Femoral artery entrapment after cerclage wiring of distal femoral shaft

Journal of Orthopaedics, Trauma and Rehabilitation xxx (2018) 1e4

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Case Report

Femoral artery entrapment after cerclage wiring of distal femoral shaft fracture: A case report 股骨遠端環紮術後股動脈卡壓情況報告1例 Gunadham Ukris a, *, Kongkreangkrai Thumrong b a b

Department of Orthopaedics, Trang Regional Hospital, Trang, Thailand Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Trang Regional Hospital, Trang, Thailand

a r t i c l e i n f o

a b s t r a c t

Article history: Received 27 November 2017 Received in revised form 16 February 2018 Accepted 5 May 2018

Femoral artery injury after femoral fracture fixation is a rare complication. Previous literature studies focused mostly on proximal femur fracture. We described a case of superficial femoral artery entrapment after internal fixation augmented with cerclage wire. An 80-year-old female underwent fixation with distal femur locking compression plate augmented with cerclage wire. Six hours after the operation, she developed pulseless limb and computed tomography angiogram showed femoral artery entrapped by cerclage wire. After vascular exploration and cerclage wire removal, the femoral artery returned to normal flow without further complication. We review available literature studies on vascular injury after cerclage wiring especially in the distal part of the femur, the so-called safe zone, for the great care needed before cerclage wiring and the importance of immediate diagnosis and treatment.

Keywords: Cerclage wiring Distal femur fracture Femoral artery injury Vascular complication

摘要股骨骨折固定後股動脈損傷是一種罕見的並發症。以前文獻研究主要集中在股骨近端骨折。我們描述了內固定加上環紮線後股淺動脈卡壓的病例。一名80歲的女性接受遠端股骨鎖定加壓板固定，輔以環紮線。手術後 6小時，她呈現無脈性肢體，斷層掃描血管造影顯示股動脈被動環紮線夾閉。在血管探查和環紮線移除後，股動脈恢復正常流動而沒有進一步的並發症。我們回顧了有關環紮術後血管損傷的文獻研究，特別是在股骨遠端部分，即所謂的安全區，在進行環紮術前需要謹慎以及立即診斷和治療的重要性。

Introduction Orthopaedic fracture associated with vascular injury is a potentially limb-threatening or even life-threatening condition.1 The known rate of vascular injury in orthopaedic fracture ranges from 1.6% to 2%.2 Although the incidence of superficial femoral artery injury is low, the anatomy of distal femur predisposes the vessels to injury as the superficial femoral artery runs through adductor hiatus and becomes popliteal artery. It is tethered proximally by the adductor hiatus and distally by the soleus arch.2 The causes of vessel injuries included open fracture, segmented or displaced fracture fragment, penetrating injury and traction force

* Corresponding author. Department of Orthopaedics, Trang Regional Hospital. 69 Kokkan Road, Tubtiang, Muang, Trang, 92000 Thailand. E-mail address: [email protected] (U. Gunadham).

to vessels. Furthermore, iatrogenic injuries caused by instrumentation, reduction tools and screws could damage the vessels.3 Cerclage wiring became popular as assisted tools for fracture reduction and adjunct fixation. It can be used to reduce the displaced fragment and increase bone contact. In the proximal part of the femur, cerclage wiring showed less risk to femoral vessels than in the distal part.3 In this case, we pointed out the risk of injury of the femoral artery after cerclage wiring of the distal femur and described its complications and how to manage these problems systematically. Case Report An 80-year-old female was admitted to the hospital with history of minor fall. She could not move her left leg due to severe pain. She was 42 kg in weight and 145 cm in height. Radiographs showed displaced, oblique fracture of the distal shaft of the left femur,

https://doi.org/10.1016/j.jotr.2018.05.004 2210-4917/Copyright © 2018, Hong Kong Orthopaedic Association and the Hong Kong College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Gunadham U, Kongkreangkrai T, Femoral artery entrapment after cerclage wiring of distal femoral shaft fracture: A case report, Journal of Orthopaedics, Trauma and Rehabilitation (2018), https://doi.org/10.1016/j.jotr.2018.05.004

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U. Gunadham, T. Kongkreangkrai / Journal of Orthopaedics, Trauma and Rehabilitation xxx (2018) 1e4

Figure 1. Preoperative radiographs. L ¼ left side.

