Medial Circumflex Research Articles

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.

Analysis of Femoral Head Microstructure and Vasculature Relevant to Legg-Calve-Perthes Disease

Purpose: Legg-Calve-Perthes disease is an idiopathic avascular necrosis of the proximal femoral epiphysis. Interestingly, even in milder cases of Perthes, the anterior epiphysis collapses most reliably rather than the more weight-bearing lateral quadrant. The purpose of this study is to investigate whether there is a vascular or microstructural predisposition for anterior femoral epiphyseal collapse in Legg-Calve-Perthes Disease.Methods: 32 cadaveric proximal femoral epiphyses from 17 subjects (age 4-14 years old) underwent microcomputed tomography at 10-micron resolution. Specimens were divided into anterior, posterior, medial, and lateral quadrants. Vascular channels entering near the posterolateral epiphyseal tubercle (from the medial femoral circumflex artery) and at the ligamentum teres footprint (from the ligamentum teres vessels) were identified by correlating surface topography with cross-sectional imaging. Each quadrant was then analyzed for four surrogate markers of trabecular bone strength: Bone Volume/Total Volume (BV/TV), Trabecular Thickness, Trabecular Separation, and Trabecular Number.
 Results: One-way ANOVA revealed a significant difference between the quadrants in trabecular microstructure and vascular patterns (p<0.001). The medial quadrant had the lowest BV/TV, trabecular number, and the greatest trabecular separation (p<0.01 for each), consistent with the fact that the medial quadrant is the least weightbearing. However, there was no significant difference between the anterior and lateral quadrants for any of the four surrogate markers of bone strength. 32/32 (100%) specimens demonstrated vascular channels from the medial femoral circumflex artery penetrating the posterior aspect of the lateral quadrant. Ligamentum teres vascular channels were visualized in the medial epiphysis in 26/32 (81%) specimens overall and 11/16 (68%) subjects aged 4-8 years. Paired samples t test revealed that the posterior half of the epiphysis had significantly more vascular channels than the anterior half (8.7±4.0 vs 3.4±3.1 vascular channels, p<0.001). Vascular channel mapping illustrated the predominance of vessels in the posterior half of the epiphysis with both the ligamentum teres (medial quadrant) and the medial femoral circumflex vessels (lateral quadrant) entering the epiphysis at the 4 and 8 o’clock positions, respectively.Conclusions: The lack of microstructural differences between the anterior and lateral quadrants, and the predominance of vascular channels in the posterior half of the epiphysis suggest that the anterior femoral epiphysis may be a relative vascular watershed region which predisposes it to collapse after the vascular insult of Legg-Calve-Perthes.Significance: This is the first study to utilize micro-computed tomography to examine trabecular microarchitecture and map vascular channels in the developing human femoral epiphysis.

Anatomical Study of Profunda Femoris Artery and it’s Variations – Cadaveric Study

