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Updated: Aug 31 2023

THA Vascular Injury & Bleeding

  • summary
    • THA Vascular Injury and Bleeding is a rare, potentially devastating, complication during total hip arthroplasty that may occur as a result of errant retractor placement, acetabular screw placement, or direct laceration of a vessel during the surgical approach.
    • Diagnosis is made with visual inspection for significant arterial bleeding and a change in patient hemodynamic status. 
    • Treatment is prompt recognization of the injured vessel, hemostasis and vascular consultation. 
  • Epidemiology
    • incidence
      • 0.1%-0.2%
    • risk factors
      • acetabular screw placement
      • prior vascular bypass or dysvascuar limb
      • revision arthroplasty
      • intra-pelvic position of acetabular component and femoral cerclage wiring
    • mechanism of Injury
      • puncture or laceration from acetabular screw placement
      • errant retractor placement
        • placement of inferior retractor under the transverse acetabular ligament places the obturator artery at risk.
      • compression by anti-protrusio acetabular components
      • direct laceration during approach
  • Anatomy
    • Medial femoral circumflex artery
      • underneath the gluteus maximus tendon and/or quadratus femoris muscle
    • Obturator artery and vein
      • distal to the transverse acetabular ligament
    • Ascending branch of the lateral femoral circumflex artery
      • ascends between tensor fasciae latae and sartorius
      • encountered during direct anterior approach
    • External iliac vessels
      • lie 7mm away from bone at level of ASIS
      • reports of vessels lying immediately adjacent bone
    • Common femoral vessels
      • lie superficial to iliopsoas
      • separated from hip by only anterior capsule and iliopsoas
    • Quadrants of acetabulum
      • posterior-superior
        • superior gluteal vessels
      • posterior-Inferior
        • inferior gluteal and internal pudendal vessels
      • anterior-inferior
        • obturator vessels
      • anterior-superior
        • external iliac and femoral vessels
  • Presentation
    • Physical Exam
      • inspection
        • variable degrees of hemodynamic instability
        • pulsatile intra-operative bleeding
        • abdominal distension
      • neurovascular
        • loss of limb pulses on palpation or doppler
  • Imaging
    • Radiographs
      • findings
        • extra-osseous acetabular screw
    • Angiography
      • indications
        • stable patient with high suspicion of uncontrolled bleed
      • findings
        • delineates specific vessels and branches
        • allows immediate embolization
  • Treatment
    • Prompt diagnosis and treatment critical
    • Operative
      • angiography with endovascular embolization
        • indications
          • hemodynamically stable
      • emergent retroperitoneal exploration
        • indications
          • Hemodynamic instability and pulsatile bleeding
  • Postoperative Anemia
  • Introduction
    • Epidemiology
      • incidence
        • decreasing with institution adoption of multi-modal restrictive blood management strategies
    • Risk factors
      • low preoperative hemoglobin
        • best predictor of the need for a blood transfusion postoperatively
      • rheumatoid arthritis
      • advanced age
      • longer operative time
      • no clear association with BMI, gender, or prophylactic anticoagulation
  • Presentation
    • Symptoms
      • syncopal
      • dyspnea
      • chest pain
    • Physical exam
      • low oxygen saturation
      • tachycardia
      • tachypnea
      • delayed capillary refill
      • pallor
  • Studies
    • CBC, coagulation panel, iron levels
  • Treatment
    • Prevention
      • pre-operative erythropoietin for anemia
      • topical or intravenous use of transexamic acid
      • hypotensive regional anesthesia
    • Treatment
      • postoperative transfusion
        • indications
          • vary by institution
          • hemoglobin under 7, symptomatic anemia, no history of ischemic cardiovascular disease
          • hemoglobin under 8, symptomatic anemia, history of ischemic cardiovascular disease (MI, CHF)
  • Complications
    • Blood transfusions associated with increased rate of prosthetic joint infection
    • Adverse transfusion reactions
  • Prognosis
    • Survival with treatment
      • mortality rate 9%
      • amputation rate 12%
      • permanent disability due to resulting ischemia 17%
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