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Journal of the Anatomical Society of India

The Arterial Architecture Of The Human Femoral Diaphysis

Author(s): Al-Motabagani, M.A.H.

Vol. 51, No. 1 (2002-01 - 2002-06)

Department of Anatomy, College of Medicine, King Faisal University, Damman, SAUDI ARABIA.

Abstract

Investigations on the vascular anatomy of long bones tended in the past to be confined to rabbits, rats and dogs. This study is of utmost importance to human because it is relevant to fracture treatment. Combined periosteal and medullary blood supply to the bone cortex helps to explain the success of nailing of long bone fractures particularly in the weight bearing femur and tibia. This work aimed to study the arterial supply of the femoral diaphysis. Intravascular perfusion of the common iliac artery of 15 cadavers (8 males, 7 females) was done using latex and radio-opaque substance. The femoral, circumflex femoral arteries and perforators of the profunda were dissected. The latter were found to be the main source of arterial supply to the femoral diaphysis. The nutrient foramina of 130 dried femora were examined. The foramen number in both sexes and both sides were studied. Regardless of sex, one nutrient foramen was found in 63 cases, two diaphyseal nurtrient foramina were present in 63 cases which were not necessarily equal in size and in four cases nutrient foramina were absent.

By statistical analysis, it was found that there is a significant sex difference in foramen number between men and women for right bones but not for left bones.

Using x-ray, diaphyseal nutrient arteries were examined and sometimes when two nutrient arteries were found, they formed loop. Longitudinal and transverse sections through the middiaphysis of femora showed the distribution of blood supply to the cortex and medulla.

Key words: Long bones; vascularization; nutrient arteries, femoral diaphysis

Introduction:

Bone is a complex tissue whose character is dominated by the inorganic salts that give it rigidity. Previous investigations of the vascularization of bone have largely centered on the respective contributions of the arterial supply to long bones derived from the periosteal network, the principal nutrient artery and arteries entering the bone at its extremities (Brookes, 1958; Kirschner et al. 1998). It is general view that the nurtrient artery of the long bones is the main blood supply not only for the osteal tissue but also for the bone marrow (Branemark, 1959). With the exception of arteries entering the human femoral head and neck, there are few works in which these arteries are the subject of exact anatomical description. Investigations on the vascular anatomy of long bones tended in the past to be confined to rats, rabbits and dogs. This study is of utmost importance to human because it is relevant to fracture treatment. Combined periosteal and medullary blood supply to the bone cortex help to explain the success of nailing of long bone fractures particularly in the weight bearing femur and tibia. In old and young fractured bones, the periosteum is conserved, thus keeping the cortex alive while the marrow regenerates (Bridgeman & Brookes, 1996).

In view of the inadequacy of accounts of femoral vascularization of human, it appeared therefore of interest to examine the participation of the vessels in the arterial supply of the femoral diaphysis and to examine the nutrient arteries.

Material and Methods:

Dried femora:

The nurtient foramina of 130 cleaned and dried femora in the bone collections of the Department of Anatomy were examined. Sex of the bone was determined according to Pearson and Bell’s tables (Knight, 1991). The nutrient foramina number in both sexes and both sides were studied.

Perfused bones:

The common iliac arteris of 15 cadavers (8 males, 7 females) were perfused using latex and radio-opaque substance to show the arterial supply of the femoral diaphysis.

Posteroanterior x-ray projections of the thighs were followed with dissection to confirm what appeared in the x-ray films.

The surrounding muscles were removed and the arteries were displayed and photographed to demonstrate the source of the blood supply to the femoral shaft. Segments of the diaphyses were decalcified in 5% nitric acid in 5% formalin solution.

When decalfication was complete, the specimens were sectioned transversely and longitudinally in 4 mm slices. Blocks embedded in paraffin were prepared, sectioned and stained with hematoxylin and eosin for light microscopic examination.

Results:

1. Gross Anatomy Observation: The femoral, profunda femoris arteries and its branches were dissected. The perforator branches of profunda femoris were demonstrated (Fig. 1). The femur received its blood supply from one or more nutrient arteries arising from the profunda femoris artery in addition to periosteal branches (Fig. 2, 3). There were two main periosteal branches, one from the profunda femoris artery at its end and the other arose from the lower end of femoral artey itself (Fig. 3).

2. Dried femora: Of the entire collection of dried femora examined without regard to sex or side, two diaphyseal nutrient foramina were present in 63 bones, one nutrient foramen was found in 63 bones and in four bones nutrient foramina were absent. When two nutrient foramina were present, they were not necessarily equal in size (Fig. 4). Femoral nutrient foramina point obliquely upwards to the femoral head as it lies away from the faster growing lower end.

