Deep Circumflex Iliac Artery-vascularized Iliac Bone Graft for Femoral Head Osteonecrosis: Computed Tomography Anatomical Study

Abstract

Background: Deep circumflex iliac artery (DCIA)-vascularized iliac graft transposition is a method for treating femoral head osteonecrosis but with inconsistent efficacy. We aim to improve the method of this surgery by recommending the optimal location of the iliac pedicle to satisfy the vascular length for transposition and the blood supply of the vascularized iliac graft.

Methods: The DCIA and its surrounding tissues were assessed on computed tomography angiography images for 100 sides (left and right) of 50 patients. The length of the vascular pedicle required for transposition and the length of the pedicle at different iliac spine positions were compared. The diameter and cross-sectional area of the DCIA and the distance between the DCIA and iliac spine were measured at different points to assess blood supply. We also compared differences in sex and left-right position.

Results: The diameter and cross-sectional area of the DCIA gradually decreased after crossing the anterior superior iliac spine (ASIS), and it approached the iliac bone. However, when the DCIA was 4 cm behind the ASIS (54 sides, 54%), it coursed posteriorly and superiorly away from the iliac spine. The vascular length of the pedicle was insufficient to transpose the vascularized iliac graft to the desired position when it was within 1 cm of the ASIS. The vascular length requirement was satisfied, and the blood supply was sufficient when the pedicle was positioned at 2 or 3 cm.

Conclusion: To obtain a satisfactory pedicle length and sufficient blood supply, the DCIA pedicle of the vascularized iliac graft should be placed 2 to 3 cm behind the ASIS. The dissection of DCIA has slight differences in sex and left-right position due to anatomical differences.

Fig. 1

Display of workstation interface. (A , B) were measured in 3D volume reconstruction, and (C) was measured under curved planar reformation. ASIS, anterior superior iliac spine; DCIA, deep circumflex iliac artery.

Fig. 2

Fifty-four sides (54%) of the DCIA coursed posteriorly and superiorly away from the iliac spine at 4 cm behind the ASIS. ASIS, anterior superior iliac spine; DCIA, deep circumflex iliac artery.

Fig. 3

Three-dimensional (3D) model of the relationship between the DCIA and the ilium drawn by software. The data were based on the mean value of the diameter of the DCIA and the quantitative relationship between the DCIA and the ilium. (A) Main view. (B) Side view. (C) Top view. ASIS, anterior superior iliac spine; DCIA, deep circumflex iliac artery.

Fig. 4

Diameter and cross-sectional area changes of the DCIA. ASIS, anterior superior iliac spine; CSA, cross-sectional area; DCIA, deep circumflex iliac artery.

Fig. 5

Changes in the distance between the DCIA, the iliac spine, and the internal iliac table. ASIS, anterior superior iliac spine; DCIA, deep circumflex iliac artery.

Fig. 6

A 29-year-old male patient, taking Medrol (methylprednisolone tablets) for 16 months because of the neuromyelitis optica, was diagnosed as ONFH (ARCOII). He was too young to be considered for a total hip arthroplasty and he also resisted it. Therefore, a DCIA-vascularized iliac bone graft transposition surgery was performed. (A) The pedicle of the DCIA-vascularized iliac bone graft was located 2.5 cm behind the ASIS along the iliac crest, so a long vascular pedicle measuring 90 mm was harvested. (B) Fenestration at the femoral head–neck junction. The necrotic bone was completely scraped, and space for transposition was reserved. (C) Establishment of the tunnel for vascular pedicle. The tunnel should have a sufficient width to allow easy passage of the index finger. (D) The tension of vascular pedicle was relaxed after transposition. The DCIA was lifted by a hemostatic forceps to show the relaxation. ARCO, Association Research Circulation Osseous; ASIS, anterior superior iliac spine; DCIA, deep circumflex iliac artery; ONFH, osteonecrosis of the femoral head.

Fig. 7

Diagram of the operative process. Transposition to the femoral head with the vascular pedicle located 2 to 3 cm behind the ASIS along the iliac crest. ASIS, anterior superior iliac spine.