There is a paucity of information on the arterial supply of the navicular, despite its anatomic neighbours, particularly the talus, being investigated extensively. The navicular is essential in maintaining the structural integrity of the medial and intermediate columns of the foot, and is known to be at risk of avascular necrosis. Despite this, there is poor understanding of the vascular supply available to the navicular, and of how this supply is distributed to the various surfaces of the bone. This study aims to identify the key vessels that supply the navicular, and to map the arterial supply to each surface of the bone. Cadaveric limbs (n=10) were dissected to identify source vessels for each navicular. The talus and navicular were removed, together with the source vessels, en bloc. The source vessels were injected with latex and processed using a new, accelerated diaphanisation technique. This quickly rendered tissue transparent, allowing the injected vessels to be visualised. Each navicular was then reconstructed using a digital microscribe, allowing a three dimensional virtual model of the bone to be assessed. The terminal points of each vessel were then mapped onto this model, allowing the distribution of each source vessel to be determined. This study will provide the as yet unpublished information on the arterial supply of the human navicular bone. The data will also give quantifiable evidence of any areas consistently restricted to single-vessel supply, and those consistently supplied by multiple vessels. This may help to explain the propensity of this bone to develop disorders such as osteochondritis, avascular necrosis and stress fractures which often have a vascular aetiology

The arterial supply of the talus has been studied extensively in the past. These have been used to improve the understanding of the risk of avascular necrosis in traumatic injuries of the talus. There is, however, poor understanding of the intra-osseous arterial supply of the talus, important in scenarios such as osteochondral lesions of the dome. Previous studies have identified primary sources of arterial supply into the bone, but have not defined distribution of these sources to the subchondral regions. This study aims to map the arterial supply to the surface of the talus. Cadaveric limbs (n=10) were dissected to identify source vessels for each talus. The talus and navicular were removed, together with the source vessels, en bloc. The source vessels were injected with latex and processed using a new, accelerated diaphanisation technique. This quickly rendered tissue transparent, allowing the injected vessels to be visualised. Each talus was then reconstructed using a digital microscribe, allowing a three dimensional virtual model of the bone to be assessed. The terminal points of each vessel were then mapped onto this model, allowing the distribution of each source vessel to be determined. This study will provide quantifiable evidence of areas consistently restricted to single-vessel supply, and those consistently supplied by multiple vessels. These data may help to explain the distribution and mechanisms behind the development of the subchondral cysts of the talus

The arterial supply of the talus has been extensively studied in the past but there is a paucity of information on the arterial supply to the navicular and a very limited understanding of the intra-osseous supply to the surface of either of these bones. This is despite the likely importance of this supply in relation to conditions such as osteochondral lesions of the dome of the talus, and avascular necrosis and stress fracture of the navicular. Using cadaveric limbs, dissection of the source vessels was performed followed by arterial injection of latex. The talus and navicular were then removed en bloc, preserving the integrity of the injected arterial vasculature. The specimens were then processed using a new, accelerated diaphanisation technique. This rendered the tissue transparent, allowing the injected vessels to be visualised and then mapped onto a 3D virtual reconstruction of the bone. The vasculature to the subchondral surfaces of the talus and navicular, and the source vessel entry points that provide arterial supply into the navicular were identified. This study gives quantifiable evidence of the areas of consistently poor blood supply which may help explain the clinical pattern of talar and navicular pathology. It also provides as yet unpublished information on the arterial supply of the human navicular bone

