External iliac pseudoaneurysm secondary to medial wall penetration of an acetabular screw: a rare cause of total hip arthroplasty failure 15 years after implantation

Abstract

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.

Keywords: Arthroplasty; Complication; Pseudoaneurysm; Revision; Total hip; Vascular.

Figure 1

(a) Anterior-posterior pelvis radiograph demonstrating bilateral total hip arthroplasty with no hardware complications. Of note, on this single view, there is no obviously malpositioned hardware in the left hip or soft tissue masses. (b) Frog-leg lateral view of the left hip, again with no hardware complications or soft tissue masses.

Figure 2

T2-weighted midsagittal cut of the lumbar spine demonstrating multilevel degenerative changes and canal stenosis, which is severe at L3-4.

Figure 3

(a) Coronal cut of noncontrast CT of the pelvis demonstrating significant medial wall perforation (>2 cm) of a left-sided acetabular screw. (b) Axial cut from the same examination demonstrating the extent of medial screw penetration, and its termination in the asymmetric fullness within the left iliacus muscle.

Figure 4

(a) Axial cut of noncontrast CT demonstrating initial left external iliac PSA that was underappreciated. Red arrow shows the location of the screw in the small PSA. (b) Three-dimensional reconstruction of the same noncontrast CT scan demonstrating mass effect in the area of PSA confused with myositis. (c) Axial image of CT angiogram done 2 months later showing large PSA with screw in the center (blue arrow). (d) Three-dimensional reconstruction of the CT angiogram demonstrating the large PSA and its mass effect on the EIA compared to image B.

Figure 5

(a) Large PSA seen as a large, circular contrast extravasation surrounding the artery. Arrow shows the acetabular screw. (b) Demonstration of the covered stent grafts (arrow) after relining the injured external iliac vessels at risk, which is what occurred in this case.

Figure 6

Immediate postoperative anteroposterior radiograph of the pelvis demonstrating removal of hardware with retention of original osteointegrated components.