Femoral Triangle Research Articles

A Phase 3, Randomized, Double Blinded, Active Controlled, Multicenter Study to Evaluate the Efficacy, Safety & Pharmacokinetics of EXPAREL vs Bupivacaine Administered as Combined Sciatic and Femoral Triangle Nerve Block, For Postsurgical Analgesia in Subjects Undergoing Lower Extremity Surgeries

A Phase 3, Randomized, Double Blinded, Active Controlled, Multicenter Study to Evaluate the Efficacy, Safety & Pharmacokinetics of EXPAREL vs Bupivacaine Administered as Combined Sciatic and Femoral Triangle Nerve Block, For Postsurgical Analgesia in Subjects Undergoing Lower Extremity Surgeries

Adductor canal versus femoral triangle anatomical locations for continuous catheter analgesia after total knee arthroplasty: a multicentre randomised controlled study

BackgroundAdductor canal (AC) catheters are being used to provide continuous postoperative analgesia after total knee arthroplasty (TKA) surgery. There are anatomical arguments that most AC catheters are being inserted into the femoral triangle (FT) compartment of the thigh rather than the AC compartment. The clinical relevance of this is unknown with respect to motor weakness, quality of analgesia, and opioid consumption. We hypothesised that AC catheters provide superior functional mobilisation on postoperative Day 1 after TKA as measured using the Timed Up and Go (TUG) test. MethodsIn this multinational, multicentre, double-blinded RCT, catheters were inserted under ultrasound guidance into the anatomical AC and FT compartments. The standardised protocol included spinal anaesthesia without intrathecal morphine, fixed catheter infusion rates, and oral analgesia. ResultsOf 151 subjects recruited, 75 were in the AC group and 76 in the FT group. There was no statistically significant difference in TUG on postoperative Day 1 between AC (38 [29–55] s) and FT subjects (44 [32–64] s) (median [inter-quartile range]); P=0.11). There was no difference in TUG Day 2, AC (38 [27–53] s) vs FT (42 [31–59] s); P=0.66. There were no statistically significant differences for secondary endpoints of pain level, effectiveness of pain relief, interference of functional activities and interpersonal relationships by pain, and opioid consumption between groups. ConclusionsThere were no differences in immediate postoperative functional mobility, analgesia, and opioid consumption provided by catheters inserted into the AC vs FT locations for TKA surgery. Clinical trial registrationANZCTR12617001421325.

Anomalous branching pattern of the profunda femoris artery with incomplete transposition of the femoral vein in the femoral triangle

During routine dissection of a female cadaver, we observed variation in vascular structures in the right femoral triangle. The profunda femoris artery was taking a high origin from the femoral artery (FA) just deep to the inguinal ligament, and the lateral femoral circumflex artery was arising from the FA. We also observed differences in the drainage pattern of great saphenous vein, wherein it was superficially crossing the FA to drain into the femoral vein which was located posterior to the FA. This type of rare vascular variation is informative to clinicians, cardiologists, and operating surgeons.

New Viewpoint of Surface Anatomy Using the Curved Sectional Planes of a Male Cadaver.

BackgroundThe curved sectional planes of the human body can provide a new approach of surface anatomy that the classical horizontal, coronal, and sagittal planes cannot do. The purpose of this study was to verify whether the curved sectional planes contribute to the morphological comprehension of anatomical structures.MethodsBy stacking the sectioned images of a male cadaver, a volume model of the right half body was produced (voxel size 1 mm). The sectioned images with the segmentation data were also used to build another volume model. The volume models were peeled and rotated to be screen captured. The captured images were loaded on user-friendly browsing software that had been made in the laboratory.ResultsThe browsing software was downloadable from the authors' homepage (anatomy.co.kr). On the software, the volume model was peeled at 1 mm thicknesses and rotated at 30 degrees. Since the volume models were made from the cadaveric images, actual colors of the structures were displayed in high resolution. Thanks to the segmentation data, the structures on the volume model could be automatically annotated. Using the software, the sternocleidomastoid muscle and the internal jugular vein in the neck region, the cubital fossa in the upper limb region, and the femoral triangle in the lower limb region were observed to be described.ConclusionFor the students learning various medical procedures, the software presents the needed graphic information of the human body. The curved sectional planes are expected to be a tool for disciplinary convergence of the sectional anatomy and surface anatomy.

