J Orthop Sci DOI 10.1007/s00776-013-0488-9
CASE REPORT
Arterial pseudoaneurysm as a cause of periprosthetic osteolysis mimicking an infected total hip arthroplasty Jesu´s Moreta • Oskar Sa´ez de Ugarte • Jose´ F. Larruscain • Iker Uriarte • In˜aki Ja´uregui Jose´ Luis Martı´nez-De Los Mozos
•
Received: 12 May 2013 / Accepted: 14 October 2013 Ó The Japanese Orthopaedic Association 2013
Introduction Although vascular injuries after total hip arthroplasty (THA) are uncommon, they may lead to severe complications which can result in a threat to life and limb. The different patterns of such injuries include lacerations with acute hemorrhage, arteriovenous fistula, thrombosis, and pseudoaneurysms [1, 2]. Periprosthetic osteolysis is a well known phenomenon caused by wear particle-induced bone resorption or other pathologic processes, including infection, metabolic disease, and neoplasia [3]. Nevertheless, as far as we are aware, no reports have yet been published on aneurysms associated with periprosthetic osteolysis. We present a case of a patient who developed a deep femoral artery pseudoaneurysm mimicking periprosthetic joint infection with osteolysis after total hip replacement.
Case report A 79-year-old woman with a history of hypertension was referred to the Hip Department in our hospital for evaluation of left groin pain. The patient had undergone a THA for end-stage osteoarthritis at another hospital in March 2010, via an anterolateral approach, with an AlizeÒ II acetabular cup with hydroxyapatite coating (Biomet France, Valence, France) and an AuraÒ hydroxyapatitecoated stem (Biomet France). Ceramic on ultra-highmolecular-weight polyethylene was the bearing surface. An
J. Moreta (&) O. Sa´ez de Ugarte J. F. Larruscain I. Uriarte I. Ja´uregui J. L. Martı´nez-De Los Mozos Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Barrio Labeaga s/n, 48960 Vizcaya, Spain e-mail: [email protected]
X-ray revealed malposition of the acetabular cup, with a low position in the acetabulum (Fig. 1a). Postoperative recovery was uneventful, but nine months after the procedure the patient experienced subacute onset of pain, which progressively worsened over four weeks. On physical examination, the patient was afebrile, there was no local warmth, and the overlying skin was normal. Deep palpation revealed minor swelling. Neurovascular examination revealed no abnormal findings. An anteroposterior radiograph of the left hip revealed periprosthetic osteolysis in Gruen zone seven (Fig. 1b). White blood-cell count was slightly elevated (11.5 9 109/L), erythrocyte sedimentation rate (ESR) was 52 mm/h (normal, 2–49 mm/h), and C-reactive protein level (CRP) was 19.1 mg/L (normal 0–5 mg/L). To preclude the possibility of infection, a bone scan was performed; this revealed a large area of activity related to the hip arthroplasty (Fig. 2a). Single-photon emission computed tomography (SPECT-CT) suggested the presence of an abscess located in the medial aspect of the proximal part of the femoral component (Fig. 2b). The hip was aspirated and 40 mL brownish fluid was obtained and sent to the Department of Microbiology. Two days later, magnetic resonance imaging (MRI) revealed a periprosthetic collection, measuring 14 cm in largest diameter, arising from a pseudoaneurysm (Fig. 3a). MR angiography accurately identified a pseudoaneurysm approximately 7.5 cm in diameter affecting the deep femoral artery (Fig. 3b). Aspirated fluid was negative for bacterial or fungal growth. The patient was transferred to the Department of Vascular Surgery and underwent surgery for the false aneurysm, including resection of the aneurysm and closure of the bleeding puncture. The surgical repair was performed via a longitudinal groin incision and the pseudoaneurysm was located in close relationship to the proximal femur,
123
J. Moreta et al. Fig. 1 Radiographs showing the periprosthetic osteolytic lesion. a Postoperative radiograph of the left hip revealing the low position of the cup, and disruption of the Kohler line and of the obturator foramen. b Radiograph 10 months after the primary THA
Fig. 2 a 99mTc-HMPAO leukocyte scintigraphy showing evident activity around the prosthesis. This finding was consistent with periprosthetic hip infection. b SPECT-CT suggesting the presence of an abscess in the medial aspect of the femoral neck
surrounding the calcar region. After removal of a large amount of organized hematoma and fibrous tissue, the arteriotomy was located posteriorly and sutured with a polytetrafluoroethylene (PFTE) patch angioplasty. Intraoperative culture results remained negative, and pathologic examination revealed a nonspecific inflammatory reaction. The patient recovered without major complications and at the last outpatient visit, two years after the vascular surgery, was mobile with full weight bearing on a crutch (because of mild osteoarthritis in her right knee) and resolution of her groin discomfort. Control radiographs revealed no progression of the osteolytic lesion and C reactive protein and ESR values had returned to the physiological threshold. Control arteriography revealed
