Modern Hip Preservation New Insights In Pathophysiology

And Surgical Treatment

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Reinhold Ganz
Editor

Modern Hip
Preservation
New Insights In Pathophysiology
And Surgical Treatment
Editor
Reinhold Ganz
Professor Emeritus, Faculty of Medicine
University of Bern
Gümligen, Bern, Switzerland

ISBN 978-3-030-91966-5    ISBN 978-3-030-91967-2 (eBook)

https://doi.org/10.1007/978-3-030-91967-2

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Foreword

The hip joint has a quite simple anatomy (a spherical head into a hemispheric
cup), but it carries the responsibility, shared with the knee and the ankle, of
the motion and of all the activities for a normal living including sports.
Despite its apparent simplicity, to my mind it deserves the concept of “hip
universe” for the following reasons.
The anatomy (neck and femoral head, acetabulum, acetabular lip, capsule)
is different for each individual. The diversity does not only concern the
dimensions, but mainly the inclination and the version of the acetabulum and
the neck, the shape of the head, the covering of the same, the CCD angle and
the neck length: hip kinematics and loads are individually variable.
Any anatomical alteration, even of small importance, and the consequent
functional dyskinesia that results, causes a non-reversible, unstoppable struc-
tural alteration, with negative consequences on the functional complex of the
hip, resulting in a crippled and unhappy patient.
Osteoarthritis is the final stage in the evolution of one or more anatomical
changes, with derangement of the hip universe, ending in irreversible joint
degeneration.
The understanding of the pathogenetic evolution of different pathologies
can lead to specific and preventive corrections of the final treatment, which is
a valid but irreversible solution (hip prosthetic replacement).
The concept of hip preserving surgery was born in the 1980s, in the mind
and in the hands of an open-minded, inspired orthopaedic surgeon, Reinhold
Ganz, and it fits well in my concept of “hip universe” that starts from the
knowledge of the vascular supply of the femoral head, which has to be man-
datorily respected in all procedures of preservation of the natural hip.
Once the vascular supply has been respected, all procedures have been
conceived to recreate the natural spherical shape of the femoral head, and
when needed, its proper coverage on the acetabular side; it can be defined as
a back-to-normal anatomical surgery, implying knowledge, innovation, dedi-
cation and surgical skills.
The entire range of hip pre-osteoarthritic pathologies, spanning from
pathogenesis to the surgical treatment, is treated in this book, which crowns
the masterwork of prof. Ganz, as well as of the GICCA group (Gruppo
Italiano di Chirurgia Conservativa dell’Anca), led by Reinhold during many
years of cooperation and teaching.

v
vi Foreword

I largely use the concept of “hip universe” during my lessons for the medi-
cal students; I have found it well fitting in the spirit of this book, and in the
foreword I have had the honour to write, as a member of GICCA.

Orthopaedics and Traumatology Francesco Benazzo

University of Pavia, Pavia, Italy
Preface

Correction of deformities of the human skeleton is an old desire. It is best

depicted by the crooked tree, introduced by the French physician Nicolas
Andry (1658–1742) to explain prevention and conservative treatment of
spine deformities. Today it serves as logo for numerous societies and jour-
nals of orthopaedic surgery. More than a century had to elapse until prog-
ress in antisepsis and anaesthesia as well as the invention of radiography
allowed surgical corrections of the skeleton to be undertaken. First proce-
dures were simple alignments of the lower limb after fracture or ankylosis;
internal fixation was not applied and pseudarthrosis was a desired end
result. Internal fixation of the hip was first attempted in the 1920s with the
three flanged nail introduced by Smith-Petersen and the first osteotomy for
coxarthrosis is attributed to McMurray, who published it in 1939. During
the following 30 years orthopaedic centres executed a high number of adult
hip osteotomies, mainly as varus correction and nearly exclusively in hips
with established osteoarthritis. With the introduction of total hip replace-
ment in the early 1970s offering long-lasting and pain-free function, joint
preserving surgery of the adult hip lost its attraction steadily with the result
that today young orthopaedic doctors may not even see a hip osteotomy in
their training.
The renaissance of attempts to preserve the natural hip started in the 1980s.
First unexpected, a growing interest was observed which had much to do with
the recognition that more young people suffered from hip problems, and on
the other side, the survival of total joint replacement significantly decreases
with younger age. Based on studies of the vascular blood supply of hip and
pelvis, better understanding of the mechanism of joint degeneration but also
new surgical techniques evolved and matured to concepts to successfully treat
the young hip joint before major degeneration takes place.
Meanwhile a sustained and worldwide interest can be observed, which
shifted from the established osteoarthritis to the symptomatic hip of adoles-
cent and young adult before advanced joint degeneration. Surgical disloca-
tion of the hip was first designed as an approach to treat intraarticular
problems and was first executed in 1996 to treat extended chondromatosis of
the hip joint. Successively, it came to be a workhorse for a new class of
intraarticular surgeries and it allowed to establish the impingement concept,
which put the aetiology of coxarthrosis on a new basis. At about the same
time the Bernese periacetabular osteotomy received increasing acceptance as

