Current Overview of Neurovascular Structures in Hip Arthroplasty

Home , Femoral artery, Femoral nerve, Superior gluteal artery

1mon.qxd 2/2/04 10:26 AM Page 73

REVIEW

Current Overview of Neurovascular Structures in Hip Arthroplasty: Anatomy, Preoperative Evaluation, Approaches, and Operative Techniques to Avoid Complications John-Paul H. Rue, MD* Nozomu Inoue, MD, PhD* Michael A. Mont, MD†

A major neurovascular injury during total hip arthroplasty (THA) is uncom- Educational Objectives mon. Nevertheless, these are worri- some due to their devastating conse- As a result of reading this article, physicians should be able to: quences. As more THAs are performed 1. Identify the bony, vascular, and neural anatomy that is relevant to the each year, the chances of this potential- surgeon performing total hip arthroplasty. ly life- or limb-threatening injury 2. Describe the common approaches to avoid neurovascular complica- increase.1 It is crucial for the orthope- tions. dic surgeon to have a thorough under- 3. Discuss the appropriate clinical work-up of these patients. standing of the anatomy of the region 4. Describe the various neurovascular complications and how to handle and the potential complications. them. This article reviews the exposures to the acetabulum for simple and complex primary THA, as well as revision cases, with particular attention to the neu- ischium, and pubis (Figure 1). The Damage to any of these vessels by rovascular anatomy of the region. acetabulum is located at the junction of retraction, drilling, reaming, or dissec- these three bones. These bones unite tion can cause massive hemorrhage, ANATOMY anteriorly at the pubic symphysis and which can lead to exsanguination with- Bone posteriorly to the sacrum to form a ring in minutes. The three-dimensional pelvic anato- of bone, which connects the torso to the The common iliac artery divides at my is complex and often hard to under- lower limbs. the L5-S1 vertebral disk. The anterior stand. Several vital vascular and viscer- division, the external iliac artery, con- al structures are contained within and Vascular Structures tinues distally to become the common immediately around the bony pelvis. The proximity of the major vessels femoral artery, whereas the posterior The bony pelvis is formed by the ilium, to bone, and therefore their risk for division becomes the internal iliac injury during acetabular surgery, artery. The internal iliac artery branch- varies. Knowledge of vessel location is es again into a posterior division, From the *Department of Orthopedic Surgery, The Johns Hopkins Medical Institutions, and important because extensive exposure which gives rise to the superior gluteal †Sinai Hospital of Baltimore, Center for Joint of the acetabulum may be required for artery, and an anterior division, which Preservation & Reconstruction, Baltimore, Md. complex revision THA. gives off the obturator artery before Drs Rue, Inoue, and Mont have not declared The major vascular structures locat- dividing into the inferior gluteal artery any industry relationships. ed within and around the pelvis are the and internal pudendal artery. Reprint requests: Michael A. Mont, MD, Sinai Hospital of Baltimore, Center for Joint internal and external iliac, femoral, The external iliac artery and vein are Preservation & Reconstruction, 2401 W Belvedere internal pudendal, obturator, and supe- immobile and lie close to the pelvis, Ave, Baltimore, MD 21215. rior and inferior gluteal vessels. and thus are at highest risk for injury in

www.orthobluejournal.com 73 1mon.qxd 2/2/04 10:26 AM Page 74

ORTHOPEDICS JANUARY 2004 VOL 27 NO 1

1 2 Figure 1: Schematic showing the intrapelvic bony anatomy of the acetabular region. Abbreviation: ASIS=anterior superior iliac spine. Figure 2: Schematic showing the excessively long screws on the quadrilateral intrapelvic surface relative to the iliac arterial system. (Reprinted with permission from Wasielewski RC et al. Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am. 1990; 72:501-508. Copyright © 1990. The Journal of Bone and Joint Surgery Inc.)

