Medial Circumflex Research Articles

Morphologic and morphometric characteristics of the adductor minimus in Korean: its topographic relationship with respect to neighbouring anatomical structure and clinical significance.

The aim of this study was to clarify the morphologic and morphometric characteristics of the adductor minimus (AMi) and to observe its topographic relationships relative to the adjacent anatomical structures. This study investigated 54 thighs of 27 Korean cadavers. The AMi was a small and flat muscle observed in 94.4% of the specimens. It originated from the inferior ramus of the pubis as the upper part of the adductor magnus (AMa), and inserted from the lesser trochanter to the upper part of the linea aspera. The AMi was completely separate from the AMa in 63.0% of the specimens. The medial circumflex femoral artery was always found at the superior border of the AMi, while the first and second perforating arteries were found inferior to the muscle in 55.6% and 37.0% of specimens, respectively. A supernumerary muscle was found with the AMi in 42.6% of the specimens, and it originated from the inferior ramus of the pubis and inserted into the posterior side of the lesser trochanter. The obturator externus and AMi were found superoposterior and inferior to the supernumerary muscle, respectively, while the posterior branch of the obturator nerve passed underneath it. The results of this study may provide physicians with the accurate anatomical knowledge that they require for managing groin pain and applying a regional nerve block with ultrasound guidance in this adductor region.

Anatomical Variations of Medial Circumflex Femoral Artery – A Cadaveric Study

Introduction: The Profunda femoris artery is a large branch that arises from the lateral or posterolateral part of the femoral artery, about 3 to 5cm below the inguinal ligament. Profunda femoris artery [1,2,4] gives Medial circumflex femoral artery, Lateral circumflex femoral artery, and Perforating arteries and muscular branches. Medial circumflex femoral artery (MCFA) originates from the posteromedial aspect of the Profunda but may originate from the femoral artery. It gives three branches ascending and transverse, acetabular branches. Aim & Objectives: To study the anatomical variations in source of origin, site of origin of MCFA. Methods: The present observational study was conducted on the dissection of 70 lower limbs of 35 adult cadavers (27 male & 8 female). Contents of the femoral triangle were dissected as per Cunningham’s manual. The source of origin distance of the origin of MCFA was noted. Collected data were analyzed statistically. Results: In the present study, MCFA from the P.F.A. in 85.71% (60/70) in both Right and Left lower limbs. The common source of Right MCFA from the Femoral Artery followed by a common stem with P.F.A. The following common source of Lt MCFA as a common stem with P.F.A. Distance of origin of MCFA from the P.F.A. was seen between 1-2cm in 34.29% of Right and 28.5% of Left Limbs in the present study. Conclusions: In most limbs (60/70 limbs), the MCFA was taking origin from P.F.A. in both Right & Left limbs (85.72%). Distance of origin of MCFA from the P.F.A. was seen between 1-2cm in 34.29% of Right and 28.5% of Left Limbs in the present study.

Anatomical study and clinical application of in situ reduction and fixation of anterior medial fenestration approach of femoral head fracture

