Common femoral artery transection during total hip arthroplasty for a neglected septic hip dislocation: A case report

Common femoral artery transection during total hip arthroplasty for a neglected septic hip dislocation: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Common femoral artery transection during total hip arthroplasty for a neglected septic hip dislocation: A case report Zied Masmoudi, Sami Bahroun, Ala Aloui, Ameur Triki, Karim Mallek, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9227381/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Vascular injury during total hip arthroplasty (THA) is a rare but life-threatening complication. Severe anatomical distortion, particularly in complex hip pathology, may substantially increase this risk. Case presentation: A 62-year-old woman with a history of childhood septic arthritis presented with a chronically dislocated hip and advanced joint destruction. During THA, sudden massive hemorrhage occurred during acetabular exposure. Postoperative absence of distal pulses and a sensorimotor deficit raised suspicion of acute limb ischemia. CT angiography confirmed femoral artery occlusion. Emergency vascular exploration revealed complete transection of the common and superficial femoral arteries, which were reconstructed using a PTFE graft. Clinical discussion: Neglected septic hip dislocation profoundly alters local anatomy, bringing major vessels into close proximity to the acetabulum and increasing the risk of vascular injury. Early recognition of abnormal bleeding and postoperative vascular compromise is essential. Close collaboration between orthopedic, anesthesiology and vascular teams is critical to achieving limb salvage and preventing fatal outcomes. Selective use of CT angiography can aid preoperative risk assessment in hips with severe anatomical distortions. Conclusion: Vascular injury during THA is a rare but serious complication. Meticulous surgical technique, systematic postoperative vascular examination, and prompt multidisciplinary intervention are critical to optimize survival and limb salvage. Orthopedic Surgery Total hip arthroplasty vascular injury acute limb ischemia case report. Figures Figure 1 Figure 2 Figure 3 Introduction Arterial injury during total hip arthroplasty (THA) is rare but a life-threatening complication. This study presents a case of a femoral artery section during THA, we describe the intra-operative management, the steps for diagnosis and the multi-disciplinary approach to this complication. We also suggest tools for prevention and risk-assessment. This work has been reported in line with the SCARE criteria 1 . Case presentation We present a case of a middle-aged women, with a history of septic arthritis of the left hip at the age of 2, neglected and treated with antibiotics until fistula formation, which eventually healed after 1 year. The patient had a limp and intermittent pain since childhood, but no fever or pus production. Her symptoms were tolerated with pain medication. She presented at our hospital at the age of 62, for persistent pain, a limp, and a limited range of motion of the left hip. On Physical exam she had no fever, the fistula was dry. Pain was located in the left groin. She had 90° flexion and 20° internal rotation. Leg length discrepancy was at 3 cm. Lab results showed no signs of infection. Imaging by plain radiograph (Fig. 1 ) and computed tomography (CT) scan showed complete resorption of the femoral head and a Crowe 4 hip dislocation. The patient underwent THA with posterolateral approach, sequential soft-tissue releases were performed to facilitate femoral distalization and reduction. Attention was then attributed to the true-acetabulum, which was covered in fibrosis. A Hohmann retractor was placed on the anterior corn, and careful electrocautery dissection was used to expose the acetabulum. When tension was loosened on the Hohmann retractor to reposition it, a severe bleeding emerged from the fibrosis near the true acetabulum. The anesthesiologist were averted. IV fluid resuscitation, ephedrine and tranexamic acid were initiated. Keeping the tension on the Hohmann retractor significantly reduced the bleeding, which allowed us to dissect and ligate a large vessel. This was necessary to control the bleeding and save the patient’s life, considering we did not have vascular surgery department in our institution. After ensuring good homeostasis, we proceeded to reaming slightly above the true acetabulum, where a cemented cup was fitted. For the femur, an uncemented dysplastic femoral stem with a short neck was used. The prosthesis was stable, with a good range of motion and leg length discrepancy of only 0.5cm. Postoperatively, the patient was hemodynamically stable. she has lost an estimated 900mL of blood, but did not require transfusion. However, we noted the absence of distal pulse and a sensorimotor deficit of the lower left extremity. Acute limb ischemia was suspected. Doppler ultra-sound and CT-angiograph (Fig. 2 ) confirmed the diagnosis, and showed the absence of opacification of the common femoral artery, at the level of the anteroinferior wall of the acetabulum, extending over 100 mm up to the proximal third of the superficial femoral artery. The patient was transferred, 4 hours post-operatively, to a center with a cardio-vascular department, where she was operated urgently. Exploration revealed a completely transected common femoral artery, tied off at the iliofemoral junction. The superficial femoral artery was transected, severely retracted and thrombosed. End-to-side anastomosis were made between the common femoral artery and the superficial femoral artery, using a 6-mm Polytetrafluoroethylene (PTFE) graft. Postoperatively, the right limb was warm. Dorsalis pedis and posterior tibial pulses were present and symmetric. However, she maintained a sciatic nerve palsy, with dorsiflexion of the foot impossible against resistance, and a paresthesia in the dorsal aspect of the foot. She was discharged with an anti-equinus splint, pain medication and lifelong direct oral anticoagulants. she was instructed to remain non-weight-bearing for 6 weeks, and to start rehabilitation immediately. At 3 months follow-up, the patient was walking using one cane, completely painless. She had 110° of hip flexion, 40° of abduction and 30° of internal rotation. The limb had good peripheral perfusion, and the sciatic paresis was recovered. Leg length discrepancy was minimal and did not require orthotic compensation. Postoperative radiograph showed good implant positioning and integreation (Fig. 3 ). Discussion Vascular injury during THA is very rare, with incidence ranging from 0.04 to 0.1% in primary THA, and 0.2% In revision THA 2 . Reported mechanisms of injury are usually punctures from Hohmann retractors, drills and acetabular screws, or thermal damage from bone cement or electrocautery 3 . In rare cases, Intimal lesion can result from traction, which can be responsible of pseudo-aneurysm formation and delayed perforation 4 . To our knowledge, this is the first case report of a transected common femoral artery. Our patient had a neglected septic hip dislocation, with significant anatomical abnormalities, soft tissue retraction, hip dysplasia and fibrosis. These are known risk factors for vascular injury in THA 5 . Other risk factors include left side THA: Kawasaki analyzed 200 normal hip CT- angiography and found that vascular structures on the left side were closer to the acetabulum 6 . There are still some controversies whether routine CT-angiography should be performed before THA. This procedure has been associated with risks of radiation-induced cancers, severe allergic reactions, and contrast-induced nephropathy 7 , 8 . However, Diesel recommends preoperative CT-angiography for revision THA, in order to assess the proximity of the vessels to the acetabular component 9 . Complete transection of arteries usually results in its retraction in soft tissue, making visualization and ligation difficult 10 . This was not the case in our patient, probably due to the extensive fibrosis and adherences. The placement and tension on the Hohmann retractor clamped the vessel proximally, and allowed dissection and ligation of the transected end. Postoperative assessment of distal pulses allowed us to suspect acute limb ischemia. This simple exam should be systematic after every THA. Close collaboration between the orthopedic and vascular surgeons allowed urgent management of this complication. The anastomosis of the common femoral artery to the superficial femoral artery using a PTFE graft, restored the distal pulses, but not the sensorimotor deficit. Acute limb ischemia can lead to sciatic palsy, particularly when the ischemic episode is prolonged or severe 11 . Leg lengthening can also be responsible for sciatic palsy 12 . One intraoperative neuromonitoring study reported that nerve lengthening of 5% relative to femoral length was found to be the critical limit 13 . In our case, leg lengthening remained within these limits. Conclusion Vascular injury during total hip arthroplasty is rare but serious complication. Neglected septic hip dislocation can significantly distort local anatomy and alter normal vascular relationships, thereby increasing the risk of vascular injury. Early recognition and multidisciplinary management of this complication are essential for patient survival and limb salvage. Declarations Ethical approval Ethical approval is not a requirement at our institution for reporting individual cases or case series. Consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Conflict of interest: none. Funding: none. References Kerwan A, Al-Jabir A, Mathew G, Sohrabi C, Rashid R, Franchi T, Nicola M, Agha M, Agha RA (2025) Revised Surgical CAse REport (SCARE) guideline: An update for the age of Artificial Intelligence. Premier J Sci :10100079 Street MWJ, Howard LC, Neufeld ME, Masri BA (2022) Vascular Injuries During Hip and Knee Replacement. Orthop Clin North Am 53(1):1–12. 