THA (Figure 2). The external iliac vein 6 mm and the pudendal vessels an aver- interval between the gluteus medius has been shown to lie within 7 mm of age of 12 mm from the posterior col- and minimus muscles. It is generally the anterior column of the pelvis at the umn. Both, however, are mobile and well protected as long as the dissec- anterior inferior iliac spine and within well protected by a layer of fat.3,4 The tion does not extend Ͼ5 cm above the 4 mm at the acetabular dome. The medial and lateral femoral circumflex greater trochanter.5 The inferior external iliac artery is at less risk due to arteries arise from the deep femoral gluteal nerve is rarely injured because its thicker intima and increased dis- artery and are vulnerable to retractors it inserts into the gluteus maximus tance from the bone. It lies within 10 placed near the femoral neck. proximal and medial to the area, mm of the bone at the anterior inferior which is split during the posterior iliac spine and within 7 mm at the Neuroanatomy approach to the acetabulum. The obtu- acetabular dome. The common femoral The primary nerves of the region are rator nerve runs with the obturator artery lies anterior and medial to the the sciatic, femoral, inferior and superi- vessels.6 hip capsule. Only the iliopsoas lies or gluteal, and obturator. The most The most common nerve injury dur- between the vessel and capsule at this common nerve injury during THA is to ing THA is to the sciatic nerve.7 point. The femoral vein lies medial to the peroneal division of the sciatic Several reasons exist, some of which the artery and is thus less likely to be nerve, followed by superior gluteal, remain conjectural. It has been postu- injured. The obturator vessels also are obturator, and femoral nerves. Injury to lated that these are common because of at risk, lying fixed within 1 mm of the these structures can lead to loss of the sciatic nerve anatomic location. In bony surface at the quadrilateral sur- function and poor outcomes. a review of normal computed tomogra- face, with their only protection being The femoral nerve is the most later- phy (CT), the sciatic nerve was found the interposition of the obturator inter- al structure within the femoral trian- to lie closest to the posterior column of nus muscle. gle. It lies on the psoas muscle belly at the pelvis at the acetabular dome, at an At the sciatic notch, the superior the approximate midpoint between the average of 9 mm. It also was shown to gluteal vessels are at greatest risk, lying anterior superior iliac spine and pubic be more protected at the ischial spine, an average of 5 mm from the notch. tubercle. Its relationship to the acetab- as the short external rotator muscles Injury to the superior gluteal artery as a ulum is anterior, thus it is primarily at are interposed between the nerve and complication of THA is rare, but has risk during capsule dissection rather bone at this point; the nerve was an been reported.2 At the ischial spine, the than during reaming or drilling. The average 15 mm away from the ischial inferior gluteal vessels lie an average of superior gluteal nerve traverses the spine.3

74 www.orthobluejournal.com 1mon.qxd 2/2/04 10:26 AM Page 75

RUE ET AL REVIEW

3 4 Figure 3: The acetabular quadrant system. The quadrants are formed by the intersection of lines A and B. Line A extends from the anterior superior iliac spine through the center of the acetabulum to the posterior aspect of the fovea, dividing the acetabulum in half. Line B is drawn perpendicular to line A at the mid-point of the acetabulum, dividing it into four quadrants: anterior-superior, anterior-inferior, posterior- superior, and posterior-inferior. Abbreviation: ASIS=anterior superior iliac spine. (Reprinted with permission from Wasielewski RC et al. Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am. 1990; 72:501-508. Copyright © 1990. The Journal of Bone and Joint Surgery Inc.) Figure 4: External view of intrapelvic vessels in the quadrilateral region with superimposed acetabular quadrant system as described by Wasielewski RC et al.3

Quadrant System bone and close proximity of the vessels of the posterior wall. It is the most com- The acetabular quadrant system to bone in that region (Figure 4). monly used approach for THA in the described by Wasielewski et al3 is use- United States. The patient is placed in ful for determining the location of APPROACHES the lateral position. Because the planned acetabular screw fixation in The anterolateral and posterior approach involves splitting of the glu- THA to avoid neurovascular complica- approaches are the most common sur- teus maximus in line with its fibers, no tions. The quadrants are formed by gical approaches to the acetabulum internervous plane is present. The sci- drawing a line from the anterior superi- during THA. Both approaches offer atic nerve is protected by the short or iliac spine through the center of the excellent visualization of the acetabu- external rotators after they are detached acetabulum and bisecting that line at lum. Comparing lateral- and posterior- from their insertions on the femur and the center of the acetabulum to form oriented approaches, lateral approaches reflected medially (Figure 5). four equal quadrants. The line from the offer better exposure, although posterior Damage to the inferior gluteal artery anterior superior iliac spine to the cen- approaches are more popular. The ilioin- is the main vascular risk of the posteri- ter of the acetabulum serves as the guinal and anterior (extended ilio- or approach. This vessel has many dividing line between anterior and pos- femoral) approach are described as intramuscular branches, which often terior, and the bisecting line as the divi- these approaches are often used for are cut when the gluteus maximus is sion between superior and inferior more extended exposures.5 In general, split, and they must be identified and (Figure 3). the surgical approach chosen for acetab- cauterized during dissection. For the In cadaver studies, the posterior- ular revision is likely to be the same as trauma surgeon dealing with complex superior and posterior-inferior quad- that used for the primary surgery unless pelvic fractures involving the greater rants were shown to have the thickest other factors are involved, such as the sciatic notch, the inferior gluteal artery bone and best potential for obtaining need for increased exposure. also is at risk as it exits the pelvis just secure fixation with the least risk for below the lower border of the piri- injury to vessels. The anterior-superior Posterior Approach formis. quadrant (the quadrant of death) and The posterior approach to the acetab- The most common nerve injury the anterior-inferior quadrant were ulum is the least technically demanding occurring during the posterior approach shown to be the most dangerous quad- approach for THA and offers good visu- is contusion to the sciatic nerve. This rants for screw fixation due to the thin alization of the acetabulum, especially can be minimized by avoiding excessive

