The main blood supply to the femoral head in the adult is believed to be the terminal extension of the deep branch (aka the deep branch) of the medial femoral artery.1–3Standard textbooks describe the additional contribution of the crossed anastomosis to the blood supply to the hip in general.4,5Vessels contributing to this anastomosis have been described in a variety of ways, including obturator, lateral femoral circumflex, gluteus infra, gluteus superior, and possibly the first perforator and medial circumflex femoral arteries.1,2,4,6,7Recently, Gautier et al.2reported that the inferior gluteal portion of this anastomosis was "constant" and was able to adequately supply blood to the femoral head when the medial circumflex femoral artery was damaged. Despite the potential importance of this portion of the crossed anastomosis, to date there is no detailed description of the course of the inferior gluteal artery in the trochanteric region or the connections between it and the medial circumflex femoral artery.
We performed a series of medial circumflex femoral and inferior gluteal artery injections to attempt to accurately delineate the junction(s) between the deep branch of the medial circumflex femoral artery and the inferior gluteal artery.
Materials and methods
We obtained eight freshly frozen pelvises with their hips (Anatomical Gift Registry, Hanover, Maryland) with no known hip disease. Two specimens were shared with other investigators, with only one side injected and dissected at a time. Bilateral studies were performed on the remaining six samples. Thus, a total of 14 examinations were carried out.
Vessel injections were through the medial circumflex femoral artery in three specimens and through the inferior iliac artery in 11 specimens. Access to the first was obtained by dissection through the femoral triangle. The angiotomy was performed on the superficial or deep femoral artery at the level of the branch of the lateral circumflex femoral artery, a point where the medial circumflex femoral artery with posterior exit could be easily identified. Access to the inferior gluteal artery was obtained by intrapelvic or extrapelvic dissection if it crossed behind the piriformis. All samples were injected in a standardized manner after cannulation with a 14-gauge angiocatheter. PMC-780 Industrial Liquid Rubber Compound (Smooth-On, Easton, Pa.) was prepared and colored with So-Strong dye (Smooth-On, Pa.). ). On) according to manufacturer's recommendations and injected with a pressurized cement gun. After injection, the latex was allowed to cure for a minimum of 16 hours according to the manufacturer's instructions.
All preparations were performed using an extended posterior approach to the hip. In each case, the vessels were dissected to their terminal branches in the trochanteric region to determine whether the deep branch of the medial femoral artery was perfused. In addition, the hip capsule was opened to assess the perfusion of the lateral epiphyseal arteries along the upper part of the femoral neck.
Results
Of the 14 possible samples, 11 were successfully injected via the medial circumflex femoral artery or the inferior gluteal artery (Table I). There were three technical failures, one due to poor pressurization and two due to an error in canalizing the inferior gluteal artery. Of the successful injections, ten specimens showed a clear anastomosis between the medial circumflex femoral artery and the inferior gluteal artery, documented by retrograde flow in the alternative vessel (Table I).
Retrograde injections into the vasculature of the inferior gluteal artery.
For all three injections into the medial circumflex femoral artery, retrograde flow to the inferior gluteal artery was observed in a characteristic pattern through one to three vessels located above or below the conjoint tendon.
Anterograde injections through the inferior gluteal artery.
Eight of nine inferior gluteal artery injections demonstrated a direct anastomosis with the deep branch of the medial circumflex femoral artery through a medium-sized vessel, 1 mm to 3 mm in diameter, at or near the point where it crosses the obturator tendon. . externa The pattern of these anastomoses was identical to that observed in those specimens in which the inferior gluteal artery filling was done retrograde after injection of the medial circumflex femoral artery.
Course of the A. glutea inferior and description of the anastomosis sites.
