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Femoral Artery Injury Secondary to Total Hip Arthroplasty
Pawan Kumar*, Pranav S Kandachar+, Raghavendra Chikkatur+, Rajesh Parida+, Vindo Ahuja+, Uday Jadhav**, Anil G Tendolkar***
 
A 50-year-old female underwent a total hip replacement, by the anterolateral approach, using a ‘Charnley’ prosthesis. The patient was referred 24 hours, post procedure, for absent distal pulsations. Clinical examination revealed an ischaemic limb and an angiography examination confirmed cutoff of the common femoral artery at the site of the prosthesis. The femoral artery was exposed and a 5 cm long contused segment was noted, which was excised and a reversed saphenous vein graft was interposed. Additional contusion of the proximal portion of the profunda required refashioning and reimplantation. Elective fasciotomy was also performed. Patient had an uneventful recovery.
 
Introduction

Injury to the femoral artery, secondary to a total hip arthroplasty is a rare complication. Presented here is a case of injury to the common femoral artery, secondary to a hip arthroplasty, by the anterolateral approach (using a ‘Charnley’ prosthesis) and its outcome.

 
Case Report

A 50-year-old housewife underwent left hip arthroplasty at a separate institute for degenerative arthritis. A Charnley prosthesis was implanted by the anterolateral approach. No intraoperative difficulty was observed. Postoperatively, the patient complained of pain in the left lower limb and was found to have absent distal pulsations. The patient was referred to our institute; 24 hours post procedure, for vascular opinion and management.

On examination, the patient had cold left lower extremity, decreased sensations and decreased movements. The common femoral artery, till just beyond the inguinal ligament, was well palpable. However, beyond this the pulsations could not be appreciated. Also no pulsations could be appreciated distally over the popliteal artery, dorsalis pedis and posterior tibial arteries. The right lower limb pulsations were normal.

The patient underwent an angiographic examination, which revealed a cutoff of the lower common femoral artery, at the level of the prosthesis, with reformation of the superficial femoral artery through collaterals (Fig. 1).

The patient was subjected for immediate vascular exploration, under general anaesthesia. An incision was taken anteriorly, directly over the artery. The common femoral artery, the superficial femoral artery and the profunda femoris were exposed. There was extensive contusion (with absent pulsations) of the distal common femoral artery and the proximal superficial femoral artery. The length of the contusion was around 5 cm (Fig. 2). There was no cement material seen in the vicinity of the contused artery. The entire segment was dissected free. The profunda femoris was found to have extensive contusion in its proximal 2 cm and was not trapped along its length. The profunda was disconnected and refashioned.
After systemic heparinisation, the contused segment of the femoral artery was excised. There was good antegrade and retrograde bleeding. There was no atherosclerotic involvement of the artery. A 5 cm segment of reversed saphenous vein graft was harvested from the opposite lower limb, and was interposed in between the healthy ends of the common femoral artery and superficial femoral artery, using 7/0 Prolene continuous sutures. An end to side anastomosis, between the profunda femoris and the vein graft was performed, using 7/0 Prolene continuous sutures. Clamps were released. No extra sutures were required. The dorsalis pedis and posterior tibial arteries were well palpable. Elective fasciotomy of the calf was performed.

The patient was kept for observation for 2 days and then transferred to the orthopaedic department for further management of post arthroplasty status. The fasciotomy wounds healed spontaneously. She had an uneventful recovery and after 1-month post procedure is walking with well palpable lower limb pulsations.

 
Discussion

Vascular complications following hip arthroplasty are uncommon.1-3 The proximity of the eurovascular bundle to the hip makes any operation on the hip potentially hazardous. The overall risk of vascular complications, associated with hip arthroplasty, is low (approximately 0.25%).2 The external iliac artery and the common femoral artery are most commonly involved.3 Injuries to these are more common in previously treated hips or during revision procedures than during primary replacement.3,4

The case presented here is of primary hip arthroplasty and involves not only the common femoral artery but also the superficial femoral artery and the profunda femoris.