Background and Aims: Profunda femoris artery is the largest branch of femoral artery. It is the principal supply to the muscles of the thigh as well as head and neck of femur. Its branches form anastomosis around the head of the femur. Profunda femoris artery is also used for arteriography. It is frequently used in vascular reconstructive procedures in the proximal thigh. It forms main route of collateral circulation in occlusion of femoral artery. The study of variation of Profunda femoris artery is of great value for radiologists and surgeons during diagnostic and surgical intervention. Aim of the study is to observe the origin of Profunda femoris artery, to measure the distance between midinguinal point and site of origin of Profunda femoris artery and to study the anatomy of Profunda femoris artery and its branches and to find out any variations in its course and its branches. Materials and Methods: The study was conducted as a prospective study from April 2018 to October 2018. All the lower limbs with the intact Femoral artery and Profunda femoris artery and their branches were included. Femoral artery and its branches had got cut during dissection were not included in the study. Thirty two Profunda femoris arteries (20 on the right side and 12 on the left side) were studied in the department of Anatomy. The femoral triangle was exposed by making incisions along the inguinal ligament from pubic symphysis to anterior superior iliac spine. Midpoint was taken as Midinguinal point (MIP). MIP was marked with a coloured pen. The distance between MIP and the site of origin of Profunda femoris artery was measured. We observed any variation in the site of origin of Profunda femoris artery, medial and lateral circumflex femoral artery and any variations in the branches of each vessel. Results: The Profunda femoris artery was found to be originated from lateral aspect of Femoral artery in 21(65%) of lower limbs. Lateral Circumflex femoral artery was found to be originating from lateral aspect of Profunda femoris artery in 28(87%) of lower limbs. Medial Circumflex femoral artery was found to be originating from medial aspect of Profunda femoris artery in 16(50%) of lower limbs. Lateral Circumflex femoral artery was found to be originating from Femoral artery in 3(10%) of lower limbs. We observed distance of origin of Profunda femoris artery from the midpoint of inguinal ligament as 10 – 20 mm in 10(31%) lower limbs. We observed absence of Lateral Circumflex femoral artery in 1(3%) of lower limbs and absence of medial Circumflex femoral artery in 6(18%) of lower limbs. Conclusions: The Profunda femoris artery is an important branch of the Femoral artery and is of clinical importance to the surgeon. Femoral artery and Profunda femoris artery were used for various imaging procedures including Cathetarization. Such a large & unexpected artery may be damaged while collecting blood in infants from Femoral vein or at the time of exposure of Saphenous vein for ligation at its junction with the femoral vein. During surgery, these vessels may be damaged easily at this region. Knowledge of anatomy and variations of Profunda femoris artery are important for surgeons in reducing intra – operative haemorrhage and postoperative complications

Clinical effects of extra-long lateral femoral supercharged perforator flaps in repair of foot and ankle wounds

Objective: To investigate the clinical effects of extra-long lateral femoral supercharged perforator flaps in repair of ankle and foot wounds. Methods: From March 2014 to October 2018, 16 patients with foot and ankle injuries were admitted to our hospital and left large area of wounds on foot and ankle after emergency treatment. There were 13 males and 3 females, with age of 27 to 60 years. The area of the wounds ranged from 14 cm×10 cm to 40 cm×17 cm. The wounds were repaired with extra-long lateral femoral supercharged perforator flaps. The widths of flaps in 8 patients were longer than 8 cm, and the bilobed flaps were designed to repair the wounds. The area of the flaps ranged from 12 cm×5 cm to 40 cm×9 cm. During the operation, 54 perforators were detected, with an average of 3.2 perforators in each flap, and 36 source arteries of perforators were detected. The blood vessel trunk of 15 patients was descending branch of the lateral femoral circumflex artery, and their supercharged mode was anastomosis of the bulky perforator of descending branch of the lateral femoral circumflex artery with the oblique branch of the lateral femoral circumflex artery and/or medial femoral circumflex artery or the descending branch of superficial illiac circumflex artery. The blood vessel trunk of 1 patient was oblique branch of the lateral femoral circumflex artery, and the supercharged mode of the patient was anastomosis of the oblique branch of the lateral femoral circumflex artery with the bulky perforator of the descending branch of the lateral femoral circumflex artery. The wounds were covered with the flaps after supercharged blood vessel anastomosis, and blood vessels in the donor sites were anastomosed with those in the recipient sites. The donor site was sutured directly. The survival of the flap after the operation and healing time of the wound, and the flap condition, the two-point discrimination distance of flap in patients who were reconstructed with sensation, the recovery of the ankle function, and the appearance of the donor site during follow-up were recorded. Results: A total of 17 flaps in 16 patients were designed, including 8 bilobed flaps and 9 non-lobulated flaps. Sixteen flaps in 15 patients survived. Vascular crisis occurred in the flap of one patient, and the flap survived when the vascular crisis was relieved by the second operation. The healing time of foot and ankle wounds ranged from 12 to 90 days. All the lateral femoral donor sites healed completely. During follow-up of 8 to 48 months, flaps in 2 patients were slightly bloated and were trimmed in 6 months after the operation. The other flaps were with good appearance, soft texture, good elasticity, and no rupture or ulceration. The two-point discrimination distances of flaps ranged from 7 to 16 mm in 8 patients who were reconstructed with sensation, and the other flaps recovered protective sensation. The flexion and extension function of ankle joint recovered well, and the walking function was not affected significantly. All donor sites formed linear scar, with no deep tissue infection such as osteomyelitis. Conclusions: The application of extra-long lateral femoral supercharged perforator flaps to repair the large area of wounds in foot and ankle can significantly reduce damage to donor sites and has advantages of rich blood supply and good safety, thus it has satisfactory clinical effects.