The course of the A. glutea inferior is mostly well described in standard texts.4,5In the gluteal region, it descends along with the sciatic nerve, giving off two to four branches posterior and lateral to the gluteus maximus, one branch to the sciatic nerve, and branches to the sacrotuberous ligament. In addition, from our latex injections, we identified three branches that contributed to the cross anastomosis. These ranged from posteromedial to anterolateral on both sides of the articular tendon. Two of these branches were described in an early issue of as 'anastomoses' and 'joint boxes', respectivelyGrays Anatomie.4We have tried to keep this nomenclature for consistency, although the terminology seems inappropriate given the distribution we encountered. We assume that the anastomotic branch is the piriform branch identified by Gautier et al. was described.2and the articulated branch as one of the two contributions.
The piriform branch ("anastomotic branch") separated from the main trunk of the inferior gluteal artery at about the level of the upper calf. It crossed posteriorly (superficially) to the sciatic nerve in all but one specimen and continued laterally, passing between the piriformis and superior gastrocnemius (illustration 1). Along the path of this vessel, many small branches detached, passing to the adjacent muscles. A branch was severed early in its course, extending deep between the piriformis and superior gastrocnemius to the posterior superior capsule and labrum. In the area of the greater trochanter, the piriform branch divides into three or four smaller branches. Some of these branched to innervate the posterior part of the gluteus medius tendon just proximal to the greater trochanter, others passed behind the piriformis tendon. A direct anastomosis between the deep branch and the piriform branch (figs 1j2) occurred in five of the seven specimens where an anastomosis was found. Whenever such an anastomosis occurred, the piriformis branch traveled posteriorly through the piriformis and associated tendons and encountered the medial femoral circumflex artery in the gap between the inferior gastrocnemius and the external obturator tendon.
The inferior anastomotic supply consisted of one or two vessels, one superficial and one deep, both of which passed in the interval between the inferior gastrocnemius and the quadratus femoris. We consider the deeper branch to be the "capsule branch" described above,4and the most superficial branch, the "square branch," which we named after the structures to which the vessels were most closely connected.
The capsular branch was present in all specimens. It originated from the inferior gluteal artery at about the level of the lower calf and ran anterior (deep) to the sciatic nerve. It always branches to supply the proximal capsule and labrum and continues laterally through the capsule just superior to the external obturator tendon.Figure 2). In four specimens, this vessel ended in the lateral part of the capsule. Just as often it continued transversely, forming a direct connection with the deep branch at the posterior inferior border of the hip capsule, just superior to the external obturator tendon. In other specimens there was a second, more superficial inferior supply, which we refer to as the square branch. This was quite large on both sides and retrogradely crossed the quadratus femoris. If present, this branch always went directly into the area of the tendon obturatorius externa and anastomoses there with the deep branch (Abb. 3). In two preparations, it ran significantly more directly to the hip capsule than to the medial circumflex femoral artery. In these specimens, the lower twin branches terminated in the lateral epiphyseal arteries, and the deep branch of the medial circumflex femoral artery appeared to enter the lower twin branches perpendicularly in a "T" shape.
Regardless of which branch of the inferior gluteal artery supplies the anastomotic vessel, in all cases the anastomosis occurred when the deep branch crossed behind and above the external obturator tendon.figs 2j3). This vessel then passed directly under the posterior orbicularis fibers of the hip capsule while still on the posterosuperior side of the femoral neck. Below the capsule, it ran subsynovally and obliquely upwards along the femoral neck, eventually dividing into two to four lateral epiphyseal arteries. We found that the deep branch always continued below the capsule before reaching the upper surface of the neck. Because the vessel penetrated deeply into the conjoint tendon, it was always protected by part of the hip capsule.
