Transperitoneal removal of an intrapelvic acetabular component after total hip replacement and salvage of a destroyed acetabulum

Intrapelvic component retrieval via anterior inferior iliac spine osteotomy in revision total hip arthroplasty

INTRODUCTION:

In the revision setting, intrapelvic acetabular components provide a unique set of challenges for the treating surgeon. Retrieval is complicated by complex anatomical relationships within the pelvis and historically, surgeons have used multiple approaches to safely retrieve the cup.

CASE PRESENTATION:

We present the case of a 53-year-old female with intrapelvic migration of the acetabular components of her total hip arthroplasty. Patient was treated through a novel, single incision approach with utilisation of an anterior inferior iliac spine (AIIS) osteotomy.

RESULTS:

An AIIS osteotomy allows for improved visualisation within the pelvis and safe retrieval through a single exposure without compromising the ability to perform definitive, revision reconstruction. At 1-year follow-up, the patient has had no complications related to infection or failure of the implants. Ambulation is performed with the aid of a cane in the community with mild, occasional pain.

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.

Intra-abdominal removal of a displaced hip prosthesis

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Laparotomy and removal of the prosthetic head is possible and preferred in some cases where further damage to the iliac bone may be caused by removal via a usual exterior approach.

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A sound planning strategy should be made with CT, ultrasound or laparoscopy.

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Retroperitoneal surgery has been described but intraperitoneal surgery is also a possibility.

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A good knowledge of pelvic organs and vessels is essential.

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Combined surgery with vascular surgeons is recommended.

INTRODUCTION

Intra-pelvic displacement of hip prostheses is an uncommon complication following arthroplasty surgery but can have significant detrimental effects on the patient. We present a case of a displaced hip prosthesis into the pelvic cavity and highlight the importance of pre-operative planning and investigation as well as choosing a suitable surgical approach.

PRESENTATION OF CASE

A 69 year old lady with developmental dysplasia of the hips was found to have displacement of her prosthesis into the pelvis on day three following complex uncemented total hip replacement. A subsequent combined procedure between vascular and orthopaedic surgeons was carried out, including access via a laparotomy incision to allow vision and control of the iliac vessels before removal of the prosthesis. The hip was reconstructed during the same operation using a cup cage construct, reinforced with plate fixation of the posterior column of the pelvis.

DISCUSSION

Intra-pelvic displacement of hip prostheses is rare and morbidity and mortality can be significant. Pre-operative imaging modalities such as CT scanning should be used to carefully delineate the anatomy. A retro-peritoneal approach has been reported, but we used a trans-abdominal approach in this case to permit greater vision and control of pelvic structures due to the significant medial displacement of the prosthesis.

CONCLUSION

Intra-abdominal removal of a displaced hip prosthesis is rarely performed but allows for visualisation and careful control of the pelvic structures without damaging further the pelvic wall. We recommend this approach should be performed in conjunction with a vascular surgeon.