Pseudoaneurysm of the superficial femoral artery after retrograde intramedullary nailing for a supracondylar femoral fracture

Comparison of three different treatment methods for traumatic and Iatrogenic peripheral artery pseudoaneurysms

Objective

To compare the efficacy of open surgery (OS), endovascular interventions (EIs), and ultrasound‐guided thrombin injection (UGTI) for the treatment of peripheral arterial pseudoaneurysms (PAs).

Methods

From January 1, 2001, to February 10, 2021, 38 patients diagnosed with traumatic and iatrogenic PAs treated with OS, EI, and UGTI were retrospectively analyzed. There were 18 females and 20 males, with an age of 56.47 ± 14.08 years (range,17–87 years). Anesthesia modality, operation duration, blood transfusion, duration of hospital stay, primary and secondary success rates, and complication rate were used to evaluate the surgical outcomes.

Results

There were 11 cases under regional anesthesia and 4 under general anesthesia in OS group, 9 under regional anesthesia and 1 under general anesthesia in EI group, and no regional or general anesthesia was required in UGTI group. There was no significant differences between any two groups (χ² = 39.80, p < 0.05). The blood tranfusion amount (units) were 3.6 ± 6.0, 0.8 ± 2.5, 0.0 ± 0.0 for OS, EI, and UGTI groups, respectively, with significant difference between OS and UGTI groups (F = 3.03, p < 0.05). The operation duration (minutes) of OS, EI, and UGTI groups were 80.0 ± 41.9, 56.0 ± 8.4, and 22.7 ± 5.3, respectively, with significant difference between any two groups (F = 15.69, p < 0.05). The duration of hospital stay (days) were 47.7 ± 39.0, 31.5 ± 17.6, and 16.3 ± 9.5, repectively, with significant difference between any two groups (F = 47.73, p < 0.05). The primary clinical success rates were 80% (12/15), 90% (9/10), and 92.3% (12/13) in OS,EI, and UGTI groups, respectively, with no significant difference between any two groups (χ² = 0.34, p > 0.05). The secondary clinical success rates were 100% for all three groups. The overall complication rates of OS, EI, and UGTI groups were 20% (3/15), 10% (1/10), and 7.7% (1/13), respectively, with no significant difference between any two groups (χ² = 1.00, p > 0.05). The infection rates were 13.3% (2/15), 10% (1/10), and 0% (0/13) in OS, EI, and UGTI groups respectively, with no significant difference between any two groups (χ² = 1.80, p > 0.05). The reintervention rates were 6.7% (1/15), 0% (0/10), 7.7% (1/13) in OS, EI, and UGTI groups, respectively, with no significant difference between two groups (χ² = 0.95, p > 0.05). Neuralgia was relieved in all patients.

Conclusions

OS, EI, and UGTI are efficacious and safe options for the treatment of appropriate patients with traumatic and iatrogenic PAs. UGTI would be considered as a first‐line therapy for this condotion.

Late-onset pseudoaneurysms of lower limb arteries following late complications of orthopaedic constructs - Two cases and review of literature

INTRODUCTION & IMPORTANCE

Damage to the adventitial layer of an artery leads to pseudoaneurysm formation. Pseudoaneurysms caused by complications of orthopaedic constructs are rare.

CASE PRESENTATION & CLINICAL DISCUSSION

Case report 01. A 27-year-old male presented with acute bleeding from an external fixator pin site. He had defaulted follow-up due to covid pandemic and presented with malunited distal tibia fracture and loosened Schanz pins. CT angiogram revealed a pseudoaneurysm of the peroneal artery over the loosened pin site. The patient underwent exploration and ligation of the peroneal artery. Case report 02. 86-year-old female presented with a gradually enlarging lump on her left anteromedial thigh for three months duration. She underwent open reduction and internal fixation of ipsilateral femur fracture 17 months back. She was found to have a pseudoaneurysm of the superficial femoral artery caused by exposed screws following bony erosion. Exploration and repair of "neck" the pseudoaneurysm was performed and the recovery was uneventful.

CONCLUSION

Pseudoaneurysms are rare but carry devastating complications following various orthopaedic procedures. The common cause for the formation of pseudoaneurysms is trauma during surgery. But loosened Schanz screws and screws are also can be the cause. Early identification of a pseudoaneurysm and proper intervention will reduce morbidities.

Surgical management of peripheral artery pseudoaneurysm following orthopedic trauma: a report of 14 cases

PURPOSE

Purpose of this study was to report the etiology, diagnosis, surgical management, and outcome of pseudoaneurysm associated with orthopedic trauma.

METHODS

A retrospective review was conducted of all patients presenting to a Level 1 trauma center between 2013 and 2019. Clinical records were reviewed for the mechanism of primary injury, associated fracture pattern, time of presentation, site of involvement, etiology of the pseudoaneurysm, diagnosis, management, and complications. We identified 14 patients with pseudoaneurysm of peripheral arteries following orthopedic trauma.