123
occlusion of the deep left femoral artery, and distal vascularization partly maintained by collateral circulation by perforating branches from the superficial femoral artery (Fig. 3c). Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
Discussion Vascular injuries after THA are extremely rare. Estimated prevalence is 0.25 % [1], but this may be increasing, because of the greater amount of difficult revision surgery
Pseudoaneurysm as a cause of osteolysis
Fig. 3 a Coronal MR image showing a large (approximately 14 cm) hematoma surrounding the hip implant on T1-weighted imaging. b MR angiography revealing an area of contrast extravasation
measuring 7.5 cm in diameter consistent with a pseudoaneurysm. c Angiogram showing occlusion of the deep left femoral artery (white arrow)
performed nowadays. These lesions involve significant complications, for example high incidence of limb loss or even life-threatening events. Shoenfield et al. [4] reported 7 % mortality and 15 % incidence of amputations among 68 patients with vascular injuries associated with THA. More recently, Troutman et al. [5] reported no mortality and limb salvage achieved for 49 patients with acute arterial complications after hip or knee replacement. Several studies have suggested that patients with previous presence of vascular disease are at greater risk of vascular injuries, and that local factors (e.g. elderly patients, complex revision procedures) have also contributed to these complications [6]. It is very important to obtain a thorough medical history with a basic vascular examination; ultrasound or arteriography can also be useful in manifest atherosclerosis or complex reintervention, especially with intrapelvic migration of the cup. One of the most prevalent mechanisms is excessive traction during dislocation and reduction maneuvers [1], but a recent article reported that direct arterial laceration was the most common mechanism [7]. Other causes, for example inadequate retractor placement [1], cerclage wiring of the femur [8], screws to enhance fixation of cementless cups, migration of the components [9, 10], and exothermic reaction during cement polymerization [1] have been reported. In our case, it is difficult to establish the cause of the injury because the surgery was performed in another institution, and information about the procedure was not available. The surgical records did not mention any adverse event or complication during the surgery. Several causes should be considered, for example inadequate retractor placement, excessive traction during surgery, or direct injury during the acetabular reaming. A pseudoaneurysm, or false aneurysm, is a collection of blood that results from traumatic penetration of the vessel
wall and subsequent hemorrhage and extravasation. Garrido-Gomez et al. [11] reported that significant bleeding may be a common manifestation during the postoperative period. Irrespective of this finding, small pseudoaneurysms (\2 cm 9 3 cm) may thrombose spontaneously within four weeks [12]. Despite this, resolution is unpredictable and rupture can occur. On physical examination, a pseudoaneurysm can be recognized as a pulsatile mass, sometimes with an audible arterial bruit. However, these findings may be less obvious in the hip, and this injury should be suspected for patients with chronic pain secondary to a mass effect, swelling, or local hematoma. In this case, the mechanism of groin pain is generally believed to be the direct pressure of adjacent structures. Early identification of vascular injury followed by appropriate treatment can reduce morbidity and mortality. The orthopaedic surgeon should perform a basic vascular examination after surgery that specifically focuses on patients at risk. To achieve this, distal pulses, capillary refill time, and skin temperature should all be monitored. However, in this case these findings were normal. If any problems with the arterial circulation of the limb are detected the patient should be referred to a vascular specialist as soon as possible, because delay in the diagnosis and treatment could be catastrophic [2]. Although bone erosion as a result of a pseudoaneurysm has been reported [13, 14], periprosthetic hip osteolysis because of the mass of this vascular complication has not yet been reported in the literature. Abdominal aortic aneurysms can cause vertebral erosion and may mimic tumors or infections [14]. Two main mechanisms lead to aneurysms complicated by bony erosion: infection related to the artery (mycotic aneurysms) and continuous pulsation causing destruction of the surrounding bone. Polyethylene wear has been accepted as a major cause of osteolysis in
