Vascular injury during total hip arthroplasty: the anatomy of the acetabulum

Perspective on the integration of optical sensing into orthopedic surgical devices

SIGNIFICANCE

Orthopedic surgery currently comprises over 1.5 million cases annually in the United States alone and is growing rapidly with aging populations. Emerging optical sensing techniques promise fewer side effects with new, more effective approaches aimed at improving patient outcomes following orthopedic surgery.

AIM

The aim of this perspective paper is to outline potential applications where fiberoptic-based approaches can complement ongoing development of minimally invasive surgical procedures for use in orthopedic applications.

APPROACH

Several procedures involving orthopedic and spinal surgery, along with the clinical challenge associated with each, are considered. The current and potential applications of optical sensing within these procedures are discussed and future opportunities, challenges, and competing technologies are presented for each surgical application.

RESULTS

Strong research efforts involving sensor miniaturization and integration of optics into existing surgical devices, including K-wires and cranial perforators, provided the impetus for this perspective analysis. These advances have made it possible to envision a next-generation set of devices that can be rigorously evaluated in controlled clinical trials to become routine tools for orthopedic surgery.

CONCLUSIONS

Integration of optical devices into surgical drills and burrs to discern bone/tissue interfaces could be used to reduce complication rates across a spectrum of orthopedic surgery procedures or to aid less-experienced surgeons in complex techniques, such as laminoplasty or osteotomy. These developments present both opportunities and challenges for the biomedical optics community.

Vascular Injuries During Hip and Knee Replacement

Vascular injuries associated with hip and knee arthroplasty are rare but can result in devastating outcomes for the patient. A sound knowledge of vascular anatomy, potential mechanisms of injury, and diagnosis and management of vascular injuries are vital to an arthroplasty surgeon. Identifying high-risk patients and procedures allows careful preoperative planning, which combined with meticulous intraoperative technique, may help avoid vascular complications. When vascular injuries do occur, early recognition and intervention are critical to an improved outcome.

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.

Anthropometric Measurement About the Safe Zone for Transacetabular Screw Placement in Total Hip Arthroplasty in Asian Middle-Aged Women: In Vivo Three-Dimensional Model Analysis

BACKGROUND

Although the pelvic vascular injury caused by a transacetabular screw is rare, it is a major local complication of total hip arthroplasty. We aimed to obtain anthropometric data about the safe zone for the placement of transacetabular screws by analyzing the three-dimensional (3D) reconstruction model and determine the safe length of transacetabular screws by performing the 3D simulated surgery.

METHODS

We reviewed 50 hips of 25 patients who underwent lower extremity angiographic computed tomography scans retrospectively. We reconstructed the 3D models of 50 hips with normal pelvic bone and vascular status using the customized computer software. We measured the central angle and safe depth of the safe zone of the transacetabular screws on the 3D models. We also performed the 3D simulated surgery to confirm the safe length of screws in each hole of the customized cup implant.

RESULTS

The measured central angle of the posterior-superior area was 79.5°. And we determined a mean safe depth of 49.8 mm in the safe zone, with a central angle of 47.7°. During the 3D simulated surgery, we determined a mean safe length of the transacetabular screw of 43.3 mm when applied to a lateral hole on a line bisecting the posterior-superior area.

CONCLUSION

Although our study was limited by the use of a virtual computer program, the quantitative measurements obtained can help reduce the incidence of pelvic vascular injury during transacetabular screw fixation in total hip arthroplasty.

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.

Intra-abdominal and intra-pelvic complications following operations around the hip: causes and management-a review of the literature