Objectives: To explore the feasibility of anterior medial fenestration approach in situ reduction and fixation in the treatment of PipkinⅠ and Ⅱ femoral head fractures,and to explore the clinical effect of this operation. Methods: Hips of two anti-corrosion adult specimens treated with formalin were dissected, then anatomical structures and directional characteristics of anterior medial main muscles,ligaments,blood vessels and nerves were observed.The anterior medial fenestration approach was performed on bilateral hips of four fresh frozen specimens to determine pulling direction of stripped muscles and ligaments required during operation,and to observe and analyze vascular and nerve traction protection directions exposed in the approach.Determine extent of exposure to the approach and assess feasibility of this approach.The clinical data of 12 patients with Pipkin Ⅰ and Ⅱ femoral head fractures who underwent in situ reduction and fixation of anterior medial fenestration at Department of Orthopaedics,Affiliated Hospital of Chengdu University from February 2016 to April 2018 were retrospectively analyzed.There were 3 males and 9 females with an age of 48.5 years(range:37 to 59 years).There were 8 cases of Pipkin type Ⅰ and 4 cases of Pipkin type Ⅱ.The operation time,blood loss,fracture healing time,last Thompson-Epstein evaluation and Harris score were observed. Results: Anterior medial fenestration approach to expose the femoral head in 4 bilateral hips with a total of 8 sides of fresh frozen specimens.The upper boundary of observation fenestration was pubic body (anterior acetabulum),and the outer upper boundary was iliacus and psoas muscle.The lateral boundary is rectus femoris and femoral vessels,the lower boundary was transverse branch of the medial femoral circumflex artery and vein.The medial boundary was pubis muscle,short adductor muscle and long adductor muscle.Pubofemoral and iliofemoral ligament were seen in fenestration. Four quadrants in front of femoral head in fenestration can be seen after cutting switch capsule active hip joint. In 12 patients with femoral head fracture,the operation time was 107.5 minutes(range:90 to 135 minutes),and the intraoperative bleeding volume was 115.0 ml(range:85 to 150 ml).The patients were followed up for 18.6 months(range:12 to 28 months).The fracture healing time of 12 patients was 144.2 days(range:120 to 180 days).The curative effect was evaluated according to Thompson-Epstein standard at the last follow-up:excellent in 6 cases,good in 4 cases and fair in 2 cases.At the last follow-up,the Harris score of hip joints was 85.1(range:75 to 93). Conclusions: Anterior medial fenestration in situ reduction and fixation surgery is feasible for the treatment of Pipkin Ⅰ and Ⅱ femoral head fractures. The short and midterm follow-up reveal satisfactory effect.

Feasibility of Magnetic Resonance Angiography in Patients With Legg-Calvé-Perthes Disease.

The etiology of Legg-Calvé-Perthes disease (LCPD) remains unknown; however, interruption of medial circumflex femoral artery (MCFA) supply to the femoral head is the key pathogenic factor. The main purpose of this study is to determine the feasibility of using magnetic resonance angiography (MRA) to evaluate the course of the MCFA in the normal and affected hips of patients with unilateral LCPD. We analyzed 24 patients with unilateral LCPD using a time-resolved imaging of contrast kinetics magnetic resonance angiography (TRICKS-MRA). The course of the MCFA was divided into 4 segments in the coronal plane and in 3 segments in the axial plane, based on its location with respect to the femoral neck. The visibility of each segment was studied in the normal and affected sides. The segments were defined as not visible when no contrast was seen within the vessel lumen or visible when the lumen was partially or completely visualized with contrast. The statistical analysis was done using the χ2 test. TRICKS-MRA provided well-defined images of the first 2 segments of the MCFA on both the normal and affected sides of patients with LCPD (P=1). In half of the patients, the third segment was also visible using TRICKS-MRA on both sides (P=1). The fourth segment of the MCFA, which was the ascending lateral epiphyseal segment, was not visible on either side (P=0.49). No significant difference was found between the normal and affected hips in terms of visibility of the 4 segments of the MCFA using TRICKS-MRA. Anastomosis of the MCFA with the inferior gluteal artery was found in 3 hips (2 hips with LCPD and 1 normal hip). TRICKS-MRA provides well-defined images of the arterial supply to the proximal femoral epiphysis in children with LCPD, presenting a noninvasive and radiation-free alternative to conventional angiography. However, the TRICKS-MRA method used did not allow visualization of the ascending lateral epiphyseal segment of MCFA in the affected and the contralateral normal side. We believe that further advancement of this noninvasive imaging technique may open new opportunities for research aimed at evaluating the vascular supply of the femoral head in children. Level IV-case-control study.

Minimally invasive medial hip approach for femoral head fixation: How much can we see and what is the anatomical at risk? – A cadaveric injection study

