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Complications of Femoroplasty

Ricardo Plancarte PhD, MD¹, FIPP ¹,², Berenice Carolina Hernández-Porras MD, MSc, FIPP, CIPS¹,², Angel Juárez Lemus MD, CIPS, ASRA-PMUC ¹, and Erika C. Lopez Montes MD²

¹ National Cancer Institute, Mexico City, Mexico
² Centro Médico ABC, Mexico City, Mexico

Introduction

Metastatic bone disease in patients with advanced cancer is frequently associated with skeletal complications. These can be debilitating, causing pain, impaired functioning, and decreased quality of life, as well as reduced survival. Percutaneous cementoplasty (PC) has been widely used for pain control and stabilization of impending fractures of the proximal femur due to metastatic lesions. The most common complications are leakage of PMMA through the pretrochanteric area and into the soft tissues. Placing the target view in the lateral view visualizing the minor trochanter, placing the major trochanter at the center of the femoral head, perfoming a venography before augementation and avoiding performing this procedure in cases where cortical bone disruption is present, can reduce the incidence of complications.

Anatomy

The femur is the longest, heaviest, and strongest bone in the human body. The main function of the femur is weight bearing and stability of gait. The capsular ligament is a strong thick sheath that wraps around the acetabulum periosteum and proximal femur holding the femoral head within the acetabulum [1].

The femur acts as the site of origin and attachment of many muscles and ligaments, and can be divided into three parts: proximal, shaft and distal.

The proximal femur consists of: femoral head, pointed in a medial, superior, and slightly anterior direction. Ligamentum teres femoris connects the acetabulum to the fovea capitis femoris; the neck attaches the spherical head at the apex and the cylindrical shaft at the base; two prominent bony protrusions, the greater trochanter and lesser trochanter, that attach to muscles that move the hip and knee.

Distal femur – shaft flares out in a cone-shaped manner onto a cuboidal base made up of the medial and lateral condyle. Medial and lateral condyle join the femur to the tibia, forming the knee joint [2].

At the proximal end of the femur, the bulbous femoral head is joined to the shaft of the femur by the femoral neck. At the base of the neck are the medially oriented lesser trochanter and laterally placed greater trochanter. A rough line called the intertrochanteric line connects the greater and lesser trochanter on the anterior aspect of the femur, while the smoother intertrochanteric crest connects the trochanters posteriorly [1].

The femoral head of the proximal femur articulates with the acetabulum of the pelvis in which the femoral head acts as the ball and the acetabulum as the socket. This allows the hip to move in three planes: flexion and extension in the sagittal plane, abduction and adduction in the frontal plane and internal and external rotation in the horizontal plane [3].

Blood Supply

The blood supply to the femoral head is variable. Three main arteries supply the femoral head. The main arteries that irrigate the head and neck femoral are the medial circumflex femoral artery posteriorly, lateral circumflex femoral artery anteriorly and the inferior gluteal artery [4]. The lateral epiphyseal branch of the medial femoral circumflex and the ascending branch of the lateral femoral circumflex both ascend from the deep femoral artery. This leaves the femoral head vulnerable to avascular necrosis in the presence of a femoral neck fracture since these vessels are easily ruptured with this injury. The ligamentum teres artery descends from the posterior branch of the obturator artery and attaches at the fovea. This artery is commonly disrupted with dislocations. It is the main blood supply to the femoral head in children. As an anatomic variant, the inferior gluteal artery is the main blood supply to the femoral head in a small number of patients [5].

Innervation

Obturator nerve: Originates from nerve roots L2–L4. The obturator nerve supplies sensory innervation to the inferomedial thigh via the cutaneous branch of obturator nerve and motor innervation to gracilis (anterior division), adductor longus (anterior division), adductor brevis (anterior/posterior divisions), and adductor magnus (posterior division) [6].

Genitofemoral nerve: Originates from nerve roots L1–L2. It pierces the psoas muscle and divides into femoral and genital branches. The femoral branch provides sensory innervation to the proximal anterior thigh over the femoral triangle. The genital branch provides sensory innervation to the scrotum/labia. It has no motor function [6].

Lateral femoral cutaneous nerve: Originates from nerve roots L2–L3. Provides sensory innervation to the lateral thigh. It has no motor function.

Femoral nerve: Originates from nerve roots L2–L4. It provides sensory innervation to the anteromedial thigh via anterior cutaneous branches and motor innervation to psoas, pectineus, sartorius, quadriceps (rectus femoris, vastus lateralis, vastus intermedius, vastus medialis).

Sciatic nerve: Originates from the sacral plexus and projects through the greater sciatic foramen descending down the posterior thigh deep to the hamstrings. It has two distinct divisions: tibial division and common peroneal division. The tibial division originates from nerve roots L4–S3 and provides motor innervation to the biceps femoris (long head), semitendinosus and semimembranosus. There is no sensory innervation in the thigh. The common peroneal division originates from nerve roots L4–L2 and provides motor innervation to the biceps femoris (short head).

Posterior femoral cutaneous nerve: Originates from nerve roots S1–S3 and passes through the greater sciatic foramen medial to the sciatic nerve. It provides sensory innervation to the posterior thigh and has no motor function [6].