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Post-op “cold foot”.

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Presentation on theme: "Post-op “cold foot”."— Presentation transcript:

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


5 20: common femoral artery
35: ischial spine 36: femoral head 37: greater trochanter

6 21: superficial femoral artery
22: deep femoral artery

7 21: superficial femoral artery
22: deep femoral artery

8 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

9 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)

10 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

11 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

12 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

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

14 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

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

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

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