Electrical cardioversion is an effective option for unstable patients with ... total hip arthroplasty (THA) dislocation after electrical cardioversion for new onset.
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Orthopaedic Surgery SURGICAL TECHNOLOGY INTERNATIONAL Volume 30
Total Hip Arthroplasty Dislocation after Cardioversion: A Case Report AHMED SIDDIQI, DO RESIDENT ORTHOPEDIC SURGERY DEPARTMENT PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE PHILADELPHIA, PENNSYLVANIA
CARL T. TALMO, MD ASSOCIATE PROFESSOR DEPARTMENT OF ORTHOPEDIC SURGERY NEW ENGLAND BAPTIST HOSPITAL BOSTON, MASSACHUSETTS
JAMES V. BONO, MD ASSOCIATE PROFESSOR DEPARTMENT OF ORTHOPEDIC SURGERY NEW ENGLAND BAPTIST HOSPITAL BOSTON, MASSACHUSETTS
ABSTRACT
N
ew onset postoperative atrial fibrillation (AF) is the most common perioperative arrhythmia in the
elderly. The incidence after total joint arthroplasty is much lower than other non-cardiac surgeries.
Since postoperative atrial fibrillation can cause increased length of hospital stay, mortality and health-
care costs, it is critical to focus on prevention and prompt management. New onset atrial fibrillation is treat-
ed with rhythm control for patients who demonstrate hemodynamic instability or refractory to rate control
measures. Electrical cardioversion is an effective option for unstable patients with known complications.
However, there is limited data on orthopedic problems after cardioversion. A unique case is reported pre-
senting postoperative total hip arthroplasty (THA) dislocation after electrical cardioversion for new onset atrial fibrillation in the postanesthesia care unit (PACU). -1-
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Total Hip Arthroplasty Dislocation after Cardioversion: A Case Report SIDDIQI/TALMO/BONO
INTRODUCTION New onset atrial fibrillation (AF) is the most common perioperative arrhythmia occurring in up to 60% of elderly patients1; however, its incidence after total joint arthroplasty (TJA) is lower at 4.8%.2 Patients with postoperative supraventricular arrhythmias are known to have delayed length of hospital stays, increased morbidity, and increased healthcare costs.3 In a 2005 report, an estimated $6.65 billion was utilized for the care of patients with atrial fibrillation.4 It is therefore imperative to efficiently manage patients with postoperative arrhythmias, especially after TJA. The 2016 American Heart Association (AHA) AF treatment guidelines focuses on either rate control versus rhythm control strategy along with anticoagulation to prevent a thromboembolic event.5 Rhythm control is generally reserved for patients who are hemodynamically unstable or refractory to rate control. 6 Direct-current cardioversion is preferred over pharmacological anti-arrhythmic agents for hemodynamically unstable patients. 6 There are several complications that can occur with cardioversion, including cerebral vascular accident (CVA), provocation of an arrhythmia, and thermal injury to the skin.6 However, there is scarce data on orthopedic complications after cardioversion, let alone after TJA.
We present a unique case of postoperative dislocation following total hip arthroplasty (THA) related to electrical cardioversion for new onset AF. We are unaware of any previously reported cases of hip dislocation after cardioversion for AF. Case Report CASE REPORT
A 64-year-old female with past medical history of only hyperlipidemia presented with end-stage right hip osteoarthritis. The patient was taken to the operating room for an elective cementless right THA. After spinal anesthesia, the patient was placed in the lateral decubitus position for THA using a conventional posterior approach. During closure, the patient developed AF, rapid ventricular response, and minimal control with intravenous esmolol, metoprolol, or digoxin. The patient continued to be tachycardic with hypotension with systolic blood pressure between 70 to 80mmHg despite continuous volume replacement. After awakening from sedation in the operating room, the patient began complaining of progressive chest discomfort and shortness of breath. Because of persistent rapid AF with hemodynamic instability, cardiology recommended electrical cardioversion in the postanesthesia care unit (PACU). After appropriate sedation, 100 joules of biphasic-synchronized
Figure 1. Anteroposterior pelvis radiograph demonstrating an anterior total hip arthroplasty dislocation.
depolarization was applied delivering 120.1 joules with restoration of sinus rhythm. Routine postoperative pelvis and hip radiographs were performed after cardioversion while the patient was still sedated, which demonstrated an anterior hip dislocation (Fig. 1). Closed reduction was performed with traction, hip extension, and internal rotation. Post-reduction radiographs showed successful closed reduction with adequate component alignment and positioning (Fig. 2). The patient was allowed full weight bearing with no extreme range of motion hip precautions. The remainder of the hospital course was uneventful with home discharge on postoperative day two. DiscussionDISCUSSION Although AF is a common cardiac comorbidity in the elderly, new onset atrial fibrillation postoperatively can lead to increased length of stay, mortality, and healthcare costs,3 thereby further emphasizing prevention and appropriate management. Aside from mitigating electrolyte imbalances and ensuring adequate isovolemic states, there is scant literature on the guidance for postoperative new onset AF prevention. Electrical cardioversion is the primary method of rhythm control in hemodynamically unstable patients but is associated with its own set of poten-
Figure 2. Anteroposterior pelvis radiograph demonstrating a reduced total hip arthroplasty with stable components.
