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Reduced blood loss with ligation of medial circumflex pedicle during total hip arthroplasty with minimally invasive posterior approach
Orthopaedics & Traumatology: Surgery & Research 100 (2014) 241–242
Available online at
ScienceDirect www.sciencedirect.com
Technical note
Reduced blood loss with ligation of medial circumflex pedicle during total hip arthroplasty with minimally invasive posterior approach P. Chiron , J. Murgier ∗ , N. Reina Service d’orthopédie traumatologie, institut de l’appareil locomoteur, cinquième étage, hôpital Pierre-Paul-Riquet, 308, avenue de Grande-Bretagne, 31059 Toulouse, France
a r t i c l e
i n f o
Article history: Accepted 4 November 2013 Keywords: Hip arthroplasty Blood loss Blood saving
a b s t r a c t A total hip arthroplasty procedure can lead to significant perioperative blood loss due to bleeding from the medial circumflex pedicle. When either the anterior or posterior approach is used, haemostasis of this pedicle, which is typically performed with electrocautery without dissection, can be inadequate. The purpose of this study was to evaluate the efficacy of a novel surgical technique in which the pedicleis is directly ligated. A single-centre, single-surgeon prospective study was performed to compare pedicle ligation to electrocautery (control group). In the ligation group, the pedicle was identified in front of the upper-third of the quadratus femoris and ligated. The mean postoperative blood loss in the ligation group (293.4 ± 34.8 mL) was significantly less than in the control group (419.0 ± 36.8 mL) (P < 0.05). Pedicle ligation is a simple procedure that reduces blood loss during total hip arthroplasty. © 2014 Elsevier Masson SAS. All rights reserved.
1. Introduction Because total hip arthroplasty (THA) procedures cause blood loss, careful planning and control measures are needed [1,2]. This blood loss can lead to postoperative anaemia, which is associated with lower functional recovery scores, higher transfusion rates and longer hospital stays [3–6]. With blood transfusion comes the risk of infection [7]. Damage to the medial circumflex pedicle is one of the major causes of blood loss [8]. We systematically ligate this pedicle when we perform THA through a posterior approach [9]. The purpose of this technical note was to describe this surgical technique and evaluate its efficacy in terms of postoperative blood loss. Patients undergoing total hip arthroplasty for hip osteoarthritis were split into two matched groups for comparison: one group with ligation of the pedicle and the other with electrocautery of the pedicle only (control group).
most of the blood supply to the femoral head and the descending branch forms the cruciate anastomosis. 2.1. Surgical technique description The medial circumflex pedicle must be ligated before any of the pelvic and trochanteric muscles are cut (Video 1). The fibres of the upper-third of the quadratus femoris muscle are spread apart using long Bengolea forceps. The artery-vein pedicle may be difficult to see because it is surrounded by fatty tissue. A suture is passed in front of this fatty tissue as soon as it is visible, without trying to dissect the individual blood vessels. Right angle forceps are used to pass the suture to reduce the risk of tearing the pedicle. The pedicle is tagged with long suture tails to avoid later cutting it proximal to the ligation later during the procedure. 2.2. Pilot comparative study
2. Anatomy review The medial femoral circumflex artery arises from the deep femoral artery and winds towards the posterior side of the femoral neck by passing between the pectineus and iliopsoas muscles and in front of the upper-third of the quadratus femoris muscle (Fig. 1). It enters the joint capsule at the inferior gemellus muscle over its greater trochanter insertion point. The ascending branch provides