Adductor canal and femoral triangle: Two different rooms with the same door

Adductor canal and femoral triangle: Two different rooms with the same door

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.

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.

Features of multi-slice spiral CT examination of indirect and direct and femoral inguinal hernia in adults

Features of multi-slice spiral CT examination of indirect and direct and femoral inguinal hernia in adults

Pain relief following a medial parapatellar arthrotomy: Comparing the favourability of a femoral triangle block to an adductor canal nlock based on the extent of blockade of the nerve to vastus medialis and saphenous nerve in the lower limb

Pain relief following a medial parapatellar arthrotomy: Comparing the favourability of a femoral triangle block to an adductor canal nlock based on the extent of blockade of the nerve to vastus medialis and saphenous nerve in the lower limb

Adjuvant radiation therapy for malignant Abrikossoff\u2019s tumor: a case report about a femoral triangle localisation

BackgroundGranular cell or Abrikossoff’s tumors are usually benign however rare malignant forms concern 1 to 3% of cases reported. Pelvic locations are exceptional.Case presentationWe report a case of a 43-years-old patient who had a benign Abrikossoff’s tumor localized in the right femoral triangle diagnosed at the biopsy. The patient underwent a surgical tumorectomy and inguinal lymph nodes resection. Histologically, the tumor showed enough criteria to give diagnosis of malignancy: nuclear pleomorphism, tumor cell spindling, vesicular nuclei with large nucleoli. Moreover, five lymph nodes were metastatic. Immunohistochemistry findings confirmed the diagnosis of granular cell tumor which is positive for S100 protein and CD68 antibodies. The mitotic index was nevertheless low with a Ki67 labeling index of 1–2%. A large surgical revision with an inguinal curage following radiotherapy were decided on oncology committee. Adjuvant radiotherapy on the tumor bed and right inguinal area of ​​50 Gy in conventional fractionation was delivered with the aim of reducing local recurrence risk. There was no recurrence on longer follow-up (10 months post radiotherapy).ConclusionsAdjuvant radiotherapy seems an appropriate therapeutic approach, even if controversial, given that some authors report effectiveness on local disease progression.

The analgesic effect of a popliteal plexus blockade after total knee arthroplasty: A feasibility study.

An obturator nerve block (ONB) and a femoral triangle block (FTB) provide effective analgesia after total knee arthroplasty (TKA) without impeding the ambulation, although the ONB produces motor blockade of the hip adductor muscles. The popliteal plexus (PP) in the popliteal fossa is formed by contribution from the tibial nerve and the posterior obturator nerve, innervating intraarticular genicular structures and the posterior capsule of the knee. We hypothesised that a popliteal plexus block (PPB) as a supplement to an FTB would reduce pain after TKA without anaesthetising motor branches from the sciatic nerve in the popliteal fossa. To assess the analgesic effect of adding a PPB to an FTB in 10 subjects with significant pain after TKA. All subjects underwent unilateral TKA with spinal anaesthesia and received an FTB. The cutaneous sensation and the postoperative pain were assessed. The primary outcome was the proportion of subjects with pain above numeric rating scale (NRS) 3 followed by a reduction to NRS 3 or below after conducting a PPB. Ten subjects with a median pain of NRS 5.5 (interquartile range [IQR] 4-8) after unilateral TKA received a PPB. All 10 subjects experienced a reduction in pain to NRS 3 or below (NRS 1.5 [IQR 0-3]) within a mean time of 8.5 (95% CI 6.8-10.2)minutes. Three subjects were completely pain free after the PPB. The ankle muscle strength was not affected. The PPB provided effective pain relief without affecting the ankle muscle strength in all 10 subjects with significant pain after TKA and an FTB.

