Intravesical Methylmethacrylate After Revision Hip Arthroplasty

Abstract

Intrapelvic extrusion of cement during total hip replacement is common but complications are infrequently reported. Tissues affected by intrapelvic cement include bowel, vessels, nerves, ureters and bladder.' We report a case of 2 pieces of cement eroding sequentially into the bladder 5 years after right total hip replacement revision. CASE REPORT A 66-year-old woman with a history of congenital hip dysplasia, bilateral total hip replacements and revision of the right hip replacement in 1989 presented with recurrent afebrile urinary tract infections and intermittent episodes of gross hematuria 4 months in duration. Urine cultures yielded Escherichia coli and the patient responded to oral antibiotics. Anteroposterior radiography of the right hip confirmed stable protrusio from the revision site but no opacity was identified in the bladder region. Excretory urography showed medial deviation of the right ureter but no opacity in the bladder. Cystoscopy revealed a calcified mass in the right portion of the bladder. Open cystolithotomy was performed. A 5 cm. piece of orthopedic cement was seen eroding through the right lateral bladder wall (see figure). Attempts to mobilize the bladder from the right pelvic side wall were unsuccessful due to adhesions secondary to multiple orthopedic surgery. Via an intravesical approach the cement was removed using circumscribing excision. The perivesical space and defect in the Accepted for publication May 24, 1996. bladder wall were inspected, and no remaining cement was detected. Convalescence was uneventful. Eight months after surgery the patient complained of right lateral leg pain and urinary tract infections that did not resolve with antibiotics. An arthrogram showed a flow of contrast material from the right total hip replacement site into the perivesical space. Aspirated sinovial fluid and urine culture yielded group D Enterococcus. Repair of this fistula revealed a new piece of cement in the bladder wall. Partial cystectomy was performed to repair the bladder with omentum brought down to barricade the bladder from the medial wall of the implant. After 18 months the patient is mobile with the right hip and has no urinary complaints. DISCUSSION