123
J. Moreta et al.
total hip arthroplasty, but we must take into account other pathologic processes, including infection, inflammatory diseases, or neoplasia. The rapidly progressive clinical and radiological scenario with pain and swelling was peculiar, and wear-induced osteolysis, characterized by a painless course, was definitely unlikely. Furthermore, the osteolytic lesion did not progress after the vascular repair. Treatment is surgical resection and evacuation of the pseudoaneurysm with repair of the damaged artery, but the vascular specialist may consider ultrasound-guided thrombin injection for small false aneurysms. This case illustrates the importance of considering a pseudoaneurysm as a possible cause of periprosthetic osteolysis, particularly if rapid progressive growth has occurred. If this vascular injury had not been diagnosed, the method of treatment would have been wrong, probably with catastrophic consequences. To the best of our knowledge, this complication after a THA has never been reported. Patient observation in the postoperative period and a basic vascular examination may aid diagnosis of the injury; when these injuries are recognized it is necessary to request specialist vascular assessment. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Nachbur B, Meyer RP, Verkkala K, Zu¨rcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res. 1979;141:122–33. 2. Calligaro KD, Dougherty MJ, Ryan S, Booth RE. Acute arterial complications associated with total hip and knee arthroplasty. J Vasc Surg. 2003;38:1170–7.
123
3. Harris WH. Wear and periprosthetic osteolysis the problem. Clin Orthop Relat Res. 2001;393:66–70. 4. Shoenfield NA, Stuchin SA, Pearl R, Haveson S. The management of vascular injuries associated with total hip arthroplasty. J Vasc Surg. 1990;11:549–55. 5. Troutman DA, Dougherty MJ, Spivack AI, Calligaro KD. Updated strategies to treat acute arterial complications associated with total knee and hip arthroplasty. Article in press 2013. 6. Beguin L, Feugier P, Durand JM, Chalencon F, Gresta G, Fessy MH. Vascular risk and total hip arthroplasty. Rev Chir Orthop Repractice Appar Mot. 2001;87:489–98. 7. Parvizi J, Pulido L, Slenker N, Macgibeny M, Purtill JJ, Rothman RH. Vascular injuries after total joint arthroplasty. J Arthroplasty. 2008;23:1115–21. 8. Mehta V, Finn HA. Femoral artery and vein injury after cerclage wiring of the femur: a case report. J Arthroplasty. 2005;20:811. 9. Iachetto J, Gallagher JJ. False aneurysm of the common femoral artery secondary to migration of a threaded acetabular component. Case report and review of the literature. Clin Orthop. 1988;231:91–6. 10. Mittag F, Kluba T. Aneurysm of the femoral artery caused by aseptic loosening and migration of a Burch-Schneider cage. J Arthroplasty. 2009;24:159.e9–12. 11. Garrido-Go´mez J, Garrido-Go´mez MN, Arrabal-Polo MA, Garrido-Pareja F, Linares-Palomino JP. Iatrogenic false aneurysms. A rare complication of hip surgery. Hip Int. 2012;22:397–402. 12. Ahmad F, Turner SA, Torrie P, Gibson M. Iatrogenic femoral artery pseudoaneurysms d a review of current methods of diagnosis and treatment. Clin Radiol. 2008;63:1310–6. 13. Kim YJ, Baek WK, Kim JY, Park SW, Jeon YS, Lee KH, Cho SG, Lim MK. Pseudoaneurysm of the popliteal artery mimicking tumorous condition. J Korean Surg Soc. 2011;80:S71–4. 14. Diekerhof CH, Reedt Dortland RW, Oner FC, Verbout AJ. Severe erosion of lumbar vertebral body because of abdominal aortic false aneurysm: report of two cases. Spine. 2002;27:E382–4.
