Nutrient foramina in the shafts of lower limb long bones: situation and number

Morphometric, morphologic and topographic evaluation of diaphyseal nutrient foramina of the femur

PURPOSE

Vascularization of bones is crucial for bone growth and repair. The nutrient artery, passing through the nutrient foramen, is key to bone blood supply, but its impact on fracture healing and complications is not fully understood. The study aims to investigate the morphology and location of the nutrient foramen in the femoral diaphysis and to understand its clinical implications for fractures.

METHODS

In this study, 88 adult dry femurs of unknown age and sex were examined. The characteristics of the nutrient foramina, including number, size, direction, and localization were evaluated. The foraminal index [(distance from foramen to proximal end of femur/total length of femur) × 100], was employed to categorize the regions [Region-I, 0-33.33; Region-II, 33.34-66.66; Region-III 66.67-100].

RESULTS

The majority of the femurs had one or two foramina (92.94%). Of the total number of nutrient foramina, 121 (97.58%) were directed towards the proximal end, while three (2.42%) were horizontal. The majority of foramina were detected in sizes 18G (34.67%) and 20G (27.42%). All nutrient foramina were found on the posterior surface of the femur and adjacent to linea aspera. Sixteen nutrient foramina were located (12.90%) in Region-I, 104 (83.87%) in Region-II, and 4 (3.23%) in Region-III.

CONCLUSIONS

The nutrient foramina were typically located in the middle third of femur, adjacent to linea aspera on the posterior surface of femur. This observation indicates that the anterior surface is safer for surgery, while caution is needed near the linea aspera on the posterior surface.

Sexual Dimorphism of the Nutrient Foramen of the Fibula and Its Importance in Vascularised Bone Grafting: A Descriptive Cross-Sectional Study

Background

Vascularised fibular bone grafting is widely used in many reconstructive surgeries to repair bony defects. It is very essential for the nutrient blood supply to be conserved in the vascular bone graft. Understanding the sexual differences of the fibular nutrient foramen can help operating surgeons make appropriate changes in their clinical methodologies according to the sex. The present study was done to evaluate the sexual dimorphism of fibular nutrient foramen and its clinical importance in the adult central Indian population.

Methods

This descriptive cross-sectional study was done on 136 dry adult central Indian human fibula bones of known sex (male: 68 and female: 68). The presence of nutrient foramen, their numbers, relation with fibular surfaces, and distance from the styloid process were assessed and were then clinically correlated.

Results

In males, single-nutrient foramen and double-nutrient foramina were seen in 92.65% and 7.35% of fibula, respectively. Whereas in females, single-nutrient foramen and double-nutrient foramina were seen in 95.59% and 4.41% of fibula, respectively. The position of the nutrient foramen and the fibular length showed significant sexual variation.

Conclusions

This study concludes that among both sexes, the single fibular nutrient foramen in the middle third segment was the most prevalent. Compared to the female population, the male population demonstrated a broader location of the nutrient foramen.

Radiographic Evaluation of Proximal Femoral Nutrient Arteries After Total Hip Arthroplasty With a Short Femoral Stem

BACKGROUND

The use of less invasive approaches and broach only press-fit femoral stems in total hip arthroplasty (THA) may increase the risk for periprosthetic fracture. Proximal femoral nutrient arteries (FNAs) can be mistaken for fractures after THA. Description of FNAs in relation to THA implants is important to better distinguish between FNAs and periprosthetic fractures. The purpose of this study was to evaluate the frequency, location, and morphology of FNAs visible on radiographs after primary THA with a broach-only stem design.

METHODS

A retrospective cohort study was performed. Patients ≥18 years who underwent primary THA with a cementless, broach-only stem, and had 6-week follow-up radiographs were included. Patient demographics were recorded. Anteroposterior and lateral radiographs at 6 weeks postoperatively were assessed for the presence of FNA; if present, measurements of vessel location and morphology were obtained. Descriptive statistics were reported. Univariate and multivariate analyses were performed to identify patient characteristics associated with the radiographic presence of perforating vessel.

RESULTS

A total of 378 hips were evaluated (332 patients). FNAs were identified radiographically in 46.3% (175 hips/378 hips). All FNAs were found to be unicortical, most observed in the posterior and lateral cortices. Gender, age, BMI, stem position, and surgical approach did not correlate with a presence of FNA on radiograph.