In the three examples in which the medial circumflex femoral artery was injected, we also observed latex filling of the medial epiphyseal arteries. This has occasionally been observed even with samples injected via the inferior gluteal artery. These vessels have been found to pass in a synovial fold binding reflex on the posteroinferior aspect of the neck. They have previously been well described by Harty8in Sevitt in Thompson.9We observed that one or two ligamentous vessels branched into four or more terminal epiphyseal vessels within 3 to 5 mm of the physeal scar. These vessels were distributed along the posteroinferior surface of the head-neck junction at the five and seven o'clock positions, respectively, depending on the side of the specimen.
discussion
Various aspects of the crossed anastomosis between the inferior gluteal circumflex and the medial femoral arteries have been described for at least 100 years.4However, the surgical implications have only recently been considered. In the 1918 editionGrays Anatomie,4Anastomotic connections between the internal and external iliac systems via the medial circumflex femoris and the inferior arteries have been described, with the anastomotic branches of the inferior gluteal artery being described as "directed downwards by the external rotators and aiding in the formation of so-called crucial anastomotic vessels." This description remained largely unchanged in the 38th edition of this classic text.10This "crucial" or "crossover" anastomosis has many different descriptions.5The constant components are the medial circumflex femoral artery and the inferior gluteal artery,4,7,11Femoral lateral Zirkumflexarterie4,7,11,12The closure7,9the superior gluteal artery11and the first puncher.11However, in the many descriptions of this anastomosis, neither the exact course of the respective arteries nor the specific sites of the anastomosis are described.
Gautieret al.2He recently mentioned the anastomosis between the inferior gluteal artery and the medial femoral circumflex artery in a report detailing the course of the medial femoral circumflex artery. They observed that there was a constant blood supply to the femoral head through the medial circumflex femoral artery, with no discernible contribution from the lateral circumflex femoral artery. In addition, they described a significant constant anastomosis with the inferior gluteal artery occurring through a branch that they indicated runs along the piriformis. Without further specific comments on this anastomosis, they expressed their belief that it "may be able to compensate for an MFCA deep limb injury."2However, a specific description of the precise location of the anastomotic junctions between these two vessels was not provided.
We were able to provide clear evidence of retrograde flow from the external iliac system via the medial circumflex femoral artery to the internal iliac system via the inferior gluteal artery in all three specimens in which the medial circumflex femoral artery was injected. The pattern was similar for the three injections, resulting in filling of the inferior gluteal artery with latex through branches extending from the trochanteric fossa. One branch ran between the superior gastrocnemius and the piriformis, and the second ran along the capsule adjacent to the external obturator tendon or more superficially between the inferior gastrocnemius and the quadratus femoris. We were able to perform these anastomoses by anterograde injections directly into the inferior gluteal artery. This enabled the precise determination of the origin and sites of a connection between the deep branch of the medial circumflex femoral artery and the inferior gluteal artery. Our dissections determined the extent of the deep branch and lateral epiphyseal arteries to test the hypothesis of Gautier et al. to confirm.2that the inferior gluteal artery is able to perfuse the femoral head in the absence of inflow from the medial circumflex femoral artery. In all successfully injected specimens with anastomosis, we were able to fill both the lateral epiphyseal arteries and the medial epiphyseal arteries.
Our dissections showed that the deep branch remained in the transverse plane near the external obturator tendon until passing under the posterior aspect of the hip capsule, the orbicularis zone. The vessel ran relatively anteromedially along the neck to reach the posterior capsule, but never ran significantly cranial and was never found in the gap between the capsule and the gastrocnemius and internal obturator.
In summary, the deep branch is regularly supplied with blood by at least one vessel of the inferior gluteal artery. We found that both the course of these tributaries and the location of the anastomoses are consistent and easily identifiable. All anastomoses occurred in an extracapsular position immediately adjacent to the external obturator tendon in the trochanteric fossa. The deep branch in all cases led deep to the posterior orbicularis fibers of the hip capsule and was never found in the gap between the short external rotators and the hip capsule, and the inferior epiphyseal arteries were seen in a ligand fold of synovial tissue.