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tial complications. Most cardioversion complications focus on systemic events with scarce literature on orthopedics adverse manifestations. Noheria et al. 7 presented a case report of a 53-year-old man with a history of obesity and a remote history of traumatic left shoulder dislocation as an adolescent with a spontaneous ventricular arrhythmia that required an emergent subcutaneous implantable cardioverter defibrillator (ICD). After implantation and detection of ventricular fibrillation, the patient was shocked with 65 joules with successful rhythm conversion. Following the procedure, there was a gross deformity of the left shoulder with the humeral head palpable anteriorly and an anterior shoulder dislocation identified on x-ray. This was treated with successful closed reduction. Gomez et al.8 reported a case of a 74-year-old female requiring electrical cardioversion for chronic atrial fibrillation. The patient had a history of operative fixation of a right femoral neck fracture with percutaneous screws fourteen years prior. After electrical therapy, the patient was unable to bear weight and experienced pain with diffuse right leg movement. Pelvis radiographs demonstrated a fracture of the greater trochanteric around the screws. The fracture was attributed to an uncontrolled violent, simultaneous contraction of pelvic and trochanteric muscles caused by electrical stimulation. The patient was managed nonoperatively with protected weight bearing and was able to recover without lingering problems at a two-month follow-up. From previous reports including our experience, electrical cardioversion causes uncontrolled violent, simultaneous muscle contraction, rendering
Orthopaedic Surgery SURGICAL TECHNOLOGY INTERNATIONAL Volume 30
elderly patients susceptible to fracture or dislocation.7,8 Our case is the first to report postoperative THA dislocation after electrical stimulation for new onset AF. From our experience, patients requiring electrical cardioversion after TJA should be appropriately sedated with propofol in conjunction with skeletal muscle paralytic agents to prevent uninhibited isometric movements. It is essential to communicate with the anesthesia team, as the use of muscle relaxants most often requires securing an airway through endotracheal intubation. Although this may seem unnecessary from an anesthetic perspective, it is imperative to minimize events that increase the risk of fracture or THA dislocation, which could significantly compromise the reconstruction. The risk of recurrent instability has been reported to occur in up to 60% of patients, after a first dislocation.9 The use of a hip abduction pillow prior to electrical cardioversion is an alternative for those patients with a contraindication to muscle relaxing agents. Conclusion CONCLUSION
Postoperative new onset atrial fibrillation can be a grave complication after TJA if not addressed promptly. Currently, electrical cardioversion is reserved primarily for patients with hemodynamic instability. To our knowledge, our report is the first in the literature to describe THA dislocation after electrical stimulation. We propose the use of propofol sedation with muscle paralytics to avoid the complication. Further supplementation with a hip abduction pillow may prove beneficial as well. STI
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Authors’ Disclosures AUTHORS’ DISCLOSURES
Dr. Bono is a paid consultant and receives royalties from Stryker and Springer Healthcare LLC. All other authors have no conflicts of interest to disclose. References REFERENCES 1. Danelich IM, Lose JM, Wright SS, et al. Practical management of postoperative atrial fibrillation after noncardiac surgery. J Am Coll Surg. 2014;219: 831–41. 2. Kahn RL, Hargett MJ, Urquhart B, et al. Supraventricular tachyarrhythmias during total joint arthroplasty. Incidence and risk. Clin Orthop Relat Res. 1993:265–9. 3. Polanczyk CA, Goldman L, Marcantonio ER, et al. Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay. Ann Intern Med 1998;129(4):279–85. 4. Coyne KS, Paramore C, Grandy S, et al. Assessing the direct costs of treating nonvalvular atrial fibrillation in the United States. Value Health 2006;9(5): 348–56. 5. “Treatment Guidelines of Atrial Fibrillation (AFib or AF)”. American Heart Association 2016. 6. Bekker JG, Macaulay TE. Strategies for the management of postoperative atrial fibrillation. Orthopedics 2011; 34(5):379. 7. Noheria A, Cha Y-M, Asirvatham SJ, et al. Shoulder joint dislocation as an unusual complication of defibrillation threshold testing following subcutaneous implantable cardioverter-defibrillator implantation. Indian Pacing Electrophysiol J 2014;14(6): 297–300. 8. Gómez J, Albareda J, Ezquerra L. Trochanteric hip fracture during cardioversion therapy. A case report. Int J Surg Case Rep 2017;33:97–8. 9. Yuan L, Shih C. Dislocation after total hip arthroplasty. Arch Orthop Trauma Surg 1999;119:263–6.