* Statistical Analysis: The foramen numbers of all 130 dried bones were submitted to chi square (X2) analysis. The effect of sex on side and the effect of side on sex were tabulated (Table 1 to 4). This revealed a significant correlation between sex and right femora with respect to foramen number where (X2 = 3.92, P£0.005) (Table 1). Out of a total of 55 right femora, 24 were identified as female’s femora; of the latter 8 had 1 nutrient foramen and 16 had 2 foramina while in male’s femora, 19 had 1 foramen and 12 had 2 foramina.

In the 71 left male and female femora, there was no significant effect of sex on side with respect to foramen number (Table 2).

The effect of side or foramen number was analysed separately in the 2 sexes. Of the 75 male bones, 19 had 1 foramen on the right against 21 on the left and 12 had 2 foramina on the right against 23 on the left. These findings contrasted with similar data in 51 female femora where the results were not significant (Table 3).

In Summary, (X2) test showed significant sex difference in foramen number between males and females for right femoral bones but not for left femoral bones. (Table 1, 2). In females, there was a 2:1 chance of being a double nutrient foramen in the right femur (Table 1). There was no significant side effect for males and females (Table 3, 4).

Table 1 : The effect of sex on foramen number in the right femora

Sex 1 Foramen 2 Foramina Total
Female 8 (33.3%) 16 (66.7%) 24
Male 19 (61.3%) 12 (38.7%) 31
Total 27   28   55
X2 = 3.92

Table 2 Effect of sex on foramen number in the left femora

Sex 1 Foramen 2 Foramina Total
Female 15 (55.6%) 12 (44.4%) 27
Male 21 (47.7%) 23 (52.3%) 44
Total 36   35   71
X2 = 0.52

Table 3 : Effect of side in male femora

Sex 1 Foramen 2 Foramina Total
Right 19 (61.3%) 12 (38.7%) 3
Left 21 (47.7%) 23 (52.3%) 44
Total 40   35   75
X2 = 1.31

Table 4 : Effect of side in female femora

Sex 1 Foramen 2 Foramina Total
Right 8 (33.3%) 16 (66.7%) 24
Left 15 (55.6%) 12 (44.4%) 27
Total 23   28   51
X2 = 2.13          

Table 5 : Summary data for 130 dried femora
(59 right, 71 left) with distribution of presence of
(0, 1 or 2 nutrient formina)

Sex Right Left
  None Single Double None Single Double
Female 0 8 16 0 15 12
Male 4 19 12 0 21 23
Total 4 27 28 0 36 35
  (3%) (20.8%) (21.6%)   (27.7%) (26.9%)

3. Angiography: In the group of 15 perfused cadaveric femora, x-ray showed the presence of single or double nutrient arteries to the diaphysis (Fig. 5, 6). The principal nutrient artery trasverses the cortex. On entering the medulla, it divides into ascending and descending limbs. Double nutrient arteries also give ascending and descending branches in the medullary cavity. These branches disperse widely and give off twigs that enter the cortex and supply the vessels of the Haversian canal. An anastomotic loop between the ascending the descending branches of the two nutrient arteries may be present in the medulla (Fig. 5). Otherwise, the two nutrient arteries go their separate ways (Fig. 6).

4. Histology: Microscopic studies of transverse and sagittal sections of the femora showed that the Haversian canals contained vessels (Fig. 7, 8). Many of the Haversian vessels were thin-walled structures resembling capillaries. In transverse sections, it was noted that the Haversian canals tended to be larger near the endosteal surface and smaller near the periosteal surface. This observation was considered indirect evidence that arterial blood flow goes from the nutrient artery in a centrifugal direction from the endosteum to the periosteum. In transverse sections, the nutrient artery was also seen in the medullary portion of the human femur (Fig. 9). In sagittal section, the vessels were longitudinally oriented in the axis of the cortex with a straight lumen (Fig. 10). In some of the cleared sections, vascular channels were demonstrated that extended from the periosteal to the endosteal surface of the bone. These channels contained only relatively large tube like vessels, the walls of which were composed solely of endothelium.

Discussion:

In this study, it was found that the blood supply to the femoral diaphysis was provided by one or two nutrient arteries arising from the profunda in addition to the periosteal branches. Similar results were reported by Trias & Fery (1979) who stated that the cortices of long bones are dependent for their nourishment on vessels from the periosteal system and medullary circulatory system, the latter are mainly derived from the branches of nutrient artery. He stated that the periosteal vessels supply the outer third or fourth of the cortex while the medullary arteries supply the inner 2/3 or 3/4.

