Medial Circumflex Artery Research Articles

The therapeutic effect of adipose-derived lipoaspirate cells in femoral head necrosis by improving angiogenesis.

Femoral head necrosis (FHN), one of the most popular joint diseases in the musculoskeletal system, is usually attributed to local ischemia of the femoral head. Thus, regenerating the vascularization capacity and restoring the local perfusion of the femoral head becomes an efficient therapeutic approach for FHN. We investigated the function of autologous lipoaspirate cells (LPCs) in regenerating circulation in FHN animal models and human subjects in this study. We also explored the mechanisms of why LPCs show a superior effect than that of the bone marrow-derived stem cells (BMSCs) in vascularization. Thirty-four FHN patients were recruited for the randomized clinical trial. Harris Hip Score (HHS) and digital subtraction arteriography (DSA) and interventional technique were used to compare the efficacy of LPCs treatment and vehicle therapy in improving femoral head circulation and hip joint function. Cellular mechanism that underlies the beneficial effect of LPCs in restoring blood supply and rescuing bone architecture was further explored using canine and mouse FHN animal models. We found that LPCs perfusion through the medial circumflex artery will promote the femoral head vascularization and bone structure significantly in both FHN patients and animal models. The HHS in LPCs treated patients was significantly improved relative to vehicle group. The levels of angiogenesis factor secreted by LPCs such as VEGF, FGF2, VEC, TGF-β, were significantly higher than that of BMSCs. As the result, LPCs showed a better effect in promoting the tube structure formation of human vascular endothelial cells (HUVEC) than that of BMSCs. Moreover, LPCs contains a unique CD44+CD34+CD31- population. The CD44+CD34+CD31- LPCs showed significantly higher angiogenesis potential as compared to that of BMSCs. Taken together, our results show that LPCs possess a superior vascularization capacity in both autonomous and paracrine manner, indicating that autologous LPCs perfusion via the medial circumflex artery is an effective therapy for FHN.

Internal and External Iliac Arterial Variations in a Single Human Cadaver: A Case Study

Introduction & ObjectiveThe common iliac arteries are the main source of blood supply to the pelvis, perineum, and gluteal region via the internal iliac arteries (IIAs) and lower limbs via the external iliac arteries (EIAs). While variation in the branching patterns of the IIA and EIA is common, previously documented studies only focus on one type of variation. The objective of this study was to document the combination of multiple IIA and EIA variations found in one human cadaver. During herniorrhaphies and other pelvic surgeries, surgeons must enter the retropubic space. This space often has significant variation in collateral circulation, making vasculature in the area susceptible to injury, especially those that cross or reside near the superior pubic ramus. Knowledge of variant IIA and EIA branching patterns will assist surgeons and interventional radiologists in modifying their approach to procedures involving the pelvic area and lower limb (e.g., hernia repairs, fixation of pelvic fractures, etc.), thereby improving patient morbidity and mortality.MethodsDetailed dissections of the IIA and EIA and their respective branches were performed in a single human cadaver following notation of bilaterally aberrant obturator arteries. All arterial variations were documented through notes, diagrams, and photography. An in‐depth literature review was performed to evaluate the significance and frequency of the observed variations.ResultsThe left lower extremity had the following variations: absence of an inferior gluteal artery, an aberrant path of the superior gluteal artery, the inferior epigastric artery sharing a common trunk with the obturator artery from the profunda femoris artery, and anomalous branching of the femoral artery consisting of three larger branches, one noted to be the medial circumflex artery and the other two noted to be unusually large muscular branches. The right lower extremity had a similar aberrant obturator artery, although the common trunk shared with the inferior epigastric artery arose from the EIA.Conclusion/SignificanceAdditional arterial variations of the EIAs and IIAs were found upon further dissection differing bilaterally. It is essential for these variations to be documented along with the many others discovered previously. Lack of knowledge about arterial variation can lead to complications, such as femoral head osteonecrosis or significant hemorrhage during herniorrhaphy, fixation of pelvic fractures, and other pelvic/lower limb procedures. Therefore, knowledge of possible arterial variations of the human body can improve patient morbidity and mortality during routine surgical procedures, emergent surgical procedures, and various injuries in patients with vascular anomalies such as those documented in this study.