10.1016/j.ocl.2021.08.009 Gobinath S, Vinojan S, Mathivaanan S et al (2022) Common Femoral Artery (CFA) injury following Total Hip Arthroplasty (THA) - a report of two cases. Ann Vasc Surg - Brief Rep Innov 2(4):100134. 10.1016/j.avsurg.2022.100134 Meknarit S, Motta JC, de Grandis E, Lee WA (2023) Diagnosis and management of vascular injuries after joint arthroplasty. Ann Vasc Surg - Brief Rep Innov 3(2):100199. 10.1016/j.avsurg.2023.100199 Girard J, Blairon A, Wavreille G, Migaud H, Senneville E (2011) Total hip arthroplasty revision in case of intra-pelvic cup migration: designing a surgical strategy. Orthop Traumatol Surg Res OTSR 97(2):191–200. 10.1016/j.otsr.2010.10.003 Kawasaki Y, Egawa H, Hamada D, Takao S, Nakano S, Yasui N (2012) Location of intrapelvic vessels around the acetabulum assessed by three-dimensional computed tomographic angiography: prevention of vascular-related complications in total hip arthroplasty. J Orthop Sci Off J Jpn Orthop Assoc 17(4):397–406. 10.1007/s00776-012-0227-7 Shams E, Mayrovitz HN, Contrast-Induced Nephropathy (2021) A Review of Mechanisms and Risks. Cureus 13(5):e14842. 10.7759/cureus.14842 Alkhorayef M, Babikir E, Alrushoud A, Al-Mohammed H, Sulieman A (2017) Patient radiation biological risk in computed tomography angiography procedure. Saudi J Biol Sci 24(2):235–240. 10.1016/j.sjbs.2016.01.011 Diesel CV, Guimarães MR, Menegotto SM et al (2022) Strategy to avoid vascular injuries in revision total hip arthroplasty with intrapelvic implants. Bone Jt Open 3(11):859–866. 10.1302/2633-1462.311.BJO-2021-0188.R1 Katoch R, Gambhir R (2010) Warfare Vascular Injuries. Med J Armed Forces India 66(4):338–341. 10.1016/S0377-1237(10)80013-9 Dietmann A, von Martial R, Scheidegger O (2022) Spontaneous ischemic neuropathy of the sciatic nerve due to arterial occlusion – a rare cause of acute neuropathy not to be missed, a report of two cases. BMC Neurol 22:410. 10.1186/s12883-022-02944-3 Higuchi Y, Hasegawa Y, Ishiguro N (2015) Leg lengthening of more than 5 cm is a risk factor for sciatic nerve injury after total hip arthroplasty for adult hip dislocation. Nagoya J Med Sci 77(3):455–463 Bayram S, Akgül T, Özmen E, Kendirci AŞ, Demirel M, Kılıçoğlu Öİ (2020) Critical Limit of Lower-Extremity Lengthening in Total Hip Arthroplasty: An Intraoperative Neuromonitorization Study. J Bone Joint Surg Am 102(8):664–673. 10.2106/JBJS.19.00988 Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9227381","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":612292682,"identity":"05277a53-09fe-4c1a-ab5e-f0b5fe882e0d","order_by":0,"name":"Zied Masmoudi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYPACZh429uYDBh8KJEjQwsdzLKFwhgEJWhjkJHIMPvMYEKFWt/340w0f26xl2CRyDDfbGFgk9jMwP3x0A48WszM5ZjdntqXzsPE8KzbOMZBInNnAZmycg0/LgRy227xth4HeT94G0mJscICHTRqvlvPPn0G0MCSY/7YAarEnqOVGghlEC0eKgTGDgYScAQNBLW/Mbs44B/LLsQTDHqAWicOE/HI+/dmND2XW9vLtwKj8UVHHw9/e/PAxPi1YADNpykfBKBgFo2AUYAEA4mdGewbhFEQAAAAASUVORK5CYII=","orcid":"","institution":"Adults B department, Kassab institute of orthopedics, Mannouba, Tunisia","correspondingAuthor":true,"prefix":"","firstName":"Zied","middleName":"","lastName":"Masmoudi","suffix":""},{"id":612292683,"identity":"d74e5904-3e71-4980-9a4b-c001a25f24cb","order_by":1,"name":"Sami Bahroun","email":"","orcid":"","institution":"Adults B department, Kassab institute of orthopedics, Mannouba, Tunisia","correspondingAuthor":false,"prefix":"","firstName":"Sami","middleName":"","lastName":"Bahroun","suffix":""},{"id":612292684,"identity":"23572ab0-4a9d-416c-a927-b2fa5370cdb7","order_by":2,"name":"Ala Aloui","email":"","orcid":"","institution":"Adults B department, Kassab institute of orthopedics, Mannouba, Tunisia","correspondingAuthor":false,"prefix":"","firstName":"Ala","middleName":"","lastName":"Aloui","suffix":""},{"id":612292685,"identity":"00a33b4b-984a-4036-bf21-eedab094f56b","order_by":3,"name":"Ameur Triki","email":"","orcid":"","institution":"Adults B department, Kassab institute of orthopedics, Mannouba, Tunisia","correspondingAuthor":false,"prefix":"","firstName":"Ameur","middleName":"","lastName":"Triki","suffix":""},{"id":612292686,"identity":"9270dad7-e6b8-40e3-b5d3-6024da64c6a2","order_by":4,"name":"Karim Mallek","email":"","orcid":"","institution":"Adults B department, Kassab institute of orthopedics, Mannouba, Tunisia","correspondingAuthor":false,"prefix":"","firstName":"Karim","middleName":"","lastName":"Mallek","suffix":""},{"id":612292687,"identity":"716000ec-904e-46a2-a0bd-fc31c0c58c16","order_by":5,"name":"Mohamed Samir Daghfous","email":"","orcid":"","institution":"Adults B department, Kassab institute of orthopedics, Mannouba, Tunisia","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Samir","lastName":"Daghfous","suffix":""}],"badges":[],"createdAt":"2026-03-25 22:40:50","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9227381/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9227381/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105572868,"identity":"c69004e3-f0a2-45a0-91b0-51a0684ad761","added_by":"auto","created_at":"2026-03-27 