Superior gluteal artery haemorrhage following pelvic features controlled by embolisation

Lateral femoral circumflex artery contribution to the articular and periarticular hip circulation: relevance to the anterior hip approach-a cadaveric study

BACKGROUND

The purpose of this cadaveric study was to anatomically demonstrate the contribution of the lateral femoral circumflex artery (LFCA) to the articular and peri-articular hip circulation with an emphasis on the vascularization of hip abductors specially tensor fasciae latae muscle (TFLM).

METHODS AND MATERIALS

Thirty hips from 26 fresh cadavers were dissected after injection of the aorta or common iliac artery by colored silicon, to study the contribution of the LFCA to the articular and periarticular hip circulation. Furthermore, the aorta was injected in another 18 fresh cadavers after unilaterally ligating the ascending branch of the LFCA (a-LFCA) as the vascular pedicle of the TFLM, to evaluate the collateral circulation to the TFLM, if available.

RESULTS

In all specimens but one, the a-LFCA was found as the single major vascular pedicle of the TFLM. When ligated, only 4 out of 18 hips demonstrated colored cast vessels in the cut surface of the muscle. The ascending branch had also consistent but variable contribution to the gluteus medius and gluteus minimus muscles in 80% of the hips. Furthermore, the a-LFCA consistently supplied the anterior and anterolateral aspects of the hip capsule. In 35% of hips, the a-LFCA contributed to the femoral head and neck circulation via one or two small anterior retinacular arteries.

CONCLUSION

LFCA contribution to the articular and periarticular hip circulation is only delivered by the ascending branch. The TFLM is specially perfused by the a-LFCA; its ligation significantly decreases the muscle perfusion. It is poorly supplied by the collateral circulation.

Superior gluteal artery injury presenting as delayed onset shock

Injury to the superior gluteal artery (SGA) is usually associated with acetabular fractures or posterior pelvic ring injuries. The diagnosis is suspected in cases of initial hemodynamic instability which is refractory to resuscitation. The initial presentation is often dramatic and is caused by direct injury to the artery at the time of traumatic impact. In these cases, patient management at most trauma centers follows a pre-arranged algorithm which decreases the likelihood of a missed diagnosis. Delayed arterial bleeding, however, is rare and potentially catastrophic since most algorithms are not designed to detect these infrequent occurrences. We present two such cases due to initial blunt buttock trauma combined with an anterior pelvic ring fracture and a L2 spine fracture which resulted in delayed massive bleeding from the SGA. Delayed arterial bleeding should be considered in late onset shock associated with pelvic or lumbar vertebrae body fractures or direct buttock injury. If active bleeding is suspected, urgent arteriography with embolization is the treatment of choice.

Urinary catheter tamponade to control intra-operative bleeding from the superior gluteal artery

Bleeding is a major complication of revision total hip replacement. We report a case where the inflated balloon of a urinary catheter was used to temporarily control intrapelvic bleeding from the superior gluteal artery, while definitive measures for endovascular embolisation were made.

Pseudoaneurysm of the deep circumflex iliac artery: a rare complication at an anterior iliac bone graft donor site

STUDY DESIGN

The formation of a pseudoaneurysm of the deep circumflex iliac artery after the harvesting of an anterior iliac bone graft for spinal fusion is reported.

OBJECTIVE

To describe a rare complication at an iliac bone graft donor site.

SUMMARY OF BACKGROUND DATA

The iliac bone is a common site for harvesting bone for spinal surgery. Although many complications have been reported, vascular injuries associated with this procedure are rare. To the authors' knowledge, deep circumflex iliac artery injury has not been reported as a complication.

METHODS

A 70-year-old man with cervical myelopathy underwent anterior cervical decompression and fusion with an anterior iliac bone graft. Fracture displacement of the anterior superior iliac spine at the donor site was noted 1 week after a second operation, which was performed to reduce the displaced grafted bone. Five months after the second operation, he reported pain and swelling at the donor site. Removal of a hematoma was attempted, which led to massive bleeding that was difficult to control.

