Anatomy of the medial femoral circumflex artery with respect to the vascularity of the femoral head

We performed a series of 16 anatomical dissections on Caucasian cadaver material to determine the surgical anatomy of the medial femoral circumflex artery (MFCA) and its anastomoses. These confirmed that the femoral head receives its blood supply primarily from the MFCA via a group of posterior superior nutrient arteries and the posterior inferior nutrient artery. In terms of anastomoses that may also contribute to the blood supply, the anastomosis with the inferior gluteal artery, via the piriformis branch, is the most important. These dissections provide a base of knowledge for further radiological studies on the vascularity of the normal femoral head and its vascularity after dislocation of the hip.     

Imaging the vascularisation of the femoral head by CT angiography

The femoral head receives its blood supply primarily from the medial femoral circumflex artery, with its deep branch being the most important. In a previous study, we performed classical anatomical dissections of 16 hips. We have extended our investigation with a radiological study, in which we aimed to visualise the arteries supplying the femoral head in healthy individuals. We analysed 55 CT angiographic images of the hip. Using 64-row CT angiography, we identified three main arteries supplying the femoral head: the deep branch of the medial femoral circumflex artery and the posterior inferior nutrient artery originating from the medial femoral circumflex artery, and the piriformis branch of the inferior gluteal artery. CT angiography is a good method for visualisation of the arteries supplying the femoral head. The current radiological studies will provide information for further investigation of vascularity after traumatic dislocation of the hip, using CT angiography.     

Blood supply of the knee joint. A microangiographic study in children and adults

The knee joint blood supply is derived from a rich anastomosis of the five major constant arteries, namely, the superior medial and lateral, the middle (posterior), and the inferior medial and lateral genicular arteries. Anastomosis also occurs with descending genicular arteries and the anterior tibial recurrent artery. These branches form anastomoses in and around the knee joint, while each major vessel was noted to provide the respective major blood supply to specific areas. The most obvious difference between vascularization of child and adult knees was the separation of vessels and relative avascularity of epiphyseal plate areas; such persisted until closure of the epiphyseal plate. The regions representing the seals of plate closure had less rich vascularization. A rich intraosseous blood supply was defined in the femoral and tibial condyles and the patella. Similarly, the adjacent and superficial soft tissues, including major ligaments and peripheral parts of the menisci, were richly vascularized. Areas of separated vascularization in children may have relevance to epiphyseal injury, growth deformity, Osgood-Schlatter disease, and hematogenous osteomyelitis. In adults, such information may be relevant to high tibial osteotomy, meniscus and cruciate ligament repair, and surgery utilizing the semitendinosus tendon, fascia lata, or patella tendon grafts.     

Hip arthroscopy: An anatomic study of portal placement and relationship to the extra-articular structures

The purpose of this study is to accurately describe the relationship of the major neurovascular structures to standard portals used in hip arthroscopy Placement of three standard arthroscopic portals was simulated in eight fresh paired cadaveric hip specimens by placing Steinmann pins into the joint under fluoroscopic control. The specimens were then dissected and the relationship of the portals to the following structures was recorded: lateral femoral cutaneous nerve, femoral nerve, ascending branch of the lateral circumflex femoral artery, superior gluteal nerve, and sciatic nerve. The lateral femoral cutaneous nerve had divided into three or more branches at the level of the anterior portal. The anterior portal averaged only 0.3 cm from one of these branches. The average minimum distance from the anterior portal to the femoral nerve was 3.2 cm. The ascending branch of the lateral circumflex femoral artery averaged 3.7 cm from the anterior portal. A terminal branch of this vessel was present in three specimens 0.3 cm from the portal. The superior gluteal nerve averaged 4.4 cm superior to the anterolateral and posterolateral portals. The sciatic nerve averaged 2.9 cm from the posterolateral portal. From this study, these portal placements appear to be safe. Proper positioning depends on careful attention to the topographical anatomy about the hip. Avoidance of the important structures depends on proper positioning and proper technique in portal placement.     

