Comparative Study of the Morphological Characteristics of Perforators of the Transverse and Descending Branches of the Lateral Circumflex Femoral Artery in Anterolateral Thigh Flap Surgery.

BACKGROUND: The anterolateral thigh flap (ALTF) is a kind of lateral thigh flap that uses branches of the lateral circumflex femoral artery (LCFA) as the vessel pedicle and is widely used in plastic surgery. During classic ALTF surgery, some perforators from the descending branch of the lateral circumflex femoral artery (LCFA-db) are hard to harvest due to their anatomical variants and individual differences; thus, it is necessary to design an appropriate alternative surgical plan. The transverse branch of the LCFA (LCFA-tb) has unique advantages and can be a potential complement to ALTF vascular pedicle selection. The aim of this study was to compare the difference in morphology between LCFA-db and LCFA-tb, and to verify the feasibility and clinical effect of ALTF with LCFA-tb as the source artery. METHODS: The morphological and clinical data of patients who underwent wound repair of the extremities with the ALTF pedicled with the LCFA-tb and LCFA-db were retrospectively analyzed. This study consisted of the clinical data of 62 patients who accepted an ALTF pedicled with LCFA-tb, and 45 patients accepted an ALTF pedicled with LCFA-db. RESULTS: A total of 68 cutaneous perforators originating from the LCFA-tb were found in the surgical field, of which 35 perforators were direct cutaneous perforators (51.5%), 28 perforators were septocutaneous perforators (41.2%), and 5 perforators were musculocutaneous perforators (7.3%). Seventy-four cutaneous perforators were found in the LCFA-db group. The proportions of septocutaneous perforators and musculocutaneous perforators were 23% and 77%, respectively, and the number of direct cutaneous perforators was 0. The harvest time of flaps pedicled with LCFA-tb was remarkably shortened. Regarding prognosis, there were no significant differences between the curative effects of the 2 types of flaps. CONCLUSIONS: This study verified that most LCFA-tb perforators are direct cutaneous perforators and that the piercing-in positions of LCFA-tb perforators on superficial fascia were higher than those of LCFA-db perforators. Furthermore, the ALTF pedicled with LCFA-tb can provide satisfactory soft tissue reconstruction and can be used as a useful supplement to the traditional flap design.

[Morphological study on the transverse branch of lateral femoral circumflex artery based on digital subtraction angiography].

Objective: To summarize the morphological characteristics of the transverse branch of lateral femoral circumflex artery (LFCA) using digital subtraction angiography (DSA) and explore its clinical significance. Methods: A retrospective observational study was conducted. From October 2020 to May 2021, 62 patients with soft tissue injuries in the extremities were hospitalized in Suzhou Ruihua Orthopedic Hospital, including 40 males and 22 females, aged from 20 to 72 years. DSA was performed in the lateral femoral region of patients before the anterolateral thigh flap transplantation, and in combination with imaging scale to observe and measure the general condition of the blood vessels and the occurrence (with the occurrence rate being calculated), source artery, location of the origin point, direction of course, and the location of the perforating point of the cutaneous perforator of the transverse branch of LFCA, and in addition to classify the morphological characteristics of the transverse branch. Results: DSA detection showed that the femoral artery, the deep femoral artery, and the branches of LFCA were clearly distinguishable in 62 patients. Transverse branches of LFCA were observed in 59 patients, including 52 cases with a single transverse branch, and 7 cases with double transverse branches. The occurrence rate of transverse branches was 95.2% (59/62). A total of 66 transverse branches of LFCA were observed, of which 3 originated from the deep femoral artery, and 63 originated from the LFCA. The origin point of the transverse branch was 6.5-12.7 cm away from the anterior superior iliac spine. The transverse branch which was approximately perpendicular to the long axis of the body, originated outwards, ran between the ascending branch of LFCA and the oblique branch of LFCA, and branched along the way, with the trunk running under the greater trochanter. The perforating point of the cutaneous perforator of the transverse branch was 8.0-18.0 cm away from the anterior superior iliac spine. In the classification of morphological characteristics of the transverse branch of LFCA, the most common type was the one that originated from the same trunk with other branches of LFCA, accounting for 50.0% (31/62), followed by the one that originated from the singular trunk of LFCA (12 cases) or deep femoral artery (3 cases), accounting for 24.2% (15/62); the special type accounted for 21.0% (13/62), including 7 cases of double transverse branches and 6 cases of the transverse branch originated from the same trunk with multiple other branches of LFCA; those with small/absent transverse branch only accounted for 4.8% (3/62). Among the above-mentioned common trunk relationship of two branches, those with shared trunk of ascending and transverse branches were most frequently observed, accounting for 77.4% (24/31); those with shared trunks of the transverse and oblique branches (5 cases) and the transverse and descending branches (2 cases) accounted for 22.6% (7/31) altogether. Conclusions: A high incidence rate of the transverse branch of LFCA is observed through DSA. The transverse branch originates from the lateral femoral artery approximately perpendicular to the long axis of the body, mainly from the same trunk with another main branch of LFCA, especially the ascending branch. This positioning analysis can provide an important reference for the design and resection of anterolateral femoral flaps.