IntroductionMost Pipkin I and II femoral head fractures are treated with either an anterior or a posterior approach. A medial hip approach is commonly used in children, and some surgeons have suggested it for femoral head fixation. The objectives of this study were to identify the structures at risk with the medial hip approach and to demonstrate the areas of the femoral head exposed using this approach. MethodsThe first part of this study involved vascular injection conducted in four fresh human cadavers using the medial hip approach. The surgical technique was described and the structures at risk, mainly arteries, were identified. The second part was done in 14 hips to identify and measured the maximum exposure area of the femoral head with the medial hip approach. ResultsThe structures at risk with the medial hip approach were the medial femoral circumflex artery (MFCA) after it branches from the deep femoral artery and runs posteromedially across the femoral neck medial to the iliopsoas tendon and the deep branch of the MFCA lies over the posterior hip capsule. The femoral head exposure area in anterior view with anteroinferior articular cartilage exposure was 4.57 ± 1.09 cm2. In the medial view with the hip in internal rotation and in external rotation, the inferomedial articular cartilage exposure was 2.50 ± 1.52 cm2 and 6.48 ± 2.29 cm2, respectively, and the combined area of exposure was 9.49 ± 2.86 cm2 . In the posterior view, the posteroinferior articular exposure was 1.69 ± 1.16 cm2. The medial hip approach allowed visualization of the small area of the posteroinferior articular cartilage in all specimens. The percentages of visualization of the femoral head articular cartilage in anterior view, medial view and posterior view were 50.07% ± 13.53, 45.56% ± 12.76 and 18.07% ± 11.27%, respectively. ConclusionsThe structures at risk with the medial hip approach is the MFCA along the anterior acetabular rim and the deep branch on the posteromedial aspect of the femoral neck. It is an alternative which provides excellent access in Pipkin I and some part of Pipkin II, but it requires that the MFCA be protected by the use of meticulous surgical techniques.

English

BACKGROUND The external iliac artery passes behind the inguinal ligament into the front of the thigh as the femoral artery (FA). The FA gives off many branches both superficial and deep. The profunda femoris artery (PFA) is one of the deep branches given off in the femoral triangle in front of the thigh. The PFA gives off the medial circumflex femoral artery (MCFA) and the lateral circumflex femoral arteries (LCFA) and continues downwards giving off the first, second and third perforating arteries. The PFA terminates as the fourth perforating artery. Many variations in the circumflex branches of the PFA have been found by various authors. These variations are of great significance during procedures done in front part of the thigh. METHODS This is a descriptive cadaveric study. We dissected the thighs of 57 embalmed bodies. We looked for the medial (MCFA) and lateral (LCFA) circumflex arteries which are branches of PFA. Each artery was followed till its termination. The distance of their origin from the point of the origin of PFA from the FA was measured and noted. The distance between pubic symphysis and anterior superior iliac spine was measured using black silk and measuring scale. The midpoint was marked using skin marking pen and an incision extending from anterior superior iliac spine to pubic symphysis was made. Another incision was made from the above midpoint to the midpoint of a horizontal incision at the level of knee joint. Femoral sheath was identified and incised. Femoral artery, profunda femoris artery and its circumflex branches were identified. The modes of origin of MCFA and LCFA were noted. The distance of origin of these from the origin of PFA were measured. Variations in the branching pattern of MCFA and LCFA were looked for and noted down. RESULTS We found that in 83 % of the total cases MCFA took origin from PFA and its origin was from the FA in 13 %. In 84 % of total cases LCFA arose from PFA on the right side and 70 % on the left side. A common stump of origin was noted in 3 cases. CONCLUSIONS Medial and lateral circumflex branches of PFA exhibit wide variations. KEY WORDS Medial Circumflex Femoral Artery, Lateral Circumflex Femoral Artery, Variations in Origin and Branching

Deep femoral artery: A new point of view based on cadaveric study

IntroductionIn diagnostic angiographic procedures, the knowledge of arterial variations in the femoral artery (FA), deep femoral artery (DFA) and lateral and medial circumflex femoral arteries (LCFA, MCFA) has a great impact. Material and methodsThe frequency of branching patterns of these arteries was investigated in 111 thighs of body donors. Gender and side differences were analyzed statistically. ResultsThe median distance of separation of the DFA from the FA in relation to the inguinal ligament (IL) was 3.29 cm. High origins (1−2 cm below IL) and middle origins (3−5 cm below IL) of the DFA were found in an equal distribution of 39.3% and 41.1%, respectively. Low origins (6−10 cm below IL) were rare (19.6%) but showed a tendential significance toward expression in males (p = 0.096). The origin of the LCFA from the FA (19.8%) or DFA (70.2%) are in line with the findings of other groups. The origin of the MCFA from FA (14.4%) or DFA (74.7%) showed that circumflex femoral arteries arose mostly from DFA. A trifurcation of the FA into the DFA, LCFA and MCFA was only observed in 9.9% and, therefore, less frequently than reported by others. Branches of the femoral nerve (FN) passed mostly anterior (46.4%) or anterior and posterior (47.8%) to the LCFA. The rare constellation of branches of FN passing only posterior to the LCFA (5.8%) showed a tendential significance to left side expression (p = 0.084). ConclusionsTaken together, this is the first classification of the median distance of separation of the DFA from the FA in relation to the IL in three defined groups. The knowledge of DFA branching pattern is essential for recent therapy options of cardiac diseases using a femoral artery access: transcatheter aortic valve replacement, catheter-based miniaturized ventricular assist device and veno-arterial extracorporal membrane oxygenation. The variant topography of the branches of FN in relation to LCFA should be kept in mind when harvesting an anterolateral thigh flap.

