Download distribution and anastomoses of arteries supplying the head neck of

DISTRIBUTION
THE
AND
HEAD
THE
S.
The
lying
femoral
on
the
the
head
neck,
and
SEVJTT
From
receives
the
Dunoyer
1955).
the adult,
the head;
communicate
than
others-for
the
references
loss
of the
because
the
arteriography
therefore
To
studied
main
blood
FEMUR
supply
capital
(Trueta
within
ENGLAND
Accident
from
retinacular
arteries
THE
SUPPLYING
Hospital
the
retinacular
arteries
(capsular)
(Wolcott
1943,
(lateral
epiphysial)
branches
and Harrison
1953; Judet,
the
head
are
believed
vessels
Tucker
1949,
of the superior
Judet,
Lagrange
to anastomose
freely
in
because
injected
preparations
show
vascular
communications
in various
parts
of
and the terminal
branches
of the lateral
epiphysial
and ligamentum
teres arteries
in the subfovea
(Wolcott
1943, Trueta
and Harrison
1953, Judet
et a!. 1955).
the role of the vessels
of the ligamentum
teres is still in doubt
even though
it is
a century
since the report
of Astley
Cooper
(1823)
which
was followed
by many
Nevertheless
more
The
ARTERIES
Birmingham
superior
the superior
importance
OF
BIRMINGHAM,
Departmezt,
its main
especially
OF
R. G. THOMPSON,
Pathology
Harty
1953);
within
the head
retinacular
supply
are ofgreat
and
ANASTOMOSES
AND
NECK
see
cervical
Nordenson
arterial
(1938)
supply
and
after
Wolcott
(1943).
intracapsular
With
fractures
head would
continue
to receive
blood
through
the ligamentum
reveals
a high
incidence
of avascularity
of the head
after
the functional
elucidate
the
by arteriographic
anastomoses
problem
the
injection
areas
within
the head
of the femoral
post-mortem
must be limited
head supplied
after
procedures
a free
anastomosis,
not
be disastrous,
would
teres.
However,
these
fractures
and
(Sevitt
1964).
by various
arteries
designed
to cut
off
were
all
vessels
to the head except
for one or more
particular
groups.
The vessels
injected
then represented
the distribution
of the arteries
left intact.
The distribution
of superior
and inferior
retinacular
arteries
and those
from
the bony
neck and from the ligamentum
teres were particularly
studied
and observations
were made
on the cervical
supply.
The vessels
in the ligamentum
teres were
also
examined
histologically.
MATERIALS
The
mostly
investigation
after
injuries
osteoarthritis
sixty-five
or
other
subjects
were
fifty-seven
preparations
acceptable
are
subjects,
most
the
of
with
Prussian
carried
out
on the
and
a few
after
burns
hip disease
made,
but
of
whom
blue
were
fifteen
(thirty-four
basis
opposite
hip, many
are shown
in Table
Arterial
injection-The
this
were
of which
I.
fluid
had
been
the dyed
from
a large
millilitres
were
barium
syringe
injected,
was
more
was
injected
560
muscle
division
for
the
required,
there
had
study
This
after
(Sevitt
femoral
external
but
iliac
the
and it is very
circumferential
pass
was
a greater
Between
of
artificial
JOURNAL
details
veins
manual
fills
“
medium
BONE
pressure
600 and
1,200
avascularity”
to over-inject
of the neck
OF
dyed
but
anastomoses
are not
the field of injection.
by strong
loss ofinjection
THE
into
artery.
difficult
incision
Other
male
of the
(Micropaque)
not
artery
possibility
technically
twenty
a fracture
1964).
have
hips of
The other
were
and
suspension
does
to
seventy-two
grounds.
which
died
at necropsy
known
female
large
capillaries
; capillary
artery
was ligated
to limit
the common
required,
femora)
sulphate
1964).
into
was
examined
Those
thirty-two
another
a barium
through
than
left
from
Twenty-four
(Sevitt
from
too little barium
had to be avoided
volume
of 1 to 1 2 litres was injected
after
the extensive
I).
perhaps
femoral
of adults
diseases.
Preparations
from
rejected
on technical
came
injected
reported
cannulated
hips
natural
twenty-three
They
injected
as previously
or
(Table
elderly
METHODS
uninjured
avoided.
were
right,
report.
arteries,
arterioles,
sinusoids
and
demonstrated.
First,
the superficial
Then
AND
was
AND
the head.
A
because,
with
(see
JOINT
below).
SURGERY
DISTRIBUTION
Successful
AND
injection
ANASTOMOSES
was
internal
iliac artery.
Procedures
on the
heralded
OF ARTERIES
by
Experience
hip-One
blueing
SUPPLYING
of the
was gained
or other
of
upper
OF THE
Main
FIFTY-TWO
clinical
Subcapital
of
the
femur
Pertrochanteric
fractures
fractures
of the femur
Head
injuries
Other
injuries
Fatal
disease
.
THE
FIFTY-SEVEN
Survival
561
OF FEMUR
retrograde
flow
Dead
on
.
I1
Less
than
.
3
I to 7 days
PREPARATIONS
arrival
from
fractured
11 and
.
in yea
17 and
the
hips.
shown
24
50 to
DERIvEn
Number
rs
2
.
.
8
60
.
3
12
60 to 80
.
22
More
.
8
1 to 4 weeks
.
16
.
.
.
.
9
4 to 8 weeks
.
10
.
.
.
.
3
More
.
5
8 weeks
than
of
patients
.
.
TABLE
WERE
Age
2
.
I day
than
of
patients
.
no injury
NECK
intact
and
in Table
Number
time
13
NATURE
Illustration
in Figure
and
of many
outlined
.
but
AND
I
WHOM
of
patients
Other
.