Anatomical and topographical features of the gracilis muscle of the thigh from the position of using it for autotransplantation

Autotransplantation of a free flap of the gracilis muscle is currently actively used in reconstructive surgery for persistent prosoplegia, injuries of the brachial plexus, for plastic closure of defects in the upper lip, and in the treatment of pelvic sepsis. This study provides important information about the anatomical features of the gracilis muscle and its neurovascular bundle, which are highly variable. The study of the anatomical and topographic features of this fine thigh muscle was carried out on a sectional study of 25 corpses of both sexes, 50 lower limbs. The present study demonstrates that the median value of the total length of m. Gracilis, the length of its muscular part, as well as the length of the tendon were 452.25 (439.7; 462.0); 225.3(208.1;239.0); 230.5 (213.0; 244.4) mm, respectively. The number of vascular pedicles included in m. Gracilis, ranged from 1 to 5. In 86% of the cases, the deep femoral artery formed the dominant vascular pedicle, and in 14% of cases, it was the medial circumflex artery. Small secondary vascular pedicles originated from the descending genicular artery or the anterior branch of the obturator arter: from the basin of the internal iliac artery. The length of the main feeding artery varied from 76 to 134 mm, the median value was 100.5(90;110) mm, and its diameter ranged from 1.4 to 2.1 mm (M = 1.9(1.8;2, 0) mm. The innervation of the fine muscle of the thigh was carried out by the anterior branch of the obturator nerve, which in 82% of the cases was represented by a single trunk; less often a loose type of structure was observed. The proper nerve was located at a distance of 108.5 (96; 117) mm from the origin of the muscle; its diameter was 2.1 (1.9; 2.2) mm. Knowledge of the topographic and anatomical relationships of the neurovascular bundle with the surrounding formations, variants of its individual anatomical variability are the key to successful reconstructive surgery.

CLINICAL ANATOMY AND VARIATION OF PROFUNDA FEMORIS ARTERY- CASE SERIES

Background:The profundafemoris artery (PFA) or deep femoral artery is a large branch that arises posterolaterally from femoral artery (FA) distal to the inguinal ligament. Primary source for the blood supply of the head of the femur is the mainly by the deep branch of profundafemoris artery (Medial circumflex artery). In the indication and choice of profundaplasty, vascular reconstructive procedure, the knowledge of the anatomy of PF may be particularly important for the clinicians dealing with them. Objectives: The study aimed at study of origin and branching pattern of PF, b. Correlation with surgical aspect of PF. Material & Methods: The present study was conducted in 10 formalin-fixed lower limbs from the Department of Anatomy, Shri AtalBihari Vajpayee Medical college& RI, Bangalore& Bangalore Medical college & Research Institute. Dissection of PFA and its branches were carried out & the following parameters were observed and photographed. Results: Origin of PF was posterolateral in 6cases , posterior in 3, & lateral in 1 to FA. Origin of MCFA was from PFA in 9cases & FA in 1. The mean distance of origin of MCFA was 1.8 cm (range 0.1-8.5 cm). Origin of LCFA was from PFA in 9 cases & FA in 1. The mean distance of origin of LCFA was 2.3 cm (range 0.3-7 cm) Conclusion: Knowledge of PFA is very important for surgeons to prevent iatrogenic injury as well as during profundoplasty as it is sole artery to supply majority of thigh region. Knowledge of variations in profundafemoris and its branches helps surgeons during preoperative clinical evaluation for surgical and interventional revascularization of the ileo-femoral and femoro-popliteal segments, in open canulation of femoral artery for cardiopulmonary bypasss, in radiological interventions for A-V malformations, and in salvage operations for traumatic limb ischemia.

