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Placement of a posterior retractor along the posterior wall
2%
77/4851
Placement of an acetabular screw in the posterior-superior quadrant
105/4851
Placement of an inferior retractor under the transverse acetabular ligament
74%
3572/4851
Placement of an acetabular screw in the anterior-superior quadrant
13%
651/4851
Placement of an anterior retractor along the anterior wall
8%
412/4851
Select Answer to see Preferred Response
Damage to the obturator artery most commonly occurs from placement of an inferior retractor inferior to the transverse acetabular ligament (into the obtrator foramen), and/or placement of an acetabular screw in the anterior-inferior quadrant. Vascular injury during total hip arthroplasty is a rare but devastating complication with a reported incidence of 0.1%-0.2%. The obturator artery travels along the quadrilateral surface of the acetabulum and exits the pelvis at the superolateral corner of the obturator foramen. If the vessel is severely damaged and bleeding cannot be controlled, ligation of the internal iliac artery has been reported. Nachbur et al. report on 15 cases of severe arterial injury during hip reconstructive surgery over a period of 8 years. The most common injury was injury to the external iliac artery, the common femoral artery, or main branches of the lateral and medial circumflex femoral artery. These were thought to be caused by the tip of a narrow-pointed Hohmann retractor used for exposure of the hip joint. Rue et al. review neurovascular injuries during total hip arthroplasty. Among other things, they recommend against placement of screws in the anterior-superior quadrant, prudent retractor placement, and avoiding excessive tension on the sciatic nerve. Della Valle and Di Cesare review complications resulting from total hip replacement. They state that injury to the obturator artery can occur with acetabular screw fixation in the antero-inferior quadrant or from retractors placed underneath the transverse acetabular ligament. Illustration A shows the obturator artery as it exits the pelvis at the superolateral corner of the obturator foramen. Illustration B reviews acetabular screw placement and the structures at risk in each quadrant. Incorrect Answers: Answer 1: This retractor places the sciatic nerve at risk. Answer 2: This screw places the sciatic nerve and superior gluteal artery at risk. Although injury to these structures is possible, this zone is considered "safe." Answer 4: This screw places the external iliac artery and vein at risk, and is considered the "danger" zone. Answer 5: Anterior retractor placement with sharp retractors place the external iliac and femoral arteries at risk.
4.9
(8)
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