Figure 2. Postoperative open reduction and internal fixation with distal femur locking compression plate and wiring.

Association for the Study of Internal Fixation /Orthopaedic Trauma Association (AO/OTA) 33-A1.2 (Figure 1). She underwent surgery 2 days after the accident with open reduction and internal fixation with distal femur locking compression plate augmented with cerclage wire (Figure 2). She was on lateral decubitus position. The cerclage wiring was aimed to assist reduction before fixation. During cerclage wiring, the single wire was placed in regular subperiosteal fashion with the assistance of a standard L-size cerclage passer (DePuy Synthes, PA) (Figure 3). The procedure was achieved in 45 minutes without difficulty, and immediate postoperative distal neurovascular evaluation by manual palpation showed no abnormality.

Figure 3. Cerclage passer; DePuy Synthes.

Six hours after the operation, her left leg was colder than the other side without severe pain. Her dorsalis pedis and posterior tibial pulse were absent when detected by both palpation and Doppler ultrasound. Computed tomography angiogram was performed and revealed superficial femoral artery entrapment by cerclage wire on her left femur with near-total occlusion (Figure 4). Emergency cerclage wire removal and femoral artery exploration



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Figure 5. 3-Month postoperative radiographs. L ¼ left side.

Figure 4. Computed tomography angiogram showed superficial femoral artery entrapment by cerclage wire.

were performed by a vascular surgeon with a medial approach to the femoral artery. We found the cerclage wire belted directly over superficial femoral artery with some muscle tissue encasement. There was no penetrating injury or contusion to the artery. After cerclage removal, the superficial femoral artery had normal flow, and both dorsalis pedis and posterior tibial pulse could be palpated. She received only single dose of an anticoagulating agent. There was no further wound complication. She had recovered and was able to ambulate with gait aid afterwards. She had been eventually discharged from the hospital 12 days after the surgery. On the short-term follow-up, her femur healed gradually in 3 months, and she could walk independently (Figure 5). Discussion The incidence of femoral artery injury after femoral fracture is rare but could be catastrophic.2 Noniatrogenic causes of femoral artery injury include segmented or bone spike of displaced fracture fragment, penetrating injury and direct traction force to vessels.

Iatrogenic causes are inappropriate use of sharp drill bit, reduction clamp, retractor, penetrating screws and wire during fracture reduction and fixation.1,3 From our case report, the patient underwent cerclage wiring that encased superficial femoral artery and surrounding muscles. The patient developed cold and pulseless limb 6 hours after the operation. Emergency cerclage removal definitely helped returning to normal condition. Previous reviews of femoral artery injury after fracture fixation mostly occurred in the proximal part of the femur.3e5 In the distal part of the femur, the superficial femoral artery comes close to the femur as it enters adductor hiatus, where it is tethered proximally by the hiatus and distally by the soleus arch. This allows little space for movement during fracture reduction and fixation. Therefore, displaced fracture causes higher risk to the vessel injury in distal femur.2 Acute presentation such as swelling, compartment syndrome, wound leakage and weak or absent distal pulse will be observed if the vessel was severely injured. In contrary, if minor injury occurred, clinical presentation is delayed and included pain, swelling, evolving anaemia or late aneurysm.3e5 Historically, there was a theory that cerclage wiring led to a strangulation of periosteal vascularisation, resulting in bone necrosis and nonunion.6 Actually, a real periosteal devascularisation comes from extensive surgical dissection and stripping to expose and reduce the fracture, causing possible bone necrosis and other complications.6 At present, cerclage wiring is still a useful technique when properly applied, especially in difficult fractures. It can obtain anatomic reduction, leading to decreased risk of nonunion. Comparing open and closed techniques, open wiring technique is thought to be safer for neurovascular injury with the expense of devitalised tissue, whereas there is concern of vessel injury with the percutaneous minimally invasive technique.7 Mehta V et al reported a superficial femoral artery and vein ligation by a femoral midshaft cerclage during revision total hip arthroplasty.3 Aleto T et al described the same complication in the proximal femur during revision total hip arthroplasty.4 Won Y et al reported a devastating outcome after intramedullary nailing augmented with multiple cerclage wiring for femoral shaft fracture and pointed out the necessity of multiple wires.8 On fracture reduction and cerclage


