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Home > Case Presentation

Introduction

Acetabular fractures are considered a major hip injury jeopardising the joint long term. An adequate anatomical reduction is associated with better outcomes [1-4]. The ilioinguinal approach is one of most common approaches in treating acetabular fractures, either alone or combined with a Kocher-Langenbeck approach [4]. Intraoperative haemorrhage leading to haemodynamic instability maybe associated with an ilioinguinal approach but this is rarely encountered [4, 5]. When it is, it maybe a result of: injury to the internal iliac artery from the initial insult, clot dislodgement during fracture manipulation, or an iatrogenic injury - including damage to the corona mortis [4, 6, 7]. Any intraoperative haemorrhage should be immediately addressed by careful exploration and repair via ligation, intraoperative embolization, packing, or percutaneous selective arteriographic embolization [6, 7]. In this report, we present an intraoperative haemorrhage from an iliac nutrient foramen. Since it has not been referred to previously in the literature even the experienced surgeon may fail to recognise it.

Case report

A 35-year-old lady presented to our institute having been struck by a motor vehicle. The patient was thrown several metres and remained unconscious for almost 20 minutes at scene. She was transferred to the nearest trauma centre for primary management.

Following examination and imaging, injuries were recorded as:

1) Displaced fractures of the right acetabulum(Figure 1)

2) Burst fracture L3/4 vertebrae

3) Concussion.

Figure 1: Displaced fractures of the right acetabulum

After resuscitation, the patient was admitted for further treatment. An open reduction and internal fixation to manage the acetabular fracture was performed 10 days later. An Ilioinguinal combined with Kocher-Langenbeck approach was used. Two constructs of plates and screws were placed to maintain the reduction of the fractures(Figure 2, 3 and 4). Several days later the patient was discharged.

Figure 2: Post ORIF Film 1

Figure 3: Post ORIF Film 2

Figure 4: Post ORIF Film 3

One month following the first operation, the patient presented to our institute complaining of pain and limited movement of the hip. Repeat radiographs were performed, including: Anterioposterior views, Judet views, and a Computed Tomograph with three-dimensional reconstruction. A postoperative both column right acetabular fracture with poor reduction was confirmed. The reduction was decided to be the main cause of the patient's complaint, and revision surgery was performed to alleviate symptoms. No surgical contraindications were revealed during preoperative examination.

We approached via the previous surgical incision to expose the fracture. During the operation, scar tissue dissection and removal of the previous metal work proved lengthy and troublesome. Meticulous care was taken though throughout surgery to protect the main artery and nerves. The posterior and anterior columns were fixed with plates and screws as shown in Figures 5, 6 and 7. During the operation, the patient received an estimated 11,000ml of blood, inclusive of 5700ml of blood salvaged by cell saver and 28 units of donor packed red cells. Late in the operation the patient demonstrated hemodynamic instability with a fall in CVP to 9mmHg and tachycardia of 130 BPM with a blood pressure of 120/70mmHg. We noticed bleeding from the second window of the approach but failed to identify the bleeding source in the first instance. We therefore packed the pelvic cavity to gain haemostasis using 11 pieces of gauze and 3 gauze pads, and closed the incision as soon as possible. The number of gauze and gauze pads left inside the incision were checked by the nurses and the surgeon. The patient was subsequently transferred to the intensive care unit without delay.

Figure 5: Post final operation Film 1

Figure 6: Post final operation Film 2

Figure 7: Post final operation Film 3

Two days later, the patient was stable and returned to theatre. A team of interventional radiologists were on standby in case of on-going haemorrhage amenable to intraoperative arteriographic embolization. The anterior incision was opened to remove all gauze and gauze pads packed inside and a repeat attempt to find the bleeding source was made. An iliac nutrient foramen was found to be oozing, and subsequently was packed with bone wax. No further active haemorrhage was detected. The incision was closed following copious irrigation with saline and placement of drain both subcutaneously and deep in the pelvis. The patient was transferred back to the intensive care unit for monitoring postoperatively.

The patient developed a persistently raised temperature and white blood cell count during the following six days. On exploration of the wound in theatre, a haematoma was identified and drained, most soft tissues were found to be viable and uninfected. Drains were left in the wound as per the previous operation.

Five days later, an inflammatory response including raised temperature accompanied with persistent bloody ooze from the wound site was observed. We decided to perform wound debridement once again and the patient returned to the operating theatre. During the operation necrotic tissue was debrided leaving clean tissue edges. Partial proximal cortex of iliac crest along with neighbouring metal work was removed to aid healing. Two catheters were left in wound as irrigation catheters. After this operation the patient was transferred to general ward and received ten days of irrigation. After a total of 46 days of inpatient stay, the patient was discharged uneventfully. At 42-month follow-up she was pain free and ambulating without assistant devices (Figure 8, 9 and 10).