CONCLUSION

FNA was seen on postoperative radiographs in 46% of patients after THA with one broach-only stem design. The FNA was unicortical and present on preoperative radiographs. Surgeons should consider this when evaluating postoperative radiographs.

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

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.

Three-dimensional topography of scapular nutrient foramina

Purpose

The aim of this study is to describe the number and location of the nutrient foramina in human scapulae which can minimize blood loss during surgery.

Methods

30 cadaveric scapulae were macerated to denude the skeletal tissue. The nutrient foramina of 0.51 mm and larger were identified and labeled by adhering glass beads. CT scans of these scapulae were segmented resulting in a surface model of each scapula and the location of the labeled nutrient foramina. All scapulae were scaled to the same size projecting the nutrient foramina onto one representative scapular model.

Results

Average number of nutrient foramina per scapula was 5.3 (0–10). The most common location was in the supraspinous fossa (29.7%). On the costal surface of the scapula, most nutrient foramina were found directly inferior to the suprascapular notch. On the posterior surface, the nutrient foramina were identified under the spine of the scapula in a somewhat similar fashion as those on the costal surface. Nutrient foramina were least present in the peri-glenoid area.

Conclusion

Ninety percent of scapulae have more than one nutrient foramen. They are located in specific areas, on both the posterior and costal surface.

What about limb long bone nutrient canal(s)? - a 3D investigation in mammals

The nutrient arteries, located in the long bone diaphysis, are the major blood supply to long bones, especially during the early phases of growth and ossification. Their intersection with the central axis of the medullary area corresponds to the ossification center, and their opening on the outer bone surface to the nutrient foramen. Nutrient arteries/foramen have essentially been analyzed in humans, and only to a much lesser extent in a few mammals. Some studies have taken measurements of the nutrient foramen; others have investigated the shape and orientation of the nutrient canals, although only partially. No studies have analyzed the nutrient canal in three dimensions inside the bone and the relationships between nutrient foramen, nutrient canal, growth, and physiology require further investigation. The current study proposes to investigate in three dimensions the shape of the nutrient canal in stylopod bones of various mammals. Qualitative and quantitative parameters are defined to discuss the diversity in, for example, morphology, orientation, and diameter encountered, resorting to two different datasets to maximize differences within mammals and then analyze variation within morphologically and phylogenetically closer taxa. This study highlights a strong intraspecific variation for various parameters, with limited biological signal, but also shows trends. It notably provides evidence that canals are generally more numerous and relatively thinner in less elongated bones. Moreover, it shows that the growth center is located distally in the humerus and proximally in the femur, and that the canals are essentially oriented towards the faster growing end, so that the nutrient foramen does not indicate the location of the growth center. This result seems general in mammals but cannot be generalized outside of Mammalia. Further analyses of the features of nutrient arteries in reptiles are required to make comparisons with the trends observed in mammals.

Differentiating Nutrient Artery Canals of the Femur versus Fracture Lines in Patients with Total Hip Arthroplasty on Plain Radiographs

BACKGROUND

Nutrient artery canals of the femur are often visible on plain radiographs as radiolucent lines which may mimic fracture lines. The purpose of this study was to distinguish nutrient artery canals from fracture lines on plain radiographs.

MATERIALS AND METHODS

Ninety-three patients (102 hips) with an average age of 65.6 years were included in the study. We retrospectively analyzed nutrient artery canals of the femur on pre and postoperative anteroposterior (AP) and cross-table lateral (CTL) hip radiographs in patients with cementless total hip arthroplasty. The shape, number, location, direction of obliquity, length of nutrient artery canal, and the distance between the tip of the greater trochanter and the proximal end of the nutrient artery canal were measured.

RESULTS

Nutrient artery canals were determined in 54 hips (53.0%) on preoperative radiographs. The numbers of nutrient artery canals were entirely found to be one for each hip. The nutrient artery canals of the femur were the most frequently seen in the cortex on CTL radiographs with 32 hips (31.4%), whereas nutrient artery canals were not seen at all in the cortex on AP radiographs. All nutrient artery canals in the cortex on CTL radiographs coursed upward obliquely. Comparing to fracture lines, nutrient artery canals show less radiolucency, smaller diameter, and blunted ends in both the cortex and medullary cavity, show sclerotic walls in the cortex and have the less straight course in the medullary cavity.

CONCLUSIONS

Based on the results of this study, there are clearly distinguishable differences between nutrient artery canals of the femur and fracture lines on plain radiographs.