The aetiology of vascular injury, during total hip arthroplasty, is attributed to direct damage of the vessel or indirect injury from stretching, tearing or compression.1 Direct injury may occur from sharp instruments (scalpels or osteotomes), Hohmann or similar sharp tipped retractors. Acetabular burr drill or thermal injury, secondary to setting of cement, may also cause injury.5 Damage by Hohmann retractors is the more common mechanism of vascular injury.1,2 Two locations, the anterior aspect of the acetabular rim and area medial to femoral neck, are more prone for injury from the Hohmann retractors. Additionally, procedures like extraction of components (like removal of loose acetabular components with associated intrapelvic cement)6 or extravasation of cement with subsequent encasement,7 may also cause vascular occlusion.

The reason for arterial trauma in this case is difficult to ascertain. Prolonged compression and occlusion (by retractors) with intimal crushing with subsequent thrombosis appears like the most probable cause.

Additionally, as in this case, most vascular complications following total hip arthroplasty have been described after an anterior or anterolateral approach.3 However the posterior approach, resulting in femoral artery injury, has also been described.5

The presentation of vascular injuries, associated with hip arthroplasty, may be as acute or delayed haemorrhage. Other rare complications are thrombosis of artery (as in this case) or vein, arteriovenous fistula formation, pseudoaneurysms or embolization.1

Immediate operative intervention is mandatory with variable postoperative results reported. In a review of 68 total hip arthroplasties, complicated by vascular injuries necessitating operative treatment, a 7% mortality and 15% subsequent amputation rate was noted.3 Mortality is higher in case of injury to the iliac artery with subsequent retroperitoneal bleed.3 Poor results of vascular reconstruction are to be anticipated with atherosclerotic arteries.1,3

Intervention procedures, for controlling minor bleeding, have also been described.8 However, timely direct vascular reconstruction of a healthy artery to a healthy artery is desirable.

 
Conclusion
In conditions where a long length single lumen ET tube is needed and not commonly available or there is non availability of certain equipments, the use of a straight metal connector of DLT with a piece of portex tube is a reliable and easy technique to increase the length of the tube.
 
References
1. David CA, Douglas AD, Norman AJ, et al. Instructional course lectures, The American Academy of Orthopedic Surgeons - Neurovascular injury Associated with Hip Arthroplasty. J Bone Joint Surg Am 1997; 79 : 1870-80
2. Nachbur B, Meyer RP, Verkkalak K, et al. Mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop 1979; 141 : 122-33.
3. Shoenfield NA, Stuchin SA, Pearl R, et al. The management of vascular injuries associated with total hip arthroplasty. J Vasc Surg 1990; 11 : 549-55.
4. Matos MH, Amstutz HC, Machleder HI. Ischemia of the lower extremity after total hip replacement. Report of 4 cases. J Bone and Joint Surg 1979; 61-A, 24-7.
5. Brismar B, Veress B, Svensson O. Injury of the femoral artery in total hip replacement causing abdominal pain and hypovolemic shock. A case report. J Bone Joint Surg Am 1992; 74 : 1560-2.
6. Berquist D, Carlsson AS, Ericsson BF. Vascular complications after total hip arthroplasty. Acta Orthop Scadinavia 1983; 54 : 157-63.
7. Aust JC, Bredenberg CE, Murray DG. Mechanisms of arterial injuries associated with total hip replacement. Arch Surg 1981; 116 : 345-9
8. Chmell SJ. Injury of the femoral artery in total hip replacement causing abdominal pain and hypovolemic shock. J Bone Joint Surg Am 1993; 75 : b1575.

LAPAROSCOPIC HYSTERECTOMY : LESS PAIN, MORE COMPLICATIONS, SIMILAR COSTS

Laparoscopic hysterectomy carries a shorter in hospital stay and results in less pain six weeks after the operation, but it has more major complications than abdominal hysterectomy. Analysing data from the eVALuate study, a large multicentre trial involving 1346 women, Garry and colleagues found a higher rate of major complications and longer operative time in the laparoscopic group than with the conventional abdominal approach. At six weeks patients who had laparoscopy had less pain and better quality of life.

The cost effectiveness of the laparoscopic methods are similar to conventional vaginal and abdominal hysterectomy. Sculpher and colleagues compared data from the eVALuate trial and found that the laparoscopic method increases costs and has a small effect on quality adjusted life years after a year. Laparoscopic vaginal hysterectomy was not cost effective, and when the abdominal approach was used, costs of laparoscopy were close to the limit of £ 30 000 per QALY the NHS is willing to pay.

BMJ, 2004; 328 : 129,131.