Morphological study of branches of lateral femoral circumflex artery based on digital subtraction angiography.

In this study, the digital subtraction angiography (DSA) data were used to describe the number, course, and distribution of the branches of the lateral circumflex femoral artery (LCFA), in order to provide an imaging basis for the application of the anterolateral thigh flap pedicled with each branch of the LCFA. The number, location, direction, and distribution of the branches of the LCFA were analyzed by selective DSA angiography in 113 patients who needed an anterolateral thigh flap to repair the wound. LCFA usually originates from the deep femoral artery or femoral artery and routinely sends out four main branches: ascending branch, transverse branch, oblique branch, and descending branch. The ascending branch is about 45 °outward and upward with the horizontal axis of the body; the transverse branch is roughly parallel to the horizontal axis of the body to the outside of the thigh or slightly upward or downward; the oblique branch is about 45 °outward and downward to the body's long axis or horizontal axis and gradually turns parallel to the body's long axis; the 5∼10 cm at the beginning of the descending branch is parallel to the long axis of the body, and the internal and external branches are separated near the midpoint of the line between the anterior superior iliac spine and the lateral edge of the patella. It is of high reference value to use DSA technology to analyze the morphological characteristics of LCFA.

Microsurgical phalloplasty: Anatomical study evaluating the use of the external pudendal vessels as recipients.

The inferior epigastric artery (IEA) is commonly used as a recipient vessel in microsurgical phalloplasty but its use can be associated with abdominal parietal complications (hernia, bulging). To preclude such complications and avoid involvement of the femoral artery, we assessed an external pudendal artery (EPA) as a recipient vessel. We studied the disposition of the external pudendal system and its general anatomy. Then we compared the external diameter of the EPA to that of the first branches of the femoral artery. The most important point was to determine the location of the EPA through a reference line to facilitate a surgical approach. We then illustrated this preliminary study with a clinical case to check the reliability of the identified landmarks. Ten adult cadavers were dissected. The arteries of interest were part of a system consisting of either a common trunk or a duplicated system. The branches of the pudendal system arose from either the femoral artery or the deep femoral artery. On a horizontal reference line passing through the two pubic tubercles, we observed that 83% of EPAs arose between the reference line and 3 cm below it, at the level of a vertical axis centered on the femoral artery. The EPA could be suitable as recipient vessel in phalloplasty owing to its location, size, and ease of dissection. Using it instead of the IEA precludes abdominal parietal complications and reduces scarring in the recipient area.

Analysis of the Common Femoral Artery and Vein: Anatomical Morphology, Vessel Relationship, and Factors Affecting Vessel Size.

Background and Objectives: We aimed to analyze the morphology of the common femoral artery (CFA) and common femoral vein (CFV) and the anatomical relationship between the two blood vessels, and to investigate the factors that influence the size of these blood vessels. Materials and Methods: This retrospective study included 584 patients who underwent abdominal and pelvic computed tomography from 1 February to 28 February 2021. We measured the vessels at three regions on both lower extremities (inguinal ligament, distal vessel bifurcation, midpoint) and analyzed and classified the degree of overlap between the CFA and CFV into three types, as well as the factors affecting vessel size. Results: After comparing the femoral vessels according to location, it was confirmed that the CFA and CFV were larger distally than proximally on both sides (p < 0.001). The degree of overlap increased distally (p < 0.001) but was less at the middle (p < 0.001) and distal (p = 0.011) regions on the right side. It was found that the size of CFA and CFV were related to age, sex, and body mass index (BMI) and that malignancy also affects the CFA size. Conclusions: The morphology of the CFA and CFV was conical and increased distally. The degree of overlap between the two blood vessels also increased distally but was less on the right than on the left. Age, sex, and BMI are significant factors affecting the sizes of the CFA and CFV, and malignancy is associated with the CFA size.