www.orthobluejournal.com 75 1mon.qxd 2/2/04 10:26 AM Page 76

ORTHOPEDICS JANUARY 2004 VOL 27 NO 1

A B Figure 5: Diagram showing exposure of the hip through a posterior approach. Note that the sciatic nerve exits below the piriformis muscle (A). The insertions of the short external rotators have been detached and retracted to protect the sciatic nerve (B). The piriformis insertion is left attached. It is normally detached and retracted as well, but does not protect the sciatic nerve such as the short external rotators.

traction and ensuring that the nerve is the right hip and the 11-o’clock posi- approximately 2.5 cm inferior to the well protected by the short external rota- tion for the left hip. Care should be anterior superior iliac spine. tors. Maintaining the hip in an extended taken to ensure that the tip of the retrac- The deep dissection is carried out position may also decrease the risk of tor is placed directly on bone and does through the plane between the rectus injury by keeping the nerve out of the not pierce the psoas muscle, the only femoris (femoral nerve) and gluteus operative field. Unless specifically indi- barrier between the acetabulum and medius (superior gluteal nerve). The cated, no attempt to dissect the nerve femoral vessels. Another reasonable femoral nerve and vessels, because of from its surrounding perineural fat alternative is to pass a blunt curved their anterior relationship to the hip, are should be made. retractor (eg, a blunt Homan) into the at risk during dissection. The femoral pelvis at the anterior acetabulum. structures are protected provided the Anterolateral Approach and Because the femoral nerve is the most dissection does not stray out of the Modifications lateral structure in the femoral triangle, plane of the sartorius and tensor fascia The anterolateral approach is a com- it also is vulnerable to retractors and latae superficially and the gluteus mon approach for THA. It offers excel- excessive retraction. Any modification medius and rectus femoris more lent exposure to the acetabulum. The of this approach that splits the gluteus deeply. The ascending branch of the patient is placed in the lateral position, medius puts the superior gluteal nerve lateral femoral circumflex artery cross- and the dissection is carried through at risk6 (Figure 6). es the operative field at the proximal the intermuscular plane of the tensor The transverse branch of the lateral interval between the sartorius and ten- fascia lata and gluteus medius. Some femoral circumflex artery may be sor fascia latae and must be ligated or surgeons prefer to perform a trochan- encountered when splitting the vastus coagulated. teric osteotomy, whereas others prefer lateralis during this approach and must More extensive exposure of the to detach the anterior two-thirds of the be cauterized or ligated. medial wall and anterior column can be gluteus medius from its insertion on the provided by incising the origin of the greater trochanter. Anterior Approach and Modifications sartorius at the anterior superior iliac A modification of this approach is This approach is primarily used for spine, as well as the direct head of the the Hardinge, which detaches the ante- open reduction of developmental hip rectus at the anterior superior iliac rior two-thirds of the gluteus medius dislocations, but offers access to the spine. Smith-Petersen et al8 modified and continues in continuity with a soft- anterior column and anterior lip of the this approach by cutting the tensor fas- tissue sleeve incorporating a split in the acetabulum. The patient is in the supine cia latae distal to the myofascial por- proximal vastus lateralis.6 position. The superficial dissection tion to allow access to the femoral neck The main risks associated with the exploits the internervous plane between and trochanteric area. A further modifi- anterolateral approach are femoral the sartorius (femoral nerve) and tensor cation of the anterior approach has artery and vein laceration, which are fascia latae (superior gluteal nerve). been described by Light and Keggi,9 vulnerable to retractors placed too far The lateral femoral cutaneous nerve which involves a lateral dissection anteriorly. The anterior retractor should can usually be identified and protected splitting the medial fibers of the tensor be placed at the 1-o’clock position for as it emerges over the sartorius, fascia latae medially to provide a mus-

76 www.orthobluejournal.com 1mon.qxd 2/2/04 10:26 AM Page 77

RUE ET AL REVIEW

cle cuff to protect the lateral femoral cutaneous nerve and to minimize nerve complications for THA.

