Deep external pudendal artery injury after percutaneous adductor tenotomy during THA in ankylosing spondylitis

Arterial injuries following total hip arthroplasty (THA) are uncommon and are usually related to revision THA. Deep external pudendal artery injury and delayed bleeding due to percutaneous adductor tenotomy during THA has not been reported.A 62-year-old man with bilateral hip osteoarthritis and ankylosing spondylitis was treated with right cementless THA. Persistent severely limited hip abduction after prosthetic implantation required a percutaneous adductor tenotomy, which was performed bilaterally. No clinical signs of bleeding existed postoperatively. On postoperative day 3, the patient had a hypotensive attack, his right anteromedial thigh at the tenotomy site was distended, and the hemoglobin was 5.9 g/dL. Computed tomography angiography of the iliac and femoral vessels showed a right hematoma medial to the common femoral artery, with active contrast extravasation. Volumetric data reconstruction revealed active bleeding from the right external pudendal artery into an inguinal collection. Angiography was performed by the standard Seldinger technique via the contralateral femoral artery. A guiding catheter was placed as near to the lesion as possible. A microcatheter system and microguidewire were used for superselective catheterization, and 2 embolization coils were used to control the bleeding. The patient remained hemodynamically stable and was discharged 12 days later. Two-year follow-up was uneventful.The deep external pudendal artery may be injured during percutaneous adductor tenotomy, especially in patients with fragile arterial walls, and life-threatening complications may occur. Angiography and embolization are the best treatment options.