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|Femoral Artery Injury Secondary to Total
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.
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
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.
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
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
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
|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.
||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
|| 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.
|| 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.
|| 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.
||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.
||Berquist D, Carlsson AS, Ericsson BF.
Vascular complications after total hip arthroplasty.
Acta Orthop Scadinavia 1983; 54 : 157-63.
||Aust JC, Bredenberg CE, Murray DG.
Mechanisms of arterial injuries associated with total
hip replacement. Arch Surg 1981; 116 : 345-9
||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.
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.