Article

[The role of understanding the media femoral circumflex artery course in total hip replacement].

I. ortopedická klinika 1. LF UK Praha, FN Motol, Praha.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca (Impact Factor: 1.63). 01/2008; 74(6):377-81.
Source: PubMed

ABSTRACT On the basis of anatomical dissection of the medial femoral circumflex artery (MFCA) in 32 lower extremities and our clinical experience with managing the deep MFCA branch during total hip replacement surgery performed from the anterolateral approach, we sought a reliable treatment of the injured artery, including identification of the site for making the ligature or the way of avoiding damage to the artery during release of the capsule and pelvitrochanteric muscles.
Anatomical dissection in the MFCA region on both lower extremities was carried out in 16 adult human cadavers. None of the bodies showed any signs of pathological lesions or post-operative, hip joint-related conditions. METHODS In 12 limbs, a gelatin injection was applied directly into the MFCA. In the remaining limbs dissection was performed without injecting the vessel. We studied the MFCA topography in relation to the surrounding structures, particularly where the MFCA runs along the femoral neck before entering the capsule. During dissection, we dislocated the hip in order to create a model situation similar to that during total hip replacement and to find out any possible changes in the course and tension of the artery due to manipulation with the limb during surgery.
Our observations confirmed that if the MFCA is injured, for instance during release of the pelvitrochanteric muscles, further manipulating with the extremity may result in squeezing the extracapsular part of the MFCA deep branch in space between the external obturator muscle and the quadratus femoris muscle. Thus bleeding from the artery is temporarily stopped, but it will reappear due to joint reduction at the end of surgery. In addition, hip external rotation and adduction may push the artery deeper between the muscles mentioned above. To treat such a situation is then very difficult. When the artery is injured, we recommend treatment by ligature. We proceed in the following way:We identify the exact site of bleeding by placing the extremity, before component implantation, in a neutral position. Using a bone hook, we gently put the femur in a lateral position and do external rotation without adduction. At the identified site of bleeding, we compress the artery with a Mikulicz clamp. Subsequently, we move the limb to adduction and external rotation and through ligature we try to intercept the arterial trunk in a position in which it passes between the quadratus femoris muscle and the external obturator muscle. In case we do not succeed to intercept the injured artery, we make a ligature that contains both the muscles and the artery.
The relevant literature has not provided information on how to treat the MFCA injured during total hip replacement surgery carried out from the anterolateral approach. Our experience has shown that, during release of the capsule and pelvitrochanteric muscles, the deep branch of the MFCA can be damaged. This intra-operative injury of the MFCA may produce serious bleeding difficult to stop. The resultant blood loss may complicate the post-operative outcome. Therefore, a good understanding of the extracapsular course of the deep MFCA branch can reduce the risk of arterial injury and may aid in a correct treatment of the injured vessel and elimination of the associated blood losses. Key words: medial femoral circumflex artery, bleeding, hip arthroplasty.

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    ABSTRACT: he primary source for the blood supply of the head of the femur is the deep branch of the medial femoral circumflex artery (MFCA). In posterior approaches to the hip and pelvis the short external rotators are often divided. This can damage the deep branch and interfere with perfusion of the head. We describe the anatomy of the MFCA and its branches based on dissections of 24 cadaver hips after injection of neoprene-latex into the femoral or internal iliac arteries. The course of the deep branch of the MFCA was constant in its extracapsular segment. In all cases there was a trochanteric branch at the proximal border of quadratus femoris spreading on to the lateral aspect of the greater trochanter. This branch marks the level of the tendon of obturator externus, which is crossed posteriorly by the deep branch of the MFCA. As the deep branch travels superiorly, it crosses anterior to the conjoint tendon of gemellus inferior, obturator internus and gemellus superior. It then perforates the joint capsule at the level of gemellus superior. In its intracapsular segment it runs along the posterosuperior aspect of the neck of the femur dividing into two to four subsynovial retinacular vessels. We demonstrated that obturator externus protected the deep branch of the MFCA from being disrupted or stretched during dislocation of the hip in any direction after serial release of all other soft-tissue attachments of the proximal femur, including a complete circumferential capsulotomy. Precise knowledge of the extracapsular anatomy of the MFCA and its surrounding structures will help to avoid iatrogenic avascular necrosis of the head of the femur in reconstructive surgery of the hip and fixation of acetabular fractures through the posterior approach.
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