Ilioinguinal Approach The ilioinguinal approach provides improved visualization of the pelvic inner surface and anterior column and medial wall of the acetabulum. This approach is effective for acetabular fractures involving the anterior wall, anterior column, and associated anterior and posterior hemitransverse fractures, both column, and transverse fractures. Advantages of this approach include excellent cosmesis, rapid recovery, and reduced heterotopic bone formation compared with other extensile approaches. The patient is placed supine or in a lazy lateral decubitus position. The principle of this approach is to dissect closely along the inner wall of the pelvis and lift each muscular and neu- Figure 6: Diagram showing the relationship of the anterior retractor to the femoral nerve, artery, and vein. The retractor tip should be placed directly on bone. rovascular structure off of the bone without avulsing or tearing it. Three windows are present in this approach, Other structures at risk include the should document range of motion of each providing access to different bowel, bladder, and spermatic cord. both hips and knees, as well as contrac- structures. The first window allows tures or limb-length discrepancies. access to the anterior sacroiliac joint, PREOPERATIVE PLANNING internal iliac fossa, and upper anterior History Imaging column. The second window, which Complex acetabular revision surgery Plain radiographs are essential for lies between the iliopsoas with accom- is challenging. As with all preoperative bone stock assessment. Significant panying femoral nerve and iliac ves- evaluations, a detailed history is para- bony defects may exist in the acetabu- sels, allows access to the pelvic brim, mount. Relevant questions include the lum secondary to osteolysis. These quadrilateral surface, and superior indications for the index procedure and defects may preclude screw placement pubic ramus. The third window allows any subsequent procedures, as well as in the optimal quadrants. Additionally, access to the pubic symphysis, superior the implant type, if known. Other rele- bone loss can lead to improper revision ramus, quadrilateral surface, and the vant questions include history of infec- component placement unless care is retropubic space. tion and prior neurovascular complica- taken to ensure its correct anatomic Nerves at risk during this approach tions. positioning. If extensive osteolysis is include the femoral nerve, which lies suspected, CT is recommended as plain under the inguinal canal on the anterior Physical Examination radiographs underestimate the extent of surface of the iliopsoas muscle. It may The physical examination should lysis. Helical CT with metal artifact be injured by retraction or lacerated document sensation and motor function minimization is the most sensitive during dissection. The lateral femoral of the entire lower extremity, as well as method for identifying and quantifying cutaneous nerve often is divided at the a thorough vascular examination, the extent of lysis.10 anterior superior iliac spine unless it including bruits or any other abnormal- In revision situations, medial migra- can be easily retracted without tension. ities that might alert the surgeon to a tion of the acetabular component may The femoral vessels run medial to possible vascular injury. If a neurolog- exist. Preoperatively, it is important to the iliopectineal fascia and are at risk as ic deficit exists, electromyogram nerve determine the location of any intrapelvic previously described. The inferior epi- conduction studies may be useful as cement or hardware in relation to major gastic artery lies medial to the deep part of the preoperative assessment for vascular and visceral structures. In these inguinal ring and must be ligated. complete documentation. Examination cases, angiography or CT may assist the

