Femoral and tibial blood supply: A trigger for non-union?

We report a case of an unusual hip fracture that involved the intracapsular area and continued vertically to the extracapsular region below the trochanteric line. The division between these two types of fractures is based on the anatomical site, the blood supply and the mechanical forces that act on the hip. This division is important and influences the different surgical techniques to treat these individual fractures. Femoral neck fractures (intracapsular), particularly those with displacement, can disrupt the blood supply to the femoral head and may be associated with an increased incidence of complications, especially non-union and avascular necrosis (AVN) of the femoral head. These fractures are usually treated either by reduction and fixation, or by hemiarthroplasty. Non-union and avascular necrosis following extracapsular fractures are rare. Treatment involves reduction of the fracture and insertion of a dynamic hip screw. The combination of these two types of fractures is extremely rare and creates a surgical problem without any optimal solution. The focus of this case report is placed on the mechanical axis and weight-bearing forces that play a role in the hip and on the optional surgical techniques in such a rare type of fracture in an elderly osteoporotic patient.

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A Challenging Case of Extraordinary – Long standing Forearm Non-union Treated with Extensive Debridement, Locking Plates, and Bone Grafting. Technical Considerations in Multiple-operated, Neglected Non-unions

Journal of Orthopaedic Case Reports ◽

10.13107/jocr.2021.v11.i01.1966 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

George A Komnos ◽

Fotis Papageorgiou ◽

Konstantinos N Malizos

Keyword(s):

Blood Supply ◽

Proper Function ◽

Locking Plates ◽

Significant Treatment ◽

Non Union ◽

Orthopedic Surgeons ◽

Extensive Debridement ◽

Thorough Debridement ◽

Fully Functioning ◽

Technical Considerations

Introduction: Forearm non-unions pose a significant treatment challenge to orthopedic surgeons. Repetitive treatment failures can lead to a devastating situation for the patient. Forearm function influences both elbow and wrist proper function. Case Report: A functionless hand is presented, describing a longstanding non-union, treated with multiple surgeries before. A thorough debridement with respect to blood supply and local biology are of major importance before applying the locking plates along with the use of bone-graft. The reconstruction of the forearm converted a functionless arm to a fully functioning arm and the patient returned eventually to her previous activities. Conclusion: Fixation with locking plates combined with the use of autograft can lead to very satisfactory results even in extraordinary cases, especially when attention is paid to local anatomy and blood supply. Keywords: Forearm nonunion, locking plates, multiple surgeries.

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Pathological Calcification and Ossification in Relation to Leriche and Policard's Theory

Proceedings of the Royal Society of Medicine ◽

10.1177/003591573302600734 ◽

1933 ◽

Vol 26 (7) ◽

pp. 853-859 ◽

Cited By ~ 1

Author(s):

Watson Jones ◽

R. E. Roberts

Keyword(s):

Blood Supply ◽

Bone Disease ◽

Myositis Ossificans ◽

Fibrous Tissue ◽

Supraspinatus Tendon ◽

Intervertebral Discs ◽

Non Union ◽

Adequate Blood Supply ◽

Pathological Calcification

Pathology of calcification and ossification.—The Leriche-Policard theories. Hyperæmia of bone causes decalcification. Reduced blood supply causes sclerosis. Diminution of vascularity of fibrous tissue causes calcification. Excess of calcium, adequate blood supply and fibroblasts give rise to bone anywhere. Subperiosteal ossification. “Myositis ossificans.” Radiological significance of density of bone shadows.—Decalcification of disuse, of infections, of neoplasms. Traumatic and infective scquestra. Evidence that a fragment of bone is avascular. Hyperæmic decalcification of bone.—Delayed and non-union of fractures. Kummel's disease. Spontaneous hyperæmic dislocation of the atlas. Hyperæmic decalcification and nephrolithiasis. Anæmic sclerosis of bone.—Syphilitic bone disease. Malignant bone disease. Fragility of sclerosed bone—Paget's, Kienboch's, Kohler's and Panner's, Albers-Schönberg's diseases. Pathological calcification.—Calcification of supraspinatus tendon. Calcification of tumours—angioma, hæmatoma, and thrombosed vessels, lipoma, cysts, etc. Calcification of semilunar cartilages and intervertebral discs. Pathological ossification.—Ossification of tendons. Ossification of semilunar cartilages.

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The Anatomical Basis of the Vascularized Pronator Quadratus Pedicled Bone Graft

Journal of Hand Surgery (European Volume) ◽

10.1016/s0266-7681(97)80365-8 ◽

1997 ◽

Vol 22 (5) ◽

pp. 644-646 ◽

Cited By ~ 29

Author(s):

J. C-H. LEE ◽

J. LIM ◽

P. B. CHACHA

Keyword(s):

Bone Graft ◽

Blood Supply ◽

Vascular Supply ◽

Anterior Surface ◽

Pronator Quadratus ◽

Non Union ◽

Anatomical Basis ◽

Anterior Interosseous Artery ◽

Interosseous Artery ◽

Pronator Quadratus Muscle

The vascular supply of the pronator quadratus was studied in 25 cadaveric dissections following coloured latex injections. This showed that the main blood supply of the pronator quadratus came from the anterior interosseous artery. There was, however, a rich anastomosis between the branches of the anterior interosseous artery and those of the radial and ulnar arteries. It was possible to raise a corticocancellous bone graft from the anterior surface of the radial styloid on a pedicle of the lower fibres of the pronator quadratus muscle. This muscle pedicle had a constant branch of the anterior interosseous artery which vascularized the bone graft. Such a vascularized pedicled bone graft may be useful in the treatment of non-union of the scaphoid and Kienböck’s disease.