CASE REPORT
Arterial pseudoaneurysm as a cause of periprosthetic osteolysis mimicking an infected total hip arthroplasty Jesu´s Moreta • Oskar Sa´ez de Ugarte • Jose´ F. Larruscain • Iker Uriarte • In˜aki Ja´uregui Jose´ Luis Martı´nez-De Los Mozos
•
Received: 12 May 2013 / Accepted: 14 October 2013 Ó The Japanese Orthopaedic Association 2013
Introduction Although vascular injuries after total hip arthroplasty (THA) are uncommon, they may lead to severe complications which can result in a threat to life and limb. The different patterns of such injuries include lacerations with acute hemorrhage, arteriovenous fistula, thrombosis, and pseudoaneurysms [1, 2]. Periprosthetic osteolysis is a well known phenomenon caused by wear particle-induced bone resorption or other pathologic processes, including infection, metabolic disease, and neoplasia [3]. Nevertheless, as far as we are aware, no reports have yet been published on aneurysms associated with periprosthetic osteolysis. We present a case of a patient who developed a deep femoral artery pseudoaneurysm mimicking periprosthetic joint infection with osteolysis after total hip replacement.
Case report A 79-year-old woman with a history of hypertension was referred to the Hip Department in our hospital for evaluation of left groin pain. The patient had undergone a THA for end-stage osteoarthritis at another hospital in March 2010, via an anterolateral approach, with an AlizeÒ II acetabular cup with hydroxyapatite coating (Biomet France, Valence, France) and an AuraÒ hydroxyapatitecoated stem (Biomet France). Ceramic on ultra-highmolecular-weight polyethylene was the bearing surface. An
J. Moreta (&) O. Sa´ez de Ugarte J. F. Larruscain I. Uriarte I. Ja´uregui J. L. Martı´nez-De Los Mozos Department of Orthopaedic Surgery and Traumatology, Hospital Galdakao-Usansolo, Barrio Labeaga s/n, 48960 Vizcaya, Spain e-mail: [email protected]
X-ray revealed malposition of the acetabular cup, with a low position in the acetabulum (Fig. 1a). Postoperative recovery was uneventful, but nine months after the procedure the patient experienced subacute onset of pain, which progressively worsened over four weeks. On physical examination, the patient was afebrile, there was no local warmth, and the overlying skin was normal. Deep palpation revealed minor swelling. Neurovascular examination revealed no abnormal findings. An anteroposterior radiograph of the left hip revealed periprosthetic osteolysis in Gruen zone seven (Fig. 1b). White blood-cell count was slightly elevated (11.5 9 109/L), erythrocyte sedimentation rate (ESR) was 52 mm/h (normal, 2–49 mm/h), and C-reactive protein level (CRP) was 19.1 mg/L (normal 0–5 mg/L). To preclude the possibility of infection, a bone scan was performed; this revealed a large area of activity related to the hip arthroplasty (Fig. 2a). Single-photon emission computed tomography (SPECT-CT) suggested the presence of an abscess located in the medial aspect of the proximal part of the femoral component (Fig. 2b). The hip was aspirated and 40 mL brownish fluid was obtained and sent to the Department of Microbiology. Two days later, magnetic resonance imaging (MRI) revealed a periprosthetic collection, measuring 14 cm in largest diameter, arising from a pseudoaneurysm (Fig. 3a). MR angiography accurately identified a pseudoaneurysm approximately 7.5 cm in diameter affecting the deep femoral artery (Fig. 3b). Aspirated fluid was negative for bacterial or fungal growth. The patient was transferred to the Department of Vascular Surgery and underwent surgery for the false aneurysm, including resection of the aneurysm and closure of the bleeding puncture. The surgical repair was performed via a longitudinal groin incision and the pseudoaneurysm was located in close relationship to the proximal femur,
123
J. Moreta et al. Fig. 1 Radiographs showing the periprosthetic osteolytic lesion. a Postoperative radiograph of the left hip revealing the low position of the cup, and disruption of the Kohler line and of the obturator foramen. b Radiograph 10 months after the primary THA
Fig. 2 a 99mTc-HMPAO leukocyte scintigraphy showing evident activity around the prosthesis. This finding was consistent with periprosthetic hip infection. b SPECT-CT suggesting the presence of an abscess in the medial aspect of the femoral neck
surrounding the calcar region. After removal of a large amount of organized hematoma and fibrous tissue, the arteriotomy was located posteriorly and sutured with a polytetrafluoroethylene (PFTE) patch angioplasty. Intraoperative culture results remained negative, and pathologic examination revealed a nonspecific inflammatory reaction. The patient recovered without major complications and at the last outpatient visit, two years after the vascular surgery, was mobile with full weight bearing on a crutch (because of mild osteoarthritis in her right knee) and resolution of her groin discomfort. Control radiographs revealed no progression of the osteolytic lesion and C reactive protein and ESR values had returned to the physiological threshold. Control arteriography revealed
123
occlusion of the deep left femoral artery, and distal vascularization partly maintained by collateral circulation by perforating branches from the superficial femoral artery (Fig. 3c). Written informed consent was obtained from the patient for publication of this case report and any accompanying images.