www.orthobluejournal.com 77 1mon.qxd 2/2/04 10:26 AM Page 78

ORTHOPEDICS JANUARY 2004 VOL 27 NO 1

surgeon by demonstrating the vascular surgeon options and a roadmap to the transacetabular screw fixation and anatomy of the pelvic region in relation vascular anatomy. Some surgeons per- acetabular component migration can to the proposed operative field.11 Several form a two-stage procedure for extrud- lead to damage of this fragile ves- case reports have described vascular ed, intrapelvic cement. sel.14,20 Avoidance of the anterior quad- pseudoaneurysms developing after When removing press-fit porous rants can decrease these risks. The unrecognized vascular injury during pri- ingrowth components, similar care anteroinferior quadrant is especially at mary THA, and proper visualization of should be taken to disrupt the interface risk for cement impingement leading to these potential hazards is critical in between the bone and component before damage to either the obturator nerve, avoiding damage to these structures dur- removing the component. Curved and vein, or external iliac vein or artery. ing dissection.11-17 straight osteotomes of varying sizes can The risk of external iliac artery and A radiograph can also ascertain var- be used to disrupt this interface and to vein damage from cement extrusion ious deformities of the acetabulum and gently lever the component free from and the heat of polymerization can be femur. For example, in developmental the bone. Finally, any soft-tissue adhe- avoided by careful cementing tech- hip dysplasia, the following bony sions should be properly ligated or nique, including the liberal use of bone abnormalities may be found and should coagulated, rather than torn free. A graft to fill any defects. be given consideration for exposure: similar technique has been described Damage to the femoral vessels is increased femoral anteversion; small, using a punch, inserted through a sepa- most commonly due to aberrant retrac- osteoporotic femur; shallow or dys- rate stab incision in the posterior-later- tor placement.17,21 Care should be taken plastic acetabulum; and a subluxated or al acetabulum, to disrupt the bone- to ensure that the retractor tip is placed dislocated femur. implant interface.18 directly on bone, and that the iliopsoas is not interposed between the retractor OPERATIVE TECHNIQUE Avoiding Arterial and Venous Injuries tip and bone. Extruded cement,22 As with all surgery, the key to suc- The etiology of vascular injuries acetabular cup migration,16 and capsule cessful acetabular surgery is careful and may be direct or indirect damage. dissection23 have also been implicated meticulous dissection. Often, the tissue Indirect damage can be due to stretch- in damage to the femoral vessels. planes are disrupted and the normal ing, tearing, or compression. Direct The inferior and superior gluteal anatomy is distorted. Anatomic land- damage can be caused by excessive arteries can be injured by poor place- marks may be present, depending on reaming or misplacement of retractors. ment of transacetabular screws, or by the degree of bone loss. Careful identi- Oftentimes, these indirect or direct pin retractors placed near the sciatic fication of remaining normal landmarks injuries cannot be distinguished. A pre- notch.2 Proper drilling technique, is vital. Knowledge of the acetabular vious review of the vascular injuries including direct palpation guidance, quadrant system and its landmarks is sustained during THA revealed the can decrease this risk. essential. most common etiology of vascular Although rare, laceration of the injury as thromboembolic, followed by obturator vessels can occur from indi- Component Removal laceration, pseudoaneurysm, and arteri- rect contact by osteophytes or pieces of The goal of the surgeon when ovenous fistula. The left side was more cement, or by direct violation by a removing existing components is to commonly involved than the right, and retractor placed into the superior-later- preserve as much bone stock as possible the overall mortality was 7%, with a al corner of the obturator foramen. and minimize the risk of neurovascular 15% incidence of major and 4% inci- injury. Care should be taken to interrupt dence of minor amputations.11 Damage Retroperitoneal Approach for the interface between the bone and to the external iliac artery is more com- Uncontrolled Bleeding cement when removing cemented mon than to the external iliac vein.19 When facing a complex acetabular acetabular components. The most Both structures are in close proximity revision or uncontrollable bleeding, the important thing to remember is not to to the acetabular dome and need to be orthopedic surgeon should also be famil- create a segmental defect. Rim fracture avoided. The mechanism of injury usu- iar with the retroperitoneal approach to should be avoided to further preserve ally is due to retractors placed too far the acetabulum. This approach has been the structural integrity of the acetabu- medially in the region proximal to the described as a two-stage procedure for lum and thus reduce the risk of neu- transverse acetabular ligament. To min- revision total THA and as an emergency rovascular injury. Intrapelvic cement imize this risk, anterior retractors procedure for intrapelvic control of a extruded through screw holes can snag should be placed directly on the anteri- major vascular injury.24,25 This approach the external iliac vessels when the com- or column. can be used when the surgeon is con- ponent is removed. In these cases, pre- Excessive reaming of the acetabu- cerned during complex acetabular revi- operative imaging with either contrast lum can cause injury to the external sions in the following situations: enhanced CT or angiography offers the iliac vein. Inadvertent laceration from intrapelvic dislocation, protrusion with

