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Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy for Acute Pulmonary Embolism After Total Hip Arthroplasty
The Journal of Arthroplasty Vol. 21 No. 3 2006
Case Report
Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy for Acute Pulmonary Embolism After Total Hip Arthroplasty Yoram Weil, MD, Yoav Mattan, MD, Vladimir Goldman, MD, and Meir Liebergall, MD
Abstract: Sciatic nerve paralysis as a complication of bleeding due to hip surgery is a rare entity. The use of thrombolysis and full-dose heparin administration for the treatment of massive pulmonary embolism increase the risk for developing major bleeding. Prompt recognition and intervention in this condition are warranted. A case of sciatic nerve palsy due to expanding thigh hematoma as a complication of thrombolytic therapy for pulmonary embolism after total hip arthroplasty is presented with a literature review. Although rare, this complication should be promptly recognized and immediate decompression should take place because of the favorable results of the early treatment. Key words: sciatic nerve palsy, acute pulmonary embolism, tissue plasminogen activator, total hip arthroplasty. n 2006 Elsevier Inc. All rights reserved.
with that treatment regimen. Several days after discharge, the patient felt shortness of breath and was admitted to another hospital where the diagnosis of massive pulmonary embolism was made based on helical dynamic computed tomography (CT). The patient was administered systemic intravenous recombinant tissue plasminogen activator (tPA) (Actilyse 100 mg, Boehringer Ingelheim Pharma, Reine, Germany) as a thrombolytic agent, received intravenous full-dose heparin according to partial thromboplastin time (PTT), and was monitored in the medical intensive care unit. At the evening of admission, she was examined by her surgeon and mild thigh swelling was noted. Hemoglobin levels dropped from 11.2 on admission to 9 g/L on the same evening, whereas the PTT value at that time was within normal limits (23 seconds). A total of 5 packed cell units were given during the 3-day period of her stay in the other hospital. On the third day after thrombolysis,
Case Report A 70-year-old female patient was admitted to our institute for right total hip arthroplasty (THA) because of osteoarthritis. The patient had no significant medical history. The patient underwent a miniposterior approach for the placement of a cementless THA. The patient was discharged 5 days postoperatively with anticoagulation prophylaxis consisting of subcutaneous injections of enoxaparin, 40 mg every day. The patient was compliant
From the Department of Orthopaedic Sugery, Hadassah Hebrew University Hospital, Jerusalem 91120, Israel. Submitted October 5, 2004; accepted March 30, 2005. No benefits or funds were received in support of the study. Reprint requests: Meir Liebergall, MD, Department of Orthopaedic Surgery, Hadassah Hebrew University Hospital, POB 12000, Jerusalem 91120, Israel. n 2006 Elsevier Inc. All rights reserved. 0883-5403/06/1906-0004$32.00/0 doi:10.1016/j.arth.2005.03.042
456
Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy ! Weil et al 457
the patient complained of numbness and paresthesia of her right foot. Examination revealed expansion of the thigh swelling, reduced force in plantar flexion, absent dorsiflexion, and toe extension in the right foot and ankle. Pedal pulses were present. The patient was immediately transferred to our institution. Blood hemoglobin level was 7.55 g/L and PTT was 83 seconds (control, 45 seconds). Heparin was stopped and packed cells were given.
An operative procedure of thigh decompression was considered at that time, and to evaluate the location of the hematoma, a CT scan (Fig. 1) of the affected limb was performed. The scan demonstrated a large hematoma in the joint, extending into all compartments of the thigh, but mainly involving the posterior compartment. As surgical intervention was contemplated, the cessation of anticoagulation together with some form of protection against repeated PE postoperatively was considered. Therefore, an inferior vena cava (IVC) filter was inserted in the angiography suite. The patient was transferred to the operating room for immediate decompression. Extending the previous surgical approach, a posterior capsulotomy resulted in immediate decompression of 1500 mL of pressurized blood. Thigh muscles were viable and the wound was closed over suction drains left in place for 48 hours. Immediate postoperative care included application of intermittent leg compression device and renewal of prophylactic enoxaparin 3 days postoperatively. Repeated chest helical CT scan demonstrated clearance of the pulmonary embolism. Neurologic function improved gradually and the patient was discharged after 2 weeks with almost normal plantar flexion, toe extension, and flicker of dorsiflexion and a support of an ankle-foot orthosis. Ten months later, the patient is walking normally without braces or walking aids, and the strength of all muscle groups returned to normal levels. Our patient was informed that data concerning the case would be submitted for publication.
