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Abstract:
Thrombosis of the femoral artery during total hip replacement is a serious limb-threatening complication. Although Iatrogenic damage of the femoral or iliac vessels is reported frequently in total hip arthroplasty, is very rare in partial hip replacement. We report here a case of cementless hemiarthroplasty of the hip complicated with extensive femoral artery thrombosis and subsequent amputation of the limb. The early diagnosis and management of such serious complications is highlighted.
 Introduction:
Thrombosis of the femoral and common iliac vessels following hemiarthroplasty of the hip joint is a very rare complication. Most of the cases of vascular complications in hip arthroplasty are reported in total hip replacement and the literature has scarce reports of vascular complications in hemiarthroplasty of the hip.
We here report a case of extensive femoral artery thrombosis following the Austin Moore hemiarthroplasty of the hip in a 75 years old man.
Case Report:
A 75 years old man presented in the Emergency
section of our hospital with a history
of fall on the left hip. On examination
the patient's general condition was good
with no systemic disorder. The left lower
limb was externally rotated and abducted.
There was no neuro-vascular deficit, peripheral
pulses were palpable normally on both
sides. X-ray of the left hip confirmed
the diagnosis of Subcapital Fracture of
the Neck of the Femur (Garden's Grade
IV). A pre-operative medical check up
was done and it was normal, since the patient
was an elderly gentleman, prophylactic
heparin was administered, Hydralazine
was used as vasodilator, this was supplemented
along with an antiroloux formation agent
PentoxYfyline. The baseline PT, PIT and
total blood counts were all with in normal
limits.
The left hip was opened through a modified
Hardinge's approach and the head of the
femur replaced by an Austin Moore's prosthesis
(size 51). The patient did well in the
first 24 hours of the surgery and there
was no obvious neurovascular deficit.
On the second post-operative day it was
noticed that the patient was not able
to flex the knee and there were no ankle
and toe movements. On examination, the
limb was anesthetic below the knee and
dorsalis pedis, posterior tibial and popliteal
arteries were not palpable. A check X-ray
of the hip showed that the prosthesis
was in satisfactory position. The patient
was put on peripheral vasodilators and
heparin injections. A color Doppler ultrasound
of the involved limb was immediately done.
It showed (Fig. 1) a thrombus in the left
femoral artery with no distinct blood
flow down to the dorsalis pedis artery.
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Fig.1 Colour Doppler
of the left lower limb showing thrombosis
of the femoral artery. Note the
absence of blood flow in distal
vessels.
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ECG, Doppler, Echo and all other investigations
to rule out other causes of emboli from
other regions of the cardiovascular system
were done and found to be non-contributory.
An emergency exploration of the femoral
artery was done and a thrombus about 20
cm long was removed using a Fogarty Catheter.
Fasciotomy of the left leg compartments
was also done. There was no objective
improvement in the neurovascular status
of the limb in the post-operative period.
Subsequently the limb became gangrenous
and ultimately an above knee amputation
had to be done.
Discussion:
Extensive femoral and iliac artery thrombosis,
during total hip replacement has been
reported frequently in world literature.
According to Fruhwrith et al(l), the vascular
complications in total hip replacement
usually occur while relocating the head
of a cemented prosthesis. They have classified
the vascular injuries during total hip
arthroplasty into lacerations, thrombosis,
pseudo- aneurysms and arterio-venous fistula.
Bindewald et al (2) feel that injuries
of the femoral vessels seem to be preventable
if the Hohmann-retractor is carefully
placed on the anterior margin of the acetabular
rim under digital control. Furthermore
drilling damage of the iliac vessel appears
to be avoidable. We had not used the Hohmann
retractor in our case.
The activation of clotting cascade leading
to deep vein thrombosis in total hip arthroplasty
has been assigned as an important cause
of vascular complication in total hip
arthroplasty (3).
The risk of vascular complications is
definitely increased in patients undergoing
revision hip arthroplasty. Revision total
hip arthroplasty is now considered as
a definite risk factor for iatrogenic
vascular injury (4).
The early diagnosis and management of
this limb threatening complication is
a must and should be realised by every
surgeon. In our case there was a delay
of around 24 hours before the diagnosis
of femoral artery thrombosis could be
established. As a result of this delay,
the limb could not be saved despite adequate
surgery. According to Fruhwrith et al
(1) the diagnosis should usually be made
on the operating table itself. They report
a case of iatrogenic femoral thrombosis
presenting after three weeks with a femoral
pseudo-aneurysm.
We were not able to find any case of vascular
complication in partial hip replacement
in world literature. Our case report highlights
the importance of being aware of the occurrence
of this dreaded complication even in hemiarthroplasty
of the hip, which is a far more common
surgery performed in this part of the
world.
References:
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