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Morphological and Morphometric Variations of Fovea Capitis Femoris: A Cross-sectional Study from Kolkata, West Bengal, India |
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Tapatati Roy, Rituparna Basu, Baisakhi Das, Ishitata Mandal, Anika Langstastang 1. Associate Professor, Department of Anatomy, Medical College, Kolkata, West Bengal, India. 2. Associate Professor, Department of Anatomy, Medical College, Kolkata, West Bengal, India. 3. Junior Resident, Department of Anatomy, Medical College, Kolkata, West Bengal, India. 4. Junior Resident, Department of Anatomy, Medical College, Kolkata, West Bengal, India. 5. Junior Resident, Department of Anatomy, Medical College, Kolkata, West Bengal, India. |
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Correspondence Address : Rituparna Basu, Flat No. 3, Mass Cooperative Housing Society Ltd., 142, Bagmari Road, Kolkata-700054, West Bengal, India. E-mail: rituparnabasu2016@gmail.com |
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| ABSTRACT |  | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
: Introduction: The proximal end of the femur is an important anatomical modification in humans, widely explored to acquire detailed knowledge that aids in determining the exact size of hip prosthesis and minimising postoperative complications. However, thorough analysis of the various parameters of the Fovea Capitis Femoris (FCF) is frequently overlooked, yet it is also important during reconstructive surgery of the ligamentum teres femoris, radiographic evaluation of hip dysplasia, or as an anatomical landmark in hip arthroscopy. Detailed morphological and morphometric measurements of the FCF in the West Bengal population would help bridge this gap, as there are few Indian studies regarding the fovea. Aim: To determine the morphological and morphometric measurements of the FCF in the West Bengal population. Materials and Methods: A cross-sectional study was conducted among 297 dry femora from the Department of Anatomy at Kolkata Medical College, Kolkata, West Bengal, India from October 2023 to February 2024. The position and shape of the fovea were recorded. Morphometric measurements of the fovea (depth, transverse diameter, and vertical diameter) and the head of the femur (transverse and vertical diameters) were taken using a vernier caliper. The collected data were compiled in a Microsoft Excel sheet and analysed using Jamovi software (free version). The Pearson’s correlation formula was used to determine the correlation between various parameters of the fovea and femoral head. A p-value of <0.05 was considered statistically significant. Results: All femora had a single distinct fovea. The most frequent shape of the fovea was oval 135 (45.45%), and its most common position was in the posterior-inferior quadrant 263 (88.55%) of the femoral head. Regarding morphometric measurements, the mean values of the transverse diameter, vertical diameter, and Depth of the Fovea (DF) were 1.53±0.367 cm, 1.28±0.303 cm, and 0.304±0.141 cm, respectively. A positive correlation was found between the transverse and vertical diameters of the fovea (Pearson’s correlation r=0.239), and a significant p-value (p<0.001) was also found between them. Conclusion: Knowledge of these variations may be useful for anatomists, radiologists, anthropologists, forensic experts, and orthopaedic surgeons when planning and executing hip replacement surgeries. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Keywords : Femur head, Hip prosthesis, Measurements, Round ligament of femur | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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DOI and Others :
DOI: 10.7860/IJARS/2024/73564.3016
Date of Submission: Jun 14, 2024 Date of Peer Review: Jul 26, 2024 Date of Acceptance: Aug 19, 2024 Date of Publishing: Sep 01, 2024 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was Ethics Committee Approval obtained for this study? Yes • Was informed consent obtained from the subjects involved in the study? NA • For any images presented appropriate consent has been obtained from the subjects. NA PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Jun 14, 2024 • Manual Googling: Aug 12, 2024 • iThenticate Software: Aug 17, 2024 (14%) Etymology: Author Origin Emendat ions: 6 |
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| INTRODUCTION |
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The proximal end of the femur is an important anatomical modification in human beings, with significant clinical relevance in hip prosthesis and hip arthroplasty. To minimise postoperative complications and ensure the accurate sizing of prosthesis, the geometry of the proximal femur is a crucial parameter (1),(2). Various radiological studies have provided valuable information regarding the clinical diagnosis and surgical intervention related to the proximal end of the femur (3),(4),(5). In addition to the various parameters of the proximal femur, the Fovea Capitis Femoris (FCF) also plays an important clinical role. It is located posterior-inferior to the center of the femoral head and is characterised by a surface depression that provides attachment