Discussion
Fig. 1. A, Computed tomography scan of the involved hip demonstrating hematoma in the hip joint area. B, Computed tomography scan distal to the hip joint demonstrating the hematoma extension into the thigh in the anterior, medial, and posterior compartments.
A complication of systemic thrombolytic therapy combined with massive anticoagulation treatment of pulmonary embolism after THA is presented here. Pulmonary embolism is a potentially fatal complication that still occurs after THA, although in a low incidence [1]. Thrombolytic therapy for acute pulmonary embolism is a relatively new modality and it is still controversial. Its rationale for use is in the massive and submassive cases to reduce mortality and to reduce the adverse outcome of pulmonary hypertension and right heart failure [2]. It was first introduced in 1962 by Browse and James [3] using streptokinase and was adopted later by other investigators using tPA [4] for the treatment of acute, massive pulmonary embolism. In recent years, several prospective randomized studies have been conducted to examine the efficacy and safety of this regimen [5,6]. In a
458 The Journal of Arthroplasty Vol. 21 No. 3 April 2006 recently published meta-analysis comparing 241 patients treated with thrombolysis with 220 patients treated with heparin [7], a slightly better outcome end point was demonstrated in the thrombolysis group regarding right heart failure and pulmonary hypertension with no increase in adverse effects. Some claim, although, that the risk of major bleeding is highly increased with thrombolytic therapy compared with heparin, based on previous studies [2]. In a recent prospective, multicenter, randomized study conducted in 256 patients [8] comparing treatment with recombinant tPA plus heparin and treatment with heparin alone, mortality was decreased with thrombolytic therapy compared with heparin, and major or fatal bleedings did not occur in the heparin plus recombinant tPA group. However, patients after trauma or surgery were excluded from this study, so its results are not applicable in our case. Therefore, it may seem that thrombolysis has a role in severe cases of pulmonary embolism but patients after surgery are probably at a high risk of major bleeding. Sciatic nerve palsy due to bleeding is rarely described in the literature. Fleming et al [9] described 5 patients with sciatic paresis due to hemorrhage post–hip surgery after administration of prophylactic anticoagulants. Of these 5 patients, only 2 patients had THA, whereas 3 others were operated because of tumors, osteotomy, and acetabular fractures. In one other report [10], a similar case after a THA was described. Another reported case was of a femoral nerve palsy after perforation of the iliac bone and a resulting hematoma [11]. Totally, there were only 3 reported cases of sciatic nerve palsy after hematoma after THA. Three cases of thigh compartment syndrome after joint arthroplasty were published by Nadeem et al [12], but these were attributed to hematoma within the posterior muscular compartment causing muscle necrosis, which was not found in our case. However, none of all the above quoted cases were the result of thrombolytic therapy. Regarding treatment of acute sciatic nerve palsy, insufficient data exist for the preferred treatment option. It seems logical that early intervention would decompress the nerve and prevent further neural damage. In the cases with thigh compartment syndromes described by Nadeem et al [12], decompression did not always occur promptly with 1 case resulting in muscle necrosis and 2 cases with permanent neurologic deficit. Fleming et al [9] described good functional results with prompt recognition and immediate decompression of the hematoma.
In our case, we decided to place an IVC filter before surgical decompression to minimize the risk for recurrent pulmonary emboli postoperatively. The use of IVC filter for prophylaxis in primary total joint arthroplasties was successfully implemented by Emerson et al [13] in 1991 on a population of 47 patients. However, this device is not devoid of complication, although rare. Pneumothorax, hemorrhage, vessel injury, filter misplacement, excessive tilt, and vascular injury have been reported with its insertion, although long-term complications are much more infrequent [14]. Although not in common use for primary joint arthroplasty, this option should be considered for selected cases where anticoagulation is contraindicated. Several studies imply that severe bleeding is the most threatening complication of thrombolytic therapy [2]. Patients after major surgery are probably in an increased risk for bleeding from the surgical site. Because altogether the evidence in favor of systemic thrombolytic therapy in general is equivocal, it is hard to recommend such treatment in patients who have undergone recent major surgery such as THA, considering the risk of major bleeding. Although thigh bleeding can also occur after prophylactic anticoagulant therapy, its signs and symptoms should be promptly recognized and immediate decompression should take place because of the favorable results of the early treatment.
