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    Investigating the Femoral Head’s Vascular Supply in Post-SUFE Patients

    Is the vascular anatomy of the proximal femoral epiphysis different in patients with healed slipped upper femoral epiphysis than in patient without this deformity? A recently published paper seeks to answer this question.

    Authors

    Emily Pflug, MD, and Pablo Castañeda, MD

    Article

    Shore BJ, Mardam-Bey SW, Kim YJ, et al. Vascular Supply to the Femoral Head in Patients with Healed Slipped Capital Femoral EpiphysisJ Pediatr Orthop. 2020;40(1):e53‐e57.

    Summary

    With the increased popularity of arthroscopic and open surgery to treat femoroacetabular impingement (FAI) for the sequela of slipped upper femoral epiphysis (SUFE), it would seem to be crucial to understand the vascular anatomy supplying the femoral head. Although previous studies have shown that the medial femoral circumflex artery typically provides this blood supply, it is hypothesized that the vascular supply is different in patients who have sustained a SUFE that has now healed.

    In this paper, Shore et al used high-resolution, 3-dimensional, contrast-enhanced MRI to examine the number of lateral epiphyseal arteries inserted into the femoral head of adults with healed SUFE compared with femoral head arteries in a matched control group. The SUFE group included 17 patients (18 hips) with a diagnosis of healed SUFE (13 stable, 5 unstable). The SUFE patients had been treated with in situ fixation and subsequent screw removal.

    Fourteen of the 18 hips in the SUFE group had 2 or fewer arteries, with 5 hips having only 1 identifiable artery. The minimum number of arteries identified in the control group was 4. The highest concentration of vessels was found in the superior posterior aspect of the femoral neck, from the 11 o’clock to the 2 o’clock position. Patients with a healed SUFE had fewer vessels in this region than the controls.

    Shore et al found that the lateral epiphyseal arteries are in an expected position in patients with SUFE. However, the number of vessels that supply the femoral head is significantly decreased compared with a control group.

    Clinical Relevance

    This study is significant for any surgeon who treats a post-SUFE deformity by a surgical procedure that requires dissection of a retinacular flap or during arthroscopic FAI surgery. Caution must be exercised to avoid injury to the lateral retinacular vessels, as there is significantly less redundancy in the vascular supply to the femoral head in patients with a healed SUFE.

    Isolated cases of avascular necrosis (AVN) of the femoral head after hip arthroscopy have been reported. [1,2] Although causality is difficult to infer, anatomic studies like the one by Shore et al can help surgeons understand the importance of protecting the vessels when considering an arthroscopic approach.

    The vascular anatomy in patients with sequelae of Legg-Calvé-Perthes disease has previously been identified. [3] However, given the much higher prevalence of SUFE, the new paper by Shore et al is fundamental to understanding the complex nature of the arteries that supply the proximal femoral epiphysis. These findings apply to both arthroscopic and open procedures. [4]

    The safe vascular zones for hip arthroscopy have been described, [5] but not with particular emphasis on post-SUFE deformity, which is a frequent cause of FAI and subsequent impingement. Impingement after SUFE leads to early arthritis, [6] and as techniques evolve to restore the anatomy, their safety must first be established. The paper by Shore et al is a huge step forward in providing a safe and reliable way to progress science.

    Author Information

    Emily Pflug, MD, is a resident physician at NYU Langone Orthopedic Hospital, New York, New York. Pablo Castañeda, MD, is The Elly and Steven Hammerman Professor of Orthopaedic Surgery at NYU School of Medicine and Division Chief, Pediatric Orthopaedic Surgery, at NYU Langone Health/Hassenfeld Children’s Hospital, New York, New York.

    Disclosures: The authors have no disclosures relevant to this article.

    References

    1. Scher DL, Belmont PJ Jr, Owens BD. Case report: Osteonecrosis of the femoral head after hip arthroscopy. Clin Orthop Relat Res. 2010;468(11):3121‐3125
    2. Sener N, Gogus A, Akman S, Hamzaoglu A. Avascular necrosis of the femoral head after hip arthroscopy. Hip Int. 2011;21(5):623‐626. 
    3. Shore BJ, Millis MB, Kim YJ. Vascular safe zones for surgical dislocation in children with healed Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 2012;94(8):721‐727. 
    4. Novais EN. Application of the surgical dislocation approach to residual hip deformity secondary to Legg-Calvé-Perthes disease. J Pediatr Orthop. 2013;33 Suppl 1:S62‐S69. 
    5. McCormick F, Kleweno CP, Kim YJ, Martin SD. Vascular safe zones in hip arthroscopy. Am J Sports Med. 2011;39 Suppl:64S‐71S. 
    6. Castañeda P, Ponce C, Villareal G, Vidal C. The natural history of osteoarthritis after a slipped capital femoral epiphysis/the pistol grip deformity. J Pediatr Orthop. 2013;33 Suppl 1:S76‐S82.