Severe vascular complications and intervention following elective total hip and knee replacement: A 16-year retrospective analysis

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.

Incidence of vascular injury associated with knee arthroplasty: series of cases

INTRODUCTION

The incidence of vascular injury associated with knee arthroplasty is scarce, but, when they occur, the consequences are serious.

OBJECTIVES

Describe the incidence of vascular lesions in our center and evaluate time to diagnosis, resolution and follow-up.

MATERIALS AND METHODS

Retrospective cohort during the 2010-2019 period of primary arthroplasties and knee revision. The incidence of vascular lesions and their demographic characteristics were analyzed. Type of lesion, diagnostic method and treatment were recorded. It was evaluated in distant follow-up of pain and functionality.

RESULTS

7.940 primary total knee arthroplasty and revision surgeries were recorded, and a report of 7 emergency cases for vascular lesions was also recorded, with an incidence of 0.088%. 3 vascular lesions were caused by direct laceration of the popliteal artery, 1 case of thrombosis of the popliteal artery and 3 cases of pseudoaneurysmal lesion of the superior genicular artery. Three vascular lesions that occurred in primary arthroplasty were immediately repaired by a vascular surgeon. Pseudoaneurysm lesions and thrombosis were resolved by angiographic procedure.

DISCUSSION

Vascular complications around the knee are rare. Time to diagnosis and treatment is essential. Digital angiography is a diagnostic and therapeutic tool. There are various repair techniques, whether it's embolization, cauterization, stenting or endoprosthesis; therefore, digital angiography is a safe method with a low complication rate.

CONCLUSION

The incidence of vascular lesions in knee arthroplasty in our center is very low. The cases were diagnosed and resolved early, without registering subsequent complications with good functional results in distant follow-up.

Management of Thrombosis of the External Iliac Artery during Total Hip Arthroplasty - A Case Report

Introduction

Vascular injury following total hip arthroplasty (THA) is uncommon but can lead to loss of life or limb. External iliac and common femoral arteries are commonly injured during THA.

Case Report

We report a case of thrombosis of the external iliac and femoral artery during THA in a mid-60-year female patient with 15-year-old neglected fracture neck of the femur. Six hours following THA through Harding's approach, a feeble pulse was palpated in the operated limb. Ischemia of the limb led to sciatic nerve palsy and foot drop in the operated limb, which was intact following surgery. Computed tomography angiography confirmed thrombosis of the external iliac and femoral artery. Removal of thrombosis with the use of a Fogarty catheter could save the limb and lead to recovery of foot drop. Early detection of pulselessness and timely intervention in the post-operative period was the cornerstone of this case report.

Conclusion

Vascular injury during THA though rare but cannot be ruled out completely. Early diagnosis with a stringent post-operative protocol and timely intervention would be the cornerstone of the management of any vascular injury following THA.

Acute Popliteal Artery Thrombotic Occlusion Post Total Knee Arthroplasty in a Patient With Antiphospholipid Syndrome: A Report of a Rare Complication

Acute popliteal arterial thrombotic occlusion following total knee arthroplasty is a rare but serious complication, most of which happens due to blunt trauma during surgery in patients with preexisting peripheral vascular disease. Historically, popliteal artery thrombosis has been approached only by open surgery. In this report, we describe a case of acute thrombotic occlusion of the popliteal artery occurring immediately after total knee arthroplasty in a patient who was presumed healthy and found to have antiphospholipid syndrome and was successfully managed by mechanical endovascular thrombectomy.

[Akute arterielle Embolie nach einer Knie-Totalendoprothese: Ein Bericht über zwei Fälle und Literaturübersicht]