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wiring, Yang KH et al found the position of femoral artery changes according to the position of the limb. The neutral or abduction position of the limb provides safer distance between the femur and the artery than the adduction.9 From the cadaveric and live human participants, Narulla RS et al demonstrated large safe zone for the superficial femoral artery on computed tomography angiography at around 172.5 ± 40.9 mm proximal to the adductor tubercle.10 In this case, the surgeon used lateral decubitus position which may cause the thigh in slightly adducted position, while the patient is quite thin with less muscle belly around femur, resulting in an increased risk for femoral artery injury. The L-size cerclage passer may be too large for the small, elderly Asian patient, and it may cause vascular entrapment during cerclage wiring. Even though the surgeon used open wiring technique and the position of wire was in the safe zone, the femoral artery entrapment still happened. After the operation, immediate vascular examination of the distal pulse showed it was still palpable. This might be because partial occlusion of the superficial femoral artery occurred or there was adequate collateral circulation at that time which gradually became near-total occlusion as time passed. This may imply that even if the surgeon checks the distal pulse immediately after the operation, this complication still occurs. Fortunately, the vessel injury was detected soon enough and was corrected immediately. There was not any long-term complication in this case. In conclusion, we emphasise that the risk of femoral artery injury after open reduction and cerclage wiring at the distal femur is very real and can cause catastrophic complications. The distal femoral area may have a higher risk due to the proximity of the femoral artery and the femur. The surgeon should pay extra attention to make sure the wire passer goes subperiosteally without trapping the medial soft tissue. Early and serial neurovascular check is mandatory after fixation as delayed diagnosis and treatment lead to disastrous outcomes. Routine Doppler ultrasound may be useful to detect postoperative vascular complication but may not feasible in every case. The most importance treatment for a vascular injury after fracture fixation is prevention, and the surgeon will have to weigh the risk and benefit of any augmented fixation before use.

Conflict of interest The authors have no conflicts of interest relevant to this article. Acknowledgement The authors thank Dr Patarawan Woratanarat, MD, PhD (Clinical Epidemiology), Faculty of Medicine, Ramathibodi Hospital, for her kind review of the manuscript. Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jotr.2018.05.004. References 1. Howard PW, Makin GS. Lower limb fractures with associated vascular injury. J Bone Joint Surg Br 1990;72(1):116e20. 2. Mavrogenis AF, Panagopoulos GN, Kokkalis ZT, Koulouvaris P, Megaloikonomos PD, Igoumenou V, et al. Vascular injury in orthopedic trauma. Orthopedics 2016;39(4):249e59. 3. Mehta V, Finn HA. Femoral artery and vein injury after cerclage wiring of the femur: a case report. J Arthroplasty 2005;20(6):811e4. 4. Aleto T, Ritter MA, Berend ME. Case report: superficial femoral artery injury resulting from cerclage wiring during revision THA. Clin Orthop Relat Res. 2008;466(3):749e53. 5. Barr H, Santer GJ, Stevenson IM. Occult femoral artery injury in relation to fracture of the femoral shaft. J Cardiovasc Surg (Torino) 1987;28(2):193e5. 6. Angelini A, Battiato C. Combination of low-contact cerclage wiring and osteosynthesis in the treatment of femoral fractures. Eur J Orthop Surg Traumatol 2016;26(4):397e406. 7. Codesido P, Mejia A, Riego J, Ojeda-Thies C. Cerclage wiring through a miniopen approach to assist reduction of subtrochanteric fractures treated with cephalomedullary fixation: surgical technique. J Orthop Trauma 2017;31(8): e263e8. 8. Won Y, Yang KH, Kim KK, Weaver MJ, Allen EM. Amputated limb by cerclage wire of femoral diaphyseal fracture: a case report. Arch Orthop Trauma Surg 2016;136(12):1691e4. 9. Yang KH, Yoon CS, Park HW, Won JH, Park SJ. Position of the superficial femoral artery in closed hip nailing. Arch Orthop Trauma Surg 2004;124(3):169e72. 10. Narulla RS, Kanawati AJ. Safe zone for the superficial femoral artery demonstrated on computed tomography angiography. Injury 2016;47(3):748e51.