FROM
Number
state
fractures
Burns
SUBJECTS
thigh
from injection
the procedures
TABLE
DETAILS
HEAD
80
25
4
11
OF THE FIFTY-SEVEN
EXPERIMENTS
Technique
1
Purpose
1
Controls
2
Loss
3
preparation
for effect
Supply
4
of
of only
only
vessels
only
from
Supply
from
teres
Supply
superior
7
Supply
(3)
(17)
retinacular
from
inferior
arteries
(8)
inferior
teres
Supply
from
vessels
to
Supply
from
vessels
to head
Intact
Divided
Transected
Intact
Incomplete
transection
and
rim
As
retinacular
Incomplete
inferior
and
arteries
9
retinacular
10
Supply
I1
and
only
Supply
arteries
retinacular
head
arteries
ligamentum
from
bony
Divided
intact
above
Intact
transection;
rim intact
As
Divided
above
Intact
(8)
Superficial
8
;
teres
(2)
retinacular
ligamentum
Ligamentum
Intact
superior
arteries
neck
Intact
(2)
teres
retinacular
teres
from
Femoral
(4)
superior
only
hips
vessels
in ligamentum
ligamentum
6
of
capsulotomy
ligamentum
arteries
5
number
of posterior
from
Supply
and
except
(6)
except
teres
superior
superior
arteries
transcervical
superior
or partial
incision
three-quarters
to half
left intact
; inferior
Intact
As above
Divided
(2)
vessels
(4)
Circumferential
from superior
and inferior
retinacular
and from ligamentum
teres vessels (1)
incision
Divided
Incomplete
transection;
superior
and inferior
rims
intact
Intact
I
diagrammatically
in Figure
exposed
posteriorly
U-shaped
internus
flap
tendon
VOL.
47 B,
NO.
; with
1 (numbers
the
in the buttock
were divided
3,
AUGUST
1965
body
1 to 1 1) was
face
down
and undercutting
near the ischial
the
done
plane
before
injection.
of the joint
was
The
hip joint
reached
of the glutei ; the gemelli
muscles
and
spine and stripped
back to the acetabular
with
was
a deep
obturator
margin.
562
S. SEVITT
The capsule
by converting
was incised
the incision
R. G. THOMPSON
the acetabular
rim and the back of the femoral
a T-shaped
one.
The posterior
part of the superior
all the
the
capsular
fossa.
To divide
the ligamentum
teres a large
part
of the posterior
wall of the acetabulum
removed,
and the femur
rotated
medially
to expose
the ligament,
which
was hooked
and
through.
The ligament
was divided
before
anything
was done to the femoral
neck.
The
cut
reflections
the various
(Desoutter).
saw
for
blade
sutured
was
retinaculum
to prevent
returned
to
because
well
of the
bone
cuts was
Acetabular
bone
the
the
were
head
supine
of the
risk
Care
to
for
from
the
showing
the various
experimental
procedures
taken
not
falling
to cut
arteries
oscillating
muscles
were
arterial
FIG.
Diagram
was
anastomotic
a power-driven
and buttock
femur
position
seen.
neck exposed
retinaculum
and
was
inferior
near
into
AND
backwards
in the
laterally
beyond
intertrochanteric
model
fitted
with
replaced
and the
or twisting
when
a small
buttock
the
body
injection.
1
(numbered
2 to I 1) done on the neck of the femur and
teres before arteriographic
injection.
2, division
of ligamentum
teres ; 3, complete
transection
of the neck ; 4, incomplete
cervical
section
but with the upper rim left intact and with division
of ligamentum
teres;
5, the same
as 4 but the ligamentum
teres has been left intact;
6, incomplete
cervical
section
with the
lower rim left intact and with division
of ligamentum
teres ; 7, the same as 6 but the ligamentum
teres
has been
left intact ; 8, superficial
or partial
division
of the upper part of the neck ; 9, the same as 8 but with division
of
the ligamentum
teres ; 10, circumferential
incision
of soft tissues and cortical
bone around
the neck with division
of ligamentum
teres ; 1 1 , a “ diaphysial
“
section
of the neck leaving
upper and lower rims intact.
on the ligamentum
For
dislocated
acetabular
extreme
the
circumferential
the neck was cut
of all retinacular
closed.
Processing-After
trochanteric
the head.
hydrogen
incision
ofthe
neck
(number
10 in Figure
posteriorly
by extending
the posterior
capsular
incision
margin
and dividing
the overlying
muscles.
This allowed
adduction
and medial
rotation
of the limb.
After
division
circumferentially
vessels.
The
injection
area
were
divided
the
head
a few millimetres
was then restored
upper
part
longitudinally
They were fixed in formol
saline,
peroxide,
dehydrated
in alcohols
1) the femoral
deep with a Gigli
to the acetabulum
of the
femur
was
removed.
into
four
to six
slices
decalcified
and cleared
saw
JOURNAL
was
to ensure
division
and the wound
was
The
head,
according
in 20 per cent
in Spaltholz’s
THE
head
antero-laterally
along
the
the head to dislocate
on
of the ligamentum
teres
neck
to the
and
size
of
formic
acid, bleached
in
mixture.
The cleared
OF
BONE
AND
JOINT
SURGERY
DISTRIBUTION
slices
of
AND
ANASTOMOSES
bone-arteriograph
trochanter
was
OF ARTERIES
preparation
included
because
especially
when
there
was
lack
with
grain
x-ray
film
arteriographs
fine
was
complete.
stained
Transverse
by
Normal
arterial
pattern
is required,
retinacular
the
one,
pass
medially
and
inferior
superior
arteries,
superior
and
give
are
and
groups
1949).