Die akute arterielle Embolie ist eine seltene, aber schwerwiegende Komplikation nach einer Knie-Totalendoprothese (Knie-TEP). Es besteht ein allgemeiner Konsens darüber, dass in dieser Situation sofort eine Revaskularisation durchgeführt werden muss, aber die spezifische Behandlung ist immer noch umstritten. Wir berichten über zwei Fälle von Embolien der Kniekehlenarterie, die durch eine akute arterielle Thrombose nach Knie-TEP verursacht wurden. Bei beiden Patienten kam es nach der Operation zu einem Gefühls- und Bewegungsverlust der rechten unteren Extremität und einer Pulsationsschwächung der Arteria dorsalis pedis; eine Angiografie zeigte eine Embolie der Arteria poplitea. Einer der Patienten erhielt eine Thrombolysetherapie, entwickelte jedoch eine großflächige Infektion und Nekrose des rechten Wadenmuskels und benötigte nach erfolgreicher Thrombolyse ein mehrfaches Debridement und Hauttransplantationen. Bei dem anderen Patienten wurde eine Thrombektomie, eine Gefäßrekonstruktion und eine prophylaktische Fasziotomie durchgeführt; nach der Operation blieben ein Taubheitsgefühl im Fuß und eine leichte Streckschwäche zurück. Die Autoren empfehlen Chirurgen, Hochrisikopatienten mit Knie-TEP eine angemessene Aufmerksamkeit zu widmen. Vor der Operation sind eine sorgfältige Anamnese und körperliche Untersuchung erforderlich. Der chirurgische Eingriff sollte präzise und schonend durchgeführt werden, nach der Operation sind das Gefühl der Gliedmaßen und die Blutzirkulation aufmerksam zu beobachten. Bei abnormalem Fußgefühl und schwacher arterieller Pulsation sollten umgehend erforderliche Untersuchungen (Doppler-Ultraschall und Arteriografie) durchgeführt werden. Wenn eine arterielle Thrombose diagnostiziert wurde, muss die Blutversorgung sofort wiederhergestellt werden. Verzögert sich die Diagnose um mehr als 6 Stunden, kann eine prophylaktische Fasziotomie erforderlich sein, um nachteilige Folgen zu vermeiden.

Treatment with selective transcatheter arterial embolization of a ruptured profunda artery perforator after internal thigh liposuction: a case report

BACKGROUND

Hemorrhage is an uncommon complication of liposuction that may be trauma-induced by the cannula on the subcutaneous perforators. It usually resolves spontaneously with external compression and results in mild to moderate ecchymosis on the liposuction site. However, in sporadic cases, active bleeding may persist and require urgent intervention for hemostasis.

CASE PRESENTATION

We report the case of a 60-year-old White female who developed a massive hematoma in the hour following liposuction of the right internal thigh, with active bleeding in the subcutaneous plane reported on contrast-enhanced computed tomography. The initial angiogram was conducted in the right common femoral artery and showed active bleeding from a profunda artery perforator. After careful selective catheterization of the feeding artery using a 2.0-French microcatheter, 0.3 mL of Onyx 34 was injected. Control angiography showed no immediate complication and confirmed the exclusion of the pseudoaneurysm. No postoperative event occurred. Blood pressure and hemoglobin levels remained stable throughout the episode.

CONCLUSIONS

Although liposuction is a very common procedure in plastic surgery, hemorrhagic complications may occur and require urgent hemostasis. This case suggests a vital place for interventional radiology in the management of hemorrhagic complications after liposuction.

Rupture of External Iliac Artery during Total Hip Arthroplasty after Rotational Acetabular Osteotomy: A Case Report

Introduction

Total hip arthroplasty (THA) is widely accepted as a safe and effective procedure to relieve hip pain and restore function, but complications can lead to a poor outcome. Although major vascular injuries during THA are rare, when they do occur, massive bleeding may threaten life.

Case Report

We describe a case of a 72-year-old woman who underwent THA after rotational acetabular osteotomy (RAO). When the soft tissue in the acetabular fossa was dissected with electrocautery, massive pulsatile bleeding suddenly occurred. A blood transfusion and metal stent graft repair saved her life. We assume that the cause of the arterial injury was a bone defect of the acetabulum and relocation of the external iliac artery after RAO.

Conclusion

To avoid arterial injury during THA, pre-operative three-dimensional computed tomographic angiography to locate the intrapelvic vessels around the acetabulum is recommended in cases with complex hip anatomy.

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.

Perioperative point-of-care ultrasound for diagnosis of acute lower extremity arterial thrombosis after total hip arthroplasty revision: a case report

PURPOSE

Acute arterial thrombosis after hip arthroplasty is a rare event associated with potentially catastrophic complications. Early clinical diagnosis of progressive limb ischemia is often difficult in the immediate postoperative period because of residual neuraxial blockade and the nonspecific nature of signs. We describe the use of point-of-care ultrasound (POCUS) in the postanesthesia care unit (PACU) to diagnose this complication early and facilitate timely intervention.