Although successful and well-established procedures, hip operations whether elective or trauma are coupled with a variety of complications. Among the most uncommon complications are injuries to intra-abdominal or intra-pelvic organs which could prove potentially life-threatening. While there are various reports of such injuries in the literature, we aimed to perform a systematic review in order to examine the causes and relationships between intra-abdominal and intra-pelvic complications and the mechanism of injury, the pattern of presentation, identification, the course of management and outcomes. We identified 69 reports describing a total of 84 complications in intra-pelvic and intra-abdominal contents in 75 patients. These involved six major categories, including the intestinal tract, the urinary tract, the genital tract, the vascular system, the viscera and peripheral nerves. The most commonly injured system was the urinary (33.33%), followed by the vascular (29.76%) and the intestinal (22.62%). Among these systems, the most prevalent complications involved injury to the urinary bladder (32.14%), the large intestine (68.42%) and the external iliac artery (44%). The majority of recorded complications were postoperative with 71 incidents in 63 cases (84.52%). In intra-operative complications the most prevalent injury was due to hardware penetration (53.85%), while in postoperative it was due to hardware migration (92.06%). The management of injuries varied widely, with the most common approach being open exploration and direct repair (77.33%). The reported management outcomes included death (8%) and Girdlestone resection (2.67%), while the majority of the patients healed uneventfully (82.67%) owing mostly to immediate intervention. Despite being rare, such complications may still occur in a variety of settings and may subsequently lead to potential life-threatening situations. Thus, in order to avoid catastrophic outcomes we emphasize the need for prompt identification, immediate intervention and a multidisciplinary approach when necessary.

Phlegmasia cerulea dolens and external iliac vein disruption after revision total hip arthroplasty

We present a unique case of phlegmasia cerulea dolens and compartment syndrome secondary to external iliac vein disruption after revision total hip arthroplasty. To our knowledge, this complication has not yet been described following revision total hip arthroplasty. We conclude that although vascular complications are fortunately rare after hip arthroplasty, they can have significant morbidity and mortality. Surgeons should have a thorough understanding of pelvic and hip anatomy for screw and retractor placement and know how to appropriately and expeditiously manage vascular complications should they occur.

Surgical anatomy of the pelvic vasculature, with particular reference to acetabular screw fixation in cementless total hip arthroplasty in Asian population

PURPOSE

Pelvic vascular injury is a serious complication associated with acetabular component setting with screw fixation in cementless total hip arthroplasty (THA). In this study, we investigated the safety zone for acetabular component setting with screw fixation in cementless THA as a means to prevent pelvic vascular injury.

METHODS

Thirty left hip joints of Japanese cadavers (11 males and 19 females) were analyzed. We used a hemispherical measuring cup with 52 guide holes designed to allow vertical insertion of a Kirschner wire. After the measuring cup was placed on the acetabulum, the Kirschner wire was inserted from each guide hole to examine the anatomical relationship between the acetabulum and the pelvic vessels. We calculated the frequency of pelvic vessel punctures and measured the distance from the acetabular surface to the pelvic vessels at each guide hole.

RESULTS

Our findings revealed that pelvic vessels do not exist in certain parts of the posterior area of the acetabulum. Furthermore, in this area, intrapelvic vessels are either lacking or located at a distance ≥31 mm from the surface of the acetabulum.

CONCLUSION

The posterior area of the acetabulum, excluding its central portion, appeared to be the safety zone for acetabular screw fixation in Japanese cadavers.

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.

Internal iliac artery pseudoaneurysm in primary total hip arthroplasty

Vascular injury is one of the rare complications of primary total hip arthroplasty (THA). We report an unusual case of lobulated pseudoaneurysm arising from one of the branches of the left internal iliac artery during acetabulum preparation in THA, which was successfully treated with coil embolization and multidisciplinary care. After 6 years follow up, patient did not have any symptoms related to the hip replacement. We recommend that surgeons should be extremely cautious while drilling medial wall of the acetabulum for depth assessment. Aggressive multidisciplinary approach, including possible support from an interventional radiologist is required for the treatment of such vascular injuries.

Iatrogenic vascular injuries during arthroplasty of the hip

Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open exploration and repair, but more recently there has been a trend towards percutaneous endovascular management.

We performed a systematic review of the literature to assess if this change in trend has led to an improvement in the overall reported rates of morbidity and mortality during the last 22 years in comparison with the reviews of the literature published previously.

We found a total of 61 articles describing 138 vascular injuries in 124 patients. Injuries because of a laceration were the most prevalent (n = 51, 44%) and the most common presenting feature, when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis was associated with the type of vascular lesion (p < 0.001) and the clinical presentation (p = 0.002).

Open exploration and repair was the most common form of management, however percutaneous endovascular intervention was used in one third of the injuries and more constantly during the last 13 years.

