To The Editor:

It is with great interest that I read the case report by Ryzewicz(1) et al. concerning post-operative arterial bleeding due to injury of a muscular branch of profonda femoris artery after fixation of an intertrochanteric hip fracture. Some addtional information would be helpful in assessing the factors that might have been associated with this complication.

The authors did not mention if this elderly patient was given any form of anticoagulation prior to or soon after the operation that might have contributed to the bleeding.

In our practice, we apply pre and intra-operative traction gently and with great care, especially in elderly patients with atherosclerosis.

The pre-operative history and physical examination should elicit whether there is claudication of the lower limbs or absence of distal pulses. The finding of arterial calcifications on pre-operative radiographs of the hip is very important and indicates poor elasticity of the vessels, rendering them more susceptible to injury(2) when traction is applied.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

References:

1. Ryzewicz M, Robinson M, McConnell J, Lindeque B. Vascular injury during fixation of an intertrochanteric hip fracture in a patient with severe atherosclerosis. A case report. J Bone Joint Surg Am. 2006;88:2483- 6.

2. Bansal R, Laing PW. Iatrogenic blunt arterial injury during a hip fracture surgery. Acta Orthop Belg. 2006;72:96-9.

To The Editor:

I read with interest the case report by Ryzewicz et al.(1) which describes a previously unreported mechanism of arterial injury post-operatively. They mention that in the previous reports “the arterial injury was either in proximity to a spike of fractured bone or a prominent screw…”. We agree that these mechanisms are unlikely to account for the arterial injury observed in their patient, as the location of the bleeding vessel was distal to the operative field.

We previously reported an instance where traction, which Ryzewicz et al. postulate as the possible mechanism of injury in their case, accounted for limb ischaemia following hip fracture surgery(2). The two patients were similar in that they were quite elderly (> 90 years) and had fragile vessels because of severe atherosclerosis.

The possible susceptibility of both large(2) and medium-sized(1) arteries to injury by traction may suggest that this mechanism of vascular insult is more common than has been appreciated. Maintaining the length of the injured extremity preoperatively to avoid shortening of soft tissues, and gradual and gentle traction of the extremity intra-operatively should help minimise this serious complication.

The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

References:

1. Ryzewicz M, Robinson M, McConnell J, Lindeque B. Vascular injury during fixation of an intertrochanteric hip fracture in a patient with severe atherosclerosis. A case report. J Bone Joint Surg Am. 2006;88:2483- 6.

2. Bansal R, Laing PW. Iatrogenic blunt arterial injury during a hip fracture surgery. Acta Orthop Belg. 2006;72:96-9.