∗ Corresponding author. Tel.: +33 (0)6 19 19 84 91; fax: +33 (0)5 61 32 22 32. E-mail address: [email protected] (J. Murgier). 1877-0568/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.otsr.2013.11.013
The surgical blood loss was compared in two groups of patients receiving a cementless total hip arthroplasty (Omnicase stem, Schuster cup, ZimmerTM , Winthetur, Switzerland). All patients were operated by the same surgeon using the posterolateral approach over a two-year period and followed prospectively. Blood loss was estimated using the Mercuriali and Inghilleri algorithm [10]. The two groups of 35 patients had similar age, gender and body mass index characteristics (Table 1). The mean postoperative blood loss in the ligation group was 293.4 mL ± 34.8 (range 104–602). It was 419.0 mL ± 36.8 (range 156–789) in the control group where electrocautery was performed during capsule exposure
242
P. Chiron et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 241–242
have described medial circumflex pedicle ligation. Electrocautery of this pedicle without first dissecting, it is often not adequate for controlling the bleeding. Intraoperative bleeding can go undetected because internal rotation of the leg narrows the artery. As a consequence, when the joint is reduced at the end of the procedure, bleeding can restart and trigger haemorrhages that can have serious consequences [15] and could have been prevented by ligating the blood vessel. This study should be supplemented by a larger, randomized study to confirm these preliminary results. 4. Conclusion Ligation of the medial circumflex pedicle is a simple surgical procedure that significantly reduces postoperative blood loss during total hip arthroplasty by the posterior approach. Disclosure of interests Fig. 1. Posterior view of hip. From superior to inferior are the gluteus medius, piriformis, superior gemellus, obturator internus, inferior gemellus, and quadratus femoris muscles. A. Deep femoral artery. a’. Medial femoral circumflex artery passes in front of the upper-third of the quadratus femoris muscle. Table 1 Characteristics of both study groups.
Age (mean value) BMI (mean value) ASA score (mean value) Gender ratio (M:F)
Appendix A. Supplementary data
Ligation group 35 cases
Control group 35 cases
Significance P
62.3 ± 12.4 (28–84) 26.8 ± 3.7 (18.4–37.0) 1.9 (1–3) 1.6
59.4 ± 14.63 (34–86) 25.7 ± 4.6 (19.7–47.4) 1.7 (1–3) 1.4
Ns Ns Ns Ns
BMI: body mass index; ASA: American Society of Anesthesiologists; M: male; F: female; Ns: not significant.
Table 2 Perioperative blood loss in the two study groups. Mean values with standard deviation and minimum/maximum are shown.
Postoperative blood loss (mL) Postoperative blood loss > 500 cc Number of units of RBCs given postoperatively Number of patients needing transfusion Overall blood loss (mL)
P. Chiron is a consultant for Zimmer, Smith and Nephew and Sanofi, and has received royalties from Zimmer and Integra. The other authors have no conflict of interest.
Ligation n = 35
Control n = 35
Significance P
293.4 ± 34.8 (104–602) 4/35
419.0 ± 36.8 (156–789) 11/35
< 0.014
0.3 ± 0.19 (0–3) 5/35
1.3 ± 0.13 (0–5) 19/35
481.92 ± 187.4 (212–984)
836.26 ± 345.9 (327–1354)
< 0.05 < 0.0002 < 0.05 < 0.0001
RBC: red blood cells.
without directly dissecting the pedicle (P < 0.05). Transfusion was required in five patients in the ligation group and 19 in the control group (P < 0.05) because of haemoglobin levels below 8 g/dL. The overall perioperative blood loss was significantly less in the ligation group (mean 481.92 mL, range 212–984) than in the control group (mean 836.26 mL, range 327–1354) (P < 0.05) (Table 2). 3. Discussion It is important to reduce surgical blood loss during a total hip arthroplasty procedure. Various published studies have described methods to reduce this blood loss, such as tranexamic acid injections [11,12], intraoperative blood salvage[13], or local administration of substances leading to haemostasis [14]. But no studies
