| BackgroundAvascular necrosis of the femoral the head (ANFH) also known as aseptic necrosis of femoral head, is the more common clinical disease of orthopedics, which was difficult to treat, and had high level of disability, to be considered as cancer but not cancer in the medical professiononce. ANFH occurs in young adults who was30-50years old. The incidence rate has been increasing every year in recent years, ranking the first of the hip joint disease. The epidemiological survey: Each year, about a20000populations in the United States. China has no specific statistical data, but researchers estimate about50000a year.The causes of ANFH can be divided into two major categories, traumatic and non-invasive. Traumatic ANFH was mostly seen in intracapsular fractures of the femoral neck, secondly in dislocation of the hip. In1981, Cai Rubin and others reported3600cases of femoral neck fractures, of which the occurrence of avascular necrosis was830cases, with an incidence of23%. Trueta reported that the main blood supply of femoral head was the upper support artery from the medial femoral circumflex artery in1953, its backbone rise for epiphysis lateral artery, which penetrates into the central femoral head between epiphyseal cartilage and epiphysis, supplying blood at least2/3volume of the femoral head. The epiphysis lateral artery closes to the bone surface, and has high vascular tone, small mobility, when the femoral neck fractured, easily hurted this vessels. The arrival and distribution of the femoral head blood vessels are several branches of the small blood vessels, although consistent, but still maintain their own independent blood supply region.Therefore, the blood supply of the femoral head is relatively poor. when the feeding artery injuried in trauma or treatment of a sudden block will result in ischemia, which will inevitably lead to a series of changes of the femoral head tissue, eventually leading to bone necrosis. The reason of Non-traumatic avascular necrosis of ANFH is very complex, and the related factors included:hormone therapy, alcoholism, obesity, blood diseases, diving disease, Gaucher disease, lipoid hyperplasia, connective tissue disease, renal transplantation, acute pancreatic, and so on. The use of corticosteroids and alcohol are the two most important risk factors. Foreign studies have shown that90%of patients relatived with them, as well as the small number of cases did not find the risk factors listed above, known as idiopathic avascular necrosis. The ideal treatment of ANFH at an early stage is preserving joint function., especially before the X-ray can be found, such as to take prompt measures to prevent the femoral head collapse. The treatments of ANFH includes:conservative treatment, palliative surgery, hip replacement surgery, and interventional treatment. Conservative treatment, also known as non-surgical therapy, including bed rest, traction, fixed limit load, pulsed electromagnetic fields, high-energy shock waves, hyperbaric oxygen and traditional Chinese medicine treatment. The main principles of conservative treatment is to reduce or avoid weight-bearing in femoral head to facilitate self-repair. The goal of treatment is the reconstruction of the femoral head blood supply, to promote the repair of necrotic bone and prevent the collapse of the femoral head, generally used for pain relief or adjuvant therapy; The method of palliative surgery refers to a variety of surgical therapy delaying the cartilage collapse and joint degeneration, including bone graft, pedicle periosteum transplantation, osteotomy, the obturator nerve transection, and so on; Palliative surgery treatment can not be effectively to improve the femoral head blood supply, and its long-term efficacy is unsatisfactory; hip replacement is the final choice of the treatment of advanced ANFH., It can be used with femoral head replacement in the context of old age of patients and the acetabulum intact. If the femoral head deformation is serious, who the acetabular also changed, which can be used in total hip arthroplasty. However, it does not apply to young people, because the surgical destruction was large; as the technological advances in interventional radiology, interventional treatment as a minimally invasive treatment was developing rapidly.Interventional treatment will treal resolve with blood supply and microcirculation of ANFH, through minimally invasive operation or selective arterial, which can be directly drug from the femoral deep femoral artery to the medial femoral artery or the lateral femoral circumflex artery, so as to improve the femoral head blood supply and reduce the femoral intramedullary pressure, drainage of inflammatory mediators, and promote the role of bone repair. In1998, Li Xidong showed that the interventional treatment of femoral head necrosis can be used in a clinical application of the method by animal tests, experiments by comparing the hormone group A, B, injection of the hormone group intervention (thrombolytic agents, vasodilators and microcirculation drugs