONCLUSIONS

Although rare, iliacus hematoma syndrome carries significant morbidity. Spontaneous iliacus muscle hematoma should be considered in the differential diagnosis of leg pain in a patient who is on anticoagulation therapy. In patients with an iliacus hematoma and neurology deficit, conservative treatment can be considered initially if there is no progression in the symptoms evident at the time of presentation. However, prompt surgical decompression has been highly recommended in patients with progressive neurological deficits.

A case report of idiopathic iliopsoas hematoma which occurred soon after transfer to the wheelchair after total hip arthroplasty

A 79-year-old woman was diagnosed with osteoarthritis of the left hip and scheduled for total hip arthroplasty. As two lesions were detected in branches of the coronary arteries, she was treated with catheter treatment. The patient was receiving anticoagulant treatment, which was suspended eight days before the operation; however, heparin was started at 6 days before the operation and was stopped 9 hours before the operation. On the 2nd postoperative day soon after transfer to the wheel chair, she was feeling unwell and was suffering from severe pain in her left buttock and left thigh. Her blood pressure had decreased to 70 mmHg. During abdominal contrast-enhanced CT, a hematoma was detected in the left iliopsoas muscle. Catheter therapy was started by the cardiovascular department and bleeding had stopped spontaneously. The patient was able to walk with a cane and was discharged on the 40th postoperative day.

Abbreviations: THA: total hip arthroplasty, CT: computed tomography, JOA score: Japanese Orthopaedic Association hip score, HA: hydroxyapatite, PMMA: polymethyl-methacrylate, APTT: activated partial thromboplastin time

Femoral Nerve Palsy due to Noninfectious Iliopsoas Bursitis and Hematoma after Total Hip Arthroplasty: A Case Report

Femoral nerve palsy after total hip arthroplasty is an uncommon complication. We present a case report of delayed-onset femoral nerve palsy associated with iliopsoas hematoma and bursitis 10 years after primary total hip arthroplasty in a 57-year-old male patient with avascular necrosis of the femoral head. The patient visited our clinic due to swelling of the inguinal area with sudden-onset knee extension weakness. Radiologic examination at admission revealed suspicion of bursitis and hematoma on iliopsoas muscle. After evacuation of the hematoma and bursitis debridement, the patient's clinical symptoms improved dramatically. This is a rare report of femoral nerve palsy due to noninfectious iliopsoas bursitis and hematoma after total hip arthroplasty.

Compressive Femoral Neuropathy Associated with Iliopsoas Hematoma Complicating Hip Hemiarthroplasty: A Case Report

Introduction

Femoral nerve compression caused by iliopsoas hematoma is a rare complication after hip surgery. To the best of our knowledge, this is the first case after hemiarthroplasty. In this case, iliacus hematoma resulted from spontaneous bleeding favored by anticoagulant therapy.

Case Report

A 78-year-old female developed left groin pain associated with typical symptoms of femoral nerve palsy about 2weeks after left hip hemiarthroplasty[1, 2, 3]. Computed tomography revealed the presence of a left iliopsoas hematoma that was surgically drained. Inguinal pain was immediately relieved, while nerve palsy recovered only partially, but the quality of life drastically improved and she was able to walk using a walker without pain.

Conclusion

Even if it is a rare condition, the formation of a hematoma of iliopsoas muscle should be considered in patients that present symptoms of femoral nerve palsy, especially if treated with heparin or other anticoagulant drugs. Surgical drainage of the hematoma is indicated when symptoms are severe and disabling, and in this way, surgery could improve quality of life.

Total Hip Arthroplasty Complicated by a Gluteal Hematoma Resulting in Acute Foot Drop

Total hip arthroplasty is a prevalent orthopedic intervention in the United States. Massive postoperative hematomas are a rare albeit serious complication of the procedure. Sequelae of these hematomas can include lower extremity paralysis from compression of the sciatic nerve. A 66-year-old woman taking aspirin and clopidogrel for coronary stents presented with a complete foot drop, paresthesias, and lower extremity pain 10 days after a total hip arthroplasty. The patient was initially seen by a neurology service at another hospital and thought to have lateral recess stenosis. At the authors' center, magnetic resonance imaging of the lumbar spine failed to show lateral recess stenosis. Urgent pelvic computed tomography showed a large hematoma and raised suspicion of sciatic nerve compression. Hip magnetic resonance imaging showed a right gluteal hematoma compressing the sciatic nerve. The patient was then taken to the operating room for the clot to be evacuated and was later referred for rehabilitation. Massive hematomas after total hip arthroplasty are an important consideration in the differential diagnosis of nontraumatic acute foot drop. Prompt diagnosis may correlate with improved neurological outcome and help reduce overall morbidity.

