Pulmonary embolism after total hip replacement in a patient by uer60003


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Pulmonary embolism after total hip replacement in a patient who had an
ovarian cyst. A case report
N Sugano, K Ohzono and S Saito
J Bone Joint Surg Am. 1992;74:1543-1545.

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                                                                                                     (opyright            1992 by        11w     Journal         of Bone            and     Joint       Surgery.            tncorporated

                                 Pulmonary                                                       Embolism                                                       after                             TotalHip                                        Replacement
                                                              in a Patient                                                             Who                             Had                           an Ovarian                                                               Cyst
                                                                                                                                            A          CASE                 REPORT*

                                     BY      NOBtJHIKO                         SUGANO.                       M.D.t.              KENJI                OHZONO.                       M.D.t,              AND              SUSUMU                          SAITO,              M.D4.               OSAKA,                      JAPAN

                                                                                       Investigation                        perfttrmed                      at the          Osaka              University                    Hospital,                     Osaka

         Pulmonary                          embolism                           after              total               hip         replacement                               severe
                                                                                                                                                                               is             osteoarthrosis                               of both                 hips,      secondary                       to congenital                           dysplasia.
                                                                                                                                                               A                   roentgenogram                                of         the       chest,           a test          of        respiratory                        function,                    an         dcc-
a serious                  complication                            and,              most              often,                occurs                   as a result
                                                                                                                                                                            trocardiogram,                         a      routine                    blood               count,            and           a coagulation                                  assay               re-
of deep-vein                              thrombosis’2.                           There     are                            many      risk                       factors
                                                                                                                                                                            vealed                normal                 findings.                  The            gynecological                             diagnosis                     was          myoma                     of
predisposing                              a patient                      to      thromboembolic                             disease”2’6.                                    the        uterus,             and            a hysterectomy                                   after          the          total          hip           replacement                              was
However,                        we        know              of      no         report                   of          an       ovarian                       tumor               in

                                                                                                                                                                FIG.          I

     Pulmonary                  perfusion                 scan.        made                two   days      after                       the onset                 of        the       symptoms                      and signs                       of a pulmonary                               embolism.                          The              view
(left)     and           posteroanterior                 view         (right)               show    perfusion                            defects               in the             upper     lobe                 of the right                        and left lungs.

