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An analytical study of number, position, size and direction of nutrient foramina of femur.

Introduction

Bone is a living tissue and similar to any other living tissue in the body. It requires nutrition for its growth and development. This is provided by continuous blood supply to the bone. [1] The blood supply to the femoral diaphysis is provided by one or two nutrient arteries arising from the profunda femoris artery branch of femoral artery. [2] It was reported that the profunda femoris artery can be used in femoral diaphysis transplant surgeries. So the number and location of nutrient artery has to be considered in the cases of graft surgeries. Grafts with good vascular supply will certainly have better results. [3] The nutrient artery enters obliquely through a nutrient foramen. [4, 5] This foramen, in the majority of cases is directed away from the growing end, hence it is popularly stated that foramina "seek the elbow and flee from the knee." [6, 7] This is because the one end of the limb bone grows faster than the other. [8, 9] Though the foramina are directed away from the growing end, their topography might vary at the non-growing end. [10] So the topographical anatomy of the nutrient foramina may be a worth study. The topographical knowledge of these foramina is useful in certain operative procedures such as in cases of tumour resection, traumas, joint replacement therapy, fracture repair, bone grafts, and vascularized bone microsurgery. [11]

Materials and Methods

This study was conducted in the Department of Anatomy, S.S. Medical College, Rewa Madhya Pradesh, India. A total of 100 adult human cleaned and dried femora (50 right sides and 50 left sides) collected from Department of Anatomy and Department of Forensic Medicine. All selected bones are serially numbered and photographed. The specific age and sex characteristics of the bones studied are unknown. The nutrient foramina are observed in all bones with the help of a hand lens. They are identified by their elevated margins and by the presence of a distinct groove proximal to them. [12] Only well-defined foramina on the diaphysis are accepted. Foramina at the ends of the bone are ignored. [13]

The following data are studied on the diaphyseal nutrient foramina of femur:

1. Number: Bones were examined for the number of nutrient foramina. With the help of magnifying hand lens, all surfaces and each border were thoroughly examined from proximal to distal end and both dominant and secondary foramina were counted and noted down.

2. Position: The positions of all nutrient foramina were determined by calculating a foraminal index (FI) using formula:

FI = (DNF/TL) x 100 (Hughes & Shulmen 1952)

DNF = The distance from the proximal end of the bone to the nutrient foramen

TL = Total bone length.

Subdivisions of foraminal position according to foraminal index (FI) can be grouped into three types as follows [14]:

Type 1: FI from 01 up to 33.33--The foramen is in the proximal third of the bone.

Type 2: FI from 33.34 up to 66.66--The foramen is in the middle third of the bone.

Type 3: FI above 66.67--The foramen is in the distal third of the bone.

3. Size: Nutrient foramina smaller than the size of 24 hypodermic needle (0.56 mm in diameter) were considered as secondary nutrient foramina (SF) whereas those equal or larger than 0.56 mm were accepted as dominant nutrient foramina (DF). [15]

4. Direction and obliquity: A fine stiff wire was used to confirm the direction and obliquity of the foramen. [16]

All measurements have taken to the nearest 0.02 mm using an Aerospace sliding caliper. Photographs were taken in natural daylight by a Nikon digital Camera of 10 megapixels. Each photograph had a definition of 16 x 12 cm.

Statistical Analysis

The results were analyzed and tabulated. The range, mean, and standard deviation of FI were determined.

Result

In the whole series of 100 femora examined, we have found total number of 159 foramina including both dominant and secondary. There are 78 (78%) femora possessing single dominant nutrient foramina whereas 22 (22%) bones possessing double dominant nutrient foramina [Table 1]. In this study, most of the nutrient foramina (78.84%) were located along the middle third of the femur (Type 2) and the rest (21.15%) were in the proximal third (Type 1), with no foramina detected in the distal third of the femur [Table 1]. The mean FI is 46.29 and range of FI floats between 30.35% and 64.97% of the bone length [Table 3]. The average total length (TL) was 43.67 [+ or -] 2.04 cm. Of the 159,122 foramina, (76.72%) were dominant in size whereas 37 foramina (23.27%) were secondary in nature [Table 2]. All nutrient foramina (100%) in the femur were directed proximally (upper end) away from the growing end.