Anatomy of the medial femoral circumflex artery and its surgical implications

The primary source for the blood supply of the head of the femur is the deep branch of the medial femoral circumflex artery (MFCA). In posterior approaches to the hip and pelvis the short external rotators are often divided. This can damage the deep branch and interfere with perfusion of the head. We describe the anatomy of the MFCA and its branches based on dissections of 24 cadaver hips after injection of neoprene-latex into the femoral or internal iliac arteries. The course of the deep branch of the MFCA was constant in its extracapsular segment. In all cases there was a trochanteric branch at the proximal border of quadratus femoris spreading on to the lateral aspect of the greater trochanter. This branch marks the level of the tendon of obturator externus, which is crossed posteriorly by the deep branch of the MFCA. As the deep branch travels superiorly, it crosses anterior to the conjoint tendon of gemellus inferior, obturator internus and gemellus superior. It then perforates the joint capsule at the level of gemellus superior. In its intracapsular segment it runs along the posterosuperior aspect of the neck of the femur dividing into two to four subsynovial retinacular vessels. We demonstrated that obturator externus protected the deep branch of the MFCA from being disrupted or stretched during dislocation of the hip in any direction after serial release of all other soft-tissue attachments of the proximal femur, including a complete circumferential capsulotomy. Precise knowledge of the extracapsular anatomy of the MFCA and its surrounding structures will help to avoid iatrogenic avascular necrosis of the head of the femur in reconstructive surgery of the hip and fixation of acetabular fractures through the posterior approach.     

股骨颈骨折后选择性血管造影评价股骨头血液循环

目的 探讨选择性血管造影检查对评价股骨颈骨折后早期股骨头血液循环损伤及影响因素的价值。方法采用选择性旋股动脉及支持带动脉造影(DSA)，对9例2～23天内单侧股骨颈骨折患者血管损伤和血液循环改变进行评价。结果髋关节囊内出血2例，骨内出血4例，下、后支持带动脉损伤和血管移位各3例。患髋牵引时，除外下支持带动脉，其他支持带动脉无显影或仅显示起始部主干，相应股骨头颈部几无灌注成像，静脉显影延迟；髋关节维持伸直内旋位或囊内注入生理盐水后造影，所有支持带动脉无明确显影或仅显示其主干，股骨头颈部无灌注、染色，静脉显影延迟。结论选择性旋股内、外侧动脉DSA技术是一项准确评价股骨颈骨折后股骨头血液循环损伤及影响因素的微创性检查方法；股骨头血液循环受髋关节体位、囊内压和牵引等因素影响；牵引可导致或加重股骨颈骨折后股骨头缺血。     

Rare origin of the inferior epigastric and medial circumflex femoral arteries arising from a common trunk

A case of unilateral anomalous arterial supply of the lower limb and the anterior abdominal wall is presented. In this case, inferior epigastric artery arose from a common trunk with the medial circumflex femoral artery. The common trunk arose from the femoral artery. The inferior epigastric artery reached the anterior abdominal wall by passing deep to the inguinal ligament. The medial circumflex artery ran between the femoral artery and vein within the femoral triangle. A possible ontogenetic explanation is provided for this situation. Awareness of the variations in anatomy of the inferior epigastric and femoral arteries is important for angiographers and the surgeon who operates in this region. Received: 28 October 1999 / Accepted: 10 July 2000     

Reversed flow lateral circumflex femoral vessels as recipients for free fibular grafting in treatment of femoral head osteonecrosis

Free fibular bone grafting is an effective treatment for early osteonecrosis of the femoral head in young patients. However, recipient vessels are often small rendering microvascular anastomosis difficult. We have developed a novel technique using retrograde flow through the branches of the lateral circumflex femoral artery to use the proximal end of the artery as the recipient vessel. A vessel diameter of up to 5 mm is obtained providing a good match with the peroneal vessels. We used this technique to perform vascularized bone grafting of the femoral head in 10 patients with Ficat grade 2 and 3 osteonecrosis. Pulsatile retrograde flow from the lateral circumflex femoral artery was observed in each case. Retrospective review gave a median follow up of 52 months (range 17–99). Symptoms improved in all 10 cases. There was no radiological deterioration over the period of follow‐up in eight cases. One patient underwent conversion to a total hip replacement 24 months after surgery. These results compare favorably with other studies. The lateral circumflex femoral artery turnover technique is a reliable and useful technique in vascularized bone grafting of the femoral head. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

