Vascular injuries due to cerclage passer: Relevant anatomy and note of caution

Abstract

Purpose: The cerclage passer instrument was introduced for aiding percutaneous reduction in spiral femur fractures, thereby overcoming the risk of devascularization of the fracture ends commonly associated with traditional open cerclage wiring techniques. This may, however, predispose to iatrogenic vascular injuries owing to the proximity of the vessels and several other factors. We report four cases with femoral artery (superficial and deep) injuries caused by the cerclage passer in proximal femur and distal femur shaft fractures and incidence of these injuries in our institution. Methods: Retrospective analysis of hospital records of femoral fractures from 2011 to 2015. All cases of femoral fractures and periprosthetic femoral fractures with cerclage wiring done using the standard or the Synthes ® cerclage passer were included. Cases with wiring done for trochanteric fractures and other locations were excluded. Results: Incidence of vascular injuries due to the cerclage passer in proximal femur shaft fractures was 1.59%, whereas in distal femur shaft fractures it was 7.14%. There were two patients with a deep femoral artery (DFA) system injury and two with a superficial femoral artery (SFA) injury caused by the cerclage passer (Synthes) in two proximal femur shaft and two distal femur shaft fractures, respectively. End-to-end anastomosis for the SFA and ligation for DFA system injuries were used, with an uneventful postoperative period in all patients. Conclusion: Caution and accuracy is imperative to avoid vascular injuries while using the cerclage passer in femur fractures, and strict vigilance is essential for early identification and prompt management.

Distances between popliteal vessels to the femur and anthropometric impacts on distal femoral fracture surgery outcome: a retrospective study

“…Injury to the SFA, deep femoral artery (DFA), or PA have been described as a result of broken sharp fragments or iatrogenic injuries such as external xation pins, plunging drill bits, medial plating, or cerclage wiring. These damages could give rise to immediate bleeding, late presented pseudoaneurysm, limb ischemia, or below knee amputation [1,5,[15][16][17].…”

There are no safe areas for avoiding the perforating arteries along the proximal part of the femur: A word of caution

“…Especially during plate osteosynthesis or cerclage wiring, the formation of pseudoaneurysms, major lesions of the vessel wall, or vascular occlusions have been reported. This may even lead to severe consequences for the patient (Neubauer et al, ; Devendra et al, ). Apivatthakakul () showed that perforating arteries were interrupted in almost one quarter of percutaneous cerclage wiring simulated on anatomic specimens.…”

“…In the worst case, the patients may lose their leg, or even their life (Neubauer et al, ). Therefore, knowledge about the course of the perforating arteries is essential during surgical approaches onto the body of the femur, for example, plate osteosynthesis (Farouk et al, ; Farouk et al, ; Neubauer et al, ), cerclage wiring (Apivatthakakul et al, ; Devendra et al, ), application of an Ilizarov apparatus (Paley, ; Goldstein et al, ), or the harvesting of free or pedicled perforator flaps (Yamamoto et al, ; Ahmadzadeh et al, ).…”

“…Almost all authors measured the level of origin of the perforating arteries from the deep artery of thigh. The arteries are actually in greater danger at their passage near the body of the femur during cerclage wiring or plate osteosynthesis (Neubauer et al, ; Devendra et al, ).…”

Role of Open Cerclage Wires Used in Patients with Comminuted Fractures of Femoral Shaft Treated with Intramedullary Nails

“…The other concern with using the open cerclage wire technique is the risk of blood supply disruption by cerclage wires. Blood supply may be disrupted through the strangulation of blood vessels [28][29] and the contact between cerclage and the bone surface. The risk of vascular injury due to the cerclage passer was 1.59% in proximal femur shaft fractures and 7.14% in distal femur shaft fractures [28].…”