CLINICAL FEATURES

A 78-yr-old female patient underwent elective right hip revision arthroplasty under spinal anesthesia and postoperatively had an absent dorsalis pedis pulse on her operative leg as screened by an audible-only Doppler. No obvious clinical symptoms were present as the patient was still under subarachnoidal blockade. A bedside POCUS vascular evaluation was performed in the PACU and showed an absence of blood flow in the superficial femoral artery, expediting the confirmation of a surgical emergency. The patient underwent a successful open thrombectomy and made an uneventful postoperative recovery.

CONCLUSION

Our case report highlights the novel use and impact of bedside POCUS to assess the presence or absence of distal limb arterial blood flow and, in this case, the level of arterial occlusion.

Erosion of Common Femoral Artery 3 Years After Total Hip Arthroplasty in a Patient with Marfan Syndrome: A Case Report

CASE

A patient with congenital hip dysplasia and Marfan syndrome presented 3 years after total hip arthroplasty (THA) with acute ischemia of the left lower extremity secondary to popliteal artery embolism. Intravenous ultrasound revealed common femoral artery (CFA) dilation with an intraluminal thrombus. Open repair showed prosthetic erosion through the CFA despite proper implant positioning and lack of hardware failure.

CONCLUSION

This is a rare complication of THA in a patient with impaired vascular integrity secondary to a connective tissue disorder. Similar patients may be at a higher risk for unusual vascular complications, and diagnosis may require atypical imaging modalities.

Intraoperative Radiographic Detection of Intrapelvic Acetabular Screw Penetration: Lessons Learned From Our Trauma Colleagues

BACKGROUND

Intraoperative vascular injury during total hip arthroplasty represents a catastrophic complication. Acetabular screw placement represents one possible mode of injury. The purpose of this study was to evaluate the utility of various fluoroscopic views in the detection of intrapelvic screw penetration.

METHODS

A radiopaque pelvis Sawbones model was instrumented with a hemispherical acetabular component. Four intrapelvic quadrants were defined. Screws were placed, 3 in each quadrant, and imaged sequentially at 3 depths: 0 mm, 5 mm, and 10 mm penetrated. Eight fluoroscopic images were used: anteroposterior, inlet, outlet, iliac oblique, obturator oblique, "down the wing," obturator outlet, and a "quad" view. Three blinded, independent surgeons evaluated the images for intrapelvic screw penetration. Images were analyzed in isolation and as a "triple-shot series" consisting of the "quad," obturator outlet, and iliac oblique views. Sensitivity and specificity values were then calculated.

RESULTS

In isolation, the "quad" view had the highest sensitivity for screw penetration (62%). The triple-shot series was found to be 100% sensitive in all 4 quadrants for detecting 10 mm of screw penetration. The specificity of the series was found to be 100% in all quadrants except for the posterior superior quadrant where it was 67%. Interobserver agreement approached perfection (Kappa ≥0.947) between all surgeons (P < .001) when using the 3-view series.

CONCLUSIONS

This study is the first to assess the use of fluoroscopy in the detection of intrapelvic penetration of transacetabular screws. We found that a 3-radiograph series provided a sensitive and specific metric for the detection of intrapelvic screw penetration.

Vascular Injuries in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Vascular injuries associated with total knee arthroplasty can have limb and life-threatening consequences. The aims of this study were to conduct a meta-analysis of the overall rate of vascular injuries after total knee arthroplasty and to conduct a systematic review of specific major and minor vessel injuries.

METHODS

All English-language literature published from January 1, 1998, to November 30, 2018, was queried in 4 unique databases using a common search term. This yielded 404 results, of which 270 were unique. Two reviewers then assessed studies for eligibility. All non-human studies, cadaver studies, studies describing only human images, and human studies with non-acute pathology were excluded. The final study included 10 large epidemiological studies and 68 case series or studies. Data from the literature were abstracted into a comma-separated database spreadsheet using Microsoft Excel. A meta-analysis was then performed. Pooled statistics were calculated with weighting by inverse variance assuming a random effect model. I was calculated as a quantifier of heterogeneity and interpreted according to the Cochrane manual. All data analysis was performed using R software.

RESULTS

Among the 1,419,557 total knee arthroplasties reported in 10 studies, there were 767 major vascular injuries (0.05% [54 per 100,000 total knee arthroplasties]). Amputation or long-term neurological complications occurred in approximately 21% of patients after major vascular injury. Presentation after 24 hours occurred in 36% of cases. The most frequently injured vessels were the geniculate arteries, popliteal artery, superficial femoral artery, and anterior tibial artery. The injuries that were most likely to result in amputation were femoral artery occlusion, popliteal artery transection, and popliteal artery arteriovenous fistula.