The vascular exploration of the proximal femoral artery perforator region, an ideal donor site to choose cutaneous flaps of thin, supple, and glabrous skin: A cadaveric study.

BACKGROUND: The thigh region is a well-known area for harvesting cutaneous flaps for microsurgery replacement, given the characteristics of the skin: thin, flexible, and glabrous. We investigated the vascular pattern of 32 cadaveric anteroproximal thighs for the possibility of an extended harvesting area, which we call the proximal femoral artery perforator region. MATERIALS AND METHODS: We injected colored, radio opaque latex in the external iliac artery and investigated the perforator branches from the superficial circumflex iliac, femoral common, superficial, and deep femoral (profunda femoris) arteries to the skin of the proximal femoral artery perforator region. This region was divided into 3 equal subregions (superior, medial, and lateral), and their perforators were counted and measured. RESULTS: There was no significant difference in the number of arterial pedicles across the three subregions: 30 superior, 35 inferolateral, and 27 inferomedial. The perforators had a cutaneous path in 81% of the cases, while 6% were musculocutaneous and 5% septocutaneous, without a significant difference in their proportion in the three subregions. The mean length and diameter of the pedicles were 5.39 ±â€¯2.1 cm and 1.07 ±â€¯0.4 mm, respectively, without significant differences in the three subregions. CONCLUSIONS: The proximal femoral artery perforator region is a suitable area to generate flaps of various sizes and shapes, as needed by the surgeon. All perforators were constant and possessed a sufficient diameter and length for a successful anastomosis during the surgical procedure. The donor site retains all technical advantages to successfully replace areas of glabrous skin.

Variation of pectineus muscle forming a hiatus.

Knowledge of the anatomic variations in the pectineus muscle is important for vascular surgeons to minimize complications following surgical approach to the distal part of the deep femoral artery. During routine dissection of the thigh, variations in the bilateral pectineus muscles were identified in an 82-year-old male cadaver. On both sides, the superficial and deep layers of the pectineus were divided at its distal part, forming a triangular-shaped hiatus between them and the femur shaft. Distally, the tendon of the superficial part intermingled with the tendon of the adductor longus. The tendon of the deep part was inserted into the pectineal line. On the right side, the deep femoral artery and its first perforating artery passed through the hiatus. On the left side, the deep femoral artery pierced the hiatus, and then, the first perforating artery was branched from the deep femoral artery. No reported case has described a pectineal hiatus. The variations observed in this study are an ontogenetic vestige of the two different origins of the pectineus. The insertion of the superficial layer into the adductor longus tendon suggests a close relationship between these muscles during prenatal development. Surgeons should be aware of the variation to minimize injury to the pectineus muscle while approaching the deep femoral artery.

Musculoseptocutaneous Perforator of Anterolateral Thigh Flap: A Clinical Study.

BACKGROUND: The anterolateral thigh flap is one of the most useful workhorse flaps for microsurgical reconstruction. However, it can pose a great challenge to surgeons because of its anatomical variability. As the technology advances, not only septocutaneous or musculocutaneous courses of anterolateral thigh perforators but also a hybrid musculoseptocutaneous perforator pattern have been identified on computerized imaging and on cadaveric study. However, there is a paucity of clinical study in the literature. The aim of this investigation was to identify the features of this pattern. METHODS: All patients undergoing anterolateral thigh flap harvest between September of 2017 and May of 2018 performed by a single surgeon are included. Every pulsatile perforator was dissected to document its location on the thigh, emerging location (septum/muscle), size, course, and origin. RESULTS: Thirty-seven patients with 115 perforators were identified. Ten percent of perforators were septocutaneous, 37 percent were musculoseptocutaneous, and 52 percent were musculocutaneous. Forty-seven percent of perforators emerged on the septum between the rectus femoris and the vastus lateralis. Eighty-one percent of patients had one or more perforators in the "hot zone." Medium and large perforators were more frequently located in the proximal and hot zones. All perforators originated from the vascular tree of the lateral circumflex femoral artery, with 10 percent originating from the transverse branch, 28 percent originating from the oblique branch, and 62 percent originating from the descending branch. CONCLUSIONS: A high proportion of musculoseptocutaneous perforators were identified. The clinical relevance of this is to be very cautious on the skin paddle design while harvesting the flap.