Delayed Femoral Nerve Palsy Associated with Iliopsoas Hematoma after Primary Total Hip Arthroplasty

Femoral nerve neuropathy after total hip arthroplasty is rare but catastrophic complication. Pain and quadriceps muscle weakness caused by this complication can significantly affect the functional outcome. Here we present a case report, describing delayed onset femoral nerve palsy associated with iliopsoas hematoma following pseudoaneurysm of a branch of profunda femoris artery after 3 months of primary total hip arthroplasty in an 80-year-old female patient with single kidney. Hip arthroplasty was done for painful primary osteoarthritis of left hip. Diagnosis of femoral nerve palsy was made by clinical examination and computed tomography imaging of pelvis. Patient was managed by surgical evacuation of hematoma and physiotherapy. The patient's clinical symptoms were improved after surgical evacuation of hematoma. This is the first case report of its kind in English literature regarding delayed onset femoral nerve palsy after primary total hip arthroplasty due to pseudoaneurysm of a branch of profunda femoris artery without any obvious precipitating factor.

Iliacus haematoma causing femoral nerve palsy: an unusual trampolining injury

We report the case of a 15-year-old boy who presented to accident and emergency following a trampolining injury. Initially, the patient was discharged, diagnosed with a soft tissue injury, but he re-presented 48 h later with worsening low back pain and neurological symptoms in the left leg. Subsequent MRI revealed a left iliacus haematoma causing a femoral nerve palsy. The patient was managed conservatively and by 6 months post injury all symptoms had resolved. This is the first reported case of an iliacus haematoma causing a femoral nerve palsy, after a trampolining injury. We believe this case highlights to our fellow clinicians the importance of a detailed history when assessing patients with trampolining injuries to evaluate the true force of injury. It also acts as a reference for clinicians in managing similar cases in future.

[Lower limb paresis after total hip arthroplasty. A rare differential diagnosis]

We report on a case of complex nerve damage during total hip arthroplasty. The most severe clinical symptom was proximal leg paresis with diffuse sensory loss. There was an extensive causal Iliopsoas hematoma which developed during the postoperative rehabilitation under therapeutic anticoagulation for atrial fibrillation. An iliopsoas hematoma with subsequent neurological deficits are rare events in the field of hip arthroplasty and a literature review is provided. The treatment of retroperitoneal hemorrhage is controversial but in most instances a conservative approach is favored. The prognosis of neurological damage is sobering as only 20 % of victims are expected to achieve complete restitution.

An unusual cause of Grey Turner's sign

A woman in her late 70s presented to the acute general surgical take with a 3-day history of worsening right leg pain and swelling. She had undergone right revision total hip arthroplasty 20 months previously and reported chronic postoperative right thigh pain attributed to a femoral deep venous thrombosis for which she had been warfarinised. On examination, Grey Turner's sign (bruising of the flanks indicating retroperitoneal haemorrhage) was present, as well as a large tender mass in the right iliac fossa and pitting oedema throughout the right lower limb. Urgent CT scan with intravenous contrast revealed a right retroperitoneal haematoma secondary to a right acetabular screw protruding into the right external iliac vein. The patient was successfully managed with warfarin reversal and surgical removal of the relevant acetabular screw. At 2-month follow-up, the patient's symptoms continue to resolve.

Retroperitoneal hematoma with bone resorption around the acetabular component after total hip arthroplasty: a case report and review of the literature

Introduction

Vascular complications related to cup-fixating screws penetrating the medial acetabular wall during total hip arthroplasty are not uncommon but rarely are associated with serious adverse events in the late post-operative period.

