Updated: 10/15/2019

THA Vascular Injury & Bleeding

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Introduction
  •  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 
      • compression by anti-protrusio acetabular components
      • direct laceration during approach 
  • Prognosis
    • survival with treatment
      • mortality rate 9%
      • amputation rate 12%
      • permanent disability due to resulting ischemia 17%
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
    • angiograpghy 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
 

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(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? Review Topic

QID: 575
1

Shorter height

0%

(1/1476)

2

Lower body weight

1%

(13/1476)

3

Previous total hip replacement on the contralateral side

1%

(21/1476)

4

Lower preoperative hemoglobin

96%

(1423/1476)

5

Female gender

1%

(11/1476)

L 1

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