The main overall reported complications included death (n = 9, 7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9, 7.3%). When compared with previous reviews there was a similar rate of mortality but lower rates of amputation and permanent disability, especially in patients managed by endovascular strategies.

Cite this article: Bone Joint J 2015;97-B:1447–55.

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

INTRODUCTION

Iatrogenic vascular injuries associated with elective orthopaedic joint procedures are relatively rare, however when they do occur they carry a risk of significant morbidity and mortality. The aim of this study was to investigate the incidence of vascular complications and resultant need for specialist intervention following elective total hip replacement (THR) and total knee replacement(TKR).

METHODS

This was a retrospective analysis of prospectively collected data. The primary outcome measure was vascular complication requiring an interventional radiology procedures or vascular surgery. As a secondary outcome measure postoperative Modified Knee Society Scores and Harris Hip Scores were analysed to assess long term clinical outcome.

RESULTS

Six cases of vascular injury requiring specialist intervention were identified. From 2073 total TKRs there were one cases of popliteal artery injury, one case of venous injury and two case of lateral geniculate artery injury (0.19%). From 1601 THRs there were two cases (0.12%) of arterial injury. All patients were treated successfully by a vascular surgeon or an interventional radiologist. Patient outcome varied considerably with the poorest results seen in the THR group.

CONCLUSIONS

Iatrogenic vascular complications following elective THR and TKR carry a risk of significant morbidity and mortality. It is important that surgeons and trainees performing these procedures are conscious of these risks and able to identify vascular injuries promptly when they occur. Detailed preoperative assessment, an awareness of anatomical variants and close liaison with a vascular surgeon may all help to reduce the number and severity of adverse outcomes.

Initial stability of cementless acetabular cups: press-fit and screw fixation interaction--an in vitro biomechanical study

Background

Press-fit and screw fixation are important technical factors to achieve initial stability of a cementless acetabular cup for good clinical results of total hip arthroplasty. However, how these factors affect one another in initial cup fixation remains unclear. Therefore, this study aimed to evaluate the mutual influence between press-fit and screw fixation on initial cup stability.

Methods

Foam bone was subjected to exact hemispherical-shape machining to diameters of 48, 48.5 and 49 mm. A compressive force was applied to ensure seating of a 48-mm-diameter acetabular cup in the foam bone prior to testing. Screws were inserted in six different conditions and tightened in a radial direction at the same torque strength. Then, the socket was rotated with a twist-testing machine, and the torque value at the start of axial rotation between the socket and the foam bone was measured under each screw condition.

Results

The torque values for the 48-mm-diameter reaming were >20 N m higher than those for the 48.5- and 49-mm-diameter reaming in each screw condition, indicating that press-fit fixation is stronger than screw fixation. Meanwhile, torque values for the 48.5- and 49-mm-diameter reaming tended to increase with increasing the number of screws.

Conclusions

According to our experiment, press-fit fixation of a cementless acetabular cup achieved rigid stability. Although the supplemental screws increased stability of the implant under good press-fit conditions, they showed little impact on whole-cup stability. In the case of insufficient press-fit fixation, cup stability depends on screw stability and increasing the number of additional screws increases cup stability.

Retrospective 12-year study of the safety and efficacy of transcatheter arterial embolization for managing bleeding complications following hip surgery

PURPOSE

This study was designed to evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) for stopping bleeding following hip surgery.

METHODS

We performed a 12-year retrospective analysis of 13 patients (M:F = 6:7, median age 72 years) who underwent angiography for bleeding following hip surgery. The types of surgery, latency time, angiographic findings, TAE details, procedure-related complications, and clinical outcomes were analyzed. Technical success was defined as no further bleeding detected on angiography following embolization.

RESULTS

Total hip replacement arthroplasty was the most common surgery performed for these patients (n = 10). Seven of the 13 study patients underwent angiography the same day as their surgery. Angiograms showed active (n = 11) or suspicious (n = 1) bleeding in 12 of the 13 patients. Gelatin sponge particles, coils, NBCA, PVA, and their combinations were used as the embolic material. For the one patient without obvious signs of bleeding, prophylactic TAE was done to achieve bleeding control. For the 11 patients with active bleeding, 10 underwent technically successful TAE, and 1 patient underwent surgery due to a large pseudoaneurysm located near the bifurcation of the common femoral artery. There were no major procedure-related complications or patient mortality. The 30-day mortality rate was 15% (2/13), and both of these patients died of multiorgan failure.