Case presentation

We present the case of a 77-year-old Japanese woman who developed progressive extensive bone resorption and large hematoma in the acetabulum 13 years after total hip arthroplasty. On admission to our hospital, she was on oral warfarin (1.5mg/day) for atrial fibrillation. About 5 months after the initiation of anticoagulant therapy, she suffered a major fall followed by massive subcutaneous and pelvic girdle bleeding, predominantly on the medial side of the right thigh, but a fracture or damage of total hip arthroplasty was not evident on an emergency orthopedic evaluation. One year after the accident, a routine follow-up examination showed an asymptomatic osteolytic lesion in the acetabulum on the right pelvis, and 2 years later our patient noticed progressive pain in her right hip during walking. A large osteolytic lesion was noted in the right acetabulum on a plain radiograph. On high-resolution computed tomography and magnetic resonance imaging, a huge granulomatous lesion in the acetabulum was suggestive of chronic hematoma in intrapelvic and extrapelvic gluteal regions. A closer computed tomography examination showed that one of the screws used for fixation of the acetabular component in the total hip arthroplasty had penetrated the acetabular bone and had reached the pelvic cavity. Surgery was performed in a single session by means of two approaches: anterior midline transperitoneal address to resect the low-density mass lesion followed by posterolateral acetabular implant re-settlement.

Conclusions

Though rare, total hip arthroplasty-related late vascular complications could be serious and potentially affect the limb and quality of life.

Massive psoas haematoma causing lumbar plexus palsy: a case report

An 84-year-old man who was receiving oral anticoagulation therapy presented with complete lumbar plexus palsy caused by a massive psoas haematoma. Conservative treatment rather than drainage of the haematoma was undertaken, because of the risk of bleeding complications and mortality. At the one-year follow-up, the patient had no clinical signs of neurological recovery. The patient died 2 months later due to his concurrent medical problems. A high degree of suspicion is needed for the diagnosis because of the insidiously developing neurological deficit.

Femoral nerve palsy caused by ileopectineal bursitis after total hip replacement: a case report

Introduction

Infectious ileopectineal bursitis is a rare complication after total hip replacement and is associated mainly with rheumatoid arthritis. The main complications are local swelling and pain, but communication of the inflamed bursa with the joint can occur, leading to subsequent cartilage damage and bone destruction.

Case presentation

We report a case of a 47-year-old Caucasian woman without rheumatoid arthritis who reported pain and palsy in her left leg almost one year after total hip replacement. She was diagnosed with an ileopectineal bursitis after total hip replacement, leading to femoral nerve palsy. The diagnosis was obtained by thorough clinical examination, the results of focused computed tomography and magnetic resonance imaging.

Conclusion

To the best of our knowledge, this is the first report of non-infectious ileopectineal bursitis in a patient without rheumatoid arthritis as a complication of total hip replacement. This rare case underlines the importance of proper neurologic examination of persistent conditions after orthopedic intervention in otherwise healthy individuals. We believe this case should be useful for a broad spectrum of medical specialties, including orthopedics, neurology, radiology, and general practice.

Rupture of the ilio-psoas tendon after a total hip arthroplasty: an unusual cause of radio-lucency of the lesser trochanter simulating a malignancy

Avulsion fracture or progressive radiolucency of lesser trochanter is considered a pathognomic finding in patients with malignancies. Although surgical release of the iliopsoas tendon may be required during a total hip arthroplasty (THA), there is no literature on spontaneous rupture of the ilio-psoas tendon after a THA causing significant functional impairment. We report here such a case, which developed progressive radiolucency of the lesser trochanter over six years after a THA, simulating a malignancy. The diagnosis was confirmed by MRI. Because of the chronic nature of the lesion, gross retraction of the tendon into the pelvis, and low demand of our patient, he was treated by physiotherapy and gait training. Injury to the ilio-psoas tendon can occur in various steps of the THA and extreme care should be taken to avoid this injury. Prevention during surgery is better, although there are no reports of repair in the THA setting. This condition should be considered in patients who present with progressive radioluceny of the lesser trochanter, especially in the setting of a hip/pelvic surgery. Awareness and earlier recognition of the signs and symptoms of this condition will aid in diagnosis and will direct appropriate management.