vii
viii Preface

a versatile procedure for different dysplasias of the acetabulum. Hip joint

preservation burgeons to grow and takes a front seat in the field of hip
surgery.
More than 10 years ago, a study group was formed in Northern Italy under
the name of Gruppo Italiano di Chirurgia Conservativa dell' Anca (GICCA)
in order to apply the principles. Meanwhile several hundred hips have been
operated. We report this experience in a book to let the reader deepen the
knowledge of the subject in one, single, comprehensive work.

Bern, Switzerland Reinhold Ganz

Acknowledgements

On the initiative of Giorgio Curradini, a study group (GICCA—Gruppo

Italiano di Chirurgia Conservativa dell’Anca) was formed in Northern Italy
15 years ago which has applied the principles of modern hip preservation and
has treated several hundred hips so far. The creation of this group allowed us
to add continuous experience and discover new aspects and evolutions of this
rather new type of surgery. Undoubtedly, Curradini’s mentorship to the
renaissance of conservative hip surgery is of outmost importance. We report
this experience in an e-book, a format allowing to add continuously experi-
ence, new aspects and further evolution of hip joint preservation.
We are indebted to Stefano Lanfranco for his extraordinary commitment.
Without his constant supervision and editing, the book would not have been
published.
Last but not least, a special thanks goes to our publisher who has believed
in the project and has made its realization possible.

ix
Contents

1 Vascular Anatomy of the Hip: An Update ������������������������������������   1

Morteza Kalhor and Reinhold Ganz
2 Femoro-Acetabular Impingement: History, Concept,
and Treatment���������������������������������������������������������������������������������� 13
Reinhold Ganz
3 Overview on Developmental Dysplasia of the Hip������������������������ 23
Alessandro Aprato, Laura Ravera, and Alessandro Massè
4 Safe Surgical Dislocation of the Hip: Anatomic Preconditions,
Technique, and Results�������������������������������������������������������������������� 37
Reinhold Ganz and Antonio Campacci
5 Extended Retinacular Flap for Intra-Articular Hip Surgery:
Operative Technique and Indications�������������������������������������������� 45
Reinhold Ganz and Michael Leunig
6 Femoro-Acetabular Impingement: Treatment
Options—Arthroscopy�������������������������������������������������������������������� 51
Ettore Sabetta and Michele Cappa
7 Femoroacetabular Impingement: Treatment Options—Open
Femoral Osteochondroplasty and Rim Trimming������������������������ 63
Alessandro Aprato, Matteo Olivero, Alessandro Massè, and
Reinhold Ganz
8 Acetabular Reorientation Procedure �������������������������������������������� 73
Luigino Turchetto, Stefano Saggin, and Reinhold Ganz
9 How to Reduce the Risk of Nerve Injury During
Bernese PAO? ���������������������������������������������������������������������������������� 89
Morteza Kalhor
10 Surgical Hip Dislocation for Anatomic Reorientation
of Slipped Capital Femoral Epiphysis�������������������������������������������� 97
Alessandro Aprato, Chiara Arrigoni, and Alessandro Massè
11 Relative Lengthening of the Femoral Neck ���������������������������������� 105
Luigino Turchetto, Stefano Saggin, and Reinhold Ganz