Prostatic Artery Embolization through the Profunda Femoris Artery

AbstractAn 88-year-old catheter-dependent patient with peripheral vascular disease and benign prostatic hyperplasia was referred for prostatic artery embolization (PAE). Selective angiography of the left internal iliac artery (IIA) revealed a 2.5-cm aneurysm and a single artery comprising the anterior division of the IIA (inferior gluteal artery). No prostatic artery (PA) was identified on the left. Additional angiography of the left external iliac artery (EIA), right IIA, and right EIA did not demonstrate prostatic perfusion. The right profunda femoris artery was then selected given previously reported atherosclerotic collaterals, which revealed an ascending branch of the medial circumflex femoral artery coursing through the upper thigh into the pelvis and reconstituting the right anterior division of the IIA. A 2.4-French microcatheter (Terumo) and 0.018-inch wire (Transcend, Boston Scientific) were used to enter the pelvic vasculature, right PA was identified, and a 2-mm coil was used to perform embolization of a potential nontarget anterior division branch. Embolization of the right PA was then performed with 250-µm particulate and Gelfoam slurry. Two-week follow-up revealed spontaneous voiding and catheter independence.

Катетеризация бедренной вены у детей. Безопасный сосудистый доступ

Objective. To identify risk factors of injuries to femoral vasculature of femoral vessel injuries, optimize the process of cannulation, reduce the risk of injury to femoral artery and its branches. Patients and methods. A screening sonography of the femoral puncture area was carried out in 466 patients. Of those, 240 patients had the bilateral sonography of the recommended optimal point for femoral vein access. The sonography of major vessels in the femoral vein access areas was performed using the ultrasound scanners Phillips HD 11 ХЕ, SonoSite М-turbo. Mindrey M7, M9, Samsung HM 70, and others; linear multi-frequency transducers with the working frequency range of 7 to 18 mHz, of 40mm and 20mm aperture. Sonography was perfromed from the level of inguinal ligament downwards, in the plane orthogonal to the major vessels in B mode and later with color Doppler mapping (CDM) of venous and arterial vessels. Results. Ultrasound findings of 240 patients were analyzed and anatomic variants of the femoral vascular bundle were identified: 29% patients had high origin of the deep femoral artery on one of the sides; 17.9% had high origin of the deep femoral artery combined with high origin of the medial circumflex femoral artery immediately behind the femoral vein; 5% had high origin of the medial circumflex femoral artery immediately from the femoral artery behind the femoral vein; in 2%, the femoral vein was located between the deep femoral artery and femoral artery 2 cm inferiorly to the inguinal fold. Sonography demonstrated that the femoral vein is easily compressible during venipuncture, and the distance between the anterior and posterior walls of the compressed femoral vein gets less than the access needle diameter. Special techniques were suggested to avoid perforation of the posterior femoral vein wall during access. It was clearly demonstrated that utilization of these techniques combined with ultrasound-assisted placement of a peripheral venous catheter on a trocar needle during femoral vein access has decreased injuries of the femoral artery and its branches from 10% to 1.3% of cases. A proprietary technology of safe stepwise cannulation of femoral veins is described. Conclusion. Ultrasound examination facilitates detection of vascular anatomy nuances and choice of the safer approach to femoral vein access. Measures preventing inadvertent puncture of the posterior wall, such as increased blood filling of the femoral vein, utilization of peripheral venous catheters for initial access, and a stepwise vein catheterization, have made it possible to achieve high percentage of successful cannulations and reduce complications. Key words: intensive care in children, ultrasound examination, venous access, femoral vein cannulation