In this study, it was found that a large part of the cortical bone thickness derives its blood supply from the medulla with a centrifugal flow. The latter is confirmed by Dillaman et al. (1991) and Trias & Fery (1979). Similar results were also obtained by Skawina et al. (1994) who found that the medullary arteries supplied both the cortex and medulla. However, De Bruyn et al. (1970) in rats, rabbits and guinea pigs and De Saint-George & Millar (1992) in rats have reported findings contrary to the above. They regarded cortical capillaries as venous structures and assumed from the start that cortical blood flow is centripetal.

Lopez-curto et al. (1980) pointed out that the diaphyseal nutrient arteries supplied the canine marrow and cortex in parallel but the cortical and medullary vascular beds were largely independent. Nelson et al. (1960) stated that the ascending and descending branches of the nutrient artery in the marrow cavity of the human tibia gave off smaller branches that proceeded radially to pierce the endosteal surface of the cortex and then subdivided into smaller vessels that supplied the vessels in the Haversian canals. In addition, Kelly (1973) who worked on the canine tibia, Brookes (1990) and De Bruyn et al (1970) have all noted the contribution of nutrient arteries to the total femoral blood flow.

In this study, the gross dissections indicated that the vascular network in the periosteum receives its major supply from the profunda femoris and from the femoral artery near its terminal end. The same results were obtained by Brooker (1986) who illustrated a periosteal supply to the human bone cortex, significantly in aged specimens.

Nelson et al., (1960) described a periosteal arterial supply to the human tibia with multiple blood vessels in the cortical canals and periosteomedullary anastomoses. Skawina et al. (1994) found that the medullary arteries supplied both cortex and marrow and there was no arterial supply to the fetal shaft cortex from the periosteal side. These two opposite observations by Brookes (1986) and Skawina et al. (1994) were explained by Bridgeman & Brookes (1996) who suggested that with increasing age after maturity, the marrow of the human femur becomes ischaemic on account of intraosseous atherosclerosis, the medullary blood supply to the cortex diminishes and a periosteal blood supply becomes increasingly important for the survival of bone cortex in old age. In this study, chi square (X2) test showed significant sex differences in foramen number between males and females for right femur only. In females, there was a 2:1 chance of being a double nutrient formina in the right femora.

Bridgeman & Brookes (1996) revealed a significant difference in foramen number between males and females from the right bones only. They found that in males only, there in roughly a 2:1 chance in favour of there being a single nutrient foramen in a right femur, and a 2:1 chance in favour of 2 foramina in a left femur.

In this study, microscopic examination of the sections of femoral cortex showed the presence of vessels in the Haversian canals. Many of them were thin-walled structures resembling capillaries. In general, it was noted that the Haversian canals tended to be larger near the endosteal surface and smaller near the periosteal surface. This observation was considered indirect evidence that arterial blood flow goes from the nutrient artery in a centrifugal direction from the endosteum to the periosteum. That was similar to the results obtained from the study of Nelson et al. (1960) who studied the vascular supply of human tibia. In this study, vascular channels were demonstrated extending from the periosteal to the endosteal surface of the femur. These channels were tube-like vessels, the walls of which were composed of endothelium.

Nelson et al. (1960) stated that these periosteal vessels always had thin walls that did not contain any muscle or elastic tissue which means that these vessels must represent capillaries. It is clear that in normal adult human, the periosteal vessels supply a narrow zone of the outer cortex but in case of damage to the medullary blood vessels, these periosteal capillary beds become a potential source of blood supply to the cortex. This concept is supported by the experimental work of Trueta (1968).

This study is also relevant to fracture treatment. The findings that a combined periosteal and medullary blood supply to bone cortex help to explain the success of intramedullary reaming and nailing of long bone fractures particularly in the weight bearing femur and tibia. In the fractured bones, the periosteum is conserved thus keeping the cortex alive while the marrow regenerates. At the same time, the intramedullary nail maintains the bone fragments in the mechanical reduction in the maximally advantageous site which is the medullary axis (Gahr et al. 1995).

References:

