Revision total hip arthroplasty with a retroperitoneal approach to the iliac vessels

A modified iliofemoral approach to intrapelvic acetabular revision – technical note

Among the patterns of acetabular osteolysis associated with acetabular loosening, the authors emphasize the severity of pelvic dissociation and medial segmental losses in which the quadrilateral lamina is severely affected. Such lesions are potentially lethal in cases of large vascular injury. This note aimed to describe a modified iliofemoral approach in cases of massive intrapelvic migration of the acetabular component in patients with total proximity of the iliac vascular bundle and absence of an anatomical demarcation plane between the migrated contents and the iliac bundle. This approach was performed in 12 of 21 patients who had these criteria.

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.

Revision of migrated pelvic acetabular components in THA with or without vascular involvement

Purpose. The literature describes a high rate of mortality in cases of intrapelvic acetabular component migration, which is a rare but serious complication. Our aim is to establish and propose a treatment protocol according to our results and experience. Material and Methods. We performed eight (8) total hip revisions with acetabular cup migration between 2006 and 2012. A vascular graft was needed in four (4) of these cases. Two (2) cases were revisions after a spacer for infected arthroplasties. The protocol included the following: X-Ray examination (frontal and lateral views), CT angiography, a biological evaluation, a suitable pre-operative plan, at least six (6) units of blood stock, an experienced anesthesiologist, an experienced surgical team that included a vascular surgeon and a versatile arsenal of revision prostheses, bone grafts and vascular grafts. The anterolateral approach was generally used for hip revisions and the retroperitoneal approach in the dorsal decubitus position was used when vascular risk was involved. Results: The acetabular defect was reconstructed using bone grafts and tantalum revision cups in 4 cases, Burch-Schneider cages in 2 cases, a Kerboull ring in 1 case and a cementless oblong cup (Cotyle Espace) in 1 case. In 4 cases, an iliac vessel graft procedure was conducted by the vascular surgeon. All patients survived the revision procedures and returned regularly for subsequent check-ups, during which they did not show any septic complications. Conclusions: Intrapelvic acetabular cup migration is a rare but serious complication that can occur after total hip arthroplasty in either septic or aseptic cases. An experienced, multidisciplinary team of surgeons should be involved in planning and conducting such complicated revisions.

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.

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

Intrapelvic migration of the acetabular component of a total hip replacement, with severe acetabular destruction making reconstruction impossible, is very rare. We present a patient in whom the component was removed using a laparotomy and a transperitoneal approach with subsequent salvage using a saddle prosthesis and a total femoral replacement.

Total hip arthroplasty revision in case of intra-pelvic cup migration: designing a surgical strategy

Intrapelvic acetabular cup migration is a rare but serious complication, which can occur after cup loosening following total hip arthroplasty. To make safe intrapelvic implant removal, several principles must be respected: identification of potential risks with a thorough preoperative workup, preoperative planing of a surgical strategy for removing protruding hardware without injuring noble anatomical structures, preserving muscle and bone stock, pelvic anatomy reconstruction (including, as needed, osteosynthesis of the pelvis), and prosthetic components selection correcting any length discrepancy. Preoperative assessment is based on a complete radiological workup, angio-CT, as well as studies searching for signs of inflammation (blood workup and joint aspiration). All cases of intrapelvic migration of an acetabular component do not systematically command a subperitoneal approach. The presence of some residual bone shell, an intrapelvic foreign body, or a path deviation from normal in a vascular bundle or an ureter must be analyzed before deciding on the approach. The potential problems managing this mode of loosening event are a reminder for the need of periodical total hip arthroplasty follow-up. This regular monitoring helps preventing complications sometimes life threatening.

External iliac vein compression and thrombosis by a migrated acetabular screw following total hip arthroplasty

A fifty-nine year old gentleman underwent a right total hip replacement in another hospital for protrusio osteoarthritis of the right hip. Post-operatively he developed a large right-sided ilio-femoral deep venous thrombosis. A pelvic radiograph showed that the acetabular construct had migrated medially into the pelvis with a CT scan showing compression of the external iliac vessels by one of the acetabular screws. Revision surgery was carried out in collaboration with the vascular surgeons. This case report highlights the importance of pre-operative planning to avoid medial wall perforation in patients with protrusio osteoarthritis. It also illustrates an unusual complication of compression of the external iliac vessels causing massive ilio-femoral thrombosis.