Research progress in osteonecrosis of femoral head following femoral intertrochanteric fractures in adults

To summarize the research progress of osteonecrosis of femoral head (ONFH) following femoral intertrochanteric fractures in adults. Relevant literature at home and abroad was extensively reviewed to summarize the pathogenesis, high-risk factors, and treatment of ONFH after femoral intertrochanteric fracture in adults. ONFH after femoral intertrochanteric fracture mostly occurs within 2 years after operation, with a lower incidence. At present, it is believed that comminuted and large displacement fractures caused by high-energy injuries, fracture line close to the base of neck, excessive external rotation deformity, improper intramedullary nail entry points, and rough intraoperative manipulating may injury the deep branch of the medial circumflex femoral artery, causing ONFH. Hip replacement is the main treatment for necrosis, which can achieve good results. Addressing the above risks, excessive external rotation, overstretching, and rough manipulating should be avoided. Anatomical reduction should be performed during the operation, the nail entry point should be accurate and avoid repeated drilling and thermally bone necrosis.

Pelvic collateral pathway during endovascular aortoiliac aneurysm repair with internal iliac artery interruption: a retrospective observational study

BackgroundIpsilateral branches of the deep femoral artery (DFA) are qualitatively identified as collateral arteries based on angiography after internal iliac artery (IIA) interruption. The purpose of this study was to quantitatively identify the major collateral pathway after unilateral IIA interruption during endovascular aortoiliac aneurysm repair to preserve the pelvic circulation and reduce the risk of ischemic complications.MethodsThe study population included 28 patients (mean age 76.3 years) with aortoiliac aneurysm who underwent endovascular aneurysm repair with unilateral IIA interruption from August 2012 to January 2020. The diameters of the bilateral preoperative and postoperative DFA, lateral femoral circumflex artery (LFCA), medial femoral circumflex artery (MFCA) and obturator artery (ObA) were measured on contrast-enhanced computed tomography using a 3-dimensional image analysis system. The measured values were evaluated and analyzed with a repeated measures two-way analysis of variance and Dunnett’s test.ResultsThe postoperative diameters of the MFCA (P = 0.051) and ObA (P = 0.016) were observed to be larger than the preoperative diameters. Such increases in the MFCA (P < 0.001) and ObA (P < 0.001) diameters were only found to be significant on the unilateral side of the IIA interruption, and the diameter of the ipsilateral LFCA (P < 0.001) was also found to have significantly increased in size. However, no significant arterial extension was found on the contralateral side.ConclusionsThe ipsilateral MFCA-ObA pathway might therefore be a major collateral pathway arising from the DFA to preserve pelvic circulation after unilateral IIA interruption.

The Feasibility of Harvesting an Innervated Profunda Artery Perforator Flap for Breast Reconstruction

Summary:The profunda artery perforator (PAP) flap has become an alternative option for breast reconstruction. Reliable perforators arise through the adductor magnus muscle, and dissection of the perforator is straightforward. Recently, we have found that the PAP flap with the sensory nerves can be harvested as an innervated flap. We discuss the feasibility of PAP flap neurotization. We reviewed 13 patients for whom innervated PAP flap harvesting was considered. The average age was 50.7 years. There are 3 different patterns of innervated PAP flap harvesting, Type 1: including a sensory nerve that can be found in the adipose tissue around the PAP flap, Type 2: including a sensory nerve that runs along the medial femoral circumflex system, and Type 3: including a sensory nerve that runs along the profunda artery perforators. The average flap harvest time was 2:11 ± 0:31, and a sensory nerve was identified in 10 of 13 cases (77%). No sensory nerves were found in the other 3 cases. The length of the included sensory nerve was 5.5 ± 1.6 mm on average. Types 1 and 2 were found in 3 patients (30%), Type 3 was found in 2 patients (20%), and combined Types 1 and 3, 2 and 3 were found in one patient each (10%). As sensory nerves run around the PAP flap or close to the perforators, it is easy to perform flap neurotization with the PAP flap. We believe that the PAP flap could be an alternative option to achieve sensate breast reconstruction.

Femoral artery anatomy is a risk factor for limb ischemia in minimally invasive cardiac surgery.

