Unique case of intraperitoneal loss of pelvic array pin in setting of routine navigated total hip arthroplasty

Pelvic array pin placement during navigated total hip arthroplasty has been known to cause complications; however, most of them are minor. While intraoperative pin migration has been documented as a complication, a complete loss of the iliac array pin within the peritoneum has not been reported in literature.

Heng Kan et al described a case of 78-year-old female who underwent a routine computer-navigated total hip arthroplasty for the indication of severe osteoarthritis. The Intellijoint HIP approach platform was used with the standard workflow whereby iliac array pins were inserted percutaneously through a stab incision prior to primary incision. The 6.5-mm self-tapping navigation pin was inserted as per surgical technique recommended by the manufacturer. Surgical landmarks were referenced at the apex of the iliac wing between the anterior superior iliac spine and posterior inferior iliac spine. The pins are then inserted 1 cm distal to that point to ensure sufficient circumferential bone stock. Upon attachment of the handheld screwdriver to advance the pin, a sudden loss of purchase was encountered whereby the shaft of the screwdriver, including the pin attached, plunged into the pelvis leading to the loss of the pin.

On-table retrieval was attempted by taking down the external oblique attachment to the iliac crest to gain access to the medial side, but the pin was unable to be located. An intraoperative x-ray was performed to demonstrate an intrapelvic position. The primary total hip arthroplasty was abandoned.

As the surgery was performed in a peripheral metropolitan center, initially an on-table general surgical opinion was obtained. Given the position of the pin to the iliac vessels, a vascular opinion was also acquired from the nearby tertiary center. On-table clinical examination revealed a hemodynamically stable patient with strong bounding pedal pulses bilaterally. A computed tomography angiogram was performed displaying the pin’s proximity to the right common iliac artery. Examining the bony details, there was no evidence of fracture, incorrect entry point, or skiving of the pin. Instead, the image revealed a circular hole just bigger than the diameter of the pin. The patient was kept anesthetized to mitigate any further harm from patient movement while the screw remained within the pelvis, and she was immediately transferred to the tertiary center 20 minutes away.

The patient was taken directly to theater, and a limited midline laparotomy was performed to retrieve the screw by a combined vascular and general surgical team. The exploratory laparotomy found that the distal one-fifth of the pin was intraperitoneal while the remaining portion was intrapelvic. The tip of the pin perforated the posterior peritoneum in close proximity to the right common iliac artery, right ureter, and small bowel. However, no structures were injured.

The patient recovered well from laparotomy and was transferred back to the original unit the following day and was successfully discharged 1 week later. She subsequently received her total hip arthroplasty as intended 2 months following this event without complications, using only primary instrumentation without the use of Intellijoint navigation. She has been subsequently followed up in clinic 3 and 12 months after her total hip replacement. The patient reports a complete recovery with no further complications from either the total hip arthroplasty or exploratory laparotomy.

The authors commented – “We describe a unique case of intraperitoneal loss of a pelvic array pin in the setting of routine navigated total hip arthroplasty. The surgical technique and pin design should be considered when inserting the Intellijoint HIP pelvic pins to prevent such devastating complications.”

Further reading:

Intraperitoneal Loss of Pelvic Array Pin During Navigated Total Hip Arthroplasty, Heng Kan, Iulian Nusem et al, Arthroplasty Today 19 (2023) 10107, https://doi.org/10.1016/j.artd.2022.11.003