Pseudoaneurysm of the internal iliac artery caused by proximal femoral nail antirotation following intertrochanteric fracture: a case report

Abstract

Pseudoaneurysm of the internal iliac artery is a very rare complication of intertrochanteric fracture. Here, the case of an 88-year-old female patient, who presented with intense pain following surgery for intertrochanteric fracture of the femur, is reported. Radiography revealed intertrochanteric fracture of the left femur fixed by proximal femoral nail antirotation (PFNA). The PFNA was found to have disassembled, and the screw had penetrated through the acetabulum. As computed tomography (CT) revealed a haematoma behind the acetabulum, CT angiography was immediately performed. A pseudoaneurysm of the internal iliac artery caused by PFNA was revealed. Percutaneous endovascular treatment of the pseudoaneurysm was undertaken on an urgent basis. Three days later, the PFNA was removed, and the fracture was reduced and fixed with locking proximal femoral plate. The patient’s pain was significantly reduced following this corrective surgery. This case illustrates that substandard PFNA surgery for intertrochanteric fracture may result in pseudoaneurysm of the internal iliac artery.

Introduction

Pseudoaneurysms are rare injuries that may be reported following trauma or orthopaedic procedures performed on the proximal femur.^1–5 Presentation may be acute or delayed, ¹ and if not diagnosed properly, this injury can be life threatening. ¹ Pseudoaneurysms of the internal iliac artery are uncommon and are usually associated with trauma.^6,7 To the best of the authors’ knowledge, there are no previously published reports of pseudoaneurysm of the internal iliac artery caused by proximal femoral nail antirotation (PFNA) following femur intertrochanteric fracture.

Case report

This study was approved by the ethics committee of Honghui Hospital, Xi’an University and written informed consent to publish the case was obtained from the patient. An 88-year-old female patient presented at Honghui Hospital, Xi’an University in December 2017 with intense pain in the left hip. Plain radiographs revealed intertrochanteric fracture of the left femur fixed by a PFNA. The PFNA had disassembled and the screw blade of the PFNA had penetrated through the acetabulum (Figure 1). Computed tomography (CT) revealed a haematoma behind the acetabulum, and immediate subsequent CT angiography revealed pseudoaneurysm of the internal iliac artery caused by the screw blade of the PFNA (Figure 2). The patient was haemodynamically stable and in a good general condition.

Figure 1.

Plain radiograph showing intertrochanteric fracture of the left femur fixed by proximal femoral nail antirotation (PFNA). The PFNA had become disassembled, and the PFNA screw blade had penetrated through the acetabulum.

Figure 2.

Computed tomography angiography image that was immediately obtained following the discovery of a haematoma behind the acetabulum, showing pseudoaneurysm of the internal iliac artery caused by the screw blade of the proximal femoral nail antirotation.

The patient had a history of acetabular fractures 2 years previously, for which she attended a clinic at the grassroots level rather than a professional trauma centre to provide a diagnosis and treatment. The grass-roots clinic suggested conservative treatment of the fracture, considering the age of the patient and the large surgical trauma. The patient and her family accepted this suggestion and the patient received conservative treatment in bed at home. Following this treatment, the patient’s pain symptoms were significantly relieved and she was able to move around the home with the aid of a walker. More than 40 days prior to presenting at Honghui Hospital, the patient went to the regional hospital for treatment of intertrochanteric fracture caused by another fall while walking at home. She underwent surgical treatment using PFNA fixation due to left intertrochanteric femur fracture. Following surgery on the left intertrochanteric fracture, the patient had no obvious relief of fracture pain and was unable to walk on the ground. Approximately 20 days following PFNA surgery, the patient felt more pain when turning over in bed, so she returned to the original regional hospital for a follow-up visit. The patient's pain symptoms did not receive the doctor's full attention, however, and she was advised to stay in bed. The patient's pain symptoms did not resolve, so the patient presented at Honghui Hospital. There was no examination of vascular injury prior to attending Honghui Hospital, and after presenting at Honghui Hospital for treatment, due to the limited information provided by X-ray, CT examination was performed and showed a retroacetabular haematoma. Immediate subsequent CT angiography revealed a pseudoaneurysm of the internal iliac artery, and emergency interventional surgery was performed. On the day following the patient’s admission to the Department of Orthopaedic Trauma, percutaneous endovascular pseudoaneurysm treatment was urgently conducted, comprising successful percutaneous transarterial embolization with coils (Figures 3 and 4). Three days following pseudoaneurysm treatment, the PFNA was removed, and the fracture was reduced and fixed with a locking proximal femoral plate (Tianjin Zhengtian Medical Instrument Co., Tianjin, China; Figure 5). An anterior limited contact locking compression plate (LC-LCP; Tianjin Zhengtian Medical Instrument Co.) was added to the surgical treatment due to poor bone mass. The patient’s pain was significantly relieved following this corrective surgery, however, the patient was lost to follow-up, so there is no follow-up imaging, and the patient’s prognosis remains unknown.

