Name: ______
Date: ______
Complication Study Case Scenarios
1)A 33-year-old female with acetabular dysplasia underwent periacetabular osteotomy. Three months after surgery x-rays revealed minor heterotopic ossification along the lateral aspect of the hip. The patient was asymptomatic. No intervention or change in treatment was required.Response:
2)A 34-year-old female underwent PAO and subsequently had a wound dehiscence which became infected and required surgical intervention. Two weeks postsurgical debridement the patient presented at a local emergency room with shortness of breath and chest pain. At that time a CT scan and ultrasound were obtained. The patient was then diagnosed with an acute pulmonary embolus in the right lower lobe. Anticoagulant therapy was introduced promptly and the patient recovered fully without any long-term disability.
Response:
3)A 12-year-old female underwent PAO and femoral osteochondroplasty. On postoperative Day one the patient was noted to have a foot drop. An MRI of the pelvis and thigh showed expected postoperative changes with no fluid collections, specifically no hematomas. Bone fragment position and fixation did not show any likely source of compression. However, the nerve conduction study showed partial peroneal nerve deficit and evidence of compression at the fibular head. She subsequently underwent peroneal nerve release and neurolysis. The patient recovered without permanent injury.
Response:
4)A 42-year-old male underwent arthroscopy and femoral osteochondroplasty. Four weeks after surgery he presented at a local ER with a 1-week history of pain, swelling, and redness around the surgical site. An ultrasound in the ER showed fluid collection. At that time, he underwent surgical debridement of the superficial wound infection and was started on IV antibiotics. One week postsurgical debridement the patient had recurrence of the swelling around the surgical site and had repeat incision and drainage. The patient fully recovered without problems.
Response:
5)A 16-year-old male with a history of spastic cerebral palsy underwent PAO. Postoperatively the patient experienced severe spasms and was prescribed Baclofen and Valium. Radiographs in the hospital showed resubluxation of the hip. The patient subsequently was returned to the operating room and underwent revision PAO and proximal femoral osteotomy, psoas release, and application of a Petrie cast. The patient was discharged a week later without further complications.
Response:
6)A 15-year-old female had a minor superficial wound dehiscence with minimal drainage develop 4 weeks after PAO. The patient was started on antibiotics and seen in clinic 10 days later for a wound check and to confirm response to treatment. The wound healed without any further difficulties.
Response:
7)A 38-year-old male underwent surgical dislocation of the hip for the treatment of combined cam and pincer FAI. For the first 36 hours after surgery, the patient had nausea. This was treated with diet restriction, medications, and continuation of intravenous fluids. The nausea completely resolved approximately 36 hours postoperatively. The patient had no other problems and was discharged from the hospital on postoperative Day 3.
Response:
8)A 52-year-old male underwent hip arthroscopy with limited open osteochondroplasty of the femoral head-neck junction. At the time of surgery, the patient was noted to have a degenerative labral tear and insufficient head-neck offset. The patient was treated with a partial labral resection and osteochondroplasty of the femoral head-neck junction. During postoperative Week 5, the patient had acute shortness of breath and chest pain develop. He was admitted to an outside hospital and was diagnosed with a pulmonary embolism. He was admitted to the ICU at that hospital and treated with initial heparin and anticoagulation and converted to Coumadin anticoagulation. The patient remained on anticoagulation for a total of 6 months. He completely recovered from this postoperative pulmonary embolism.
Response:
9)A 17-year- old male fell on his surgically treated hip 2 weeks after periacetabular osteotomy. Radiographs revealed loss of fixation and return of his acetabular fragment to the original position. X -rays showed complete loss of correction and his hip was noted to be lateralized and uncovered. The patient underwent repeat surgery with reposition of the acetabular fragment and the osteotomy healed without any further intervention.
Response:
10)Fourweeks after periacetabular osteotomy, a 22-year-old female had a suture abscess develop. She did not have any systemic signs, such as fevers, chills, or sweats. No treatment was required. The wound healed without problems.