Supplementary data (Video 1) associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.otsr. 2013.11.013. References [1] Liu X, Zhang X, Chen Y, Wang Q, Jiang Y, Zeng B. Hidden blood loss after total hip arthroplasty. J Arthroplasty 2011;26:1100e1–5e1. [2] Charrois O, Kahwaji A, Gagnaire AL, Courpied JP. Variables influencing bleeding during total hip arthroplasty. Rev Chir Orthop 2005;91:132–6. [3] Conlon NP, Bale EP, Herbison GP, McCarroll M. Postoperative anemia and quality of life after primary hip arthroplasty in patients over 65 years old. Anesth Analg 2008;106:1056–61. [4] Callaghan JJ, O’Rourke MR, Liu SS. Blood management: issues and options. J Arthroplasty 2005;20:51–4. [5] Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 2008;79:168–73. [6] Saleh E, McClelland DB, Hay A, Semple D, Walsh TS. Prevalence of anaemia before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions. Br J Anaesth 2007;99:801–8. [7] Murphy P, Heal JM, Blumberg N. Infection or suspected infection after hip replacement surgery with autologous or homologous blood transfusions. Transfusion 1991;31:212–7. [8] Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 2000;82:679–83. [9] Laffosse JM, Chiron P, Molinier F, Bensafi H, Puget J. Prospective and comparative study of the anterolateral mini-invasive approach versus minimally invasive posterior approach for primary total hip replacement. Early results. Int Orthop 2007;31:597–603. [10] Mercuriali F, Inghilleri G. Proposal of an algorithm to help the choice of the best transfusion strategy. Curr Med Res Opin 1996;13:465–78. [11] Clave A, Fazilleau F, Dumser D, Lacroix J. Efficacy of tranexamic acid on blood loss after primary cementless total hip replacement with rivaroxaban thromboprophylaxis: a case-control study in 70 patients. Orthop Traumatol Surg Res 2012;98:484–90. [12] Irisson E, Hemon Y, Pauly V, Parratte S, Argenson JN, Kerbaul F. Tranexamic acid reduces blood loss and financial cost in primary total hip and knee replacement surgery. Orthop Traumatol Surg Res 2012;98:477–83. [13] Mengal B, Aebi J, Rodriguez A, Lemaire R. A prospective randomized study of wound drainage versus non-drainage in primary total hip or knee arthroplasty. Rev Chir Orthop 2001;87:29–39. [14] Levy O, Martinowitz U, Oran A, Tauber C, Horoszowski H. The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty. A prospective, randomized, multicenter study. J Bone Joint Surg Am 1999;81:1580–8. [15] Vielpeau C. Perioperative bleeding and early mortality in hip and knee surgery. Orthop Traumatol Surg Res 2012;98:475–6.
Available online at
ScienceDirect www.sciencedirect.com
Technical note
Reduced blood loss with ligation of medial circumflex pedicle during total hip arthroplasty with minimally invasive posterior approach P. Chiron , J. Murgier ∗ , N. Reina Service d’orthopédie traumatologie, institut de l’appareil locomoteur, cinquième étage, hôpital Pierre-Paul-Riquet, 308, avenue de Grande-Bretagne, 31059 Toulouse, France
a r t i c l e
i n f o
Article history: Accepted 4 November 2013 Keywords: Hip arthroplasty Blood loss Blood saving
a b s t r a c t A total hip arthroplasty procedure can lead to significant perioperative blood loss due to bleeding from the medial circumflex pedicle. When either the anterior or posterior approach is used, haemostasis of this pedicle, which is typically performed with electrocautery without dissection, can be inadequate. The purpose of this study was to evaluate the efficacy of a novel surgical technique in which the pedicleis is directly ligated. A single-centre, single-surgeon prospective study was performed to compare pedicle ligation to electrocautery (control group). In the ligation group, the pedicle was identified in front of the upper-third of the quadratus femoris and ligated. The mean postoperative blood loss in the ligation group (293.4 ± 34.8 mL) was significantly less than in the control group (419.0 ± 36.8 mL) (P < 0.05). Pedicle ligation is a simple procedure that reduces blood loss during total hip arthroplasty. © 2014 Elsevier Masson SAS. All rights reserved.