(see
teres
(Figs.
head
under
with
smaller
circulus
and
less
of the
penetrate
into
the
wax
and
the
normal
Harrison
arteries,
The
especially
The
anterior,
vascular
(1953).
main
the
vessels
posterior
are
and
other
of William
Hunter
(1743).
largest,
with a mean diameter
the
head
metaphysial
on
neck.
constant
vasculosus
are
processing
in paraffin
histologically.
and
femoral
synovium
articuli
superior
word
Trueta
radiology;
before
recognised
3)-A
greater
of injection,
by
results
processed
circumflex
the
The
controlled
gave
563
OF FEMUR
the success
easily
from
the
NECK
investigation.
were
2 and
to six in number,
and
this
was
were
borrowed
from
They
below)
of
AND
demonstrated
They
arteries
neck
HEAD
Decalcification
ligamenta
being
the
four
basis
obtained.
Injected
derived
to the
(Tucker
off cervical
of the
head
which
together
form
retinacular
arteries,
0#{149}84
millimetres
filling.
terminology
which
the
of its vessels
were
eosin.
of the
some
arteries,
medial
of capital
and
supply
filling
sections
haematoxylin
are
good
SUPPLYING
at the
medial
The
branches.
end
latter
The
of
of the
may
neck
be derived
2
FIG. 3
in mid-sections
of the head and neck (see text).
Note that in Figure 2 the lateral part
of the head is supplied
by lateral
metaphysial
arteries
which spring from the lateral epiphysial
supply ; but
that in Figure
3 this area is supplied
by medially
directed
vessels which arise from the cervical
and superior
metaphysial
arteries.
FIG.
Normal
arterial
from
the
Harrison,
the
patterns
former.
continue
fovea.
cartilage.
absent
They
superior
off
many
vessels,
called
lateral
epiphysial
the line of the old epiphysial
multi-arcaded
supplied.
The one
; they give off small
vessels
terminate
as
posterior
retinacular
vessels
of
the
epiphysial
to be injected
teres
locally
The
retinacular
and
laterally
VOL.
47 B,
neck
supply
to
NO.
3,
are
vessels
and
ramify
AUGUST
not
often
of the
; these
from
do
1965
to join
vessels
the
with
important
from
the
terminal
superior
cortex
the
branch
trochanter
and
the
both
artery
head,
obturator
after
This
transection
when
branches
of
cervical
vessels
and
articular
artery
groups.
but
pursue
the
arteries
are smaller
than
the cortex
near the head
quadrant.
The anterior
up into a local network.
of
from
femoral
into
cervical
a
or comes
common
pass
receives
penetrate
with
the
always
seem
femur
from
vessels,
towards
2) but they vary and may be
the medial
and superior
retinacular
penetrate
in the inferior
capital
the cortex
and break
derived
femoral
by Trueta
and
in a gentle curve to
arteries
plate
branches
inferior
branches,
through
teres
the circumflex
ligament
ramify
arteries.
pass
ligamentum
or two
cervical
branches
vessels
with
Ligamentum
metaphysial
inferior
the
anastomoses
they
give
superior
along
Metaphysial
branches
often
come
off laterally
(Fig.
(Fig.
3).
Obviously
a large
part
of the head-especially
quadrants-is
allows
The main
prominently
they
the
a straight
with
cervical
ofthe
neck.
the
fovea
lateral
course
which
anastomosis
enter
from
the
and
and
The
epiphysial
the
superior
downwards
branches
of the
564
S. SEVITT
inferior
and
lateral
other
retinacular
nietaphysial
metaphysial
arteries;
vessels
or from
vessels.
AND
The
R.
G.
vessels
they
arise
from
the lateral
epiphysial
THOMPSON
in the
the
lateral
part
of
the
head
we
cervical
anastomosis
or from
arteries
or from a variable
mixture
will
term
the superior
of sources.
RESULTS
Controls
(three
capsule
incised
found
in each
experiments,
number
to
the
determine
experiment
(Figs.
1 in
possible
2 and
3).
Figure
1)-The
effect
of this,
Thus
the
hip
but
joint
operative
exposed
vascular
approach
4
FIG.
was
a normal
had
and
the
pattern
was
no effect.
5
FIG.
FIG. 6
FIG. 7
Complete
transections
of the neck.
Figure 4 shows one vessel in the ligamentum
teres injected
proximally
but
not distally
and none of the head is injected.
In Figure
5 vessels
in the ligamentum
teres
penetrate
the head
and ramify in a relatively
small subfoveal
area, but the remainder
of the head is not injected.
Figure
6 shows,
in
addition,
anastomotic
area in the upper
filling
of
many
vessels
beyond
half of the neck next to the saw-cut.
the vessels
Division
ofthe
was
also
The
results
Complete
experiments
ligamentum
without
also
the
filling
in
experiments
teres
on
the
supplement
transection
of capital
sixteen
effect
role
after
(two
experiments,
capital
arterial
controls.
of the neck (seventeen
of the
all
the
subfovea.
In Figure
of ligamentum
number
pattern
Note
7 nearly
teres.
also
the
all the head
2 in Figure
including
the
well
defined
has been
1)-Cutting
uninjected
injected
this
subfoveal
part
through
ligament
of the
head.
the
arteries
other
(94 per
in the
vessels
cent).
experiments,
ligamentum
had
been
number
teres
was
divided.
In six preparations
3 in
Ligamentum
(35
THE
Figure
1)-By
that
is, the
amount
were
injected
determined,
per
cent)
JOURNAL
vessels
no capital
OF BONE
AND
these
vessels
JOINT
were
SURGERY
DISTRIBUTION
filled
(Fig.