Response:
11)A 14-year-old male had a deep vein thrombosis develop in the leg after surgical dislocation, femoral osteochondroplasty, and femoral intertrochanteric osteotomy. He was admitted to the hospital, started on inpatient anticoagulation therapy, and recovered without persistent symptoms.
Response:
12)A 45-year-old female underwent a hip arthroscopy for labral debridement. Following surgery she noted severe pain in the lower extremity accompanied by recurrent cyanosis and dysesthesia. She was diagnosed with complex regional pain syndrome secondary to femoral nerve injury and has been refractory to all treatment including pharmacologic management, epidural steroids, and spinal cord stimulation. One year postoperatively she is completely disabled.
Response:
13)A 34-year-old female who underwent PAO was noted to have a fractured ilium 8 weeks after surgery. No surgical intervention was required. Since this fracture and her osteotomy had signs of healing her postoperative treatment did not change andshe was allowed to continue weightbearing as tolerated. The patient returned for followup 6 weeks later and although x-rays did not show complete healing of the fracture and PAO, further healing was noted and she continued with routine back-to-activity protocol at 3 months for a PAO.
Response:
14)Four weeks after periacetabular osteotomy a21-year-old femalepresented to a local ER with erythema and swelling at the inferior aspect of the incision. She was diagnosed with cellulitis in conjunction with a suture abscess. She was started on oral antibiotics and returned earlier then previously scheduled for a clinic visit to evaluate the incision. The infection resolved on antibiotics. The patient recovered without further treatment.
Response:
15)A 28-year-old female suffered from a spinal headache following periacetabular osteotomy. She was readmitted for a blood patch and recovered without further complications.
Response:
16)A 16-year-old male underwent bilateral surgical dislocations of the hip. Three months after the second procedure radiographs showed mild displacement of the right and left greater trochanters. He subsequently underwent repeat open reduction and internal fixation of both greater trochanters. Complete union was achieved and the patient recovered without further complications.
Response:
17)A 33-year-old female was treated with PAO for symptomatic acetabular dysplasia. The surgery was without problems or complications. The patient was treated with an epidural and a Foley catheter for 24 hours postoperatively. The epidural and Foley catheter were then removed. The patient reported dysuria after removal of the Foley catheter. Urine cultures were obtained and were positive. She was treated with Bactrim for 3 days and had routine postoperative followup. She had no subsequent problems.
Response:
18)A 21-year-old male had a superficial wound hematoma develop that was noted before discharge after periacetabular osteotomy. The hematoma resolved without intervention and this was confirmed at the routine 2-week followup.
Response:
19)A 20-year-old female who underwent Ganz osteotomy on exposure was noted to have significant uncontrolled bleeding from an intrapelvic arterial vessel. Since the bleeding was uncontrollable the patient had the wound packed and was transferred to interventional radiology. The intrapelvic vessel was embolized and the patient was taken to the ICU for 24 hours due to hypovolemia and she eventually was transferred to the inpatient unit. At a later date the PAO was performed without incident.
Response:
20)A 42-year-old female was noted to have peroneal nerve dysesthesia after undergoing periacetabular osteotomy. She was treated with observation. At final followup, the patient reported no improvement in her symptoms. She was bothered by persistent pain and activity limitation.
Response:
21)A 24-year-old male underwent hip arthroscopy for the treatment of cam impingement and an associated labral tear. The patient tolerated the procedure well and there were no intraoperative complications. Nevertheless, after surgery the patient complained of ankle pain. This was treated symptomatically with ice, elevation, and the pain medications ordered for the hip surgery. Within 48 hours, the ankle discomfort resolved and there was no residual clinical problem with the ankle.
Response:
22)A 20-year-old male with cerebral palsy was noted to have global sciatic and femoral nerve palsies following periacetabular osteotomy. He was treated with close clinical observation, lower extremity bracing, and physical therapy, and had complete resolution of sensory and motor function within 3 months of surgery.