Figure 3.

Radiography image showing extravasation of contrast agent in the internal iliac artery.

Figure 4.

Radiography image showing successful coil embolization of the feeding arteries, with no visible extravasation of the contrast agent.

Figure 5.

Plain radiograph showing that the proximal femoral nail antirotation had been removed, and the fracture was reduced and fixed with locking proximal femoral plate. Surgical treatment included the addition of the anterior limited contact locking compression plate (LC-LCP) due to poor bone mass.

Discussion

Pseudoaneurysms of the internal iliac artery may be caused by different mechanisms, ⁷ such as trauma to the abdomen, ⁷ pelvic surgery, intravascular catheterization, ⁸ infection, connective tissue disorders, vasculitis, and erosion secondary to malignancy. ⁹ In 2013, Arthur and colleagues published a report on a patient with pseudoaneurysm of the internal iliac artery due to diverticular disease. ⁸ Pseudoaneurysm of the internal iliac artery has also been reported in a multiparous patient at three months post-curettage, ¹⁰ and in 2008, Bozdag and colleagues reported an oocyte pick-up procedure complicated with internal iliac artery pseudoaneurysm. ¹¹ Pseudoaneurysm of the internal iliac artery has been reported following vaginal hysterectomy, ¹² and Rottoli et al. (2014) ¹³ reported two cases of bleeding internal iliac artery pseudoaneurysm following extended resection for advanced rectal cancer. To the best of the authors’ knowledge, the present case report is the first to describe pseudoaneurysm of the internal iliac artery following orthopaedic repair due to intertrochanteric femur fracture.

The reason for internal iliac artery pseudoaneurysm in the present case may be complex. It is possible that poor restoration of the intertrochanteric femur fracture in the first operation, and disassembly of the PFNA due to improper implantation, resulted in movement of the screw blade. Penetration of the screw blade into the acetabulum and puncture of the internal iliac artery resulted in the pseudoaneurysm formation, and may have been connected to the dated acetabulum fracture. However, a crucial factor may have been improper implantation of the PFNA. According to the present authors’ personal experience, in developing countries, and particularly in western China, primary trauma orthopaedic doctors, especially young doctors, lack standardized training in the operation of surgical instruments. In addition, professional and perfect surgical instruments may not be available in primary hospitals. In many primary hospitals, surgery conducted by young, relatively inexperienced doctors relies upon the guidance provided by those with higher seniority, with a lack of specialized and standardized training. This situation leads to the scenario whereby young doctors at the primary level are unable to operate with specialised surgical instruments in a standard way. Such unregulated practices can have irreparable catastrophic consequences for patients and may increase healthcare costs. ¹⁴ Thus, there is a need for more professional surgical training for primary trauma orthopaedic surgeons in western China.

Surgical management and exploration of iliac artery branch injuries is described to be extremely difficult,^6,15 and historically, endovascular techniques have been preferred for the management of internal iliac artery pseudoaneurysms. Occlusion of the internal iliac artery can result in multiple sequelae, including lumbosacral plexus ischaemia, buttock necrosis and claudication, colorectal infarction, and impotence.^6,15,16 Buttock claudication, the most common of these complications, is estimated to occur in 28–40% of patients, with severe debilitating claudication in 9%. ¹⁶ In the present case, percutaneous endovascular treatment of the pseudoaneurysm was undertaken on an urgent basis. Considering the advanced age of the patient, the problem of pseudoaneurysm needed to be solved quickly, and due to the high cost of covered stents and requirement of long-term anticoagulation therapy following surgery, and the poor economic conditions of the patient, embolization with coils was adopted as a solution to the problem.

The present case highlights the importance of standardized surgical instrument operation in the treatment of femur intertrochanteric fracture. Surgeons must follow the standard operating procedure, otherwise life-threatening complications may affect their patients.