2012年Ganz教授Hip Int：股骨头血供的解剖变异

作者：Morteza Kalhor, Kevin Horowitz, Jaber Gharehdaghi, Martin Beck, Reinhold Ganz.

作者单位: Department of Orthopaedic Surgery, Tehran University of Medical Sciences, Firouzgar Medical Centre, Tehran, Iran.北京大学人民医院骨关节科陶可

译者：陶可（北京大学人民医院骨关节科）

摘要

这项尸体研究的目的是明确定义股骨头的血液供应，以帮助进一步降低医源性缺血性坏死(AVN)的发生率。28具新鲜尸体的35臀关节注射了彩色硅胶。（髋关节）前方和后方均进行解剖，以充分评估股骨头血管分布。在29个样本中，发现旋股内侧动脉(MFCA)是髋关节的主要血液供应；臀下动脉（IGA）被发现是6例髋关节的主要血供。旋股内侧动脉(MFCA)始终至少（为股骨头）提供一根较小直径的内侧下支持带动脉。在任何标本中，中央凹动脉都没有提供显著的股骨头血流贡献。上支持带血管的数量和直径表明它们在股骨头血管分布中占主导地位，尽管下支持带动脉始终存在。为了降低医源性AVN的风险，手术期间必须保护臀下动脉（IGA）和旋股内侧动脉(MFCA)的分支穿过股方肌和梨状肌之间的间隔。由于所有关节囊内血管都在其远端附着区的附近穿透关节囊，因此远端关节囊切开术比近端关节囊切开术具有显著更高的AVN风险，特别是后外侧和下内侧。

文献出处：Morteza Kalhor, Kevin Horowitz, Jaber Gharehdaghi, Martin Beck, Reinhold Ganz. Anatomic variations in femoral head circulation. Hip Int. May-Jun 2012;22(3):307-12.doi: 10.5301/HIP.2012.9242.

Anatomic variations in femoral head circulation

Abstract

The purpose of this cadaveric study was to clearly define the blood supply to the femoral head to help further reduce the incidence of iatrogenic avascular necrosis (AVN). Thirty-five hips of twenty-eight fresh cadavers were injected with colored silicone. Anterior and posterior dissection was performed to assess the vessels contributing to femoral head vascularity. The medial femoral circumflex artery (MFCA) was found to be the main blood supply to the hip in twenty-nine specimens; the inferior gluteal artery (IGA) was found to be the main blood supply in six. The MFCA consistently provided at least one smaller-calibre inferomedial retinacular artery. The foveal artery provided no significant vascular contribution in any specimen. The quantity and calibre of superior retinacular vessels demonstrated their dominance in head vascularity, although inferior retinacular arteries were consistently present. To reduce the risk of iatrogenic AVN, branches of both the IGA and MFCA traversing the interval between the quadratus femoris and piriformis muscles must be protected during surgery. Since all intracapsular vessels penetrated the capsule near its distal attachment, distal capsulotomy carries a significantly higher risk of AVN than proximal capsulotomy, particularly posterolaterally and inferomedially.

Fig. 1 - Anteromedial aspect of a right hip showing the inferior retinacular artery (arrow head) running on top of Weitbrecht’s ligament. 1 = profunda femoris; 2 = LFCA; 3 = MFCA; 4 = femoral head.

图1 右侧髋关节的前内侧显示在Weitbrecht韧带上方走形的下支持带动脉（箭头）。1 = 股深动脉；2 = 旋股外侧动脉LFCA；3 = 旋股内侧动脉MFCA；4 = 股骨头。

Fig. 2 - Posterior aspect of right hip after reflection of the gluteus maximus muscle showing the anatomic position of the deep branch of the MFCA and its relation to the short external rotators (posterior to obturator externus and anterior to conjoint tendon). 1 = greater trochanter; 2 = quadratus femoris; 3 = obturator externus; 4 = conjoint tendon; 5 = gluteus medius; Arrow head = trochanteric branch of MFCA; Arrow = first capsular branch of MFCA (typically anastomosing with branches of IGA).

图2 臀大肌反射后的右侧髋关节后部，显示旋股内侧动脉MFCA深支的解剖位置及其与短外旋肌的关系（闭孔外肌后部和联合肌腱前部）。1 = 股骨大转子；2 = 股方肌；3 = 闭孔外肌；4 = 联合肌腱；5 = 臀中肌；长箭头 = MFCA转子分支；短箭头 = MFCA第一关节囊支（通常与IGA的分支吻合）。

Fig. 3 - A) Posterior right hip showing the most frequent variation in femoral head vascularity. The distal deep branch of the IGA primarily supplies the superior retinacular vessels. The deep branch of the MFCA provides anastamotic contribution. Black arrow = distal deep branch of the IGA; white arrow = deep branch of the MFCA; white arrow head = trochanteric branch of MFCA. GT = greater trochanter; QF = quadratus femoris. B) Posterior aspect of same hip shown in Fig. 3A after capsulotomy demonstrating the dominance of the IGA over the MFCA in perfusion of the femoral head and an anastomosis between the two vessels (arrow head). GT = greater trochanter; QF = quadratus femoris; OE = obturator externus muscle; 1 = distal deep branch of the IGA; 2 = deep branch of MFCA; 3 = trochanteric branch of MFCA; 4 = posterior capsule (reflected).

图3

A)右侧髋关节后部显示股骨头血管分布最常见的变化。臀下动脉（IGA）远端深支主要供应上支持带血管。旋股内侧动脉(MFCA)的深层分支提供了吻合支的贡献。黑色长箭头 = IGA远端深支；白色长箭头 = MFCA深支；白色短箭头 = MFCA转子分支。GT = 股骨大转子；QF = 股方肌。

B) 图3A所示的同一髋关节的后侧在关节囊切开后显示IGA在股骨头灌注和两条血管（臀下动脉与旋股内侧动脉）之间的吻合（黑色短箭头）中比MFCA有优势。GT = 大转子；QF = 股方肌；OE = 闭孔外肌；1 = IGA 远端深支；2 = MFCA 的深层分支；3 = MFCA 转子支；4 = 后关节囊（反射）。