Hatchet Thigh Flap with Hemi-gluteus Flap for Recurrent Ischial Sore Reconstruction

Background: Ischial pressure sores are the most challenging sores to treat because of associated bursa and high rate of recurrence. Reconstruction flaps originating in the thigh have a disadvantage as movement may increase shear forces, and tension during closure may lead to wound dehiscence. To circumvent these problems, we hereby present a hatchet thigh flap with good mobility, which can be used for recurrent cases as well.Methods: All patients treated at our hospital in the last 5 years for ischial pressure sores were included in the study. The flap is elevated in the subfascial plane from lateral to medial until the medial circumflex artery perforators are revealed. In recurrent cases the lower half of the gluteus maximus muscle is used to fill in the cavity while the flap from the previous surgery is re-advanced.Results: Sixteen patients (11 males and five females) were in the study. The median age of the patient was 54 years (range, 25–82 years). All the flaps survived fully. Two patients had recurrence at three sites, which were successfully reconstructed by advancing the same flap and hemi-gluteus muscle. An average of 6 months follow-up after surgery for recurrence showed stable reconstruction.Conclusion: The hatchet thigh flap is easy to dissect and reliable for ischial pressure sores. It can be used effectively in recurrent cases when combined with hemi-gluteus flaps.

Cadaveric study of variations of origin of lateral circumflex and medial circumflex artery in a Sri Lankan population

Cadaveric study of variations of origin of lateral circumflex and medial circumflex artery in a Sri Lankan population

Redefining the Anatomic Boundaries for Safe Dissection of the Skin Paddle in Free Gracilis Myofasciocutaneous Flaps—An Indocyanine Green Cadaveric Study

There is no financial information to disclose. Anatomical studies of the gracilis myocutaneous flap describe the skin paddle to be limited to the proximal two-thirds overlying the gracilis muscle. This study describes the area of skin that can be safely harvested with a free extended gracilis muscle flap on a single vascular dominant pedicle with wide fascia harvest. The skin paddle is designed overlying the length of the gracilis muscle and dissection is carried down to the deep fascia. The deep fascia is then harvested wider than the margins of the skin paddle circumferentially, from the anteromedial fascia of the thigh to the posterior edge of the gracilis with its investing fascial sleeve. The gracilis and overlying skin are kept in continuity to preserve distal skin paddle perfusion. The deep fascia and skin paddle are sutured together to prevent shearing injury of the fasciocutaneous perforating branches. Using a cadaveric model, 9 free flaps were evaluated using indocyanine green (ICG) with cadaveric blood as the carrier. The ICG was injected into the single vascular dominant pedicle, the deep branch of the medial circumflex artery. These extended gracilis free flaps were compared with the standard gracilis free flap (investing fascia only) with the same sized skin paddle via the same injection technique. Imaging was performed using the SPY Elite and SPY-PHI (Stryker). In a cadaveric model, the extended gracilis free flap exhibited ICG perfusion to a 40 x 21-cm skin paddle, whereas the standard gracilis skin paddle demonstrated ICG perfusion to an area of 22 x 11 cm (Figure 71-1). The extended gracilis free flap demonstrated perfusion of 587 cm2 more surface area, equating to over 330% greater skin surface coverage than the standard gracilis myocutaneous free flap. •Wide dissection of the deep fascia beyond the margins of the skin paddle can improve viability of the distal skin overlying the gracilis myocutaneous flap (Figure 71-2).•The extended myofasciocutaneous gracilis free flap is useful in patients for whom free functional muscle transfer and additional skin coverage are required.•Wide fascial dissection of the extended gracilis free flap can increase viable skin overlying the gracilis myocutaneous flap by over 330% of the standard surface area.•ICG can be a valuable tool to evaluate perforasomes in cadaveric studies.Figure 71-2Myofasciocutaneous gracilis free flap zone of skin perfusion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Breast reconstruction using free medial circumflex artery perforator flaps: intraoperative anatomic study and clinical results