78 www.orthobluejournal.com 1mon.qxd 2/2/04 10:26 AM Page 79

RUE ET AL REVIEW

no bony barrier, intrapelvic cement or until a vascular surgeon performs the implants, and anomalous vessels or path definitive vascular procedure. It should detected on preoperative angiography. be noted that ligation as a damage con- This approach lowers the risk of damag- trol procedure for major vascular ing intrapelvic vessels, which may be injury is a valid option, provided the inaccessible through standard approach- consequences are understood. In most es to the hip. patients, ligation of the iliac, common For two-stage revisions, the patient femoral, and superficial femoral arter- is placed in the lateral decubitus posi- ies results in critical limb ischemia and tion, and the posterior pad is removed should be followed by open fascioto- to allow the patient to assume a slight- my of all thigh and lower leg compart- ly more supine “lazy lateral” position. ments, as compartment syndrome is The retroperitoneal approach is per- common postoperatively and often dif- formed to remove any intrapelvic ficult to diagnose in these patients. cement and mobilize the vessels. The Conversely, all limb veins can be ligat- Figure 7: Diagram showing the skin incisions for the two-incision retroperitoneal approach. posterior pad is then replaced and the ed without severe complications.26 patient returned to the lateral position, If hemorrhage continues, but the and the second stage revision of the patient is stable, selective arterial formed for developmental dysplasia or joint through either a lateral or posteri- embolization may be another option. dislocation.7 For revision surgery, the or approach is performed. The advan- This procedure has been used in pelvic incidence may be as high as 7.6%.19 tage of this technique is that it allows fractures for control of bleeding. In Sciatic nerve palsy is the most common for a combined anterior and lateral or large centers where emergency angiog- nerve injury following THA, with esti- posterior approach to the acetabulum raphy is readily available, it offers a less mates ranging from 0.5%-2%.28,29 during a single operation. A similar invasive, perhaps more precise method Clinically, patients with a sciatic nerve technique can be used in an emergency for identifying and embolizing select palsy complain of weakness or inabili- without repositioning the patient, vessels without extensive surgical dis- ty to dorsiflex the foot. Approximately should immediate intrapelvic vascular section, which could cause worsening 50% of these injuries have been related control be required. hemorrhage. Halpern et al27 reported a to lengthening and increasing lateral The curvilinear incision for the case of delayed massive bleeding from displacement of the leg, 22% from retroperitoneal approach is made start- the inferior gluteal artery, which was direct injury, 20% from bleeding com- ing approximately 3 cm medial to the selectively embolized using angiogra- plications, and 10% from postoperative anterior superior iliac spine and ending phy. dislocations. Leg lengthening should at the inguinal ligament, over the be minimized to р6% of the limb femoral artery (Figure 7). The subcuta- Postoperative Care length. Thus, small individuals will be neous tissue, external and internal Several postoperative considera- at increased risk, as well as females due obliques, and the transversus abdomi- tions exist for patients after severe to size and less muscle mass. Improved nus muscles are divided to enter the bleeding complications. The patient outcome may be expected from retroperitoneum. At this level, the should be closely monitored and patients who have full or returning external iliac vein lies posterior to the aggressively resuscitated. Drain output motor function postoperatively. During artery. For emergency control of severe should be followed closely. Laboratory surgery, the surgeon should minimize bleeding, a vessel loop can be used to studies should include serial hemat- the tension on the sciatic nerve by temporarily ligate the external iliac ocrits and coagulation panels. The sur- maintaining the knee in a flexed posi- vessels until the bleeding vessel can be geon should have a low threshold for tion as much as possible, and femoral cauterized or ligated. For two-stage re-exploration of the wound if high shortening osteotomy in the dislocated revisions, these vessel loops can be drain outputs persist or signs of active dysplastic hip should be considered to loosely brought out of the wound, and bleeding such as tachycardia, hypoten- reduce the risk of nerve palsy.19 the wound packed and skin temporarily sion, or a falling hematocrit are pre- Femoral nerve palsies are most often closed in the event that intrapelvic sent. caused by retractor placement. Clinical- proximal vascular control is needed ly, patients with femoral nerve palsies during the joint revision stage.26 Avoiding Nerve Injury have weakness or loss of quadriceps Ideally, the orthopedic surgeon Following primary THA, the inci- function. In general, femoral nerve should be comfortable with the initial dence of nerve palsy has been reported palsies occur in combination with sciat- retroperitoneal exposure and clamping to be approximately 1.3%, but may be ic nerve palsies; however, they may of the large feeder vessels of the pelvis as high as 5.2% for primary THA per- occur independently. The incidence of