In the
one
AND
4) and
other
in six others
five
or two
ANASTOMOSES
(294
epiphysial
metaphysial
vessels
were
or two lateral
epiphysial
injection
of most
Injection
the
injection
head
(five
head
ligament
only
cent)
were
specimens)
SUPPLYING
filled
HEAD
a small
subfoveal
capital
vessels
other
in both
hips
AND
NECK
area
were
of one
(Fig.
7).
and
of the
head
were
related.
or when
vessels
Capital
was
subject
and
was
Incomplete
section
rim and the superior
a normal
which
shows
is from
normal
from
vascular
of
the
inferior
absent
when
did not
penetrated
reach
the
10
of the neck
retinacular
8 a section
Figure
shows
5).
9
8 TO
FIGS.
(Fig.
much
much
filling of one
cent)
had a normal
filling
FIG.
In
injected
injected:
injection
of vessels
along
the ligament
8
565
OF FEMUR
also
on the left side ; two other
heads showed
(Fig.
6); and one preparation
(59 per
absent
(one specimen)
(Fig. 4).
When
injected
was
FIG.
cent)
per
vessels
injected
arteries
of the
of the
ligamentum
(35 per
preparations
lateral
OF ARTERIES
the
with the superior
arteries
left intact.
middle
pattern;
the anterior
part
vascular
injection.
of the
and
of
the
In
Figure
head,
Figure
head
9,
also
10
there is normal
vascular
filling except in part of the
head and neck on either side of the saw-cut.
FIG.
fovea,
at least
Only
the
the
subfovea
ligament
(one
subfovea
was
to
10
was
injected
three
injected
in four
arteries)
but
and
sometimes
part
of the five specimens
the other
also
showed
of the head
(eleven
specimens).
with few injected
vessels
in the
anastomotic
capital
injection
(Fig. 6). On the other
hand four of the six preparations
with more
numerous
injected
vessels
in the ligament
had anastomotic
capital
filling,
one of which
was very extensive
(Fig.
7).
Histology
of the ligaments
showed
that the arteries
visibly
injected
ranged
from
0#{149}2
to 0#{149}8
millimetres
microns
relatively
in diameter
(mostly
03 to 05
diameter)
were
often
present
and
large vessel was not injected.
Incomplete
Figure
VOL.
section
1)-These
47 B,
NO.
with the superior
experiments
3,
AUGUST
1965
millimetres).
were
not
Vessels
infrequently
rim of the neck intact
demonstrated
the
importance
(six
of arteriole
injected.
size (50 to 100
Occasionally
a
experiments,
numbers
4 and
of the superior
retinacular
5 in
and
566
S. SEVITF
AND
R. G. THOMPSON
lateral
epiphysial
supplies
to the head
and the extensive
anastomoses
anterior,
posterior
and medial
capital
areas and, usually,
with the lateral
In four preparations
all vessels except
the superior
retinacular
arteries
the ligamenta
including
the
teres were divided.
Three
showed
a normal
vascular
pattern
anterior
(Fig. 9) and posterior
segments.
Filling
was good
for a relatively
lateral
epiphysial
was
not
Incomplete
usual
uninjected
supply
(see
section
infero-lateral
area.
although
injection
of
FIG.
11
FiG.
13
neck
the lower
teres were also divided.
ligamenta
teres
in one
were
preparation
left
rim
and
the inferior
The infero-lateral
the
intact
head
injected
in two
there
(Fig.
10).
In the head this was because
lateral
epiphysial
arteries
and to interruption
ofthe
The loss of cervical
filling is discussed
below.
Incomplete
transection
with the inferior
1)-Of
in two);
14
arteries
left intact.
the sixteen
in five the
retinacular
distribution
of the inferior
In Figures
metaphysial
1 1) to a more extensive
area of the head (Fig. 12).
retrograde
injection
(Fig. 13) but only occasionally
in which
saw-cut
6 and 7 in Figure
(a possible
artefact
12
FIG.
with
all
except
(Fig. 8)
except
was always
injected
from
the
the ligamentum
teres
vessels
FIG.
varies from a small zone near the cortex (Fig.
parts of the lateral epiphysial
arteries
sustained
The
The subfovea
the head
from
in the head
in the fourth
above).
of the
11 to 13 the ligamenta
normal
with
vessels
in the
and inferior
arteries.
were interrupted
and
(Fig.
14).
experiments.
were
arteries
Sometimes
was nearly
The
uninjected
injection
areas
of the
on either
head
side
was
of the
of the absence
of lateral
branches
from the
superior
metaphysial
vessels
by the saw-cut.
rim of the neck
preparations,
injection
was
intact
(sixteen
experiments,
five showed
little
or no
confined
to the lower
part
THE
JOURNAL
OF
BONE
AND
numbers
capital
of the
JOINT
filling
head;
SURGERY
DISTRIBUTION
and
AND
in six there
head
was
ANASTOMOSES
also
OF
anastomotic
ARTERIES
SUPPLYING
injection
HEAD
elsewhere,
AND
which
NECK
filled
OF
567
FEMUR
nearly
all
parts
intact
only
of the
in two.
In eight
experiments
retinacular
filling (Fig.
the ligamentum
vessels : three
1 1) but technical
teres
heads
were
interference
nearly
with
was
also
avascular
the inferior
divided
leaving
showing
retinacular
only very slight
vessels cannot
the
inferior
infero-lateral
be eliminated
in one specimen
; two others
showed
infero-lateral
(mainly
posterior)
filling involving
20 to 33
per cent of the head but without
anastomotic
injection
elsewhere
(Fig. 12) ; and the other three
also had retrograde
filling of one or two lateral
epiphysial
vessels,
centrally
in one, in posterior
slices
In
of another
(Fig.
13) whilst
three-quarters
eight
experiments
the ligamentum
variations
noted
and
: the
limitations
of filling
ligamentum
teres
teres
from
was
the
injected
of the
was
other
left
inferior
only
head
intact.
was
retinacular
proximally
injected.
