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A STUDY OF ADULT HUMAN FEMORAL DIAPHYSEAL NUTRIENT FORAMINA.

BACKGROUND

Bones are dynamic structures that undergo constant change & remodelling in response to ever-changing environment. They have the ability to regenerate without scarring. Adequate blood supply is necessary for growth of the bones and their mutability in response to changing environment. Antonie Van Leeuwenhoek, [1] observed many little holes on tibia extending from cortex to medulla like as small pipes going long ways. For a bone the blood supply is mainly through periosteal vessels, nutrient arteries and their interosseous medullary branches. [2] The nutrient artery enters the bone through an opening called nutrient foramen and travels via nutrient canal into the marrow cavity where it ramifies. Due to the rapid growth of one end of bone than the other the nutrient canal becomes oblique with respect to long axis of the bone. This was first reported by Berard. [3] He stated that nutrient foramina were directed towards elbow in upper limb and away from the knee in lower limb.

Femur is the proximal weight bearing bone of the lower limb. Stress fractures are relatively common in the area of nutrient foramen.

As femur is a weight bearing bone fracture of its shaft ends in severe deformity, so careful evaluation and correct treatment needed. [4] The details of nutrient foramen help the surgeons to avoid damage to nutrient vessels during operations.

MATERIALS AND METHODS

This Descriptive study of the present study consists of 100 cleaned and dried human adult femora, Hepburn Osteometric board, sliding calipers, hand lens, stiff wire and 21-gauge needle. They were obtained from the Department of Anatomy, Guntur Medical College, Guntur and Osmania Medical College, Hyderabad.

Bones without any abnormalities were selected for the present study. Parameters like age & sex were not considered.

Each femur was observed by using a magnifying lens for nutrient foramen on the shaft. Nutrient foramen was identified by its specific features like elevated margins and distinct groove proximal to it. Only well-defined foramina on the diaphysis were accepted. Foramina at the ends of the bone were ignored.

Parameters Observed in Each Femur

1. Total Length of Bone

The maximum length of each bone was measured using Hepburn Osteometric board. The total length of femur was determined by measuring the distance between the most proximal part of the head to the distal most part of the medial condyle.

2. Number of Nutrient Foramina

All femora were observed for the number of nutrient foramina in each bone.

3. Location of Nutrient Foramina

The shaft of a long bone consists of three surfaces separated by three borders. The borders are medial, lateral and posterior. The surface between medial and lateral borders is anterior surface, between medial and posterior borders is medial surface and between lateral and posterior borders is lateral surface. The posterior border in the middle third of the shaft is represented by a prominent crest, the linea aspera. The two lips of the linea aspera diverge to enclose posterior surface in the upper third and popliteal surface in the lower third of the shaft.

4. Distance of Nutrient Foramina From Upper End of Bone

It is measured from the most proximal part of the head of the femur to the nutrient foramen by sliding calipers.

5. Position

a. Calculation of Foraminal Index:

* Position of nutrient foramen was determined by calculating Foraminal Index (FI)

* FI = (DU/TL) x 100 (Hughes [5]).

* DU = distance from upper end of head of the femur to the nutrient foramen

* TL = total length of the bone.

b. Subdivisions of Position of Foramina Based on FI:

* Proximal Third--FI up to 33.33.

* Middle Third--FI from 33.34 to 66.66.

* Distal Third--FI more than 66.66.

6. Direction and Obliquity

A fine stiff wire was used to observe the direction of the nutrient foramen and obliquity of the nutrient canal.

RESULTS

This study was conducted in 100 human femora.

In all femora observed, the direction of nutrient foramina is upwards, i.e. away from the knee. No difference in the obliquity of the nutrient canal, whether in the center of the bone or nearer to the ends.

DISCUSSION

In the present study, femur found to have variable number of nutrient foramina ranging from one to three. 52% of the femora have single, 44% have double and 1% have 3 nutrient foramina. Absence of nutrient foramen was observed in 3% of femora. These results are similar to the study of Lutken P [6], Sharma M et al, [7] Bhatnager S et al. [8] Some authors like Kizilkanat E et al [9] {75%}, Gupta AK et al [10] {71%}, Vinay G et al [11] {66.7%} observed higher percentage of single nutrient foramen than that of present study. Few authors like Mysorekar VR, [12] Gupta RK et al, [13] Bridgeman G et al [14] observed a little higher percentage of femora with double nutrient foramina than femora with single nutrient foramen. Gumusburun E et al, [15] Sendemir E et al [16] observed femur with 6 to 9 nutrient foramina. Mysorekar VR, [12] Bridgeman G et al, [14] Motabagani, [17] Gupta RK et al, [13] Sharma M et al [7] reported femur having no nutrient foramen.