1. Introduction Because total hip arthroplasty (THA) procedures cause blood loss, careful planning and control measures are needed [1,2]. This blood loss can lead to postoperative anaemia, which is associated with lower functional recovery scores, higher transfusion rates and longer hospital stays [3–6]. With blood transfusion comes the risk of infection [7]. Damage to the medial circumflex pedicle is one of the major causes of blood loss [8]. We systematically ligate this pedicle when we perform THA through a posterior approach [9]. The purpose of this technical note was to describe this surgical technique and evaluate its efficacy in terms of postoperative blood loss. Patients undergoing total hip arthroplasty for hip osteoarthritis were split into two matched groups for comparison: one group with ligation of the pedicle and the other with electrocautery of the pedicle only (control group).
most of the blood supply to the femoral head and the descending branch forms the cruciate anastomosis. 2.1. Surgical technique description The medial circumflex pedicle must be ligated before any of the pelvic and trochanteric muscles are cut (Video 1). The fibres of the upper-third of the quadratus femoris muscle are spread apart using long Bengolea forceps. The artery-vein pedicle may be difficult to see because it is surrounded by fatty tissue. A suture is passed in front of this fatty tissue as soon as it is visible, without trying to dissect the individual blood vessels. Right angle forceps are used to pass the suture to reduce the risk of tearing the pedicle. The pedicle is tagged with long suture tails to avoid later cutting it proximal to the ligation later during the procedure. 2.2. Pilot comparative study
2. Anatomy review The medial femoral circumflex artery arises from the deep femoral artery and winds towards the posterior side of the femoral neck by passing between the pectineus and iliopsoas muscles and in front of the upper-third of the quadratus femoris muscle (Fig. 1). It enters the joint capsule at the inferior gemellus muscle over its greater trochanter insertion point. The ascending branch provides
∗ Corresponding author. Tel.: +33 (0)6 19 19 84 91; fax: +33 (0)5 61 32 22 32. E-mail address: [email protected] (J. Murgier). 1877-0568/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.otsr.2013.11.013
The surgical blood loss was compared in two groups of patients receiving a cementless total hip arthroplasty (Omnicase stem, Schuster cup, ZimmerTM , Winthetur, Switzerland). All patients were operated by the same surgeon using the posterolateral approach over a two-year period and followed prospectively. Blood loss was estimated using the Mercuriali and Inghilleri algorithm [10]. The two groups of 35 patients had similar age, gender and body mass index characteristics (Table 1). The mean postoperative blood loss in the ligation group was 293.4 mL ± 34.8 (range 104–602). It was 419.0 mL ± 36.8 (range 156–789) in the control group where electrocautery was performed during capsule exposure
242
P. Chiron et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 241–242
have described medial circumflex pedicle ligation. Electrocautery of this pedicle without first dissecting, it is often not adequate for controlling the bleeding. Intraoperative bleeding can go undetected because internal rotation of the leg narrows the artery. As a consequence, when the joint is reduced at the end of the procedure, bleeding can restart and trigger haemorrhages that can have serious consequences [15] and could have been prevented by ligating the blood vessel. This study should be supplemented by a larger, randomized study to confirm these preliminary results. 4. Conclusion Ligation of the medial circumflex pedicle is a simple surgical procedure that significantly reduces postoperative blood loss during total hip arthroplasty by the posterior approach. Disclosure of interests Fig. 1. Posterior view of hip. From superior to inferior are the gluteus medius, piriformis, superior gemellus, obturator internus, inferior gemellus, and quadratus femoris muscles. A. Deep femoral artery. a’. Medial femoral circumflex artery passes in front of the upper-third of the quadratus femoris muscle. Table 1 Characteristics of both study groups.
Age (mean value) BMI (mean value) ASA score (mean value) Gender ratio (M:F)
Appendix A. Supplementary data
Ligation group 35 cases
Control group 35 cases
Significance P
62.3 ± 12.4 (28–84) 26.8 ± 3.7 (18.4–37.0) 1.9 (1–3) 1.6
59.4 ± 14.63 (34–86) 25.7 ± 4.6 (19.7–47.4) 1.7 (1–3) 1.4
Ns Ns Ns Ns
BMI: body mass index; ASA: American Society of Anesthesiologists; M: male; F: female; Ns: not significant.
Table 2 Perioperative blood loss in the two study groups. Mean values with standard deviation and minimum/maximum are shown.