The results
and
in
two
teres
reflected
supplies
specimens
and
one
not injected
; five heads
showed
ligamentum
and
filling
varying
from
a small zone in one to larger
subfoveal
injection
; and seven
had
cross-sectional
areas
(20 to 50 per
the head.
considerable
in four heads,
One of these
Anastomotic
filling
filling
of lateral
injected
(Fig. 14).
Thus,
inferior
or not
the
teres
into
vessels.
was
rarely
superior
saw-cut
of the
ligamentum
ligamentum
Partial
filling
rim
were
of
early
latter
including
deeper
filling
of which
head
was
(Figs.
vessels
quarters
had
was
was
through
in its upper
15 and
17).
posterior
offilling
injected
In
head,
which
the lateral
considerable
were
in Figure
the
neck.
divided
to decide
if it was entirely
three-quarters
preparations
can
explained
47B,
incision
the
on
head
none
was
of the
by interruption
retinacular
NO.
from
3,
vessels
AUGUST
the
was
eighth
to the anatomical
subfoveal
zone.
1965
(see
These
with
division
all
head
could
the retinacular
uninjected
head
and
of the
below).
be
was
superior
(such
The
neck,
as
ligamentum
subject
also
side
there
of the
importance
of
where
lateral
special
the
(four
and
preparation
but
threeshowed
inferior
metaphysial
experiments.
teres
neck
cervical
medial
seventeen
anteriorly
the
of
epiphysial
and also the variable,
but often
left intact.
These
anastomoses
injected
through
and ligamentum
of the
filling
of lateral
in the
showed
usually
preparations,
of the
partial
neck.
from
neck,
of vascular
eight
aged
of filling
vessels
in each
little
were
preparations
filling
a man
in other
retinacular
1)-A
retinacular
the superior
epiphysis
(Fig. 16). The
The other
hip of this
of ligamentum
the
Figure
cuts
of the
injection
groups
intact
in the
section
of the
varied
in depth
one-half
of the
In four
no
of the head
of vessels
vessel
left
out
whether
vessels
reduction
from
experiments
isolated
9 in
The
anastomotic
there
; and
teres)
experiments
whether
dependent
of the
In two
superior
than
these
was
the superior
part
the combination
ligamentum
cervical
1)-In
two
neck.
same
the
the superior
cutting
off
a greater
of the
there
the
that
ligaments.
superior
part of the head but this
(Fig.
17). There
was also a lack
into
about
synovium
and
the effect
of
was
inferior
cent) of
specimens
showed
nearly
completely
supply
of the head.
numbers
8 and
so-in
half
specimen
the
of the
Circumferential
but
ofvessels
restricted
but supplied
only
greater
or those
be
part
epiphysial
supply
for
anastomoses
from
naturally
vessels
upper
head
extended
three
was
evidence
producing
virtually
the
of the
a lack of filling in the
anastomotic
injection
were
other
divided
obliquity
another
third
filling
the
with
the
reduced
of the
an absence
teres was
VOL.
preparations
anteriorly,
the cut
and
heads
led to the preparations
with incomplete
teres were also transected.
The cut
experiments)
to between
one-third
and
in the posterior
part of the head.
Filling
of the head
was normal-or
in one
the
two
than
anastomotic
supports
divided
the
to investigate
neck
experiments
the
posteriorly
and
This
the
retinacular
supply
and the results
In two preparations
the ligamenta
one restricted
to the cortex
(two
the
or slight
vessels.
significantly
to the
neck (eight
experiments,
of the
upper
These
head
divided.
contribute
division
the
was absent
epiphysial
the
already
number
ligamentum
teres
vessels
within
teres
supplies.
but
were
the
injected
arteries
none
experiments,
the
of the
near
head,
the neck or
The medial
lateral
(Fig.
their
was
10
were
part
1 8).
varied.
The
origin
injected
from
latter
the
in the
568
S. SEVITT
division
lower
of
half
injected
the
direct
epiphysial
teres.
of the
partial
section
channels,
while
even
retinacular
anastomotic
division
of
the
with
much
the
of
distal
arteries-have
connections.
Figures
16 and 17-Preparations
(Fig. 16) and left (Fig. 17) femora
after
16
Vessels
in the
head
have
been
vessels-and
of the superior
filled
through
THOMPSON
FIG.
cervical
ligamentum
lateral
part
through
lateral
ends
been
superior
the
and
G.
15-17
FIGS.
1 5-Partial
R.
15
FIG.
Figure
AND
from the
ofa young
upper
part
right
man
of
the
femoral
neck with the ligamenta
teres left intact.
In Figure
16 all the old epiphysis
is left uninjected
but elsewhere
the head is fIlled.
Note also that
only
the
local
through
subfoveal
area
the ligamentum
has
teres.
been
In Figure
injected
17 lateral
epiphysial
vessels
have
been
injected
through
anastomoses
from
vessels
in the
inferior
and/or
medial
parts
of the
head,
but
few
medial
or
superior
branches
within
the epiphysis
have
been
filled.
Much
of the lateral
part
of the head
and
medial
because
part
of
and
of the neck
interruption
metaphysial
are not injected,
of the superior
arteries
FIG.
The
In
necks
Figure
adjoining
have
been
18 neither
lateral
by
the
of the
head
FIG.
17
FIG.
19
saw-cut.
18
circumferentially
the head nor
part
probably
cervical
incised to divide
the adjoining
neck
were
filled
but
the
all retinacular
arteries
and the ligamenta
teres were cut.
have been injected.
In Figure
19 all the neck and the
medial
three-quarters
THE
JOURNAL
of the
OF
head
was
BONE
AND
not
injected.