RESULTS

The mean interval between primary injury and the manifestation of clinical symptoms was 88.5 days (range, 16-304 days). There were 3 upper limb injuries and 11 lower limb injuries. The presenting symptoms were pain associated with excessive extremity swelling in most of the patients. A significant drop in hemoglobin (mean fall- 2.9 g/dL) was noted in nine patients. Most common artery involved was the superficial branch of femoral artery and posterior tibial artery followed by the brachial artery. Fractured bone spike was the cause of injury in eight patients and iatrogenic injury in six patients. Diagnosis was confirmed by CT angiography with duplex scan in eight patients, duplex scan alone in one patient, MRI along with duplex scan in one patient. The remaining four patients were diagnosed intraoperatively. Excision of the pseudoaneurysm and ligation of the involved minor arteries was done in eight patients. Surgical repair of the major artery with critical vascular injury was done in six patients. One patient underwent secondary amputation following the anastomotic blowout.

CONCLUSION

Early diagnosis of pseudoaneurysm requires knowledge and a high index of suspicion. Surgical reconstruction of major arteries should always be done and ligation of major vessels can lead to catastrophes. Excision of pseudoaneurysm can be done when minor arteries are involved with the presence of good collateral circulation.

LEVEL OF STUDY

Level IV Study.

Identification of the lateral femoral safe zone for drilling during LISS plate fixation of distal femur fractures

BACKGROUND

The incidence of arterial injury associated with femoral fractures is approximately 1%. Lateral sub-muscular plate fixation is gaining popularity for the management of distal femoral fractures. The objective of this study was to assess the iatrogenic risk to the superficial femoral artery (SFA) during Less Invasive Stabilisation System (LISS) plate fixation of distal femoral fractures by analysing the range of distances and angles between LISS plate screws and the drilling line to the SFA.

MATERIALS AND METHODS

We identified all patients who underwent LISS plate fixation of distal femoral fractures between 2008 and 2018 in our level-1 trauma centre. Patients who underwent postoperative computed tomography for any reason were eligible for inclusion in the study. Twenty-five patients met the inclusion criteria. The sample comprised 10 male and 15 female patients with a mean age of 55 years. The most common fracture type was a supracondylar femur fracture (56%), followed by an intercondylar fracture (36%). A 13-hole LISS plate was the most common plate length used (44%). A consultant radiologist reviewed all scans to verify the visibility and marking of the SFA.

RESULTS

The median distance between the screw tip and the SFA was 21 mm (range, 8-65 mm). There was a negative correlation between the LISS plate hole number and the trajectory of drilling (Pearson coefficient: -0.87, p < 0.001). Using a linear regression model, the SFA was more likely to be in the line of drilling when the 6th to 10th holes in the LISS plate were used.

CONCLUSION

Extra care is needed when drilling into the LISS plate holes from the lateral to the medial direction in order to reduce the risk of iatrogenic injury to the SFA, especially in the high-risk plate zone where the artery can be close to the drilling line.

Femur Lengthening in a Patient with a Pseudoaneurysm of the Superficial Femoral Artery Treated with Covered Stent

This case report presents a 29-year-old male patient who presented an articular distal femoral fracture sustained in a road traffic accident in Benin. After the different surgical procedures, the patient presents a knee stiffness and a shortening of the left leg of 7 cm. An ablation of osteosynthesis material and a Judet procedure was done. After this surgical intervention, the patient developed pain, pulsatile swelling of the left knee. A false aneurysm of the superficial femoral artery was evidenced, and a percutaneous endovascular procedure was performed. As a result of the important leg-length discrepancy, a femoral lengthening of 6 cm was performed using intramedullary skeletal kinetic distractor nail. We show that a 6 cm femur lengthening in a patient with a femur stent is possible using intramedullary nails provided that orthopedic and vascular surgeons monitor the patient in strict clinical and paraclinical followup conditions.

Pseudoaneurysm of the anterior tibial artery after interlocking tibial nailing: an unexpected complication

Anterior tibial pseudoaneurysm is a rare complication after interlocking screw insertion in tibial nailing. We present the case of a 28-year-old male patient with this complication with a 6-week delay after tibial nailing of a right tibial fracture type 42-A1 of the Association for the Study of Internal Fixation (AO/ASIF) classification. On presentation to our emergency department, the patient's complaints were solemnly intermittent pain and occasional swelling of his proximal lower leg. Deep vein thrombosis, compartment syndrome, and implant dislocation were ruled out, and the patient was discharged after his symptoms improved without further intervention. Four weeks later, the patient was readmitted for similar symptoms. A computed tomography (CT) angiography then revealed a pseudoaneurysm of the anterior tibial artery at the level of the proximal interlocking screw insertion. Aneurysmal sac excision with vessel repair was performed while reconstructing the additional dislocated proximal fibular fracture using standard AO/ASIF plating. Postoperatively, sufficient flow through the repaired vessel was documented using Doppler ultrasound and CT angiography. However, the patient sustained a temporal damage to the peroneal nerve after surgery. This case highlights the risk of a pseudoaneurysm of the anterior tibial artery after interlocking screw insertion as a rare but major complication of a routine surgical procedure. Early ultrasound diagnostics, CT angiography, or magnetic resonance (MR) angiogram should be performed to prevent the delay in diagnosis and treatment of such complications.