Total Hip Arthroplasty Failure Leading to a Delayed Life-Threatening Hematoma: A Case Report and Analysis of the Pathological Mechanism

Total Hip Arthroplasty Failure Leading to a Delayed Life-Threatening Hematoma: A Case Report and Analysis of the Pathological Mechanism | 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 Total Hip Arthroplasty Failure Leading to a Delayed Life-Threatening Hematoma: A Case Report and Analysis of the Pathological Mechanism Yanqing Liu, Jiaxuan Zhou, Jianguo Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9028784/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Chronic expanding hematoma (CEH) represents a rare complication subsequent to total hip arthroplasty (THA), characterized by a delayed-onset, progressively enlarging soft-tissue mass capable of inducing severe osteolysis. Its imaging characteristics frequently overlap with granulomatous lesions induced by wear particles, thereby necessitating a systematic diagnostic approach to exclude pseudotumor, malignant soft-tissue neoplasm, and deep periprosthetic joint infection. Reported cases in the literature predominantly involve cementless prosthetic fixation. However, its occurrence in association with a cemented acetabular component featuring a ceramic-on-polyethylene bearing surface, particularly in the absence of significant prosthetic wear, is exceedingly rare and, to our knowledge, undocumented. Case Presentation: We present the case of a 66-year-old male with a remote history of acetabular fracture who underwent left THA in 2015 for secondary osteoarthritis, receiving a cementless femoral stem and a cemented all-polyethylene acetabular component. Eight years postoperatively, he presented with progressively worsening hip pain. Imaging studies revealed catastrophic failure of the acetabular construct, manifesting as massive osteolytic defects involving the ischial and pubic rami, alongside a complex soft-tissue mass exhibiting heterogeneous signals indicative of an organized hematoma. Intraoperative exploration confirmed the evacuation of approximately 800 mL of mixed acute and chronic hematoma and identified a persistently bleeding venous plexus at the site of a medial acetabular wall defect. Histopathological examination confirmed old hemorrhage with hemosiderin deposition, ruling out infection and neoplasia. A staged revision strategy was consequently employed. The initial stage focused on hematoma evacuation and securing hemostasis. The definitive reconstruction in the second stage was achieved using a patient-specific, 3D-printed titanium acetabular component designed from preoperative CT data. At the two-year postoperative follow-up, the prosthesis remained radiographically stable, accompanied by significant clinical and functional improvement. Discussion and Conclusion: In conclusion, this case illustrates that mechanical abrasion from a loosened cemented acetabular component can erode adjacent vascular structures, culminating in an expanding hematoma. Furthermore, it highlights that for such complex presentations involving concurrent hematoma and massive acetabular bone loss, reconstruction utilizing three-dimensionally printed, patient-customized implants is pivotal for achieving successful and stable revision outcomes. Chronic expanding hematoma Total hip arthroplasty Aseptic loosening Acetabular osteolysis Vascular complication 3D-printed prosthesis Revision hip arthroplasty Case report Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 02 Apr, 2026 Editor invited by journal 05 Mar, 2026 Editor assigned by journal 05 Mar, 2026 Submission checks completed at journal 05 Mar, 2026 First submitted to journal 04 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9028784","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":617248376,"identity":"caf1ca14-9491-4878-aca0-a8760690f860","order_by":0,"name":"Yanqing Liu","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yanqing","middleName":"","lastName":"Liu","suffix":""},{"id":617248377,"identity":"3f292a8b-3f92-47f0-a9e2-3634d3cd9b13","order_by":1,"name":"Jiaxuan Zhou","email":"","orcid":"","institution":"Beijing Shijitan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiaxuan","middleName":"","lastName":"Zhou","suffix":""},{"id":617248378,"identity":"ff449960-dc70-4b0b-b77e-2f1f61240b3a","order_by":2,"name":"Jianguo Wang","email":"data:image/png;base64,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","orcid":"","institution":"The First Affiliated Hospital of Baotou Medical College","correspondingAuthor":true,"prefix":"","firstName":"Jianguo","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2026-03-04 09:58:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9028784/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9028784/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106404171,"identity":"61b72202-5af6-40d3-a6a5-ad3e728d8cca","added_by":"auto","created_at":"2026-04-08 09:15:34","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":543526,"visible":true,"origin":"","legend":"","description":"","filename":"case.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9028784/v1_covered_d13763ae-7e99-48da-9e93-1c1395c1249a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Total Hip Arthroplasty Failure Leading to a Delayed Life-Threatening Hematoma: A Case Report and Analysis of the Pathological Mechanism","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic expanding hematoma, Total hip arthroplasty, Aseptic loosening, Acetabular osteolysis, Vascular complication, 3D-printed prosthesis, Revision hip arthroplasty, Case report","lastPublishedDoi":"10.21203/rs.3.rs-9028784/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9028784/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Chronic expanding hematoma (CEH) represents a rare complication subsequent to total hip arthroplasty (THA), characterized by a delayed-onset, progressively enlarging soft-tissue mass capable of inducing severe osteolysis. Its imaging characteristics frequently overlap with granulomatous lesions induced by wear particles, thereby necessitating a systematic diagnostic approach to exclude pseudotumor, malignant soft-tissue neoplasm, and deep periprosthetic joint infection. Reported cases in the literature predominantly involve cementless prosthetic fixation. However, its occurrence in association with a cemented acetabular component featuring a ceramic-on-polyethylene bearing surface, particularly in the absence of significant prosthetic wear, is exceedingly rare and, to our knowledge, undocumented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e We present the case of a 66-year-old male with a remote history of acetabular fracture who underwent left THA in 2015 for secondary osteoarthritis, receiving a cementless femoral stem and a cemented all-polyethylene acetabular component. Eight years postoperatively, he presented with progressively worsening hip pain. Imaging studies revealed catastrophic failure of the acetabular construct, manifesting as massive osteolytic defects involving the ischial and pubic rami, alongside a complex soft-tissue mass exhibiting heterogeneous signals indicative of an organized hematoma. Intraoperative exploration confirmed the evacuation of approximately 800 mL of mixed acute and chronic hematoma and identified a persistently bleeding venous plexus at the site of a medial acetabular wall defect. Histopathological examination confirmed old hemorrhage with hemosiderin deposition, ruling out infection and neoplasia. A staged revision strategy was consequently employed. The initial stage focused on hematoma evacuation and securing hemostasis. The definitive reconstruction in the second stage was achieved using a patient-specific, 3D-printed titanium acetabular component designed from preoperative CT data. At the two-year postoperative follow-up, the prosthesis remained radiographically stable, accompanied by significant clinical and functional improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion and Conclusion:\u003c/strong\u003e In conclusion, this case illustrates that mechanical abrasion from a loosened cemented acetabular component can erode adjacent vascular structures, culminating in an expanding hematoma. Furthermore, it highlights that for such complex presentations involving concurrent hematoma and massive acetabular bone loss, reconstruction utilizing three-dimensionally printed, patient-customized implants is pivotal for achieving successful and stable revision outcomes.\u003c/p\u003e","manuscriptTitle":"Total Hip Arthroplasty Failure Leading to a Delayed Life-Threatening Hematoma: A Case Report and Analysis of the Pathological Mechanism","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-07 19:30:27","doi":"10.21203/rs.3.rs-9028784/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-02T04:48:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-05T10:55:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-05T09:39:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-05T09:34:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-03-04T09:48:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1d4725d-8d68-4b08-9667-374a665933de","owner":[],"postedDate":"April 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T19:30:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-07 19:30:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9028784","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9028784","identity":"rs-9028784","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}