JOINT
SURGERY
DISTRIBUTION
third
preparation
the
head
Thus,
any
19).
cular
lateral
ofthe
must
the
anastomosis
arteries
supply-Judet
leagues
(1955)
found
cervical
vessels
lateral
half
of
but
that
they
would
part
of
of the
head.
Itsnormal
neck and
:
#{149}
off
the
the
concept
per
was
is
vessels
among
transected.
the
The
20
“
diaphysial
“
section
divides
all the neck except
for
the upper
and
lower
rims.
The
effect
was to prevent
injection
of vessels
in the lateral
third
of the head,
which
in this specimen
must
have been supplied
from
the neck.
of
This
cervical
-
FIG.
The
cent
head.
tested
completely
\
the
postulated
that
of much
of the neck
superior
St
superior
retinacular
the
They
‘.
col-
from
20
near
avascularity
his
would
at
forty
whole
follow
their
a subcapital
fracture
because
this
origin.
preparations
neck
in which
was
well
filled
the
neck
was
in all except
completely
six specimens
in which
there
was an uninjected
zone next to the saw cut.
In three
specimens
area was about
a centimetre
wide and restricted
to the upper
half of the neck
6) mainly
anteriorly
in one
and
centrally
in the
other
two;
in two
and in the middle
ofthe
neck (Fig.
10), and in one it was relatively
large
wide)
involving
the whole
depth
of the neck centrally
and posteriorly.
with
part
anastomoses.
rims,
epiphysial
superior
cases
per cent)
uninjected
(Fig.
lateral
pattern
arose
in about
interrupt
The
(15
the
the
came
or nearly
lateral
the
cervical
uninjected
the
that
experience.
in such
to the
and
the
retina-
and
usually
arteries
our
inferior
the lateral
neck
also
neck
from
569
FEMUR
defective.
Femoral
cases
is limited
the
OF
the
except
inferior
from
from
was
of
arose
NECK
to
(Fig.20).
been
injection
ANI)
1)-This
a large
head
have
HEAD
(one
vascular
for
SUPPLYING
arteries
neck
neck
cut through
The
except
part
supply
the
the
and
intact.
normal
good
and
superior
vessels
was
was
superior
the
showed
metaphysial
complementary
neck
narrow
leaving
fourth
lateral
1 1 in Figure
was
All the
ARTERIES
through
of
number
preparatioll
for
supply
section
“
OF
the
These
vascular
experiment,
above.
ANASTOMOSES
while
(Fig.
Diaphysial
“
AND
cervical
injection
is shown
in Figures
17 and
others
it was
narrower
(1 to 15 centimetres
Similar
interference
18.
DISCUSSION
It
has
retinacular,
and then
been
possible
transcervical
injecting
the
arterial
blood
supply
The findings
explain
neck and after some
Superior
when
the
retinacular
only
nature
medial,
branches
the
delineate
and lateral
the
distribution
teres arteries
the common
epiphysial
retinacular
experiment,
subfovea
and
arteries-All,
vessels
generally
central
and usually
lateral
of the lateral
epiphysial
segments,
the
of
the
superior
by cutting
femoral
retinacular,
inferior
off other
vessels
to the head
artery.
The results
reflect the
because
the injection
agent
filled few capillaries
and did not enter
adequately
avascular
necrosis
of the head
after
many
fractures
dislocations
of the hip.
superior
of the
to
and ligamentum
hip vessels
through
interfered
parts
vessels;
the inferior
were
with
of the
these
sector,
or nearly
left
head
also
intact;
but
the
filling
are supplied
extend
into
all of which
receive
all, of the head
their
division,
of the
head.
veins.
of the
was injected
according
to
The
superior,
by the widely
distributed
the anterior
and posterior
arteries
from
other
sources.
the inferior
or lateral
connections
are defective
so that the inferior
or the lateral
part of the head remains
uninjected
when the inferior
retinacular
or transcervical
arteries
are
cut off.
That
the superior
retinacular
and lateral
epiphysial
arteries
are the most important
Sometimes
vessels
for
47 B,
VOL.
M
head
the
NO.
3,
is confirmed.
AUGUST
1965
s.
570
Ligamentum
conflicting.
SEVITT
AND
R.
G.
THOMPSON
teres-Studies
of the importance
of the vessels
in the ligamentum
From
histological
studies
of 1 14 adult
ligaments
Chandler
and
thought
that its vessels
were important
and they showed
that
vessels
in the head.
On the other hand,
Nordenson
(1938) examined
and found
that, with advancing
age, there
were more
insignificant
there
were connections
with
129 ligaments
histologically
arteries
and vessels
which
divided
into fine branches
before
reaching
the head ; in half his subjects
years the vessels
in the ligament
did not reach the head.
Kolodny
(1925),
thought
that the ligament
later in life the small teres
the
the
those
least
circulation
problems
head,
and
the
are
other
in the ligamentum
Our results
indicate
in elderly
adults,
in adult
involved.
life.
is the
amount
vessels
reached
the
and they concluded
One
the
because
all the
head-including
ligament.
After
cervical
transection,
quality
of vessels
between
the
none
filling,
injected
numerous
there
was extensively
was often-but
injected.
partly,
partly,
but
in
only
This
to the
contrast
not in adults;
Wolcott
(1943),
head
after
these
birth
they did not
vessels
contributed
along
the
the
arteries
ligament
are unimportant
important.
or
which
of the
join
to
reach
head
and
of
for most
heads,
at
Teres
vessels
are not
well
injected
after
only
a small
subfoveal
division
of the
area
was
the ligament
in about
two-thirds
of the preparations.
Other
parts of the head
in the others
but only one head was extensively
filled.
Absence
of subfoveal
to lack of distal
injection
of the ligamentum
vessels
although
(in all except
with subfoveal
were few, the
anastomoses.
be
subfovea-was
of the
one) they were injected
proximally.