References 1. Phillips CB, Barrett JA, Losina E, et al. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am 2003; 85-A:20. 2. Dalen JE, editor. The uncertain role of thrombolytic therapy in the treatment of pulmonary embolism. Arch Intern Med 2002;162:2521. 3. Browse NL, James DC. Streptokinase and pulmonary embolism. Lancet 1962;2:1039. 4. Dong B, Pineo G, Mulrooney T. Thrombolytic therapy for pulmonary embolism (Protocol for a Cochrane Review). The Cochrane Library, Issue 4. Chichester (UK): John Wiley & Sons, Ltd; 2003. 5. Yamasawa F, Okada Y, Asano K, et al. The role of recombinant human tissue-type plasminogen activator in the treatment of acute pulmonary thromboembolism. Intern Med 1992;31:885. 6. Stein PD, Alavi A, Athanasoulis C, et al. Tissue plasminogen activator for the treatment of acute pulmonary embolism. Chest 1990;97:528. 7. Angelli G, Becattini C, Kirschtein T. Thrombolysis vs heparin in the treatment of pulmonary embolism: a
Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy ! Weil et al 459
8.
9.
10.
11.
clinical outcome-based meta-analysis. Arch Intern Med 2002:2537. Konstantinides S, Geibel A, Heusel G, et al. Heparin plus altepase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002;347:1143. Fleming RE, Michelsen CB, Stinchfield FE. Sciatic paralysis—a complication of bleeding following hip surgery. J Bone Joint Surg Am 1979;61:37. Sorensen JV, Christensen KS. Wound hematoma induced sciatic nerve palsy after total hip arthroplasty. J Arthroplasty 1992;7:551. Wooten SL, McLuaghlin RE. Iliacus hematoma and subsequent femoral nerve palsy after pe-
netration of the medical acetabular wall during total hip arthroplasty. Report of a case. Clin Orthop 1984:221. 12. Nadeem RD, Clift BA, Martindale JP, et al. Acute compartment syndrome of the thigh after joint replacement with anticoagulation. J Bone Joint Surg Br 1998;80-B:866. 13. Emerson RH, Cross R, Head WC. Prophylactic and early therapeutic use of the Greenfield filter in hip and knee joint arthroplasty. J Arthroplasty (United States) 1991;6:129. 14. Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava filters. Am Surg (United States) 2003;69:654.
Case Report
Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy for Acute Pulmonary Embolism After Total Hip Arthroplasty Yoram Weil, MD, Yoav Mattan, MD, Vladimir Goldman, MD, and Meir Liebergall, MD
Abstract: Sciatic nerve paralysis as a complication of bleeding due to hip surgery is a rare entity. The use of thrombolysis and full-dose heparin administration for the treatment of massive pulmonary embolism increase the risk for developing major bleeding. Prompt recognition and intervention in this condition are warranted. A case of sciatic nerve palsy due to expanding thigh hematoma as a complication of thrombolytic therapy for pulmonary embolism after total hip arthroplasty is presented with a literature review. Although rare, this complication should be promptly recognized and immediate decompression should take place because of the favorable results of the early treatment. Key words: sciatic nerve palsy, acute pulmonary embolism, tissue plasminogen activator, total hip arthroplasty. n 2006 Elsevier Inc. All rights reserved.
with that treatment regimen. Several days after discharge, the patient felt shortness of breath and was admitted to another hospital where the diagnosis of massive pulmonary embolism was made based on helical dynamic computed tomography (CT). The patient was administered systemic intravenous recombinant tissue plasminogen activator (tPA) (Actilyse 100 mg, Boehringer Ingelheim Pharma, Reine, Germany) as a thrombolytic agent, received intravenous full-dose heparin according to partial thromboplastin time (PTT), and was monitored in the medical intensive care unit. At the evening of admission, she was examined by her surgeon and mild thigh swelling was noted. Hemoglobin levels dropped from 11.2 on admission to 9 g/L on the same evening, whereas the PTT value at that time was within normal limits (23 seconds). A total of 5 packed cell units were given during the 3-day period of her stay in the other hospital. On the third day after thrombolysis,
Case Report A 70-year-old female patient was admitted to our institute for right total hip arthroplasty (THA) because of osteoarthritis. The patient had no significant medical history. The patient underwent a miniposterior approach for the placement of a cementless THA. The patient was discharged 5 days postoperatively with anticoagulation prophylaxis consisting of subcutaneous injections of enoxaparin, 40 mg every day. The patient was compliant
From the Department of Orthopaedic Sugery, Hadassah Hebrew University Hospital, Jerusalem 91120, Israel. Submitted October 5, 2004; accepted March 30, 2005. No benefits or funds were received in support of the study. Reprint requests: Meir Liebergall, MD, Department of Orthopaedic Surgery, Hadassah Hebrew University Hospital, POB 12000, Jerusalem 91120, Israel. n 2006 Elsevier Inc. All rights reserved. 0883-5403/06/1906-0004$32.00/0 doi:10.1016/j.arth.2005.03.042
456
Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy ! Weil et al 457
the patient complained of numbness and paresthesia of her right foot. Examination revealed expansion of the thigh swelling, reduced force in plantar flexion, absent dorsiflexion, and toe extension in the right foot and ankle. Pedal pulses were present. The patient was immediately transferred to our institution. Blood hemoglobin level was 7.55 g/L and PTT was 83 seconds (control, 45 seconds). Heparin was stopped and packed cells were given.
