Multidisciplinary approach to the treatment of patients with periprosthetic joint infection of the hip complicated by injury to the great vessels

Introduction Total counts of total hip arthroplasty (THA) have been increasing for several decades, and the procedures are associated with considerable risk of intra- and postoperative complications. Vascular complications are defined as multiple pathological conditions. They are subdivided into acute adverse events such as intraoperative bleeding, acute ischemia and hematoma and chronic complications such as pseudoaneurysms and arteriovenous fistulas which can cause late ischemic events. A specialized and well-trained multidisciplinary team is required to perform surgical interventions due to the small number of intravascular lesions. The objective was to demonstrate findings of clinical, instrumentation methods and staged treatment of patients with periprosthetic joint infection (PJI) of the hip and complications associated with injury to the great vessels.

Material and methods We report two cases of vascular complications in patients with PJI and migration of femoral components into the lesser pelvis.

Results An integrated approach to the diagnosis and treatment of patients with PJI and complications associated with injury to the great vessels helped to avoid lethal outcomes of the Girdlestone operation.

Discussion Revision THA requires careful planning and an interdisciplinary approach with the help of a clinical pharmacologist, microbiologist, plastic or angiosurgeon. PJI is associated with a high risk of recurrence that would require two-stage, three-stage surgical interventions. With the bone deficiency of the acetabulum and the proximal femur the Girdlestone operation is performed as the final procedure with resultant significant decrease in the functional adaptation of patients.

Conclusion Careful preoperative preparation of patients with unstable hip replacement components including migration of the acetabular component into the pelvic cavity and associated PJI would help to avoid such a devastating complication as great vessel injury.

1. Ratliff AH. Arterial injuries after total hip replacement. J Bone Joint Surg Br. 1985;67(4):517-8. doi: 10.1302/0301-620X.67B4.4030843

2. Wasielewski RC, Crossett LS, Rubash HE. Neural and vascular injury in total hip arthroplasty. Orthop Clin North Am. 1992;23(2):219-35.

3. Nachbur B, Meyer RP, Verkkala K, Zürcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res. 1979;(141):122-133.

4. Barrack RL. Neurovascular injury: avoiding catastrophe. J Arthroplasty. 2004;19(4 Suppl 1):104-7. doi: 10.1016/j.arth.2004.02.013

5. Shoenfeld NA, Stuchin SA, Pearl R, Haveson S. The management of vascular injuries associated with total hip arthroplasty. J Vasc Surg. 1990;11(4):549-555. doi: 10.1016/0741-5214(90)90301-P

6. Parvizi J, Pulido L, Slenker N, Macgibeny M, Purtill JJ, Rothman RH. Vascular injuries after total joint arthroplasty. J Arthroplasty. 2008;23(8):1115-21. doi: 10.1016/j.arth.2008.02.016

7. Prokhorenko V.M., Mashkov V.M., Mamedov A.A., Dolgopolov V.V. Features of revision hip arthroplasty: prolapse of the acetabular component into the pelvis cavity. Acta Biomedica Scientifica. 2013;(6):49-58. (In Russ.)

8. Wera GD, Ting NT, Della Valle CJ, Sporer SM. External iliac artery injury complicating prosthetic hip resection for infection. J Arthroplasty. 2010;25(4):660.e1-4. doi: 10.1016/j.arth.2009.03.006

9. Moura DL, Moreira M, Antunes L, et al. External iliac artery laceration caused by hip prosthesis migration. Rev Bras Ortop (Sao Paulo). 2019;54(5):597-600. doi: 10.1016/j.rbo.2017.09.020

10. Giaretta S, Micheloni GM, Mosconi F, et al. A vascular lesion in hip revision arthroplasty: a case report. Acta Biomed. 2021;92(S3):e2021031. doi: 10.23750/abm.v92iS3.11818

11. Beguin L, Feugier P, Durand JM, et al. Risque vasculaire et arthroplastie totale de hanche [Vascular risk and total hip arthroplasty]. Rev Chir Orthop Reparatrice Appar Mot. 2001;87(5):489-98.

12. Smith DE, McGraw RW, Taylor DC, Masri BA. Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg. 2001;9(4):253-7. doi: 10.5435/00124635-200107000-00005

13. Ahmad MA, Biant LC, Tayar R, et al. A manoeuvre to facilitate acetabular component retrieval following intra-pelvic migration. Hip Int. 2009;19(2):157-9. doi: 10.1177/112070000901900215

14. Kotela A, Lorkowski J, Chmielewski D, et al. Revision hip arthroplasty in patient with acetabulum migration into subperitoneal space-a case report. Medicina (Kaunas). 2020;57(1):30. doi: 10.3390/medicina57010030

15. Girard J, Blairon A, Wavreille G, et al. Total hip arthroplasty revision in case of intra-pelvic cup migration: designing a surgical strategy. Orthop Traumatol Surg Res. 2011;97(2):191-200. doi: 10.1016/j.otsr.2010.10.003

16. Preston JS, Mennona S, Kayiaros S. Phlegmasia cerulea dolens and external iliac vein disruption after revision total hip arthroplasty. Arthroplast Today. 2017;4(4):401-406. doi: 10.1016/j.artd.2017.09.005

17. Mesfin A, Lum YW, Nayfeh T, Mears SC. Compartment syndrome in patients with massive venous thrombosis after inferior vena cava filter placement. Orthopedics. 2011;34(3):229. doi: 10.3928/01477447-20110124-23

18. Voloshin VP, Galkin AG, Oshkukov SA, et al. Additive technologies in the management of patients with extensive lower limb bone defects. Genij Ortopedii. 2021;27(2):227-231. doi: 10.18019/1028-4427-2021-27-2-227-231

19. Oshkukov SA. Surgical treatment of hip and knee periprotary infection: Kand. Dis. Мoscow; 2017:153. Available at: https://www.dissercat.com/content/khirurgicheskoe-lechenie-periproteznoi-infektsii-tazobedrennogo-i-kolennogo-sustavov. Accessed May 31, 2023.