Response:
23)A 50-year-old man suffered an isolated, associated, both-column fracture of the left acetabulum. He underwent an uncomplicated open reduction and internal fixation through an ilioinguinal approach. A followup CT scan was performed postoperatively, which documented intraarticular fragments. Hip arthroscopy was performed to remove the fragments. During the procedure, arthroscopic fluid extravasated through the fracture site under pump pressure and resulted in an intraabdominal compartment syndrome that presented as cardiopulmonary arrest. An emergent exploratory laparotomy was performed to release the fluid and resume blood flow. Despite prolonged asystole, the patient survived without neurologic deficit.
Response:
24)A 19-year-old male with Down’s syndrome had a wound hematoma develop after PAO. The patient required subsequent evacuation of the hematoma. He recovered without further complications.
Response:
25)A 43-year-old male status-post PAO presented with mechanical symptoms and persistent hip pain. The patient underwent hip arthroscopy and was found to have a large degenerative labral tear. This was debrided back to stable labral remnant. Postoperatively, the patient was noted to have a pudendal nerve palsy. He had marked decreased sensation in the perineum and scrotum. This was followed clinically on a monthly basis for 4 months. The nerve dysfunction completely resolved 5 months after the operative procedure.
Response:
26)A 33-year-old male had an ischial nonunion following PAO. He was treated with ORIF and bone grafting. The nonunion eventually healed without further intervention.
Response:
27)A 43-year-old male underwent PAO and combined osteochondroplasty of the femoral head-neck junction. This was performed for treatment of symptomatic acetabular dysplasia. The surgical procedure was without major complications. On postoperative Day 2 the patient reported abdominal distension, mild abdominal pain, and minimal appetite. The patient was clinically thought to have a postoperative ileus. The patient was treated with restriction of PO intake, IV fluids, and reduction of narcotic pain medicines. The abdominal symptoms resolved within 36 hours with no subsequent need for medical intervention.
Response:
28)A 29-year-old female underwent a PAO which was complicated by an intraarticular acetabular fracture that required surgical ORIF. The patient subsequently had a wound dehiscence which became infected and required surgical debridement. The wound dehiscence healed but her hip symptoms worsened and she underwent a THA 12 months after surgery.
Response:
29)A 45-year-old female underwent surgical dislocation of the hip for treatment of pincer hip impingement. The procedure was without major complications. Three weeks after surgery, the patient fell down a flight of stairs and sustained a nondisplaced trochanteric facture. The fracture was apparent on radiographs at the level of trochanteric fixation screws. The patient was kept on toe-touch weightbearing for an additional month (three additional weeks of touch-down weightbearing). The patient was seen 2 months after surgery and was found to have progressive healing on radiographs. The patient was then allowed full weightbearing and had eventual healing of the trochanteric fracture without need of additional intervention.
Response:
30)A 26-year-old female had a posterior column nonunion develop after periacetabular osteotomy. She was successfully treated with repeat open reduction and internal fixation. The patient recovered without further complications.
Response:
31)A 24-year-old male underwent hip arthroscopy, debridement of a torn labrum, and removal of a prominent pincer lesion for femoroacetabular impingement. At the 3-month followup, MRI showed osteonecrosis with collapse. An eventual THAwill be needed.
Response:
32)An 18-year-old female underwent hip arthroscopy for an acetabular labral tear associated with mild acetabular dysplasia. The patient had an acetabular labral repair without intraoperative problems or complications. Postoperatively, the patient noted numbness and discomfort in the small finger and ring finger. This was treated symptomatically with no change in postoperative course and completely resolved without intervention.
Response:
33)A 20-year-old male with femoroacetabular impingement underwent surgical dislocation. Three months after surgery x-rays revealed Grade II heterotopic ossification, but the patient was asymptomatic. No intervention was required.
Response:
34)A 42-year-old female underwent surgical dislocation for FAI. The patient felt an acute pop and pain in her hip 2 weeks postoperative when getting into her car to attend her first postoperative appointment. She was diagnosed with a comminuted trochanteric fracture and underwent operative refixation. She had a trochanteric nonunion develop, walks with a persistent Trendelenburg gait, but she has no pain and is satisfied with her result.
