Broken Acetabular Augmentation cage Causing Multiple Ileal Perforations – A Rare Complication
Vol 1 | Issue 1 | Jan-Apr 2016 | page: 11-13 |Harminder S Sohal, Rakesh Sharma, Neeraj Malhotra, Yadwinder Singh Sohal.
Author: Harminder S Sohal, Rakesh Sharma, Neeraj Malhotra, Yadwinder Singh Sohal.
 Dept. Of Orthopaedics, Govt. Medical College, AMRITSAR, Punjab, India -143001.
 SGRD Medical College, Amritsar, Punjab, India.
Address of Correspondence
Dr. Rakesh Sharma
Dept. Of Orthopaedics, Govt. Medical College, AMRITSAR, Punjab, India -143001.
Email : firstname.lastname@example.org
Background: Complications following total hip arthroplasty (THA) are common. To name a few are loosening, infection, implant migration, nerve palsy and dislocation. We present here a rare case of broken acetabular augmentation cage causing multiple perforations of ileum after three years of total hip replacement and its management with explorative laparotomy.
Case report: In our case, a fifty five year old male patient presented with discharge from surgical site after 3 years of total hip replacement while he was full weight bearing during this period. Suspecting communication with the abdomen, a general surgeon was consulted and exploratory laparotomy was done to repair the perforation in ileal loops and simultaneously the broken cage was removed partially from the abdomen and partially laterally. Patient was in ICU for few days, but he developed speticimia and died in few days after surgery.
Conclusion: There can be numerous complications following THA surgery but the possibility of acetabular cage breakage and migration into abdomen should be kept in mind though its not that common.
Keywords: Arthroplasty, acetabular augmentation cage, laparotomy.
The indications for THA are hip arthritis ,avascular necrosis of hip, fracture of weight bearing part of acetabulum or head of femur and failed osteosynthesis for proximal femur fractures in elderly. There are postoperative complications associated with THA which include dislocation , wound infection, urinary tract infection and deep venous thrombosis  The three early complications are pulmonary embolism, dislocation and deep infection which usually occur within first three to six months. Other complications are inaccurate reduction , loosening or graft migration , malposition especially in rheumatoid patients  and nerve injuries . Our study is to present an unusual case of broken acetabular augmentation cage causing multiple perforation of ileum after three years of total hip replacement which was managed with the help of a general surgeon by repairing the ileal loops and extracting out the broken cage .
A fifty five year old male patient presented with discharge from surgical site and difficulty in weight bearing 3 years after primary total hip replacement done at our institute. The discharge was insidious in onset around 5 months ago. The patient reported significant fall 8 days back but continued to walk full weight bearing. Patient was admitted in the ward and routine investigations, pus culture and X-rays were advised. Radiograph showed that the acetabular cage was broken and displaced far up in the abdomen (Fig. 1). Suspecting communication with the abdomen an ultrasound was done which confirmed the suspicion. Meanwhile culture reports came as Ecoli and appropriate antibiotics were started. Decision of implant removal was taken and general surgeon colleagues was also involved to perform an exploratory laparotomy. Lateral approach was taken through the prior surgical incision on the hip. The dislocated femoral component was removed with ease but acetabular component was found rigidly fixed and with some sharp edges. Simultaneous laparotomy was done and acetabular component were partly removed through abdominal incision and partly laterally (Fig. 2).
Loops of ileum were found adherent to the sharp edge of broken cage (Fig 3) .On careful removal and inspection, the perforation in distal ileum was found and repaired (Fig 3). The abdomen was washed with copious amount of saline and complete hemostasis ensured. A bypass ileostomy was done over two drains, one in Morrison’s pouch and other one in pelvis (Fig 3). The broken cage and the femoral stem were put together to check the completeness of implant removal (Fig. 4). Postoperatively patient was admitted in intensive care unit however he developed frank abdominal infection and septicimia. Patient expired within few day of surgery.