Unaddressed arterial injuries in revision total hip arthroplasty: mortality outcomes of a low-prevalence complication.

Peri-operative major arterial haemorrhage after revision total hip arthroplasty (RTHA) is an odd but limb- and life-threatening complication. In this retrospective analysis, we sought to determine the prevalence of such injuries requiring selective catheter embolization or bypass after RTHA and to evaluate the associated mortality rate. Between 1995 and 2016, 2524 RTHAs were performed at a high-volume centre (1031 one-stage revisions, 1370 two-stage revisions and 123 resection arthroplasties). Throughout this period, nine patients presented with signs of persistent bleeding unaddressed during index surgery (9/2524; 0.35%), causing haemodynamic instability. All patients underwent angiographic exploration within the first 24 post-operative hours. Angiography evidenced four cases of bleeding pseudoaneurysms (three of them related to the common femoral artery and one to the medial circumflex femoral artery) and five cases of direct lacerations (one case in the inferior epigastric artery, one in the hypogastric artery, one in the external iliac artery, one in the popliteal artery and another in the superior gluteal artery). Six cases underwent selective percutaneous angiographic embolization with gelatin microspheres, obtaining immediate haemodynamic stabilization; whereas three cases required a further bypass surgery with synthetic graft. Of the former group, four patients had an uneventful evolution, while two died at a mean of 49days after surgery due to multi-organ failure (MOF). Two cases of the bypass group died because of MOF at a mean of 22days. Overall mortality rate was 44%. The overall risk of arterial injury associated with RTHA was low. However, recognition of such a complication is imperative since it was associated with a high mortality rate.

Analysis of Trabecular Microstructure and Vascular Distribution of Capital Femoral Epiphysis Relevant to Legg–Calve–Perthes Disease

Legg-Calve-Perthes disease is characterized by the capital femoral epiphyseal collapse, which occurs more reliably in the anterior quadrant than the more weight-bearing lateral quadrant. The purpose of this study was to determine whether there is a vascular or microstructural predisposition for anterior femoral epiphyseal collapse in Perthes disease. Thirty-two cadaveric proximal femoral epiphyses from 17 subjects (age 4-14 years old) underwent micro-computed tomography at 10-μm resolution. Each quadrant was analyzed for four markers of trabecular architecture: bone volume fraction (BV/TV), trabecular thickness, trabecular separation (TbSp), and trabecular number (TbN). Vascular channels were then mapped in each quadrant, identified by correlating surface topography with cross-sectional imaging. One-way analysis of variance revealed an overall difference between quadrants (p < 0.001) in BV/TV, TbN, and TbSp. However, post hoc analysis revealed there was no significant difference between the anterior and lateral quadrants for any of the four markers of trabecular architecture. Vascular channel mapping illustrated a predominance of vessels in the posterior half of the epiphysis compared to the anterior half (8.7 ± 4.0 vs. 3.4 ± 3.1 vascular channels, p < 0.001). The lack of microstructural differences between the anterior and lateral quadrants, and the predominance of vascular channels in the posterior half of the epiphysis with posteriorly-based medial femoral circumflex and ligamentum teres vessels suggests that the anterior femoral epiphysis may be a relative vascular watershed region, which predisposes it to collapse after the vascular insult of Perthes disease. Clinical significance: Improved understanding of the pathophysiology of anterior femoral epiphyseal collapse may inform future treatments aimed at revascularization. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1784-1789, 2019.

Surgical Hip Dislocation for Exposure of the Posterior Column.