Shoulder girdles of 20 cadavers (68–94yrs) were harvested. The anterior (ACHA) and posterior circumflex humeral arteries (PCHA) were injected with ink and the extra and intraosseous courses of the dyed vasculature dissected through the soft tissues and bone to the osteotendinous junctions of the rotator cuff. The ink injection and bone dissection method was newly developed for the study. Rates of cross-over at the osteotendinous juntion were 75% in the supraspinatus, 67% in subscapularis, 33% in infraspinatus and 20% in teres minor. The supraspinatus and subscapularis insertions were vascularised by the arcuate artery, a branch of the ACHA. The insertions of the infraspinatus and teres minor were supplied by an unnamed terminal branch of the PCHA. The insertions of the rotator cuff receive an arterial supply across their OTJ's in 50% of cases. This may explain observed rates of AVN in comminuted proximal humeral fractures. The terminal branch of the PCHA supplying the infraspinatus and teres minor insertions was named the “Posterolateral Artery”. Finally, the new method employed for this study which allowed for direct visualisation of intraosseous vasculature, will enhance our understanding of skeletal vascular anatomy and have clinical applications in orthopaedic and reconstructive surgery

The posterior midline approach used in spinal surgery has been associated with a significant rate of wound dehiscence. This study investigates anatomical study of the arterial supply of the cervical and thoracic spinal muscles and overlying skin at each vertebral level. It aimed to provide possible anatomical basis for such wound complications. A dissection and angiographic study was undertaken on 8 cadaveric neck and posterior torso from 6 embalmed and 2 fresh human cadavers. Harvested cadavers were warmed and hydrogen peroxide was injected into the major arteries. Lead oxide contrast mixture was injected in stepwise manner into the subclavian and posterior intercostal arteries of each specimen. Specimens were subsequently cross-sectioned at each vertebral level and bones elevated from the soft tissue. Radiographs were taken at each stage of this process and analysed. The cervical paraspinal muscles were supplied by the deep cervical arteries, transverse cervical arteries and vertebral arteries. The thoracic paraspinal muscles were supplied by the superior intercostal arteries, transverse cervical arteries and posterior intercostal arteries. In the thoracic region, two small vessels provide the longitudinal connection between the segmental arteries and in the cervical region, deep cervical arteries provide such connection from C3 to C6. The arterial vessels supplying the paraspinal muscles on the left and right side anastomose with each other, posterior to the spinous processes in all vertebral levels. At cervical vertebral levels, source arteries travel near the surgical field and are not routinely cauterised; Haematoma is postulated to be the cause of wound complications. At thoracic levels, source arteries travel in the surgical field and tissue ischemia is a contributing factor to wound complications, especially in operations over extensive levels. Post-operative wound complications is a multi-factorial clinical problem, the anatomical findings in this study provide possible explanations for wound dehiscence in the posterior midline approach. It is postulated that drain tubes may reduce the incidence of haematoma in the cervical level