In minimally invasive cardiac surgery (MICS), femoral artery cannulation during cardiopulmonary bypass (CPB) can cause limb ischemia. This study evaluated the association between femoral artery anatomy and the risk of limb ischemia in MICS. Eighty-one patients who underwent MICS with CPB using single femoral artery cannulation between 2010 and 2018 were included. The patients were stratified by their femoral artery diameter and anatomy of ectopic side branch, i.e., medial or lateral femoral circumflex arteries: Type A, deep femoral artery (DFA) ≥ superficial femoral artery (SFA); type B, DFA < SFA with an ectopic side branch of the common femoral artery (CFA); type C, DFA < SFA with an ectopic side branch at the CFA bifurcation; and type D, DFA < SFA without an ectopic side branch. The ratio of the postoperative creatine kinase concentration and the cross-sectional area of the femoral muscles (CK/MA) was used as a surrogate marker of limb ischemia. Predictors of high CK/MA were evaluated. No critical limb ischemia was observed in this study. The median postoperative creatine kinase and CK/MA were 1954 (1305-2872) IU/l and 15.2 (9.2-19.8) IU/l/cm2. Multivariable logistic regression found that anatomical type D (odds ratio 4.19, 95% confidence interval: (1.26-14.0); p = 0.020) and prolonged CPB time (OR 1.01, 95% CI (1.00-1.02); p = 0.045) were independent risk factors of high CK/MA. Anatomical type D and prolonged CPB time were associated with risk of limb ischemia in MICS.

Hip arthroscopy for lateral cam morphology: how important are the vessels?

The purpose of this narrative review is to identify the anatomy and relevant blood supply to the femoral head as it pertains to hip arthroscopy and lateral cam morphology. The primary blood supply to the femoral head is the lateral ascending superior retinacular vessels, which are terminal branches of the medial femoral circumflex artery. These vessels penetrate the femoral head at the posterolateral head–neck junction. Surgeons performing posterolateral femoral osteoplasty must respect this vasculature to avoid iatrogenic avascular necrosis (AVN). Avoidance of excessive traction, avoidance of distal posterolateral capsulotomy and avoidance of disruption of the superior retinacular vessels should keep the risk for AVN low. Hip extension, internal rotation and distraction are useful in hip arthroscopy to better visualize lateral/posterolateral cam morphology to facilitate an accurate comprehensive cam correction and avoid vascular disruption.

Anatomic Variations of the Deep Femoral Artery and Its Branches: Clinical Implications on Anterolateral Thigh Harvesting.

The deep femoral artery (DFA) is the largest branch of the common femoral artery (CFA), supplying with its branches, the medial circumflex femoral artery (MCFA) and lateral circumflex femoral artery (LCFA), the thigh muscles, the hip joint, and the femur. Their anatomical variations have a great impact on both interventional and surgical procedures. The anterolateral thigh (ALT) flap, a versatile soft tissue with highly increasing use in reconstructive surgery, is noticeably influenced by this variability. A total of 25 articles were incorporated into the review. Studies conducted after the year 2009 were included. After the assessment of all studies included, we concluded that the DFΑ arises from the CFA with a varying site of origin, the posterolateral being the prevalent one found in 51.32% of cases. Of all cases studied, the MCFA and the LCFA most often originated from the DFA in 63.125% and 74.92%, respectively, but the CFA constitutes another frequent source of origin in 27% and 12.12% of cases, respectively. The descending branch of the lateral circumflex femoral artery (dLCFA) is the prominent pedicle in the ALT flap, originating from the LCFA in 83.55% of cases. However, the presence of an oblique lateral circumflex femoral artery (oLCFA) branch with changeable origination was observed. Knowledge of the anatomical variants in the deep femoral artery is imperative both for interventional radiologists and surgeons. Especially in reconstructive surgery, the possibility for different sources supplying the skin and the pedicle compel surgeons to acquire an awareness of this subject.

Detection of vascularity of femoral head using sub-millimeter resolution steady-state magnetic resonance angiography-initial experience.