injected directly into the femoral arterial supply), C control group. Finally, observe the femoral head by the X-ray and microscope, to study the X-ray and pathological changes of the femoral head. The results of the average diameter of fat cells in the femoral head vacancies of Group B lacunae bone marrow cavity did not reach normal levels, but there were significant improvements. The number of blood vessel down cartilage basically reached the normal, the diameter of blood vessel increased significantly, the X-ray film was visible that femoral head significantly repair, this experiment supply physical therapy and experimental techniques for the interventional treatment. In1998, Zhou Weisheng reported that using the contralateral femoral artery puncture super selective into the medial femoral artery, lateral circumflex femoral artery and obturator artery catheterization direct infusion of drug treatment of102cases with satisfactory results. After treatment, the vessel count and vascular increase in the number of the DSA imaging also showed that the staining in the arterial end of the femoral head in real terms, the same femoral head blood supply improved. The advantages of interventions treatment mainly include:mediated trauma and recovery fast and simple. It has the better effect in animal experiments and clinical validation, especially for stage Ⅰ～Ⅱ avascular necrosis, it had significant effect in the recent. And the means belong to preservation treatment, patients will accept it in both physiological and psychological. The method is suitable for patients of all age groups and fear of surgery patients, especially suitable for young patients with advanced early and should not be artificial hip replacement. It has larger clinical significance in alleviating symptoms and improving quality of life and postponing the time of joint replacement. However, the mechanism of femoral head necrosis is not very clear, so that they hinder the studies on the mechanism of interventional treatment in future work. So, the study of these mechanisms should be strengthened, while interventional treatment for avascular necrosis of long-term efficacy is still lack of a clear assessment. This new treatment procedure is not uniform, it also has many thing to study in part of the operation. The purpose of this subject is to study the anatomy of the treatment AFNH surgical approach, and to clarify the relatively constant and easy to observe the anatomical structure of the characteristics of the interventional treatment AFNH. Observe the femoral artery branch, the starting point position of the deep femoral artery, branch type simultaneously measurement of the length, diameter and the beginning part of the angle of each branch of the deep femoral artery and branches, in order to provide more detailed morphological evidence, for the clinical, the use of this treatment is more standardized, the treatment process more smoothly.This research is divided into two parts:\Objective: Through the anatomy study of the interventional treatment of avascular necrosis, provide anatomical basis, find the femoral artery and anatomical structures of its branches. At the same time, we describe its surrounding neighbors with a view to expediting this surgical method in clinical application.Methods:20cases of10%formalin the antisepsis fixed adult lower limb specimens, mixed with dye latex via the femoral artery perfusion, in order to maintain the normal thickness of the blood vessels. fresh adult lower limb specimens, the body supine, thigh Fair for all, from the groin to the pubic tubercle of the spine along the anterior superior iliac mouth, from the pubic tubercle down to the inner thigh. Along the lower limb in front of the middle to make a vertical incision, the bottom until the first two toes on the back. Expose the femoral artery, femoral vein, femoral nerve, and the anatomy of the deep femoral artery, which is the branch of the femoral artery. Near the femoral artery and/or deep femoral artery found the femoral artery and its branches outside. Look for some of the relatively constant and easy to observe the anatomical structures, establish these structures as signs of the operation points, and make the use of instrument to make the anatomical observation of the anatomical landmark points on the around adjacent to the relationship.Results:Observed in the20side of the lower limb specimens fixed in10%formalin preservative and2fresh specimens of the lower extremity, the femoral artery is a direct continuation of the iliac artery, the main branche is the deep femoral artery. Issued by the deep femoral artery below the inguinal ligament,2-5cm at the posterior wall or outer sidewall of the femoral artery and its terminal branches wear adductor muscle only the lower part of the point to the back of the thigh. Medial femoral artery is issued from the deep femoral artery, and wear through the pubic bone between the muscles and the iliopsoas muscle to the obturator muscle edge near the branch to the. adjacent muscles. The lateral femoral