Figure 8: Hip function at 42 months following final operation - Internal rotation

Figure 8: Hip function at 42 months following final operation - External rotation

Figure 8: Hip function at 42 months following final operation - Flexion

Discussion

The patient’s age, poor reduction in the first operation and resulting hip pain and dysfunction were appropriate indications for revision surgery [10, 11]. Results of total hip arthroplasty (THA) for delayed acetabular fractures are reliable and comparatively less technically demanding. However, THA should be reserved for two general situations:

1) Acute fractures in the elderly patient with extensive osteoporosis, combined acetabular and femoral neck fractures and pathological fractures [9].

2) In the treatment of the sequelae of acetabular fractures, namely post-traumatic arthritis or osteonecrosis [10].

Our patient did not meet either of these criteria. Furthermore, Johnson et al [8] reported on a series of patients treated by delayed reconstruction of acetabular fractures between 21 and 120 days following injury. Although the delayed management increases the difficulty of operative treatment it may result in a significantly improved outcome. In this case, the procedure was challenging but the final reduction proved excellent according to Matta criteria with the long-term outcome scoring 'excellent' using the Harris hip scoring system.

Intraoperative haemorrhage may be encountered during the reconstruction of delayed acetabular fractures due to the wide dissection and exposure required to overcome difficulties such as soft tissue contractures and loss of anatomical markers. This haemorrhage is therefore a leading cause of death. Intraoperative blood loss during acetabular fracture surgery is associated with injury involving an acute laceration of the superior gluteal artery, corona mortis or a delayed rupture of a pseudo-aneurysm. Once recognised, the bleeding source needs to be addressed with careful exploration, ligation or embolization and/or packing. Vascular injury associated with acetabular fractures is rare in the literature [12]. This report is thought by the authors to be the first describing iliac nutrient foramen oozing as major bleeding source encountered during the ilioinguinal approach to the acetabulum and therefore, worth particular attention when considering revision surgery.

Conclusion

The management of delayed acetabular fractures is still a challenging job even with improved surgical techniques. An ORIF by an experienced surgeon to gain a good reduction of the dislocation is suggested in the majority of literature. The ilioinguinal approach is widely used for repairing acetabular fractures. Surgeons should be familiar with the local anatomy and know how to address the intraoperative complications such as active haemorrhage despite its rare occurrence. Our case report highlights the iliac nutrient foramen as a potential bleeding source, which can cause significant mortality if left untreated. Packing with bone wax was an easy and effective treatment.

Original Author: Dr J. Wang, Beijing, China

References:

  1. Letournel, E., Acetabulum fractures: classification and management. Clin Orthop Relat Res, 1980(151): p. 81-106.
  2. Matta, J.M. and P.O. Merritt, Displaced acetabular fractures. Clin Orthop Relat Res, 1988(230): p. 83-97.
  3. Mayo, K.A., Open reduction and internal fixation of fractures of the acetabulum. Results in 163 fractures. Clin Orthop Relat Res, 1994(305): p. 31-7.
  4. Letournel, E., The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res, 1993(292): p. 62-76.
  5. Matta, J.M., Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. J Orthop Trauma, 2006. 20(1 Suppl): p. S20-9.
  6. Karkare, N., et al., Anatomical considerations of the internal iliac artery in association with the ilioinguinal approach for anterior acetabular fracture fixation. Arch Orthop Trauma Surg, 2011. 131(2): p. 235-9.
  7. Moreno, C., et al., Hemorrhage associated with major pelvic fracture: a multispecialty challenge. J Trauma, 1986. 26(11): p. 987-94.
  8. Johnson, E.E., et al., Delayed reconstruction of acetabular fractures 21-120 days following injury. Clin Orthop Relat Res, 1994(305): p. 20-30.
  9. Sermon, A., P. Broos and P. Vanderschot, Total hip replacement for acetabular fractures. Results in 121 patients operated between 1983 and 2003. Injury, 2008. 39(8): p. 914-21.
  10. Haidukewych GJ: Acetabular fractures: the role of arthroplasty. Orthopedics 2010, 33:645.
  11. Ranawat A, Zelken J, Helfet D, Buly R. Total hip arthroplasty for posttraumatic arthritis after acetabular fracture. J Arthroplasty. 2009. 24(5): 759-67
  12. Chen AL, Wolinsky PR, Tejwani NC. Hypogastric artery disruption associated with acetabular fracture. A report of two cases. J Bone Joint Surg Am. 2003. 85-A(2): 333-8.

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