The management of vascular injuries associated with total hip arthroplasty

Abstract

Approximately 100,000 total hip reconstructions are done annually in the United States. The nature of the surgical technique in a field close to the iliac and femoral vessels makes the occurrence of vascular injury an occasional but serious complications. We have reviewed retrospectively our experience of five cases of vascular injuries with total hip replacement and an additional 63 cases in the literature to identify those patients at risk and to define the management of these injuries. For the entire group of 68 patients, most injuries were sustained on the left side (66%), and 39% were seen in revisions. Complications were related to cement incorporation of the iliac vessels (44%), aggressive medial retraction (17%), excessive traction on atherosclerotic vessels (10%), and improper technique in preparation of the acetabulum. The most commonly injured vessels were the external iliac artery (36), common femoral artery (17), and external iliac vein (6). Twenty-seven of these injuries required emergent surgery, most for hemorrhage (66%). Injuries consisted of thromboembolic complications leading to distal ischemia (46%), vessel lacerations (26%), pseudoaneurysms (25%), and arteriovenous fistulas (3%). Vascular repair was individualized and included suture repair, thrombectomy and patch angioplasty, embolectomy, and arterial and venous bypass procedures. There was an overall 7% mortality and a 15% incidence of limb loss. Risk factors include (1) revision procedures, (2) left-sided procedures, and (3) intrapelvic migration of the acetabular component of the hip prosthesis. Elective vascular workup and preliminary retroperitoneal exposure of the iliac vessels at time of hip arthroplasty is recommended for patients at risk.

Outcome of iatrogenic injuries to the abdominal and pelvic veins

“…10 Hip arthroplasties and cement-related and retractor injuries have been reported as the main mechanisms of iliac lesions. 11,12 In our series, two patients sustained iliac vein injuries during an arthroplasty and two sustained iliac artery and vein injuries caused by the insertion of screws during arthrodesis. The injuries associated with limb ischemia were diagnosed and treated late, with high associated morbidity.…”

Neurovascular Structure Proximity to Acetabular Retractors in Total Hip Arthroplasty

“…Multiple studies have found subclinical electromyography-derived evidence of SGN injury [6,[19][20][21]. Female gender is the most well-established risk factor for neurologic injury during THA, with multiple studies reporting that at least 74% of these events occur in women [4,18,22,23].The external iliac artery and femoral artery are the most frequently injured vascular structures in THA [9]. Acetabular retractors placed too far medially are the most frequent cause of femoral artery injury [7,24,25].…”

“…Vascular injury in THA, with a reported incidence of 0.1% to 0.2%, is less common than neurologic injury but more emergent [7]. False aneurysm or fistula formation, thromboembolism, loss of limb, or even mortality may result [8][9][10][11][12].In THA, the most common identifiable cause of intraoperative nerve injury is compression by retractors [13]. In order of decreasing frequency, the sciatic, femoral, and superior gluteal nerves (SGN) are most commonly injured during THA [3,9].…”

“…False aneurysm or fistula formation, thromboembolism, loss of limb, or even mortality may result [8][9][10][11][12].…”

Superficial Femoral Artery Injury Resulting From Cerclage Wiring During Revision THA

“…Fourteen of the 26 cases occurred during revision surgery and 86% occurred either immediately or within 48 hours of surgery. Shoenfeld et al [10] retrospectively reviewed five patients from their experience and 63 from the literature to further define vascular injury during hip arthroplasty. Thirty-nine percent of these injuries occurred in revisions and 43% required emergent surgery.…”