Vascular injuries associated with elective orthopedic procedures.

Abstract

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.