Defective
technical
artefact
from
injection
of the femoral
from
the internal
iliac artery
(from
which
the
observed
as part
of the injection
technique.
associated
ligament
head
that
of anastomosis
is
teres.
that the vessels
in the ligament
but that occasionally
they can
essential
injected
through
were also injected
filling
was related
but
of sixty
studies,
that in only 20 per cent of specimens
did injected
vessels
of the
the fovea ; at least one artery
in the others
reached
the head and
vessels.
Similar
studies
by Trueta
and Harrison
(1953)
and Trueta
that,
although
ligament
for three
or four years;
capital
Two
over the age
from injection
vessels
were important
to the head
in children
vessels
could not be followed
to the foveal
insertion.
also by injections,
found
ligament
fail to penetrate
anastomosed
with other
(1957)
showed
its circulation
teres have been
Kreuscher
(1932)
not
Thus
related
curious
regular
proving
foveal
the
to
penetration
zone was
of the head.
generally
small
always-anastomotic
limitation
of
poor
and almost
anastomotic
branches.
Inferior
retinacular
arteries-These
arteries.
After
all the other
sources
posterior
and lateral-was
injected
filling
of the ligamentum
vessels
was not a
artery,
because
retrograde
anastomotic
flow
ligamentum
vessels
are derived)
was regularly
Injection
of vessels
along
the ligament
was
vessels
constant
filling
When
injected
vessels
; but when
they were
filling
anastomoses
in the
ligamentum
failure
of the
of the head,
but only
beyond
the subfovea
teres
to inject
subfovea
and
beyond
through
there
may
in the
more
one
is
be no
the subfovea
was
lateral
epiphysial
are much
less important
than
the superior
retinacular
have been cut off, the inferior
part of the head-generally
through
the inferior
metaphysial
branches.
Sometimes
the
area was very small and sometimes
it was relatively
large.
Central
and superior
capital
vessels
were injected
through
anastomoses
in a small
number,
but only rarely
was most of the head
injected.
The differences
in the capability
of anastomosis
between
the lateral
epiphysial
and
inferior
metaphysial
vessels,
according
to the direction
of injection,
was similar
to that already
noted
between
Transcervical
or
only
the
the lateral
arteries-After
lateral
part
epiphysial
division
of
the
head
and teres supplies.
of all retinacular
was
injected.
importance
except
for the lateral
metaphysial
supply
is no connection
between
the branches
of the nutrient
vessels
because
Wolcott
(1943)
found
that injection
the
capsular
(retinacular)
vessels
and
vice
vessels
Thus,
and
vessels
in some.
This
artery
in the
of the nutrient
the
inside
ligamentum
the
neck
teres
none
are
of no
does not mean that there
diaphysis
and the capital
artery
successfully
filled
versa.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
DISTRIBUTION
Cervical
AND
ANASTOMOSES
arteries-The
cervical
superior
branches.
short
cervical
Other
to the
arising
of
saw-cut.
medial
avascularity
the
in
the avascular
of good
anastomoses.
Anterior
and posterior
or posterior
these vessels
locally
to
the
for
a
They
were
successfully
head
were
limited
generally
are
not
area
from
fractures
after
intracapsular
particularly
above
of the
injected
through
a pinned
and
vulnerable
teres
other
the
Considerable
upward
or subtotal
capital
through
the intact
VOL.
47 B,
viable
NO.
3,
intact
the
fractures.
only
because
the anterior
contribution,
to be more
areas
because
when
all other
but
than
these
vessels
displacement
either
capital
area
of the
and
vascular
AUGUST
22
1965
had
depends
lower
been
the
teres
at necropsy.
vessels
entirely
fragment
kept
retinacular
findings
and
vessels
head
except
Figure
5).
is avascular
and
with Figure
explain
make
then
When
the
4).
results
on
the
teres
dependent
Arteriography
cent of the heads
had
necrosis
(Sevitt
1964).
associated
with
subfoveal
area kept
21).
When
necrosis
in a few
had
head
supply.
generally
of the
(Fig.
the
capital
distribution
and
the inferior
retinacular
or was intact
but
injected
ligaments
alive
with
vessels
are very often
torn,
have been widely displaced.
would
was
is avascular
teres (compare
and
the size
restricted
head
(compare
All the bony
showed
that 64 per
cent total
or partial
been torn by the nail
necrosis
with vascular,
after
ligamentum
vessels
important.
at necropsy
and 84 per
of the
head
The
experimental
retinacular
head
at necropsy.
and retinacular
when the fragments
necrosis.
With
subtotal
necrosis
teres supply
was generally
very
the ligament
had
examples
of total
medial
left
the vessels of the ligamentum
synovium
especially
superior
the
injected
and inferior
retinacular
vessels
becomes
very
of the
torn
of
necrosis-Our
subjects
necrosis
remained
fracture
avascular
future
a larger
experiments
injected
vessels
through
in twenty-five
or almost
total
total
were
arteries
presumably
be sure of the extent
of their
absent
so they were unlikely
fracture
the
subcapital
and histology
suffered
total
also
postulated,
except
found
concerning
intracapsular
for the anterior
and posterior
the lateral
epiphysial
arteries
transcervical
fractures.
Cervical
and anteriorly,
and
on the ligamentum
anastomoses
with
are
of our
they
anterior
cervical
(1955)
FIG.
a pinned
only the foveal soft tissue has been injected
Interruption
than
situated
through
the
of the neck
zone was
superior
et al.
21
from
subfoveal
Intracapsular
of the
of Judet
superior
upwards
from
on injection
an uninjected
medially
smaller
essential
through
probably
their
of
divided.