Discussion Vascular injuries after THA are extremely rare. Estimated prevalence is 0.25 % [1], but this may be increasing, because of the greater amount of difficult revision surgery
Pseudoaneurysm as a cause of osteolysis
Fig. 3 a Coronal MR image showing a large (approximately 14 cm) hematoma surrounding the hip implant on T1-weighted imaging. b MR angiography revealing an area of contrast extravasation
measuring 7.5 cm in diameter consistent with a pseudoaneurysm. c Angiogram showing occlusion of the deep left femoral artery (white arrow)
performed nowadays. These lesions involve significant complications, for example high incidence of limb loss or even life-threatening events. Shoenfield et al. [4] reported 7 % mortality and 15 % incidence of amputations among 68 patients with vascular injuries associated with THA. More recently, Troutman et al. [5] reported no mortality and limb salvage achieved for 49 patients with acute arterial complications after hip or knee replacement. Several studies have suggested that patients with previous presence of vascular disease are at greater risk of vascular injuries, and that local factors (e.g. elderly patients, complex revision procedures) have also contributed to these complications [6]. It is very important to obtain a thorough medical history with a basic vascular examination; ultrasound or arteriography can also be useful in manifest atherosclerosis or complex reintervention, especially with intrapelvic migration of the cup. One of the most prevalent mechanisms is excessive traction during dislocation and reduction maneuvers [1], but a recent article reported that direct arterial laceration was the most common mechanism [7]. Other causes, for example inadequate retractor placement [1], cerclage wiring of the femur [8], screws to enhance fixation of cementless cups, migration of the components [9, 10], and exothermic reaction during cement polymerization [1] have been reported. In our case, it is difficult to establish the cause of the injury because the surgery was performed in another institution, and information about the procedure was not available. The surgical records did not mention any adverse event or complication during the surgery. Several causes should be considered, for example inadequate retractor placement, excessive traction during surgery, or direct injury during the acetabular reaming. A pseudoaneurysm, or false aneurysm, is a collection of blood that results from traumatic penetration of the vessel
wall and subsequent hemorrhage and extravasation. Garrido-Gomez et al. [11] reported that significant bleeding may be a common manifestation during the postoperative period. Irrespective of this finding, small pseudoaneurysms (\2 cm 9 3 cm) may thrombose spontaneously within four weeks [12]. Despite this, resolution is unpredictable and rupture can occur. On physical examination, a pseudoaneurysm can be recognized as a pulsatile mass, sometimes with an audible arterial bruit. However, these findings may be less obvious in the hip, and this injury should be suspected for patients with chronic pain secondary to a mass effect, swelling, or local hematoma. In this case, the mechanism of groin pain is generally believed to be the direct pressure of adjacent structures. Early identification of vascular injury followed by appropriate treatment can reduce morbidity and mortality. The orthopaedic surgeon should perform a basic vascular examination after surgery that specifically focuses on patients at risk. To achieve this, distal pulses, capillary refill time, and skin temperature should all be monitored. However, in this case these findings were normal. If any problems with the arterial circulation of the limb are detected the patient should be referred to a vascular specialist as soon as possible, because delay in the diagnosis and treatment could be catastrophic [2]. Although bone erosion as a result of a pseudoaneurysm has been reported [13, 14], periprosthetic hip osteolysis because of the mass of this vascular complication has not yet been reported in the literature. Abdominal aortic aneurysms can cause vertebral erosion and may mimic tumors or infections [14]. Two main mechanisms lead to aneurysms complicated by bony erosion: infection related to the artery (mycotic aneurysms) and continuous pulsation causing destruction of the surrounding bone. Polyethylene wear has been accepted as a major cause of osteolysis in
