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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00998-2
10.1016/j.ijscr.2024.110217
110217
Case Report
Caecal perforation secondary to intrapelvic migration of a total hip prosthesis: A case report and a review of the literature
Ben Ismail Imen imen_bi@yahoo.fr
⁎
Sghaier Marwen
Rebii Saber
Manai Ghazi
Zoghlami Ayoub
Department of General Surgery, Traumatology and Great Burns Center, Ben Arous, Tunisia
University of Tunis el Manar, Faculty of Medicine of Tunis
⁎ Corresponding author. imen_bi@yahoo.fr
28 8 2024
10 2024
28 8 2024
123 11021731 7 2024
20 8 2024
25 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Total hip arthroplasty (THA) is commonly performed to alleviate hip pain and restore function. While generally safe, complications such as prosthesis migration can occur. Intrapelvic migration of hip prostheses, leading to bowel perforation and fistula formation, is a rare but severe complication requiring prompt diagnosis and management. This case report, presented in line with the SCARE criteria, highlights a case of caecal perforation due to hip prosthesis migration.

Case presentation

A 78-year-old female with a history of right THA presented with severe hip pain, loss of function, and a persistent fistula exuding fecaloid fluid. Examination revealed fever, rigidity, and limited hip motion. CT scans showed intrapelvic protrusion of the prosthetic components and a colo-cutaneous fistula. Emergency laparotomy revealed caecal perforation by a screw from the acetabular component, necessitating resection of the perforated caecum. A subsequent surgery addressed the hip prosthesis. The patient recovered uneventfully and was discharged on day 7.

Discussion

Prosthesis migration into the pelvis is a serious complication of THA. Risk factors include implant loosening, acetabular bone loss, surgical technique issues, and patient factors like obesity and osteoporosis. Diagnosis relies on imaging studies. Management typically involves surgical removal of the migrated prosthesis and repair of the perforation, necessitating a multidisciplinary approach.

Conclusion

Caecal perforation due to intrapelvic migration of a hip prosthesis is rare but potentially life-threatening. Prompt diagnosis and appropriate management are crucial. Further research is needed to better understand risk factors and prevention strategies.

Highlights

• Rare caecal perforation from intrapelvic migration of a total hip prosthesis

• CT and laparotomy confirmed prosthesis migration causing caecal perforation.

• Emergency resection of perforated caecum due to prosthesis screw penetration

• Two-stage surgery effectively managed intrapelvic prosthesis migration.

• Multidisciplinary approach key to successful diagnosis and treatment

Keywords

Colo articular fistula, intrapelvic migration
Revision
Total hip arthroplasty
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pmc1 Introduction

Total hip arthroplasty (THA), commonly known as hip replacement surgery, is a widely performed procedure that aims to alleviate pain and restore function in patients with hip joint pathology. While this procedure is generally safe and effective, complications can arise, including prosthesis migration [1].

According to a study by C. Faldini et al., the anterior minimally invasive surgical technique for THA demonstrated a complication rate of 9.4 % in the first 1000 consecutive patients, including dislocations, nerve injuries, fractures, infections, and leg length discrepancies [2].

Intrapelvic migration of hip arthroplasty components is a rare but serious complication that can lead to bowel perforation and fistula formation. This potentially life-threatening condition requires prompt diagnosis and management. Understanding the risk factors, clinical presentation, and management strategies for caecal perforation due to hip prosthesis migration is essential for healthcare providers involved in the care of patients who have undergone hip replacement surgery.

This work has been reported in line with the SCARE criteria [3].

2 Case presentation

A 78-year-old female with a history of right total hip arthroplasty (THA), performed two years earlier for coxarthrosis, presented to the emergency department with severe pain in her right hip, which had progressively worsened over the past two weeks. Furthermore, she noted a complete loss of function in the affected hip and the presence of a persistent fistula on the lateral scar on her right buttock. Physical examination revealed a febrile patient (38.5 °C) with significant rigidity and pain upon movement of the right hip. Notably, there was an external fistulous opening on the lateral aspect of the right buttock, which was exuding a fecaloid fluid, and the hip joint exhibited marked stiffness and limited range of motion. CT scans of the pelvis showed intrapelvic protrusion of the acetabular cup and the prosthetic head, suggesting significant migration of the prosthetic components (Fig. 1). The Pelvis X-ray confirmed right hip prosthesis intrapelvic migration (Fig. 2). The CT scan revealed also the presence of a colo-cutaneous fistula extending from the peritoneal cavity to the external skin surface.Fig. 1 CT of the pelvis showing intrapelvic protrusion of the acetabular cup and the prosthetic head.

Fig. 1

Fig. 2 Pelvis X-ray revealed a right hip prosthesis intrapelvic migration.