The vascularization of the peroneal tendons: An anatomic study.

BACKGROUND: Arterial vascularization is intimately related to the peroneal tendon ruptures. Our purpose is to describe the vascular anatomy of peroneal tendons and assess differences in the vascularization patterns between peroneus brevis tendon (PBT) and peroneus longus tendon (PLT). METHODS: Anatomical study of 22 cadaveric lower extremities. We exposed tendons' vascularization by injecting latex. To systematize the vascular description, we considered four anatomical regions in the PBT and six in the PLT. RESULTS: Vascularization was supplied by the peroneal, anterior tibial and lateral plantar arteries and from the deep plantar arch through the vincula connecting the tendons. No avascular areas were found in the PLT. 22.7% of specimens had avascular areas in the PBT. Two visual vascularization patterns were found (arcuate and weblike). Increasing age and a web-like vascularization were associated with a lower number of blood vessels at the tendons' post malleolus area. CONCLUSION: Peroneal tendons are well vascularized throughout their course, running through a common vincula, with vascularization provided by various arteries. Avascular areas were observed in the PBT, but none at the PLT.

Profunda femoris artery perforator flaps: a detailed anatomical study.

The thigh region has many perforators when compared to the other areas in the body. Surgeons have disregarded the posterior thigh region as a potential donor site for perforator flap surgeries, presumably owing to the positioning difficulties of the patients during the intervention and inadequate anatomical information. The purpose of this study was to provide comprehensive data concerning the profunda femoris artery. Perforator flaps on an anatomical basis, and to describe anatomical landmarks, easing topographical flap dissection in various combinations. Eleven fresh cadaver thighs were obtained from different individuals using the Willed Body Program. The mean age was 43.5 years (29-63), and the male/female ratio was 7/4. We evaluated each cutaneous perforator for localization, diameter, source artery, numbers, length, and type (musculocutaneous or septocutaneous).We observed at least two perforators in all thighs in the study. Medial perforators consisted of 74.5% musculocutaneous and 25.5% septocutaneous perforators. Lateral perforators consisted of 68.3% septocutaneous perforators and 31.7% musculocutaneous perforators. Positioning difficulties of the patient during surgery and inadequate anatomical information cause surgeons to avoid this area. However, surgeons may easily perform these flaps in reconstructive surgery as a local or free flap with substantial success.

Surgical anatomy of the lateral circumflex femoral artery branches: Contribution to the blood loss control during hip arthroplasty.

BACKGROUND: The lateral circumflex femoral artery (LCFA) branches encountered during anterior and lateral hip approaches; although vessels' haemostasis is suggested in surgical textbooks, literature is scarce regarding their topography. The current study defines the exact location of the LCFA and its branches, based on osseous landmarks, as well as their size and possible variants, providing helpful information for intraoperative identification and demonstrating the magnitude of potential haemorrhage during hip surgery. METHODS: Twenty-three human cadavers (46 lower limbs) were dissected. The LCFA branching pattern was recorded. The distances of the LCFA origin and its first branch from the anterior superior iliac spine (ASIS) were measured. Length and width of the LFCA, LCFA ascending and transverse branches (LCFAab and LCFAtb) were calculated and compared to the ipsilateral ulnar artery (UA) width, which was served as a comparative guide. RESULTS: The LFCA origin was located 106.9 ± 17.5 mm distal and 65.6 ± 14.7 mm medial to the ASIS, while the LFCA first branch origin was 115.1 ± 24.3 mm distal and 48.2 ± 14.3 mm medial to the ASIS. The mean lengths of the LCFA, LCFAab and LCFAtb were 23.2 ± 12.6 mm, 44.8 ± 14.9 mm and 42.3 ± 13.6 mm, respectively. Their mean widths were 4.3 ± 1.0 mm, 2.9 ± 0.9 mm and 2.7 ± 0.7 mm, respectively, while the mean UA width was 2.7 ± 0.4 mm. CONCLUSION: The surgeon may detect the LCFA and its branching, at a mean distance of 110 mm (range 100-126 mm), distal to the ASIS. The LCFAab and LCFAtb widths are similar to the UA width. Meticulous knowledge of the branching pattern topography and vessels' size may contribute to a successful management of the intraoperative blood loss.

