Noninflammatory pseudotumor simulating venous thrombosis after metal-on-metal hip resurfacing

Metal-on-metal hip resurfacing has become a widespread procedure, especially in young, physically active patients. Pseudotumor is a new complication that can occur after hip resurfacing and metal-on-metal total hip arthroplasty (THA). This article presents a case of a 37-year-old woman who underwent metal-on-metal resurfacing of the left hip for symptomatic osteoarthritis. Twelve months following implantation, the patient reported painless swelling of the left lower leg. There was no clinical evidence of a deep venous thrombosis. Ultrasound and computed tomography showed a solid cystic lesion in the iliopsoas muscle, which communicated with the hip joint and compressed the external iliac vein. As a consequence, the cystic lesion was resected marginally. A few months later, the patient reported some discomfort in the groin and symptoms of instability, metallic clicking, and a restricted range of motion. Clinical and radiological examination revealed normal findings. Determining the serum concentration of cobalt and chromium revealed high increased levels of these metal ions. Ten months following excision of the pseudotumor, the patient reported recurrent swelling of the left lower leg. Computed tomography of the affected area showed a lobulated cystic formation; therefore, a relapse was suspected. At the second revision, the mass was excised and the implant was revised to a conventional ceramic-on-ceramic THA. At 30-month follow-up, the patient was doing well and there were no signs of local recurrence. Additionally, the metal ion levels of cobalt and chromium in the blood had significantly decreased.     

Atypical pseudotumour after metal-on-polyethylene total hip arthroplasty causing deep venous thrombosis

We describe a patient who developed a mass extending into the pelvis, five years after a metal-on-polyethylene total hip arthroplasty (THA). The histological pattern of perivascular lymphocytic infiltrate and fibrinoid necrosis was more in keeping with a metal-on-metal bearing failure. The pseudotumour compressed the femoral vein causing a deep venous thrombosis.     

Common femoral vein thrombosis caused by a metal-on-metal hip arthroplasty-related pseudotumor

We present a case of a pseudotumor causing a deep femoral vein thrombosis 16 months after undergoing a metal-on-metal total hip arthroplasty. There is increasing concern over the effect of metal ions that are produced by wear in metal-on-metal hip arthroplasty systems. Recently, a number of articles have reported the development of an inflammatory pseudotumor causing a number of different problems early on in the lifespan of the implant necessitating revision surgery. This case reports the first presentation of a pseudotumor causing a serious venous thrombosis due to pressure effect and indicates further possible evidence for caution when considering metal-on-metal bearing hip arthroplasty.     

Inflammatory Pseudotumor Causing Deep Vein Thrombosis After Metal-On-Metal Hip Resurfacing Arthroplasty

Metal-on-metal hip resurfacings have recently been associated with a variety of complications resulting from adverse reaction to metal debris. We report a case of extensive soft tissue necrosis associated with a huge pelvic mass causing extensive deep vein thrombosis of the lower limb secondary to mechanical compression of the iliac vein. This is a rare and unusual cause of deep vein thrombosis after metal-on-metal hip resurfacing arthroplasty.     

Endovascular treatment of bleeding external iliac artery pseudo-aneurysm following control of haemorrhage with Sengstaken tube during revision total hip arthroplasty

We report a case of false aneurysm of the external iliac artery and compression of the external iliac vein, which subsequently caused deep venous thrombosis in a 63-year-old female patient with a revised total hip arthroplasty. This is the first case of control of life-threatening intraoperative haemorrhage of an external iliac pseudo-aneurysm by Sengstaken tube which allowed time for successful management of the external iliac artery pseudo-aneurysm with endovascular covered stent. Recognition of delayed vascular injury following revision of total hip arthroplasty and the need of pre-operative imaging should be considered in revision hip arthroplasty.     

Treatment of May-Thurner syndrome with catheter-directed thrombolysis and stent placement, complicated by heparin-induced thrombocytopenia.