The purpose of this study was to use the steady-state (SS) magnetic resonance angiography (MRA) with a sub-millimeter resolution to detect the arteries supplying to the femoral head (FH). SS MRA scanning of hips was performed bilaterally in 15 healthy volunteers. A blood pool contrast agent was used. The scanning protocol included a 0.8-mm3 isotropic T1-fast field echo sequence with spectral fat suppression technique. Two highly qualified radiologists independently evaluated the medial circumflex femoral artery (MCFA), the lateral circumflex femoral artery (LCFA), and the three retinacular arteries including superior retinacular artery (SRA), inferior retinacular artery (IRA), and anterior retinacular artery (ARA). The intraosseous branches of the three retinacular arteries were also evaluated. An orthopaedic surgeon was consulted in case of disagreement. Observation by the two radiologists and support from the orthopaedic surgeon served as the end result. Agreement between the two observer radiologists was evaluated. Interobserver agreement between the two radiologists was found to be substantial to perfect. Of the 30 hips, the LCFA and MCFA were detected in all hips; the SRA and IRA were detected in most hips (100%, 90%), and the ARA was detected in 13 hips (43%). The intraosseous branches of SRA and IRA were detected in 30 and 22 hips (100%, 73%), respectively, while the intraosseous branches of ARA were detected in 11 hips (37%). The main arteries supplying the FH can be detected by the SS MRA, making it a novel method to detect the vascularity of FH.

A Report on a Novel Variation of the Lateral Circumflex Femoral Artery Among Humans

The medial and lateral circumflex femoral arteries are critical to the proper perfusion and function of the hip joint. The lateral circumflex femoral artery (LCFA) is used a graft material in coronary artery bypass, and tissue flaps that include this artery, are harvested for plastic surgery reconstructions. Although the two circumflex femoral arteries typically originate from the deep (profunda) femoral artery (DFA), variations in their origins have been reported. Here we report on a unique variation of the LCFA in a donor body. A cadaveric dissection of the anterior thigh was bilaterally performed at the University of Incarnate Word School of Osteopathic Medicine to demonstrate the origin and branching of the LCFA. Bilateral asymmetry in the origin of the LCFA and the medial circumflex femoral artery (MCFA) was observed in this cadaver. On the left side, the LCFA originated from the common femoral artery (CFA) deep to the inguinal ligament. On the right side of the body, the LCFA originated from the DFA. While the MCFA took origin from the DFA on the left side of the body, it shared a common origin with the DFA from the CFA on the right side. In summary, we report a unique unilateral variation of the LCFA where it originates from the CFA deep to the inguinal ligament. This high origin for the LCFA, at the boundary between the external iliac and femoral arteries, has not been previously reported and is unique even among mammals. It is important to determine the branching patterns of the LCFA and the derivative branches of the femoral artery as they are critical arterial pathways for the lower limbs and because the LCFA is a target in coronary grafts and plastic surgery skin flaps.

Vascular Supply to the Femoral Head in Patients With Healed Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders. The vascularity of the lateral epiphyseal vessels supplying the femoral head in patients with healed SCFE has not been well defined. The purpose of this study was to characterize the location and number of lateral epiphyseal vessels in young adults with healed SCFE. This was a retrospective study of 17 patients (18 hips) with a diagnosis of SCFE and a matched control group of 17 patients (17 hips) with developmental dysplasia of the hip. All patients underwent high-resolution contrast-enhanced magnetic resonance imaging to visualize the path of the medial femoral circumflex artery and the lateral epiphyseal arterial branches supplying the femoral head. There were 5 unstable SCFEs and 13 stable SCFEs with an average slip angle of 31 degrees. (All patients had been treated with in situ pinning and screw removal). Average age at time of magnetic resonance imaging was 24.5 years (range, 15 to 34 y). The lateral epiphyseal vessels reliably inserted on the posterior-superior aspect of the femoral neck from the superior-anterior to the superior-posterior position in both the SCFE and control groups. An average of 2 (±0.8) retinacular vessels were identified in the SCFE group compared with 5.2 (±0.7) retinacular vessels in the control group (P<0.001). In healed SCFE, the lateral epiphyseal vessels reliably insert in the same anatomic region as patients with hip dysplasia; however, the overall number of vessels is significantly lower.