Surgical hip dislocation is performed for safe and efficient management of acetabular fractures predominantly involving the posterior column. The dislocation of the femoral head allows for direct visualization of the hip joint during fracture treatment. The patient is placed in the lateral decubitus position with sterile preparation and draping of the ipsilateral leg to allow for dislocation. The skin incision is straight and centered over the greater trochanter. After the skin incision, the interval between the gluteus maximus and medius muscles is developed. The sciatic nerve is identified, and special attention to the course of the medial circumflex femoral artery is given during dissection of the piriformis and triceps coxae muscles (obturator internus and superior and inferior gemelli muscles). The latter are incised 2 cm posterior to their insertion on the posterior aspect of the greater trochanter. The vastus lateralis muscle belly is elevated from the lateral femoral shaft, and a trochanteric osteotomy is performed. The trochanteric medallion is rotated 90°, and the gluteus minimus muscle is released from the capsule. After complete exposure of the hip capsule, a z-shaped capsulotomy is performed whereby any injury to the posterior capsular attachments of a posterior wall fragment is avoided. The posterior column and the greater and lesser sciatic notches are exposed, with the sciatic nerve under protection. The femoral head is dislocated either anteriorly or posteriorly to obtain direct visualization of the hip. Reduction begins at the articular surface, in cases of marginal impaction, and proceeds to the posterior wall and/or posterior column and the anterior column, when involved. For fixation, 3.5-mm cortical screws acting as positioning or lag screws and reconstruction plates are used. The capsule is sutured, the trochanteric fragment is reduced anatomically and stabilized with two 3.5-mm cortical screws, the piriformis and triceps coxae muscles are sutured, and a layered closure is performed. The Kocher-Langenbeck approach might be used instead. Surgical hip dislocation facilitates assessment of cartilage damage at the acetabulum, marginal impaction, labral tears and femoral head lesions, removal or reinsertion of free intra-articular fracture fragments, direct visualization of the accuracy of reduction, and verification of extra-articular screw placement.

Vascular Anatomy of the Medial Femoral Neck and Implications for Surface Plate Fixation.

To describe the inferior retinacular artery (IRA) as encountered from an anterior approach, to define its intraarticular position, and to define a safe zone for buttress plate fixation of femoral neck fractures. Thirty hips (15 fresh cadavers) were dissected through an anterior (Modified Smith-Petersen) approach after common femoral artery injection (India ink, blue latex). The origin of the IRA from the medial femoral circumflex artery and the course to its terminus were dissected. The IRA position relative to the femoral neck was described using a clock-face system: 12:00 cephalad, 3:00 anterior, 6:00 caudad, and 9:00 posterior. The IRA originated from the medial femoral circumflex artery and traveled within the Weitbrecht ligament in all hips. The IRA positions were 7:00 (n = 13), 7:30 (n = 15), and 8:00 (n = 2). The IRA was 0:30 anterior to (n = 24) or at the same clock-face position (n = 6) as the lesser trochanter. The mean intraarticular length was 20.4 mm (range 11-65, SD 9.1), and the mean extraarticular length was 20.5 mm (range 12-31, SD 5.1). The intraarticular course of the IRA lies within the Weitbrecht ligament between the femoral neck clock-face positions of 7:00 and 8:00. A medial buttress plate positioned at 6:00 along the femoral neck is anterior to the location of the IRA and does not endanger the blood supply of the femoral head. The improved understanding of the IRA course will facilitate preservation during intraarticular approaches to the femoral neck and head.

Effect of arterial flow on muscle atrophy

This study analyzed the inherent relation between arterial blood mass flow and muscle atrophy of residual limb to provide some necessary information and theoretical support for the clinical rehabilitation of lower limb amputees. Three-dimensional arterial model reconstruction was performed on both intact side and residual limb of a unilateral transfemoral amputee who is the subject. Then hemodynamic calculation was carried out to comparatively analyze the mass flow state at each arterial outlet of both lower extremities. The muscle atrophy ratio of residual limb was calculated by measuring the cross-sectional area of bilateral muscles. Based on the blood supply relationship, the correlation between arterial blood flow reduction ratio and muscle atrophy ratio was discussed. The results showed that the mass flow of superficial femoral arteries and lateral circumflex femoral arteries severely reduced. Meanwhile rectus femoris, vastus lateralis and vastus medialis which were fed by these arteries showed great atrophy too. On the contrary, the mass flow of deep femoral arteries and medial femoral circumflex arteries slightly reduced. Meanwhile gracilis, adductor longus, long head of biceps which were fed by these arteries showed mild atrophy too. These results indicated that there might be a positive and promotion correlation between the muscle atrophy ratio and the blood mass flow reduction ratio of residual limb during rehabilitation.

