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

Morphology of the lateral circumflex femoral artery in adult cadavers

The lateral circumflex femoral artery (LCFA) is important for surgical approaches to the hip joint; its branches are often used as grafts and pedicled flaps. Our aim was to contribute to the literature by reporting variations. The LCFA branching pattern was studied in 26 lower limbs of formalin-fixed cadavers. It was recorded whether the LCFA originated from the femoral artery (FA) or the deep femoral artery (DFA). The distances of LCFA from the mid-inguinal point (MIP) and DFA; and the diameters of LCFA and its branches were measured with metric caliper. Side differences were analyzed by Wilcoxon test. The mean shortest distance from the LCFA to the MIP was 59.45 ± 13.06 mm and to the DFA was 19.23 ± 9.63 mm. The mean diameters of LCFA and its ascending, transverse, and descending branches were 5.82 ± 1.87 mm, 3.28 ± 0.87 mm, 3.02 ± 0.92 mm, and 3.61 ± 0.98 mm, respectively. The LCFA originated from 80.8% DFA and 19.2% FA. Data were evaluated jointly (p > 0.05). In one case, an accessory transverse branch was found. Spearman analysis shows that as the distance between the LCFA and the MIP increased, the diameter of the LCFA and its branches increased. Knowledge of the LCFA branching pattern is essential for interventional options in arterial grafts, such as bypass surgery, pedicled flaps, and surgical approaches to the hip joint. Preoperative radiologic evaluation for accurate knowledge of the topography of the branching pattern and vessel size can contribute to successful management of intraoperative blood loss and avoidance of iatrogenic injury.

The accessory vascularization of the tensor fasciae latae muscle: towards a new classification?

PURPOSE

The tensor fasciae latae (TFL) muscle is supplied by the lateral femoral circumflex artery (LCFA), arising from the deep femoral artery. However, it has been noted that there is also a consistent vascular anastomotic network. The aim of this study was to describe the accessory vascularization of the TFL muscle through a descriptive anatomical study, in order to hypothesize the feasibility of harvesting a TFL flap in the event of an injury to the main pedicle. In addition, we illustrate this hypothesis with a successful clinical case of Scarpa freconstruction following ligature of the deep femoral artery.

METHODS

The description of the accessory vascularization was obtained by injecting dye into seven lateral femoral circumflex arteries (LCFA), six superficial circumflex iliac arteries (SCIA), and three inferior gluteal arteries (IGA).

RESULTS

The TFL muscle was vascularized primarily by the LCFA. A vascular anastomotic network with the SCIA and the IGA was observed. After selective injection to the SCIAs and IGAs, the subsequent injection to the LCFA showed a diffusion of the TFL skin paddle with a perforasome overlapping between the different vascular territories.

CONCLUSION

The ascending branch of the lateral femoral circumflex plays a dominant role in the vascularization of the TFL muscle. As a result of a periarticular anastomotic network of the hip, this artery establishes several connections with the proximal arteries. Consequently, in cases where blood flow through the LCFA is interrupted, it should be equally possible to harvest the TFL flap through its accessory vascularization.

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.

Vastus Lateralis and Vastus Intermedius Myocutaneous Flap Reconstruction for Complicated Trochanteric and Ischial Pressure Sores with Extended Girdlestone Resection: A Case Series

OBJECTIVE

Most paraplegic patients with complicated trochanter sores or ischial sores present with lower limb muscle atrophy. Therefore, in patients who have undergone Girdlestone arthroplasty, filling the dead space and replacing the volume defect through an appropriate surgical technique is extremely challenging. This study presents a case series of vastus lateralis and vastus intermedius myocutaneous flap reconstruction after extended proximal femoral osteotomy in paraplegic patients. The aim of study is to investigate (i) whether sufficient volume replacement was achieved, (ii) whether muscle volume was maintained during long-term follow-up, and (iii) the presence of donor site morbidity.

METHOD

A retrospective review was conducted with eight patients who underwent this method from March 2017 to December 2021. A total of nine flaps was elevated, and the defect was successfully reconstructed without dead space. Computed tomography was performed to identify the changes in thickness and volume of the muscle portion. The Wilcoxon signed-rank test was performed to assess the significance of the differences in muscle thickness between pre- and post-measurements.

RESULTS

After surgery, all patients healed within 1 month; three patients experienced minor complications. The average follow-up period was 14.5 months, during which only one patient with an ischial pressure ulcer developed wound disruption and recurrence. The average thickness of the rotated muscle was 51.95 mm at 2 to 4 weeks postoperatively and 53.07 mm at 6 months postoperatively (𝑝 = 0.071).

CONCLUSION

All nine cases healed well without major complications. When comparing the volume of the rotated muscle on radiological examinations before and after surgery, no significant differences were observed. Our modified Girdlestone resection technique provides a simple and reliable method for reconstructing complex trochanteric or ischial sores in paraplegic patients. It ensures anatomical consistency, ample volume, and structural stability by leaving the rectus femoris (RF) in place. Careful tension management is required when using this flap in the ischial area.