Introduction. Precise knowledge of the Femoral Head (FH) arterial supply is critical to avoid FH avascular necrosis following open and arthroscopic intra-capsular surgical procedures about the hip. The Medial Femoral Circumflex Artery (MFCA) provides the primary FH vascular contribution. Distribution of vascular foramina at the Femoral Head-Neck Junction (FHNJ) has been reported previously using an imaginary clock face. However, no quantitative information exists on the precise Capsular Insertion (CI) and intra-capsular course of the MFCA Terminal Branches (TBs) supplying the FH. This study seeks to determine the precise anatomic location of the MFCA's TBs supplying the FH, in order to help avoid iatrogenic vascular damage during surgical intervention. Methods. In 14 fresh-frozen cadaveric hips (9 left and 5 right), we cannulated the MFCA and injected a polyurethane compound. Using a posterior approach, careful dissection of the MFCA allowed us to identify and document the extra- and intra-capsular course of the TBs penetrating the FHNJ and supplying the FH. An H-type capsulotomy provided joint access while preserving the intracapsular Retinaculum of Weitbrecht (RW), followed by circumferential capsulotomy at the acetabular margin exposing the FH. The dome of the FH was osteotomized 5 mm proximal to the Articular Border (AB) providing a flat surface for our 360° scale. Right-side equivalents were used for data processing. Results. Gross dissection revealed a constant single branch arising from the transverse MFCA penetrating the capsule at the level of the anterior-inferior neck at 177° (range 167–187°), then courses within the medial RW obliquely (elevated from the neck) to the posterior-inferior FHNJ (Figure 1). This vessel was found to have an average of 5 TBs (range 3–9) penetrating the inferior FHNJ 4 mm (range 1–7 mm) from the AB at 204° (range 145–244°; 14% . 10. /. 69. anterior; 86% . 59. /. 69. posterior). In 79% (. 11. /. 14. ) of specimens, an average of 1.5 branches (range 1–3) arising from the ascending MFCA entered the Femoral Capsular Attachment (FCA) at 244° (range 216–269°), running subsynovial through the neck, and terminating in 2 TBs (range 1–3) penetrating the inferior-posterior FHNJ 5 mm (range 3–9) from the AB at 254° (range 207–281°). The deep branch of the MFCA penetrated the FCA at 327° (range 310–335°) providing an average of 6 TBs (range 4–9) running subsynovial and within the lateral RW, finally penetrating the superior FHNJ 6 mm (range 4–9) from the AB at 339° (range 286–25°; 20%. 15/74. anterior; 80%. 59/74. posterior). Discussion and Conclusion. This study demonstrates that TBs of the MFCA penetrate the joint through the mid-substance of the capsule (from the transverse MFCA) or the FCA (from the ascending or deep MFCA). Once intra-capsular, these vessels course subsynovial or within the RW and terminate at the posterior FHNJ superiorly (from the deep MFCA) and inferiorly (from the ascending and transverse MFCA). Any surgical hip intervention should preserve the posterior FCA, and lateral and medial RW in order to preserve the FH vascular supply. These results illustrate a vascular danger zone that should be respected during surgery and can be easily interpreted with the commonly used clock face

Purpose of the study: Surgical reconstruction procedures using the gracilus myocutaneous flap may be compromised if partial or total necrosis of the skin cover develops. The purpose of this study was to describe the anatomic blood supply to the gracilus muscle and the corresponding skin cover in an attempt to better understand the arterial afferences to the skin and define the safest topography for a transferable zone of skin.

Material and methods: We dissected the thighs of human adult cadavers to detail the vascular bundles feeding the gracilus muscle.

Selective injections of methylene blue were used in the main gracilus pedicle; the area of skin colored was then measured (greatest and smallest diameter) for computation of the surface area using an imaging software.

Results: Preliminary results of nine dissections showed that the main blood supply of the gracilus muscle arose from the deep femoral artery (n=8 dissections) or the common femoral artery (n=1 dissection) then penetrated the muscle 90.55 mm below the pubis with a mean diameter of 1.32 mm. The muscle was fed by one to four accessory arteries. The skin cover was stained in all cases, the area involved lying over the proximal and mid thirds of the muscle. The surface area was irregular, the mean length being 127.5 mm and the mean width 91.66 mm. The computed surface area was 88.08 cm² on average (range 58–120.95 cm²). Each muscle had two to six perforating vessels issuing from the opposite side of the main pedicle and comprised within a 48 mm long segment before dividing at the subcutaneous level. A mathematical model correlated the skin surface area to the number of perforating arteries.

Discussion and conclusion: Our findings suggest it would be possible to determine the surface area of skin transferable with a gracilus muscle flap based on high-frequency duplex-Doppler assessment of the number and position of the perforating arising from the muscle and feeding the skin surface. The linear distribution of the surfaces measured as a function of the number of perforating arteries suggests that more reliable conditions for gracilus myocutaneous flap harvesting could be proposed to minimize the risk of cutaneous necrosis.

Previous investigations have postulated that the asymmetry of the breasts in female adolescents may be linked with the development of right convex thoracic scoliosis, although there is no correlation between breast asymmetry and curve type or scoliosis magnitude. This breast asymmetry is supposed to be linked with anatomic and functional asymmetry of the internal mammary artery that is the main supplier to the mammary gland. However, no measurements of anatomic and haemodynamic parameters of internal mammary artery have been made to justify or to reject the hypothesis of asymmetric blood flow volume to the breasts and costosternal junction in female adolescent scoliotics.