螺旋CT评价股骨颈骨折后股骨头血运的临床研究

目的探讨应用64排螺旋CT薄层增强扫描技术,观察股骨颈骨折后股骨头血液循环的变化,从而为预测股骨颈骨折后股骨头缺血性坏死提供影像学依据。方法选择2007年9月至2009年12月收治的30例股骨颈骨折患者。术前行双侧髋关节64排螺旋CT薄层增强扫描,健侧髋关节设为自身对照组。观察旋股内侧动脉、旋股外侧动脉、支持带动脉,测量双侧上述血管的管径和长度,计算比较血管容积。结果 GardenⅢ型股骨颈骨折患侧旋股内侧动脉、旋股外侧动脉以及头下型、基底型股骨颈骨折患侧旋股外侧动脉血管容积较健侧明显降低,差异具有统计学意义（GardenⅢ型旋股内侧动脉t=-2.379,P〈0.05;GardenⅢ型旋股外侧动脉t=-3.052,P〈0.05;头下型旋股外侧动脉t=-2.578,P〈0.05;基底型旋股外侧动脉t=-7.908,P〈0.05）。GardenⅠ型、GardenⅡ型以及经颈型骨折双侧血管容积比较,差异无统计学意义。GardenⅠ型、GardenⅡ型、GardenⅢ型股骨颈骨折3组间对比,各组患侧血管容积差异无统计学意义。头下型、经颈型、基底型股骨颈骨折3组间对比,各组患侧血管容积之间差异无统计学意义。支持带动脉因CT分辨率不足未能完全显示。结论股骨颈骨折可改变旋股内侧动脉和旋股外侧动脉血管容积,从而影响股骨头的血液循环状态,是股骨颈骨折后发生股骨头缺血坏死的病理基础之一。64排螺旋CT薄层增强扫描技术是一种直接、实时、无创的观察股骨头血液循环的方法,对评价股骨头血运,预测股骨颈骨折预后及选择治疗方案有一定的参考价值。由于CT分辨率不足,不能清晰显示及测量支持带动脉的血管容积,使其临床应用价值受到一定的局限。     

Blood flow to the immature hip: Ultrasonic measurements in pigs

We quantitatively analyzed blood flow through the major arteries supplying the pig's femoral head during various hip positions and following ligation of various vessels in order to identify the vascular abnormalities which may be responsible for the development of avascular necrosis during the treatment of developmental dysplasia of the hip.

Our findings reveal that a decrease in total blood flow to the femoral head occurs when the hip is held in the frog leg position with ligation of the deep femoral artery and proximal ligation of the lateral femoral circumflex artery, and ligation of the deep femoral artery, together with the lateral femoral circumflex artery proximally. In contrast, neither distal ligation of the medial femoral circumflex artery nor lateral femoral circumflex artery alone nor holding the hip in the Lange position caused a statsitically significant decrease in total flow. We also observed a unique steal effect on total proximal femoral blood flow, with the hip held in the frog leg position. In 4 of 7 pigs, we found a reversal of flow in the medial femoral circumflex artery.     

Selective medical circumflex femoral arteriography in idiopathic ischemic necrosis of the femoral head in adults (author's transl)]

It is generally accepted that the medial circumflex femoral artery nourishes about two-thirds to four-fifths of the femoral head. In order to study the arteries in the idiopathic ischemic necrosis of the femoral head in adults, selective medial circumflex femoral arteriography was performed on 24 affected hips and 14 normal hips. This method enabled the better visualization of the medial circumflex femoral arterial system than the conventional femoral or internal iliac arteriography. The affected hips showed similar vascular patterns compared to normal hips. Anastomoses between the ascending branch or the medial circumflex femoral artery and the gluteal arteries, however, were rarely found in the affected hips. In the affected hips, various pathologic changes were demonstrated angiographically mainly in the portion of the ascending branch and the retinacular arteries. The existence of some degree of vascular insufficiency of the femoral head was assumed. However, complete occlusion of the medial circumflex femoral artery and its main branches that might cause head necrosis was seldom observed.     

基于三维重建的股骨头支持带血管的显微外科定位研究及临床意义

目的通过对股骨头血供的灌注和三维重建对股骨头支持带血管进行定位,探讨应用显微外科技术对股骨颈骨折后通过支持带血管进行探查和修复,以重建股骨头血供的可行性及临床意义。方法采用新鲜成人股骨头标本25例进行显微解剖及动脉灌注,应用Micro-CT扫描及三维软件重建股骨头血运,以360°角度盘及骨性解剖标志进行定位,并测量相关的临床数据。结果股骨头血供由上、下、前3组支持带动脉血管供应,其在股骨头内形成互相连接的动脉网,3组血管在角度盘的定位分别为288°-342°、192°-226°、118°-155°。结论来源于旋股内侧动脉的上、下支持带血管是股骨头的主要供血动脉,其走行位置较为恒定,在股骨颈骨折切开复位术中可根据骨性标志定位支持带血管,以探查、判断股骨头血运损伤情况。     