Collateral circulation of the femoral and genicular systems in human lower limbs is highly uncommon.

The descending branch of the lateral circumflex artery is a septocutaneous vessel that is vital for free and pedicle thigh flap transfer surgeries when repairing tissue defects. It also forms an anastomosis with the superior lateral genicular artery to create a collateral pathway for circumventing occlusions in the superficial femoral artery (SFA). Many anatomical texts and atlases imply the persistence of this anastomosis. However, previous studies indicate variability in the source of the arteries that form the anastomosis, and have reported cases where an anastomosis does not exist. We hypothesized that variations from the conventional accepted pattern can be predicted by comparisons of arterial diameters, and that unconventional anastomoses may be present to facilitate collateral circulation to the limb. Fifty-one limbs were dissected and analyzed to establish the source of the descending branch of the lateral circumflex artery, classify the types of anastomoses, and compare the diameters of the descending branch of the lateral circumflex artery, the SFA and the profunda femoris artery to the common femoral artery (CFA). Vessel diameters were normalized to the diameter of the CFA to allow comparison of limbs from both sexes and to minimize the effects of cadaver size on correlating vessel size to the presence or absence of collateral circuits. We report that 62.7% of limbs (32/51) had typical branching patterns; however, only 27.4% of limbs (14/51) had any anastomosis to connect the proximal and distal regions of the thigh. Importantly, the SFA had a wider relative diameter in limbs without anastomoses than in limbs that had normal anastomoses, perhaps precluding the formation of a collateral pathway. Overall, collateral circulation of the lower limb was highly uncommon, in contrast to information inferred from anatomical texts. This study suggests the need for more thorough procedures for determining viable anastomoses prior to thigh flap surgeries to ensure flap survival.

There are no safe areas for avoiding the perforating arteries along the proximal part of the femur: A word of caution.

Knowledge about the variable course of the perforating arteries near the body of the femur is essential during surgical procedures (e.g., percutaneous cerclage wiring, plate osteosynthesis, Ilizarov technique). Our aims were to determine the number of perforating arteries, and to identify safe zones along the body of the femur within which perforating arteries are unlikely to pass toward the back of the thigh. The number of perforating arteries was determined in both legs of 100 formalin-fixed anatomic specimens of both sexes. The level of passage of perforating arteries near the body of the femur was measured in reference to a line from the anterior superior iliac spine to the medial femoral condyle. In each leg, two to seven perforating arteries were present. In 64% of legs, at least one artery divided into two to four branches before entering the back of the thigh. Thus, the total number of branches passing near the body of the femur varied between two to nine. Perforating arteries passed to the back of the thigh at every level between 14.0 and 36.5 cm from the anterior superior iliac spine (16-39% of the leg length). Within this distance, no safe zones along the body of the femur could be identified. The present study shows the high variability regarding number and course of the perforating arteries. Surgeons can be faced with an artery at every level on the posteromedial aspect of the body of the femur between 14.0 and 36.5 cm distally to the anterior superior iliac spine. Clin. Anat. 33:507-515, 2020. © 2019 Wiley Periodicals, Inc.

Anatomical Study of the Descending Genicular Artery Chimeric Flaps.

Purpose: With increasing use of the chimeric flap of the descending genicular artery, the authors systematically investigated the anatomy of its branches in cadavers. Methods: Fifteen fresh cadaveric thighs were studied by anatomical dissection. The branches of the descending genicular arteries were skeletonized along their courses to the femoral arteries. Branches' lengths and diameters were measured to simulate the combined application of the skin, muscle, bone, osteochondral and osteocutaneous flaps with tendon enthesis. Results: The descending genicular artery was noted in 11 thighs, with an average diameter of 1.94 ± 0.36 mm and an average length of 10.69 ± 4.41 mm. In addition, the saphenous artery was noted in all 15 thighs, and the average diameter of the original part was 1.35 ± 0.18 mm. Branches arose from the saphenous artery to supply the skin above the knee, the anterior of tibia, the sartorius muscle and the pes anserinus. The average diameter of the osteoarticular artery was 1.80 ± 0.46 mm which divaricated into a periosteal branch to supply the bone above the medial femoral epicondyle and a few articular branches to supply the bone and the cartilage of the medial femoral condyle. Conclusions: This study systematically investigated the anatomy of the descending genicular artery and its branches. Based on the anatomical features of descending genicular artery, chimeric flap offers combination therapy with other tissue flaps. Besides, considering its long chimeric arm, chimeric flap could be used to repair not only local complex injuries but also defects in different locations. Clinical Relevance: The descending genicular artery chimeric flap is a clinical option for reconstructing compound tissue defects of limbs.