CONCLUSIONS

Transcatheter angiography is useful for identifying bleeding arteries. TAE is safe and effective for managing bleeding after hip surgery.

[Lower limb paresis after total hip arthroplasty. A rare differential diagnosis]

We report on a case of complex nerve damage during total hip arthroplasty. The most severe clinical symptom was proximal leg paresis with diffuse sensory loss. There was an extensive causal Iliopsoas hematoma which developed during the postoperative rehabilitation under therapeutic anticoagulation for atrial fibrillation. An iliopsoas hematoma with subsequent neurological deficits are rare events in the field of hip arthroplasty and a literature review is provided. The treatment of retroperitoneal hemorrhage is controversial but in most instances a conservative approach is favored. The prognosis of neurological damage is sobering as only 20 % of victims are expected to achieve complete restitution.

Location of intrapelvic vessels around the acetabulum assessed by three-dimensional computed tomographic angiography: prevention of vascular-related complications in total hip arthroplasty

BACKGROUND

During total hip arthroplasty (THA), the external iliac, femoral, and obturator vessels are at risk of vascular injury when penetrating the inner cortex of the pelvis. The purpose of this study was to clarify the location of these vessels using three-dimensional computed tomographic angiography (3DCT-A).

METHODS

We enrolled 100 subjects (200 hips) without hip disease and performed examinations on the following. (1) External iliac-femoral vessels: we measured the shortest distance from these vessels to the pelvis on axial CT images and investigated the factors affecting distance. The anatomical course of the iliac artery was classified as straight, curved, or tortuous, and the correlation between course and age was established. (2) Obturator vessels: we measured the shortest distance from the obturator vessels to the quadrilateral surface on axial CT images. (3) Visualization of pelvic vessels was through the pelvis by dual-phase 3DCT-A.

RESULTS

(1) The external iliac vein was located significantly closer to the pelvis than the artery, especially on the left side and in aged and female subjects. The single-curved and tortuous double-curved vessel types were found in aged subjects, and external iliac vessels of these types were closer to the pelvis than vessels of the straight type. In 36 subjects, the external iliac veins lay directly on the osseous surface of the pelvis (right 16, left 36). Of these 36 subjects, only one had straight-type vessels. (2) Obturator vessels were located just behind the acetabulum near the obturator foramen. (3) Reconstructed 3DCT images enabled us to visualize the pelvic vessels and demonstrated the danger area for penetrating the inner cortex of the pelvis.

CONCLUSION

Understanding the anatomical orientation of the pelvic vessels around the acetabulum using 3DCT-A could be helpful for preventing vascular injury during THA.

Arthroscopic reconstruction of the ligamentum teres

We describe a case of arthroscopic reconstruction of the ligamentum teres using a novel technique. This technique is both simple and reproducible. We believe it to be a useful addition to the procedures available to the arthroscopic hip surgeon.

Femoral nerve palsy associated with iliacus hematoma following pseudoaneurysm after revision hip arthroplasty

Iliacus hematoma associated with femoral nerve palsy is a very rare but considerable complication of hip arthroplasty. A 76-year-old woman had femoral nerve palsy 6 months after revision hip arthroplasty using a reinforcement plate. Computed tomography and selective angiography revealed the pseudoaneurysm on an extension of one of the screws fixing the hardware. Transcatheter arterial embolization proximal to the aneurysm was performed to resolve the aneurysm and to prevent further bleeding. Surgical removal of the hematoma was successfully achieved, as was full functional recovery. This case report describes our diagnosis and treatment of this rare condition and also the therapeutic usefulness of the radiologic intervention to control further bleeding before and after surgical removal of the hematoma.