骨盆骨折出血超选择动脉栓塞的影像学基础

[目的]探讨骨盆动脉吻合的影像学特点及骨盆骨折出血超选择动脉栓塞的方法。[方法]自1999年1月-2005年6月，60例患者因血流动力学不稳而行骨盆动脉造影。男42例，女18例；年龄21—52岁，平均34．5岁。对造影片上骨盆动脉吻合出现的类型及数量进行观测。[结果]从骨盆的动脉造影上观测到的动脉吻合支为：腰动脉与髂腰动脉100％；髂腰动脉与旋髂深动脉88．33％：闭孔动脉与腹壁下动脉吻合（或髂外动脉）36．67％；臀下动脉与阴部内动脉吻合26．67％；骶外侧动脉与骶中动脉及对侧骶外侧动脉吻合100％；臀下动脉与旋股内外动脉及股深动脉升支吻合56．67％；臀上动脉与臀下动脉吻合61．67％。[结论]骨盆骨折出血时，应实施超选择栓塞即栓塞出血动脉的断端及其吻合支，从而减少动脉栓塞引起的并发症。     

Arterial supply of the femoral condyles

INTRODUCTION: The most frequent site for aseptic bone necrosis and osteochondrosis dissecans in the human knee joint is the medial femoral condyle. The aim of this study is to analyze the three-dimensional vascularization of the human knee joint and to find out if there are any differences in the blood supply of the medial and lateral femoral condyles which may explain the preponderance of aseptic bone necrosis in the medial side. MATERIAL AND METHODS: The femoral arteries of 14 unfixed lower extremities have been injected with epoxy resin. After documentation of the extraosseous course of the blood vessels the bone was macerated with 10% formic acid. The insertions of tendons and ligaments were investigated by light microscopy and immunohistochemistry. RESULTS: The arterial supply of the lateral femoral condyle originates from the upper lateral geniculate artery, the terminal ends of which penetrate the bone from lateral. Branches of the middle geniculate artery reach the bone from the medial wall of the intertubercular notch. The subchondral bone of the medial femoral condyle draws its blood supply mainly from the descending geniculate artery. Branches of the middle geniculate artery penetrate the medial femoral condyle only in the posterior part of the intercondylar fossa. These posterior vessels do not contribute to the supply of the subchondral bone. In the anterior part of the medial wall of the intercondylar fossa there is the wide femoral insertion of the posterior cruciate ligament. Injection techniques and immunohistochemical investigations show that the fibrocartilage of the chondral apophyseal insertion of the posterior cruciate ligament is avascular and acts as banier which impedes blood vessels to penetrate the bony surface in this region. The subchondral bone adjacent to the femoral insertion of the posterior cruciate ligament receives its blood supply from vessels that penetrate the bone at the medial wall of the medial femoral condyle. The blood vessels which supply the lateral parts of the medial condyle have the longest intraosseous course. The density of vessels within this region is largely reduced. CONCLUSIONS: The region adjacent to the femoral insertion of the posterior cruciate ligament is the most frequent site for osteochondrosis dissecans in the knee joint. Our results show that the arterial supply of the subchondral bone may be considered as a cofactor for the etiology of osteochondrosis dissecans.     

不断股直肌起点髋前侧入路行吻合血管游离腓骨治疗股骨头坏死的解剖学研究

目的：探讨在保持股直肌完整前提下,经髋关节前侧手术入路行股骨头坏死病灶清除吻合血管游离腓骨移植术治疗股骨头坏死的可行性。方法自2012年06月至2013年06月,选择本组采用常规髋关节前侧入路行股骨头坏死病灶清除吻合血管游离腓骨移植术治疗股骨头坏死病例53例共67髋。男38例（49髋）,女15例（18髋）;年龄22～57岁,平均37.4岁;身高150～192 cm,平均171.9 cm;体重45～92 kg,平均70.0 kg;身高体重指数（ BMI）值为17.1～30.7,平均23.6。在显露股直肌后,观察记录支配股直肌神经的走行和入肌点位置、旋股外侧动、静脉升支的走行和距离股直肌起点距离以及股直肌与切口和髋关节的相对位置关系。结果（1）支配股直肌的神经由股神经分支发出,走行于缝匠肌深面,自内上方走向外下方,在入股直肌前分为两支神经支,外上支于股直肌内侧深面入肌,入肌点距髂前下棘下方（7.07＆#177;1.14） cm;内下支切口内未见。将股直肌向外侧牵开可见股直肌外上支张力增大,向内拉开则张力减小。（2）旋股外侧动、静脉升支发自股深动脉,经缝匠肌及股直肌深面、髂腰肌前面向外上走行至股中间肌前侧,旋股外侧动、静脉升支血管束中点距髂前下棘下方（6.16＆#177;0.52）cm。所有病例向内拉开股直肌均可很好地显露旋股外侧动、静脉其分支血管束全长。（3）股直肌直头起于髂前下棘,约1/4～1/5肌纤维位于切口线外侧,其余部分位于切口线内侧。股直肌肌腹遮挡髋关节头颈交界处内侧约1/3～1/2部分。结论（1）沿股直肌外侧间隙将股直肌向内侧牵开暴露髋关节,可保护位于内侧的血管神经束,为手术安全间隙。（2）股直肌对于髋关节遮挡较少,大部分肌纤维位于髋关节内侧,向内拉开股直肌可完全显露旋股外侧动、静脉升支及髋关节,故不?     

