Pseudoaneurysms of lower limb of orthopaedic traumatological origin: a literature review and our experience of 18 cases.

INTRODUCTION AND AIMS

Arterial pseudoaneurysm is a rare yet potentially life-threatening complication that can arise as a late sequelae of penetrating injuries or orthopaedic procedures. We aim at sharing our institutional experience of managing 18 cases of lower limb arterial pseudoaneurysms in orthopaedic practice and to provide technical tips for emergency management of severe bleeding. A comprehensive literature review resulting from fractures and orthopaedic surgeries is also presented.

RESULTS

The study group consisted mainly of male patients with a mean age of 48.5 years. The mean duration between injury and pseudoaneurysm diagnosis was 86.7 days. CT angiography and USG Doppler were the main diagnostic modality. Among the cases, five resulted from fracture fragments and 13 from iatrogenic injuries. Surgical interventions varied based on the artery involved and included excision and ligation, bypass grafting with dacron or vein graft, primary repair, and amputation in two cases. Complications included one patient with blowout at the anastomotic site and another case of deep infection. The literature review encompassed 108 cases of pseudoaneurysm of lower limb associated with fractures and iatrogenic injuries during orthopaedic procedures. Clinical manifestations varied widely which included painful swelling, pulsatility, bleeding, and neurological deficits. CT angiography was the most utilized diagnostic modality, while therapeutic embolization was the most common treatment method.

CONCLUSION

Iatrogenic arterial injuries contributed to more than 60% of the cases as per the literature review. The most frequent mechanisms related to instrumentation were the placement of the third and fourth screws of the DHS plate, and the distal screw of a short nail in treating pertrochanteric fractures. This can be avoided by external rotation and abduction of the limb during distal screw insertion. A high index of clinical suspicion is needed especially when bleeding from the hardware site is noted. A swelling in the previously operated site should raise a suspicion of pseudoaneurysm and incision and drainage must be avoided without further imaging (Duplex USG or CT angiography). This study highlights the importance of cautious surgical techniques to minimize the occurrence of vascular injuries during orthopaedic surgeries.