Orthopedics

Case Reports 

Lower Extremity Bypass Graft Occlusion After Intramedullary Fixation of Intertrochanteric Hip Fracture on a Fracture Table

Roger E. Wiltfong, MD; Benjamin C. Taylor, MD; Robert N. Steensen, MD

Abstract

This article presents a case of a 90-year-old woman who previously underwent a common femoral to anterior tibial artery bypass grafting with a Gore-Tex graft (Gore Medical, Flagstaff, Arizona). She subsequently sustained an ipsilateral intertrochanteric hip fracture after a mechanical fall and underwent internal fixation with an intramedullary nail using a fracture table. In the immediate postoperative period, she developed limb-threatening ischemia in her leg due to graft thrombosis. The patient underwent a successful thrombectomy and embolectomy. However, she subsequently developed nonhealing ulcers to this extremity over the course of weeks, requiring surgical debridement. Gangrene ensued and she underwent a below-the-knee amputation.

Complications from the use of fracture tables have been described for perineal soft tissue injury, leg malrotation or malalignment, neurologic injury, and iatrogenic compartment syndrome of the healthy leg. Arterial complications after intramedullary fixation of femur fractures are rare and may be caused by direct arterial trauma during placement of the locking screws through the intramedullary nail. This article is the first, to our knowledge, to describe an occlusion of a lower extremity bypass graft after intramedullary fixation on a fracture table. Surgeons should be aware of potential limb threatening ischemia in patients with peripheral vascular disease, especially in those with prior lower extremity bypass grafts. Proper preoperative counseling should be given to these patients when using fracture tables during hip fracture surgery.

Complications from the use of fracture tables have been described for perineal soft tissue injury, leg malrotation or malalignment, neurologic injury, and iatrogenic compartment syndrome of the healthy leg. Arterial complications after intramedullary fixation of femur fractures are rare and may be caused by direct arterial trauma during placement of the locking screws through the intramedullary nail. This article is the first, to our knowledge, to describe an occlusion of a lower extremity bypass graft after intramedullary fixation on a fracture table. Surgeons should be aware of potential limb-threatening ischemia in patients with peripheral vascular disease, especially in those with prior lower extremity bypass grafts. Proper preoperative counseling should be given to these patients when using fracture tables during hip fracture surgery.

This article presents a case of a 90-year-old woman who had undergone a common femoral to anterior tibial artery bypass grafting. She subsequently sustained an ipsilateral intertrochanteric hip fracture after a mechanical fall and underwent internal fixation with an intramedullary nail using a fracture table.

A 90-year-old woman presented with a closed left intertrochanteric hip fracture after a nonsyncopal mechanical fall from standing height. She had previously undergone a common femoral to anterior tibial artery bypass grafting with a Gore-Tex graft (Gore Medical, Flagstaff, Arizona) for significant peripheral vascular disease 4 years prior, with no negative sequelae or complications. On presentation, she had no evidence of vascular insufficiency to this extremity. Radiographs demonstrated a left intertrochanteric hip fracture (Figure 1).

The patient subsequently underwent uncomplicated fixation of the fracture with an antegrade intramedullary nail using a fracture table (Figure 2). The patient was placed onto the table in a well-padded manner; due to the patient’s limited muscle mass, significant traction on the extremity was not needed to obtain or maintain fracture reduction.

Postoperatively, the patient was restarted on warfarin, which was withheld 1 day prior. It was then discovered that her left foot was cool and pulseless; she was diagnosed with left limb-threatening ischemia. She underwent a left femoral graft thrombectomy and left anterior tibial artery embolectomy. The on-table arteriogram confirmed that the graft was patent with intact anastomoses (Figure 3). Her postoperative course was prolonged and she was discharged to an external care facility on postoperative day 7 from her original hip…

Abstract

This article presents a case of a 90-year-old woman who previously underwent a common femoral to anterior tibial artery bypass grafting with a Gore-Tex graft (Gore Medical, Flagstaff, Arizona). She subsequently sustained an ipsilateral intertrochanteric hip fracture after a mechanical fall and underwent internal fixation with an intramedullary nail using a fracture table. In the immediate postoperative period, she developed limb-threatening ischemia in her leg due to graft thrombosis. The patient underwent a successful thrombectomy and embolectomy. However, she subsequently developed nonhealing ulcers to this extremity over the course of weeks, requiring surgical debridement. Gangrene ensued and she underwent a below-the-knee amputation.