Twenty female adolescents with right thoracic scoliosis and 16 comparable female individuals without spine deformity were included in this study. Standing roentgenograms of the whole spine were made in all scoliotics to measure scoliosis curve, vertebral rotation and concave and convex rib-vertebra-angle at three vertebrae (apical, one level above and one below the apical vertebra). The Color Doppler Ultrasonography was used to measure at the origin of internal mammary artery its lumen diameter, cross sectional area, time average mean flow and flow volume per minute in scoliotics and controls and were compared each other. The roentgenographic parameters were compared with the ultrasonographic parameters in the scoliotics to disclose any relationship.

The reliability of color Doppler ultrasonography was high and the intraobserver variability low (ANOVA, P=0.92–0.94). There was no statistically significant difference in the ultrasonographic parameters of the internal mammary artery between right and left side in each individual as well as between scoliotics and controls. In scoliotics the right mammary artery time average mean velocity increases with the convex and concave rib-vertebra-angle one level above the apical vertebrae (P< 0.01), convex rib-vertebra angle one level below the apical vertebra (P< 0.05), and concave apical rib-vertebra angle (P< 0.01). The left internal mammary artery time average increases with only the convex rib-vertebra angle one level above the apical vertebra (P< 0.05). The right and left internal mammary artery flow volume increases with the convex rib-vertebra-angle one level above the apical vertebra (P< 0.05), while the right internal mammary artery flow volume increases furthermore with the apical concave rib-vertebra-angle (P< 0.01) and concave rib-vertebra angle one level above the apical vertebra (P< 0.01). The concave apical rib-vertebra-angle (P< 0.01) and concave rib-vertebra-angle one level above the apical vertebra (P< 0.01) increases with left internal mammary artery cross sectional area.

We concluded that anatomic and haemodynamic flow parameters measured at the origin of internal mammary artery are significantly correlated with apical rib-vertebra-angle in female adolescents suffering from right convex idiopathic thoracic scoliosis. This study did not find any evidence for side-difference in vascularity of the anterior thorax wall thus could not justify previous theories for development of right thoracic scoliosis in female adolescents.

Purpose: The purpose of this work was to study arterial blood supply to the coxal bone in order to minimise the risk of postsurgical necrosis during acetabular osteosynthesis. Necrosis of the coxal bone is a rare but well-known complication of acetabular fracture surgery. Material and methods: Ten fresh cadavers were dissected after intra-arterial injection of coloured resin. All collaterals feeding the bone were described and counted. An arterial map was drawn. Results: The acetabulum is supplied by four main arterial sources: 1) the ischion artery, a collateral of the pudendal artery, which supplies the posterior and lateral part of the acetabulum; 2) the artery of the roof of the acetabulum, a collateral of the superior gluteal artery, supplies the upper and lateral part of the acetabulum: 3) branches of the anterior and posterior division of the obturator artery which supply the upper part and the rim of the obturated foramen and the anteroinferior and posteroinferior parts of the acetabulum; 4) branches issuing from the obturator artery supply the quadrilateral surface. Discussion: The Kocher approach can easily injure the ischion artery. The wide lateral approach described by Letournel and the triradiate approach described by Mears can injure the ischion artery and the artery of the roof of the acetabulum. Theoretically, the risk of bony necrosis would be greater if an endopelvic approach is associated due to the risk of injury to the endopelvic arteries issuing from the obturator artery. The anterior approach to the acetabulum appears to carry the less risk of ischemia, theoretically, than the other approaches to the acetabulum