Evaluating the Blood Supply of the Femoral Head During Different Stages of Necrosis Using Digital Subtraction Angiography.

The authors investigated changes in the blood supply of necrotic femoral heads using digital subtraction angiography (DSA). Digital subtraction angiography was used to evaluate the blood perfusion of osteonecrosis of the femoral head of 81 patients (81 hips). Necrotic hips were grouped according to the Association Research Circulation Osseous staging classification. Five parameters were assessed to evaluate the intraosseous blood supply of the necrotic femoral heads. The authors chose the most effective images retrospectively and measured the following parameters: the blood vessel diameter ratio between the medial circumflex femoral artery (MCFA) and the deep femoral artery (DFA) (MCFA/DFA); the blood vessel diameter ratio between the lateral circumflex femoral artery (LCFA) and the DFA (LCFA/DFA); the ratio between the MCFA extending length and the width of the femoral neck (A); the number of vessels that reach or exceed line I (a, horizontal line through the junction of the upper femoral head and neck); and the number of vessels that reach or exceed line II (b, the boundary between the femoral head and neck). Significantly negative correlation with Association Research Circulation Osseous stage II to IV necrosis was found for A, a, and b. These parameters were significant (P<.05). Compared with the length and distribution of the vessels, differences in width (MCFA/DFA and LCFA/DFA) were not statistically significant in patients with Association Research Circulation Osseous stage II to IV necrosis. The relative length of the MCFA and the number of vessels above line I and line II are related to the severity of osteonecrosis of the femoral head, as revealed by DSA. Evaluation of blood supply by DSA can be used as one element to predict the fate of precollapsed femoral head. [Orthopedics. 2019; 42(2):e210-e215.].

A study of anomalous origin of medial circumflex femoral artery and its significance

Background: Femoral artery, a branch of external iliac artery, is the blood supply to the anterior compartment of the thigh. Its branch, medial circumflex femoral artery (MCFA), supplies the head and neck of femur, adductor muscles and the acetabular pad of fat. By virtue of its anatomical location, usually there is a high risk of severing the artery after trauma or during total hip arthroplastic surgeries. Methods: We studied variations in the femoral artery and its branches in 100 femoral triangles from 50 properly embalmed and formalin-fixed human cadavers, from Sri Venkateswara Institute of Medical Sciences, Sri Padmavathi Medical College for Women, Tirupati, and NRI Institute of Medical Sciences, Visakhapatnam, Andhra Pradesh, India. Results: We observed that the MCFA arose from the common femoral artery in 10% of the cases and from the deep femoral artery in 88% of the cases and was absent in 2% of the cases. Conclusions: The MCFA variability must be taken into account by surgeons, especially during orthopaedic interventions in the region of the hip to prevent iatrogenic injury to the circulation of the femoral head.

Ligature of the deep medial femoral circumflex artery decreases the incidence of transfusion in primary total hip arthroplasty

Background: Primary total hip arthroplasty (THA) is associated with substantial blood loss during the surgical approach and the postoperative period. This causes a decrease in hemoglobin levels up to 5 g/dL, and blood transfusion rates that vary between 30% and 73%. The purpose of this study was to compare the rate of blood transfusions in patients with or without ligature of the deep branch of the medial femoral circumflex artery (MFCA) during THA. Methods: A randomized controlled trial of patients who underwent primary THA between January and October 2011 was conducted. Patients were randomly allocated to either ligature or no ligature of the deep branch of the MFCA. The number of units of red blood cells transfused and surgical time were defined as main outcomes. Differences between groups were assessed using Student’s t-test. Results: A total of 146 patients were analyzed. Artery ligation reduced the need for blood transfusion in 74% (P&lt;0.001) of patients and was identified as a protective factor in 76% of the sample. A mean decrease in bleeding of 200 cc (P&lt;0.001) and mean increase of 2 minutes (P=0.61) in surgical time were found in the ligature group. This difference in the total surgical time between the two groups was not significant. Discussion: Ligature of the deep branch of the MFCA decreases the need for blood transfusion without increasing the surgical time or the difficulty of the procedure. We recommend that surgeons include this step during a THA surgical approach.

