**3. Management**

#### **3.1. Preoperative management**

#### *3.1.1. Preoperative clinical investigation*

The preoperative clinical examination of vessels must be carefully performed. Knowledge and local anatomy of vessel status surrounding the pelvis before surgery is essential and if necessary, surgeons must use the easier method like Doppler scan to measure the arterial occlusion pressure. Few arteries like femoral artery defects are easily identified in these examinations, while artery defects for the arteries like obturator and superior gluteal artery are often difficult to diagnose in early preoperative period.

#### *3.1.2. Preventive measures*

In case of revision total hip surgeries and traumatized hip, an appropriate vascular surgeon must be intimated prior to performing total hip replacement surgeries.

#### **3.2. Intraoperative management**

A high index of disbelief and careful intraoperative inspection are fundamental to immediate diagnosis and treatment of most intraoperative vessel injuries, both in primary and revision total hip surgeries. Sudden vascular injury at the time of surgery may be caused my many means for example instrumentation, broken bone edges, implants etc. Prompt recognition of vessel injury is important. In these injuries, the essential step is of course bleeding control. Surgeon must not underestimate the urgency of vessel injury even in slight signs of bleeding. There are many steps that must be followed in such types of situation, which are listed below


**2.4. Acetabular reinforcement ring and antiprotrusio cage**

intrapelvic cement is unwisely extracted.

**2.5. Cement**

152 Total Hip Replacement - An Overview

**3. Management**

**3.1. Preoperative management**

*3.1.2. Preventive measures*

**3.2. Intraoperative management**

*3.1.1. Preoperative clinical investigation*

are often difficult to diagnose in early preoperative period.

must be intimated prior to performing total hip replacement surgeries.

Acetabular reinforcement ring and antiprotrusio cages are generally used in traumatic hips and revision surgeries [35]. These prosthesis enable to fix the screws to actualize the preexisting anatomical conditions of acetabulum. Avoiding the risk of vascular injuries, screw positioning in ventral and dorsal type of prosthesis is generally avoided. However, in such critical anatomical situations, radiological interventions must be required during surgery.

During cemented total hip replacement surgeries, cement must be allowed to reach lesser pelvis. Postoperative vascular complications occur due to cement extrusion in defect of acetabular wall can put external iliac vessels at risk. Excessive use of cement (methyl-methacrylate) can cause exothermic reaction, resulting in vessel thrombosis. Cement spiculae can erode through the artery and result in perforation and pseudoaneurysm formation in postoperative duration. The vessels are susceptible to avulsion if a revision surgery becomes necessary and

The preoperative clinical examination of vessels must be carefully performed. Knowledge and local anatomy of vessel status surrounding the pelvis before surgery is essential and if necessary, surgeons must use the easier method like Doppler scan to measure the arterial occlusion pressure. Few arteries like femoral artery defects are easily identified in these examinations, while artery defects for the arteries like obturator and superior gluteal artery

In case of revision total hip surgeries and traumatized hip, an appropriate vascular surgeon

A high index of disbelief and careful intraoperative inspection are fundamental to immediate diagnosis and treatment of most intraoperative vessel injuries, both in primary and revision total hip surgeries. Sudden vascular injury at the time of surgery may be caused my many means for example instrumentation, broken bone edges, implants etc. Prompt recognition of vessel injury is important. In these injuries, the essential step is of course bleeding control.


**Figure 7.** Photograph showing postoperative vessel injury. (A) Arterial injury between the distal external iliac artery and the femoral artery to the origin of deep femoral artery. (B) Arterial bypass (reprinted with permission from Barbier et al. [36]).

#### **3.3. Postoperative management**

Postoperative insult of vessel injury by surgeons, which is the slightly lesser common cause of unexplained pathological complications, might even result in death. Immediate after surgery to few days of recovery, careful monitoring of vessel status is essential to avoid postoperative vessel complications. After surgery and in the late postoperative period there are many sign and symptoms, the surgeons, and even individual must not circumvent, of course, it may be the sign of late vascular injury. Unexplained hypotension, tachycardia, nerve palsy, hypovolemic shock and decreased hemoglobin and blood pressure are the signs of vascular injury, postoperatively. In postoperative cases with the above signs and symptoms, immediate axial imaging or radiography, contrast-angiography, color ultrasonography are the more natural way to diagnose the bleeding source. Monitoring of these signs wisely is better and can be treated with open repair, stenting, bypass, coiling, or chemoembolization without any delay (**Figure 7**) [37–39]. The late symptoms from false aneurysm formation might be in the broad range of spectrum and very confusing and can be treated by surgical intervention, once the vascular injury is determined by diagnosis [13, 19].

**Author details**

India

Varanasi, India

**References**

Nishant Kumar Singh1

, Sanjay Rai2

963-974. DOI: 10.2106/00004623-200405000-00012

DOI: 10.1097/00003086-197906000-00014

641-644. DOI: 10.1007/s10016-003-0074-2

DOI: 10.2106/00004623-199072040-00006

DOI: 10.1067/mva.1990.18087

2000.4807

\*Address all correspondence to: skrai.bme@iitbhu.ac.in

Banaras Hindu University, Varanasi, India

\* and Amit Rastogi3

Vascular Injury in Total Hip Replacement: Management and Prevention

http://dx.doi.org/10.5772/intechopen.77256

155

1 Department of Biomedical Engineering, National Institute of Technology, Raipur,

2 Biomechanics Lab, School of Biomedical Engineering, Indian Institute of Technology,

3 Department of Orthopedics, Institute of Medical Sciences, Banaras Hindu University,

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Total hip replacement surgery is largely performed in aged patients and possibility of arteriosclerosis vessel must be taken into account, as these vessels are more vulnerable to injury [29].
