Abstract

Background: Arterial injury caused by hip fracture is not commonly encountered. We report acase of pseudoaneurysm of the profundafemor is artery that presented 13 month safter internal fixation of an intertrochanteric hip fracture. The study was conducted at BYL Nair Charitable Hospital, Mumbai. Casedescription: An 84-year-old female presented to us with a 4 month history of increasing groin pain, inability to bear weight through the affected limband swelling in the right groin. She had under gone Dynamic Hip Screw fixation for an unstable three part intertrochanteric fracture elsewhere 14 months prior to this. She had no medical comorbidity apart from hypertension, which was well-controlled and anemia.

Clinical examination demonstrated adiffuse swelling in the right femoraltri angle, which was cool to touch, non fluctuant and non pulsatile. Radiographs demonstrated superior cut out of the compression screw and nonunion of the fracture. ACT scan and Duplexscan showed a large pseudoaneurysm of the profunda femoris artery. She underwent removal of the implant and conversion of this to acemented hemiarthroplasty. The pseudoaneurysm was explored and ligated during the same procedure. She was discharged home two weeks post surgery. A year later following the surgery she was asymptomatic and was moving unaided. Conclusion: Arterial injury following fixation of hip fractures is rare and greater awareness of this complication should lead to earlier detection and effective treatment.

Case Report

A 84-year-old female, who had no prior remarkable illness, was admitted in our hospital with a 3-month history of groin pain, swelling in the right upper thigh and an inability to bear weight through the affected extremity. She had no additional medical comorbidity apart from anemia and hypertension, which was well-controlled on anti-hypertensive medication. The patient had an unstable 3 part intertrochanteric fracture, which was fixed elsewhere 14 months prior to current admission with an AO Dynamic Hip Screw (90mmlag screw and 4 hole 135° barrel plate). She was discharged home a week after the surgery and was moving with a walking frame.

Within a few months of surgery she experienced marked pain in the right groin; this was preceded by a swelling in the upper thigh. On examination, there was a globular, nonpulsatile, firm swelling in the right femoral triangle measuring 10 cm x 5 cms, with enlarged overlying veins. No bruit was palpable over the swelling. Movements of the right hip were globally restricted and painful and she could move with marked difficulty with a walking frame. Inguinal lymph nodes were not enlarged and distal pulses were wellfelt.

Plain radiographs demonstrated implant failure evidenced by superior cut out of the compression screw (Fig. 1) and non union of the fracture. Acontrast-enhanced CT scan of the hip was performed, which showed a large pseudoaneurysm of profunda femoris artery with patchy intramural calcification (Fig. 2). A Duplex Scan (Fig. 3) demonstrated the pseudoaneurysm more clearly, which measured 12.04x7.33cms.

A joint Orthopedic and Vascular reconstruction was undertaken. The failed implant was removed and the hip was reconstructed with a cemented Charnley stem with a large diameter bipolar head (Fig. 4). The pseudoaneurysm was found to arise from the posterior wall of the profunda femoris artery and was carefully dissected and ligated at its origin from the profunda femorisartery.

The patient was mobilized full weight- bearing in the postoperative period. Six months post surgery this patient is mobilizing full weight bearing without any walking aids andpain.

Discussion

The profunda femoris artery is the largest branch of femoral artery and provides major blood supply to the thigh muscles. It arises from the lateral side of the femoral artery within the femoral triangle about 4 cm inferior to the inguinal ligament. Branches include the medial femoral circumflex, lateral femoral circumflex and four perforating branches. Acute arterial injury following intertrochanteric fractureis rare. A pseudoaneurysm often presentslate with a proximal thigh swelling increasing pain and progressive anemia.

The majority of reported cases have been caused by drill or screw penetration of the artery, which usually remain unrecognized at the time of surgery and present months or years later with the formation of pseudoaneurysms.

Most previous authors have stressed the need to prevent traumaticaneurysm of the profunda femoris artery duringoperations on the hip by careful drilling, proper selection of screw length and a generally careful surgical technique. Care should be taken when drilling to avoid penetration of the artery by the drill tip by using short drillbitsorguards.

Figure 1. Non union and implant cut out.

Figure 2. CT of pseudoaneurysm

Figure 3. Duplexs can showing pseudoaneurysm

Suggested Reading

1. Bassett FH, Houck WS. False aneurysm of the profunda femoris artery after subtrochanteric osteotomy andnail-platefixation.JBoneJointSurgAm1964;46:583-5.
2. Keel JD, Eyers KS. Vascular injury by an intertrochanteric fracture fragment. Injury 1993;24(5): 350-2.
3. Abraham E, Pankovich AM, Jansey F. False aneurysm of the profunda femoris artery resulting from intertrochantericfracture.Acasereport.JBoneJointSurgAm1975;57(6):871.