An anatomical investigation into the blood supply of the proximal humerus: surgical considerations for rotator cuff repair

Abstract

BackgroundThe purpose of this study was to investigate the blood supply of the humeral head (HH) originating from the anterior (ACHA) and posterior circumflex humeral arteries (PCHA).MethodsFormalin preserved specimens were used to measure ACHA length, ACHA length in the bicipital groove (BG), the length of the ascending branch of the ACHA, the penetration point of the ascending branch of the ACHA at the greater tuberosity (GT), and the penetration point of the ascending branch PCHA at the GT. Fresh specimens were used to identify the intraosseous vascular network by both the ACHA and PCHA by injecting a contrast medium using a high-resolution microfocus computed tomography. Specimens were then dissected to expose where the branches of the ACHA and PCHA penetrate the bone, and a small section of the medial head was removed to visualize dye penetration of the cancellous bone.ResultsSeven variations for the course of the ACHA were observed. In 36%, the ACHA runs posterior to the BG and posterior to the long head of biceps tendon, and splits into the anterolateral ascending and descending branch. The ascending branch enters the medial wall of the GT. Microfocus computed tomography demonstrated that the intraosseous branch of the ascending branch of the ACHA runs within the GT in a medial direction from its penetration point just along the lateral edge of the BG. Intraosseous accumulation of contrast within the GT supply occurs more toward the inferior aspect of the HH, and the anterior-superior and superior-medial aspect of the HH is not perfused. This region is a high-risk zone for avascular necrosis.ConclusionThe results of this study suggest that 7 variations for the course of the ACHA exist. These variations and the interruption of the intraosseous arterial network in the GT with surgery and suture anchor placement result in a high-risk zone in the superomedial aspect of the humeral head overlapping with the area where early aseptic necrosis is identified.

Anatomical Study for the Treatment of Proximal Humeral Fracture Through the Medial Approach

“…Second, in clinical study of treatment for complex PHFs, no intact ACHA were found in 16 cases except 1 patient But successful fracture healing was achieved in all 17 cases [29]. Last, Natalie Keough et al emphasized the variations exist for the course of the ACHA, which suggest a more signi cant contribution from the PCHA to the epiphysis [30]. In our study, a separate origin for the ACHA and PCHA was 84.3%.…”

The humeral head: A review of the blood supply and possible link to osteonecrosis following rotator cuff repair

“…It has also been reported that branches of the PCHA may communicate dorsally with the ACHA (de la Garza et al, 1992;Duparc et al, 2001;Gerber et al, 1990). However, these anastomotic branches were not observed in other studies (Kasai et al, 1984;Keough et al, 2019;Meyer et al, 2005).…”

“…Recently, seven variation patterns have been identified with regard to the ACHA's course towards and within the intertubercular groove (Figure 2), specifically its origin, branches and its relation to the long head of biceps tendon (Keough et al, 2019). Out of 50 cadaveric To the authors' knowledge, these variations have not been mentioned or studied before, and these variations may be of clinical importance in procedures that involve the long head of biceps tendon, such as tenotomies and tenodesis surgeries.…”

“…2. A descending branch (Kasai et al, 1984;Keough et al, 2019; Figure 1, branch 6). Garza et al, 1992;Duparc et al, 2001;Kasai et al, 1984; Figure 1, possibly branch 7).…”

Incidence of avascular necrosis following biceps tenodesis during proximal humerus open reduction and internal fixation

“…It has been suggested that the proximal humerus is significantly perfused by the anterolateral ascending branch of the anterior circumflex artery (24), which runs parallel to the LHBT in the bicipital groove before forming the arcuate artery. It has been suggested that this branch of the anterior circumflex humeral artery is at risk of damage during LHBT tenotomy and tenoodesis, which may theoretically disrupt perfusion to the proximal humerus and predispose it to AVN and its associated complications (25).…”