Postoperative blood loss (mL) Postoperative blood loss > 500 cc Number of units of RBCs given postoperatively Number of patients needing transfusion Overall blood loss (mL)
P. Chiron is a consultant for Zimmer, Smith and Nephew and Sanofi, and has received royalties from Zimmer and Integra. The other authors have no conflict of interest.
Ligation n = 35
Control n = 35
Significance P
293.4 ± 34.8 (104–602) 4/35
419.0 ± 36.8 (156–789) 11/35
< 0.014
0.3 ± 0.19 (0–3) 5/35
1.3 ± 0.13 (0–5) 19/35
481.92 ± 187.4 (212–984)
836.26 ± 345.9 (327–1354)
< 0.05 < 0.0002 < 0.05 < 0.0001
RBC: red blood cells.
without directly dissecting the pedicle (P < 0.05). Transfusion was required in five patients in the ligation group and 19 in the control group (P < 0.05) because of haemoglobin levels below 8 g/dL. The overall perioperative blood loss was significantly less in the ligation group (mean 481.92 mL, range 212–984) than in the control group (mean 836.26 mL, range 327–1354) (P < 0.05) (Table 2). 3. Discussion It is important to reduce surgical blood loss during a total hip arthroplasty procedure. Various published studies have described methods to reduce this blood loss, such as tranexamic acid injections [11,12], intraoperative blood salvage[13], or local administration of substances leading to haemostasis [14]. But no studies
Supplementary data (Video 1) associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.otsr. 2013.11.013. References [1] Liu X, Zhang X, Chen Y, Wang Q, Jiang Y, Zeng B. Hidden blood loss after total hip arthroplasty. J Arthroplasty 2011;26:1100e1–5e1. [2] Charrois O, Kahwaji A, Gagnaire AL, Courpied JP. Variables influencing bleeding during total hip arthroplasty. Rev Chir Orthop 2005;91:132–6. [3] Conlon NP, Bale EP, Herbison GP, McCarroll M. Postoperative anemia and quality of life after primary hip arthroplasty in patients over 65 years old. Anesth Analg 2008;106:1056–61. [4] Callaghan JJ, O’Rourke MR, Liu SS. Blood management: issues and options. J Arthroplasty 2005;20:51–4. [5] Husted H, Holm G, Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 2008;79:168–73. [6] Saleh E, McClelland DB, Hay A, Semple D, Walsh TS. Prevalence of anaemia before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions. Br J Anaesth 2007;99:801–8. [7] Murphy P, Heal JM, Blumberg N. Infection or suspected infection after hip replacement surgery with autologous or homologous blood transfusions. Transfusion 1991;31:212–7. [8] Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 2000;82:679–83. [9] Laffosse JM, Chiron P, Molinier F, Bensafi H, Puget J. Prospective and comparative study of the anterolateral mini-invasive approach versus minimally invasive posterior approach for primary total hip replacement. Early results. Int Orthop 2007;31:597–603. [10] Mercuriali F, Inghilleri G. Proposal of an algorithm to help the choice of the best transfusion strategy. Curr Med Res Opin 1996;13:465–78. [11] Clave A, Fazilleau F, Dumser D, Lacroix J. Efficacy of tranexamic acid on blood loss after primary cementless total hip replacement with rivaroxaban thromboprophylaxis: a case-control study in 70 patients. Orthop Traumatol Surg Res 2012;98:484–90. [12] Irisson E, Hemon Y, Pauly V, Parratte S, Argenson JN, Kerbaul F. Tranexamic acid reduces blood loss and financial cost in primary total hip and knee replacement surgery. Orthop Traumatol Surg Res 2012;98:477–83. [13] Mengal B, Aebi J, Rodriguez A, Lemaire R. A prospective randomized study of wound drainage versus non-drainage in primary total hip or knee arthroplasty. Rev Chir Orthop 2001;87:29–39. [14] Levy O, Martinowitz U, Oran A, Tauber C, Horoszowski H. The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty. A prospective, randomized, multicenter study. J Bone Joint Surg Am 1999;81:1580–8. [15] Vielpeau C. Perioperative bleeding and early mortality in hip and knee surgery. Orthop Traumatol Surg Res 2012;98:475–6.