xi
xii Contents

12 Indications and Results of Femoral Neck Osteotomy

in Adults�������������������������������������������������������������������������������������������� 109
Paulo Rego
13 Subtrochanteric Osteotomy for the Management
of Femoral Mal-Torsion������������������������������������������������������������������ 119
Mattia Loppini, Reinhold Ganz, Luigino Turchetto, Giuseppe
Mazziotta, and Guido Grappiolo
14 Surgical Hip Dislocation in Traumatology������������������������������������ 129
Alessandro Aprato, Ettore Sabetta, Matteo Giachino,
and Alessandro Massè
15 Intra- and Juxta-Capsular Osteotomies for Childhood
Deformities of the Hip. Surgical Technique and Follow-Up
of Selected Cases������������������������������������������������������������������������������ 137
Luigino Turchetto and Reinhold Ganz
 Vascular Anatomy of the Hip:
An Update 1
Morteza Kalhor and Reinhold Ganz

1.1 Introduction an appropriate technique for full access to the hip

joint with minimal or no risk of AVN [8].
Vascular anatomy of the pelvis and hip joint in More recent cadaveric injections have shown
general and that of the femoral head, in particu- precisely the surgical anatomy of the hip vessels
lar, has been the subject of investigation since and acetabulum [9–15], which finally led to the
many years. General aspects of hip vascular anat- development of new procedures in hip surgery
omy have been described in anatomy books and [16, 17]. The extracapsular approach for intra-­
literature [1–3]. Tuker in 1949 and Trueta in 1953 articular problems was replaced by direct intra-­
following injection studies concluded that MFCA capsular techniques. It is now possible to safely
was the main source of blood supply to the femo- dislocate the hip joint and manage various intra-­
ral head [4–6]. Their findings were confirmed by articular conditions directly, with minimal or no
subsequent studies. Despite the available histori- risk of AVN. The prerequisites to obtain favor-
cal knowledge in hip vascular anatomy, iatro- able results in these complex procedures are pro-
genic femoral head AVN continued to be a major tection of the supplying vessels in their extra- and
complication following hip surgery. intra-capsular courses.
The mystery was disclosed when recent arte- Our goal in this chapter is to demonstrate the
rial injection studies have shown that surgical or surgical anatomy of the vessels supplying the hip
traumatic injury of MFCA in its extracapsular joint and acetabulum. The description is based on
course was the usual cause of damage to the fem- our findings in fresh cadaveric dissections fol-
oral head blood supply. Gauthier et al. confirmed lowing arterial injection studies. The correspond-
the frequent occurrence of this vascular injury in ing vessels are followed from the origin to their
tenotomy of the short hip external rotators during final distribution.
routine hip surgeries [7]. Introduction of surgical
hip dislocation provided the orthopedic surgeons
1.2 Topographic Anatomy

M. Kalhor (*) The main vascular supply to the external aspect

Department of Orthopedic Surgery, Firoozgar of the pelvis comes from five vessels: Medial and
Medical Center, Iran University of Medical Sciences, lateral femoral circumflex arteries (MFCA,
Tehran, Iran
LFCA), superior and inferior gluteal arteries
R. Ganz (SGA, IGA), and obturator artery (OA).
Faculty of Medicine, University of Bern,
Bern, Switzerland

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 1

R. Ganz (ed.), Modern Hip Preservation, https://doi.org/10.1007/978-3-030-91967-2_1
2 M. Kalhor and R. Ganz

1.3 Course and Distribution

of the Medial and Lateral
Circumflex Femoral Arteries

The circumflex femoral arteries have an extra-­

pelvic origin branching either from profunda
femoris or femoral artery (Fig. 1.1).

1.3.1  FCA: Lateral Femoral

L
Circumflex Artery Fig. 1.1 Anterior aspect of right hip distal to the inguinal
ligament after distal retraction of sartorius and rectus fem-
Usually originating from the profunda femoris oris muscles. MFCA: Medial Femoral Circumflex Artery;
artery, the LFCA courses laterally underneath the LFCA: Lateral Femoral Circumflex Artery; P.F.: Profunda
Femoris artery
rectus femoris muscle. After giving off the
descending and transverse branch the LFCA runs
laterally toward the tensor fasciae latae muscle as
ascending branch (Fig. 1.1). The ascending por-
tion of the artery invariably supplies the anterior
capsule by a prominent branch (Fig. 1.2).
Additionally, the ascending part of the artery
variably provides one or two small branches to
contribute to the femoral head blood supply as
anterior retinacular arteries (Fig. 1.3).
After supplying the tensor fascia latae muscle,
the ascending branch turns cephalad and cross
the hip capsule anterolaterally toward the supe-
rior aspect of the acetabulum. In its way the Fig. 1.2 Anterior aspect of right hip after retraction of ante-
ascending branch supplies the most anterior part rior hip muscles to show the capsular branch of LFCA
of the hip abductor muscles (gluteus medius and (arrow). AIIS: Anterior inferior iliac spine. LFCA: lateral
gluteus minimus) as well as the anterolateral femoral circumflex artery. Broken line indicates to the loca-
tion of the femoral head. Adapted with permission from [11]
aspect of the capsule (Fig. 1.4). The ascending
branch finally anastomoses with the supra-ace-
tabular branch of the SGA to take part in the peri-
acetabular vascular ring (Fig. 1.5).