A Consistent Anatomic Landmark for Identifying the Lateral Femoral Circumflex Artery in a Direct Anterior Hip Approach

A direct anterior approach (DAA) is a technique practiced by arthroplasty surgeons that can be technically challenging, most notably for inexperienced surgeons. The lateral femoral circumflex artery (LFCA) is a branch of the femoral artery that crosses the surgical field during DAA and is an important landmark for superficial surgical dissection. If the vessel is not identified, significant bleeding may occur, and visualization may be impaired. This study aimed to develop a reliable method to identify and ligate the LFCA with minimal bleeding. First, a retrospective review was performed on a series of patients who underwent primary DAA total hip arthroplasty. Epidemiologic and intraoperative radiologic information was collected to determine the 2-dimensional location of the LFCA as it coursed through the surgical interval. Second, a series of computed tomography (CT) angiograms were compared to validate the intraoperative anatomic findings. In this study, 108 patients were evaluated fluoroscopically and 100 CT angiograms were obtained, for 208 total patients. The distance of the LFCA from the lesser trochanter with standard fluoroscopy (LT/TD) was 0.600 vs 0.438 on CT angiogram. Mean offset from midline (offset/femur diameter) was 0.166 lateral to midline vs 0.36 medial to midline. Median value of offset was 0 vs 0.411-representing a position on the anatomic axis of the femur. This study confirmed that the LFCA is found approximately one-third to two-thirds of the way between the lesser and greater trochanters along the anatomic axis of the femur for most patients. Surgeons who are new to DAA can use the LFCA as a reliable landmark to confirm the correct interval. [Orthopedics. 2022;45(5):262-268.].

3D Mapping of Bone Channel of Blood Supply to Femoral Head in Proximal Femur

Background

A detailed depiction of nutrient foramina is useful for defining guidelines and minimising iatrogenic damage during hip surgery. Therefore, this study aimed to define the location and frequency of nutrient foramina in the proximal femur using mapping techniques.

Methods

One hundred dry human cadaveric proximal femurs, comprising 56 left and 44 right femurs, were scanned using a three-dimensional scanner, with scanning distance 200 mm, precision 0.01 mm, and measuring point 0.04 mm. The image resolution of 1,310,000 pixels was obtained. Digital imaging models were acquired from the proximal femur surface. All the nutrient foramina in each model were identified and marked. The nutrient foramina models were superimposed on one another and oriented to fit a standard template of the femur’s proximal aspect. Three-dimensional mapping in the proximal femur’s nutrient foramina was performed.

Results

The nutrient foramina’s location and dense zones were identified. The dense zones were distributed along the vascular course and gaps between the muscle attachment sites. Eighteen dense zones were identified and found to be location-dependent. They were located in the central part of the fovea capitis femoris, subcapital and basicervical areas of the femoral neck, and muscle attachment gaps of the femoral trochanter.

Conclusions

The terminal branch of the nutrient vessels entering the nutrient foramina is at risk for iatrogenic damage during hip surgeries, especially in cases of close bone exposures. There are 18 dense zones that need to be considered for a safer approach to the proximal femur. To minimise iatrogenic damage to the nutrient vessels entering the nutrient foramina, the dense areas should be avoided when technically possible.

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

INTRODUCTION

In diagnostic angiographic procedures, the knowledge of arterial variations in the femoral artery (FA), deep femoral artery (DFA) and lateral and medial circumflex femoral arteries (LCFA, MCFA) has a great impact.

MATERIAL AND METHODS

The frequency of branching patterns of these arteries was investigated in 111 thighs of body donors. Gender and side differences were analyzed statistically.

RESULTS

The median distance of separation of the DFA from the FA in relation to the inguinal ligament (IL) was 3.29 cm. High origins (1-2 cm below IL) and middle origins (3-5 cm below IL) of the DFA were found in an equal distribution of 39.3% and 41.1%, respectively. Low origins (6-10 cm below IL) were rare (19.6%) but showed a tendential significance toward expression in males (p = 0.096). The origin of the LCFA from the FA (19.8%) or DFA (70.2%) are in line with the findings of other groups. The origin of the MCFA from FA (14.4%) or DFA (74.7%) showed that circumflex femoral arteries arose mostly from DFA. A trifurcation of the FA into the DFA, LCFA and MCFA was only observed in 9.9% and, therefore, less frequently than reported by others. Branches of the femoral nerve (FN) passed mostly anterior (46.4%) or anterior and posterior (47.8%) to the LCFA. The rare constellation of branches of FN passing only posterior to the LCFA (5.8%) showed a tendential significance to left side expression (p = 0.084).

CONCLUSIONS

Taken together, this is the first classification of the median distance of separation of the DFA from the FA in relation to the IL in three defined groups. The knowledge of DFA branching pattern is essential for recent therapy options of cardiac diseases using a femoral artery access: transcatheter aortic valve replacement, catheter-based miniaturized ventricular assist device and veno-arterial extracorporal membrane oxygenation. The variant topography of the branches of FN in relation to LCFA should be kept in mind when harvesting an anterolateral thigh flap.