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Life threatening external iliac artery injury following total hip replacement

New Delhi, India

To the Editor:

Consequences of serious vascular injuries during total hip replacement (THR) have received little attention in the anesthesia literature as these rarely present in the immediate postoperative period.¹ We report the anesthetic and intensive care management implications of an undiagnosed external iliac artery injury following THR. A 36-yr-old male weighing 56 kg underwent THR under general anesthesia for osteonecrosis of the right femoral head. After an uneventful induction and maintenance of anesthesia, he developed manifestations of hypotension towards the end of surgery which persisted in the immediate postoperative period. The hemoglobin concentration fell from 11 g•dL^-1 to 7 g•dL^-1 along with a fall in central venous pressure and urine output in the immediate postoperative period. Colloids and blood products were administered to improve volume status but hypotension persisted and vasopressor infusions were started. The patient remained hemodynamically unstable, developed metabolic acidosis and required intubation and ventilation six hours after surgery. Increasing distension in the right lower quadrant of the abdomen was noticed. A diagnosis of retroperitoneal bleeding was made and an emergency laparotomy performed. Operative findings included a large retroperitoneal hematoma extending up to the diaphragm. The screw used for THR had perforated the right external iliac artery. Evacuation of the hematoma and end-to-end anastomosis of the artery were preformed under general anesthesia. The patient was extubated 24 hr after the laparotomy and had an uneventful postoperative course.

External iliac and femoral vessels lie in close proximity to the hip joint and hence are prone to injury during the operation.² A high index of suspicion and aggressive hemodynamic management involving fluid therapy, inotropes, invasive perioperative monitoring, vasopressors and early surgery will help prevent morbidity and mortality.

References

1 Nachbur B, Meyer RP, Verkkala K, Zurcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop 1979; 141: 122–33.

2 Salama R, Stavorovsky MM, Iellin A, Weissman SL. Femoral artery injury complicating total hip replacement. Clin Orthop 1972; 89: 143–4.[Medline]

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