Estudio anatómico de la vascularización peroneal y su importancia clínica para el injerto vascularizado de peroné

Introducción: Desde que Ueba utilizara por primera vez el injerto óseo vascularizado de peroné en 1973, esta técnica se ha usado con éxito como método de reconstrucción de múltiples tipos de defectos óseos. La correcta vascularización del injerto es clave para su supervivencia. El objetivo de este trabajo es describir la vascularización diafisaria y epifisaria proximal del peroné.

Material y método: Se utilizaron 12 especímenes de cadáver criopreservado inyectados con látex negro. Se procedió a su disección, seguida de una técnica de corrosión en solución alcalina para demostrar la distribución de la red vascular del peroné de forma precisa.

Resultados: Observamos que el peroné recibe su irrigación sobre todo de una abundante red de vasos periósticos en la diáfisis y en menor medida de la arteria nutricia. Apreciamos que la epífisis proximal presenta entre 2 y 6 ramos recurrentes, procedentes de las arterias tibial anterior y tronco tibioperoneo.

Conclusión: El aporte vascular perióstico de la diáfisis del peroné es el mayoritario, siendo limitada la vascularización a través de la arteria nutricia. En la epífisis proximal, la presencia de vasos recurrentes accesorios puede ser de relevancia durante la cirugía.

An Anatomical Study of the Nutrient Foramina of the Human Humeral Diaphysis

Background

Understanding the nutrient foramina is critical to clinical practice. An insult to the nutrient foramina can be caused by trauma and/or surgical dissection and lead to devascularization and bad outcomes. Few studies have looked at the humerus, and no studies have described relative information of humeral nutrient foramen related to anatomical structures that might be located by palpable landmarks. In this study, we analyzed the anatomical features of the nutrient foramina of the diaphyseal humerus and provide a discussion of clinical relevance.

Material/Methods

We dissected 19 cadavers and analyzed the relative positions of the foramina and surrounding muscles, and the number, direction, diameter, and location of the nutrient foramina. Foramina index and a new landmark index were used to calculate the location. We compared the data from both sides and the relationships between transverse and longitudinal locations, diameter and total length, and foramina index and landmark index were also analyzed.

Results

The humeri had one or two main nutrient foramina located in a small area between the coracobrachialis and brachial muscles and oriented toward the elbow. The mean diameter was 1.11±0.32 mm. The mean index and landmark index were 43.76±4.94% and 42.26±5.35%, respectively. There were no differences between sides in terms of diameter, length, or nutrient foramina index. There were no significant correlations between transverse and longitudinal locations or diameter and total length. The foramina index and landmark index showed strong positive correlation (r=0.994, p<0.0001).

Conclusions

Our study provides details about the nutrient foramina that will benefit clinicians who treat injuries and diseases of the humerus. Surgeons should be mindful of soft tissue in the foraminal area during surgical procedures.

A New Measurement Technique of the Characteristics of Nutrient Artery Canals in Tibias Using Materialise's Interactive Medical Image Control System Software

We established a novel measurement technique to evaluate the anatomic information of nutrient artery canals using Mimics (Materialise's Interactive Medical Image Control System) software, which will provide full knowledge of nutrient artery canals to assist in the diagnosis of longitudinal fractures of tibia and choosing an optimal therapy. Here we collected Digital Imaging and Communications in Medicine (DICOM) format of 199 patients hospitalized in our hospital. All three-dimensional models of tibia in Mimics were reconstructed. In 3-matic software, we marked five points in tibia which located at intercondylar eminence, tibia tuberosity, outer ostium, inner ostium, and bottom of medial malleolus. We then recorded Z-coordinates values of the five points and performed statistical analysis. Our results indicate that foramen was found to be absent in 9 (2.3%) tibias, and 379 (95.2%) tibias had single nutrient foramen. The double foramina was observed in 10 (2.5%) tibias. The mean of tibia length was 358 ± 22 mm. The mean foraminal index was 31.8%  ± 3%. The mean distance between tibial tuberosity and foramen (TFD) is 66 ± 12 mm. Foraminal index has significant positive correlation with TFD (r = 0.721, P < 0.01). Length of nutrient artery canals has significant negative correlation with TFD (r = -0.340, P < 0.01) and has significant negative correlation with foraminal index (r = -0.541, P < 0.01).