An operative procedure of thigh decompression was considered at that time, and to evaluate the location of the hematoma, a CT scan (Fig. 1) of the affected limb was performed. The scan demonstrated a large hematoma in the joint, extending into all compartments of the thigh, but mainly involving the posterior compartment. As surgical intervention was contemplated, the cessation of anticoagulation together with some form of protection against repeated PE postoperatively was considered. Therefore, an inferior vena cava (IVC) filter was inserted in the angiography suite. The patient was transferred to the operating room for immediate decompression. Extending the previous surgical approach, a posterior capsulotomy resulted in immediate decompression of 1500 mL of pressurized blood. Thigh muscles were viable and the wound was closed over suction drains left in place for 48 hours. Immediate postoperative care included application of intermittent leg compression device and renewal of prophylactic enoxaparin 3 days postoperatively. Repeated chest helical CT scan demonstrated clearance of the pulmonary embolism. Neurologic function improved gradually and the patient was discharged after 2 weeks with almost normal plantar flexion, toe extension, and flicker of dorsiflexion and a support of an ankle-foot orthosis. Ten months later, the patient is walking normally without braces or walking aids, and the strength of all muscle groups returned to normal levels. Our patient was informed that data concerning the case would be submitted for publication.
Discussion
Fig. 1. A, Computed tomography scan of the involved hip demonstrating hematoma in the hip joint area. B, Computed tomography scan distal to the hip joint demonstrating the hematoma extension into the thigh in the anterior, medial, and posterior compartments.
A complication of systemic thrombolytic therapy combined with massive anticoagulation treatment of pulmonary embolism after THA is presented here. Pulmonary embolism is a potentially fatal complication that still occurs after THA, although in a low incidence [1]. Thrombolytic therapy for acute pulmonary embolism is a relatively new modality and it is still controversial. Its rationale for use is in the massive and submassive cases to reduce mortality and to reduce the adverse outcome of pulmonary hypertension and right heart failure [2]. It was first introduced in 1962 by Browse and James [3] using streptokinase and was adopted later by other investigators using tPA [4] for the treatment of acute, massive pulmonary embolism. In recent years, several prospective randomized studies have been conducted to examine the efficacy and safety of this regimen [5,6]. In a
458 The Journal of Arthroplasty Vol. 21 No. 3 April 2006 recently published meta-analysis comparing 241 patients treated with thrombolysis with 220 patients treated with heparin [7], a slightly better outcome end point was demonstrated in the thrombolysis group regarding right heart failure and pulmonary hypertension with no increase in adverse effects. Some claim, although, that the risk of major bleeding is highly increased with thrombolytic therapy compared with heparin, based on previous studies [2]. In a recent prospective, multicenter, randomized study conducted in 256 patients [8] comparing treatment with recombinant tPA plus heparin and treatment with heparin alone, mortality was decreased with thrombolytic therapy compared with heparin, and major or fatal bleedings did not occur in the heparin plus recombinant tPA group. However, patients after trauma or surgery were excluded from this study, so its results are not applicable in our case. Therefore, it may seem that thrombolysis has a role in severe cases of pulmonary embolism but patients after surgery are probably at a high risk of major bleeding. Sciatic nerve palsy due to bleeding is rarely described in the literature. Fleming et al [9] described 5 patients with sciatic paresis due to hemorrhage post–hip surgery after administration of prophylactic anticoagulants. Of these 5 patients, only 2 patients had THA, whereas 3 others were operated because of tumors, osteotomy, and acetabular fractures. In one other report [10], a similar case after a THA was described. Another reported case was of a femoral nerve palsy after perforation of the iliac bone and a resulting hematoma [11]. Totally, there were only 3 reported cases of sciatic nerve palsy after hematoma after THA. Three cases of thigh compartment syndrome after joint arthroplasty were published by Nadeem et al [12], but these were attributed to hematoma within the posterior muscular compartment causing muscle necrosis, which was not found in our case. However, none of all the above quoted cases were the result of thrombolytic therapy. Regarding treatment of acute sciatic nerve palsy, insufficient data exist for the preferred treatment option. It seems logical that early intervention would decompress the nerve and prevent further neural damage. In the cases with thigh compartment syndromes described by Nadeem et al [12], decompression did not always occur promptly with 1 case resulting in muscle necrosis and 2 cases with permanent neurologic deficit. Fleming et al [9] described good functional results with prompt recognition and immediate decompression of the hematoma.
