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%
QUESTIONS 1 of 2 1 2 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.189) A 65-year-old female scheduled to undergo a total hip replacement is concerned about the need of a blood transfusion. The surgeon should explain that which factor is the best predictor of the need for a blood transfusion? QID: 575 Type & Select Correct Answer 1 Shorter height 0% (2/1985) 2 Lower body weight 1% (17/1985) 3 Previous total hip replacement on the contralateral side 2% (30/1985) 4 Lower preoperative hemoglobin 96% (1914/1985) 5 Female gender 1% (14/1985) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
All Videos (2) Podcasts (1) Login to View Community Videos Login to View Community Videos 2019 Orthopaedic Summit Evolving Techniques Evolving Technique: Blood Management: TXA, IV, Topical or Oral - Is There A Difference - Ed McPherson, MD Edward McPherson Recon - THA Vascular Injury & Bleeding C 11/20/2020 79 views 5.0 (1) 2017 Orthopaedic Summit Evolving Techniques Blood Management: TXA, IV, Topical or Oral: Is There A Difference? Edward J. McPherson, MD, FACS Edward McPherson Recon - THA Vascular Injury & Bleeding A 4/27/2018 973 views 4.5 (2) Recon | THA Vascular Injury & Bleeding Recon - THA Vascular Injury & Bleeding Listen Now 11:18 min 5/13/2020 172 plays 4.5 (2)