The role of interventional radiology in the treatment of lower limb vascular injuries after orthopaedic surgery.

PurposeThis paper focuses on the role of interventional radiology embolisations in a series of patients presenting with iatrogenic vascular injuries of the lower limbs following orthopaedic interventions.Material and methodsFourteen patients (mean age: 64 years, range 23-90 years) were retrospectively analysed. Clinical presentation consisted of palpable pulsatile mass, pain, reduced lower limb motion, or visible haematoma; 11 patients had also anaemia (haemoglobin < 7 g/dl).ResultsThe time between orthopaedic surgery and embolisation ranged between 0 and 67 days (mean: 15 days). Injured arterial vessels were as follows: inferior gluteal artery (2), superficial external pudendal artery (2), deep femoral artery (1), lateral circumflex femoral artery (3), medial circumflex femoral artery (2), articular branch of descending genicular artery (1), perforating femoral arteries (3), posterior tibial recurrent artery (1), and anterior tibial artery (1). The typologies of vascular lesion were: pseudoaneurysm 57%, bleeding with extraluminal contrast agent blush of the terminal arterial segment 36%, and laceration and bleeding with extraluminal contrast agent blush of the arterial main trunk 7%. Embolising agents adopted were microcoils 57%, glue 14%, microplug 7%, particles 14%, and covered stent 7%. In all cases clinical and procedural technical successes were obtained (100%).ConclusionsFor the management of vascular injuries occurring after different orthopaedic interventions of the lower limbs, endovascular embolisations have proven to be safe and effective; orthopaedic surgeons should be aware of the support that interventional radiology could provide in the case of iatrogenic vascular complications.

Medial Femoral Circumflex Artery Perforator Based Fasciocutaneous Flap Aided in Healing of Scrotal Defect due to Fournier Gangrene

Medial Femoral Circumflex Artery Perforator Based Fasciocutaneous Flap Aided in Healing of Scrotal Defect due to Fournier Gangrene

A novel approach for posterior acetabular fractures: Surgical technique.

This article describes a novel approach, the Direct Posterior Approach (DPA) for the treatment of posterior acetabular fractures (posterior column, posterior wall, or both posterior column and wall). This technique allows direct visualization of the entire posterior wall, part of the hip capsule and the posterior column between the space of the gluteus medius and the piriformis superiorly. The approach spares the division of short external rotators, abductors, and hip capsule, thus preventing iatrogenic damage to the medial femoral circumflex artery, sciatic nerve, and superior and inferior gluteal neurovascular bundles, as well as protecting the vascularity of the fracture fragments. In addition to the low blood loss, short operative time and low risk of iatrogenic injury, patients who are treated by the DPA approach exhibit positive functional recovery in follow-up. DPA is an effective, safe and minimally-invasive technique for the treatment of posterior acetabular fractures.

Anatomical and radiological study of the variations of profound femoris artery and its branches

Introduction The femoral artery begins at the level of the midinguinal point as a continuation of the external iliac artery, and profound femoris artery (PFA) is the main branch of femoral artery that arises variably. Aim The aim of this study was to show the anatomical variations of PFA and its branches. Patients and methods (i) In the cadaveric study, femoral triangles of 20 lower limbs of 10 cadavers were dissected to study origin, course, and branches of PFA. The origin, course, and branches were noted. The distance of origin of PFA from midinguinal point was measured with the help of a scale. The width of femoral and PFA was measured with the help of a divider and a scale. (ii) In the radiological study, we retrospectively reviewed 49 patients (92 sides) undergoing femoral computed tomography angiography. Results Overall, 49.2% of them showed posterolateral origin of PFA on the right side and 62.7% on the left side followed by lateral origin in 33.9% on the right side and 23.7% on the left side, but the least percentage was to be posteromedial origin with no significant variations of other parameters (P≥0.05) except for medial circumflex femoral artery origin to lateral circumflex femoral artery origin site of origin between right and left sides (P≤0.05). Conclusion It could be concluded that variations of PFA and its branches are common, and it is most important to know variant origin of PFA and its branches, as they have an important role during preoperative clinical evaluation.