1.3.2  FCA: Medial Femoral

M
Circumflex Artery

1.3.2.1 Extracapsular Course

It originates from the posteromedial aspect of the
profunda femoris and less often from the com-
mon femoral artery (Fig. 1.1). It runs medially
and then posteriorly lying between iliopsoas and
Fig. 1.3 Anterior aspect of right hip after capsulotomy.
pectineus muscle. In its way posteriorly and Arrow shows the anterior retinacular artery originating
before turning laterally, the MFCA supplies the from LFCA. Dotted line indicating capsular insertion.
adductor muscles in addition to hip capsule and MFCA: Medial Femoral Circumflex Artery
1 Vascular Anatomy of the Hip: An Update 3

Fig. 1.6 Anterior aspect of right hip after proximal

retraction of iliopsoas muscle to show the anatomic posi-
Fig. 1.4 Anterolateral aspect of right hip demonstrates
tion of circumflex femoral arteries. Arrows indicating cap-
vascularization of tensor and abductor muscles by
sular branches of LFCA. Broken circular line: femoral
LFCA. The tensor is flipped over to show its undersurface.
head. Pect.: pectineus muscle. MFCA: Medial Femoral
ASIS: Anterior superior iliac spine. GT: Greater
Circumflex Artery; LFCA: Lateral Femoral Circumflex
trochanter
Artery; Common F.A.: Common femoral artery

Fig. 1.7 Arrow shows the medial retinacular artery

branching off from MFCA before capsulotomy. MFCA:
Medial Femoral Circumflex Artery; LFCA: Lateral
Femoral Circumflex Artery; Profunda femoris a.:
Profunda femoris artery

externus tendon near their attachments to the

Fig. 1.5 Anterolateral surface of right hip to demonstrate
the anastomosis between ascending branch of LFCA
greater trochanter (Fig. 1.8). After giving off the
(long arrow) and supra-acetabular branch of SGA (shorttrochanteric branch, the artery crosses the obtu-
arrow). G minimums.: Gluteus minimus rator externus tendon in close contact posteri-
orly and runs superomedially to enter the joint
femoral head (Fig. 1.6). The first femoral head-­ (Fig. 1.9).
supplying artery pierces the medial capsule near
its femoral attachment to enter the joint (Fig. 1.7). 1.3.2.2 Intra-Capsular Course
On the posterior aspect of the hip joint the The terminal branch of MFCA perforates the fem-
MFCA courses laterally toward the greater tro- oral attachment of the capsule in the posterolat-
chanter running along the inferior border of the eral aspect of the hip joint between the capsular
obturator externus muscle to emerge between attachment of obturator externus and conjoint ten-
the quadratus femoris muscle and obturator don (Fig. 1.9). After entry into the joint it divides
4 M. Kalhor and R. Ganz

Fig. 1.8 Posterior aspect of right hip to show the deep branch Fig. 1.10 Posterior aspect of hip after capsulotomy to
of the MFCA before entry into the joint (black arrow). White demonstrate the terminal branches of the MFCA after
arrow pointing toward the origin of trochanteric branch. SN: entry into the joint. Broken line: imprint of capsular
sciatic nerve; 1. vastus lateralis; 2. quadratus femoris; 3. attachment. 1. greater trochanter (osteotomized); 2. qua-
obturator externus; 4. gemellus inferior; 5. gemellus supe- dratus femoris; 3. obturator externus
rior; 6. piriformis; 7. gluteus medius; 8. greater trochanter