Observed by Different Authors

In this study 55.2% of the nutrient foramina were observed on linea aspera and its lips, 22.4% on medial surface. It correlates with the study of Gupta RK et al. [13] But Gupta RK et al [13] also observed 25.6% of nutrient foramina on posterior surface, which is not seen in this study. Many authors reported that there is no nutrient foramen on anterior surface. But Sendemir E et al [16] examined 7.1% on the anterior surface. Malukar O et al [18] examined 4.5% on the anterior surface. Sendemir E et al [16] and Deepa Bhat, [19] Lutken P [6], Longia GS et al [20] observed a higher percentage of nutrient foramina on linea aspera and its lips. Gupta AK et al [10] observed 58.8% of nutrient foramina on lateral surface.

In this study most of the nutrient foramina were observed in middle third of the shaft similar to most of the other studies. No femur with nutrient foramen in distal third was observed. Mysorekar VR [12], Gupta RK et al [13] observed most of the NF in 3/5th and 4/5th of the shaft of femora. Lutken P [6] and Forriol CF et al [21] stated nutrient foramina were close to hip joint. Kumar, R. et al [22] reported 48% of nutrient foramina in proximal third and 52% in middle third. Most of the authors do not found nutrient foramen on distal third. Bhatnager S et al [8] found 1.17% of femur with nutrient foramen on distal third. Mysorekar VR [12] found 1.4% on distal 1/5Th.

In the present study all nutrient foramina were directed proximally away from the knee. Similar observations were reported by many authors. Lutken P [6]--1%, Longia GS et al [20]--0.5%, Vinay G et al [11]--1.3% reported nutrient foramina directed distally. Hughes H [5] stated that anomalous canals were found frequently in the femur which might be the cause of later findings.

CONCLUSION

In femur, single nutrient foramen was little more commonly observed than double nutrient foramina. Most nutrient foramina were observed in middle third of the bone that too on linea aspera. All foramina are directed proximally.

Detailed study of nutrient foramen is important clinically, especially in orthopaedic surgical procedures like vascularized bone microsurgery, non-unions, bone grafting, intramedullary reaming and plating. Appropriate understanding of extraosseous vascular supply of bones along with careful planning before surgeries is important for successful outcome.

The findings of the present study on nutrient foramen add to the information from the studies in the past.

REFERENCES

[1] Leeuwenhoek N, Cross AR, Ifju PG, et al. Understanding stress concentration about a nutrient foramen. J Biomech 2003;36(10):1511-21.

[2] Hollinshead HW. Anatomy for surgeons. Vol. 3. North America: Hobber and Harper 1958: p. 5, 664, 660.

[3] Berard A. 'Memoire Sur Le Rapport Qui Existe Entre La Direction Des Conduits Nourriciers Des Os Longs Et L'ordre Suivant Lequel Les Epiphyses See Soudent Au Corps De L'os.' Archives Generales De Medicine Series 2, 7, 176-183, 1835.

[4] Ramey EE Jr. Femoral shaft fractures--a study of closed reduction and open treatment. Calif Med 1960;92(2):150-4.

[5] Hughes H. The factors determining the direction of the canal for the nutrient artery in the long bones of mammals and birds. Acta Anat (Basel) 1952;15(3):261-80.

[6] Lutken P. Investigation into the position of the nutrient foramina and the direction of the vessel canals in the shafts of the humerus and femur in man. Acta Anat (Basel) 1950;9(1-2):57-68.

[7] Sharma M, Prashar R, Sharma T, et al. Morphological variations of nutrient foramina in lower limb long bones. Int J Med and Dent Sci 2015;4(2):802-8.

[8] Bhatnager S, Deshwal AK, Tripathi A. Nutrient foramina in the upper and lower limb long bones: a morphometric study in bones of Western Uttar Pradesh. International Journal of Scientific Research 2014;3(1):301-3.

[9] Kizilkanat E, Boyan N, Ozsahin ET, et al. Location, number and clinical significance of nutrient foramina in human long bones. Ann Anat 2007;189(1):87-95.

[10] Gupta AK, Ambekar MN. Study of nutrient foramina in adult human femur bones. Journal of Nepalgunj Medical College 2016;14(2):44-9.

[11] Vinay G, Gowri MSR. Anatomical study of the nutrient foramen of lower limb long bones in South Indian population. Indian Journal of Clinical Anatomy and Physiology 2017;4(2):222-4.

[12] Mysorekar VR. Diaphysial nutrient foramina in human long bones. J Anat 1967;101(Pt 4):813-22.

[13] Gupta RK, Gupta AK. A study of diaphyseal nutrient foramina in human femur. Int J Res Med Sci 2016;4(3):706-12.

[14] Bridgeman G, Brookes M. Blood supply to the human femoral diaphysis in youth and senescence. J Anat 1996;188(Pt 3):611-21.

