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Institute for Joint Replacement, Department of Orthopedic Surgery, Kyoto Katsura Hospital, Yamada-hirao-cho, Nishikyo-ku, Kyoto 615-8256, Japan
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A 79-year-old woman was diagnosed with osteoarthritis of the left hip and scheduled for total hip arthroplasty. As two lesions were detected in branches of the coronary arteries, she was treated with catheter treatment. The patient was receiving anticoagulant treatment, which was suspended eight days before the operation; however, heparin was started at 6 days before the operation and was stopped 9 hours before the operation. On the 2nd postoperative day soon after transfer to the wheel chair, she was feeling unwell and was suffering from severe pain in her left buttock and left thigh. Her blood pressure had decreased to 70 mmHg. During abdominal contrast-enhanced CT, a hematoma was detected in the left iliopsoas muscle. Catheter therapy was started by the cardiovascular department and bleeding had stopped spontaneously. The patient was able to walk with a cane and was discharged on the 40th postoperative day.
Abbreviations: THA: total hip arthroplasty, CT: computed tomography, JOA score: Japanese Orthopaedic Association hip score, HA: hydroxyapatite, PMMA: polymethyl-methacrylate, APTT: activated partial thromboplastin time
Iliopsoas muscle hematomas are relatively rare. They are often complicated with hemophilia in cases involving hemorrhagic risk factors.1) Iliopsoas muscle hematomas can also occur as a rare complication of total hip arthroplasty (THA).2-7) We report a case in which an iliopsoas hematoma occurred after THA for osteoarthritis of the hip joint and perioperative antithrombotic treatment.
79-year-old Japanese female had suffered from left hip joint pain during walking for two years. Her height was 148 cm, and her body weight was 50.6 kg. She had a history of lung cancer and thrombocytopenia and was receiving treatment at our hospital’s Department of Hematology. Three months preoperatively, she was hospitalized for angina at our hospital’s cardiovascular department. Two lesions were detected in branches of the coronary arteries. Right coronary artery which was constricted to 99% was expanded by balloon catheter. The patient’s left hip joint pain worsened during her hospitalization, and she consulted our orthopedic department. Advanced osteoarthritis of the left hip joint was detected on X-rays (Fig. 1-a, ,b).b). Thus, she was diagnosed with osteoarthritis of the left hip, and THA was recommended. Preoperative computed tomography (CT) of the abdomen and pelvis did not detect any abnormal findings, such as swelling of the iliopsoas muscle (Fig. 2). The patient’s Japanese Orthopaedic Association hip score (JOA score)8) was 32 points (Table 1. Pre-operative leg-length discrepancy was 7 mm short for left limb. Total hip arthroplasty was scheduled three months after the cardiovascular catheter treatment.
The patient was receiving antithrombotic treatment (100 mg cilostazol and 200 mg hydrochloric acid ticlopidine), which was suspended eight days before the operation. Instead, as she had normal renal function (Table 2), heparin sodium injection of 15000unit per day by intravenous infusion was started 6 days before the operation and was stopped 9 hours before the operation. A left THA was performed via Dall’s anterolateral approach9) under general anesthesia whilst the patient was in the lateral position. A modern cementing technique combined with the interface bioactive bone cement technique,10-12) in which hydroxyapatite (HA) granules are smeared over the target site (Boneceram P G-2, Olympus Terumo Biomaterials Corp., Tokyo, Japan) just prior to the application of the cement, was used. The HA granules were manufactured by sintering at 1200°C, before being sieved to obtain granules with diameters of 300–600 μm. On the acetabular side, after reaming, pulsatile lavage followed by gauze packing were performed to obtain a dry bony surface during the cement mixing. When the polymethyl-methacrylate (PMMA) bone cement reached the dough stage, the gauze was removed from the acetabulum, and then 2 grams of HA granule were smeared onto the reamed bony surface. Finally, the PMMA bone cement was pressurized, and then a highly cross-linked ultra-high molecular weight polyethylene cup sized 44mm was fixed in place. On the femoral side, after complete containment had been achieved by distal bone grafting, pulsatile lavage followed by gauze packing were performed to obtain a dry bony surface. After 2 grams of HA granules had been smeared on the bony surface, the PMMA bone cement was pressurized, and then an Exeter stem (Stryker Orthopedics, Mahwah, New Jersey)13) was fixed in place. Surgical Simplex P radiopaque bone cement (Stryker Orthopedics, Mahwah, New Jersey) was used as the PMMA bone cement. The operative duration was two hours and seven minutes, and 130 ml of intraoperative bleeding occurred. The fixation of the implant was performed without any problems, and the length of the patient’s left leg was extended by 7 mm. As a result, postoperative X-rays demonstrated that the discrepancy between the lengths of the patient’s legs had improved (Fig. 3). The extension of the hip joint was improved from –5 degrees to 2 degrees. Extension angle of the hip joint was measured in prone position using a goniometer. No problems with the patient’s vital signs were detected after the operation, and her blood pressure did not decrease during or after the operation.
