EFFECT OF CIRCUMFLEX ARTERY LIGATION ON INTRA- AND POSTOPERATIVE BLEEDING DURING HIP PROSTHESIS SURGERY

Abstract

Material and methods: Two series of 35 total hip arthroplasties (THA) implanted by the same surgeon using the posterior approach were compared. The first group underwent surgery in 1999 and the second in 2001. Ligation of the posterior medial circumflex artery was systematically performed in the second group. The same prosthesis was used in all cases: an omnicase stem and a Schuster (Centerpulse) or polyethylene cup. The series included cemented (n=37) and non-cemented (n=32) prostheses with one hybrid implant. We analysed retrospectively, intra- and postoperative bleeding, haematocrit before and just after surgery, and the number of packed red cell units transfused during and after surgery in order to determine the degree of intra- and postoperative bleeding. Statistical tests were applied.

Technique: Via the posterior approach, before sectioning the pelvitrochanteric muscles, the upper third of the fibres of the quadratus femoris muscle were dissociated. The artery runs upwardly and anterior toward the posterior border of the greater trochanter and is difficult to identify in the fatty tissue. Ligation is performed at this level with the satellite veins. Ligation decreases bleeding when the pelvitrochanteric muscles and the capsule are sectioned. Likewise, section of the femoral neck appears to be less haemorrhagic as is the preparation of the proximal greater trochanter.

Results: Intra- and postoperative bleed, expressed in ml, was significantly decreased by ligation of the posterior circumflex artery and its two satellite veins. Mean intraoperative bleeding was decreased by more than half. Six of the 35 patients who did not have ligation lost more than 600 cc blood during the operation. This degree of bleeding was not observed in the ligation group. The postoperative haematocrit was significantly higher in the ligation group and the difference in pre- and postoperative haematocrit was decreased 7-fold. Postoperative transfusion became exceptional. Finally, it is interesting to note that among the variables studied, mode of implant fixation did not affect blood loss.

Discussion: The conventional technique without ligation of the posterior circumflex artery does not always lead to significant bleeding. It is quite possible to perform such procedures with less than 200 cc blood loss. Use of posterior circumflex artery ligation leads to much more regular control of intraoperative bleeding, making autologous blood collection and postoperative transfusions unnecessary. The ligation is a simple procedure. Electric coagulation is generally insufficient for the calibre of these vessels and veins are not always accessible to effective coagulation. Intraoperative bleeding due to section of the circumflex artery is underevaluated due to the tension created by the forced internal rotation. Haemostasis after section is difficult due to retraction of the proximal segment under the muscles.