[15] Gumusburun E, Yucel F, Ozkan Y, et al. A study of the nutrient foramina of lower limb long bones. Surg Radiol Anat 1994;16(4):409-12.

[16] Sendemir E, Cimen A. Nutrient foramina in the shafts of lower limb long bones: situation and number. Surg Radiol Anat 1991;13(2):105-8.

[17] Al-Motabagani MAH. The arterial architecture of the human femoral diaphysis. J Anat Soc India 2002;51(1):27-31.

[18] Malukar O, Joshi H. Diaphysial nutrient foramina in long bones and miniature long bones. NJIRM 2011;2(2):23-6.

[19] Deepa B. Study of nutrient foramina of adult femora with its correlation to length of the bone. Int J Anat Res 2015;3(4):1573-7.

[20] Longia GS, Ajmani ML, Saxena SK, et al. Study of diaphyseal nutrient foramina in human long bones. Acta Anat (Basel) 1980;107(4):399-406.

[21] Forriol CF, Gomez PL, Gianonatti AM, et al. A study of the nutrient foramina in human long bones. Surg Radiol Anat 1987;9(3):251-5.

[22] Kumar R, Mandloi RS, Singh AK, et al. Analytical and morphometric study of nutrient foramina of femur in Rohilkhand region. Innovative Journal Medical & Health Science 2013;3:52-4.

Pratyusha Challa (1), D. Madhavi (2)

(1) Assistant Professor, Department of Anatomy, Guntur Medical College, Guntur, Andhra Pradesh, India.

(2) Associate Professor, Department of Anatomy, Guntur Medical College, Guntur, Andhra Pradesh, India.

'Financial or Other Competing Interest': None.

Submission 30-01-2019, Peer Review 09-03-2019, Acceptance 16-03-2019, Published 25-03-2019.

Corresponding Author: Dr. D. Madhavi, 4-4-136/3, 7th Line, Chandramouli Nagar, Guntur-522007, Andhra Pradesh, India.

E-mail: madhavikondepudi@gmail.com

DOI: 10.14260/jemds/2019/197

Caption: Figure 1. [A] Femur Showing Double Nutrient Foramina, both on Linea Aspera of The Shaft, [B] Both Foramina are Directing Upwards
Table 1. General Observations About the Nutrient
Foramen in 100 Femora

Observation                               Range      Mean

Total Length in Centimeters              36.1-48     42.28

Distance from Upper End of Femur to      14-31.5     20.5
Nutrient Foramen in Centimeters

Foraminal Index                          31-66.6      49

Table 2. Observations About the Number of Nutrient
Foramina in 100 Femora

Number of Nutrient Foramen      Number of Bones     %

Absent                                 3           3%
One                                   52           52%
Two                                   44           44%
Three                                  1           1%

Table 3. Observations About the Location of Nutrient
Foramen in 100 Femora

Location of Nutrient Foramen      Number of Bones     %

Linea Aspera                            79          55.2%
Medial Surface                          32          22.4%
Lateral Surface                         31          21.7%
Medial Supracondylar Ridge               1          0.7%

Table 4. Observations About the Position of Nutrient
Foramen in 100 Femora According to Foraminal Index
{FI}.

Position of Nutrient         Number of    Percentage
Foramen According to FI        Bones

Proximal 1/3rd                  25          17.5%
Middle 1/3rd                    118         82.5%
Distal 1/3rd                     0            0%

Table 5. Showing Comparison of Number of Nutrient Foramina {NF} in
Femora

        Author            No. of Femora   % of Femora    % of Femora
                            Observed      without NF    with Single NF

Lutken P [6]                   410            --             53.4
Gupta RK et al [13]            312             0             44.6
Kizilkanat E et al [9]         100             0              75
Vinay G et al [11]             90              0             66.7
Gupta AK et al [10]            100             3              71
Mysorekar VR [12]              180            3.3             45
Bridgeman G et al [14]         109           2.75           44.03
Sharma M et al [7]             50              2              54
Present study                  100             3              52

        Author             % of Femora     % of Femora with   Mean No.
                          with Double NF     3 or more NF      of NF

Lutken P [6]                   44.4              2.2            1.49
Gupta RK et al [13]            49.4              6.1            1.64
Kizilkanat E et al [9]          25                0             1.24
Vinay G et al [11]             33.3               0             1.33
Gupta AK et al [10]             25                1             1.24
Mysorekar VR [12]               50               1.6            1.5
Bridgeman G et al [14]        53.21               0             1.5
Sharma M et al [7]              42                2             1.44
Present study                   44                1             1.43
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Title Annotation:Original Research Article
Author:Challa, Pratyusha; Madhavi, D.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Mar 25, 2019
Words:2302
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