CONCLUSIONS

Amputation and long-term neurological complications are common complications after a vascular injury associated with a total knee arthroplasty. Preoperative consultation with vascular surgery physicians may be a prudent approach before a surgical procedure for patients with known peripheral vascular disease, diabetes, hypertension, or smoking; however, more data on risk factors are needed. Awareness by the surgical team and implementation of specific strategies during a surgical procedure such as gentle manipulation of the knee and careful retraction may further reduce the rate of injuries.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The role of interventional radiology in the treatment of lower limb vascular injuries after orthopaedic surgery

Purpose

This paper focuses on the role of interventional radiology embolisations in a series of patients presenting with iatrogenic vascular injuries of the lower limbs following orthopaedic interventions.

Material and methods

Fourteen patients (mean age: 64 years, range 23-90 years) were retrospectively analysed. Clinical presentation consisted of palpable pulsatile mass, pain, reduced lower limb motion, or visible haematoma; 11 patients had also anaemia (haemoglobin < 7 g/dl).

Results

The time between orthopaedic surgery and embolisation ranged between 0 and 67 days (mean: 15 days). Injured arterial vessels were as follows: inferior gluteal artery (2), superficial external pudendal artery (2), deep femoral artery (1), lateral circumflex femoral artery (3), medial circumflex femoral artery (2), articular branch of descending genicular artery (1), perforating femoral arteries (3), posterior tibial recurrent artery (1), and anterior tibial artery (1). The typologies of vascular lesion were: pseudoaneurysm 57%, bleeding with extraluminal contrast agent blush of the terminal arterial segment 36%, and laceration and bleeding with extraluminal contrast agent blush of the arterial main trunk 7%. Embolising agents adopted were microcoils 57%, glue 14%, microplug 7%, particles 14%, and covered stent 7%. In all cases clinical and procedural technical successes were obtained (100%).

Conclusions

For the management of vascular injuries occurring after different orthopaedic interventions of the lower limbs, endovascular embolisations have proven to be safe and effective; orthopaedic surgeons should be aware of the support that interventional radiology could provide in the case of iatrogenic vascular complications.

Femoral artery intimal injury following total hip arthroplasty through the direct anterior approach: a rare but potential complication

Vascular injury following total hip arthroplasty (THA) is a rare but known complication. Various vascular lesions have been described in the literature, with arterial intimal damage being uncommon. Despite the recent popularity of the direct anterior approach in THA, only 1 case of iatrogenic vascular injury has been reported. We report 3 cases of common femoral artery intimal damage with thrombosis following direct anterior THA. We propose that misplacement of the anterior retractor in this approach, especially in certain susceptible patients, can lead to vascular damage. Therefore, maintaining a step-wise approach to placing the retractor with caution is essential. One of our cases had a delayed presentation of undetectable arterial pulse, highlighting the significance of regular postoperative vascular examinations.

External iliac pseudoaneurysm secondary to medial wall penetration of an acetabular screw: a rare cause of total hip arthroplasty failure 15 years after implantation

Vascular injury as a result of total hip arthroplasty (THA) represents an uncommon complication. Although these injuries typically present acutely, delayed presentation has been reported. In this case, a 70-year-old female presented with groin pain and medial thigh numbness 15 years after a left THA. After initially being misdiagnosed, repeat imaging revealed a large external iliac pseudoaneurysm as a result of a transacetabular screw penetrating the medial acetabular wall. The patient underwent staged endovascular exclusion of the pseudoaneurysm, percutaneous drainage, and revision THA. She had resolution of her symptoms. To our knowledge, this is the only reported case of a late vascular injury related to an aseptic THA with well-fixed components. Staged treatment with endovascular exclusion and revision THA is a viable approach.

Anterior tibial artery occlusion post total knee arthroplasty: A case report

RATIONALE

Total knee arthroplasty (TKA) is a globally well-accepted surgery because of its good outcome and safety. Although TKA-associated arterial injuries occur, postoperative anterior tibial artery (ATA) occlusion has not been reported yet. Herein, we present a case of ATA occlusion after TKA.

PATIENT CONCERNS

A 42-year-old man with a 6-year history of right knee pain after right patella fracture treated with open reduction was referred to our clinic. Valgus and contracture deformities were detected in the right knee. Severe osteoarthritis (OA) in the right knee and multiple osteochondromas were observed on radiography.

DIAGNOSIS

On the basis of clinical and imaging findings, the patient was diagnosed with OA and multiple osteochondromas.