May-Thurner syndrome is an uncommon process in which the right common iliac artery compresses the left common iliac vein, resulting in left iliofemoral deep vein thrombosis and severe leg edema. We report the case of a 41-year-old female who presented with severe left leg edema present for 1 day. One week earlier she had experienced acute shortness of breath and pleuritic chest pain. Duplex ultrasound revealed a left iliofemoral deep vein thrombosis. A computed tomography (CT) scan performed for abdominal pain revealed thrombosis of the entire left common and external iliac veins. A ventilation-perfusion scan diagnosed a pulmonary embolism. The patient was treated with systemic intravenous heparin and catheter-directed thrombolysis of the iliofemoral deep vein thrombosis. Complete thrombolysis and iliofemoral vein patency was achieved over 5 days. A persistent stenosis in the left common iliac vein consistent with May-Thurner syndrome was alleviated with percutaneous balloon angioplasty and placement of a Wallstent. Heparin therapy was terminated at the time of stenting because of suspected heparin-induced thrombocytopenia. The patient was started on a continuous infusion of 10% dextran 40, and warfarin therapy was initiated. Heparin-induced antibodies were confirmed by a C-14 serotonin release assay. The endovascular reconstruction remains patent 4 months later. Heparin-induced thrombocytopenia complicating endovascular reconstruction of the iliofemoral venous system in a patient with May-Thurner Syndrome is an uncommon occurrence. This case and a review of the literature are discussed.     

Magnetic resonance venography in the diagnosis and management of May-Thurner syndrome

Isolated left lower extremity swelling secondary to left iliac vein compression was first described by McMurrich in 1908, and defined anatomically by May and Thurner in 1957 and clinically by Cockett and Thomas in 1965. The left iliac vein is usually located posterior to the right iliac artery and can be compressed between the artery and the fifth lumbar vertebrae. Symptoms include left lower extremity edema, pain, varicosities, venous stasis changes, and deep venous thrombosis. Evaluation of these patients historically included a venous duplex scan to rule out deep venous thrombosis and an abdominal computed tomography scan to rule out pelvic mass. This paper describes the use of magnetic resonance imaging and venography in the evaluation of patients with isolated left lower extremity swelling. A retrospective analysis of a series of 24 patients who presented with symptomatic left lower extremity edema was performed. Infrainguinal deep venous thrombosis and valvular reflux was evaluated by duplex scan. The presence of suprainguinal deep venous thrombosis and pelvic mass was evaluated by magnetic resonance imaging. Magnetic resonance imaging was used to define the anatomic characteristics of the May-Thurner syndrome. Patients identified with the syndrome were treated either conservatively with lower extremity compression and elevation or with angioplasty and stenting. Follow-up of this subset of patients was performed with clinical assessment of the resolution of their symptomatic lower extremity edema as well as quality of life assessments via phone interviews. Twenty-four patients were evaluated for isolated left lower extremity swelling. Seven patients had positive results on duplex scans for deep venous thrombosis. Magnetic resonance imaging results demonstrated 1/24 (4%) had a pelvic mass compressing the iliac vein; 2/24 (8%) patients had iliac vein thrombosis; 1/24 (4%) patients with a history of deep venous thrombosis demonstrated a long stenotic segment of the left iliac vein unrelated to its association with the right iliac artery; 9/24 patients (37%) had anatomic evidence of May-Thurner syndrome; and 2/24 patients (8%) had isolated left lower extremity swelling of unknown etiology. Five patients diagnosed with May-Thurner syndrome were treated conservatively with compression stockings and leg elevation. Four patients with May-Thurner syndrome underwent iliac vein angioplasty and stenting. Technical success was 100%. On clinical follow-up, the patients with May-Thurner syndrome have had improvement/resolution of their symptoms. There have been no complications from either therapy. May-Thurner syndrome is a clinical entity of left iliac vein compression by the right iliac artery, resulting in isolated left lower extremity swelling and may be a precipitating factor for iliofemoral deep venous thrombosis. Magnetic resonance imaging is the best modality for diagnosis of this entity as it can rule out the presence of pelvic masses and deep venous thrombosis while simultaneously demonstrating the anatomy characteristic of this syndrome.     

Compartment syndrome due to massive leg hematoma after primary total hip arthroplasty: a previously unreported complication of fondaparinux

Fondaparinux is an accepted form of deep venous thrombosis prophylaxis after hip arthroplasty. Cited advantages of its use include once-daily administration, standard dosage, and superiority as compared with enoxaparin. However, there have been several case reports of serious associated bleeding complications. We describe the case of a 77-year-old woman who developed a massive leg hematoma in the operative extremity nearly 3 weeks after a primary total hip arthroplasty while on fondaparinux. The patient developed a compartment syndrome requiring decompression of the hematoma, fasciotomy, and subsequent additional plastic surgery for split thickness skin grafting.     