We hypothesized the surgical and pathological implications of these findings. Jedral et al.13described the fetal pattern of blood supply to the hip as being dominated by the inferior gluteal artery in more than 50% of the cases studied. In some of our preparations, the inferior gluteal artery appeared to be the most dominant vessel, in terms of the direct course from certain branches of the inferior gluteal artery to the lateral epiphyseal arteries and the many sources of entry into the deep branch of the inferior gluteal artery relative to the bottom. to the single origin of the medial femoral circumflex artery. It may be that some aspects of this variability in fetal development make some hips more susceptible to vascular damage in this region. In addition, we believe our dissections provide a better understanding of the ultimate blood supply to the femoral head. In all seven anastomotic specimens, the deep branch of the medial circumflex femoral artery received significant additional inflow from vessels derived from the inferior gluteal artery immediately after crossing the external obturator tendon. It may be more accurate to view the deep branch destined to become the lateral epiphyseal arteries as a common vessel with input from many sources.
The consequences of a traumatic hip dislocation can be better understood using this anatomical concept. The presence of proximal basal blood flow at the level of the posterior hip capsule may protect against vascular insult. In the event of a posterior dislocation, vessels based on the inferior gluteal artery must have greater capacity to accommodate the extreme displacement of the femoral head. Clinical reports indicate that not all posterior dislocations, with or without associated fractures, result in avascular necrosis of the femoral head.14–sixteenIn these circumstances, it may be this additional supply to the deep branch of the medial circumflex femoral artery that prevents the development of avascular necrosis.
In summary, we reliably cannulated the inferior gluteal artery and were therefore able to document the exact course and location of the branch anastomoses that contribute to the cross anastomosis. We found that both the occurrence and location of these anastomoses were remarkably consistent and near easily identifiable local landmarks. This information may be relevant in surgical practice to reduce the risk of iatrogenic avascular necrosis in posterior hip approaches.
Table I
For each sample, the injected container is listed for each side. The presence and location of the observed anastomosis between the medial circumflex femoral artery (MFCA) and the inferior gluteal artery (IGA) are listed as described in the text.
| Probe | right side | Left side | Anastomosis | For the anastomosis |
|---|---|---|---|---|
| * LFCA, lateral femoral Zirkumflexarterie | ||||
| † SGA, small Gesäßarterie | ||||
| 1 | MFCA | life cycle assessment* | MFCA only | piriform and capsular branches |
| 2 | AIG | AIG | yes on both sides | Piriform branches and lower twin branches |
| 3 | SGA† | AIG | NO | |
| 4 | AIG | AIG | yes on both sides | Lower twin branch |
| 5 | AIG | MFCA | yes on both sides | Lower twin, capsular and piriform branches |
| 6 | not injected | AIG | Sim | Rama-Capsule |
| 7 | IGA (bad injection) | AIG | yes on both sides | piriform and capsular branches |
| 8 | MFCA | not injected | Sim | Rama piriforme |
Figure 1a, Figure 1b
a) Photograph and b) diagram showing anterograde injection through the inferior gluteal artery. The abductors are on the left and the sciatic nerve can be seen in the top center of the image (A). The injected vessel descending from the top of the image and crossing the conjoint tendon is the piriform branch of the inferior gluteal artery (B). The quadratus branch (C) runs through the quadratus femoris. Other structures marked are: D, external obturator; E, greater trochanter; F, gluteus medius; G, quadratus femoris; H, lower calf; i, superior twin; J, internal obturator; K, deep branch of medial circumflex femoral artery; L, piriform.
Figure 2a, Figure 2b
a) Photograph and b) Diagram showing anterograde injection through the medial femoral artery. The trochanter is inferior (A). The quadratus femoris was reflected to the right (B), exposing the capsule (C) and external obturator tendon (D). The blue localization paper at the top of the image is placed below the piriformis branch of the inferior gluteal artery (E, superior sacral supply), which here runs laterally between the piriformis (F) and the conjoint tendon (G). This vessel filled retrogradely after injection into the medial circumflex femoral artery. The deep branch (H) crosses the tendon of the external obturator and runs deep under the posterior capsule. It disappears deep into the capsule before merging deep into the conjoint and piriformis tendons (here still attached to the trochanter). Transversely running along the capsule is the capsular branch of the inferior gluteal artery (I), which has filled retrogradely from this medial circumflex femoral artery (J, gluteus medius; K, lower calf).
