Stoppa approach, an alternative for total hip arthroplasty in an intra-pelvic cup

Intrapelvic Cup Migration Following Revision Total Hip Arthroplasty: A Case Report and Review of the Literature

Intrapelvic acetabular cup migration is a rare but serious complication that can occur following either primary or revision total hip arthroplasty. Medial acetabular wall weakening is considered the main predisposing factor for acetabular protrusion. A thorough preoperative plan is essential to advocate proper pelvic anatomy reconstruction, including osteosynthesis of the pelvis, if necessary, preservation of muscle and bone stock, and selection of the right prosthetic components without damaging adjacent anatomical structures. We present a rare case of an 84-year-old woman with a hip dislocation and complete intrapelvic migration of the acetabular component, nine years after her second revision surgery of a hip prosthesis placed 60 years ago due to congenital hip dysplasia. The protruded acetabulum was not removed since preoperative CT and digital subtraction angiography (DSA) revealed no vascular compromise. A non-cemented, tantalum acetabular cup, reinforced by a short flange titanium acetabular cage, was placed with a cemented, polyethylene-bearing surface, which was revised to a cemented, constrained acetabular insert three months postoperatively due to dislocation after mobilization on the bed. We conducted a literature review to elucidate the causes, proper diagnostic tools, and preoperative planning of this rare occurrence while trying to evaluate a potential treatment protocol.

Revision Hip Arthroplasty in Patient with Acetabulum Migration into Subperitoneal Space-A Case Report

Revision hip arthroplasty procedures have been extensively discussed in the literature. At the same time, discussions of the management of acetabular component protrusion into the pelvic cavity, and, more specifically, the subperitoneal space, necessitating an additional abdominal approach for the revision arthroplasty, have only been published as case reports and descriptions of transperitoneal approaches have been even rarer. This paper presents the case of a 63-year-old female patient in whom a peritoneal approach was necessary to access a migrated acetabular component. The outcome of the treatment, which represented a complex orthopedic and general surgical problem, was good. We believe that the complexity of revision hip arthroplasty in patients with protrusion of the acetabular component together with the head and proximal part of the stem of the implant into subperitoneal space calls for a careful re-analysis of the category of Type III bony acetabulum defects according to Paprosky, where the recognition of two subtypes would facilitate analysis of such cases.

The use of pararectus approach for Type 3B Paprosky acetabular defect with intrapelvic cup migration. Case report

Case: A case of Type 3B Paprosky acetabular defect with intrapelvic cup migration where anterior column plating and cup extraction was done through an abdominal pararectus approach.

A male patient 63 years old reported progressive pain and walking disability after five years of cementless THR for right hip AVN.

CT pelvis showed loose intrapelvic migrated cup, extensive osteolytic acetabular defects, and pelvic discontinuity.

Pararectus approach was used to remove the cup and the head with concomitant plating of the anterior column

Conclusion: The pararectus approach is a valid option for intrapelvic cup extraction and pelvic discontinuity fixation.

Intra-abdominal and intra-pelvic complications following operations around the hip: causes and management-a review of the literature

Although successful and well-established procedures, hip operations whether elective or trauma are coupled with a variety of complications. Among the most uncommon complications are injuries to intra-abdominal or intra-pelvic organs which could prove potentially life-threatening. While there are various reports of such injuries in the literature, we aimed to perform a systematic review in order to examine the causes and relationships between intra-abdominal and intra-pelvic complications and the mechanism of injury, the pattern of presentation, identification, the course of management and outcomes. We identified 69 reports describing a total of 84 complications in intra-pelvic and intra-abdominal contents in 75 patients. These involved six major categories, including the intestinal tract, the urinary tract, the genital tract, the vascular system, the viscera and peripheral nerves. The most commonly injured system was the urinary (33.33%), followed by the vascular (29.76%) and the intestinal (22.62%). Among these systems, the most prevalent complications involved injury to the urinary bladder (32.14%), the large intestine (68.42%) and the external iliac artery (44%). The majority of recorded complications were postoperative with 71 incidents in 63 cases (84.52%). In intra-operative complications the most prevalent injury was due to hardware penetration (53.85%), while in postoperative it was due to hardware migration (92.06%). The management of injuries varied widely, with the most common approach being open exploration and direct repair (77.33%). The reported management outcomes included death (8%) and Girdlestone resection (2.67%), while the majority of the patients healed uneventfully (82.67%) owing mostly to immediate intervention. Despite being rare, such complications may still occur in a variety of settings and may subsequently lead to potential life-threatening situations. Thus, in order to avoid catastrophic outcomes we emphasize the need for prompt identification, immediate intervention and a multidisciplinary approach when necessary.

