The management of orthopedic patients with arterial insufficiency

The identification and management of the orthopedic patient who has chronic arterial insufficiency is presented in four cases in which failure to appreciate marginal arterial supply led to major and costly complications. Every orthopedic surgeon treating elderly patients should be aware of these possibilities. After a through history and physical examination, patients with signs or symptoms of significant arterial compromise should be evaluated by means of Doppler segmental limb pressures. This evaluation should be performed prior to the institution of the indicated orthopedic treatment whenever possible. If the segmental ankle pressure is less than 50 mm Hg, or the ankle brachial pressure index is less than 0.3, the patient should undergo complete vascular evaluation and consideration for revascularization in order to preserve marginal arterial flow and tissue perfusion during and after the orthopedic procedure. Constrictive straps, bandages, or dressings should be scrupulously avoided, as well as decreasing tissue perfusion by unnecessarily elevating the already vascular compromised extremity. The development of pain or ulceration after lower extremity surgery mandates immediate consideration of arterial ischemia and the institution of appropriate diagnostic and therapeutic measures to improve circulation to the extremity.