Fig. 1.9 The same as Fig. 1.8 after removal of gluteus Fig. 1.11 Anteromedial aspect of hip joint to demonstrate
medius and vastus lateralis. 1. vastus lateralis; 2. quadra- the medial retinacular artery on top of Weitbrecht’s liga-
tus femoris; 3. obturator externus; 4. conjoint tendon of ment (arrow). MFCA: Medial Femoral Circumflex Artery;
triceps coxae; 5. piriformis; 6. gluteus minimus; 7. greater FA: Femoral Artery. Adapted with permission from [11]
trochanter

into 2–6 branches running on the posterolateral superior retinacular arteries. It also provides blood
surface of the neck toward the femoral head while supply to the Pipkin fractures in femoral head frac-
covered and fixed by the retinaculum (Fig. 1.10). ture dislocations. Unlike what is frequently men-
In the inferomedial aspect of the joint the first tioned in the literature a sub-capital and basal neck
retinacular artery, a branch of the MFCA pierces the vascular ring rarely is seen inside the capsule.
femoral attachment of the capsule to enter the joint.
Inside the joint it lies on the medial or posterome-
dial aspect of the neck as inferior retinacular artery 1.4 Course and Distribution
and runs toward the head in a fold of a relatively of the Obturator and Gluteal
mobile retinaculum called Weitbrecht’s ligament Arteries
(Fig. 1.11). This relative mobility allows the artery
to escape from being damaged in some femoral The superior gluteal, inferior gluteal, and obtura-
neck fractures. Mobilization of this artery during tor arteries have intra-pelvic origin and branching
intra-articular procedures is much easier than the off from the internal iliac artery.
1 Vascular Anatomy of the Hip: An Update 5

1.4.1 SGA: Superior Gluteal Artery

Underlying the gluteus maximus and medius mus-

cles, the SGA emerges from the pelvis at the
uppermost part of the sciatic notch and proximal to
the piriformis muscle (Fig. 1.12). The artery turns
anteriorly and laterally and ramifies to supply the
gluteal muscles and the acetabular bone by its
muscular and periosteal branches, respectively.
The most prominent periosteal branch is the supra-
acetabular artery; it is protected and covered by the
gluteus minimus muscle along its course from the
posteromedial to the anterolateral aspect of the
Fig. 1.13 Posterior aspect of hip joint after reflection of
acetabulum. Its terminal 1/2 is periosteal and short hip rotators and gluteal muscles to expose the supra-­
underlies the gluteus minimus muscle. The supra- acetabular branch of the SGA (arrow). Arrowhead indi-
acetabular branch gives multiple small arteries cates the acetabular branch of IGA. Thin arrows indicating
the reflected triceps coxae muscles. Broken line: acetabu-
toward the hip capsule and finally anastomose
lar capsular attachment; GT: Greater trochanter. Adapted
with the ascending branch of LFCA (Fig. 1.13). with permission from [11]
Variable anastomoses can be found between the
intra-pelvic and extra-pelvic vascular system in
the area between and around the iliac spines.

1.4.2 IGA: Inferior Gluteal Artery

Branching off from the internal iliac artery the

IGA courses distally along the sciatic nerve and
posteromedial to it (Fig. 1.14). It supplies the
short hip external rotators and the periacetabular

Fig. 1.14 Posterior aspect of hip joint to demonstrate the

course and branches of the IGA (arrows) relative to sciatic
nerve and short rotators. The hook is retracting the qua-
dratus femoris muscle. SN: sciatic nerve

bone by its muscular and periosteal branches that

leave the artery superficial or deep to the sciatic
nerve. The IGA consistently contributes to the
perfusion of the femoral head by a branch anasto-
mosing with the MFCA in the area of the short
hip external rotators. This anastomotic branch
most often originates from the deep acetabular
Fig. 1.12 Posterior aspect of right hip after retraction of
gluteus medius and maximus to show the distribution of the
branch in the area between gemellus inferior and
SGA (long arrow). Short arrow indicating branch of the quadratus femoris muscles (Fig. 1.15), but less
IGA. SGA: Superior Gluteal Artery; IGA: Inferior Gluteal often from the muscular branches crossing the
Artery SN: sciatic nerve; GT: Greater trochanter; G.med: proximal short rotators superficially to reach the
gluteus medius; G.min: gluteus minimus; GT: greater tro-
chanter; piri: piriformis; Cran.: cranial; Lat.: lateral
deep branch of MFCA.
6 M. Kalhor and R. Ganz