Response:
35)A 15-year-old female underwent a surgical dislocation for hip pain following a SCFE. During the procedure the labrum was repaired using a Mitek suture anchor. Six weeks postoperatively she was referred for worsening pain and severe stiffness. A CT scan showed an intraarticular anchor, and on surgical dislocation the patient was noted to have diffuse chondrolysis and has not improved following treatment.
Response:
36)One day after periacetabular osteotomy a 21-year-old female was noted to have evidence of motor and sensory femoral nerve paralysis. She was treated with protected weightbearing, a drop-lock brace, and physical therapy. The nerve palsy resolved completely within 4 months of surgery.
Response:
37)A 13-year-old female underwent a PAO. During the operation the profunda femoris artery was inadvertently ligated. Lower extremity cyanosis and pain prompted a vascular surgical consultation. The injured vessel was repaired, however, the patient had a compartment syndrome develop resulting in a below knee amputation.
Response:
38)A 16-year-old female underwent PAO and on postoperative Day 2 had a fever of 101.0odevelop. This was treated with Tylenol and incentive spirometer and resolved within 24 hours. The patient had no additional problems.
Response:
39)Six months after periacetabular osteotomy, a 35-year-old female presented with pain and limited hip flexion. Radiographs showed Brooker Class III heterotopic bone formation. The patient subsequently underwent surgical excision of the heterotopic bone and had complete relief of her symptoms.
Response:
40)A 24-year-old patient with cerebral palsy presented with painful acetabular dysplasia. The patient was household ambulatory. The patient was treated with PAO and combined proximal femoral varus osteotomy. The surgical procedure was without complication. Three months following the procedure the patient presented with fever, chills, and purulent drainage from the osteotomy site. The patient underwent open, irrigation and debridement of the femoral osteotomy wound and the PAO wound. The patient was treated with a 6-week course of IV antibiotics and then presented 3 months later with recurrent sepsis and purulent drainage from both wounds. Attempted irrigation and debridement and IV antibiotics were attempted again. The treatment failed and the patient had recurrent persistent infection of the hip. During treatment for this third infectious episode, the hip dislocated. The diagnosis of the dislocation was delayed. The patient eventually underwent resection arthroplasty of the hip to treat the recurrent infection and the dislocation. The patient had permanent limitation of function and activity due to this resection arthroplasty.
Response:
41)A 23-year-old male retuned for his 3-month visit after surgical hip dislocation. An AP radiograph of his pelvis indicated that his trochanteric osteotomy was not completely healed. The two 3.5-mm screws were intact and there was early callous. A bone stimulator was applied and he was instructed to return to clinic monthly for the next 2 months and at his 5-month followup the trochanteric osteotomy was healed. At his 1-year visit he had no limp and returned to all activities.
Response:
42)A 33-year-old woman was noted at her 2-week postoperative visit after hip arthroscopy to have continued drainage of clear fluid from her anterolateral arthroscopic portal. There was no erythema or swelling and she had typical postoperative discomfort. She was given Keflex due to the persistent drainage and was asked to return the following week for a wound check. By the next visit, the drainage had decreased. She was seen again 4 weeks postoperativefor evaluation of the drainage and an examination. By that time the drainage had stopped and the remainder of her postoperative course was normal.
Response:
43)A 30-year-old female had a hip arthroscopy, labral repair, and osteochondroplasty. She had complete dysesthesia in the peroneal distribution of the sciatic nerve. She was given Neurontin and returned for followup 2 weeks later for evaluation of her symptoms. She was followed closely in clinic and seen monthly until her symptoms resolved at 6 months.
Response:
44)A 19-year-old female status-post left PAO presented with left thigh pain. This was associated with numbness and a burning sensation over the lateral femoral cutaneous nerve distribution. She was given a prescription for Neurontin and was told to return on a monthly basis until her symptoms resolved. The patient had complete resolution of symptoms by 9 months.
Response:
Reading #1 Page 1 of 8