The demonstration of the number, course, and the location of nutrient artery canals of the femur by multidetector computed tomography

PURPOSE

The aim of this study was to evaluate the number, course, width and location of nutrient artery canals of the femur by using multidetector computed tomography (MDCT).

METHODS

Sixty-six adult (35 right and 31 left) dry femurs were included in this study and scanned by MDCT. Nutrient artery canals were evaluated on the multi-planar reformatted and volume rendered images which were reproduced on the basis of axial images.

RESULTS

The median value of nutrient artery canals was two (minimum 1 and maximum 6). We determined that there was a negative correlation between the number of nutrient canals and the canal diameters. The outer ostia of the nutrient artery canals were most frequently located at the middle third segment of femoral diaphysis (65%). While the vast majority of the canals were showing upward courses (95%), only a few canals were having transverse (3%) or downward (2%) courses. Most encountered location of outer ostia of the canals according to linea aspera was the medial lip of the linea aspera (44%). Various variations were demonstrated in the number, course, and location of nutrient artery canals using MDCT.

CONCLUSIONS

In conclusion, the knowledge of the topographic features of the nutrient artery canals may be useful in various clinical implications such as bone grafting or radiologic evaluation for the fracture lines.

Morphological and topographical anatomy of nutrient foramina in the lower limb long bones and its clinical importance

BACKGROUND

Knowledge regarding nutrient foramina of bones is useful in surgical procedures such as microvascular bone transfer in order to preserve the circulation. The objective of the present study was to study the morphology and topography of nutrient foramina and to determine the foraminal index of the lower limb long bones to provide detailed data on such features.

METHOD

The study comprised examination of 206 lower limb long bones which included femora, tibiae and fibulae. The nutrient foramina were identified analysed macroscopically and the foramen index calculated. Each bone was divided into five parts and topographical analysis was performed on each section.

RESULTS

Femora had single nutrient foramen in 47.7% of the cases, double foramen in 44.2% of the cases, triple in 3.5% of the cases and an absence of foramen in 4.6%. In the case of tibiae, 98.6% showed single foramen and in 1.4% of the cases, the foramen was absent. With respect to fibulae, 90.2% had single foramen and foramen was absent in 9.8%. The mean foraminal index was 38.9 for the femora, 32.5 for tibiae and 49.2 for fibulae. The majority (51.3%) of the foramina in the femora were located at the 2/5(th) part, 98.3% of the tibiae foramina at the 2/5(th) part and 60% of the fibulae at the 3/5(th) part.

CONCLUSION

The study provides information on the morphology and topography of nutrient foramina in lower limb long bones. The double foramina were more common in femur and rare in the tibia and fibula. The foramina of the femur and tibia were commonly observed at their upper part, whereas in the fibula they were present on the lower part. This knowledge of the nutrient foramina has to be kept in mind during surgical procedures.

Morphometric study of cricoid cartilages in Western India

BACKGROUND

It is important to determine the size and proportion of the larynx as such information is useful in procedures such as intubation, endoscopy and surgical manipulations. Recent interest in the cases of subglottic stenosis and postintubational stenosis of the lower respiratory tract has led to renewed interest in ascertaining the measurements of the various laryngeal cartilages. The aim of the present study was to collect morphometric data of cricoid cartilage from a regional population.

METHOD

Fifty laryngeal preparations from adult cadavers of Western India were assessed. Sections were prepared via dissection and the removed cricoid cartilages then measured and weighed.

RESULTS

The mean antero-posterior diameter (19.29±2.47) of the cricoid cartilage was greater than the average transverse diameter (18.33±2.26). The height of arch of cricoid cartilage was 6.54±1.23mm and height of lamina was 21.45±1.97mm. Mean weight of cricoid cartilage was 4.53±1.27grams. The shape of the cricoid cartilage was ovoid in 46% of cases, oval in 38%, pear shaped in 12% and narrow-oblong in 4% of cases.

CONCLUSION

Inter-subject variability in the dimensions of cricoid cartilages was observed. The large difference in almost all sizes and shapes of the cricoid cartilage makes it difficult to standardise the rigid stents used in these organs. Endotracheal tubes of the appropriate size should therefore be based on the measurements of individual patients. Clinicians should therefore be aware of morphological variations as they are of fundamental clinical importance.