A free fascioadipocutaneous flap obtained from the medial thigh is suitable for breast reconstruction in Asian women with a small-to-moderate breast size. In this region, both a medial circumflex femoral artery perforator flap (MCFAp flap) and a posterior medial thigh perforator flap (PMTp flap) are options, based on perforators from the deep femoral vessels. Here, we evaluated the anatomic basis of the medial circumflex femoral artery (MCFA) perforators from the medial circumflex femoral vessels. Between July 2010 and June 2014, 53 patients (55 flaps) underwent breast reconstruction using a fascioadipocutaneous flap from the medial thigh. MCFA perforators larger than or equal to 0.5mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator locations, distance of the perforating point from the proximal thigh crease and anterior border of the gracilis muscle. The total number of perforators was 131, with a mean of 2.4. The number of perforators coursing through the gracilis muscle (gracilis perforators) was the largest, followed by septocutaneous perforator coursing between the adductor longus and gracilis muscle. The average perforating point was located 6.5cm below the proximal thigh crease and 2.2cm from the anterior border of the gracilis muscle. Of the 102 procedures performed since 2006, 15 flaps were elevated as MCFAp flaps and there was no major complication. In some cases, MCFA perforators are dominant in this region compared to PMT perforators. A perforator map can be helpful for identifying adequate MCFA perforators intraoperatively.

Variations in the origin of profunda femoris and circumflex femoral arteries: A cadaveric study

Introduction: Profunda femoris artery (PFA) normally originates from posterolateral aspect of femoral artery and circumflex arteries arise from profunda femoris artery near its origin. As femoral artery (FA) & PFA are commonly assessed for various procedures for diagnosis and treatment for many diseases, knowledge of its course and branching pattern is very important for clinicians to prevent complications. Methods: The present study was conducted on 38 thighs. The origin, diameter at the point of origin, branching pattern of profunda femoris and circumflex femoral arteries were observed and their distances from mid inguinal point (MIP) was measured and recorded. Results: In 100% cases on both right and left side PFA was arising from FA. The site of origin of PFA was maximally (63.16%) found on posterior surface of FA. The mean distance of origin of PFA was 39.55 mm. In majority of cases, lateral & medial circumflex arteries were originating from PFA i.e. 84.21% and 73.68% respectively and the mean distance from MIP was 52.27 mm and 42.62 mm respectively. The lateral circumflex artery was arising from FA on right side in 22.23% while on left side in 10% cases. The medial circumflex artery was arising directly from FA on right side in 33.33% and on left side in 20% cases. Conclusion: In present study, the most common site of origin of the PFA was from posterior side of FA. The origin of the PFA observed was slightly proximal than noted in other studies. However, the left profunda femoris originates more distally than the right. Lateral & medial circumflex arteries commonly originated from the PFA artery close to its origin. This knowledge is very valuable in preventing injury to these vessels during different procedures. Keywords: Femoral artery, Profunda femoris Artery, Lateral circumflex artery, Medial circumflex artery

BLEEDING OF FEMORAL HEAD DURING TOTAL HIP ARTHROPLASTY FOR OSTEOARTHROSIS.

ABSTRACTObjective: To evaluate the bleeding of the femoral head on hip osteoarthritis in patients who underwent total hip arthroplasty. Methods: One hundred and three hips affected by primary hip osteoarthritis were evaluated. After surgical dislocation, the femoral head was divided into four quadrants, and micro perforations were made in order to observe and assess the presence of bleeding, as early type (EB), late type (LB) or without bleeding (WB). Results: We observed early bleeding (EB) in the upper quadrant in 16 hips (15.5%), late bleeding in 14 hips (13.6%) and no bleeding (WB) in 73 hips (70.9%). The anterior quadrant showed EB in 24 hips (23.3%), LB in 7 hips (6.8%) and WB in 72 hips (69.9%). The lower quadrant presented EB in 40 hips (38.8%), LB 14 hips (13.6%) and WB in 49 hips (47.6%). The posterior quadrant showed EB in 39 hips (37.9%), LB 19 hips (18.4%) and WB in 45 hips (43.7%). Comparing BMI and gender, we found no association between these parameters(p> 0.05). Conclusions: The inferior and posterior quadrant had the highest bleeding levels, following the path of the medial circumflex artery. Level of Evidence III, Therapeutic Study.