Subperitoneal approach in revision arthroplasty for acetabular component protrusion: Analysis of practices within the French Hip and Knee Society (SFHG)

INTRODUCTION

The complications related to revision for acetabular component protrusion with material migrating into the intrapelvic region remain rare but potentially serious. Today, the literature reports no epidemiological data on the subperitoneal approach (SPA) in revision total hip arthroplasty (RTHA) for protrusion. Therefore we conducted a retrospective study on a large revision arthroplasty database to answer the following questions: (1) What is the frequency of this approach in this population? (2) What are the factors related to this procedure? (3) Is morbidity and mortality of the SPA higher than for an isolated conventional approach?

HYPOTHESIS

Major protrusions with material in the superomedial quadrant (SMQ) have a higher probability of being operated using a SPA.

MATERIAL AND METHODS

This multicenter retrospective study included 260 cases of THA with endopelvic protrusion of material at least 15mm inside the Kohler line. The degree of protrusion was assessed on the AP pelvic X-ray with the construction of the SMQ. The reason for the subperitoneal approach, the duration of surgery, and the preoperative exams were also collected.

RESULTS

Nineteen procedures out of the 260 RTHAs included (7.8%) had a SPA in addition to the approach for the revision THA. The frequency of the SPA varied among centers (range: 1.7-50%). In four cases, the SPA was indicted to care for a vascular complication identified preoperatively. For one patient, the SPA was indicated intraoperatively. The other indications were either to extract the implant (n=7) or prevent a potential intraoperative assault of neurovascular structures (n=9). The cases presenting major protrusion on the AP X-ray with material in the SMQ were more often operated through the SPA (12/19; 63.2%) than cases with no SMQ involvement (4/241; 1.7%) (P<0.001). Vascular structures were explored with imaging in 15 out of 19 (88.9%) of the SPA cases versus 26 out of 177 (14.7%) of the revisions without the SPA (41 with no information in the non-SPA group) (P<0.001). Early mortality (before 45 days) of patients who had undergone the SPA (1/19; 5.3%) was not significantly different than for the patients who had not undergone the SPA (3/241; 1.2%) (P=0.26). Although the duration of surgery was longer in the SPA group (210±88 [range: 70-360] versus 169±52 [range: 60-300]; P=0.04), bleeding was not greater in the SPA group (1488±1770mL [range: 500-5000mL]) than in the non-SPA group (1343±987mL [range: 75-3500mL]; p>0.05).

DISCUSSION

Despite the limitations related to the retrospective and multicenter design of this study, to our knowledge it is the only one that examines SPA procedures within the context of severe material protrusion with THA. Based on these results, it seems preferable to plan for SPA every time there is an acetabular protrusion in the SMQ, after exploration with CT angiography. The SPA does not result in greater mortality or morbidity.

LEVEL OF EVIDENCE

IV, retrospective study.

Stoppa approach for intrapelvic damage control and reconstruction of complex acetabular defects with intra-pelvic socket migration: A case report

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A novel surgical technique for reconstructing pelvic defects in hip revision surgery is described.

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The Stoppa approach allows for pelvic damage control and reconstruction of bone defect.