Complications from the use of fracture tables have been described for perineal soft tissue injury, leg malrotation or malalignment, neurologic injury, and iatrogenic compartment syndrome of the healthy leg. Arterial complications after intramedullary fixation of femur fractures are rare and may be caused by direct arterial trauma during placement of the locking screws through the intramedullary nail. This article is the first, to our knowledge, to describe an occlusion of a lower extremity bypass graft after intramedullary fixation on a fracture table. Surgeons should be aware of potential limb threatening ischemia in patients with peripheral vascular disease, especially in those with prior lower extremity bypass grafts. Proper preoperative counseling should be given to these patients when using fracture tables during hip fracture surgery.

Complications from the use of fracture tables have been described for perineal soft tissue injury, leg malrotation or malalignment, neurologic injury, and iatrogenic compartment syndrome of the healthy leg. Arterial complications after intramedullary fixation of femur fractures are rare and may be caused by direct arterial trauma during placement of the locking screws through the intramedullary nail. This article is the first, to our knowledge, to describe an occlusion of a lower extremity bypass graft after intramedullary fixation on a fracture table. Surgeons should be aware of potential limb-threatening ischemia in patients with peripheral vascular disease, especially in those with prior lower extremity bypass grafts. Proper preoperative counseling should be given to these patients when using fracture tables during hip fracture surgery.

This article presents a case of a 90-year-old woman who had undergone a common femoral to anterior tibial artery bypass grafting. She subsequently sustained an ipsilateral intertrochanteric hip fracture after a mechanical fall and underwent internal fixation with an intramedullary nail using a fracture table.

Case Report

A 90-year-old woman presented with a closed left intertrochanteric hip fracture after a nonsyncopal mechanical fall from standing height. She had previously undergone a common femoral to anterior tibial artery bypass grafting with a Gore-Tex graft (Gore Medical, Flagstaff, Arizona) for significant peripheral vascular disease 4 years prior, with no negative sequelae or complications. On presentation, she had no evidence of vascular insufficiency to this extremity. Radiographs demonstrated a left intertrochanteric hip fracture (Figure 1).

Figure 1
Figure 1: Preoperative radiograph of the left hip showing a standard obliquity intertrochanteric hip fracture.

The patient subsequently underwent uncomplicated fixation of the fracture with an antegrade intramedullary nail using a fracture table (Figure 2). The patient was placed onto the table in a well-padded manner; due to the patient’s limited muscle mass, significant traction on the extremity was not needed to obtain or maintain fracture reduction.

Figure 2A Figure 2B
Figure 2: Postoperative AP radiograph of the left hip showing the intramedullary hip screw in place (A). Postoperative lateral radiograph of the left hip showing the intramedullary hip screw in place (B).

Postoperatively, the patient was restarted on warfarin, which was withheld 1 day prior. It was then discovered that her left foot was cool and pulseless; she was diagnosed with left limb-threatening ischemia. She underwent a left femoral graft thrombectomy and left anterior tibial artery embolectomy. The on-table arteriogram confirmed that the graft was patent with intact anastomoses (Figure 3). Her postoperative course was prolonged and she was discharged to an external care facility on postoperative day 7 from her original hip surgery and postoperative day 5 from her vascular surgery.

Figure 3A Figure 3B
Figure 3: Angiogram showing the patent proximal end of a Gortex graft (A). Angiogram showing the patent distal end of a Gor-Tex graft (B).

Although the patient began rehabilitation, she began to develop left leg and heel ulcers. Approximately 6 weeks after her original left hip fracture, she underwent wide debridement of the left leg and heel ulcers using a wound vacuum for the skin necrosis. Through the next several weeks, these ulcerations and wounds showed no healing potential and therefore, a left below-the-knee amputation was performed for gangrene of the left heel and ulcer of the left leg. She was subsequently discharged to an external care facility with follow-up to her vascular surgeon.