English

Address for Correspondence: Dr Sowmya S, Assistant Professor, Department of Anatomy, Bangalore Medical College & Research Institute, Bangalore-560002, Karnataka, India. E-Mail: drsowmyanandan@gmail.com Access this Article online Quick Response code Web site: *1 Assistant Professor, Department of Anatomy, Bangalore Medical college & Research Institute, Bangalore, Karnataka, India. 2 Associate Professor, Department of Anatomy, Bangalore Medical college & Research Institute, Bangalore, Karnataka, India. 3 Tutor, Department of Anatomy, Bangalore Medical college & Research Institute, Bangalore, Karnataka, India. Background: The diagnosis and treatment of idiopathic ischemic necrosis of head of femur needs the anatomy of medial circumflex femoral artery (MCFA) which is the main source for the blood supply of head of femur. As it gives the muscular perforators its knowledge is important in the posteromedial cutaneous flap (gracilis flap). In the femoral artery obstruction, MCFA takes bypass route for the blood supply of lower limb as it forms anastomosis with branches of other arteries. Objectives: The study describes the origin and course of the medial circumflex artery. Methods: The present study was conducted on 50 lower limbs from embalmed human cadavers from the Department of Anatomy, Bangalore Medical College and Research Institute, Bengaluru. Femoral triangle was dissected and the medial circumflex artery and branches were traced. Results: The study describes that in 8-10% cases MCFA showed variations whereas in 90-92% cases the MCFA has taken normal origin and course

Iatrogenic perforation of the medial circumflex artery following femoral venous cannulation for transcatheter aortic valve replacement, presenting with retroperitoneal hematoma and successfully managed by percutaneous embolization and coiling

Vascular complications are a major concern during transcatheter aortic valve replacement and can occur independently of introducer size. Arterial and venous access must be meticulous to avoid potentially life-threatening bleeding, which most commonly results from injury to the common femoral or iliac arteries. We report an unusual case of perforation of the medial circumflex branch of the common femoral artery resulting from attempted femoral venous cannulation. Injury to this vessel is characteristically associated with silent retroperitoneal extravasation and is notoriously difficult to recognize and treat. Despite identification of the perforation on contrast-enhanced computed tomography, the anatomical site could only be localized to the medial circumflex branch on highly selective contrast angiography. Thereafter, it was successfully treated percutaneously by embolization and coiling.

Analysis of Osteonecrosis Following Pemberton Acetabuloplasty in Developmental Dysplasia of the Hip

The favorable results of Pemberton acetabuloplasty in children with developmental dysplasia of the hip have been well reported. We reviewed our long-term results related to osteonecrosis of the femoral head after this surgery, especially with regard to the effect of excessive inferior displacement of the femoral head. From 1993 to 1997, we performed 167 Pemberton acetabuloplasties in patients with developmental dysplasia of the hip who were eighteen months of age or older. Patients who had had prior treatment or developmental dysplasia of the hip due to neuromuscular disease were excluded. We selected patients who had unilateral developmental dysplasia of the hip, had undergone simultaneous open reduction and Pemberton acetabuloplasty between the ages of eighteen and thirty-six months, and had been followed for a minimum of ten years. Forty-nine patients met these criteria. The patients were divided into osteonecrosis-absent and osteonecrosis-present groups according to the criteria described by Kalamchi and MacEwen. Preoperative, interim follow-up and final radiographs were available for evaluation, as were the results of clinical examination. We used the femoral head inferior displacement percentage, measured on the radiographs, to quantify the amount of excessive correction postoperatively. Outcomes were measured with use of the McKay criteria and the Severin criteria. The mean age at the time of surgery was 20.8 months, and the mean duration of follow-up was 134.6 months. Twenty-four patients (49%) were classified as not having osteonecrosis (the osteonecrosis-absent group) and twenty-five patients (51%), as having osteonecrosis (the osteonecrosis-present group). There were no significant differences between the two groups in terms of sex, age, laterality, Tönnis grade, or preoperative acetabular index. Seven of the cases of osteonecrosis were type I, thirteen were type II, one was type III, and four were type IV. The inferior displacement percentage revealed significant differences between the two groups (p < 0.0001). In the osteonecrosis-absent group, 96% of the patients had a radiographically satisfactory result (Severin class I or II); however, only 76% of the patients in the osteonecrosis-present group had a radiographically satisfactory result (p < 0.0001). According to the McKay criteria, there were significant clinical differences between the groups (p < 0.0001). Our results showed significant correlation between excessive reduction of the femoral head and the development of osteonecrosis. In light of the high prevalence of type-II osteonecrosis, we postulated that the lateral epiphyseal branch of the medial circumflex artery was vulnerable to compression with increased inferior displacement of the femoral head. The latest radiographic and functional results corresponded to the severity of the osteonecrosis.