a patient                   who            had           thromboembolic                               disease                    after             a total                             To prevent                       menstruation                             at the            time          of the              hip       replacement.                                the
                                                                                                                                                                            patient               was         given              Norlutin-D.                             a progestogen-estrogen                               combination
hip       replacement.
                                                                                                                                                                            product,from                           the      third            to the seventh                         postoperative                              day.In              June               1987.
         We report                         here            the           occurrence                              of        a pulmonary                                     em-
                                                                                                                                                                            the left           hip         was           replaced                    with           a metal-cancellous                         LObeck                 prosthesis
bolus   after                     total    hip                   replacement                                   in         a patient                        who              had and
                                                                                                                                                                            (S                G Implants.                        LObeck.                      Germany).                    inserted                  without                 cement.                   with
an ovarian                       chocolate                        cyst.                                                                                                     the        patient                under               general                     anesthesia                    and              through                  a posterolateral
                                                                                                                                                                            approach.                   The         total             blood              loss       was         28(X)       milliliters,                     and           24(X)         milliliters
                                                         Case                 Report                                                                                        of blood                was       replaced.                     Anticoagulant                           medication                        and          elastic            stockings
         A      forty-five-year-old                      woman                 was         seen           at        the      Osaka                University                were            not         used.            The           limb              on        the       side          of     the           operation                        was            elevated
Hospital              in January                  1987        because                of         increasing                   pain          in     the          hip         bilat-
                                                                                                                                                                            immediately                         after           the         procedure.                      and       exercises                      for       the          muscles                   of      the
erally         that        had        begun           when               she      was            twenty                  years          old.          She       had         calf were
                                                                                                                                                                              had                    begun                on the                 first        postoperative                        day.            Standing                  was            allowed
congenital                 dislocation                   of       both           hips.            which               had           been              treated               nine
                                                                                                                                                                             with         days          postoperatively.
closed           reduction                  and          immobilization                   in     a      cast             when            she          was            ten               When              walking                 with              crutches                on       the         eleventh                    postoperative                                  day,
months            old.      There             was      no        history             of        thromboembolic                disease.                                       the        patient                suddenly                       noticed                 discomfort                         in      the          chest               and            dyspnea
         The          patient              was        160         centimeters                         tall          and          weighed                    fifty-three and            then          became                    unconscious,                          hypotensive,                        cyanotic,                   and           tachypneic.
kilograms.                 Examination                        revealed                 a       firm          tumor,               ten           centimeters                The in oxygen                         partial                   pressure                   (Po2)           of         the           arterial                  blood              was              64.6
diameter.              in the         lower         part          of the         abdomen.                        Roentgenograms                 showed                      millimeters                    of mercury                            (8.6         kilopascals).                     Thirty              minutes                  later.             she         had
                                                                                                                                                                            respiratory                    and          cardiac                  arrest.           Intubation                    and           cardiopulmonary                   rcsus-
                                                                                                                                                                            citation                were           performed                             immediately.                       and              the           sinus            rhythm                    of      the
         *No          benefits             in any          form           have            been          received                  or     will         he       received
                                                                                                                                                                            heart          was          restored                 within                 fifteen            minutes.
from    a commercial                          party          related        directly      or indirectly                                          to      the         subject
                                                                                                                                                                                       An         ultrasonic                   cardiogram                          showed             obvious                   cardiomegaly.                               an dcc-
of this   article.   No                    funds          were       received        in support        of                                this         study.
                                                                                                                                                                            trocardiogram                              showed                    acute             overload                of      the             right           side          of       the         heart,
       tDepartment                     of Orthopaedic            Surgery.       Osaka                                             University                     Mcd-
ical    School.                  1-1-50      Fukushima,          Fukushima-ku,    Osaka                                              553,              Japan.               and        a roentgenogram                                of     the           chest           revealed                enlargement                              of        the        right
Please      address                 requests       for reprints       to Dr. Sugano.                                                                                        side of the heart.
        Department                      of Orthopaedic           Surgery.      Sumitomo                                                    Hospital.                  5-2-2            A diagnosis                        of      a pulmonary                              embolus                 was             made,             and           the          patient
Nakanoshima.                       Kita-ku.      Osaka       530, Japan.                                                                                                   was         given            urokinase                      and           heparin                sodium.               Two              days            after          the        onset                of

VOL..        74-A,          NO. 10.         I)E(’EMBER                    1992                                                                                                                                                                                                                                                                    1543
1544                                                                                       NOBUHIKO                                 SUGANO.                          KENJI                       OHZONO.                      AND        SUSUMU                 SAITO

                                                                                                                                                                                       Fyi;.           2

    Pulmonary                         perfusion          scan.                         made             twelve                days            later.           No          perfusion                          defect       could       be        identified        on     either           the          view
                                                                                                                                                                                                                                                                                                  anteroposterior (left)       or    the
posteroanterior                        view     (right).

