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


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

In This Article

Vascular Anatomy About the Hip

The external iliac and the femoral artery are the two most commonly injured vessels during THA.[6,11–13] Risk of direct laceration or rupture occurs with drill or screw penetration during acetabular implant fixation or can also occur with resection of the acetabular cup during revision surgeries. There has not been any association noted in the literature between the risk for arterial injury and the particular surgical approach to the hip used during THA;[13] thus vigilance and knowledge of the vascular anatomy about the hip is essential for all THA surgeons.

The external iliac artery arises from the bifurcation of the common iliac artery and continues as the femoral artery once it passes beneath the inguinal ligament into the thigh (Figure 1). Along the inner table of the pelvis, the external iliac artery and vein lie directly on the bone in the region corresponding to the anterior quadrant of the acetabulum. Fukunishi et al,[14] using 3-dimensional angiography, demonstrated that the distance between the anterior edge of the acetabulum and the vessels is 11.7 mm (range 4.8 to 18.1 mm) in primary THA and 16.3 mm (range 10.0 to 21.1 mm) in revisions. In addition, in this location, the external iliac artery is fairly fixed to the bone because of the pelvic retroperitoneum and its own collateral vessels.[15] The superior and inferior gluteal arteries are at risk for injury from acetabular screw penetration in the posterior quadrants of the acetabulum; however, because those vascular bundles are further in distance from the cortex of the bone, there exists greater tolerance for drill and screw penetration.[15,16]

Figure 1.

Figure demonstrating hip vasculature and the corresponding quadrants of the acetabulum.

The common femoral artery in the thigh is also at risk because of surgical steps about the acetabulum and at risk for tearing with dislocation of the hip and for direct laceration with aberrant placement of retractors or passage of cerclage wires or cables (Figures 2 and 3). At the hip joint, the common femoral artery overlies the psoas muscle, and it lies between the femoral nerve (lateral to artery) and femoral vein (medial to artery). As it exits the pelvis from under the inguinal ligament, the common femoral artery gives off the following branches: the superficial circumflex iliac artery, the superficial epigastric artery, the superficial external pudendal artery, the deep external pudendal artery, and the profunda femoral artery. It continues as the superficial femoral artery down the medial thigh passing posterior to the sartorius muscle toward the adductor (Hunter) canal.

Figure 2.

Illustration demonstrating the common femoral vasculature surrounding the hip.

Figure 3.

Figure demonstrating the aberrant placement of an acetabular retractor (*) leading to injury of the common femoral artery. A, Malposition of an anterior retractor over the anterior wall from the posterior approach. B, The proximity of the common femoral vessels to the tip of an improperly placed anterior retractor.