**1. Introduction**

This chapter gives an etiology, management, and prevention of common injuries that occur at the time of total hip replacement surgeries or postoperative period. A total hip replacement has become one of the most successful procedures with minimal complications and longterm result [1]. According to the data published by various major national and international joint registries, an increasing number of total hip replacements are performed each year. The incidence of vascular injury occurs at the time of hip surgery or immediate postoperatively or in the late postoperative period, which is quite rare (0.2–0.3%), but the inevitable and serious issue may cause morbidity and even mortality [1, 2]. The most common pattern of vessel injuries include lacerations, pseudoaneurysms, thromboembolic and arteriovenous fistula [3–5].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Contiguous arteries to the acetabulum that are susceptible to be injured during total hip replacement are mostly branches of common iliac vessels; external iliac vessels, obturator vessels, superior and inferior gluteal artery, and internal pudendal arteries and veins as shown in **Figure 1** [6–12]. Indeed, many vascular structures surrounding the acetabulum may be injured by direct and indirect trauma have been reported [12, 13]. In particular, the primitive cause of injuries includes reaming during acetabular preparation, and retractor induced injury, drilling holes for fixation of screws in cementless acetabular cups, excessive traction in surgery, postoperative cup migration (**Figure 2a** and **b**). Also, cement erosion, excessive local heating by methyl methacrylate in cemented total hip replacement are further reasons of occurrence of arterial injuries during total hip replacement [4, 14–20]. However, there are many reported reasons in which symptoms of vessel injury were not evident. The possible reasons might be bone fragments or contamination caused due to soft tissue defect, result in infections [21].

Vessel injuries giving immediate symptoms of total hip replacement are the severe hemorrhage. The most common ischemic symptoms in the delayed postoperative period include pain, the decrease of hemoglobin, swelling, reduced blood pressure and hypovolemic shock [1, 2, 4, 6, 10, 11, 22, 23]. Other presenting signs and symptoms of vessel injury in revision surgeries include excessive bleeding, loss of pulse and instability during extraction of hip prosthesis [19].

In some reports, gender biasing has also been observed as one of the causes of vessel injury. In several retrospective studies, the female dominance of vessel injury as compared to male (3:2) has been confirmed [1, 4, 5, 16, 24].

At present, the participating physicians in total hip replacement are increasing, and indeed, vessel injury is a credit to those who are engaged in these types of surgeries. The relationship of pelvic vascular structures surrounding the acetabulum has been described in several studies [7, 9, 25]. Currently, substantial work by researchers has been carried out to visualize the

detailed vascular structures surrounding the acetabulum with the use of three-dimensional computed tomographic angiography (3DCT-A) [26–30]. These studies identified the actual distance of vessel structures to the osseous surface of the acetabulum to prevent the injuries

**Figure 2.** Vessel injury. (a) Photograph illustrating inserted acetabular screw close to external iliac artery and vein (arrow) (reprinted with permission from Hwang [25]). (b) Postoperative false aneurysm of superior gluteal artery (circled lines) by protruding cement to fix acetabular component (horizontal arrow) (reprinted with permission from

Vascular Injury in Total Hip Replacement: Management and Prevention

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Earlier, in continuation to prevent these injuries during fixation of acetabular screws, a simple method of acetabular quadrant system was described by Wasielewski et al. and accepted widely till date [9]. Various anatomical studies have shown the fixation of screws in cementless primary total hip replacement, particularly in revision surgeries being most prominent

Wasielewski et al. defined the acetabular-quadrant system for managing safe placement of screws during primary and revision total hip replacement surgeries. The quadrant system is proposed to explain the relationship between the osseous structure of acetabulum and sur-

caused by fixation of screws in cementless total hip replacement.

rounding vascular structures to prevent the vascular structures.

**2. Prevention of vascular injuries**

**2.1. Obey quadrant system**

Bakker and Gast [10]).

reason for vascular injuries.

**Figure 1.** Three-dimensional construction of pelvis and vessel structures using computed tomographic images.

**Figure 2.** Vessel injury. (a) Photograph illustrating inserted acetabular screw close to external iliac artery and vein (arrow) (reprinted with permission from Hwang [25]). (b) Postoperative false aneurysm of superior gluteal artery (circled lines) by protruding cement to fix acetabular component (horizontal arrow) (reprinted with permission from Bakker and Gast [10]).

detailed vascular structures surrounding the acetabulum with the use of three-dimensional computed tomographic angiography (3DCT-A) [26–30]. These studies identified the actual distance of vessel structures to the osseous surface of the acetabulum to prevent the injuries caused by fixation of screws in cementless total hip replacement.