13:30:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44348729,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative\u003cstrong\u003e \u003c/strong\u003eanteroposterior (A) and lateral (B) radiograph of the pelvis showing a Crowe 4 anterior hip dislocation. CT-scan (C) showing complete resorption of the femoral head and neck, and displasic acetabulum\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9227381/v1/d978827f364f59d1c7b644c5.png"},{"id":105572907,"identity":"93d2e2fe-e05e-43ca-90dd-7eac9e0eb453","added_by":"auto","created_at":"2026-03-27 13:30:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":11670430,"visible":true,"origin":"","legend":"\u003cp\u003eCoronal view (A) and 3D reconstruction (B) of CT-angiograph showing the absence of opacification in the common femoral artery, at the level of the anteroinferior wall of the acetabulum, extending over 100 mm in the proximal third of the superficial femoral artery.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9227381/v1/8069020a9ddf0bdae43f0d6b.png"},{"id":105573507,"identity":"58a1855c-be21-449f-becd-e30a5b6c2801","added_by":"auto","created_at":"2026-03-27 13:31:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2257723,"visible":true,"origin":"","legend":"\u003cp\u003epostoperative\u003cstrong\u003e \u003c/strong\u003eanteroposterior pelvis radiograph showing good implant positioning and integreation.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9227381/v1/2887b08f977a4fafa90bad68.png"},{"id":105728959,"identity":"5ceb5868-8c25-4b2d-bcee-74d44de7ee92","added_by":"auto","created_at":"2026-03-30 11:13:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":52433080,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9227381/v1/a3311170-28ee-48a6-b6e9-ae43c9dbac33.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eCommon femoral artery transection during total hip arthroplasty for a neglected septic hip dislocation: A case report\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eArterial injury during total hip arthroplasty (THA) is rare but a life-threatening complication. This study presents a case of a femoral artery section during THA, we describe the intra-operative management, the steps for diagnosis and the multi-disciplinary approach to this complication. We also suggest tools for prevention and risk-assessment. This work has been reported in line with the SCARE criteria \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eWe present a case of a middle-aged women, with a history of septic arthritis of the left hip at the age of 2, neglected and treated with antibiotics until fistula formation, which eventually healed after 1 year.\u003c/p\u003e \u003cp\u003eThe patient had a limp and intermittent pain since childhood, but no fever or pus production. Her symptoms were tolerated with pain medication.\u003c/p\u003e \u003cp\u003eShe presented at our hospital at the age of 62, for persistent pain, a limp, and a limited range of motion of the left hip. On Physical exam she had no fever, the fistula was dry. Pain was located in the left groin. She had 90\u0026deg; flexion and 20\u0026deg; internal rotation. Leg length discrepancy was at 3 cm.\u003c/p\u003e \u003cp\u003eLab results showed no signs of infection. Imaging by plain radiograph (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and computed tomography (CT) scan showed complete resorption of the femoral head and a Crowe 4 hip dislocation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient underwent THA with posterolateral approach, sequential soft-tissue releases were performed to facilitate femoral distalization and reduction. Attention was then attributed to the true-acetabulum, which was covered in fibrosis. A Hohmann retractor was placed on the anterior corn, and careful electrocautery dissection was used to expose the acetabulum.\u003c/p\u003e \u003cp\u003eWhen tension was loosened on the Hohmann retractor to reposition it, a severe bleeding emerged from the fibrosis near the true acetabulum. The anesthesiologist were averted. IV fluid resuscitation, ephedrine and tranexamic acid were initiated. Keeping the tension on the Hohmann retractor significantly reduced the bleeding, which allowed us to dissect and ligate a large vessel. This was necessary to control the bleeding and save the patient\u0026rsquo;s life, considering we did not have vascular surgery department in our institution.\u003c/p\u003e \u003cp\u003eAfter ensuring good homeostasis, we proceeded to reaming slightly above the true acetabulum, where a cemented cup was fitted. For the femur, an uncemented dysplastic femoral stem with a short neck was used. The prosthesis was stable, with a good range of motion and leg length discrepancy of only 0.5cm.\u003c/p\u003e \u003cp\u003ePostoperatively, the patient was hemodynamically stable. she has lost an estimated 900mL of blood, but did not require transfusion. However, we noted the absence of distal pulse and a sensorimotor deficit of the lower left extremity. Acute limb ischemia was suspected.