The management of this potentially limb threatening complication is described in this case report.

Common femoral artery intimal injury following total hip replacement. A case report and literature review

Vascular injuries diagnosed during the course of total hip arthroplasty (THA) implantations are rare. They must be constantly feared as they sometimes put at risk the vital and functional prognosis of the operated limb. We report the case of a common femoral artery injury diagnosed by arteriography within two days of THA replacement in the presence of atypical symptoms. The vascular damage was caused by an arterial lesion resulting from positioning a retractor on the anterior wall of the acetabulum. A literature review on the topic of vascular complications arising after THA made us aware of multiple possible mechanisms and clinical presentations relating to such complications while identifying specific risk factors in THA replacement cases. Acetabular revision constitutes a major risk situation. Most of these vascular complications may be better prevented or more efficiently treated by thorough preoperative assessment and careful postoperative monitoring.

Intrapelvic cementless component extraction with immediate triflange acetabular reconstruction using the retroperitoneal approach

Use of the retroperitoneal approach has been well documented and used for intrapelvic cemented components or cement masses. We report on a single stage revision hip arthroplasty that incorporates a retroperitoneal approach for safe removal of an extensively entrapped porous-coated acetabular component and modular femoral head followed by an immediate reconstruction using a triflange acetabular prosthesis via a posterior approach.

Dépose par laparotomie des composants d’une prothèse totale de hanche compliquée de migration intra-pelvienne avec complication urinaire

We present the first report of transabdominal removal of femoral and acetabular components of a severely loosened hip prosthesis protruding into the pelvis. In a 73-year-old woman post-operative development of urinary tract complications emphasize importance of careful assessment of the prosthetic relations with the vascular and nervous structures as well as pelvic organs before removal of the hip prosthesis. Angio-computed tomography is the most contributive exploration to assess vascular relations. In patients with particular clinical presentations or with threatened structures in the vicinity of the prosthesis, this examination must be completed by complementary opacifications (urinary and gastrointestinal tracts, joints). Ureteral catheterization may be needed if the structures are close or if there is a suspected modification of the urinary tract (retraction, mass effect). In present case, we did not opacify the urinary tract before laparatomy despite the presence of urinary signs preoperatively. A suspected ureterovaginal fistula was discovered. But they where also a ureteral lesions which can result from difficult dissection in contact with infected tissues. In this patient, urinary complications led to nephrectomy after temporary pyelostomy for urine bypass. At last follow-up, the urinary tract infection was controlled but reimplantation was not attempted because of insulin dependent diabetes mellitus and poor general condition. The spontaneous course of this infection with prosthesis loosening recalls the importance of regular surveillance of total hip replacements.

Current overview of neurovascular structures in hip arthroplasty: anatomy, preoperative evaluation, approaches, and operative techniques to avoid complications

Total hip arthroplasty is a common and relatively safe procedure with consistently good results. Despite its popularity and excellent results, THA is a major operation with several major neurovascular structures within reach of retractors, scalpel blades, drills, screws, and reamers. A thorough knowledge of their anatomic location and proximity to the operative field, along with a basic understanding of the principles of vascular surgery can help avoid potentially devastating consequences. Specifically, the surgeon should avoid placement of screws in the anterior-superior quadrant, be vigilant when placing retractors, and avoid excessive tension on the sciatic nerve.

Modified iliofemoral approach for major isolated acetabular revision arthroplasty

Multiple specialized exposures have been described for revision total hip arthroplasty. In this article, we report on a series of 7 patients who underwent major isolated acetabular revision surgery through a modified iliofemoral approach. The use of this approach was deemed desirable because of the individual pathology present in each case, particularly major acetabular bone loss (Paprosky 2C/3B). However, successful reconstruction was achieved in all cases with the most frequent complication being meralgia paresthetica.