www.orthobluejournal.com 79 1mon.qxd 2/2/04 10:26 AM Page 80

ORTHOPEDICS JANUARY 2004 VOL 27 NO 1

femoral nerve palsy is approximately taken to minimize the insult to all neu- Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, Pa: Lippincott Williams 2%. Injury to the obturator nerve is rare. rovascular structures during surgery to and Wilkins; 1994:323-399. The use of somatosensory evoked lessen the chance of developing DVT 7. Schmalzried TP, Amstutz HC, Dorey FJ. potentials has been studied in patients and subsequent complications. Nerve palsy associated with total hip replacement. Risk factors and prognosis. J Bone Joint undergoing THA. Its use was not indi- Postoperative limb ischemia can Surg Am. 1991; 73:1074-1080. cated for primary procedures, although result from THA. In patients with pre- 8. Smith-Petersen MN, Cave E, VanGorder it may play a role in revision surgery, existing atherosclerosis, various intra- G. Intracapsular fractures of the neck of the femur: treatment by internal fixation. Arch Surg. especially in cases where limb lengthen- operative maneuvers required for posi- 1931; 23:707-715. ing is expected.7,30 tioning and dislocating the hip have 9. Light TR, Keggi KJ. Anterior approach to been implicated.11 Another possible hip arthroplasty. Clin Orthop. 1980; 152:255-260. Hematomas 10. Puri L, Wixson RL, Stern SH, Kohli J, mechanism is occlusion of the external Hendrix RW, Stulberg SD. Use of helical com- The formation of a hematoma can iliac artery by protrusio of the acetabu- puted tomography for the assessment of acetabu- produce immediate or delayed onset lar component.34 Preoperative vascular lar osteolysis after total hip arthroplasty. J Bone Joint Surg Am. 2002; 84:609-614. nerve palsy subsequent to THA. When consultation is helpful for patients 11. Shoenfeld N, Stuchin SA, Pearl R, Harveson it involves the gluteal compartment, the with atherosclerosis undergoing elec- S. The management of vascular injuries associated sciatic nerve is at risk.31 The same is tive THA. with total hip arthroplasty. J Vasc Surg. 1990; 11:549-555. true for a hematoma around the iliacus, 12. Gruen GS, Mears DC, Cooperstein LA. which can cause femoral nerve palsy, SUMMARY Three-dimensional angio-computed tomography. especially after perforation of the Total hip arthroplasty is a common New technique for imaging the acetabulum and adjacent vessels in a patient with acetabular pro- medial wall in complex or revision and relatively safe procedure with con- trusio. J Arthroplasty. 1989; 4:353-360. THA. Symptoms associated with the sistently good results. Despite its popu- 13. Scullin JP, Nelson CL, Beven EG. False formation or secondary nerve palsy larity and excellent results, THA is a aneurysm of the left external iliac artery following total hip arthroplasty. Clin Orthop. 1975; include excessive pain exacerbated by major operation with several major neu- 113:145-149. passive stretch of the involved com- rovascular structures within reach of 14. Ryan JA, Johnson ML, Boettcher WG, partment. retractors, scalpel blades, drills, screws, Kirkpatrick JN. Mycotic aneurysm of the external iliac artery caused by migration of a total hip and reamers. A thorough knowledge of prosthesis. Clin Orthop. 1984; 186:57-59. Aneurysm/Pseudoaneurysm their anatomic location and proximity 15. Hopkins NF, Vanhegan JA, Jamieson CW. Unrecognized injury to vascular to the operative field, along with a basic Iliac aneurysm after total hip arthroplasty. Surgical management. J Bone Joint Surg Am. structures during THA may not result understanding of the principles of vas- 1983; 65:359-361. in immediate hemorrhage because of cular surgery can help avoid potentially 16. Giacchetto J, Gallagher J. False aneurysm vasoconstriction temporarily occluding devastating consequences. Specifically, of the common femoral artery secondary to migration of a threaded acetabular component. A the arterial lumen. The manifestation of the surgeon should avoid placement of case report and review of the literature. Clin these injuries may include arteriove- screws in the anterior-superior quad- Orthop. 1988; 231:91-96. nous fistula between the common rant, be vigilant when placing retrac- 17. Nachbur B, Meyer RP, Verkkala K, Zurcher R. The mechanisms of severe arterial femoral artery and vein, false aneurysm tors, and avoid excessive tension on the injury in surgery of the hip joint. Clin Orthop. of the common femoral artery, and hip sciatic nerve. 1979; 141:122-133. dislocation from a false aneurysm of 18. Markovich GD, Banks SA, Hodge WA. A 32,33 new technique for removing noncemented the medial femoral circumflex. REFERENCES acetabular components in revision total hip 1. Ratliff AH. Editorial: arterial injuries after arthroplasty. Am J Orthop. 1999; 28:35-37. Avoiding Other Surgery-Related total hip replacement. J Bone Joint Surg Br. 1985; 19. Wasielewski RC, Crossett LS, Rubash HE. Complications 67:517-518. Neural and vascular injury in total hip arthroplas- 2. Lozman H, Robbins H. Injury to the supe- ty. Orthop Clin North Am. 1992; 23:219-235. Deep venous thrombosis (DVT) is rior gluteal artery as a complication of total hip- 20. Mallory TH. Rupture of the common iliac replacement arthroplasty. A case report. J Bone estimated to occur in up to 70% of vein from reaming the acetabulum during total Joint Surg Am. 1983; 65:268-269. hip replacement. A case report. J Bone Joint Surg patients after THA without prophylax- 3. Wasielewski RC, Cooperstein LA, Kruger Am. 1972; 54:276-277. is, with fatal pulmonary embolism MP, Rubash HE. Acetabular anatomy and the 21. Salama R, Stavorovsky M, Iellin A, transacetabular fixation of screws in total hip occurring in 2%. With appropriate pro- Weissman SL. Femoral artery injury complicat- arthroplasty. J Bone Joint Surg Am. 1990; 72:501- ing total hip replacement. Clin Orthop. 1972; phylaxis, either mechanical or pharma- 508. 89:143-144. cologic, the incidence of DVT and pul- 4. Keating EM, Ritter MA, Faris PM. 22. Dorr LD, Conaty JP, Kohl R, Harvey JP Jr. Structures at risk from medially placed acetabular monary embolism decreases signifi- False aneurysm of the femoral artery following screws. J Bone Joint Surg Am. 1990; 72:509-511. total hip surgery. J Bone Joint Surg Am. 1974; cantly. Mobilization of the femoral ves- 5. Ramesh M, O’Byrne JM, McCarthy N, 56:1059-1062. sels during dissection and kinking dur- Jarvis A, Mahalingham K, Cashman WF. 23. Brismar B, Veress B, Svensson O. Injury Damage to the superior gluteal nerve after the ing dislocation of the femoral head has of the femoral artery in total hip replacement Hardinge approach to the hip. J Bone Joint Surg causing abdominal pain and hypovolemic shock. been implicated in the etiology of DVT. Br. 1996; 78:903-906. A case report. J Bone Joint Surg Am. 1992; During revision THA, care must be 6. Hoppenfeld S, deBoer P. In: Surgical 74:1560-1562.