Extra-articular Debridement of Hip Joint for Management of Anterior Hip Pain

Groin pain is a common problem that is known to be a complex issue. The wide variety of possible pathologies in numerous anatomical structures contributes to this complexity. For patients who have anterior hip pain in Patrick's test and tenderness at Scarpa's triangle, we perform periarticular debridement based on the hypothesis that rectus femoris tendinosis, subacute/chronic fibrosis of the anterior inferior iliac spine fat pad, and gluteal muscle adhesion are responsible for such anterior hip pain. This Technical note illustrates the surgical procedure of periarticular debridement for extra-articular pathology-associated anterior hip pain. Repair of the injured labrum and correction of femoroacetabular impingement deformity have never been performed in this cohort. Arthroscopic periarticular debridement is a reliable surgical technique that can relieve anterior hip pain and provide a rapid to return to normal activities.

F189. Reciprocal excitation: A hidden component of the myotatic stretch reflex

Introduction The Myotatic Reflex (MR) and Reciprocal Inhibition (RI) are well documented phenomena. They fit well into the framework of negative feedback control of muscle length and complementary control of movement by opposite groups of muscles. Reciprocal excitation (RE) has been reported intermittently and controversially, only in patients with spasticity of various forms. While using quantitative measures of the MR, we recorded clear and consistent electrical evidence of RE in normal subjects. Our experiments show that the standard textbook model of the MR is in fact incomplete. In this paper we present experimental evidence confirming the presence of RE as a spinal reflex, in normal subjects. Methods Three methods were used to elicit the MR of the quadriceps muscle: the patellar tendon tap, rapid mechanical flexion at the knee, electrical stimulation of the femoral nerve. The electrical response from the agonist and antagonist muscles were recorded simultaneously using surface EMG. Following the stretch of the quadriceps, the reflex excitation from the quadriceps and a smaller excitation from the hamstrings was recorded. Mechanical artefacts and cross-pickup from neighbouring muscles were excluded. Data from 28 normal subjects was processed and analysed with custom programs in Python. The mechanical stretch stimulus was the flexion at the knee lasting roughly 100 ms making it difficult to identify a single time-point of stretch stimulus. On electrical stimulation of the femoral nerve in the femoral triangle it was difficult to separate the reflex wave from the stimulation artefact as most subjects required strong stimulus. Results Excitation of the heteronymous group of muscles as a component of the MR in normal subjects has been clearly observed in our experiments. Though this excitation is around 10% of the primary reflex excitation, its latency and reproducibility confirm its physiological origin as a spinal reflex. The patellar tendon tap latency(ms) and amplitude(mV) ranges averaged over 25 trials for each of the 28 subjects, seen distinct from background noise are, respectively: Rectusfemoris = 15–22, 0.0473–2.1503; Bicepsfemoris = 17–33, 0.0076–0.3462, Semitendinosus = 17–33, 0.003–0.2015. The recordings with mechanical stretch and electrical stimulation of the femoral nerve confirm distinct RE in the hamstrings. Conclusion There are a few reports of RE in spasticity. We have demonstrated its presence in normal subjects. The coexcitation of the antagonist at the same time as the agonist may play an important role in providing stability around a joint to prevent injuries when there is rapid stretch of the agonist. Our data suggests that further studies are required to understand its neuronal pathway, relevance and potential clinical use in normal subjects and pathology.

Analgesia of Combined Femoral Triangle and Obturator Nerve Blockade Is Superior to Local Infiltration Analgesia After Total Knee Arthroplasty With High-Dose Intravenous Dexamethasone.

