Predictors of Lower Extremity Arterial Injury After Total Knee or Total Hip Arthroplasty

Christopher J. Abularrage, MD, Jonathan M. Weiswasser, MD, Anton N. Sidawy, MD, Kent J. DeZee, MD,Kevin M. Douglas, MD, Walter Reed Army Medical William T. Shimeall, MD, Niten Singh, MD, Subodh Arora, MD, Tracy Shifftner, PhD,; Shukri Khuri, MD and William Henderson, PhD
Veterans Affairs Medical Center, Georgetown University Hospital, Washington, DC, Walter Reed Army Medical Center, Washington, DC, Veterans Affairs Medical Center, Boston, MA;and NSQIP Data Center, Denver, CO

Objective(s): Lower extremity arterial injury is a rare complication following total knee (TKA) or total hip arthroplasty (THA). To date, no multi-institutional study has identified preoperative factors that may portend increased risk for these injuries. We queried a large clinical database for the incidence and predictors of arterial injury and/or compromise following lower extremity arthroplasty.
Methods: Prospectively collected preoperative and postoperative data by the National Surgical Quality Improvement Program (NSQIP) of the Veterans Affairs Medical Centers were analyzed. All patients from 1995-2003 in the NSQIP database who underwent TKA or THA were identified via CPT codes. Data were compared using univariate analysis, as well as multivariate logistic regression.
Results: A total of 41,633 arthroplasties (24,029 TKA, 13,494 THA, 2,077 redo-TKA, 2,033 redo-THA) were identified in the NSQIP database. A total of 34 (0.08%) lower extremity arterial injuries were recognized (0.10% TKA, 0.05% THA, 0.21% redo-TKA, 0.22% redo-THA). Eighteen injuries were detected on the same day of surgery (7 intra-op, 11 post-op), 8 between postoperative days 1-5, and 8 between days 6-30. Only two patients underwent lower extremity amputation (overall limb loss rate of 5.8%). Initial recognition of these two arterial injuries occurred on postoperative days 12 and 15. Statistically significant predictors of lower extremity arterial injury identified on logistic regression analysis included redo procedure (OR 2.7, 95%CI 1.2-6.0, P=.013), African-American race (OR 2.5, 95%CI 1.2-5.3, P=.02), and chronic dyspnea (OR 2.4, 95%CI 1.1-5.4, P=.028). Previous angioplasty, atherectomy, bypass, or amputation were not associated with arterial injury.
Conclusions: Lower extremity arterial injury was exceedingly rare after total knee or total hip arthroplasty; certain preoperative conditions seem to increase its incidence. Among patients who sustain vascular injury, excellent limb salvage rates can be achieved with close post-operative surveillance to achieve early detection of injuries since those injuries detected beyond the fifth postoperative day may be associated with a higher rate of limb loss.