INTERVENTIONS

TKA was performed in the right knee and the osteochondromas were resected. ATA occlusion was found postoperatively and was treated conservatively.

OUTCOMES

Although the right ATA occlusion did not resolve, the patient recovered well postoperatively, with pain relief and recovery of right knee range of motion.

LESSONS

The clinical outcome in a case of ATA occlusion after TKA demonstrates that conservative treatment could be appropriate in this context.

Knee Implant Dislocation Leading to Major Amputation 13 Years Later

Introduction

Injury to the popliteal vessels during total knee replacement is rare but can lead to catastrophic outcomes.

Report

An 81 year old female presented with Rutherford IIb acute left limb ischaemia (ALI) 13 years after total knee replacement. The polyethylene insert in the knee implant had dislocated from the other components and had moved into the popliteal fossa, leading to popliteal artery compression. She underwent emergency multidisciplinary surgery including removal of the polyethylene component, thrombectomy, and popliteal artery stenting, but major amputation was required. The popliteal artery and the stent were removed and submitted to histological analysis. The stent was well expanded but focal malapposition was observed.

Conclusion

Regular follow up is mandatory in order to anticipate malfunction of the prosthesis and avoid long term complications.

•

This is the first case describing total occlusion of the popliteal artery due to polyethylene insert dislocation 13 years after total knee replacement.

•

This case highlights that regular follow-up is mandatory in order to anticipate implant malfunction and avoid long-term complications.

•

This is the first report describing peripheral stent histopathology in the setting of acute limb ischaemia.

Possible Vascular Injury Due to Screw Eccentricity in Minimally Invasive Total Hip Arthroplasty

BACKGROUND

Vascular injury during minimally invasive total hip arthroplasty (THA) is uncommon, yet a well-recognized and serious issue. It emerges because of non-visibility of vascular structures proximal to the pelvic bone during reaming, drilling holes, and fixing of screws. Numerous studies have found that screw fixation during cementless THA is beneficial for the initial stability of cup; yet, no anatomical guidelines support angular eccentric screw fixation.

MATERIALS AND METHODS

In this study, we obtained the pelvic arterial-phase computed tomographic data of thirty eight humans and reconstructed the three-dimensional models of osseous and vessel structures. We performed the surgical simulation to fix these structures with cementless cups and screws with angular eccentricities.

RESULTS

The effect of screw eccentricities (angular eccentricities of ±17° and ±34°) on the vascular injury was determined. Measurement between screw and adjoining vessels was performed and analyzed statistically to ascertain a comparative risk study for blood vessels that are not visible during surgery.

CONCLUSION

Authors similarly discussed the significant absence of appreciation of quadrant systems proposed by Wasielewski et al. on eccentric screws. Adjustment of quadrant systems provided by Wasielewski et al. is required for acetabular implants with eccentric holes for fixation of acetabular screws.

Preclinical Study of Cell Therapy for Osteonecrosis of the Femoral Head with Allogenic Peripheral Blood-Derived Mesenchymal Stem Cells

PURPOSE

To explore the value of transplanting peripheral blood-derived mesenchymal stem cells from allogenic rabbits (rPBMSCs) to treat osteonecrosis of the femoral head (ONFH).

MATERIALS AND METHODS

rPBMSCs were separated/cultured from peripheral blood after granulocyte colony-stimulating factor mobilization. Afterwards, mobilized rPBMSCs from a second passage labeled with PKH26 were transplanted into rabbit ONFH models, which were established by liquid nitrogen freezing, to observe the effect of rPBMSCs on ONFH repair. Then, the mRNA expressions of BMP-2 and PPAR-γ in the femoral head were assessed by RT-PCR.

RESULTS

After mobilization, the cultured rPBMSCs expressed mesenchymal markers of CD90, CD44, CD29, and CD105, but failed to express CD45, CD14, and CD34. The colony forming efficiency of mobilized rPBMSCs ranged from 2.8 to 10.8 per million peripheral mononuclear cells. After local transplantation, survival of the engrafted cells reached at least 8 weeks. Therein, BMP-2 was up-regulated, while PPAR-γ mRNA was down-regulated. Additionally, bone density and bone trabeculae tended to increase gradually.

CONCLUSION

We confirmed that local transplantation of rPBMSCs benefits ONFH treatment and that the beneficial effects are related to the up-regulation of BMP-2 expression and the down-regulation of PPAR-γ expression.