Intraarticular isolation of the femoral head and neck makes it highly dependent on its tenuous vascular supply. Its susceptibility to circulatory compromise is an ongoing source of concern to physicians who treat hip pathology. Ischemic insult followed by avascular necrosis (AVN) of the femoral head, similar to other forms of osteonecrosis, has been clearly linked to certain disease states and types of exposure although it is less clearly associated with others and often purely idiopathic.10 AVN has been associated with previous trauma including fracture and dislocation and may occur iatrogenically in association with surgical procedures that violate the vascular pattern.
branches of the medullary artery from the shaft of the femur; and (3) the artery of the ligamentum teres from the posterior division of the obturator artery.
The poorly defined and uncertain nature of AVN is reflected in the myriad surgical procedures that have been described in its management, none of which has proven to be superior, and few of which have even been shown to be truly effective in altering the natural course of the process.11
Arterial blood supply to the femoral head is achieved through an anastomosis of three sets of arteries (Figure 6.13). The principal vessels ascend in the synovial retinaculum, which is a reflection of the lig-amentous capsule onto the neck of the femur. These vessels arise mainly posterior superiorly and posterior inferiorly from the medial circumflex femoral artery, which is supplemented to a lesser extent from the lateral circumflex femoral artery. These vessels anastomose with the terminal branches of the medullary artery from the shaft of the femur. The third source is the anastomosis within the femoral head from the artery of the ligamentum teres, which arises from a posterior division of the obturator artery. This vessel may persist with advanced age, but in approximately 20% of the population it never develops.
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