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Post-op “cold foot”

Post-op “cold foot”. Acute Arterial Injury. Major vessel injuries occur in approximately 1% of patients with pelvic fractures Mortality rate as high as 75-83% Iatrogenic arterial injury as a complication of hip fracture surgery occurs in approximately 0.21%. Review of Anatomy…..

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Post-op “cold foot”

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  1. Post-op “cold foot”

  2. Acute Arterial Injury • Major vessel injuries occur in approximately 1% of patients with pelvic fractures • Mortality rate as high as 75-83% • Iatrogenic arterial injury as a complication of hip fracture surgery occurs in approximately 0.21%

  3. Review of Anatomy….. • In hip surgery, the common femoral artery and deep femoral artery or its branches are the mostly injured arteries

  4. 20: common femoral artery • 35: ischial spine • 36: femoral head • 37: greater trochanter

  5. 21: superficial femoral artery • 22: deep femoral artery

  6. 21: superficial femoral artery • 22: deep femoral artery

  7. Causes of acute arterial occlusion(in general cases) • Aortic dissection or trauma that occlude the artery by disrupting the integrity of the vessel • Systemic Emboli: • Cardiac emboli: mural thrombus in LV secondary to old or recent MI or dilated hypocontractile ventricle; valvular heart dz (rheumatic MV dz), prosthetic heart valve, infective endocarditis, left atrial myxoma, ATRIAL FIBRILLATION!!! • Atheroemboli originating from atheromatous lesions in the abdominal aorta or iliac or femoral artery

  8. Causes of acute arterial occlusion in lower extremity surgery • Nature of injury: avulsion injury to the vessels • Preexisting artherosclerotic disease: h/o lower extremity arterial insufficiency: patients with ankle/brachial index less than 0.4 or 0.3 have a higher rate of occlusion. However, it is not recommended a pre-op arterial bypass be preformed (due to use of tourniquet, positioning)

  9. Causes of acute arterial occlusion in lower extremity surgery • Use of tourniquet: the mechanical pressure of a pneumatic tourniquet can cause fracture and dislodgement of a plaque. • Use of cement: thrombotic occlusion caused by the heat of polymerization of bone-cement

  10. Causes of acute arterial occlusion in lower extremity surgery • Positioning of patient: Kinking or twisting of the vessels; more likely in patient with a previous bypass graft causing a thrombogenic response with extreme torsion • Prolonged extrensic occlusion with surgical equipment: use of clamps to achieve desired reduction • Vascular injury with screws/drills: Placement of screws or inappropriate size of screws can cause adjacent vascular injury

  11. Physical Findings • Abrubt drop in BP and H/H • LOSS OF PALPABLE PULSES!! • Anywhere from feeling of cool sensation of skin to intense pain • Decrease or loss of motor strength • Loss of sensation • Skin color changes • +/- mass

  12. Diagnosis • Arteriography • Doppler • Pulse Ox on extremity • IF epidural/block performed: postop arterial monitoring such as doppler of LE or angiography in high risk

  13. Treatment • Surgical thrombectomy • Bypass, especially in patients with underlying atherosclerotic disease • Anticoagulation if possible • Intra-arterial thrombolysis (urokinase or recombinant tissue plasminogen activator) • Amputation • Fascitomy

  14. Bottom Line: • Have high index of suspicion • Post-op palpation of pulses and/or pulse oximeter • Don’t delay diagnostic test/treatment

  15. References • Calligaro, et al. Acute arterial thrombosis associated with total knee arthroplasty. Journal of vascular surgery 1994 Dec 20(6); 927-932. • Frank, et al. Traumatic iliofemoral arterial injury: An association with high anterior acetabular fractures. Journal of vascular surgery. 1989 August 10(2);198-201. • Johnson, et al. Extrensic femoral artery occlusion following internal fixation of an acetabular fracture. Clinical orthopeadics and related research. 1987 April 217; 209-213. • Parfenchuck, et al. Intraoperative arterial occlusion in total joint arthroplasty. Journal of arthroplasty. 1994 9(2); 217-220. • Probe et al. Femoral artery thrombosis after open reduction of an acetabular fracture. Clinical orthopaedics and related research. 1992 Oct 283;258-260. • Storm, et al. Iatrogenic arterial trauma associated with hip fracture treatment. Journal of trauma. 2000 May 28(5); 957-959. • Stubbs, et al. Thrombosis of the iliofemoral artery during revision of a total hip replacement. Journal of bone and joint surgery. 1986 March 68-A(3); 454-455.

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