As an important anatomic variation, in about atic nerve. It runs anteriorly and laterally, first
15% of hips the IGA is the main supplier of the between gemellus inferior and quadratus femo-
femoral head from the posterior aspect, while the ris, and then between conjoint and obturator
MFCA is then accessory. The femoral head-­ externus tendon (Fig. 1.16). It never crosses the
supplying artery usually branches off from the tendon of obturator externus as the deep branch
IGA at the level of the lesser sciatic notch or of MFCA does. It finally perforates the capsule in
ischial tuberosity and lies usually deep to the sci- immediate vicinity to the capsular attachment of
the conjoint tendon as well as the deep branch of
MFCA.

1.4.3 OA: Obturator Artery

The OA has an intra-pelvic course along with the

obturator nerve. Principally it supplies the ham-
string and adductor muscles after exiting the pel-
vis through the obturator foramen. By its
acetabular branch the OA contributes to the vas-
cularization of the acetabulum (Fig. 1.17). Its
contribution to the femoral head circulation via
the ligamentous teres is not significant in adults.
Fig. 1.15 Posterior aspect of hip joint to show the distal In spherical acetabular osteotomies, which are
acetabular branch of the IGA (arrow) contributing to the placed very near to the acetabulum, this artery
circulation of the femoral head. Pirif: piriformis; Q. fem.: remains one of the main suppliers of the acetabu-
quadratus femoris; G. med.: gluteus medius; SN: sciatic
nerve lar fragment.

Fig. 1.16 Posterior aspect of right hip to show the domi- anastomosis between the two. Right: After removal of the
nance of the IGA over the MFCA in perfusion of the external rotators except obturator externus, the IGA
femoral head as an anatomic variation. Left: black arrow branch continues directly into the retinacular vessels
pointing to branch of the IGA. White arrow pointing to the while the deep branch of the MFCA is a small guage anas-
deep branch of the MFCA; Yellow arrow pointing to the tomosis. GT: greater trochanter. QF: quadratus femoris.
trochanteric branch; Black arrowhead pointing to the OE: obturator externus; GI: gemellus inferior
1 Vascular Anatomy of the Hip: An Update 7

Fig. 1.18 Posterior aspect of right hip to demonstrate

parts of the periacetabular periosteal ring formed by both
gluteal arteries. Dotted black line: capsular imprint.
Broken white lines: greater and lesser sciatic notch. IGA:
inferior gluteal artery. Adapted with permission from [11]

1.6  lood Supply to Capsule

B
and Labrum
Fig. 1.17 Acetabular artery mainly fed by the obturator
artery The hip capsule receives its blood from three
sources: Vessels coming from the acetabular
1.5 Periacetabular Vascular Ring side originating principally from the periace-
tabular vascular ring, vessels coming from the
Underlying the gluteal and short external rotator femoral side originating from the circumflex
muscles and running on the external iliac sur- femoral arteries, and perforating vessels from
face exists a network of periosteal vessels origi- overlying muscles and tendons (Fig. 1.19). All
nating principally from the gluteal arteries these vessels enter to the non-articular surface
(Fig. 1.18). of the capsule and make variable numbers of
Vessels derived from SGA form the superior anastomoses with each other. Capsular vessels
part of this periosteal network. The most promi- communicate with the acetabular bone through
nent periosteal branch of the SGA is the supra-­ the vessels running superficially on the non-
acetabular branch. Arterial branches derived from articular surface of the capsule; this contribution
IGA form the distal part of this network. however only exists as long as the overlying
Anastomoses between periosteal branches of the muscles are not dissected from the capsule for
gluteal arteries in one side and between gluteal exposure.
and circumflex femoral arteries in the other side The acetabular labrum receives its blood supply
configure the so-called periacetabular vascular exclusively from radial arteries originating from
ring. The ring receives also contributions from periacetabular periosteal ring (Fig. 1.20). Number
intra-pelvic periosteal vessels in the anterior and and size of these vessels are highly ­variable in dif-
medial aspect of the acetabulum. The periace- ferent parts of the labrum but are more concen-
tabular vascular ring supplies the acetabular trated in the posterior and superior aspect of the
bone, capsule, and labrum. joint. After traversing the capsule subperiosteally