Anatomic characterization of the femoral nutrient artery: Application to fracture and surgery of the femur.

The localization of nutrient foramina and direction of nutrient canals have been studied. However, information about the origin and extraosseous course of nutrient arteries is lacking in some types of long tubular and irregular bones. Thus, we aimed to reexamine the origin and course of the femoral nutrient artery (FNA) through cadaveric dissection to clarify its anatomic characteristics. Sixty thighs were collected from 57 cadavers. To fix the cadavers and visualize the small arterial branches, 10% formalin was injected from the femoral artery, followed by an injection of acrylic ink. The arterial tree in the posterior part of the thigh was recorded by line drawings. The femur received single or double FNAs via the femoral nutrient foramina, which were on and along the linea aspera. In cases with single FNA (41 of the 60 thighs), it typically arose from the four parts of the profunda femoris system: profunda femoris artery between the origins of the third and fourth perforating arteries; second perforating artery; third perforating artery; and terminal branch. In cases with double FNAs (remaining 19 thighs), the superior FNA typically arose from the second perforating artery, and the inferior FNA arose from the terminal branch of the profunda femoris artery and popliteal system. FNAs are described as branches of the perforating arteries in Terminologia Anatomica and anatomy textbooks. However, we found that FNAs also frequently arose from the profunda femoris artery and popliteal system, in addition to the perforating arteries. Clin. Anat. 33:479-487, 2020. © 2019 Wiley Periodicals, Inc.

Anterior acetabular retractors and the femoral neurovascular bundle in anterior total hip arthroplasty: a cadaveric study.

PURPOSE: The direct anterior approach for primary total hip arthroplasty (THA) has become increasingly popular in recent years. Nerve compression or traction with a retractor is a common cause of nerve injury in this approach. The purpose of this cadaveric study was to evaluate the anatomic relationship of the femoral neurovascular bundle to the anterior acetabular retractor during direct anterior approach THA. METHODS: Eleven fresh-frozen cadavers underwent a standard direct anterior THA, with placement of an anterior acetabular retractor in the usual fashion between the iliopsoas and acetabulum for visualization during acetabular preparation. Careful dissection of the femoral triangle was performed, and the distances from the anterior retractor tip to the femoral nerve, artery, and vein were recorded and analyzed as mean distance ± standard deviation. RESULTS: In all 11 cadavers, the retractor tip was medial to the femoral nerve. The mean distance from retractor tip to femoral artery and vein was 5.9 mm (SD = 5.5, range 0-20) and 12.6 mm (SD 0.7, range 0-35), respectively. CONCLUSIONS: Surgeons should be aware of the proximity of the neurovascular structures in relation to the anterior acetabular retractor in the direct anterior approach, taking care to avoid perforating the iliopsoas muscle during retractor insertion and limit excessive traction to prevent nerve injury.

Anatomy of the lateral circumflex femoral artery: Does the direct anterior approach to the hip jeopardize vascularization of the proximal femur?