123
J. Moreta et al.
total hip arthroplasty, but we must take into account other pathologic processes, including infection, inflammatory diseases, or neoplasia. The rapidly progressive clinical and radiological scenario with pain and swelling was peculiar, and wear-induced osteolysis, characterized by a painless course, was definitely unlikely. Furthermore, the osteolytic lesion did not progress after the vascular repair. Treatment is surgical resection and evacuation of the pseudoaneurysm with repair of the damaged artery, but the vascular specialist may consider ultrasound-guided thrombin injection for small false aneurysms. This case illustrates the importance of considering a pseudoaneurysm as a possible cause of periprosthetic osteolysis, particularly if rapid progressive growth has occurred. If this vascular injury had not been diagnosed, the method of treatment would have been wrong, probably with catastrophic consequences. To the best of our knowledge, this complication after a THA has never been reported. Patient observation in the postoperative period and a basic vascular examination may aid diagnosis of the injury; when these injuries are recognized it is necessary to request specialist vascular assessment. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Nachbur B, Meyer RP, Verkkala K, Zu¨rcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res. 1979;141:122–33. 2. Calligaro KD, Dougherty MJ, Ryan S, Booth RE. Acute arterial complications associated with total hip and knee arthroplasty. J Vasc Surg. 2003;38:1170–7.
123
3. Harris WH. Wear and periprosthetic osteolysis the problem. Clin Orthop Relat Res. 2001;393:66–70. 4. Shoenfield NA, Stuchin SA, Pearl R, Haveson S. The management of vascular injuries associated with total hip arthroplasty. J Vasc Surg. 1990;11:549–55. 5. Troutman DA, Dougherty MJ, Spivack AI, Calligaro KD. Updated strategies to treat acute arterial complications associated with total knee and hip arthroplasty. Article in press 2013. 6. Beguin L, Feugier P, Durand JM, Chalencon F, Gresta G, Fessy MH. Vascular risk and total hip arthroplasty. Rev Chir Orthop Repractice Appar Mot. 2001;87:489–98. 7. Parvizi J, Pulido L, Slenker N, Macgibeny M, Purtill JJ, Rothman RH. Vascular injuries after total joint arthroplasty. J Arthroplasty. 2008;23:1115–21. 8. Mehta V, Finn HA. Femoral artery and vein injury after cerclage wiring of the femur: a case report. J Arthroplasty. 2005;20:811. 9. Iachetto J, Gallagher JJ. False aneurysm of the common femoral artery secondary to migration of a threaded acetabular component. Case report and review of the literature. Clin Orthop. 1988;231:91–6. 10. Mittag F, Kluba T. Aneurysm of the femoral artery caused by aseptic loosening and migration of a Burch-Schneider cage. J Arthroplasty. 2009;24:159.e9–12. 11. Garrido-Go´mez J, Garrido-Go´mez MN, Arrabal-Polo MA, Garrido-Pareja F, Linares-Palomino JP. Iatrogenic false aneurysms. A rare complication of hip surgery. Hip Int. 2012;22:397–402. 12. Ahmad F, Turner SA, Torrie P, Gibson M. Iatrogenic femoral artery pseudoaneurysms d a review of current methods of diagnosis and treatment. Clin Radiol. 2008;63:1310–6. 13. Kim YJ, Baek WK, Kim JY, Park SW, Jeon YS, Lee KH, Cho SG, Lim MK. Pseudoaneurysm of the popliteal artery mimicking tumorous condition. J Korean Surg Soc. 2011;80:S71–4. 14. Diekerhof CH, Reedt Dortland RW, Oner FC, Verbout AJ. Severe erosion of lumbar vertebral body because of abdominal aortic false aneurysm: report of two cases. Spine. 2002;27:E382–4.