circumflex artery is issued from the deep femoral artery sidewall, an outsider to the sartorius and rectus femoris deep surface is divided into the ascending branch of the descending branch and horizontal branch. Ascending branch of the distribution of the tensor fascia lata and sartorius; descending branch of the distribution of the quadriceps lower and knee; transverse branch wear the vastus lateralis muscle to the femur behind. Greater trochanter below and medial femoral artery and its branches, the inferior gluteal artery and the first to wear the artery.The vascular on femoral head and neck distributed more varied, mainly through the deep femoral artery (accounting for70%～80%of the femoral head blood supply) and the obturator artery artery.Conclusion:The blood circulation of the femoral head and femoral neck are mainly from medial femoral circumflex artery、lateral femoral circumflex artery and obturator artery.The three arterial lines and their branches, the internal iliac artery and its branches coincide with each other to form a "hip Cross consistent ". The blood supply on femoral head is very limited, making very particularly sensitive for ischemia caused by remote vascular damage. Given the characteristics of the femoral head blood vessels, being vulnerable to trauma and other factors, it would cause reduced blood supply of femoral head, and then cause avascular necrosis.Objective:On the basis of establishing the anatomy the of interventional treatment in AFNH, observe the starting point position of the deep femoral artery, branch type, measure the length and diameter of deep femoral artery and its branches, and the angle of the beginning part of the various branches, in order to provide more detailed morphological basis.Methods:20cases of10%formalin the antisepsis fixed adult lower limb specimens, mixed with dye latex via the femoral artery perfusion, in order to maintain the normal thickness of the blood vessels, fresh adult lower limb specimens, the body supine, thigh Fair for all, from the groin to the pubic tubercle of the spine along the anterior superior iliac mouth, from the pubic tubercle down to the inner thigh. Along the lower limb in front of the middle to make a vertical incision, the bottom until the first two toes on the back. observe starting point for orientation and branch type of the deep femoral artery, measure the length and diameter of the deep femoral artery and its various branches,and the angles of beginning part of branches.Results:The deep femoral artery issued from behind the femoral artery (36.4%) and posterolateral side (36.4%), medial femoral artery is issued from the deep femoral artery (72.7%). can also be issued from the femoral artery (27.3%). The length of the major blood vessels:the deep femoral artery was19.22±10.19mm, a distance of the roots from the inguinal ligament was38±11.78mm, length of the medial femoral artery was12.56±6.17mm, the length of the lateral femoral circumflex artery was13.93±11.04mm. The outer diameter of the major blood vessels:the deep femoral artery was5.20±1.57mm, medial femoral artery was3.64±0.99mm, the deep branch of it was2.66±0.99, mm of the lateral femoral circumflex artery, the ascending branch outside diameter of2.12±0.59mm. The medial femoral arteries of the deep branch to the trunk as close to90°angle between the line backwards; femoral lateral artery and its ascending branch of about a115.82°angle.Conclusion:The more distance from the puncture site should be away from the inguinal ligament, as close as possible to avoid the needle strayed into the deep femoral artery. After puncturing, it should be angiography at the beginning of the ipsilateral femoral artery, to determine the starting point for orientation and branch type of deep femoral artery. and it should not be inserted too deep, so as not to cross the deep femoral artery. And then insert ultra-selective catheter into the medial femoral for angiography, in the absence of obvious branch supply of the femoral head, then the catheter exit, in order to make the femoral artery, obturator artery, inferior gluteal artery angiography to find the femoral head feeding vessels. It can be exchanged with a balloon catheter with side holes when indeed can not insert into femoral, lateral artery. temporarily blocking the blood supply to the branch on the far side with a balloon, and then drug injection. Catheter super-selective into the femoral, lateral arteriography should be at the start of contrast, should not be inserted too deep, the maximum should not exceed3.0mm. The deep branch of medial and lateral femoral circumflex artery were the major blood vessels of the femoral head. In line with requirements of catheter insertion, can be used as the target vessel intervention treatment. Choice of J-shaped guide wire plugged into the medial femoral artery is safer; selection of the front steerable guide wire, with the end of the handle adjustment allows the guidewire to successfully enter the lateral femoral circumflex artery of the ascending branch. |
PDF Full Text Request