Deep venous thrombosis after total hip or total knee arthroplasty in patients in Japan

A single center, prospective, epidemiologic study was conducted to estimate the incidence of deep venous thrombosis detected by venography in patients in Japan undergoing total hip arthroplasty or total knee arthroplasty without prophylactic anticoagulant therapy. Venograms of 164 patients who had total hip arthroplasty and 138 patients who had total knee arthroplasty were evaluated. The incidences of deep venous thrombosis were 22.6% in patients who had total hip arthroplasty and 48.6% in those who had total knee arthroplasty. The incidences of proximal deep venous thrombosis were 9.8% in patients who had total hip arthroplasty and 14.5% in those who had total knee arthroplasty. Statistical analysis revealed that the type of operation influenced the development of deep venous thrombosis. Patients who had total knee arthroplasty were 3.2 times more likely to have deep venous thrombosis develop than were patients who had total hip arthroplasty. Body mass index and age were identified as statistically significant risk factors.     

Compartment Syndrome Due to Massive Leg Hematoma After Primary Total Hip Arthroplasty : A Previously Unreported Complication of Fondaparinux

Fondaparinux is an accepted form of deep venous thrombosis prophylaxis after hip arthroplasty. Cited advantages of its use include once-daily administration, standard dosage, and superiority as compared with enoxaparin. However, there have been several case reports of serious associated bleeding complications. We describe the case of a 77-year-old woman who developed a massive leg hematoma in the operative extremity nearly 3 weeks after a primary total hip arthroplasty while on fondaparinux. The patient developed a compartment syndrome requiring decompression of the hematoma, fasciotomy, and subsequent additional plastic surgery for split thickness skin grafting.     

Tube cavoplasty using autologous vein grafts for resected inferior vena cava reconstruction

Reconstruction of inferior vena cava (IVC) defects after surgical resection of the IVC is associated with significant complications, such as venous thrombosis and graft infection. We herein report a new technique called “tube cavoplasty” that uses only autologous venous grafts to reconstruct IVC defects after resection of leiomyosarcomas of the IVC. The patient’s own left internal jugular and left external iliac veins are procured independently and incised along their axes to create an independent venous patch that is approximated together to make a wider “tube” graft. The size and length of the “tube” graft perfectly matches the IVC defect. In this study, no complications associated with this new procedure were observed except for transient mild edema of the left leg. This new technique could be a valuable tool to reconstruct IVC defects, such as those that occur after resection of IVC tumors or IVC stenosis for Budd–Chiari syndrome.     

Metal ion levels decrease after revision for metallosis arising from large-diameter metal-on-metal hip arthroplasty

Concerns have been renewed regarding the possible long-term effects of elevated circulating levels of cobalt and chromium as a direct result of implantation of large femoral head diameter metal-on-metal bearings. In order to establish whether metal ion levels remain persistently elevated, we compared metal ion levels before and after revision surgery in patients with large head diameter (greater than 38 mm) metal-on-metal total hip arthroplasty or hip resurfacing arthroplasty. At greater than one year post removal of a large-diameter metal-on-metal hip implant for the indication of symptomatic metallosis, metal ion levels were found to fall to almost normal levels.     

Primary metal-on-metal total hip arthroplasty with large-diameter femoral heads: a clinical trial of 59 hips

Large-diameter femoral heads with nearly anatomical sizes became available for metal-on-metal total hip arthroplasty after recent advances in metal-on-metal technology. We retrospectively studied the clinical and radiological results in 59 hips of 54 patients (32 women and 22 men, mean age 54.4 years) who underwent cementless metal-on-metal total hip arthroplasty with large-diameter heads. Patients were followed for a mean of 48.6 months. Range of motion improved significantly after surgery (p = 0.001). Harris hip scores improved from 38.5 points to 903 points at latest follow-up. We found no gender-related differences in Harris hip scores, whereas there was a correlation between age and Harris hip scores (p < 0.001), with excellent results being observed predominantly in younger patients. Mean acetabular inclination of the acetabular cup was 42.2 degrees (range: 37-51 degrees). Radiologically, a 1 mm thick radiolucency was detected in three acetabula, which were asymptomatic. One acetabulum was revised because of displacement. Three patients reported squeaking within their hips, which however disappeared in a short time. We did not observe any dislocation, deep infection or loosening. Grade 1 heterotopic ossification was detected in one hip. Although the inherent stability and the functional results of large anatomical heads are encouraging, longer follow-up data and larger series are essential to evaluate the real advantages of this type of prosthesis over conventional femoral heads.     