RESULTS

Angiography demonstrated a pseudoaneurysm of the deep circumflex iliac artery. Selective embolization of the artery was performed, and the bleeding was arrested.

CONCLUSIONS

Vascular injury after anterior iliac bone harvesting is rare but can occur. Selective arterial embolization was an effective solution.

Superior gluteal artery in the extended iliofemoral approach

OBJECTIVE

To determine the incidence of superior gluteal artery injury following fracture of the acetabulum and to determine whether the combination of a superior gluteal artery injury and the use of an extended iliofemoral approach to the acetabulum creates abductor muscle necrosis.

DESIGN

Prospective protocol, consecutive cases.

SETTING

A consecutive series from the referral practice of the senior author plus seven cases from the practices of two other authors.

PATIENTS

Two hundred twenty-seven patients with fractures of the acetabulum were treated operatively between November 1992 and January 1995. Forty-one were treated with the use of the extended iliofemoral approach. Preoperative angiograms were not performed for any of the patients. All fractures involved the posterior column, and all but two fractures had displacement of the greater sciatic notch. The average displacement of the notch was 2.5 centimeters (range 6 to 60 millimeters).

INTERVENTION

All patients were treated with open reduction and internal fixation via the extended iliofemoral approach. Intraoperative Doppler examination of the superior gluteal artery was performed before and after reduction and fixation of the posterior column.

MAIN OUTCOME MEASURE

Wound complications, abductor manual muscle testing, hip range of motion.

RESULTS

Pulsatile flow was confirmed in forty of forty-one patients. All patients were followed for a minimum of six months with an average follow-up of 1.4 years. At most recent follow-up, no patients had evidence of complete loss of abductor function. Sixty-three percent of patients had achieved Grade 4 of 5 motor strength, and 25 percent of them had achieved normal motor strength.

CONCLUSIONS

No instances of superior gluteal artery laceration and only one instance of superior gluteal artery thrombosis were encountered in these forty-one patients despite significant fracture displacement involving the sciatic notch. The incidence of superior gluteal artery injury was significantly less than would be expected from previous studies. Massive abductor necrosis resulting from superior gluteal artery injury combined with an extended approach has been described primarily in animal and cadaver studies. Although arteriograms are useful in the control of hemodynamic instability, we cannot support the recommendation of preoperative angiographic study of all patients undergoing acetabular fracture surgery via an extended approach. In one case, an extended iliofemoral approach was tolerated in a patient with absent superior gluteal artery flow.

Effects of surgical approaches for acetabular fractures with associated gluteal vascular injury

OBJECTIVES

To examine the viability of the abductor muscles following extensile exposures to the acetabulum in the presence of superior gluteal artery (SGA) or vein (SGV) injury.

DESIGN

In vivo animal study.

INTERVENTION

Twenty-two dogs underwent either an extensile or combined two-incision acetabular approach; either the SGA, the SGV, or no vessel was ligated.

MAIN OUTCOME MEASUREMENTS

Blood flow to the affected gluteal region was evaluated by angiography, laser Doppler flowmetry, and fluorescent microspheres, and histologic and wet weight analyses were performed on the abductor muscles.

RESULTS

Complete ischemic necrosis of the abductor muscles did not occur in any specimen; however, there were statistically significant reductions in immediate postoperative gluteal muscle perfusion (-47 percent, p < 0.01), loss of abductor muscle mass (-41 percent, p < 0.001), and histologic evidence of moderate to severe necrosis in five of seven specimens with extensile exposures and SGA ligation (p = 0.01). Extensile exposure and SGV ligation also caused a significant loss of muscle mass (-25 percent, p < 0.02), with moderate to severe necrosis occurring in four of seven specimens (p < 0.04). Dogs with SGA ligation undergoing the two-incision approach had no significant changes in muscle mass (-3 percent) or perfusion. Moderate to severe necrosis occurred in only one of four specimens.

CONCLUSIONS

This study fails to support the hypothesis that extensile approaches to complex acetabular fractures eliminate abductor collateral circulation when performed in the presence of SGA injury.