Usefulness of vascular bundle interposition of the descending branch of the lateral circumflex femoral vessels for free flap reconstruction of the calvarial defect

Usefulness of the descending branch of the lateral circumflex femoral vessels as a vascular bundle interposition graft was introduced. Large calvarial defect with no recipient vessel for direct anastomosis was successfully covered with free flap nourished by the cervical vessels through the vascular bundle interposition graft of the descending branch of the lateral circumflex femoral artery and its venae comitantes. The vascular bundle interposition has remarkable advantages over the venous graft regarding its patency and durability, especially in the head and neck region in which grafted vessels is difficult to be set on the straight. The descending branch of the lateral circumflex femoral vessels can be harvested up to 20 cm, and its diameter is suitable for interposition between conventional free flaps and recipient vessels in the head and neck region.     

Circulatory and vascular changes in the hip following traumatic hip dislocation.

An experimental study of the extraosseous and intraosseous vascular and circulatory changes following traumatic hip dislocation in dogs and rabbits is reported. The observations were made by dissection, angiography and histology following posterior dislocation and reduction at varying intervals. Traumatic dislocation of the hip causes extraosseous circulatory disturbance in the hip resulting in intraosseous circulatory deficiency in the femoral head. The sites of the vascular lesions are the extraosseous branches of the femoral circumflex arteries and their extraosseous branches of the epiphyseal and metaphyseal arteries and the retinacular artery of the circulus vasculosus articularis. The types of the vascular damage are irreversible tear of the minority of vessels along the ruptured capsule and teres ligament, and the compression, traction and spasm of the majority of intact vessels which are reversible by early reduction. In prolonged dislocation the circulatory disturbance persists or worsens due to additional pathological changes such as posttraumatic inflammatory changes, fixed deformity in the dislocated position, thrombosis, fibrosis and occlusion of vessels which may eventually cause an ischemic necrosis of the femoral head. Early reduction within several hours after dislocation restores nearly normal regional anatomy and relieves vessels from compression, traction or spasm and restores extra and intraosseous circulation. It also prevents or minimizes thrombosis, fibrosis and occlusion of vessels and avascular necrosis of the femoral head.     

Vascular supply of the femoral head in sheep—Implications for the ovine femoroacetabular impingement model

Sheep hips have a natural non‐spherical head similar to a cam‐type deformity in human beings. By performing an intertrochanteric varus osteotomy, cam‐type femoroacetabular impingement can be induced experimentally. In sheep, the aspherical portion is located superiorly—exactly matching the region where the superior retinacular vessels enter the femoral head–neck junction in human beings. In order to fully exploit the potential of this experimental FAI model, a safe osteochondroplasty of the superior asphericity would need to be done without the risk of avascular necrosis. The aim of this study was to describe the vascular anatomy of the femoral head in sheep from the aorta to the retinacular vessels in order to perform safe femoral osteochondroplasty of the superior femoral asphericity in sheep. Sixty‐two ovine hips were analyzed using CT angiography (30 hips), post mortem intravascular latex injection (6 hips), vascular corrosion casting (6 hips), and analysis of the distribution of vascular foramina around the femoral head–neck junction in macerated ovine femora (20 hips). The ovine femoral head receives its blood supply from anterior retinacular arteries from the lateral femoral circumflex artery, and from posterior retinacular arteries from the medial femoral circumflex artery. The superior aspherical portion is free of vessels. Detailed knowledge about vascular anatomy of sheep hips is of clinical significance since it allows to perform osteochondroplasty of the superior aspherical portion in the experimental ovine FAI model safely without the risk of osteonecrosis. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2340–2348, 2018.

     

股前外侧皮瓣联合股外侧皮神经营养血管吻合技术治疗前中足严重脱套伤

目的 探讨股前外侧皮瓣联合股外侧皮神经营养血管吻合技术修复前中足严重脱套伤的临床疗效.方法 2016年3月-2019年6月,应用股前外侧皮瓣修复创面同时将股外侧皮神经营养血管与旋股外侧动脉降支远端吻合用以修复前中足严重脱套伤13例,并在患者出院后定期复诊、随访.结果 13例移植皮瓣全部成活,外观恢复满意,根据感觉功能评...