Retroperitoneal false aneurysm presenting as anterior thigh pain and weakness: a case report

This case highlights the importance of considering retroperitoneal pathology in the differential diagnosis of anterior thigh pain and weakness. We describe a woman in her mid seventies with a history of a left total hip arthroplasty and lumbar decompression who presented with left anterior thigh pain and left lower-extremity weakness. A computed tomography scan of the retroperitoneum revealed a mass along the left iliopsoas muscle. An arteriogram revealed a large false aneurysm that communicated with the left common femoral artery. Surgery to resect the aneurysm revealed exposed parts of the hip replacement that may have contributed to the formation of the aneurysm. We concluded that imaging of the retroperitoneum should be considered in any patient presenting with anterior thigh pain and weakness.

Acetabular anatomy and transacetabular screw fixation at the high hip center

A quadrant system that defines the safe acetabular locations for screw placement exists for the anatomic hip center. We wanted to develop a similar system for the high hip center. The purposes of our study were to identify the anatomic structures at risk during placement of transacetabular screws in the high hip center, to identify maximum bone depth for screw purchase, and to determine if a high hip center quadrant system could be validated to guide placement of screws during acetabular arthroplasty. For this cadaver study of nine pelves, an acetabulum was reamed superiorly into the high hip center a distance equal to (1/2) of the native acetabular diameter. Screws exiting the acetabular bone by 15 mm were inserted before a computed tomography scan and a precise anatomic dissection were done. Structures at risk of penetration by screws include the external iliac vessels, the obturator nerve and vessels, the superior gluteal nerve and vessels, and the sciatic nerve. We found that a quadrant system at the high hip center can demarcate safe zones for screw placement. At the high hip center, only the peripheral (1/2) of the posterior quadrants are safe for screw placement.

Radiographic evaluation of screw position in revision total hip arthroplasty

Injury to intrapelvic structures during removal of screws in revision acetabular arthroplasty is an uncommon, yet potentially serious complication. Bicortical screws are at greatest risk for causing injury during removal, especially if directed toward intrapelvic vessels and nerves. Complications can be minimized with thorough evaluation of screw position before revision surgery. A study of seven cadaveric pelves was done to determine if plain radiographic views provide useful information regarding screw position. In each pelvis, bicortical transacetabular screws were fixed in all acetabular quadrants 15 mm longer than the measured depth. Afterward, anteroposterior, inlet, Judet, and cross-table lateral radiographic views were obtained and intrapelvic dissections were done. Radiographs and intrapelvic dissections were compared to determine screw position. We found that the obturator and iliac oblique (Judet) views were most useful in defining screw position. The iliac oblique view clearly revealed screws that violated the quadrilateral surface and therefore were directed toward the obturator vessels and nerve. The obturator oblique view revealed screws that violated the anterior column and therefore were directed toward the external iliac vessels. The lateral view additionally clarified such screws by determining general anterior or posterior direction.

Malformation of the acetabular fossa as a cause of intrapelvic injury in total hip arthroplasty: a report of 2 cases

We report 2 cases of bone defects of the acetabulum. The first case was a patient who underwent a total hip arthroplasty. An intraoperative bleeding occurred because of an injury of an intrapelvic artery. Preoperative radiographs did not show this bone defect. A similar abnormality of the acetabulum was found in a series of 30 pelves that were dissected for a cadaver study. In this case, the bone defect was located in the center of the right acetabulum.

Placement of screws in the uncemented acetabulum: anatomic analysis of the danger zone

Six cadavers were used to define the projection of the external iliac artery on the inner table of the acetabulum, and to quantitatively determine bony dimensions of the danger zone with regard to screw placement. The results showed that the majority of projections of the external iliac arteries were located on the superior portion of the posterosuperior quadrant and extended to the mid-superior portion of the anterosuperior quadrant (danger zone). The inferior portion of the danger zone was relatively far from the external iliac artery. The greatest depths of bone were found in the inferior portion of the danger zone, and the depths of bone in the middle and superior portion of the danger zone were relatively thinner. This anatomic study showed that the real danger zone was found in the middle and superior portions of the anterosuperior quadrant of the acetabulum. The inferior portion of the anterosuperior quadrant was relatively safer. This area may be considered if transacetabular screw replacement in the anterosuperior quadrant is required.