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ORIGINAL ARTICLE

Pseudoaneurysm Of Medial Branch Of The Profunda Femoral Artery Following Dynamic Hip Screw Fixation Of Proximal Femoral Fracture. A Case Report

Thomas Papageorgiou, Ioannis Gigis, Vasilios Goulios, Theodoros Beslikas, Ilias Bisbinas, John Christoforidis

2nd Orthopaedic Department, Aristotle University of Thessaloniki, Greece

Address for Correspondence:

Ioannis Gigis
2nd Orthopaedic Department,
Aristotle University of Thessaloniki,
Greece

E-mail: jgigis@otenet.gr

Abstract:

Arterial injury is a rare complication of hip fracture surgery. Pseudoaneurysm of the femoral artery after internal fixation of a trochanteric fracture is caused primary by overpenetration of the artery by a drill, screw, or, less commonly, displaced fracture fragments [7]. We present a case in which an arterial injury was discovered 3 days after open reduction and plate fixation with dynamic hip screw device of a comminuted intertrochanteric hip fracture and was successfully treated by embolisation.

J.Orthopaedics 2010;7(1)e10

Keywords:

Pseudoaneurysm; Proximal femoral fracture; Dynamic hip screw fixation; Profunda femoral artery.

Introduction:

Dynamic hip screw fixation is one of the most commonly performed orthopaedic operations[2]. Pseudoaneurysm of the profunda femoral artery after proximal femoral fracture fixation is rare and diagnosis is often delayed [3, 4, 6, 9]. Pseudoaneurysms typically present late and signs such as persistent hip pain, thigh swelling and the presence of a pulsatile mass and unexplained anaemia may suggest the diagnosis. Early diagnosis and appropriate intervention is the essential mode of management.

Case Report:

In our department, an 80 years-old lady underwent a fixation of a complicated proximal femoral fracture (Fig. 1). The osteosynthesis was done with a dynamic hip screw device (Fig. 2). Apart from an immediate three-unit blood transfusion for replacement of intra-operative blood loss, she initially made a straightforward recovery. On the 3rd post-operative day however, she developed a tense, tender swelling in her right thigh and anaemia was found which required blood transfusion. It was then investigated in the form of duplex ultrasound scanning which identified a 6 to 8cm haematoma with areas of both damped and pulsatile flow (Fig. 3).

Figure 1:  Intratrochanteric fracture of the left hip.

Figure 2: Dynamic hip screw fixation of the intratrochanteric fracture.

Figure 3: Duplex ultrasound scanning identifying a 6 to 8cm haematoma on the left femur.

Figure 4: CT angiogram confirmed the presence of pseudoaneurysm of medial branch of the profunda femoral artery.

Figure 5:  Embolisation of the profunda femoral artery

As it was unclear whether the pulsatile flow was actually within the haematoma or simply lying beneath it, coupled with evidence of ongoing coagulation (represented by the areas of damped flow), a conservative management approach was pursued. Unfortunately, the patient required repeated blood transfusions and correction of a coagulopathy over the following 10 days, despite remaining haemodynamically unstable. We therefore proceeded to  CT angiogram, which confirmed the presence of pseudoaneurysm of medial branch of the profunda femoral artery (Fig. 4).

She was then successfully treated with embolisation under fluoroscopic control in the profunda femoris artery immediately related to the origin of the pseudoaneurysm (fig. 5). There was no evidence of recurrence at 3-month follow-up.

Discussion :

Pseudoaneurysm of the profunda femoral artery after proximal femoral fracture fixation is rare [2, 4, 6, 9]. Iatrogenic injury is caused by over-penetration of the drill bit or sharp instrument while applying dynamic compression plate, retractor tip pressure or by fracture edges during manipulation [5, 10]. The diagnosis is usually delayed because pain, haematoma and anaemia are attributed to post-operative complications and are non-specific [3, 4]. Clinical signs such as a tense thigh swelling, hip pain (as a direct pressure effect), persistent or recurrent anaemia from continued haemorrhage, neurological compromise and distal ischaemia due to impaired blood flow or microembolisation should suggest the possibility of false aneurysm formation. Our case presented unusually early, as the patient was still in hospital, recovering from her initial hip surgery.