Abb. 3a, Abb. 3b
a) Photograph and b) diagram showing anterograde injection through the inferior gluteal artery. This is a deeper dissection of the same specimen shown in FIGillustration 1, in the same orientation. The short external rotators have been removed except for the external obturator tendon. The capsule has been opened to reveal lateral epiphyseal vessels running right to left across the neck. The structures marked are as follows: A, external obturator; B, greater trochanter; C, gluteus medius; D, quadratus femoris; E, lower calf; F, femoral neck; G, lip; H, hip capsule; i, lateral epiphyseal arteries; J, deep branch; K, synovial membrane; L, sciatic nerve; M, piriform.
FAQs
What is the structure that supplies blood to the femoral head? ›
The ligamentum teres artery descends from the posterior branch of the obturator artery and attaches at the fovea. This artery is commonly disrupted with dislocations. It is the main blood supply to the femoral head in children.
What is the blood supply of the femoral neck? ›Most of the femoral head blood supply is done by the extracapsular arterial ring, which is formed by the lateral femoral circumflex and the medial femoral circumflex arteries. The femoral circumflex arteries arise from the deep femoral artery.
What is the blood supply to the femoral head and avascular necrosis? ›The medial and lateral circumflex arteries supply blood to the femoral head keeping the bone healthy. In avascular necrosis, this blood supply is impaired, resulting in death of the bone in the femoral head. As a result, the femoral head begins to collapse, losing its round contour.
What nerve supplies the head of the femur? ›The femoral nerve is a mixed nerve of the lower limb that innervates the muscles and skin of the hip and thigh. The femoral nerve originates from the lumbar plexus, arising from the anterior rami of spinal nerves L2-L4. In fact, it is the longest branch of the lumbar plexus.
What is the anatomy of femoral artery? ›The femoral artery emerges underneath the inguinal ligament medial to the midpoint of the inguinal ligament and medial to the deep inguinal ring, halfway between the anterior superior iliac spine and symphysis pubis. The femoral vein lies medially.
What ligament contains blood vessels to the femoral head? ›The ligament of the head of femur (LHF), or ligamentum teres, is believed to provide blood supply to the head of femur and mechanical stability to the hip joint.
What supplies femoral head and neck? ›Introduction. The femoral head obtains most of its blood supply from the medial femoral circumflex artery (MFCA) and the lateral femoral circumflex artery (LFCA) [1,2,3,4]. A 1953 study reported that the LFCA provides two-thirds to four-fifths of the blood supply to the femoral neck [4].
Where does the femoral vein supply blood to? ›Blood from your lower leg drains into your femoral vein, sometimes known as your superficial femoral vein. Your femoral vein then moves this blood into your external iliac vein. From there, blood enters the veins in your abdomen.
Which nerve supplies the major blood supply to the hip? ›Nerves supplying the hip joint include branches of the femoral nerve, obturator nerve and the superior gluteal nerve.
What is avascular necrosis of femoral head anatomy? ›Avascular necrosis (AVN) of the femoral head is a type of aseptic osteonecrosis, which is caused disruption of the blood supply to the proximal femur, which results in osteocyte death. AVN may occur due to ischemia developing on a traumatic or non-traumatic background [1,2].
What is the role of blood supply in avascular necrosis? ›
Avascular necrosis is a disease that results from the temporary or permanent loss of blood supply to the bone. When blood supply is cut off, the bone tissue dies and the bone collapses. If avascular necrosis happens near a joint, the joint surface may collapse. This condition may happen in any bone.