Perineoscrotal reconstruction following fournier's gangrene using the upper medial thigh perforator flap

Background: Fournier's gangrene (FG) is a synergistic necrotizing fasciitis that involves the genitalia, perineum, or anal region and can be life threatening and generally necessitates urgent surgical intervention. It often causes scrotal defects that require reconstruction after surgical debridement. The reconstruction of these serious scrotal defects poses certain challenges for surgeons. In this study, reconstruction of scrotal defects caused by FG with medial circumflex femoral artery perforator (MCFAP) flap evaluated. Patients and Methods: Seventeen patients with FG reconstructed using a MCFAP flap, admitted to our hospital between February 2003 and March 2017, are included in this study. Reconstruction with MCFAP flap results, mean debridement number, comorbid diseases, and length of hospital stay are analyzed together. Patients with FG reconstructed using techniques other than MCFAP were not included in this study. Results: Eighteen MCFAP flaps were performed in 17 patients. The mean duration of operation was 2 h 55 min. Diabetes mellitus was the most common comorbid disease. The mean days of hospital stay were 19.9. Total flap loss was not seen in 17 patients. Donor area of the flap is closed primarily, by V-Y advancement flaps or by split-thickness skin grafts. Acceptable cosmetic results and scrotal contours were obtained in all patients. No major complications were observed. Conclusions: Using a MCFAP flap, a method that has minimal donor site morbidity, requires single session surgery, provides good skin quality and color similar to the scrotum, is an easy-to-perform process, proving to be a reliable flap for scrotal reconstruction.

Expanding the applications of the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for extensive defects.

The medial thigh is a well-hidden area. The two most common flaps from this area are the transverse upper gracilis (TUG) and profunda artery perforator (PAP) flaps. Herein, we explored the applications of combined TUGPAP flap to reconstruct large and complex defects in different regions. Between November 2015 and May 2017, 28 patients who underwent reconstruction and extensive soft tissue coverage with the TUGPAP flap for the breasts, head and neck, and pelvi-perineal regions were included. The defects size ranged from 22 to 29 × 6-8 cm. All flaps were based on the two pedicles: the medial circumflex femoral artery for TUG flap and the profunda artery perforator for PAP flap. They were each anastomosed to a set of recipient vessels. A "Y"-shaped interposition vein graft (YVG) was used if only one recipient artery was available. The harvested skin paddle had dimensions ranged from 20 to 30 × 6-9 cm and all flaps survived completely. Postoperative complications included one case each of donor and recipient site seroma, and one case of wound dehiscence. They were all successfully managed conservatively. During an average follow-up period of 12.7 months, one patient reported permanent paresthesia in the donor site and another developed hypertrophic scar. All patients were able to resume daily activity without major concerns. The combined TUGPAP flap is a safe, effective, and a good alternative to the common workhorse flaps as it offers the potential for a large skin paddle and decent soft tissue volume with low donor site morbidity in a well-concealed area.

Redefining the Anatomic Boundaries for Safe Dissection of the Skin Paddle in a Gracilis Myofasciocutaneous Free Flap: An Indocyanine Green Cadaveric Injection Study.

The gracilis free flap remains a versatile option in the reconstructive ladder. The flap itself can be harvested with or without a skin paddle. The gracilis myocutaneous free flap, however, is known for partial skin flap necrosis, especially in the distal one-third of the skin island. The gracilis myofasciocutaneous flap has been previously described as a technique to improve perfusion to the skin by harvesting surrounding deep fascia in a pedicled flap. However, limitations to this study required injection of multiple pedicles to demonstrate its perfusion. We demonstrate a novel technique using a cadaveric model that shows perfusion through injection via a single dominant pedicle (medial circumflex) with a large cutaneous paddle (average 770 cm2) with included deep fascia, using indocyanine green and near-infrared imaging. For comparison, we are also able to confirm the lack of perfusion to the distal cutaneous paddle when the fascia is not harvested, correlating with previous findings and ink injection studies. This novel technique is versatile, relatively inexpensive, and can demonstrate perfusion patterns via perforasomes that were otherwise not possible from previous techniques. Additionally, real-time imaging is possible, helping to elucidate the sequence of flow into the flap and potentially predict areas of flap necrosis.