The artery could either be lacerated or punctured by the drill bit or sharp instrument over-penetration [5]. While applying clamps to hold the plate against the bone the vessel might fix against the medial wall of the femur making it more susceptible for injury while drilling. The chances of vascular injury could be reduced if overpenetration of the drill bit is avoided into the medial soft tissues, using proper sized screws and careful placement of the clamps used to hold the plate against the femur.

There should be low threshold to diagnosis because though rare it can be a serious complication. Diagnosis is best confirmed by the duplex scan or a CT angiogram and endovascular embolisation is the standard management of this condition [4].

Conclusion:

Pseudoaneurysm of the profunda femoral artery following dynamic hip screw fixation of a femoral fracture is rare and presentation is usually late. High index of suspicion is required for early diagnosis. Careful use of sharp instruments, drill bits, clamps and retractors during the operation especially when dealing with complicated fracture pattern. Duplex scanning often establishes the diagnosis but arteriography may be required.

The advent of interventional radiology has allowed minimally invasive treatment of false aneurysms and we present a case of successful embolisation of an iatrogenic profunda femoral artery pseudoaneurysm which is the standard management in this condition.

Reference :

  1. Barnes DI, Broude HB. False aneurysm of the profunda femoris artery complicating fracture of the femoral shaft and treated by transcatheter embolization. A case report. S Afr Med J. 1985; 67:824-826

  2. Canbaz S, Acipayam M, Gurbuz H, Duran E. False aneurysm of perforating branch of the profunda femoris artery after external fixation for a complicated femur fracture. J Cardiovasc Surg (Torino). 2002; 43:519-521

  3. Chong KC, Yap EC, Lam KS, Low BY. Profunda femoris artery pseudoaneurysm presenting with triad of thigh swelling, bleeding and anaemia. Ann Acad Med Singapore. 2004; 33:267-269

  4. Fernandez Gonzalez J, Terriza MD, Cabada T, Garcia-Araujo C. False aneurysm of the femoral artery as a late complication of an intertrochanteric fracture. A case report. Int Orthop. 1995; 19:187-189

  5. Fordyce A. False aneurysm of the profunda femoris artery following nail and plate fixation of an intertrochanteric fracture. Report of a case. J Bone Joint Surg [Br]. 1968; 50:141-143

  6. Kleintz R, Nolte U. [Development of aneurysma spurium of the arteria profunda femoris as a late complication of DHS osteosynthesis]. Unfallchirurg. 1993; 96:39-40

  7. Laohapoonrungsee A, Sirirungruangsarn Y, Arpornchayanon O. Pseudoaneurysm of profunda femoris artery following internal fixation of intertrochanteric fracture: two cases report. J Med Assoc Thai. 2005; 88:1703-1706

  8. Manner M, Rosch B, Roy K. [Vascular injuries complicating osteosynthesis in proximal femur fractures]. Unfallchirurg. 1999; 102:227-231

  9. Murphy PG, Geoghegan JG, Austin O, More-O'Ferrall R, Quinlan WR, Keaveny TV. Pseudoaneurysm of the profunda femoris artery due to intertrochanteric fracture of the hip. Arch Orthop Trauma Surg. 1999; 119:117-118

  10. Obry C, Mertl P, Woestelandt T, Vives P. [False aneurysm of the profunda femoris artery after fracture of the upper end of the femur. Apropos of a case]. Rev Chir Orthop Reparatrice Appar Mot. 1988; 74:585-587
     

This is a peer reviewed paper 

Please cite as: Ioannis Gigis: Pseudoaneurysm Of Medial Branch Of The Profunda Femoral Artery Following Dynamic Hip Screw Fixation Of Proximal Femoral Fracture. A Case Report.

J.Orthopaedics 2010;7(1)e10

URL: http://www.jortho.org/2010/7/1/e10

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