A young woman with rheumatoid arthritis underwent revision of an acetabular component of a total hip prosthesis because of progressive osteolysis about the acetabular screw holes. During curettage of the membrane of one of the screw holes, a portion of the colon adjacent to the acetabulum was grasped and inadvertently injured. To the best of our knowledge, this is the first report of this intra-abdominal complication. We obtained institutional review board approval for this retrospective report. Our patient was informed that data concerning the case would be submitted for publication, and she consented.
A twenty-nine-year-old woman with a medical history of rheumatoid arthritis underwent right and left total hip arthroplasties in August and October 1993, respectively. Approximately 8.5 years later, in January 2002, the patient underwent revision arthroplasty of the right hip because of progressive periacetabular osteolysis. Preoperatively, an anteroposterior pelvic radiograph and computed tomographic scan demonstrated that the stems were well fixed. The right acetabular cup was medial to the ilioischial line, and there were osteolytic lesions in the acetabulum adjacent to the screw holes (Figs. 1 and 2). Since the metallic acetabular component appeared to be solidly fixed on these images, the preoperative plan was to remove the polyethylene component only, curette the lytic lesions through the screw holes, pack them with morcellized allograft, and insert a highly cross-linked polyethylene component liner.
The patient was positioned in the lateral decubitus position, and an anterolateral approach was used. Intraoperatively, mucinous material was found in two of the lytic lesions; this material was curetted, and the lesions were packed with morcellized bone graft. In attempting to curette the third hole, the surgeon encountered a membrane, which was grasped with a Kerrison rongeur and delivered into the screw hole for a distance of a few millimeters. It was then apparent that the membrane was not the lining of a lytic lesion, but an intrapelvic structure. Initially, this tissue was thought to be vascular. It was clamped, and a general surgeon was consulted. Throughout this time frame, the patient's vital signs remained stable. With the general surgeon in attendance, the membrane was cut between the clamps, thus revealing a lumen. The wall was thin, however, and no bleeding was encountered. It was decided to perform a biopsy, repair the structure, complete the arthroplasty revisions, and then perform a laparotomy to explore the involved region.
The repaired structure was reinserted into the abdomen through the acetabular screw hole, and the wound was copiously irrigated. A new polyethylene liner was seated, the hip was reduced, and the wound was closed. Histologic examination of the biopsied tissue revealed colonic mucosa. The patient was repositioned, and an exploratory laparotomy was performed by the general surgeon. A 15-cm section of the colon was found to be bruised. The 3 to 4-cm iatrogenic sutured laceration was located, and another 1-cm perforation was also discovered 3 to 4 cm from the first one. There was no gross contamination with fecal material. Examination of the remaining colon and small bowel from the ligament of Treitz to the terminal ileum was normal. The ureter could be seen and was palpated through the thin posterior peritoneum, just adjacent to the injured area of colon. The damaged section of colon was resected, and a Hartmann procedure1 with diverting colostomy was performed. Postoperatively, the patient was managed with an intravenous course of the broad-spectrum antibiotic Zosyn (piperacillin-tazobactam; 2.25 g every eight hours) for two weeks. The patient did well postoperatively and was discharged home after four days. The colostomy was taken down two months later, and normal gastrointestinal function was restored. The patient had no other adverse effects and continued to have good function of the revised hip prosthesis two years postoperatively.