BACKGROUND: Blood supply of the proximal metaphysis of the femur comes mainly from the lateral circumflex femoral artery (LCFA). Essentially, the anterior approach has gained popularity in hip surgery but routinely requires the ligation of the ascending branch of the LCFA. Until now, there is no study analysing the effect of previous hip surgery on the vascularization of the proximal femur. Notably, it might, however, have consequences on osteointegration of uncemented prosthesis as well as in the management of early complications. Therefore we conducted a retrospective study to address the following questions: (1) Is the blood supply of the trochanteric region impaired by previous hip surgery, (2) does the anterior approach alter it more than other ones? HYPOTHESIS: We hypothesised that the surgical approach to the hip influences blood supply of the proximal femur, as visualised by retrospective analysis of femoral digital subtraction arteriograms (FDSA). PATIENTS AND METHODS: A retrospective review of 1280 FDSA, performed for vascular indications with a standard frame rate, between 07/2014 and 06/2016 in a single institution. Qualitatively sufficient FDSA were divided into 4 groups according to the history of previous hip surgery: hip replacement through an anterior approach (n=10) or through a lateral approach (n=31), cephalomedullary nailing for fractures of the proximal femur (n=5), and a control group of 50 continuous patients without previous hip surgery. The number of frames was counted between contrast injection into the femoral bifurcation and filling of the ipsilateral vessels of the greater trochanter to measure a potential delay/impairment of its arterial perfusion. Anatomic variations of the LCFA were also recorded. RESULTS: The number of frames between contrast injection and visualisation of the blood supply of the greater trochanter was 3.6±0.9 (mean±SD) in the control group (p<0.001 vs. all other groups). In patients with a hip replacement, the delay was 7.0±1.9 frames for the anterior approach and 5.2±1.1 frames for the lateral approach, respectively. In patients after cephalomedullary nailing, a delay of 4.8±1.5 frames was measured. The delay in the anterior approach group was significantly longer (p<0.001) compared to all other investigated groups. The ascending branch of the LCFA could not be detected after the anterior approach. As after lateral approach or as in the control group, the transverse branch was detectable in approximately 2/3 of the patients. DISCUSSION: Arterial perfusion of the greater trochanter is impaired after hip surgery, particularly after an anterior approach. The clinical relevance of these findings still needs to be investigated. It might, however, explain some early aseptic failures of uncemented stems. Moreover, it should be considered in early revision surgery, because combining different approaches might critically impair femoral blood supply. LEVEL OF EVIDENCE: III, retrospective case control study.

Intraoperative anatomy of the vascular supply to the medial femoral condyle.

The arterial anatomy of the medial femoral condyle (MFC) for vascularized bone grafting has been extensively studied in cadaveric specimens. A majority of cadaveric studies have limited numbers of specimens, and the data from these studies are extrapolated to the surgical environment. The purpose of this study is to evaluate the vascular anatomy of the medial femoral condyle in a large clinical series. A retrospective review of operative reports was conducted of medial femoral condyle and trochlea vascularized bone grafts performed by the senior surgeons between 2005 and 2018. A total of 113 patients were included in the study. Demographic data, preoperative diagnosis, and type of graft harvested were collected. The descending genicular artery, a branch of the superficial femoral artery, was the dominant pedicle in 77% of cases. It was also the dominant arterial pedicle for medial femoral trochlea (MFT) bone grafts in 7 out of the 9 cases (77.8%). The superomedial genicular artery was the dominant pedicle in 23% (26 of 113 total) of all cases. In eight patients, a descending genicular branch was not identified. The superomedial genicular artery was absent in 2% of cases (2 of 113). The descending genicular artery was the dominant arterial pedicle for vascularized bone grafts from the medial femur and was present in 93% of cases. This is in contrast to published cadaveric studies showing the artery was present in 89% of specimens.

Age-related changes in inguinal region anatomy from 0 to 19 years of age.

Knowledge of the age-related changes in inguinal region anatomy is essential in pediatric urological and abdominal surgery, yet little is published. This study aimed to determine the position of inguinal region structures and growth of the surrounding pelvis and inguinal ligament in subjects from 0 to 19 years of age. Anonymized contrast-enhanced CT DICOM datasets of 103 patients (63 male: 40 female) aged from 0 to 19 years had left and right sides analyzed by three independent observers. Exclusion criteria were applied. Growth of the pelvis and inguinal ligament were determined using fixed bony reference points. The position of the deep inguinal ring and femoral vasculature were determined as ratio of inguinal ligament length, measured from the anterior superior iliac spine. Growth of the pelvis in vertical and horizontal dimensions and of the inguinal ligament followed a positive polynomial relationship with increasing age, with no observed increase in growth rate during puberty. From 0 to 19 years, the deep inguinal ring moved superolaterally with respect to the inguinal ligament (from 0.74 to 0.60 of the distance along the inguinal ligament) and the femoral artery and vein moved medially (from 0.50 to 0.58, and 0.61 to 0.65 of the distance along the inguinal ligament, respectively). The position of the femoral artery, vein, and deep inguinal ring followed a logarithmic relationship with age. No significant left:right side or male:female differences were observed. From 0 to 19 years of age the femoral vasculature and deep inguinal ring change position as the pelvis grows around them. Clin. Anat. 32:794-802, 2019. © 2019 Wiley Periodicals, Inc.