22-Specimen
vessels
by certain
vessels-None
injected
21-Specimen
Figure
were
retinacular
FIG.
Figure
neck
trochanter,
571
OF FEMUR
because
and
division
hypothesis
NECK
the
no effect
in which
with
the
retinacular
supply;
so we cannot
were generally
small and sometimes
important.
zones
the
of
from
had
AND
important
arteries,
consistent
support
HEAD
also
laterally
retinacular
were
and
zones
come
are
Cervical
section
of the preparations
zones
part
SUPPLYING
arteries
inferior
vessels.
per cent)
saw-cut
caused
However,
the
These
to
ARTERIES
retinacular
contributions
branches
and posterior
retinacular
in a small number
(15
next
OF
been
not
injected,
(Fig.
22).
specimens
interrupted
but
total
alive
was
there
Sometimes
all
the
(Fig.
head
23).
572
S. SEVITT
There
were
which
also
two
specimens
inferior
retinacular
These
findings
are
roles
the
of
the
superior
and
lateral
teres
of the
with
the
necrosis
retinacular
and
limited
lateral
vessels,
when
clinical
which
and
have
necropsy
this
radiological
been
included
has
(Fig.
24).
a posterior
been
23-Specimen
Figure
24-Specimen
The
the
head
retinacular
posterior
the
femoral
1
At necropsy
avascular
by
of
the
by
arteriographic
2.
Before
which
day
femoral
by
had
been
injected
at necropsy.
The
the fracture
line (compare
part
the
lateral
have
or
its
avascular,
no
part
lateral
the arterial
distribution
vessels
to
or
in the
the
been
This
supply
which
admission.
because
is normal
is avascular
of damage
and
tearing
The
would
remaining
head
all the head
mechanisms.
avascularity.
studied
after
stretching
both
of
One
by
not
be
of
ruptured
influenced
intact.
CONCLUSIONS
AND
the head
uninjured
head
have
few
24
Virtually
must
from
be
injuries
soon
origin-from
metaphysial
within
in fifty-seven
this
at their
attachment,
played
possible
and
neck-or
to
vascular
pattern
of the
with
Figure
7).
around
followed
a
(1957).
multiple
reduced
of
source
are
head,
first
severe
in
branches
Not-
main
Laufer
the
after
in great
all
dislocations
the
apparently
the
are the
hip
FIG.
its
head
contributions
they
reported
was
injection
injection
that
as
died
hip
of
dislocated
hip injected
at necropsy.
(compare
with Figures
18 and 19).
at
of the
part ofthe
head.
to the dominant
restricted
vessels
necrosis
arteriography,
years
SUMMARY
.
teres
a posteriorly
could
neck
the
from
vessels
teres
by
studied
sector
the superior
with regard
vessels,
ligamentum
such
a subcapital
fracture
for disruption
at
capsule
ligamentum
all except
especially
23
from
except
femoral
the
to
to a superior
supply
results
epiphysial
of
ofeighteen
dislocation
FIG.
Figure
restricted
histologically,
A man
THOMPSON
head (Sevitt
1964).
necrosis
of the head-Some
evidence
confirmed
specimen
means
G.
and the poverty
of their anastomoses
with
the superior
retinacular
supply
is interrupted.
of the
contribution
of revascularisation
of the necrotic
Dislocation
of the hip and avascular
by
R.
and teres vessels could
explained
by the present
inferior
retinacular
epiphysial
arteries
withstanding
ANI)
hips
except
for
and
neck
of the femur
of mostly
one
or
elderly
more
was
investigated
subjects.
particular
groups
were
divided.
3. The superior
retinacular
arteries
were found
to be the most important
arterial
supply
to
the head.
Through
the widely
distributed
branches
of their lateral
epiphysial
vessels
(superior
capital)
they supplied
the superior,
medial,
central
and usually
the lateral
parts ofthe
head:
through
anastomoses
they could
also supply
the anterior
and posterior
segments,
the subfovea
and
lateral
the
inferior
connections
sector,
were
which
receive
defective.
separate
contributions.
THE
Sometimes
JOURNAL
OF BONE
the
AND
inferior
JOINT
or the
SURGERY
DISTRIBUTION
4.
The
AND
arteries
ANASTOMOSES
in the
ligamentum
OF ARTERIES
teres
were
SUPPLYING
either
absent
most subjects.
Either
the vessels
in the ligament
never
a limited
subfoveal
zone.
In only one out of sixteen
through
the vessels
of the ligamentum
teres.
The
5.
inferior
retinacular
arteries
were
supplied
a variable
infero-lateral
there
was an anastomotic
supply
specimens
6.
was
The
nearly
regular
all the
anastomotic
to the inferior
of the lateral
7.
Vessels
medial
three-quarters.
The neck of the femur
but
only
We
are
within
the
head
injected
supply
from
in a small
indebted
to
femoral
received
(15 per
sometimes
for
branches
part
was
head
in
supplied
only
head injected
importance
posteriorly.
but only
the
573
and
generally
In a small number
in two out of sixteen
vessels.
supplied
cent)
OF FEMUR
unimportant
retinacular
important
R. Gill and his colleagues
Mr
these
superior
NECK
the head or they
was the whole
to be of subsidiary
through
the
AND
arteries
to the
was in curious
contrast
to the infrequent
from the inferior
retinacular
or ligamentum
neck
number
or
reached
specimens
part of the head,
particularly
to other
parts
of the head,
part of the head
epiphysial
arteries
the
8.
found
HEAD
the
lateral
from
of the Photographic
part
the
of it entirely
subfovea
of the
head
superior
retinacular
dependent
on this
Department
and
anastomotic
filling
teres arteries.
but
never
arteries
supply.
of this hospital
for their
help.
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P. H. (1932):
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A Study ofthe
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Journal
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