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Vascularized medial femoral condyle graft for management of scaphoid non-union

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193414561900 ◽

2014 ◽

Vol 40 (8) ◽

pp. 848-854 ◽

Cited By ~ 21

Author(s):

A. Elgammal ◽

B. Lukas

Keyword(s):

Bone Graft ◽

Blood Supply ◽

Femoral Condyle ◽

Medial Femoral Condyle ◽

Proximal Pole ◽

Previous Surgery ◽

Level Of Evidence ◽

Non Union ◽

Structural Support

The purpose of this study was to assess the results of the management of difficult scaphoid non-unions using a vascularized medial femoral condyle graft. We operated on 30 patients with necrosis of the proximal pole or with severe humpback deformity or who presented with persistent non-union despite previous surgery. Twenty-four cases in our series showed full consolidation and six cases showed persistent non-union. The free vascularized medial femoral condyle bone graft can provide not only structural support, but also a consistent and good blood supply that results in excellent rates of union. Level of evidence: IV

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The Anatomy of the Tibial Nutrient Artery Canal—An Investigation of 106 Patients Using Multi-Detector Computed Tomography

Journal of Clinical Medicine ◽

10.3390/jcm9041135 ◽

2020 ◽

Vol 9 (4) ◽

pp. 1135 ◽

Cited By ~ 1

Author(s):

Haidara Almansour ◽

Eleftherios Armoutsis ◽

Marie K. Reumann ◽

Konstantin Nikolaou ◽

Fabian Springer

Keyword(s):

Computed Tomography ◽

Blood Supply ◽

Angular Position ◽

Tibial Fractures ◽

Non Union ◽

Screw Insertion ◽

Tibial Length ◽

Nutrient Artery ◽

Nutrient Foramina ◽

Significant Difference

Radiologic evaluation of the tibial nutrient artery is clinically important as disruption of tibial blood supply is a risk factor for delayed or non-union of tibial fractures. Damage to the tibial nutrient artery canal (TNAC) may occur by a traversing fracture or iatrogenic cause in the context of pin/screw placement. Furthermore, TNAC could be misdiagnosed as a stress fracture. The aim of this study was to characterize the normal anatomy of TNAC and to delineate its gender and side-specific differences. Patients who underwent contrast-enhanced computed-tomography encompassing the pelvis and lower extremities were included. TNAC was identified with an external and internal foramen and a traversing intercortical canal. Various anatomical morphometrics were evaluated: total number of nutrient canals, angular position of the outer and inner nutrient foramina, absolute and relative position of the nutrient foramina, as well as the intercortical canal length with respect to tibial length. The majority of patients of both genders had only one tibial nutrient canal, multiple canals or complete absence were rare. In most cases, the outer nutrient foramen was found on the posterolateral aspect of the upper-third of tibia at about 32% of tibial length; the inner foramen was found at the middle third of the tibia (41% of tibial length). The course of nutrient canal was mostly cranio-caudal with a small, but significant difference in relative canal length: 8.5% vs. 10% of tibial length for females and males, respectively. The angular location of the outer and inner foramen was between 20–30° and did not reveal a statistically significant difference between genders. No statistically significant side specific differences were found for all analyzed parameters and both genders. The clinical relevance of this anatomical study pertains to establishing “safe corridors” of pin/screw insertion in the context of surgical management of tibial fractures in order to avoid iatrogenic disruption of tibial blood supply.

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Innervation of endoneurial microvessels in human sural nerve

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100125002 ◽

1992 ◽

Vol 50 (1) ◽

pp. 920-921

Author(s):

John L. Beggs ◽

Peter C. Johnson ◽

Astrid G. Olafsen ◽

C. Jane Watkins

Keyword(s):

Blood Flow ◽

Blood Vessels ◽

Blood Supply ◽

Peripheral Nerves ◽

Sural Nerve ◽

Nerve Fibers ◽

Arterial Supply ◽

Autonomic Nerve ◽

Vasa Nervorum ◽

Endoneurial Blood Flow

The blood supply (vasa nervorum) to peripheral nerves is composed of an interconnected dual circulation. The endoneurium of nerve fascicles is maintained by the intrinsic circulation which is composed of microvessels primarily of capillary caliber. Transperineurial arterioles link the intrinsic circulation with the extrinsic arterial supply located in the epineurium. Blood flow in the vasa nervorum is neurogenically influenced (1,2). Although a recent hypothesis proposes that endoneurial blood flow is controlled by the action of autonomic nerve fibers associated with epineurial arterioles (2), our recent studies (3) show that in addition to epineurial arterioles other segments of the vasa nervorum are also innervated. In this study, we examine blood vessels of the endoneurium for possible innervation.

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