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

Massive pseudotumor of unknown etiology in a cemented metal-on-polyethylene total hip arthroplasty: a case report

Background

The formation of destructive pseudotumors is a well-documented, albeit rare, complication of total hip arthroplasties. They tend to be progressive and, if left untreated, can result in extensive periprosthetic bony destruction. The current case presents a large benign mass consistent with a pseudotumor on both imaging and intraoperative findings but histologic findings demonstrating chronic hematoma.

Case Description

An 86-year-old female with a metal-on-polyethylene total hip presented with a massive pseudotumor accompanied by extensive bony lysis. Due to pain and chronic anemia, a palliative debulking procedure was undertaken as a palliative measure. At one year follow-up, the patient reported significant pain relief and was able to ambulate safely with gait aids. Her hemoglobin stabilized post-operatively and ongoing transfusions were not required. Final pathology was not supportive of particle disease despite this being the leading diagnosis. Microscopic sections showed tissue mostly composed of fibrin and blood with multiple foci of calcification and reactive papillary endothelial hyperplasia which can be seen in chronic hematomas.

Conclusions

This case presents the diagnostic dilemma of a large benign mass consistent with a pseudotumor on both imaging and intraoperative findings but histologic findings consistent with a chronic hematoma. It highlights the importance of close follow-up and early intervention when periprosthetic osteolysis is detected.

Mechanic ileus due to retroperitoneal migration of total hip prosthesis; A case report

Intrapelvic migration of total hip prosthesis is a rare but severe complication of total hip arthroplasty that can cause severe outcomes for elderly patients. A 78-year-old female patient was referred to our hospital with the complaint of no gas-stool excretion for 3-4 days, abdominal distension, nausea, vomiting, and a preliminary diagnosis of ileus. Computed tomography showed the migration of the left total hip prosthesis to the pelvis, causing a hematoma around the prosthesis and mechanical ileus due to the compression of the hematoma. To our knowledge, this case report is the only reported mechanic ileus due to migration of total hip prosthesis. Although postop paralytic ileus is one of the complications of total hip arthroplasty, mechanical ileus has not been described before. This case report shows that mechanical ileus might be an unreported complication of total hip arthroplasty. It should be kept in mind that mechanical ileus complications may also occur after hip arthroplasty.

Intraoperative external iliac venogram and intravenous ultrasound to assist retrieval of intrapelvic acetabular screw

Intrapelvic acetabular screw placement is a known complication of total hip arthroplasty and is associated with risks including damage to neurovascular and intrapelvic structures such as the external iliac vessels, obturator vessels, and iliopsoas muscles. Retrieval of intrapelvic acetabular screws is similarly fraught with risk, and appropriate imaging should be performed preoperatively. We report on a case of intrapelvic acetabular screw placement with abutment of the external iliac vein, which was managed with intraoperative venogram and intravenous ultrasound to maintain access to the external iliac vein and successfully show no vascular tear before and after screw removal.

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

The efficiency of risedronate in reducing bone resorption after total hip arthroplasty: a meta-analysis of randomized control trials at a minimum of 6 months' follow-up

Background

Recently risedronate is suggested to be effective for the prevention and treatment of for osteoporosis in total hip arthroplasty. This meta-analysis aimes to evaluate the efficacy of risedronate in reducing femoral periprosthetic bone mineral density loss in patients undergoing primary total hip arthroplasty.

Methods

A systematic search was performed in Medline (1966-31 October 2017), PubMed (1966-31 October 2017), Embase (1980-31 October 2017), ScienceDirect (1985-31 October 2017) and the Cochrane Library. Only randomized controlled trial (RCT) were included. Fixed/random effect model was used according to the heterogeneity tested by I2 statistic. Meta-analysis was performed using Stata 11.0 software. The outcome measures included periprosthetic bone mineral density, length of stay and adverse effects.

Results

Four RCTs including 198 patients met the inclusion criteria. The present meta-analysis showed that there were significant differences between treatment groups in terms of periprosthetic bone mineral density in Gruen zones 1 (standard mean difference (SMD) = 0.758, 95% CI 0.469 to 1.047, P = 0.000), 2 (SMD = 0.814, 95% CI 0.523 to 1.106, P = 0.000), 3 (SMD = 0.340, 95% CI 0.059 to 0.622, P = 0.018), 6 (SMD = 2.400, 95% CI 2.029 to 2.771, P = 0.000), and 7 (SMD = 2.400, 95% CI 2.029 to 2.771, P = 0.000).

Conclusion

Oral risedronate could significantly reduce periprosthetic bone resorption around an uncemented femoral stem (Gruen zones 1, 2, 3, 6, and 7) up to 6 months after THA. In addition, no severe adverse events were identified. Future trials of risedronate treatment after THA should focus on clinically relevant end points such as the risks of fracture and revision arthroplasty.

Profunda Femoris Pseudoaneurysm following Total Hip Arthroplasty Revision

Vascular injuries following total hip arthroplasty (THA) are very rare, with pseudoaneurysm being a small subset. We report a case of profunda femoris artery (PFA) pseudoaneurysm in a 61-year-old male following a posterior approach revision left THA. Presentation involved continued blood transfusion requirements several weeks postoperatively. Diagnosis of the pseduoaneurysm was made by contrast CT of the lower extremity, with confirmation via IR angiography. Successful embolization was achieved with selective coiling and Gelfoam. Presenting complaints of such complications are often vague and therefore lead to delayed diagnosis. Causes of such complications are not completely understood, particularly with PFA injuries in THA. Possible mechanisms are discussed in this paper. Vascular complications following THA can be difficult to diagnose. High suspicion in the setting of continued postoperative pain or bleeding may allow prompt diagnosis and avoidance of serious limb-threatening complications.

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.