High-dose intravenous dexamethasone reduces the postoperative opioid requirement and is often included in the multimodal analgesia strategy after total knee arthroplasty (TKA). Combined obturator nerve and femoral triangle blockade (OFB) reduces the opioid consumption and pain after TKA better than local infiltration analgesia (LIA). The question is whether preoperative high-dose intravenous dexamethasone would cancel out the superior analgesic effect of OFB compared with LIA. The aim was to evaluate the analgesic effect of OFB versus LIA after TKA when all patients received high-dose intravenous dexamethasone. Eighty-two patients were randomly assigned either to OFB or LIA after primary unilateral TKA. All patients received 16 mg dexamethasone. Primary outcome was morphine consumption via patient-controlled analgesia during the first 20 postoperative hours. Secondary outcomes were pain, nausea, dizziness, and length of hospital stay. Seventy-four patients were included in the analysis. Median total intravenous morphine consumption during the first 20 postoperative hours was 6 mg (interquartile range [IQR], 2-18 mg) in the OFB group and 20 mg (IQR, 12-28 mg) in the LIA group. The 14-mg difference (95% confidence interval, 6.4-18.0 mg) was significant (P < 0.001). There was no difference in pain score at rest at 20 hours postoperatively: 2 (IQR, 1-4) in the OFB group and 3 (IQR, 2-5) in the LIA group. Combined OFB reduces morphine consumption better than LIA after TKA even when all patients received high-dose intravenous dexamethasone. This study was registered at ClinicalTrials.gov, identifier NCT02374008.

Aberrant configuration of femoral vessels as cause of arterial occlusive disease

Variations in the branching pattern of femoral and profunda femoris arteries have clinical implications while performing various diagnostic imaging procedures as well as during surgeries that are performed in the femoral triangle. Awareness about these variations aid 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 bypass, in radiological interventions for A-V malformations, and in salvage operations for traumatic limb ischemia. Here we report an aberrant configuration of profunda femoris artery which presented as a case of arterial occlusive disease of lower limb. On surgical exploration, Profunda femoris artery was found originating on the medial aspect of left common femoral artery high up in the inguinal region as compared to its usual lower and lateral origin. There was atheromatous occlusion of superficial femoral artery from its origin upto distal femoral metaphysis. In case of occlusion of the superficial femoral artery, the profunda femoris artery forms an effective collateral bed between the ileo-femoral segment and the popliteal artery and its branches. The clinical implications associated with these variations in therapeutic and diagnostic interventions is been discussed along with relevant literature review. Further study is necessary to identify aberrant configuration of femoral vessels as a cause of arterial occlusive disease in the lower limbs.

Regional Distribution of the Saphenous Nerve below the Adductor Canal: An Anatomical Study

The adductor canal is an aponeurotic tunnel that courses between the anterior and medial compartments in the middle third of the thigh. The canal begins at the apex of the femoral triangle and extends to the adductor hiatus. Its major contents are the superficial femoral artery, the nerve to vastus medialis, and the saphenous nerve. The latter two nerves are branches of the posterior division of the femoral nerve. Along with the medial and intermediate cutaneous nerves of the thigh and the lateral femoral cutaneous nerve the saphenous nerve contributes to the sensory distribution around the anterior aspect of the knee. This anatomic cadaveric study defined the course of the saphenous nerve and its divisions along the medial aspect of the knee. Landmark-based distance measurements were recorded in reference to the proximal border of the patella, medial border of the patella, medial epicondyle, medial femoral condyle, and posterior femoral condyle. The clinical implications of our findings suggest there is opportunity to obtain medial sensory analgesia during total knee arthroplasty when periarticular injections of bupivacaine derived medications are injected in the region of saphenous nerve proximal and posterior to the medial femoral condyle.

