Objective: To our knowledge, ours is the largest single-center experience with diagnosis and management of acute arterial hemorrhagic and limb-threatening ischemic complications associated with total hip arthroplasty (THA) and total knee arthroplasty (TKA).
Methods: Between 1989 and 2002, 23,199 TKA procedures (13,618 total, 11,953 primary, 1665 revision) and THR procedures (9581 total, 7812 primary, 1769 revision) were performed at the orthopedic service of Pennsylvania Hospital, Philadelphia. Arterial injuries were grouped according to type (ischemia, bleeding, pseudoaneurysm, ischemia plus bleeding) and time of recognition of injury (0-5 days after orthoplasty).
Results: Acute arterial complications developed in 32 patients (0.13%), associated with 24 TKA procedures (0.17%) and 8 THA procedures (0.08%; P =.0609). There were no deaths, and limb salvage was achieved in all patients. Arterial injury was detected by the orthopedic service on the same day (SD group) as performance of joint replacement in 18 patients (56%), but was not recognized until the first to fifth postoperative day (PO group) in 14 patients (44%). Arterial complications included acute lower-limb ischemia only in 18 patients SD group, 9; PO group, 9), bleeding only in 4 patients (SD group), arterial transection resulting in both ischemia and bleeding in 5 patients (SD group), and arterial pseudoaneurysm in 5 patients (PO group). Of the 18 patients with acute ischemia only, preoperative arteriography was performed in 12 patients (67%), and 6 patients (33%) were brought directly to the operating room because of advanced ischemia. Revascularization procedures in these 18 patients included bypass to the infrapopliteal artery (n = 7), popliteal artery (n = 5), or common femoral artery (n = 1); in only 5 patients (28%) was thrombectomy alone successful. These 18 patients tended to require fasciotomy (4 of 9 vs 2 of 9; P =.6199) and have foot drop (3 of 9 vs 1 of 9; P =.5765) more frequently when ischemia was recognized after the day of surgery. Bleeding was managed with arteriorrhaphy. Arterial transection was treated with end-to-end anastomosis (n = 3), interposition grafting (n = 1), and below-knee popliteal bypass (n = 1). Popliteal artery pseudoaneurysm was treated with percutaneous methods (n = 3) or surgery (n = 2).
Conclusion: In this series, risk for arterial injury associated with THA and TKA was remarkably low. Nonetheless, even at a high-volume orthopedic hospital, acute arterial injury was not recognized on the day of surgery in about half of patients. Judicious use of preoperative arteriography and aggressive revascularization are critical to achieving limb salvage. Simple arterial thrombectomy to treat ischemic complications of THA and TKA is rarely sufficient.