Hospital for Special Surgery and New York Presbyterian Hospital, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021. E-mail address for L.E. Lazaro:
J Bone Joint Surg Am. 2013 Dec 4;95(23):e1821-8. doi: 10.2106/JBJS.L.01185.
The purpose of the present study was to quantify perfusion to the femoral head and head-neck junction using gadolinium-enhanced magnetic resonance imaging following three surgical dislocations of the hip (trochanteric flip osteotomy, standard posterior approach, and modified posterior approach).
The medial femoral circumflex artery was cannulated in fifty fresh-frozen cadaveric hips (twenty-five pelvic specimens). One hip on each pelvic specimen was randomly chosen to undergo one of the three surgical dislocations, and the contralateral hip was used as a control. Gadolinium enhancement on the magnetic resonance imaging scan was quantified in both the femoral head and head-neck junction by volumetric analysis using custom magnetic resonance imaging analysis software. A polyurethane compound was then injected, and gross dissection was performed to assess the extraosseous vasculature.
Magnetic resonance imaging quantification revealed that the trochanteric flip osteotomy group maintained almost full perfusion (mean, 96% for the femoral head and 98% for the head-neck junction). The standard posterior approach almost completely compromised perfusion (mean, 4% for the femoral head and 8% for the head-neck junction). Six specimens in the modified posterior approach group demonstrated partial perfusion (mean, 32% in the femoral head and 26% in the head-neck junction). Three specimens in the modified posterior approach group demonstrated almost full perfusion (mean, 96% in the femoral head and 97% in the head-neck junction). Gross dissection revealed that all specimens in the standard posterior approach group and seven of ten in the modified posterior approach group sustained disruption of the ascending branch of the medial femoral circumflex artery. All specimens in the standard posterior approach group demonstrated disruption of the inferior retinacular artery. The inferior retinacular artery remained intact in nine of ten specimens in the modified posterior approach group. One specimen in the modified posterior approach group that had disruption of both the ascending medial femoral circumflex artery and inferior retinacular artery demonstrated a substantial decrease in perfusion (7% in the femoral head and 5% in the head-neck junction).
The trochanteric flip osteotomy preserves the vascular supply to the femoral head and head-neck junction. The standard posterior approach disrupts the vascular supply and should be completely abandoned for surgical hip dislocation. Despite reduced enhancement, substantial perfusion of the femoral head and head-neck junction was present in the modified posterior approach group, likely because of the preservation of the inferior retinacular artery. The modified posterior approach produced variable results, indicating that improvement to the modified posterior approach is needed.
Our study provides previously unreported quantitative magnetic resonance imaging data on the perfusion to the femoral head and head-neck junction during common surgical approaches to the hip.
本研究旨在使用钆增强磁共振成像（MRI）定量评估髋关节（转子间翻转截骨术、标准后入路和改良后入路）三种手术脱位后股骨头和头颈交界处的灌注情况。
在五十个新鲜冷冻尸体髋关节（二十五个骨盆标本）中对股内侧旋骺动脉进行插管。每个骨盆标本的一侧髋关节随机选择进行三种手术脱位中的一种，对侧髋关节作为对照。使用定制的 MRI 分析软件进行容积分析，对 MRI 扫描的钆增强进行定量评估，以评估股骨头和头颈交界处的灌注情况。然后注射聚氨酯复合物，进行大体解剖以评估骨外脉管系统。
MRI 定量显示转子间翻转截骨组保持几乎完全的灌注（股骨头平均 96%，头颈交界处平均 98%）。标准后入路几乎完全阻断了灌注（股骨头平均 4%，头颈交界处平均 8%）。改良后入路组 6 个标本显示部分灌注（股骨头平均 32%，头颈交界处平均 26%）。改良后入路组 3 个标本显示几乎完全灌注（股骨头平均 96%，头颈交界处平均 97%）。大体解剖显示，标准后入路组所有标本和改良后入路组 10 个标本中的 7 个均发生股内侧旋骺动脉升支的中断。标准后入路组所有标本均显示下支持带动脉中断。改良后入路组 10 个标本中有 9 个下支持带动脉保持完整。改良后入路组中一个同时发生股内侧旋骺动脉升支和下支持带动脉中断的标本，灌注显著减少（股骨头 7%，头颈交界处 5%）。
转子间翻转截骨术保留了股骨头和头颈交界处的血供。标准后入路破坏了血供，应完全放弃用于髋关节脱位手术。尽管增强程度降低，但改良后入路组仍存在股骨头和头颈交界处的大量灌注，可能是因为保留了下支持带动脉。改良后入路组的结果存在差异，表明需要对改良后入路进行改进。
本研究提供了以前未报道的关于髋关节常见手术入路过程中股骨头和头颈交界处灌注的定量磁共振成像数据。