Impact of extra-articular pathologies on groin pain: An arthroscopic evaluation

PurposeFor patients who have anterior hip pain evaluated by Patrick’s test and tenderness at Scarpa’s triangle, we perform periarticular debridement based on the hypothesis that extra-articular pathologies are responsible for the hip pain. The purpose of this study was to categorize the endoscopic extra-articular findings and to evaluate the clinical significance of periarticular pathologies in anterior hip pain.MethodsArthroscopic findings of 77 patients who underwent periarthritic debridement were evaluated. As extra-articular pathologies, injuries of the direct head and reflective head of the rectus femoris muscle were evaluated. A thin layer of fat tissue normally exists on the anterior inferior iliac spine (AIIS), the attachment site of the direct head of the rectus femoris muscle. The macroscopic appearance of the fat pad on the AIIS was categorized as normal, blood vessel-rich adipose tissue or adipose tissue with fibrosis or scar formation and histologically confirmed. Adhesion of gluteal muscles to the joint capsule was also evaluated.ResultsOf the 77 patients, 75 had rupture of the direct head of the rectus femoris. In contrast, rupture of the reflective head was extremely rare. Seven patients had a normal fat pad on the AIIS, 11 had blood vessel-rich adipose tissue and 55 had adipose tissue with fibrosis. Fat tissue was completely replaced by fibrous scar tissue in another 4 patients. In 64 patients, adhesion between the anterior joint capsule and gluteus muscles was marked. Groin pain disappeared soon after the operation even when labral tears were not repaired and all patients returned to daily life and sports activities within 2 weeks after operation.ConclusionRectus femoris tendinosis, fibrosis of the AIIS fat pad, and adhesion of gluteal and rectus femoris muscles are common extra-articular pathologies in patients with anterior hip pain. Management of only these lesions induces rapid relief of anterior hip pain even in the absence of labral tear repair. My observations suggest that it is desirable to be aware of the presence of periarticular pathologies as a cause of groin pain.

Case of Unusual Abscess Localization in Lumbar Pott’s Disease

In Pott’s disease, cold abscesses usually sit and spread along the psoas muscle. This case concerned a 60 years old man who came to us with bilateral lomboradicular pain and a swelling of inguinal area and the anterior part of the left thigh. We found a 2 years long lasting story of low back pain complaint. Physical examination showed good general health status, stiffness of lumber spine, a left psoitis and no neurological deficit. CT scan going downward from the lumbar spine to the pelvic region and femoral limb with coronal reconstruction demonstrated a huge disco-vertebral destruction of L2-L3 with translation, and bilateral paramedian psoas abscess migrating subfascially toward Scarpa triangle and cleaving anteriorly mainly muscles of the left thigh. After 12 months medical treatment, the evolution has been favorable with clinical cure. The localization of the cold abscess in the left thigh anterior muscles compatment is uncommon. It is why we report this case.

Lower Extremity Free Flaps for Breast Reconstruction.

Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flaps: transverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient's fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.

Results of Infrageniculate Bypasses Using the Profunda Femoris Artery as Inflow Source

When the common femoral artery is not accessible for infrainguinal bypass grafting, the profunda femoris artery (PFA) can be a valuable alternative inflow source for distal arterial revascularization. The purpose of this retrospective study was to evaluate the results of infrageniculate bypass grafting via the PFA as inflow source for critical limb ischemia. Between 1994 and 2016, 68 patients, 51 men of a mean age of 74years, underwent an infrageniculate arterial bypass grafting for critical limb ischemia, using the PFA as inflow site. PFA was exposed at the Scarpa's triangle in 38 patients (56%) and at its medio-crural segment in 30 patients (44%). The distal anastomosis was performed on the infragenicular popliteal artery in 33 patients (48%), the peroneal artery in 14 patients (20%), the tibioperoneal trunk in 8 patients (12%), the posterior tibial artery in 8 patients (12%), and the dorsalis pedis artery in 5 patients (8%). The graft material consisted of a reversed great saphenous vein (GSV) in 62 patients (91%) and a 6-mm polytetrafluoroethylene graft in 6 patients (9%). The median duration of follow-up was 51months (range, 6-72months). As main results, postoperative mortality and morbidity, overall late patients' survival, primary grafts' patency, and limb salvage rate were considered. Operative mortality and morbidity were 3% and 4%, respectively. Overall patients' survival, primary patency and limb salvage rate, at 36 and 60months were, respectively, 62% and 53%, 66% and 59%, and 92% and 77%. The PFA, both exposed at the Scarpa's triangle and at mid-thigh, is an excellent inflow source for infrageniculate revascularizations. It should remain an important part of the technical armamentarium of vascular surgeons, even in the endovascular era.