Subclinical cerebrovascular cognitive function, and mood changes in patients with systemic lupus erythematosus.

To estimate the prevalence of neuropsychiatric disorders, cerebral atherosclerosis in patients with systemic lupus erythematosus (SLE) and explore the relation between transcranial duplex findings of different intracranial vessels with neuropsychiatric affect, and Systemic lupus erythematosus disease activity index (SLEDAI). Twenty-six consecutive SLE patients were evaluated for neurological and psychiatric disorders. Another 26 subjects matched with respect to age, sex, education, and socioeconomic status formed the control group. SLE disease activity was assessed by the SLEDAI. For each participant, a complete medical history was obtained and clinical, laboratory, and neurophysiological examinations, magnetic resonance imaging of the brain, transcranial duplex for intracranial vessels, and psychometric evaluations were performed. For the psychometric evaluation, we used the Modified Mini-mental State Examination and Cognitive Assessment Scale Inventory to assess cognitive function, and Hamilton Depression Rating Scale and Hamilton Anxiety Scale to assess symptoms of depression and anxiety. Anxiety in 65.4% is the most prevalent manifestation followed by depression in 57.7%, headache in 38.5%, peripheral neuropathy in 26.9%, seizures in 23.1%, psychosis in 19.2%, radiculopathy and dementia in 15.4% for each, myositis in 11.5%, and stroke in 7.7%. There was a significant increased mean velocity and decreased pulsatility index of most studied intracranial vessels in both patient groups than in the control group. There was significant negative correlation between SLEDAI and transcranial Doppler findings in the pulsatility index of medial circumflex artery and procoagulant activity. Neurological disorders, cognitive impairment, depression, anxiety, psychosis and cerebrovascular changes detected by transcranial Doppler ultrasound are common in SLE.

Letter to the Editor: Use of a Trochanteric Flip Osteotomy Improves Outcomes in Pipkin IV Fractures

To the Editor: We were interested to read the article by Solberg et al. [3] entitled “Use of a trochanteric flip osteotomy improves outcomes in Pipkin IV fractures.” The authors reported that combined fractures of the femoral head and acetabulum are relatively rare injuries and the debate continues regarding optimal surgical management of these injuries. We commend the authors on their excellent results and would like to add our support to their selection of this surgical approach. St George’s Healthcare NHS Trust provides a supraregional service for pelvic and actetabular trauma referrals. We corroborate the authors’ observation that a trochanteric flip osteotomy during the course of a posterior approach allows excellent access to the femoral head and acetabular fragments through one incision. However, we note some differences in our practice and wish to bring these to the authors’ attention. While describing the surgical approach, Solberg et al. explained that they tag and release the piriformis tendon but preserve the short external rotators. This contrasts with the approach originally described by Siebenrock et al. [2], which is the technique we tend to follow. Releasing the gemelli and obturator internus close to their insertion at the posterior trochanteric crest improves exposure of the posterior wall and facilitates application of a buttress plate for osteosynthesis. We do not believe this approach jeopardizes the vascularity of the femoral head. The retinacular vessels are identified and protected during surgery. The obturator externus and quadratus femoris, however, are not released, thus preserving the deep branch of the medial circumflex artery. Solberg et al. identified coexisting labral tears in all their patients and repaired seven of 12 tears by direct osteosynthesis. The technique of osteosynthesis is not described and a brief description would be appreciated. We also have found coexistent labral tears that we have repaired using Mitek suture anchors to exposed cancellous bone at the acetabular rim. We also administer low molecular weight heparin (eg, Fragmin) 6 hours postoperatively. Subsequently, warfarin is commenced with a loading regimen and is continued for 3 months. We do not routinely perform duplex ultrasound screening, although high-risk patients would be considered for a vena cava filter. Solberg et al. reported one case of wound dehiscence in their series and we would be interested to know if a cause was identified. Prophylaxis for heterotopic ossification remains controversial with a recent review [1] stating the benefit of prophylactic radiotherapy when compared with nonsteroidal antiinflammatory drugs. Another systematic review [4] however, concluded the opposite. In our practice, we reserve prophylactic radiation for high-risk patients, for example, those who have a coexisting head injury or a history of heterotopic ossification. We once again commend the authors on their contribution and look forward to their clarification of these issues.

