Acute Surgical Management of Vascular Injuries in Hip and Knee Arthroplasties

Christopher M. Melnic, MD; Marilyn Heng, MD, MPH, FRCSC; Santiago A. Lozano-Calderon, MD, PhD

Disclosures

J Am Acad Orthop Surg. 2020;28(21):874-883. 

In This Article

Abstract and Introduction

Abstract

With an increasing number of total hip and knee arthroplasties being done at surgical centers and vascular surgeons often not immediately available in this setting, it is critical for orthopaedic surgeons to be comfortable with the acute surgical management of vascular injuries. Although they are fortunately uncommon in primary total hip and knee arthroplasties, damage to a major artery or vein can have potentially devastating consequences. Surgeons operating both in a hospital and an ambulatory surgical setting should be familiar with techniques to gain proximal control of massive bleeding because the principles can be helpful in primary and revision arthroplasties. In this study, we review the vascular anatomy around the hip and knee and the surgical management of these potentially catastrophic complications.

Introduction

The completion of total joint arthroplasty on an outpatient-basis is an increasing trend.[1,2] In a 2017 study of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, from 2011 to 2014, the incidence of outpatient total joint arthroplasty was 0.7%.[3] Multiple authors have published on the safety of outpatient hip and knee arthroplasty in carefully selected patients;[4,5] however, a full elucidation of the risks and outcomes of outpatient joint arthroplasty remains to be seen, especially whether should it eventually become the mainstream. Ambulatory surgery centers (ASC) are a significantly different setting from an acute inpatient hospital, mostly notably in the level of supporting resources and personnel. Depending on the level of specialization of the ASC, the availability of a surgeon with vascular surgery expertise may be limited. Although uncommon, vascular injury during total joint arthroplasty is an observed complication. In the literature, major arterial injury resulting from total hip and knee arthroplasties (THA and TKA) has been reported at rates of 0.05% to 0.2%.[6–8] Damage to a major artery or vein can have potentially devastating consequences. Surgeons operating both in a hospital and an ambulatory surgical setting should be familiar with techniques to gain proximal control of massive bleeding because the principles can be helpful in primary and revision arthroplasties.

The mechanisms for vascular injury differ slightly between total knee arthroplasty and total hip arthroplasty. In general, indirect mechanisms of injury resulting from stretching and compression while dislocating the knee are the main causes of vascular complication after total knee arthroplasty.[6] Direct laceration of a vessel during TKA is very rare but does occur.[9] By contrast, direct injury to the vessels is the most common mechanism for vascular injury during THA[6] and surgical ability to control unexpected intraoperative bleeding about the hip and pelvis can be the difference between a satisfactory and a poor outcome.

Rapid identification of vascular injuries is crucial. The literature surrounding outcomes is sparse. Parvizi et al noted 76% (13/16 patients) had full neurovascular function of the affected limb at the time of discharge. In their series, 50% of patients required four compartment fasciotomies, one required above the knee amputation for late ischemia, and they did have one death in the series after direct external iliac vessel laceration during THA.[6] In the series by Troutman et al,[10] 4 of 49 patients developed foot drop, but all had a salvageable limb at the final follow-up.

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