In our case, we decided to place an IVC filter before surgical decompression to minimize the risk for recurrent pulmonary emboli postoperatively. The use of IVC filter for prophylaxis in primary total joint arthroplasties was successfully implemented by Emerson et al [13] in 1991 on a population of 47 patients. However, this device is not devoid of complication, although rare. Pneumothorax, hemorrhage, vessel injury, filter misplacement, excessive tilt, and vascular injury have been reported with its insertion, although long-term complications are much more infrequent [14]. Although not in common use for primary joint arthroplasty, this option should be considered for selected cases where anticoagulation is contraindicated. Several studies imply that severe bleeding is the most threatening complication of thrombolytic therapy [2]. Patients after major surgery are probably in an increased risk for bleeding from the surgical site. Because altogether the evidence in favor of systemic thrombolytic therapy in general is equivocal, it is hard to recommend such treatment in patients who have undergone recent major surgery such as THA, considering the risk of major bleeding. Although thigh bleeding can also occur after prophylactic anticoagulant therapy, its signs and symptoms should be promptly recognized and immediate decompression should take place because of the favorable results of the early treatment.
References 1. Phillips CB, Barrett JA, Losina E, et al. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am 2003; 85-A:20. 2. Dalen JE, editor. The uncertain role of thrombolytic therapy in the treatment of pulmonary embolism. Arch Intern Med 2002;162:2521. 3. Browse NL, James DC. Streptokinase and pulmonary embolism. Lancet 1962;2:1039. 4. Dong B, Pineo G, Mulrooney T. Thrombolytic therapy for pulmonary embolism (Protocol for a Cochrane Review). The Cochrane Library, Issue 4. Chichester (UK): John Wiley & Sons, Ltd; 2003. 5. Yamasawa F, Okada Y, Asano K, et al. The role of recombinant human tissue-type plasminogen activator in the treatment of acute pulmonary thromboembolism. Intern Med 1992;31:885. 6. Stein PD, Alavi A, Athanasoulis C, et al. Tissue plasminogen activator for the treatment of acute pulmonary embolism. Chest 1990;97:528. 7. Angelli G, Becattini C, Kirschtein T. Thrombolysis vs heparin in the treatment of pulmonary embolism: a
Sciatic Nerve Palsy Due to Hematoma After Thrombolysis Therapy ! Weil et al 459
8.
9.
10.
11.
clinical outcome-based meta-analysis. Arch Intern Med 2002:2537. Konstantinides S, Geibel A, Heusel G, et al. Heparin plus altepase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002;347:1143. Fleming RE, Michelsen CB, Stinchfield FE. Sciatic paralysis—a complication of bleeding following hip surgery. J Bone Joint Surg Am 1979;61:37. Sorensen JV, Christensen KS. Wound hematoma induced sciatic nerve palsy after total hip arthroplasty. J Arthroplasty 1992;7:551. Wooten SL, McLuaghlin RE. Iliacus hematoma and subsequent femoral nerve palsy after pe-
netration of the medical acetabular wall during total hip arthroplasty. Report of a case. Clin Orthop 1984:221. 12. Nadeem RD, Clift BA, Martindale JP, et al. Acute compartment syndrome of the thigh after joint replacement with anticoagulation. J Bone Joint Surg Br 1998;80-B:866. 13. Emerson RH, Cross R, Head WC. Prophylactic and early therapeutic use of the Greenfield filter in hip and knee joint arthroplasty. J Arthroplasty (United States) 1991;6:129. 14. Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava filters. Am Surg (United States) 2003;69:654.