Avascular Necrosis of the Femoral Head in Pertrochanteric Fractures

To evaluate patients with pertrochanteric fractures (Type 31A1 + 2 ASIF/OTA classification) treated surgically and who subsequently developed avascular necrosis of the femoral head (ANFH). University hospital. Retrospective clinical study and analysis of the literature. From 1995 to 2003 the authors operated on 1,373 patients with pertrochanteric fractures. Eight patients with a mean age of 69 years (range, 52-78 years) subsequently developed ANFH. Five patients were treated with a dynamic hip screw (DHS), and 3 were treated with an intramedullary hip nail (IMHN). All fractures in these 8 patients healed without complications in 3 to 4 months. Avascular necrosis of the femoral head developed 4 months to 4 years after the operation. Detailed analysis of these cases did not reveal any risk factors or errors in surgical technique to account for the ANFH. Results of a literature review of 41 cases in addition to our 8 cases give us reason to believe the etiology of postoperative AFNH following surgical treatment of pertrochanteric fractures is probable injury to the deep branch of the medial circumflex artery at time of fracture. Other possible risk factors include high-energy trauma, comminution, displacement of the fragments, and atypical fracture line. ANFH develops in approximately 0.5-1% of all pertrochanteric fractures, mostly within 4 years after the injury and predominantly in patients older than 50 years of age. The diagnosis should be considered in patients who have undergone an operation previously and have symptoms that are unclear. Prevention of ANFH in these fractures includes an early reduction, stable fixation, and correct surgical technique.

Hip resurfacing: why does it fail? Early results and critical analysis of our first 60 cases

Resurfacing replacement represents the most conservative solution available for total arthroplasty of the hip. However, despite the excellent results reported by highly experienced surgeons, a small but not insignificant body of literature has been published on the more controversial aspects of this approach, mainly those related to the biological and mechanical vulnerability of the retained epiphysis. We report here our evaluation of most of the variables inherent to this procedure (surgical exposure, implant design, technical steps). Based on our results, we conclude that the short-term outcome is strongly related to the surgical approach and the relationship between implant design and cementing technique. Even if posterior approaches are currently widely accepted for resurfacing replacement, the ability to preserve the medial circumflex artery has been questioned, and an alternative exposure has been proposed with good results (antero-lateral, lateral and digastric trochanteric osteotomy). Moreover, a minimally invasive posterior approach could increase the risks of vascular damage. Alternatively, inner implant geometry could affect the distribution of cement over the epiphysis when other variables (direct or indirect cementing technique, viscosity) are not properly selected.

Treatment of osteonecrosis of the femoral head with hBMP-2-gene-modified tissue-engineered bone in goats

The efficacy of beta-tricalcium phosphate (beta-TCP) loaded with bone morphogenetic protein-2 (BMP-2)-gene-modified bone-marrow mesenchymal stem cells (BMSCs) was evaluated for the repair of experimentally-induced osteonecrosis of the femoral head in goats. Bilateral early-stage osteonecrosis was induced in adult goats three weeks after ligation of the lateral and medial circumflex arteries and delivery of liquid nitrogen into the femoral head. After core decompression, porous beta-TCP loaded with BMP-2 gene- or beta-galactosidase (gal)-gene-transduced BMSCs was implanted into the left and right femoral heads, respectively. At 16 weeks after implantation, there was collapse of the femoral head in the untreated group but not in the BMP-2 or beta-gal groups. The femoral heads in the BMP-2 group had a normal density and surface, while those in the beta-gal group presented with a low density and an irregular surface. Histologically, new bone and fibrous tissue were formed in the macropores of the beta-TCP. Sixteen weeks after implantation, lamellar bone had formed in the BMP-2 group, but there were some empty cavities and residual fibrous tissue in the beta-gal group. The new bone volume in the BMP-2 group was significantly higher than that in the beta-gal group. The maximum compressive strength and Young's modulus of the repaired tissue in the BMP-2 group were similar to those of normal bone and significantly higher than those in the beta-gal group. Our findings indicate that porous beta-TCP loaded with BMP-2-gene-transduced BMSCs are capable of repairing early-stage, experimentally-induced osteonecrosis of the femoral head and of restoring its mechanical function.