  1. Branemark, P.I. : (1959): Vital microscopy of bone marrow in rabbit. Scandenavian Journal of Clinical Laboratory Investigation 11 Suppl., 38: 1-82.
  2. Bridgeman, G. and Brookes, M. (1996): Blood supply to the human femoral diaphysis in youth and senescence. Journal of Anatomy 188: 611-621.
  3. Brookes, M. (1958): The vascularization of long bones in the human fetus. Journal of Anatomy 92: 261-267.
  4. Brookes, M. (1986): An anatomy of the osseous circulation. Bone 3: 32-35.
  5. Brookes, M. (1990): Blood flow in the diaphysis of long bones. Association International pour la Recherche sur la circulation Osseuse (Toulouse), ARCO News latter 2 Suppl., 2: 75-85.
  6. De Bruyn, P.H., Breen, P.C., and Thomas, T.B. (1970): Microcirculation of the bone marrow. Anatomical Record 168: 55-68.
  7. De Saint George L., and Miller, S.C. (1992): The microcirculation of bone marrow in the diaphysis of the rat hemopoietic long bones. Anatomical Record 23: 169-177.
  8. Dillamen, R.M., Roer, RD., and Gay, D.M. (1991): Fluid movement in bone : theoretical and empirical. Journal of Biomechanics 24 Suppl, 1: 163-177.
  9. Gahr, R.H; Hein, W; and Seidel, H: Dynamische Osteosythese. Berlin, Springer, 1995.
  10. Kelly, P.J. (1973): Comparison of marrow and cortical bone blood flow by 125I labeled 4-iodonatipyrine (I-Ap) washout. Journal of Laboratory & Clinical Medicine 81: 497-505.
  11. Kirschner, M.H., Mench, J., Hennerbichler, A., Gaber O., and Hofmann G. (1988): Importance of arterial blood supply to the femur and tibia for transplantation of vascularized femoral diaphysis and knee joint World Journal of Surgery Aug 22 Suppl. 8: 845-851.
  12. Knight, B. Forensic Pathology. Great Britain, London and Kent, 1991.
  13. Lopez-Cuto, J.A., Bassingthwaighte, J.B., and Kelly, P.J. (1980): Anatomy of the microvasculature of the tibial diaphysis of the adult dog. Journal of Bone & Joint Surgery 62: 1362-1369.
  14. Nelson, G.E., Kelly, P.J., Peterson, L.F.A., and Janes, J.M. (1960): Blood supply of the human tibia. Journal of Bone & Joint Surgery 42A: 625-635.
  15. Skawina, A., Litwin, J.A, Gorzyca, J., and Miodonski, A.J. (1994): The vascular system of human fetal long bones: a scanning electron microscope study of corrosion casts. Journal of Anatomy 185: 369-376.
  16. Trias, A., and Fery, A. (1979): Cortical circulation of long bones. Journal of Bone & Joint Surgery 61A: 1052-1059.
  17. Trueta, J. Studies of the development and decay of the human frame. London, Heinemann, 1968.

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Fig. 1 : A photograph of the anterior aspect of thigh showing the four perforators (PT) originating from the profunda femoris (P). Nutrient arteries (n1, n2) are seen supplying the femur bone (Fb). AL : Adductor longus; F : Femoral artery.

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Fig . 2 Dissected specimen of the anterior surface of the thighshowing the four perforators (PT) originating from the profundafemoris artery (P) and piercing the adductor magnus (AM). Anutrient artery (n) is seen arising from the second perforator (PT2). A periosteal branch (>>) from the terminal part of the profundafemoris artery (P) is seen crossing the anterior aspect of thefemur. F : Femoral artery ; L : lateral circumflex femoral artery.

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Fig. 3 : A dissected femoral diaphysis (Fb) showing the femoral artery (F) and its branches, the profunda femoris (P), the medial (M) and the lateral circumflex femoral artery (L). The lateral circumflex femoral artery (L) is seen arising from the femoral artery and giving its ascending (a), transverse (t) and descending (d) branches.

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Fig. 4 : Posterior view of the upper femoral bone (Fb) showing a single nutrient foramen (N) at the upper end of linea aspera.

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Fig. 5 : An angiogram of the perfused femur (Fb) showing the femoral (F), profunda (P) and lateral circumflex femoral arteries (L) with its ascending (a) and descending (d) branches. It shows double nutrient arteries (n1, n2) arising from the first and second perforators. An anastomotic loop (¬) between the descending branch of the first nutrient artery and the ascending branch of the second one is seen.

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Fig. 6 : Angiogram of the perfused femur (Fb) showing double nutrient arteries (n1, n2) arising from the first and second perforators which are branches of profunda femoris (P) that originates from the femoral artery (F). There is no anastomotic loop between the two nutrient arteries.

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Fig. 7 : A transverse section from the human femur showing the outer part of the cortex near the periosteum. The vessels inside the lumen of the Haversian canal (H) is seen (Hematoxylin and eosin X 100).

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Fig. 8 : A transverse section from the human femur showing the outer part of the cortex near the periosteum. Vessels of Haversian canal (H) are seen (hematoxylin and eosin X 1000).

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Fig. 9 : Nutrient artery after entering the medullary portion of the human femur (hematoxylin and eosin X 100).

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Fig. 10 : A longitudinal section of the cortex. The perpendicular vascular system permeates the whole cortical thickness from the endosteum to the periosteum (hematoxylin and eosin X 200).

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Fig. 11 : A vascular tubelike vessel extending from the periosteal surface and entering the cortex. Its wall is composed solely of endothelium (hematoxylin and eosin X 100).

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