Location, number and clinical significance of nutrient foramina in human long bones

Nutrient arteries, the main blood supply to long bones, are particularly important during the active growth period, as well as during the early phases of ossification. In the present study, 569 adult human long bones of the upper (101 humeri, 93 radii, 102 ulnae) and lower (100 femora, 100 tibiae, 73 fibulae) limbs were investigated to determine the number and location of their nutrient foramina. For each bone, a foraminal index was calculated giving the location of the nutrient foramen in relation to its proximal end. In the upper limb, foramina were located on the diaphysis 15-69% of the overall length of the humerus, 22-46% for the radius and 27-54% for the ulna. In the lower limb, foramina were located on the diaphysis 29-69% of the overall length of the femur, 27-63% for the tibia and 26-83% for the fibula. In addition, the number and the distribution of the foramina in relation to specific regions/surfaces of the diaphysis were identified. This study provides additional and important information on the location and number of nutrient foramina in the long bones of the upper and lower limbs in the Turkish Caucasian population.

Incidence of mylohyoid bridging in 13th century Byzantine mandibles

Mylohyoid bridging on the mandible is a hyperostotic variation considered as one of the cranial non-metric characteristics. Most researchers have indicated that such non-quantitative traits can be used for the investigation of population history and these traits show differences according to societies. In the present study, we investigated the incidence of mylohyoid groove bridging on 89 half-mandibles (48 right sides, 41 left sides; 39 complete mandibles, nine right and two left half-mandibles) from the Byzantine period, dated approximately eight centuries back. We observed that the incidence of mylohyoid bridging was 8.9% for the Byzantine mandibles with no side predilection. The incidence of bridging observed in the present sample was compared with those of earlier studies. Mylohyoid bridging may be useful as a non-metric feature in population studies when used in combination with other characteristics.

The medial malleolar approach for arthrodesis of the ankle: a report of 13 cases

A series of thirteen patients that had primary fusion of the ankle joint through an isolated medial approach is presented. The technique involves transection of the medial malleolus for access to the articular surfaces, rather than the traditional transfibular approach. The medial malleolus was replaced in all cases, preserving the deltoid ligament. Union was achieved in 12 of 13 patients. The technique is described in detail and the advantages of this approach are discussed with respect to preservation of the blood supply to the talus and tibia.

Diaphyseal nutrient foramina in the first metatarsals in normal and hallux valgus feet: location and surgical implications

We examined 47 first metatarsals from amputated lower limbs to determine the situation of the main diaphyseal nutrient foramina (NFs) in normal and hallux valgus feet. All the NFs, excepting one, were in a plantar-fibular location. The NF situation was analyzed by means of the foraminal index and three minimum distances: from NF to proximal extremity, from NF to the shaft dorsal face (NFDS) and from NF to the border of the cartilaginous coating of the metatarsal head. We found a constant location of the NF in the middle of the total metatarsal length and sexual dimorphism in NFDS (lower in females); there were no differences by side, neither by digital or metatarsal types, nor between normal and hallux valgus types. Vascular complications in some osteotomies are discussed. In the surgical design, the NF situation can be estimated from either the total or physiological metatarsal length by means of the corresponding equations as reported here.

The arterial supply of the ankle joint and its importance for the operative fracture treatment

The operative exposure of a fracture causes disturbances in the blood supply, which may lead to a prolonged healing process or even to bone necrosis, especially when using the complex and complicated methods of osteosynthesis at the ankle. In order to damage the supplying vessels as little as possible, position, direction and penetration of the bone arteries of the talocrural joint were examined by corrosion preparation. The tibial nutrient artery arises from the posterior tibial artery or from the popliteal artery and penetrates constantly from posterior at the level of the proximal third. The fibular nutrient artery, coming from the peroneal artery, penetrates more distally from medial into the middle third of the diaphysis. In one specimen it did not exist at all. Distal tibia and fibula are supplied by the perimalleolar arterial ring, which is connected with the three arteries of the leg. The talus is supplied by numerous very small vessels, which are provided with extraosseous anastomoses and penetrate the whole non-articular surface. Implications for the operation will be explained.

A study of the nutrient foramina of lower limb long bones

In this study a total of 269 adult lower limb long bones were examined to determine the number and location of the nutrient foramina in the shafts of bones. The mean of foraminal index was 48.82 for femur, 33.17 for tibia, and 47.82 for fibula. The number of foramina noted were: two on the linea aspera in the middle third of the femur, one on the posterior surface of the upper third of the tibia, and one on the posterior surface of the middle third of the fibula.