Iatrogenic Pseudo-aneurysm of Profunda Femoris Artery Following Fixation of Intertrochanteric Femur Fracture – A Case Report and Review of Literature

Abstract

A 55-year-old female presented with a right-sided intertrochanteric femur fracture following a fall while walking. The patient was posted for fixation with dynamic hip screw and barrel plate [Table/ Fig-1] on third day following trauma. While drilling hole for the second shaft screw, there was an inadvertent over-drilling of the medial cortex followed by immediate sudden bleeding from the medial soft tissues. Packing was done with sterile mops and the bleeding stopped spontaneously. Further procedure was uneventful. Postoperative vitals were stable. On day four postoperatively, sudden bleeding along suture line was noted with appearance of thigh swelling and pain. Blood tests revealed severe anaemia with a fall in haemoglobin from 10.2mg/dl preoperatively to 5.9mg/dl on the fourth Postoperative day. Local ultrasonography was performed which revealed a pseudo-aneurysm arising from Profunda Femoris Artery (PFA). Angiography confirmed the diagnosis of pseudoaneurysm and the PFA was embolized using 2 coil wires in the same setting [Table /Fig-2]. The patient was given three pints of packed cells and closely monitored. At three weeks the patient showed no signs of active bleeding or distal vascular deficit with eventual uneventful recovery. DisCussionOccurrence of pseudo-aneurysms of the proximal femoral artery after orthopaedic procedures in the peri-trochanteric region and the proximal femur is rarely described in literature. Many such cases might be sub-clinical and therefore might be missed. Diagnosis of The Profunda Femoris is a common site for arterial pseudo-aneurysms and these have been described in literature following fractures as well as orthopaedic procedures of the femur and hip region. These are an uncommon complication and a high index of suspicion is required for correct diagnosis and prompt management. We present a case of pseudo-aneurysm of the Profunda Femoris in an operated case of Intertrochanteric femur fracture with acute presentation. The case was managed successfully by angiographic coil embolization.

Superior gluteal artery pseudoaneurysm following intramedullary nailing of an atypical femoral fracture

“…Vascular complications related to orthopaedic hip fracture surgery are rare, with studies reporting an overall incidence of about 0.2% 5 6. Of the reported cases, the majority of the iatrogenic injuries related to intramedullary femoral nailing involve branches of the profunda femoris artery 5–10. Due to the proximity of the profunda femoris artery to the placement of the intramedullary femoral nail, the most common mechanism of injury is penetration of the vessel by a drill, retractor or screw 9 10.…”

“…Of the reported cases, the majority of the iatrogenic injuries related to intramedullary femoral nailing involve branches of the profunda femoris artery 5–10. Due to the proximity of the profunda femoris artery to the placement of the intramedullary femoral nail, the most common mechanism of injury is penetration of the vessel by a drill, retractor or screw 9 10. This subsequently results in either acute onset of intraoperative haemorrhage or pseudoaneurysm formation with delayed onset bleeding 8.…”

Late Presentation of an Iatrogenic Pseudoaneurysm of the Profunda Femoris Artery following Intramedullary Nailing

“…A high index of suspicion supported by additional radiological imaging such as (Doppler) ultrasound, computed tomography, and angiography are necessary to reach the diagnosis [13]. …”

Iatrogenic profunda femoris artery pseudoaneurysm: late presentation with successful endovascular microcoil embolisation

“…Occurrence of pseudoaneurysms of the PFA is an uncommon but documented complication following fractures and orthopaedic procedures in the upper thigh. They have been reported following various orthopaedic procedures including external fixation of femur, core decompression and internal fixation of the proximal femoral fractures 1. Pseudoaneurysms can result secondary to injury to PFA due to a spike of fractured bone, displaced implants, retractors, protruding cortical screw tip, gamma nail or overpenetration by a drill bit 2…”

“…Small (up to 2–3 cm) and asymptomatic pseudoaneurysms may be simply observed as they often thrombose spontaneously. Larger and symptomatic pseudoaneurysms may be treated with US-guided obliterative compression, direct US-guided thrombin injection, endovascular management using stent-graft placement or coil embolisation or open surgical repair 1. Recently, endovascular management is the preferred modality of treatment with surgery reserved for cases not amenable to embolisation 2.…”