Aims: Asymmetry of the breasts in female adolescents may be linked with right convex thoracic scoliosis. This is a prospective comparative study of the internal mammary artery (IMA) with Color Doppler Ultrasonography (CDU) in female adolescents and controls. Methods: 20 female adolescents with right thoracic scoliosis and 16 comparable individuals without spine deformity were included in this study. Scoliosis curve, vertebral rotation and concave and convex rib-vertebra-angle (RVA) at three vertebrae close to apical were measured. IMA- lumen, cross sectional area, time average mean ßow and ßow volume per minute were measured with CDU in scoliotics and controls. Results: The reliability of CDU. was high and the intraobserver variability low (ANOVA, P=0.92–0.94). There was no difference in CDU-parameters of IMA between right and left side, as well as between scoliotics and controls. In scoliotics the right IMA- time average mean velocity increases with both RVAs one level above the apical vertebrae (P< 0.01), convex RVA one level below the apical vertebra (P< 0.05), and concave RVA (P< 0.01). The left IMA-time average increases with only the convex RVA one level above the apical vertebra (P< 0.05). IMA- ßow volume increases with the convex RVA one level above the apical vertebra (P< 0.05), while the right IMA-ßow volume increases furthermore with the apical RVA (P< 0.01) and concave RVA one level above the apical vertebra (P< 0.01). The concave apical RVA (P< 0.01) and concave RVA one level above the apical vertebra (P< 0.01) increases with left IMA cross sectional area. Conclusion: This study showed that anatomy and haemodynamic ßow parameters of IMA signiþcantly correlated with apical roentgen-ographic parameters. However, there was no evidence for side-difference in vascularity of the anterior thorax wall that could justify the previous theories for development of right thoracic scoliosis in adolescent females

Summary. Arthroscopic decompression of the lunate decreases clinical symptoms and slows progression of Kienböck's Disease. Introduction. The purpose of this study was to investigate the outcomes of patients suffering from avascular necrosis of the lunate, or Kienböck's Disease, who received arthroscopic decompression to treat the ischemic lunate. Previous studies have demonstrated an elevated intraosseus pressure in the ischemic lunate, and it has been hypothesised that ischemia in the lunate is secondary to this elevated pressure and subsequent venous congestion, as opposed to diminished arterial supply. Based on this work we have used decompression of the lunate to prevent progression of the disease. Patients and Methods. 21 patients, (22 wrists), reported to a single surgeon with a chief complaint of unremitting wrist pain and the subsequent diagnosis was Kienböck's disease, stages I, II, IIIA or IIIB. Range of motion measurement and grip strength, as well as self-reported outcome measures such as Disabilities of the Arm, Shoulder and Hand (DASH) and Modified Mayo, were obtained preoperatively and post operatively at 2, 7 and 12 months. The patients were treated operatively with arthroscopic decompression of the lunate. The lunate was approached dorsally at the interosseous lunotriquetral and the scapholunate ligament areas with an arthroscopic shaver until brisk bleeding was achieved upon deflating the tourniquet. In some cases, the core of the lunate had to be penetrated with a 45 k-wire until bleeding was obtained. Of the 22 wrists treated arthroscopically with lunate decompression, 18 had both pre-surgical and post-surgical follow-up evaluations. Results. The patients who underwent lunate arthroscopic decompression surgery demonstrated a statistically significant improvement in DASH score at 7 and 12 months postoperatively (p<0.05). The preoperative DASH score average for this cohort was 51, while post-operative DASH scores averaged 23 and 17 at 7 and 12 months, respectively. The patients also demonstrated some overall improvement in pain, functionality, range of motion, and grip strength as demonstrated by the Modified Mayo wrist score. Notably, the patients demonstrated statistically significant improvement in grip strength post-operatively at 7-months (p<0.05) and 12-months (p<0.01). In addition, there was noted to be improvement in supination and ulnar deviation measurements post-operatively at 7 months and 12 months, respectively. Conclusion. This study demonstrates the clinical outcome of arthroscopic decompression of the lunate in patients suffering from Kienböck's Disease using the patient's subjective evaluations as well as range of motion and grip strength measurements. Arthroscopic decompression of the lunate decreases clinical symptoms and slows progression of Kienböck's Disease using a less invasive surgical intervention