\u003c/p\u003e \u003cp\u003eDoppler ultra-sound and CT-angiograph (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) confirmed the diagnosis, and showed the absence of opacification of the common femoral artery, at the level of the anteroinferior wall of the acetabulum, extending over 100 mm up to the proximal third of the superficial femoral artery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient was transferred, 4 hours post-operatively, to a center with a cardio-vascular department, where she was operated urgently.\u003c/p\u003e \u003cp\u003eExploration revealed a completely transected common femoral artery, tied off at the iliofemoral junction. The superficial femoral artery was transected, severely retracted and thrombosed.\u003c/p\u003e \u003cp\u003eEnd-to-side anastomosis were made between the common femoral artery and the superficial femoral artery, using a 6-mm Polytetrafluoroethylene (PTFE) graft.\u003c/p\u003e \u003cp\u003ePostoperatively, the right limb was warm. Dorsalis pedis and posterior tibial pulses were present and symmetric. However, she maintained a sciatic nerve palsy, with dorsiflexion of the foot impossible against resistance, and a paresthesia in the dorsal aspect of the foot.\u003c/p\u003e \u003cp\u003eShe was discharged with an anti-equinus splint, pain medication and lifelong direct oral anticoagulants. she was instructed to remain non-weight-bearing for 6 weeks, and to start rehabilitation immediately.\u003c/p\u003e \u003cp\u003eAt 3 months follow-up, the patient was walking using one cane, completely painless. She had 110\u0026deg; of hip flexion, 40\u0026deg; of abduction and 30\u0026deg; of internal rotation. The limb had good peripheral perfusion, and the sciatic paresis was recovered. Leg length discrepancy was minimal and did not require orthotic compensation. Postoperative radiograph showed good implant positioning and integreation (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eVascular injury during THA is very rare, with incidence ranging from 0.04 to 0.1% in primary THA, and 0.2% In revision THA \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eReported mechanisms of injury are usually punctures from Hohmann retractors, drills and acetabular screws, or thermal damage from bone cement or electrocautery \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In rare cases, Intimal lesion can result from traction, which can be responsible of pseudo-aneurysm formation and delayed perforation \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first case report of a transected common femoral artery. Our patient had a neglected septic hip dislocation, with significant anatomical abnormalities, soft tissue retraction, hip dysplasia and fibrosis. These are known risk factors for vascular injury in THA \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOther risk factors include left side THA: Kawasaki analyzed 200 normal hip CT- angiography and found that vascular structures on the left side were closer to the acetabulum \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere are still some controversies whether routine CT-angiography should be performed before THA. This procedure has been associated with risks of radiation-induced cancers, severe allergic reactions, and contrast-induced nephropathy \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. However, Diesel recommends preoperative CT-angiography for revision THA, in order to assess the proximity of the vessels to the acetabular component \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eComplete transection of arteries usually results in its retraction in soft tissue, making visualization and ligation difficult \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. This was not the case in our patient, probably due to the extensive fibrosis and adherences. The placement and tension on the Hohmann retractor clamped the vessel proximally, and allowed dissection and ligation of the transected end.\u003c/p\u003e \u003cp\u003ePostoperative assessment of distal pulses allowed us to suspect acute limb ischemia. This simple exam should be systematic after every THA.\u003c/p\u003e \u003cp\u003eClose collaboration between the orthopedic and vascular surgeons allowed urgent management of this complication. The anastomosis of the common femoral artery to the superficial femoral artery using a PTFE graft, restored the distal pulses, but not the sensorimotor deficit.\u003c/p\u003e \u003cp\u003eAcute limb ischemia can lead to sciatic palsy, particularly when the ischemic episode is prolonged or severe \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Leg lengthening can also be responsible for sciatic palsy \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. One intraoperative neuromonitoring study reported that nerve lengthening of 5% relative to femoral length was found to be the critical limit \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. In our case, leg lengthening remained within these limits.