Fig. 2

The patient was prepared for emergency surgery. An exploratory laparotomy via a midline incision was performed. The peritoneal cavity was clean, but the caecum was perforated by one of the screws from the acetabular component of the THA (Fig. 3). The segment of the caecum containing the perforation was resected using a GIA 60 stapler and a side-to-side ileocolic anastomosis was performed to restore bowel continuity. Following stabilization, a second operative session was planned to address the hip prosthesis. A lateral approach to the hip was performed, involving a femorotomy to access and remove the remaining femoral components of the prosthesis. During this procedure, all the prosthetic material was carefully extracted, and the femur was thoroughly cleaned to prevent any residual infection. The fistulous tracts were also meticulously resected to eliminate any sources of ongoing infection. To prevent recurrence, the hip prosthesis was revised with particular attention to secure fixation, using cementless components and ensuring proper alignment to avoid further migration. The patient's recovery was uneventful, and she was discharged on day 7 with a plan for close follow-up. Postoperatively, her hip function was gradually restored, and she remained free of complications at subsequent follow-up visits.Fig. 3 Intraoperative view of the perforated caecum.

Fig. 3

3 Discussion

The migration of hip prostheses into the pelvis is a serious concern in orthopedic surgery. Hip replacement surgeries are commonly performed to alleviate pain and improve mobility in patients with hip joint degeneration or trauma. However, complications such as prosthesis migration can lead to severe discomfort, functional impairment, and the need for revision surgery. Several risk factors have been identified for intrapelvic migration of a total hip prosthesis [4].

One of the major risk factors for hip prosthesis migration is implant loosening. Loosening can occur due to inadequate fixation, poor bone quality, or excessive mechanical stress on the implant. A review by Katzer A et al. [5] found that loosening was the primary cause of prosthesis migration in 62 % of cases. Therefore, ensuring proper implant fixation during surgery and monitoring for signs of loosening postoperatively are essential in preventing migration.

Another significant risk factor is acetabular bone loss. In cases where the acetabulum is severely damaged or eroded, the implant may not have sufficient support, leading to migration [1]. Adequate preoperative planning, including the assessment of bone quality and the use of augmentation techniques, can help mitigate this risk.

Surgical technique plays a vital role in preventing prosthesis migration. Improper implant positioning, inadequate soft tissue balancing, and suboptimal component fixation can all contribute to migration [6]. A systematic review by Migliorini F et al. [7] highlighted the importance of surgical precision in reducing the risk of complications, including prosthesis migration. Surgeons should adhere to established guidelines and techniques to ensure accurate implant placement and stability.

Patient-related factors, such as obesity osteoporosis, and previous abdominal surgery, may also contribute to the development of this complication [8].

This literature review will explore the current understanding of this complication, including its incidence, clinical presentation, diagnostic approaches, management strategies, and potential risk factors.

Caecal perforation secondary to intrapelvic migration of a total hip prosthesis is an extremely rare complication, with only a few cases reported in the medical literature [[9], [10], [11], [12]]. The exact incidence of this condition is difficult to determine due to its rarity, but it is estimated to occur in less than 1 % of all hip replacement surgeries [12].

The migrated components can lead to fistula formation between the hip joint and the bowel, particularly affecting the caecum [9,10] or sigmoid colon [11,12]. Diagnosis may be challenging, often requiring imaging studies and endoscopic procedures.

Clinical presentation can vary depending on the severity of the perforation and the presence of associated complications. Patients may present with symptoms such as abdominal pain, fever, nausea, vomiting, and signs of peritonitis. In some cases, the symptoms may be nonspecific, leading to delayed diagnosis and treatment. Therefore, a high index of suspicion is necessary in patients who have undergone hip replacement surgery and present with abdominal symptoms.

Abdominal X-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI) can provide valuable information about the position of the prosthesis and the extent of the caecal perforation. MRI offers superior soft tissue contrast and may provide detailed images that help in identifying the fistulous tract [13]. In some cases, diagnostic laparoscopy or laparotomy may be necessary for a definitive diagnosis and management.

The management of caecal perforation secondary to intrapelvic migration of a total hip prosthesis typically involves a multidisciplinary approach, including orthopedic surgeons, general surgeons, and gastroenterologists. The primary goal of treatment is to remove the migrated prosthesis and repair the caecal perforation. The surgical approach may vary depending on the individual patient's condition, and options include laparoscopic or open surgery. In some cases, a two-stage procedure may be necessary, with initial removal of the prosthesis followed by delayed repair of the perforation. The time between initial hip surgery and complication onset can vary significantly, from immediate post-operative periods to decades later [6].

4 Conclusion

Caecal perforation secondary to intrapelvic migration of a total hip prosthesis is a rare but potentially life-threatening complication of hip replacement surgery. Prompt diagnosis and appropriate management are crucial to prevent further complications and improve patient outcomes. However, due to the limited number of reported cases, further research and larger studies are needed to better understand the risk factors, prevention strategies, and long-term outcomes associated with this complication.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Not applicable. Our institution (Traumatology and Great Burns Center Ben Arous) requires no ethical approval for case reports.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Guarantor

Dr Imen Ben Ismail.

CRediT authorship contribution statement

Manuscript writing: Dr Imen Ben Ismail.

Study concepts: Dr Imen Ben Ismail and Dr Marwen Sghaier.

Helped in data interpretation and manuscript evaluation: Dr Saber Rebii.

Data acquisition: Dr Ghazi Manai.

Critical revision: Dr Ayoub Zoghlami.

Declaration of competing interest

Authors declare no conflict of interest.
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