Purpose: Management of extensive tibial loss raises the question of indications for vascularised grafts. These techniques depend on the number of functional vascular trunks available. We developed a modified technique which allows using this type of graft without sacrificing the tibial pedicle, making it usable when only one trunk remains functional. We use the fibular arterial supply to bridge the remaining axis. The purpose of this work was to detail the modalities of this technique and provide early results. Material and method: Since 2000, we have reserved this technique for infected nonunion with loss of tibial tissue extending over 5 cm in patients who decline amputation. Four patients (four men, mean age 30 years) underwent the procedure. The initial trauma resulted from a motorcycle (n=3) or firearm (n=1) accident. The patients were referred to our unit within three months on the average. Prior treatments (cancellous graft in an open or intrafocal procedure) had failed in all patients who presented persistent infection. Antibiotics were administered until bone healing in all patients. Mean length of the gap was 10 cm (7 – 15 cm). The composite graft (skin and fibula with a vascularised fibular bundle) was raised from the contralateral limb and cross-leg anastomosed proximally and distally on the receiver anterior tibial bundle (all four cases). Results: All fractures consolidated between six and twelve months after initiating management of this technique. Bone and soft tissue losses healed without shortening. There were not repeated fractures after mean follow-up of twelve months (range eight months to two years). No complementary bone graft was necessary. Infection resolved in all patients. Discussion and conclusion: As for classical vascularised fibula grafts, this technique enables controlling bone and soft tissue problems together (composite graft). The graft is vascularised favouring antibiotic diffusion. The mechanical quality is better than with a pure cancellous graft but longer follow-up would be required to determine the rate of repeated fractures. This technique broadens indications for vascularised fibula grafts which can be used in unfavourable vascular contexts where only one or two leg trunks persist

Aims

Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck.

MIS (minimally invasive surgery) aims to improve cosmesis and facilitate early recovery by using a small skin incision with minimal soft tissue disruption. When using MIS in the forefoot, there is concern about neurovascular and tendon damage and cutaneous burns. The aim of this anatomical study was to identify the structures at risk with the proposed MIS techniques and to determine the frequency of iatrogenic injury. Materials and Methods. 10 paired normal cadaver feet were used. All procedures were performed using a mini C-arm in a cadaveric lab by 2 surgeons: 1 consultant who has attended a cadaveric MIS course but does not perform MIS in his regular practice (8 feet), and 1 registrar who was supervised by the same consultant (2 feet). In each foot, the surgeon performed a lateral release, a MICA (minimally invasive chevron and Akin) procedure for the correction of hallux valgus, and a minimally invasive DMO (distal metatarsal extra-articular osteotomy) procedure. Each foot was then dissected and photographed to identify any neurovascular or tendon injury. Results. The dorsal medial cutaneous and the plantar interdigital nerves were intact in all specimens. There was no obvious damage to the arterial plexus supplying the first metatarsal head. No flexor or extensor tendon injuries were identified. There is a significant learning curve to performing the osteotomy cuts in the desired plane. In the DMO, the dissection also revealed some intact soft tissue at the osteotomy site indicating that the metatarsal heads were not truly floating. Discussion. Although there has been concern regarding neurovascular and tendon injury, our findings indicate minimal risk, which is consistent with reports in the literature. This study also reflects the learning curve. Conclusion. We suggest that training on cadaveric specimens may be advantageous, particularly, with regard to the plane of the osteotomy

Objectives

Legg–Calvé–Perthes’ disease (LCP) is an idiopathic osteonecrosis of the femoral head that is most common in children between four and eight years old. The factors that lead to the onset of LCP are still unclear; however, it is believed that interruption of the blood supply to the developing epiphysis is an important factor in the development of the condition.