Discussion

Anatomical characteristics of the nutrient foramen, such as its number, position, size, and direction, are important factors considered in orthopedic surgeries including bone grafting and fracture repair. These characteristics also contribute to the prognosis after a fracture because they are essential to blood flow. [17] It has been reported that the ideal bone graft for the free transfer should include endosteal and periosteal blood supply with good anastomosis. [18, 19] Kizilkanat et al. stated that the position of the nutrient foramina was directly related to the requirements of a continuous blood supply to specific aspects of each bone, for example areas of some major attachments such as flexors require more blood supply as compared to extensors because of more activity. Many theories have been put forward to account for the direction of foramina and also the anomalously directed ones. In our study, femur obeys the growing-end theory of Mysorekar that opinioned the direction of nutrient foramina is determined by the growing end of the bone. The growing end is supposed to grow at least twice as fast as the other end. The nutrient artery runs away from the growing end as the growing bone might pull and rupture the artery. So the nutrient foramina are directed away from the growing end.

This study analyzes the following four parameters:

1. Number of the nutrient foramina: In this study, 78% femora possessing single dominant nutrient foramina whereas 22% bones had double dominant nutrient foramina [Table 1], which shows the majority of bones have single nutrient foramina that may represent the single source of blood supply. This is in agreement with previous studies reported by Kizilkanat et al. and Pereira et al.

2. Position of nutrient foramina: In this study, most of the nutrient foramina (78.84%) were located along the middle third of the femur (Type 2) and the rest were in the proximal third (Type 1) with no foramina detected in the distal third of the femur [Table 1]. Range of FI floats between 30.35% and 64.97% of the bone length. These results were in accordance with the studies by Kizilkanat et al., Sammera Yassin Shaheen, and ShamsunderRao and Kothapalli. Also, 68.60% nutrient foramina of the femora was located mainly around the linea aspera and along a narrow strip on either side of it [Table 2].

3. Size of nutrient foramina: Our study shows that about 76% nutrient foramina were dominant in nature and 24% were secondary. This result also follows the previous studies.

4. Direction and obliquity of nutrient foramina: In this study, all the nutrient foramina in the femur were directed proximally (upper end) away from the growing end (lower end).

Conclusion

The study confirmed previous reports regarding the number, location, size, and direction of the nutrient foramina in the femur. The single foramina were more common as compared to double. All the foramina were located on flexor surface (posterior surface) of femur near the linea aspera especially in middle one-third of bone (Type 2). So it is important to know the exact location and distribution of the nutrient foramina to improve the surgical outcomes. This study provides additional information on the nutrient foramina of femur as techniques such as microvascular bone transfer, which are becoming more popular.

DOI: 10.5455/ijmsph.2016.0508201589

References

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

[2.] Gray's--Elsevier, Churchill Livingstone. A text book of human anatomy, 40th Edition.

[3.] Nagel A. The clinical significance of the nutrient artery. 1993.

[4.] Patake SM, Mysorekar VR. Diaphysial nutrient foramina in human metacarpals and metatarsals. J Anat 1977;124:299-304.

[5.] Malukar O, Joshi H (2011). Diaphysial nutrient foramina in long bones and miniature long bones. Nat J Integr Res Med 2011;2(2):23-6.

[6.] Murlimanju BV, Prashanth KU, Prabhu LV, Chettiar GK, Pai MM, Dhananjaya KVN. Morphological and topographical anatomy of nutrient foramina in the lower limb long bones and its clinical importance. Australas Med J 2011;4(10):530-7.

[7.] Shamsunder rao V, Kothapalli J. The diaphyseal nutrient foramina architecture--a study on the human upper and lower limb. IOSR J Pharma Biol Sciences 2014;9(1):36-41.

[8.] Pereira GAM, Lopes PTC, Santos AMPV, Silveira FHS. Nutrient foramina in the upper and lower limb long bones: morphometric study in bones of southern Brazilian adults. Int J Morphol 2011; 29(2):514-20.

[9.] Ukoha UU, Umeasalugo KE, Nzeako HC, Ezejindu DN, Ejimofor OC, Obazie IF. A study of the nutrient foramina in long bones of Nigerians. Nat J Med Res 2013;3(4):304-7.

[10.] Kirschner MH, Menck J, Hennerbichler A, Gaber O, Hofmann GO. Importance of arterial blood supply to the femur and tibia for transplantation of vascularized femoral diaphyses and knee joints. World J Surg 1998;22:845-52.