单侧与双侧使用间歇充气加压在预防髋膝置换术后DVT中的效果比较

目的探讨间歇充气加压（IPC）非手术侧使用,在髋膝关节置换术后下肢深静脉血栓（DVT）预防中的效果和安全性。 方法前瞻性收集2017年4月至2017年9月烟台市烟台山医院拟行髋、膝关节置换术且符合纳入及排除标准的患者172例,采用随机数字表法将患者随机分为试验组和对照组,所有患者均于麻醉后手术开始前开始行非术侧IPC治疗,术后给予利伐沙班抗凝预防DVT,试验组术后继续行持续性非术侧IPC预防DVT,共85例;对照组术后行持续性双侧IPC预防DVT,共87例。术后3 d后改为1 h,2次/日。术后3 d、7~10 d行双下肢超声检查监测DVT发生情况。 结果患者术后常规继续住院7~10 d,故术后患者无脱落,随访率100%。随访时间为7~10 d,平均（8.3±1.3）d,试验组术后3 d发生血栓11例,占12.9%,均为肌间静脉血栓;对照组术后3 d发生血栓8例,占9.2%,1例腘静脉血栓,2例胫腓静脉血栓,余为肌间静脉血栓;术后3 d两组膝关节置换患者、髋关节置换患者及总的DVT发生率均无统计学差异。术后7~10 d试验组新增血栓5例,占6.8%,对照组新增血栓4例,占比5.1%,两组术后7~10 d膝置换患者、髋置换患者及总DVT发生率均无统计学差异。 结论IPC非手术侧使用在预防髋膝置换术后下肢DVT发生中可达到与IPC双侧同时使用相同的预防效果,安全性更高。     

Iliofemoral venous obstruction without thrombosis

Nonthrombotic iliofemoral venous obstruction, masquerading as deep vein thrombosis, was diagnosed in four patients. In each instance the patient was hospitalized and intravenous heparin therapy was started. Phlebography demonstrated venous outflow obstruction without thrombosis; subsequent CT scanning revealed an obstructing lesion in each case. At surgical exploration, (1) endoaneurysmorrhaphy of a hypogastric artery aneurysm decompressed an obstructed right iliac vein; (2) a primary iliac vein leiomyosarcoma was extirpated; (3) a synovial cyst arising from the right hip joint, which obstructed the femoral vein, was excised; and, (4) a postherniorrhaphy inflammatory mass obstructing the left iliofemoral vein junction was confirmed with biopsy results. Improved diagnostic accuracy with its attendant specific therapy is achieved in suspected cases of iliofemoral vein thrombosis if, in addition to noninvasive venous studies or phlebography, CT scanning of the abdomen and pelvis is performed.     

Venous thromboembolic disease after hybrid hip arthroplasty with negative duplex screening

Postoperative duplex ultrasonography screening after total hip arthroplasty has been shown to identify patients who may require treatment or additional monitoring for venous thromboembolic disease. The potential for manifestation of venous thromboembolic disease subsequent to screening remains a concern. The objective of this study was to determine the prevalence of symptomatic venous thromboembolic disease after total hip arthroplasty and after inhospital prophylaxis, inhospital screening with negative results for proximal deep venous thrombosis, and no posthospitalization venous thromboembolic disease prophylaxis. One hundred fifty patients undergoing primary hybrid total hip arthroplasty and using pneumatic compression stockings and aspirin as prophylaxis against venous thromboembolic disease were screened for deep venous thrombosis with duplex ultrasonography on the fourth day after surgery. Duplex ultrasonography screening revealed 17 (11.3%) patients with asymptomatic proximal deep venous thrombosis. In response to duplex ultrasonography screening, these patients with proximal deep venous thrombosis received therapeutic anticoagulation. Of 133 patients with a duplex screen with negative results for proximal deep venous thrombosis, 131 (98.5%) continued to have no symptoms of venous thromboembolic disease and two (1.5%) began to have symptoms for venous thromboembolic disease (one with proximal deep venous thrombosis, one with nonfatal pulmonary embolism) during 12 months of clinical followup after total hip arthroplasty. The overall prevalence of venous thromboembolic disease requiring anticoagulation was 19 of 150 (12.6%) patients. The remaining 131 (87.4%) were not exposed to the risks of postoperative anticoagulation and did not have subsequent symptomatic venous thromboembolic disease.     

