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      A rare case of arterial avulsion presenting with occult blood loss following total hip arthroplasty: a case report

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          Abstract

          Introduction

          Iatrogenic arterial damage during total hip replacement is a rare but potentially life- or limb-threatening complication. To the best of our knowledge, this is the first reported case of an avulsion injury to a posterior branch of the profunda femoral artery during primary hip arthroplasty.

          Case presentation

          We describe the case of a 55-year-old Caucasian man who underwent a total hip replacement. The patient's hemoglobin levels dropped postoperatively, but there was no obvious bleeding, hemodynamic instability, pulsatile mass, or limb ischemia. The patient's hemoglobin levels continued to drop despite nine units of transfused blood. Three days after surgery, the patient underwent an angiography that showed an avulsion injury to a posterior branch of the profunda femoral artery. The avulsion was ligated and the hematoma was evacuated.

          Conclusion

          Vascular damage may present in many ways including obvious bleeding, haemodynamic instability, a pulsatile mass, limb ischemia, and occult blood loss. Any of these signs in isolation or in combination could represent a vascular injury and an urgent angiogram should be considered.

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          Most cited references7

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          Vascular injuries associated with elective orthopedic procedures.

          The objective of this study was to review the diagnosis, management, and outcome of the rare iatrogenic arterial injury associated with elective orthopedic joint procedures. A retrospective review was conducted of all patients presenting to the vascular surgery service with arterial injury after elective orthopedic procedures between 1997 and 2002. Clinical records were reviewed for presentation, type of injury, management, and outcome. During the study period, 20 patients having 21 total orthopedic procedures were identified with 27 arterial injuries. There were 4350 elective orthopedic procedures during this period for an incidence of 0.005%. There were 14 total knee arthroplasties, 4 total hip arthroplasties, and 3 ankle reconstructions in the study group. Presenting signs included acute ischemia with loss-of-limb Doppler-detected arterial flow/pulses (13 patients, 62%), intraoperative arterial bleeding (3 patients, 14%), nonhealing wounds (3 patients, 14%), and limb edema (2 patients, 10%); the diagnosis was delayed >24 hr in 5 patients (25%). Arterial thrombosis was the most common abnormality identified (21 of 27 injuries, 78%), followed by laceration/avulsion (3 injuries, 11%) and pseudoaneurysm development (3 patients, 11%), and involved the iliac ( n = 3), common femoral ( n = 2), profunda ( n = 1), superficial femoral ( n = 4), popliteal ( n = 12), or tibial ( n = 5) arteries. Concomitant popliteal venous injury was present in one patient. Injured arterial segments had preexisting atherosclerotic disease (33%) and 15 patients (71%) had prior surgery in proximity to the arterial injury while an additional 9 (43%) had prior traumatic injury (7 [78%] of whom had revision orthopedic surgery as well). Management consisted of vein bypass grafting ( n = 15, 56%), primary repair ( n = 3, 11%), and thrombectomy with thrombolysis ( n = 2, 7%). One patient (5%) underwent primary above-knee amputation. There was one death from septic shock and there were three limb losses (14%). Arterial injury associated with elective orthopedic joint surgery is more common during redoprocedures and in patients with preexisting atherosclerosis. Despite arterial repair/bypass, limb morbidity is common and related to preexisting occlusive disease or extent of arterial thrombosis.
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            Variational anatomy of the deep femoral artery.

            The deep femoral artery is frequently incorporated in vascular reconstructive procedures in the proximal leg. To study the branching variations of this artery, we dissected 100 legs and then classified the anatomical patterns. The deep femoral artery originates a median distance of 4.4 cm from the inguinal ligament. The origin of the lateral circumflex artery varied greatly. When it branched from the deep femoral, the origin of the lateral circumflex was 1.5 cm (median) from the origin of the deep femoral. The medial circumflex artery originated from the deep femoral in 63% of the specimens. It arose separately from the common femoral and more proximally in 26% of the specimens, branching an average of 2.15 cm (median) above the deep femoral origin. Familiarity with these variations is essential to the vascular surgeon and,therefore, we have included diagrams based on our study as a ready reference.
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              Iatrogenic arterial trauma associated with hip fracture surgery.

              During a 5 year period, 1417 patients with various types of hip fractures were surgically treated. Three cases of iatrogenic arterial injuries occurred during the correction procedures, giving an incidence of 0.21%. In 2 patients the profunda femoral and in one the common femoral artery were involved. The mechanisms of injury were: a protruding screw, beyond the medial border of the femur in the first patient, arterial tear, due to bone speculae in the second and external pressure to the artery from an avulsed lesser trochanter in the third. The clinical findings were false aneurysms in two and distal ischaemia in the third patient. All patients were surgically treated. Early diagnosis of this type of injuries is the cornerstone for a good outcome.
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                Author and article information

                Journal
                J Med Case Reports
                Journal of Medical Case Reports
                BioMed Central
                1752-1947
                2009
                6 December 2009
                : 3
                : 9320
                Affiliations
                [1 ]Department of Trauma & Orthopaedics, North Manchester General Hospital, Crumpsall Street, Manchester, M8 5RB, UK
                [2 ]Faculty of Life Sciences, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
                Article
                1752-1947-3-9320
                10.1186/1752-1947-3-9320
                2803843
                20062749
                03719f09-fda5-43f0-a212-5fc46acdd4ed
                Copyright ©2009 Hall et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 30 September 2008
                : 6 December 2009
                Categories
                Case report

                Medicine
                Medicine

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