A morphological study of the medial and lateral femoral circumflex arteries: a proposed new classification

Confirming the branching pattern of the deep femoral artery (DFA) is vital in planning radiological and surgical procedures involving the medial circumflex femoral artery (MFCA) and the lateral circumflex artery (LFCA). The aim of this study was to characterise the course and morphology of branches of the DFA. The anatomical dissection included 80 lower limbs which were fixed in 10% formalin solution. A dissection of the femoral region was carried out according to a pre-established protocol, using traditional techniques. Morphometric measurements were obtained twice by two researchers. Six types of medial and lateral femoral circumflex artery variations were distinguished. In type I, the DFA divides into the MFCA and the LFCA (observed in 45% of cases). In type II, the MFCA is absent and the LFCA origin normally from the DFA (18.75%). In type III, the MFCA arises from the femoral artery above the origin of the DFA, while the LFCA starts from the DFA (15%). Finally, in type IV, the LFCA arises from the femoral artery above the origin of the DFA, while the MFCA starts from the DFA (10%). In type V, the LFCA origin alone from the femoral artery below the origin of the DFA, while the MFCA origin from the DFA (7.5%), while in type VI (3.75%), both the MFCA and the LFCA origin from the femoral artery. The mean diameter of the femoral artery at the level of the DFA origin was greatest in type 2 (10.62 ± 2.07 mm) and the least in type 6 (7.90 ± 1.72 mm; p = 0.0317). The distance from inguinal ligament to where the DFA arose was the greatest in type 6 (78.24 ± 29.74 mm) and least in type 5 (28.85 ± 11.72 mm; p = 0.0529). The medial and lateral femoral circumflex arteries were characterised by high morphological variations. The diameter of the femoral artery at the level of inguinal ligament correlated with the diameter of the DFA and distance to where the DFA arises from femoral artery.

In Situ Reduction and Fixation of the Anterior Medial Fenestration Approach for Femoral Head Fracture.

ObjectiveTo investigate the feasibility and clinical application of the anterior medial fenestration approach in the treatment of Pipkin type I and II femoral head fractures.MethodsThe hips of two anti‐corrosion adult specimens treated with formalin were dissected and the anatomical structures and directional characteristics of the anterior medial main muscles, ligaments, blood vessels, and nerves were observed. The anterior medial fenestration approach was performed on bilateral hips of four fresh frozen specimens to determine the required pulling direction of the stripped muscles and ligaments during surgery. In addition, the vascular and nerve traction protection directions exposed in the approach were observed and analyzed. The feasibility of this approach was assessed, and the operative approach and critical anatomical depth were measured. We retrospectively analyzed 12 patients with Pipkin type I and II femoral head fractures who underwent in situ reduction and fixation by anterior medial fenestration in our hospital from February 2016 to April 2018. The study group included 3 men and 9 women aged 37–59 years (mean, 48.50 years). There were 8 cases of Pipkin type I and 4 cases of Pipkin type II. The operation time, blood loss, fracture healing time, last Thompson–Epstein evaluation, and Harris score were recorded.ResultsA total of 8 fresh frozen specimens from 4 bilateral hips were exposed by anterior medial fenestration. The upper boundary of observation fenestration was the pubic body (anterior acetabulum), and the outer upper boundary was the iliacus and the psoas muscle. The lateral boundary was the rectus femoris and the femoral vessels, while the lower boundary was the transverse branch of the medial femoral circumflex artery and vein. The medial boundary was the pubis muscle, the short adductor muscle, and the long adductor muscle. The pubofemoral and iliofemoral ligaments were observed during fenestration. By cutting open the joint capsule and moving the hip joint, the four quadrants of the femoral head can be exposed. Twelve patients with femoral head fractures who were treated with anterior medial fenestration underwent in situ reduction and fixation. The operation time was 96.25–118.75 min (median, 100 min), and the blood loss was 115.00 ± 22.76 mL. The follow‐up time was 18.58 ± 4.48 months, and the fracture healing time was 144.17 ± 14.53 days. The last Thompson–Epstein evaluation was excellent in 6 cases, good in 4 cases, and fair in 2 cases; the excellent and good rate was 83.33%. Finally, the last Harris score was 85.08 ± 5.73 points.ConclusionsThe upper and lower boundaries, inner and outer boundaries, and rear anatomical structure of the anterior medial fenestration approach were defined. The movable hip joint can expose the four quadrants in front of the femoral head in this fenestration. Anterior medial fenestration in situ reduction and fixation surgery is feasible and safe for the treatment of Pipkin type I and II femoral head fractures.