Post-op “cold foot”

Acute Arterial Injury Major vessel injuries occur in approximately 1% of patients with pelvic fractures Mortality rate as high as 75-83% Iatrogenic arterial injury as a complication of hip fracture surgery occurs in approximately 0.21%

Review of Anatomy….. In hip surgery, the common femoral artery and deep femoral artery or its branches are the mostly injured arteries

20: common femoral artery 35: ischial spine 36: femoral head 37: greater trochanter

21: superficial femoral artery 22: deep femoral artery

21: superficial femoral artery 22: deep femoral artery

Causes of acute arterial occlusion (in general cases) Aortic dissection or trauma that occlude the artery by disrupting the integrity of the vessel Systemic Emboli: Cardiac emboli: mural thrombus in LV secondary to old or recent MI or dilated hypocontractile ventricle; valvular heart dz (rheumatic MV dz), prosthetic heart valve, infective endocarditis, left atrial myxoma, ATRIAL FIBRILLATION!!! Atheroemboli originating from atheromatous lesions in the abdominal aorta or iliac or femoral artery

Causes of acute arterial occlusion in lower extremity surgery Nature of injury: avulsion injury to the vessels Preexisting artherosclerotic disease: h/o lower extremity arterial insufficiency: patients with ankle/brachial index less than 0.4 or 0.3 have a higher rate of occlusion. However, it is not recommended a pre-op arterial bypass be preformed (due to use of tourniquet, positioning)

Causes of acute arterial occlusion in lower extremity surgery Use of tourniquet: the mechanical pressure of a pneumatic tourniquet can cause fracture and dislodgement of a plaque. Use of cement: thrombotic occlusion caused by the heat of polymerization of bone-cement

Causes of acute arterial occlusion in lower extremity surgery Positioning of patient: Kinking or twisting of the vessels; more likely in patient with a previous bypass graft causing a thrombogenic response with extreme torsion Prolonged extrensic occlusion with surgical equipment: use of clamps to achieve desired reduction Vascular injury with screws/drills: Placement of screws or inappropriate size of screws can cause adjacent vascular injury

Physical Findings Abrubt drop in BP and H/H LOSS OF PALPABLE PULSES!! Anywhere from feeling of cool sensation of skin to intense pain Decrease or loss of motor strength Loss of sensation Skin color changes +/- mass

Diagnosis Arteriography Doppler Pulse Ox on extremity IF epidural/block performed: postop arterial monitoring such as doppler of LE or angiography in high risk

Treatment Surgical thrombectomy Bypass, especially in patients with underlying atherosclerotic disease Anticoagulation if possible Intra-arterial thrombolysis (urokinase or recombinant tissue plasminogen activator) Amputation Fascitomy

Bottom Line: Have high index of suspicion Post-op palpation of pulses and/or pulse oximeter Don’t delay diagnostic test/treatment

References Calligaro, et al. Acute arterial thrombosis associated with total knee arthroplasty. Journal of vascular surgery 1994 Dec 20(6); 927-932. Frank, et al. Traumatic iliofemoral arterial injury: An association with high anterior acetabular fractures. Journal of vascular surgery. 1989 August 10(2);198-201. Johnson, et al. Extrensic femoral artery occlusion following internal fixation of an acetabular fracture. Clinical orthopeadics and related research. 1987 April 217; 209-213. Parfenchuck, et al. Intraoperative arterial occlusion in total joint arthroplasty. Journal of arthroplasty. 1994 9(2); 217-220. Probe et al. Femoral artery thrombosis after open reduction of an acetabular fracture. Clinical orthopaedics and related research. 1992 Oct 283;258-260. Storm, et al. Iatrogenic arterial trauma associated with hip fracture treatment. Journal of trauma. 2000 May 28(5); 957-959. Stubbs, et al. Thrombosis of the iliofemoral artery during revision of a total hip replacement. Journal of bone and joint surgery. 1986 March 68-A(3); 454-455.