Discussion

A recently published review article summarized many of the known complications of using a traction table during orthopedic surgery.1 These complications include perineal soft tissue injury, leg malrotation or malalignment, neurologic injury, and iatrogenic compartment syndrome of the healthy leg. In general, arterial complications of intramedullary fixation are rare. One study that examined 120 femur fractures fixed on fracture tables demonstrated 5 thromboembolic complications (likely deep venous thrombosis or pulmonary embolism) and described no specific arterial complications.2 Isolated arterial complications are described in case reports, with all of these arterial complications resulting from direct trauma to the vessel related to interlocking screw placement.3-5 We found 1 case of arterial thromboembolism after use of a fracture table in the literature, and the patient described had radiographic evidence of extensive atherosclerotic vascular calcification, which caused a low-flow state in the lower extremity.6 It was thought that the perineal post caused temporary occlusion of the vessel, which resulted in thromboembolism.

Virchow’s triad describes 3 categories thought to increase the risk of thrombosis. They include hypercoagulable states, endothelial damage, and stasis. Our patient had a known diagnosis of peripheral vascular disease that created both endothelial damage and a low flow state. Manipulation of the lower extremity, especially one with an already low flow state, can theoretically worsen flow via torsion, compression, and kinking. In fact, a recent case report demonstrates acute limb ischemia following compression of a popliteal aneurysm during closed reduction of a hip arthroplasty dislocation.7 Therefore, it is reasonable to assume that the use of a fracture table can worsen the low flow state of a diseased artery, especially if the patient already has a prior bypass graft. It is important to consider the patient’s lower extremity vascular status when using a fracture table for orthopedic surgery. If a fracture table is used, then conscious efforts should be made to limit the forces of the fracture table on the lower extremity to what is necessary for fracture reduction. Not only will this theoretically minimize reductions in flow through vascular grafts and damaged arteries, but it should also limit complications while using fracture tables.

References

  1. Flierl MA, Stahel PF, Hak DJ, Morgan SJ, Smith WR. Traction table-related complications in orthopaedic surgery. J Am Acad Orthop Surg. 2010; 18(11):668-675.
  2. Braten M, Terjesen T, Rossvoll I. Femoral shaft fractures treated by intramedullary nailing. A follow-up study focusing on problems related to the method. Injury. 1995; 26(6):379-383.
  3. Bose D, Hauptfleisch J, McNally M. Delayed pseudoaneurysm caused by distal locking screw of a femoral intramedullary nail: a case report. J Orthop Trauma. 2006; 20(8):584-586.
  4. Coupe KJ, Beaver RL. Arterial injury during retrograde femoral nailing: a case report of injury to a branch of the profunda femoris artery. J Orthop Trauma. 2001; 15(2):140-143.
  5. Handolin L, Pajarinen J, Tulikoura I. Injury to the deep femoral artery during proximal locking of a distal femoral nail--a report of 2 cases. Acta Orthop Scand. 2003; 74(1):111-113.
  6. Kadzielski J, Vrahas M. A vascular complication of trochanteric-entry femoral nailing on a fracture table. Am J Orthop (Belle Mead NJ). 2010; 39(7):E64-66.
  7. Marsh J, Turgeon T, Guzman R. Acute limb ischemia following closed reduction of a hip arthroplasty dislocation. Orthopedics. 2010; 33(10):768.

Authors

Drs Wiltfong and Steensen are from the Department of Orthopedic Surgery, Mount Carmel Medical Center and Dr Taylor is from Grant Medical Center, Columbus, Ohio.

Drs Wiltfong, Taylor, and Steensen have no relevant financial relationships to disclose.

Correspondence should be addressed to: Roger E. Wiltfong, MD, Department of Orthopedic Surgery, Mount Carmel Medical Center, 793 W State St, Columbus, OH 43222 (roger.wiltfong@gmail.com).

doi: 10.3928/01477447-20110317-27

10.3928/01477447-20110317-27

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