the       symptoms                       and              signs           of        a pulmonary                          embolus.                      a pulmonary                                    scan
showed                 perfusion                    defects                  in the            upper              lobe            of both              lungs          ).     The
                                                                                                                                                                           (Fig.             1
patient                regained                     consciousness                                 three               days            after              the          onset                      of        the
symptoms.                       The           endotracheal                                 tube             was          removed                       six      days                  after             the
onset          of the            symptoms.                         Fourteen                    days           after           the      onset                of the              symptoms,
the       arterial                  oxygenation                                was           normal.                  and           there               was          no               perfusion
defect           on        the         pulmonary                          scan           (Fig.          2).       The          patient                 began               to         walk             one
week           later.            Fifty-five                     days           after           the          onset            of      the        symptoms.                             radioiso-
tope          venography                           with           the          use      of      technetium-99m                      human               serum                   alhu-
mm         revealed                    a collateral                          pathway                   of     the        left         iliac       vein             and           suggested
that       the          thrombi                    that           had          formed                in that             vein           had            caused                   the          pulmo-
nary          embolus                   (Fig.             3).
          A       hysterectomy                                  and          bilateral                 oophorcctomy                                was             performed                            in
September                        1987.          The              postoperative                              diagnosis                 was          endometriosis                                      and
a chocolate                      cyst         of the               left        ovary            (Fig.          4).      The          rate         of blood                      flow             in the
left      femoral                 vein          was             measured                     with           a Doppler                       flowmeter                       before                    and
after         the          hysterectomy                               and           oophorectomy:                    before             the        operation.                           the
mean             blood                flow           was              10.8          centimeters                        per          second.                  and           it     increased
markedly                    after            the          operation.                     to 22.8               centimeters                        per          second.
          A       total           hip         replacement                              without                 cement                  was         performed                             on           the
right.         with             the         patient                   under             general                   anesthesia.                     in         March                    1988:             the
same          type          of prosthesis                             was           inserted                as had             been            placed                in the              left          hip.
Elastic               stockings                    were               used.            but        an         anticoagulant                             or      antithromhotic
medication                       was            not             used.           At       the         most              recent               examination.                                in        April
1991.          the         patient                 could              walk           without                  aid        and          had         no         pain.


          Thromboembolic                                                disease                      is the               most                 common                                 com-
plication         after                             an           elective    operation          on                                             the           hip            in adults.
The       prevalence                                            of deep-vein           thrombosis                                                            has             been      re-
ported                     to         be           35            to          60        per              cent              and               the              prevalence                                       of
pulmonary                               embolus,                               1 to 3 per cent75’”’3’6.                                                               However,
deep-vein                             thrombosis                                 and  pulmonary         embolus                                                          are                          un-
common                          in Asian                          patients”:                         our            patient                   was              the              only              one
at our institution                                                who        was                  known     to have                                          had            a pulmo-
nary  embolus                                       after                 a total                 hip replacement.
          There                       are             many                      risk              factors                       for            thromboembolic
                                                                                                                                                                                                                                                                 Fi;.      3
disease6”’2’6.                                Our                  patient        had                             received                      five    milligrams
of norethisterone                                                   (progestogen)                                      and                  0.05     milligram                                              Radioisotope
                                                                                                                                                                                                           of            venography            performed           with                                the      use of technetium-
                                                                                                                                                                                                 99m      human    serum         albumin.          fifty-five      days                                 after      the  onset       of the
mestranol                             (estrogen)                                each              day.               Because                       of          the              low            dos-
                                                                                                                                                                                                 pulmonary       embolism.           revealing          an obstruction                                        of the   left   iliac   vein
age,             it        seems                 unlikely                               that    this                          therapy        was      a                                       major a collateral
                                                                                                                                                                                                 and                    pathway.
cause                 of      the             pulmonary                                  embolus.                             but     it may     have                              been
a contributing                                        factor’.                                                                                                                       thromboembolic                                           disease              after    a total   hip                         replacement.
    We believe                                         that,                   in       our             patient,                      extrinsic                            compres- so one should                                           consider              resection      of such                         a tumor       before
sion             of          the             iliac                vein                by          the              tumor                      may               have                          the
                                                                                                                                                                                         caused                     replacement.
venous                      stasis                  and                 formation                             of         a thrombus.                                       The                   pres-
                                                                                                                                                                                                                 Nw,    ihe    authors th,,tik      Professor    K. Ono        or   help    in   the   reviev   and editing    of   the
ence              of         an            abdominal                                   tumor                      may               increase                         the                risk                 of

                                                                                                                                                                                                                                       THE           JOURNAL              OF        BONE           AND          JOINT         SURGERY
                       PULMONARY                                         EMBOLISM                            AFTER                 TOTAL                      HIP         REPLACEMENT                    IN         A        PATIENT                 WHO                  HAD              AN      OVARIAN                             CYST     1545

                                                                                                                                                                           FIG.         4
                                Photograph                           of the              resected                 specimen                   of     the         uterus           and         ovaries.              The        chocolate                  cyst         of the         left       ovary          has         been           opened.

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VOL.             74.A,           NO.             10.      DECEMBER                                  1992

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