There are numerous complications following THA like malposition, dislocation, infection, component loosening ,nerve injuries[1-9], peri prosthetic fractures perioperative mortality aseptic loosening,recurrent instability, osteolysis, cement disease and limb length inequality .In our case study, we present an unusual complication of broken acetabular cage and its migration into the abdomen in a fifty five year old male due to fracture in acetabulum. The fracture and breakage of acetabkum cage was probably due to fall which was reported by patient 8 days prior to presenting to us. He continued to walk on the fracture and subsequently develop intraabdominal dislocation and perforation. One of the reason for such fracture can be local infection which weakened the bones around the acetabulum and caused fracture dislocation of the cage. This can be an indirect consequence of infection and patients should be advised against full weight bearing in case of deep infection and local osteoporosis. Infected THR cases in these scenario should be revised as soon as possible to avoid such complications.
Possibility of acetabular cage breakage and migration into abdomen is very rare, and in such cases the infection may be due to abdominal contamination. These cases require interdisciplenary approach to tackle intraoperative eventualities.
Such difficult complication require good preoperative planning and preparation of complex hip and abdominal surgeries are to be made. All attempts should be made to remove implant in totality or persistent of infection is a real possibility.
1. Simko P, Braunsteiner T, Vajcziková S. Early primary total hip arthroplasty for acetabular fractures in elderly patients Acta Chir Orthop Traumatol Cech. 2006 Aug; 73(4):275-82.
2. Tabsh I, Waddell JP, Morton J. Total hip arthroplasty for complications of proximal femoral fractures. J Orthop Trauma. 1997 Apr;11(3):166-9.
3. Green DL. Complications of total hip replacement. South Med J. 1976 Dec;69(12):1559-64.
4. Phillips CB1, Barrett JA, Losina E, Mahomed NN, Lingard EA, Guadagnoli E, Baron JA, Harris WH, Poss R, Katz JN. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am. 2003 Jan;85-A(1):20-6.
5. R Poss ; FC Ewald ; WH Thomas ; CB Sledge Complications of total hip-replacement arthorplasty in patients with rheumatoid arthritis. J Bone Joint Surg Am, 1976 Dec;58(8):1130-1133
6. Goodman S, Saastamoinen H, Shasha N, Gross A.Complications of Ilioischial Reconstruction Rings in Revision Total Hip Arthroplasty J Arthroplasty. 2004 Jun;19(4):436-46.
7. Megan A. Swanson, Justin R. Knight, Michael H. Huo, Total Hip Arthroplasty Following Previous Acetabular Fracture Oper Tech Orthop 19:150-154 Published by Elsevier Inc
8. Steven N. Shah, Rachel J. Kaye, BS, Natalie H. Kelly, Edwin P. Su, Douglas E. Padgett,and Timothy M. Wright Retrieval Analysis of Failed Constrained Acetabular Liners The Journal of Arthroplasty Vol. 24 No. 6 Suppl. 1 2009
9. Rajgopal R1, Martin R, Howard JL, Somerville L, MacDonald SJ, Bourne R.Outcomes and complications of total hip replacement in super-obese patients Bone Joint J. 2013 Jun;95-B(6):758-63
10. Pui CM1, Bostrom MP, Westrich GH, Della Valle CJ, Macaulay W, Mont MA, Padgett DE. Increased Complication Rate Following Conversion Total Hip Arthroplasty After Cephalomedullary Fixation For Intertrochanteric Hip Fractures A Multi-center Study J Arthroplasty. 2013 Sep;28(8 Suppl):45-7
11. James L Nutt ,Kleomenis Papanikolaou,Catherine F Kellett Complications of total hip Arthroplasty Original Research Article Pages 272-276;2013 .
12. Makridis KG, Obakponovwe O, Bobak P, Giannoudis PV. Total Hip Arthroplasty after Acetabular Fracture: Incidence of Complications, Reoperation Rates and Functional Outcomes: Evidence Today J Arthroplasty. 2014 Oct;29(10):1983-90.
13. Cooke CC1, Hozack W, Lavernia C, Sharkey P, Shastri S, Rothman RH. Early Failure Mechanisms of Constrained Tripolar Acetabular Sockets Used in Revision Total Hip Arthroplasty J Arthroplasty. 2003 Oct;18(7):827-33.
14. Michael R. Dayton, and Stephen J. Incavo Component Loosening in Total Hip Arthroplasty Volume16,Issue2,June2005,Pages 161-170.
|How to Cite this article: Sohal HS, Sharma R, Malhotra N, Sohal YS. Broken Acetabular Augmentation cage causing Multiple Ileal perforations – A rare complication. Journal of Orthopaedic Complications Jan-April 2016; 1(1): 11-13.|