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

[12.] Sammera yassin shaheen (2009). Diaphyseal nutrient foramina in human upper and lower limb long bones. King Saud University. Available at: Repository.Ksu.Edu.Sa/Jspui/Bitstream/123456789/ ... /Final%20thesis.Pdf

[13.] Longia GS, Ajmani ML, Saxena SK, Thomas RJ. Study of diaphyseal nutrient foramina in human long bones. Acta Anatomica (Basel) 1980;107:399-406.

[14.] Kumar R, Mandloi RS, Singh AK, Kumar D, Mahato P. Analytical and morphometric study of nutrient foramina of femur in Rohilkhand region. Innovative J Med Health Sci 2013;3:52-4.

[15.] Forriol Campos F, Gomez Pellico L, Gianonatti Alias M, Fernandez-Valencia R. A study of the nutrient foramina in human long bones. Surg Radiol Anat 1987;9:251-5.

[16.] Gumusburun E, Yucel F, Ozkan Y, Akgun Z. A study of the nutrient foramina of lower limb long bones. Surg Radiol Anat 1994;16:409-12.

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

[18.] Collipal E, Vargas R, Parra X, Silva H, Sol M. Diaphyseal nutrient foramina in the femur, tibia and fibula bones. Int J Morphol 2007;25(2):305-8.

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

Nidhi Agrawal (1), Amrish Tiwari (1), Deepak C Naik (2)

(1) Department of Anatomy, N.S.C.B. Medical College, Jabalpur, Madhya Pradesh, India.

(2) Department of Anatomy, S.S. Medical College, Rewa, Madhya Pradesh, India.

Correspondence to: Nidhi Agrawal, E-mail: drnidhi1995@rediffmail.com

Received August 05, 2015. Accepted August 18, 2015
Table 1: Number and position of nutrient foramina of Femur

Bone              Number of foramina              Number of bones (%)
Femur (n = 81)           0                              0 (0%)
                         1                             78 (78%)
                         2                             22 (22%)
                         2                             22 (22%)
                  Position of foramina                Direction

                 Type 1      Type 2      Type 3
                 21.15 (%)   78.84 (%)    -       All are directed
                                                  proximally
                                                  (towards upper end)

Table 2 : Position and number of dominant (DF) and secondary
(SF) nutrient foramina observed in the femur

Location                 Total no.   %         No. of foram      Absent
                         of                  Single    Double
                         foramina            foramen   foramen
                                             DF   SF   DF  SF

Between the two lips        52       32.7    29   10   10   03     --
  of lineaaspera
Medial lip of               51       32.07   29   04   18   --     --
  lineaaspera
Lateral lip of              12        7.5    05   02   05   --     --
  lineaaspera
Posteromedial surface       26       16.3    10   08   08   --     --
Posterolateral surface      09        5.6    01   02   03   03     --
Medial to spiral line       09        5.6    04   03   --   02     --
Total                      159       100     78   29   44   08     --

Table 3: The range, mean [+ or -] standard deviation (SD) of foramina
indices observed in the femur

Location                     Side   Range   Mean [+ or -] SD

Between the two lips of       R     30.35-64.97   41.36 [+ or -] 8.73
  linea aspera                L     31.74-62.40   32.05 [+ or -] 0.13
Medial lip of linea aspera    R     36.64-60.76   57.96 [+ or -] 3.95
                              L     31.82-62.62   32.98 [+ or -] 1.64
Lateral lip of linea          R     34.79-54.89   43.25 [+ or -] 16.48
  aspera                      L        40.50             40.50
Posteromedial surface         R     48.98-55.59   56.67 [+ or -] 1.53
                              L     52.06-61.46   58.46 [+ or -] 2.34
Posterolateral surface        R     45.84-49.25   47.54 [+ or -] 2.41
                              L     33.49-51.24   49.07 [+ or -] 3.06
Medial to spiral line         R     30.84-33.50   32.31 [+ or -] 2.07
                              L        32.60             32.60
R, right; L, left.
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Article Details
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Title Annotation:Research Article
Author:Agrawal, Nidhi; Tiwari, Amrish; Naik, Deepak C.
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Geographic Code:9INDI
Date:Mar 1, 2016
Words:2197
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