The unstable iliac fracture: a biomechanical evaluation of internal fixation

Neither plating nor lag screw fixation of a displaced iliac wing fracture as part of an unstable pelvic ring disruption has been studied biomechanically. The purpose of this study was to compare the stability of various combinations of fixation, specifically contrasting lag screws placed between the tables of the ilium with plating in different locations across the fracture line. Various combinations of these fixation implants were evaluated for an unstable iliac fracture. A longitudinal iliac fracture was created in each of six hemi-pelvic specimens prior to testing. Compressive force, up to 500 N or to the magnitude necessary to displace the fracture 2 mm, was applied to the fracture line through the hemi-pelvis for each of the plate and lag screw combinations tested. There was no statistical difference between any of the implants or combinations tested. A single 3.5-mm reconstruction (cephalad) plate placed along the cephalad internal aspect of the iliac crest provided the least stability allowing 2 mm of displacement with a mean load of 80 N. The two combinations of fixation that required the greatest loads for 2 mm of displacement were a single 3.5-mm lag (cephalad) screw inserted into the iliac crest between the tables of the ilium coupled with either a 3.5-mm reconstruction (brim) plate placed along the internal aspect of the inferior iliac fossa at the pelvic brim (239 N) or a 4.5-mm lag (brim) screw between the inner and outer tables at the inferior aspect of the fracture just above the greater sciatic notch (225 N).

Superior gluteal artery injury during iliac bone grafting for spinal fusion. A case report and literature review

STUDY DESIGN

This article reports a complication encountered when harvesting bone graft from the posterior iliac crest during a contemplated spinal fusion.

OBJECTIVES

Posterior iliac crest bone grafting is commonly performed with posterior spinal instrumentation and fusion.

SUMMARY OF BACKGROUND DATA

Review of the literature reveals a few case reports of damage through the superior gluteal artery during harvesting of bone grafts; this complication is managed with direct vessel ligation.

METHODS

This article reviews the pertinent anatomy of posterior iliac crest bone grafting and addresses areas of caution important in preventing this complication.

RESULTS

The case report offers alternative management, that is, selective arterial embolization for hemodynamic control of the massive life-threatening bleeding that can occur with superior gluteal artery lacerations.

CONCLUSIONS

Injury to the superior gluteal artery is a common complication in pelvic trauma. In this patient, therapeutic arterial embolization proved to be a useful tool in controlling hemorrhage, which prevents additional bleeding problems. Superior gluteal artery injury after elective bone graft surgery is a relatively uncommon, serious, but avoidable complication. In this patient, the use of radiographically controlled arterial embolization of the lacerated vessel proved to be a quick and effective solution to this potentially life-threatening complication.

The superior gluteal artery in complex acetabular procedures. A cadaveric angiographic study

A study of fresh cadavera was performed to assess the collateral circulation to the abductor muscle flap created by the various pelvic exposures in the presence of an occlusive injury to the ipsilateral superior gluteal artery. Through a bilateral extended iliofemoral, extended triradiate, modified extensile, or combined ilioinguinal and posterior approach, the right superior gluteal artery was occluded and an arteriogram was made. After use of the extended iliofemoral, the extended triradiate, and the modified extensile approaches, no angiographic evidence of circulation to the abductor muscles was demonstrated on the side of the occluded superior gluteal artery. There was circulation to the abductor muscles, despite occlusion of the superior gluteal artery, in cadavera in which the combined ilioinguinal and posterior approach had been used. After completion of the extended iliofemoral, extended triradiate, and modified extensile exposures, a Microfil injection study was performed on the cadavera to assess the presence of microcirculation. No evidence of Microfil circulation was observed in the abductor muscles macrosurgically or microsurgically. Preoperative assessment of the superior gluteal artery is recommended for a patient who is a candidate for an extensile exposure for an acetabular procedure. If the superior gluteal artery is occluded, a combined ilioinguinal and posterior operative approach should be considered.