Nachbur B, Meyer R P, Verkkala K, Zürcher R
Clin Orthop Relat Res. 1979 Jun(141):122-33.
Vascular accidents occurring in the course of hip surgery may reach potentially catastrophic dimensions by posing an immediate and sudden threat to life and limb. This is a report of 15 cases with severe arterial injury representing 0.2--0.3% of all reconstructive hip operations performed during an 8 year period. In 6 cases perforation of either the external iliac artery, the common femoral artery of main branches of the lateral and medial circumflex femoral artery were caused by the tip of a narrow-pointed Hohmann retractor used to expose the hip joint. Other mechanisms were: intimal tear with appositional thrombosis, probably caused by mechanical strain imposed on atherosclerotic arteries, giving rise to complete limb ischemia (2 cases); the dangers associated with the entry of bone cement through a defective acetabulum into the pelvis causing thrombotic occlusion due to polymerization heat (one case) or intimate adhesion of artificial bone to the external iliac artery subsequently being ripped open during replacement of the cup (one case); the increased hazards of replacing firmly embedded hip prosthesis (3 cases of direct arterial injury with chisel, knife and cutting edge of protruding bone); and the complications associated with the development of a false aneurysm (2 cases). Fourteen of the 15 extremities were salvaged. Above-knee amputation was unavoidable in one case owing to delay of vascular repair. There was no immediate operative mortality. Knowledge of the causative mechanisms prevents arterial injury during hip surgery. The relatively low rate of vascular complications in spite of vicinity of main vessels gives credit to the well standardized technique of hip surgery, especially hip replacement. However, it is suggested that the surgeon should be sufficiently acquainted with the exposure of the main vessels above and below the groin to be able to control life threatening hemorrhage at all times. A McBurney incision with retroperitoneal exposure and clamping of the external iliac artery will suffice to diminish bleeding considerably. Thereupon careful dissection and placement of snares around the common femoral artery, the arteria profunda femoris, and whenever necessary, the lateral or medial circumflex femoral artery will enable closure of the lacerated artery. For hemorrhage resulting during replacement of firmly embedded hip prosthesis it might become necessary to ligate the internal iliac artery. Reconstruction of obliterated arteries should call for the cooperation of the vascular surgeon for eventual angioplasty. Angiologic examination of the lower extremities is mandatory whenever severe arterial trauma has occurred in the course of hip surgery and is best performed by measuring the ankle blood pressure with a Doppler ultrasound probe.
髋关节手术过程中发生的血管意外可能会对生命和肢体构成直接且突然的威胁，从而达到潜在的灾难性程度。本文报告了15例严重动脉损伤病例，占8年期间所有髋关节重建手术的0.2%至0.3%。在6例病例中，用于暴露髋关节的窄头霍曼牵开器尖端导致髂外动脉、股总动脉或股外侧和内侧旋股动脉主要分支穿孔。其他机制包括：内膜撕裂伴附壁血栓形成，可能是由于对动脉粥样硬化动脉施加机械应力所致，导致肢体完全缺血（2例）；骨水泥通过有缺陷的髋臼进入骨盆，因聚合热导致血栓闭塞（1例），或人工骨与髂外动脉紧密粘连，随后在髋臼杯置换过程中被撕开（1例）；更换牢固嵌入的髋关节假体时风险增加（3例因凿子、刀和突出骨边缘直接损伤动脉）；以及与假性动脉瘤形成相关的并发症（2例）。15例肢体中有14例得以挽救。由于血管修复延迟，1例不可避免地进行了膝上截肢。无即刻手术死亡。了解病因机制可预防髋关节手术期间的动脉损伤。尽管主要血管位置临近，但血管并发症发生率相对较低，这归功于标准化程度较高的髋关节手术技术，尤其是髋关节置换术。然而，建议外科医生应充分熟悉腹股沟上下主要血管的暴露方法，以便能够随时控制危及生命的出血。采用麦克伯尼切口进行腹膜后暴露并钳夹髂外动脉足以显著减少出血。随后仔细解剖并在股总动脉、股深动脉以及必要时在股外侧或内侧旋股动脉周围放置圈套器，将能够闭合撕裂的动脉。对于更换牢固嵌入的髋关节假体时出现的出血，可能有必要结扎髂内动脉。对于闭塞动脉的重建，最终可能需要血管外科医生合作进行血管成形术。每当髋关节手术过程中发生严重动脉创伤时，对下肢进行血管造影检查是必要的，最好使用多普勒超声探头测量踝部血压来进行。