At one postoperative day, no wound bleeding or abnormal swelling of the hip was observed. Thus, the drainage tube was withdrawn, and the patient was able to sit at the edge of her bed. Antithrombotic therapy (100 mg cilostazol, 200 mg hydrochloric acid ticlopidine) was re-started. The patient was able to move uneventfully to a wheelchair with the assistance of a nurse at 09:00 on the 2nd postoperative day. At 11:30, she called a nurse because she was feeling unwell and was suffering from severe pain in her left buttock and left thigh. Her blood pressure was measured immediately, and it was found that it had decreased to 70 mmHg. No femoral nerve paralysis, significant bleeding from the wound, swelling of the wound, or thoracic or abdominal symptoms were observed. A blood test revealed that the patient’s hemoglobin level had fallen to 5.1 g/dl, her prothrombin percentage activity had reduced to 32.1%, and her activated partial thromboplastin time (APTT) had elongated to 111.1 seconds (Table 2). The patient was administered a transfusion of 2 units of concentrated red blood cells. No deep vein thrombosis was detected in the patient’s lower extremities during an ultrasonic echogram. During abdominal contrast-enhanced CT, a hematoma was detected in the left iliopsoas muscle at the L2 and L4 levels (Fig. 4-a, ,b,b, ,c).c). The iliopsoas muscle was enlarged compared with its size on the preoperative CT scan (Fig. 2). We concluded that the mass had been caused by active bleeding because the leakage of contrast media into the left iliopsoas muscle was observed (Fig. 4-b, ,c).c). At 15:30, catheter therapy was started by the cardiovascular department. Contrast medium was selectively injected into the aorta, renal arteries, inferior mesenteric artery, and internal and external iliac arteries, but no contrast media pooling was detected. At 19:00, after it had been confirmed that the bleeding had stopped spontaneously, the patient was transferred to the intensive care unit. After her blood pressure recovered to within the normal range, she was transferred to the general ward on the third postoperative day, and standard rehabilitation therapy was started. A CT scan performed on the 27th postoperative day demonstrated that the hematoma in her iliopsoas muscle had reduced to approximately 60% of its original size (Fig. 5-a, ,b,b, ,c).c). The patient was able to walk with a cane and was discharged on the 40th postoperative day. Her subsequent clinical course was good and asymptomatic. At one postoperative year, X-rays did not detect any problems (Fig. 6), and a CT scan showed that the hematoma had completely disappeared (Fig. 7-a, ,b).b). At 3 years, the patient’s JOA score was 97 points (Table 1), and she was able to walk with a single cane.
The symptoms of iliopsoas muscle hematoma include inguinal pain, flexion of the hip, femoral nerve palsy, mass formation in the iliac fossa, bleeding-related anemia, and constipation.14) In the present case, the patient’s main symptoms were pain extending from the buttocks to the femoral region and hypotension due to anemia. No tenderness or swelling of the inguinal region or femoral nerve palsy was observed. It was reported that hemorrhagic risk factors in patients with hemophilia,15) antithrombotic therapy,16) damage due to exercise or injury, and other unidentified factors10) can cause hematomas of the iliopsoas muscle. As for the causes of iliopsoas muscle hematomas that occur after THA, blood vessel damage caused by drilling or the setting of the screw during the setting of the acetabular component,2-5) and impingement due to malpositioning of the acetabular component6, 7) have been suggested. No reports, however, which described about hemorrhagic shock due to iliopsoas muscle hematoma soon after moving to wheel-chair at 2 days after total hip arthroplasty have been found. It was considered unlikely that the hematoma in the present case was caused by direct blood vessel damage during the operative procedure because the bleeding occurred away from the surgical site and did not start until more than one day after the operation.
As the patient had suffered angina shortly before the operation, the continuation of antithrombotic therapy was necessary to prevent restenosis of the coronary arteries. Because this patient had a history of thrombopenia after aspirin was used orally, cilostazol and ticlopidine were reluctantly used instead of clopidrogel. Blood tests detected a reduction in the patient’s prothrombin percentage activity and an elongation of her APTT. It was thought that heparin was stopped nine hours before operation, an influence continued after the operation. Thus, the continuation of antithrombotic therapy clearly carried a risk of hemorrhaging.
It has been reported that rupturing of the iliopsoas muscle occurs during excessively strong contractions from an extended position.17, 18) Preoperatively, extension of the left hip joint was restricted to –5 degrees. This had improved to 2 degrees at 3 months after the operation. The length of the patient’s left leg was extended by 7 mm, and X-rays obtained after the operation demonstrated that the discrepancy between the lengths of the patient’s legs had reduced (Fig. 3). Therefore, it was considered that the patient’s psoas muscle had been elongated by the THA, and the iliopsoas muscle had been subjected to excessive tension when the patient moved to a wheelchair, which had resulted in bleeding.
Generally treatment of iliopsoas hematomas depends on the speed onset, volume and neurological impairment.16) In the present case there was no need to perform further therapy as the bleeding stopped when a catheter therapy was performed. It had been necessary, however, to perform an embolization for a bleeding point when bleeding had not stopped spontaneously.
In conclusion, the reason of the iliopsoas hematoma of the present case was a combination of mechanical effects on the muscle and insufficient coagulation management. When hemorrhagic shock occurs after THA in cases involving hemorrhagic risk factors, iliopsoas muscle hematoma should be included in the differential diagnoses, and contrast-enhanced CT should be performed as soon as possible.
1. We performed THA for osteoarthritis of the hip joint and continued antithrombotic therapy before the operation. A hematoma developed in the iliopsoas muscle soon after moving to wheel-chair on the second postoperative day.
2. When hemorrhagic shock occurs after THA in cases involving hemorrhagic risk factors, contrast-enhanced CT should be performed promptly in case an iliopsoas muscle hematoma has developed.
The authors did not receive and will not receive any benefits or funding from any commercial party related directly or indirectly to this article.