Which artery that supplies the femoral head if compromised would lead to avascular necrosis? ›Blood is supplied to the femoral head via a branch of the obturator artery that is conveyed across the intra-articular space on the ligamentum teres or round ligament. Avascular necrosis, also known as osteonecrosis, occurs when compromised vascular supply causes ischemia and eventually necrosis of the femoral head.
Which muscles does femoral nerve supply? ›The femoral nerve supplies the iliacus muscle. Because the psoas major muscle is located medial to the union of the ventral rami to form the femoral nerve, the psoas major is innervated by the ventral rami of L2-L4. These muscles will flex the thigh at the hip.
Which main structure does the femoral nerve supply quizlet? ›The femoral nerve supplies the hip flexors and knee extensors.
What is the femoral head called? ›The hip joint is a “ball and socket” joint. The “ball” is known anatomically as the femoral head; the “socket” is part of the pelvis known as the acetabulum. Both the femoral head and the acetabulum are coated with articular cartilage.
Where is the femoral anatomy? ›The femur is the only bone in your thigh. It runs from your hip to your knee.
Where is the femoral region anatomy? ›The femoral triangle is a wedge-shaped area formed by a depression between the muscles of the thigh. It is located on the medial aspect of the proximal thigh. It is the region of the passage of the main blood vessels between the pelvis and the lower limb, as well as a large nerve supplying the thigh.
What artery supplies the femoral triangle? ›The femoral artery is a continuation of the external iliac artery and constitutes the major blood supply to the lower limb. In the thigh, the femoral artery passes through the femoral triangle, a wedge-shaped depression formed by muscles in the upper thigh.
Which hip ligament helps to provide the blood supply to the head of the femur? ›Within the hip joint, only one ligament resides; the ligamentum teres, or ligament of head of femur. A triangle shaped ligament, the ligamentum teres supplies blood to the femoral head with help from the obturator artery, and branches from the acetabular fossa to the fovea of the femur.
Which ligament connects the femoral head to the acetabulum and provides a direct blood supply to the femur? ›Ligamentum teres:This is a small ligament that extends from the tip of the femoral head to the acetabulum. Although it has no role in hip movement, it does have a small artery within that supplies blood to a part of the femoral head.
Which vessel is the femoral artery? ›
The femoral artery is the main blood vessel supplying blood to your lower body. It starts in your upper thigh, near your groin and runs down to the back of your knee. The function of the femoral artery and its branches is to supply the lower body with blood. Your tissues need blood to get oxygen and nutrients.
What causes lack of blood supply to femoral head? ›These causes include fractures, dislocations, chronic steroid use, chronic alcohol use, coagulopathy, congenital causes; among many others. Avascular necrosis of the femoral head is a debilitating disease and is an important condition requiring healthcare professionals to be vigilant for its presentation.
What is the applied anatomy of femoral vein? ›The femoral vein is a direct continuation of the popliteal vein just proximal to the knee. The vein ascends to the inguinal region, where it passes posterior to the inguinal ligament as the external iliac vein to enter the abdomen. The main function of the femoral vein is to drain the lower limb.
Which artery is damaged in femoral neck fracture? ›The blood supply to the femoral head comes from three main sources, i.e., medial femoral circumflex artery, lateral femoral circumflex artery and obturator artery through intracapsular terminal branches which run parallel to the neck. Any femoral neck fracture disrupts the terminal blood vessels producing AVN.
What artery supplies blood to the femoral artery? ›This is predominantly through the medial circumflex femoral artery, which lies directly on the intra-capsular femoral neck. Consequently, displaced intra-capsular fractures disrupt the blood supply to the femoral head and, therefore, the femoral head will undergo avascular necrosis (even if the hip is fixed).
What artery supplies the neck muscles? ›The head and neck region obtain the majority of its blood supply via the carotid and also vertebral arteries.