Ankylosing spondylitis (AS) is an inflammatory rheumatologic disease characterized by inflammation and progressive structural damage of the affected joints. Hip involvement often results in severe deformities and significant impairment on function. Although, tremendous progress has been made in conservative management for AS, effective prevention strategies for hip involvement and long-term need for total hip arthroplasty (THA) remain indefinite. When hip involvement has progressed to intractable pain and disability, THA is still the most effective treatment strategy to relieve pain and restore function. However, certain AS-specific problems regarding "preoperative preparation," "intraoperative difficulties," "perioperative pharmacological management," "postoperative physiotherapy," "operation benefits," and "operation complications" need more concern and further discussion.

Management of hip involvement in ankylosing spondylitis

There are an increasing number of vascular complications after hip replacement, some of which can be life-threatening. However, there are few reports of lower limb ischemic symptoms after undergoing an otherwise uncomplicated classic total hip replacement. We report a patient with low weight who developed postoperative limb ischemia resulting from blood clots caused by insertion of a Hohmann retractor close to small anterior acetabular osteophytes. Ultrasonography and angiography revealed her symptoms to be the result of femoral artery intimal injury with lower extremity arterial thrombosis, which led to pain, numbness, and decreased skin temperature. The patient underwent timely percutaneous intervention with a femoral artery stent, which relieved her symptoms. The discussion reviews femoral artery injury during total hip arthroplasty.

Femoral artery injury during total hip arthroplasty.

Die iatrogene Gefäßverletzung der Extremitäten

Arterial injuries following total hip arthroplasty (THA) are uncommon and are usually related to revision THA. Deep external pudendal artery injury and delayed bleeding due to percutaneous adductor tenotomy during THA has not been reported.A 62-year-old man with bilateral hip osteoarthritis and ankylosing spondylitis was treated with right cementless THA. Persistent severely limited hip abduction after prosthetic implantation required a percutaneous adductor tenotomy, which was performed bilaterally. No clinical signs of bleeding existed postoperatively. On postoperative day 3, the patient had a hypotensive attack, his right anteromedial thigh at the tenotomy site was distended, and the hemoglobin was 5.9 g/dL. Computed tomography angiography of the iliac and femoral vessels showed a right hematoma medial to the common femoral artery, with active contrast extravasation. Volumetric data reconstruction revealed active bleeding from the right external pudendal artery into an inguinal collection. Angiography was performed by the standard Seldinger technique via the contralateral femoral artery. A guiding catheter was placed as near to the lesion as possible. A microcatheter system and microguidewire were used for superselective catheterization, and 2 embolization coils were used to control the bleeding. The patient remained hemodynamically stable and was discharged 12 days later. Two-year follow-up was uneventful.The deep external pudendal artery may be injured during percutaneous adductor tenotomy, especially in patients with fragile arterial walls, and life-threatening complications may occur. Angiography and embolization are the best treatment options.

Deep external pudendal artery injury after percutaneous adductor tenotomy during THA in ankylosing spondylitis.

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Deep external pudendal artery injury after percutaneous adductor tenotomy during THA in ankylosing spondylitis.