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The bone reconstruction is made by combining an intrapelvic plating with augmented socket reconstruction.

Introduction

Failed hip arthroplasty with intrapelvic acetabular migration can be challenging due to the potential damage of intrapelvic structures.

Presentation of the case

We present a case of a 75 year-old lady with failed hip arthroplasty with loosening of implants and intra-pelvic migration of the cup, antiprotrusio cage mesh, screws and plate. A modified Stoppa approach was performed, a part of the migrated elements were safely removed, the intrapelvic structures were controlled, and the bone defect was reconstructed through the Stoppa approach combined with the lateral window of ilioinguinal approach by means of bone struts and metallic plates, which is a novel technique. Then an extended posterolateral hip approach was done and the acetabulum was reconstructed using porous tantalum augments and morselized allograft. A cemented constrained socket was implanted. After one-year follow-up the patient is able to walk with one crutch without pain.

Discussion

Due to intrapelvic migration, the implants used in hip arthroplasty may become entrapped between the anatomical structures lodged in the pelvis and cause damage to them. A careful preoperative assessment and planning are mandatory. A migrated socket can be inaccessible through a conventional hip approach and removal could be very difficult and dangerous.

Conclusion

The Stoppa approach in hip revision surgery can be a complement to traditional approaches to control the intrapelvic structures, remove migrated implants of previous surgery and reconstruct the pelvic defect.

The ilio-inguinal approach for recent acetabular fractures: ultrasound evaluation of the ilio-psoas muscle and complications in 24 consecutive patients

INTRODUCTION

The ilio-inguinal approach is used to achieve internal fixation of acetabular fractures. Although the outcomes of this procedure have been extensively reported, information is lacking on potential complications. More specifically, the effect on the ilio-psoas muscle, whose iliac attachments are almost completely released, has not been accurately evaluated.

HYPOTHESIS

Endopelvic dissection does not alter the ultrasound structure of the ilio-psoas muscle compared to the normal side at a distance from acetabular internal fixation via the ilio-inguinal approach.

PATIENTS AND METHODS

We retrospectively evaluated 26 patients who underwent internal fixation of acetabular fractures via the ilio-inguinal approach between 2006 and 2010. Two patients with multiple injuries died shortly after the procedure, leaving 24 patients with unilateral fractures for the study. In 2012, an observer who was not involved in the surgical treatment of these patients conducted an assessment (Oxford score except in the 8 patients who required revision surgery for arthroplasty and evaluation for a deficit of the lateral femoral cutaneous nerve in the full cohort). At the same time point, ultrasonography was performed to compare ilio-psoas muscle morphology on the two sides. Any other complications (vascular, nervous, or parietal) were recorded.

RESULTS

Of the 24 patients, 11 (45%) experienced complications, of whom only 3 required further surgery, 2 with infections that recovered fully after lavage and 1 with a haematoma responsible for compression of the urinary bladder. The lateral femoral cutaneous nerve was injured in 8 (33%) patients, including 4 who had achieved a full recovery at last follow-up. At last follow-up, none of the 24 patients had ultrasound evidence of a significant difference in ilio-psoas muscle size at the lateral window: mean transverse diameter was 51.8±0.8mm (range, 44-58 mm) on the operated side versus 51.7±0.79 mm (range, 44-59 mm) on the other side (P=0.9). After a mean follow-up of 49 months (range, 31-70 months), the mean Oxford score in the 16 patients who had not required further surgery was 20.5/60 (range, 12-44).

DISCUSSION

Our results show that, despite extensive endopelvic dissection, the ilio-inguinal approach has no effect on the ultrasound morphology of the ilio-psoas muscle. There is a high risk of injury to the lateral femoral cutaneous nerve that should be disclosed to the patient before the procedure. In contrast, no parietal complications were recorded. In selected patients, the Cole-Stoppa approach is an alternative that spares the lateral femoral cutaneous nerve.

LEVEL OF EVIDENCE

Level IV, retrospective study.