80 www.orthobluejournal.com 1mon.qxd 2/2/04 10:26 AM Page 81

RUE ET AL REVIEW

24. Petrera P, Trakru S, Mehta S, Steed D, 28. Edwards BN, Tullos HS, Noble PC. Mechanisms of arterial injuries associated with Towers JD, Rubash HE. Revision total hip Contributory factors and etiology of sciatic nerve total hip replacement. Arch Surg. 1981; 116:345- arthroplasty with a retroperitoneal approach to palsy in total hip arthroplasty. Clin Orthop. 1987; 349. the iliac vessels. J Arthroplasty. 1996; 11:704- 218:136-141. 33. Mariconda M, Chello M, Lotti G, 708. 29. Lewallen DG. Neurovascular injury asso- Mastroroberto P, Milano C. Dislocation of total 25. Rorabeck CH, Partington PF. Retroperi- ciated with hip arthroplasty. Instr Course Lect. hip prosthesis by false aneurysm of the medial toneal exposure in revision total hip arthroplasty. 1998; 47:275-283. circumflex femoral artery. Orthopedics. 2000; Instruct Course Lect. 1999; 48:27-36. 30. DeHart MM, Riley LH Jr. Nerve injuries 23:69-70. 26. Aucar JA, Hirshberg A. Damage control in total hip arthroplasty. J Am Acad Orthop Surg. 34. Reiley MA, Bond D, Branick RI, Wilson for vascular injuries. Surg Clin North Am. 1997; 1999; 7:101-111. EH. Vascular complications following total hip 77:853-862. 31. Fleming RE Jr, Michelsen CB, Stinchfield arthroplasty. A review of the literature and a 27. Halpern AA, Rinsky LJ, Burton DS. FE. Sciatic paralysis. A complication of bleeding report of two cases. Clin Orthop. 1984; 186:23- Selective arterial embolization for hemorrhage following hip surgery. J Bone Joint Surg Am. 28. following hip arthroplasty. Clin Orthop. 1977; 1979; 61:37-39. 124:144-148. 32. Aust JC, Bredenberg CE, Murray DG.