Evaluation of haemodynamic flow to the hip in patients with systemic lupus erythematosus

Objective: One of the groups with high risk for osteonecrosis is patients with systemic lupus erythematosus (SLE). No predictive test, however, is known to detect osteonecrosis. The purpose of this study was to evaluate haemodynamic flow to the proximal femur in SLE patients.Methods: Twenty‐two SLE patients without osteonecrosis were evaluated in comparison with 15 healthy controls. Medial and lateral circumflex arteries of 44 hips in the 22 SLE patients and 30 hips in the healthy controls were examined using ultrasound equipment with colour and power Doppler capability. Arterial pulsatility index (PI) and peak systolic velocity (PSV) were determined with neutral and internal rotation positions (stimulated ischaemia).Results: PSV was significantly increased in SLE patients compared to healthy controls in both the neutral position (70.6±40.4 vs. 46.9±19.3; p<0.001) and after internal rotation of the femoral head (74.8±42.3 vs. 49.9±19.9; p<0.001). PI was also higher in SLE patients than in healthy controls in both the neutral position (8.9±6.3 vs. 5.5±3.4; p<0.001) and after internal rotation (8.1±7.1 vs. 3.9±2.4; p<0.001).Conclusion: PSV and PI of arteries to the femur head in SLE patients were significantly higher than in healthy controls.

Surgical treatment of late developmental displacement of the hip

The Journal of Bone and Joint Surgery. British volumeVol. 87-B, No. 9 CorrespondenceFree AccessSurgical treatment of late developmental displacement of the hipI. GAVRANKAPETANOVIC, Z. VUKASINOVICI. GAVRANKAPETANOVICSearch for more papers by this author, Z. VUKASINOVICSearch for more papers by this authorPublished Online:1 Sep 2005https://doi.org/10.1302/0301-620X.16754AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Sir,We read with interest this article in the March 2005 issue by Angliss et al1 entitled ‘Surgical treatment of late developmental displacement of the hip: results after 33 years’ and would like to congratulate the authors upon their excellent results.We consider iliopsoas to be a key factor in both operative and non-operative treatment of developmental displacement of the hip. We always use vertical instead of longitudinal traction for conservative treatment. Operative reduction and visualisation of the joint through a Smith-Petersen approach without exposure of iliopsoas is almost impossible. Iliopsoas is always shortened and it should be lengthened. This can be done by using the transverse two-incision technique, strictly in the zone of tendinous fibres. Careful protection of the medial circumflex artery is vital.2The majority of revisions which we have performed were required because of unresolved pathology of iliopsoas. With adequate exposure and meticulous surgical technique, the circumflex vessels can be protected. References 1 Angliss R, Fujii G, Pickvance E, Wainwright AM, Benson MKD. Surgical treatment of late developmental displacement of the hip: results after 33 years. J Bone Joint Surg [Br] 2005;87-B:384–94. Link, Google Scholar2 Herring JA, ed. Tachdjian’s pediatric orthopedics. Vol. 1, Second ed. Philadelphia: W.B. Saunders Co., 2001:383. Google ScholarFiguresReferencesRelatedDetailsCited byDevelopmental hip dysplasia in adolescenceSrpski arhiv za celokupno lekarstvo, Vol. 137, No. 7-8 Vol. 87-B, No. 9 Metrics History Published online 1 September 2005 Published in print 1 September 2005 InformationCopyright © 2005, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download