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

Abstract

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.

Intra-abdominal removal of a displaced hip prosthesis

“…Displaced arthroplasty components may be caused by trauma, infection, aseptic loosening, or excessive acetabular reaming leading to intrapelvic migration. Injury to the vasculature during arthroplasty surgery is rare, with a reported frequency of 0.008–0.67%, 1 although this is increased when intrapelvic surgery is required to remove displaced components. Morbidity such as limb loss may be significant, and mortality rates of 7% are quoted in the literature.…”

“…Morbidity such as limb loss may be significant, and mortality rates of 7% are quoted in the literature. 1,2 As well as damage to the vasculature, intrapelvic displacement of arthroplasty components beyond the pelvic inlet may damage the sciatic and obturator nerves, the ureters, bladder, bowel and pelvic organs.…”

Unique case of delayed external iliac artery pseudoaneurysm after a remote total hip arthroplasty

“…Delayed intrapelvic complications secondary to hip arthroplasty failure are rare. These can result by intrapelvic cup migrations secondary to infection, injury, mechanical loosening and other causes and from the inserted hardware so long that it penetrates the pelvic cavity 1. Of these, the most common complications involve the external iliac with fewer than 30 cases reported in the literature 2.…”

“…Of these, the most common complications involve the external iliac with fewer than 30 cases reported in the literature 2. Vascular complications could happen due to the close relation of the anterior cortex of the acetabulum to the external iliac artery, typically less than 1 cm, although it is protected by iliopsoas muscle 1…”

Revision hip replacement with retention of the acetabular component for intrapelvic cup migration

“…1 Although rare, the frequency of this complication is increasing, mainly because of increasing life expectancy, the growing number of prosthetic implantations, and the greater frequency of mechanical loosening after THA. 2 Revision total hip replacement in patients with displaced intrapelvic migration of the acetabular component is a complex problem that poses several challenges to the operating surgeon while placing patients at a higher risk for complications such as neurovascular injury, involvement of pelvic organs, and potentially death. 1 Revision surgery using a multidisciplinary approach and either a retroperitoneal or a transperitoneal approach have been described.…”