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVascular injury during total hip arthroplasty is rare but serious complication. Neglected septic hip dislocation can significantly distort local anatomy and alter normal vascular relationships, thereby increasing the risk of vascular injury. Early recognition and multidisciplinary management of this complication are essential for patient survival and limb salvage.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval is not a requirement at our institution for reporting individual cases or case series.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003enone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003enone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKerwan A, Al-Jabir A, Mathew G, Sohrabi C, Rashid R, Franchi T, Nicola M, Agha M, Agha RA (2025) Revised Surgical CAse REport (SCARE) guideline: An update for the age of Artificial Intelligence. Premier J Sci :10100079\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStreet MWJ, Howard LC, Neufeld ME, Masri BA (2022) Vascular Injuries During Hip and Knee Replacement. 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BMC Neurol 22:410. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12883-022-02944-3\u003c/span\u003e\u003cspan address=\"10.1186/s12883-022-02944-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiguchi Y, Hasegawa Y, Ishiguro N (2015) Leg lengthening of more than 5 cm is a risk factor for sciatic nerve injury after total hip arthroplasty for adult hip dislocation. Nagoya J Med Sci 77(3):455\u0026ndash;463\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBayram S, Akg\u0026uuml;l T, \u0026Ouml;zmen E, Kendirci AŞ, Demirel M, Kılı\u0026ccedil;oğlu \u0026Ouml;İ (2020) Critical Limit of Lower-Extremity Lengthening in Total Hip Arthroplasty: An Intraoperative Neuromonitorization Study. J Bone Joint Surg Am 102(8):664\u0026ndash;673. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.19.00988\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.19.00988\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Adults B department, Kassab institute of orthopedics, Mannouba, Tunisia","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Total hip arthroplasty, vascular injury, acute limb ischemia, case report.","lastPublishedDoi":"10.21203/rs.3.rs-9227381/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9227381/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVascular injury during total hip arthroplasty (THA) is a rare but life-threatening complication. Severe anatomical distortion, particularly in complex hip pathology, may substantially increase this risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 62-year-old woman with a history of childhood septic arthritis presented with a chronically dislocated hip and advanced joint destruction. During THA, sudden massive hemorrhage occurred during acetabular exposure. Postoperative absence of distal pulses and a sensorimotor deficit raised suspicion of acute limb ischemia. CT angiography confirmed femoral artery occlusion. Emergency vascular exploration revealed complete transection of the common and superficial femoral arteries, which were reconstructed using a PTFE graft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical discussion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeglected septic hip dislocation profoundly alters local anatomy, bringing major vessels into close proximity to the acetabulum and increasing the risk of vascular injury. Early recognition of abnormal bleeding and postoperative vascular compromise is essential. Close collaboration between orthopedic, anesthesiology and vascular teams is critical to achieving limb salvage and preventing fatal outcomes. Selective use of CT angiography can aid preoperative risk assessment in hips with severe anatomical distortions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVascular injury during THA is a rare but serious complication. Meticulous surgical technique, systematic postoperative vascular examination, and prompt multidisciplinary intervention are critical to optimize survival and limb salvage.\u003c/p\u003e","manuscriptTitle":"Common femoral artery transection during total hip arthroplasty for a neglected septic hip dislocation: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-27 13:03:37","doi":"10.21203/rs.3.rs-9227381/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1233b981-7a40-4e64-acb3-edbdbe4c6320","owner":[],"postedDate":"March 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65257629,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2026-03-27T13:03:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-27 13:03:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9227381","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9227381","identity":"rs-9227381","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}