Extravascular compression of the femoral vein due to wear debris-induced iliopsoas bursitis: a rare cause of leg swelling after total hip arthroplasty

We present a patient with unilateral, spontaneous, late leg swelling that developed 4 years after total hip arthroplasty. The etiology was the compression of the internal iliac vein by a voluminous iliopsoas bursitis caused by polyethylene debris. The expansive lesion was detected by ultrasound, arthrography, and magnetic resonance imaging. An ultrasound-guided aspiration provided transient relief of the patient's symptoms. The patient later required surgical excision through an abdominal approach. A second recurrence was detected and treated with revision surgery. We present the diagnosis and the treatment of this rare cause of late, unilateral leg swelling after total hip arthroplasty together with a review of the literature.     

Late deep venous thrombosis and delayed weightbearing after total hip arthroplasty

One hundred ninety-nine patients who underwent primary total hip arthroplasty and used in hospital pneumatic compression stockings and aspirin as thromboembolic prophylaxis were screened for deep venous thrombosis using duplex ultrasonography on the fourth postoperative day. Of the initial 98 patients, 21 underwent noncemented arthroplasty, maintained touchdown weightbearing for 6 weeks after surgery, and then began progressive partial weightbearing. Of the subsequent 101 patients, 28 underwent noncemented arthroplasty and began progressive weightbearing immediately after surgery. All other patients underwent hybrid arthroplasty and began weightbearing to tolerance immediately after surgery. After duplex screening examination, patients with proximal deep venous thrombosis were given anticoagulation therapy, and patients with negative study results were observed clinically. The relative risk of proximal deep venous thrombosis after noncemented arthroplasty using delayed weightbearing was compared with that after noncemented arthroplasty using immediate progressive weightbearing. Of patients with noncemented arthroplasty, the prevalence of proximal deep venous thrombosis was significantly lower in those using progressive weightbearing immediately after surgery (none) than in those using delayed weightbearing rehabilitation (19%). This study showed that patients undergoing noncemented total hip arthroplasty with delayed weightbearing rehabilitation risk greater potential for deep venous thrombosis after hospital discharge. This study suggests consideration for continued thromboembolic prophylaxis or routine deep venous thrombosis surveillance, or both measures, after hospital discharge, unless more rapid progression of weightbearing is allowed.     

An extraluminal leiomyosarcoma of the iliac vein without thrombosis--a case report

Vascular leiomyosarcoma (LMS)is a rare malignant tumor arising from the muscle cells of the media of the vessels. Vascular LMS is often diagnosed as a result of the clinical manifestations of impaired venous flow such as edema and phlebothrombosis. The authors present a case of an LMS in a 72-year-old woman. Physical examination revealed a round mass deep in the left inguinal region close to the inguinal vessels, fixed and not pulsating. There was no sign of left lower-limb edema nor of articular impairment of the hip. Inguinal and distal pulses were normal. Results of laboratory analysis, including values for the oncologic markers, were normal. An ultrasound scan of the left inguinal fossa showed a 50-by-30 mm mass of mixed aspect that adhered to the left common iliac artery. An echo color Doppler showed conservative arterial flow. Thus, a thrombotic aneurysm of the left iliac artery was diagnosed. Chest x-ray showed no pathological findings. An abdominal computerized tomograph (CT) scan confirmed the location of the neoplasm and revealed a narrowing of the left iliac vein compressed behind the mass. The finding was interpreted as a colliquative lymph node. The patient underwent explorative laparotomy with midline incision. The finding was a neoplastic bilobed mass compressing and infiltrating the left iliac vein with no cleavage surface between the mass itself and the venous wall. An intraoperative frozen section revealed a necrotic mass with a cortex of ambiguous interpretation. Surgical procedure was then finished with no further venous resection. Histologic examination revealed the presence of leiomyosarcomatous tissue with nuclear pleomorphisms inside necrotic material limited by a thin fibrotic capsule. According to Coindre's classification the tumor was a G3. After six months the patient is fit and a CT scan showed no evidence of recurring disease.     

Upper extremity deep venous thrombosis leading to pulmonary embolism after total hip arthroplasty

Upper extremity deep venous thrombosis most commonly occurs secondary to the presence of subclavian central venous catheters. Of all upper extremity deep venous thromboses, 12% may cause pulmonary embolism; however, pulmonary embolism from a so-called primary thrombosis is uncommon. We report an unusual case of pulmonary embolism after primary deep venous thrombosis in the down arm after total hip arthroplasty.