for the ligamentum teres femoris (6). Sports-related injuries to this ligament may be diagnosed presurgically by observing fractures at the site of the FCF. This ligament serves as a conduit for blood vessels (the acetabular branch of the obturator artery and the medial circumflex femoral artery) that supply the central part of the femoral head. Since, the FCF is the pathway through which blood vessels travel to supply the femoral head, it is a potential factor in the development of avascular necrosis of the femoral head (7). Zhao K et al., revealed an association between osteonecrosis and the narrowing of nutrient foramina in the fovea (8). Furthermore, a detailed analysis of the position of the fovea and its various measurements is required during the reconstructive surgery of the ligamentum teres femoris (9). This anatomical knowledge is also essential for the radiographic evaluation of hip dysplasia and can serve as a landmark in hip arthroscopy (3),(10). There is a gap in the evidence regarding the most common position of the fovea, as indicated by previous studies by Perumal V et al., and Golpinar M, (posteroinferior position) [11,12], in contrast to the findings of Esra SE et al., (posterosuperior position) (7). Methodological gaps have been noted in earlier studies concerning the morphometry and/or morphology of the fovea, which utilised calipers (13), calipers with digital software (7), and Computed Tomography (CT) images (3). Additionally, there is a population gap in the studies conducted, as some were carried out outside India (4),(11),(12),(14),(15), while only a few were conducted within India (13),(16),(17). Moreover, the Indian studies Gupta M et al., and Panda D et al., focused on the morphometry of the fovea, highlighting the need for further thorough analysis (13),(17). Therefore, the present study aimed to provide a detailed record of the morphological and morphometric measurements of the FCF (including shape, position, depth, and both transverse and vertical diameters) and the femoral head (transverse and vertical diameters) in the West Bengal population. The present research will contribute to the existing knowledge of anatomists, radiologists, and surgeons in the region and will serve as a foundation for future studies. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Material and Methods |
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A cross-sectional study was conducted on 297 dry femora in the Department of Anatomy at Medical College, Kolkata, West Bengal, India, from October 2023 to February 2024. Ethical clearance was obtained (MC/KOL/IEC/NON-SPON/2203/09/2023 dated 29.09.2023). Inclusion criteria: Adult dry femora from both sides were selected for present study. Exclusion criteria: Femora with diseases, surgical resections, or any distortion or breakage of the proximal end during storage were excluded from the study. Sample size calculation: Sample size was calculated by using the formula: n’= n/1+z2×p(1-p)/?2N Where: Z is the z-score, E is the margin of error, N is the population size, and p is the population proportion. Assuming a population proportion of 50%, a 90% level of confidence, and a margin of error of 5%, this study required a minimum sample size of 273 (18). However, from October 2023 to February 2024, 297 dry bones were collected for the study. Study Procedure To determine the morphometric measurements of the fovea of the femur, the method used by Golpinar in his study was adopted in the present research (12). A vernier caliper, calibrated up to 5 inches (12.5 cm) with an accuracy of 0.001 cm, was employed to measure all parameters of the fovea and the head of the femur (Table/Fig 1)a,b. Tools and techniques: Visual inspection and categorisation of shape were conducted according to the methodology described by Perumal V et al., for the morphologic pattern of the fovea (11). A vernier caliper was used for the morphometric measurements of the fovea and the head of the femur. Statistical Analysis The collected data was entered into an Excel sheet and organised and summarised using descriptive statistics. It was analysed using Jamovi software (free version). Correlation was sought between various parameters of the fovea and femoral head, namely the vertical and transverse diameters of the fovea and femoral head, using the Pearson’s correlation formula. A p-value of <0.05 was considered statistically significant. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Results |
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The mean values of the Transverse Diameter of the Fovea (TDF), Vertical Diameter of the Fovea (VDF), and Depth of the Fovea (DF) were 1.53±0.367 cm, 1.28±0.303 cm, and 0.304±0.141 cm, respectively (Table/Fig 2). Although the total sample size was 297, DF could not be measured for 52 dry femora due to the shallowness of the fovea (DF <0.01 cm, which is the least count of the vernier caliper) (Table/Fig 3)a,b. A positive correlation was found between the transverse and vertical diameters of the fovea (Pearson’s r=0.239). A negative correlation was observed between DF and both the vertical and transverse diameters of the fovea (Table/Fig 4). The most common shape was the oval type (45.45%), while the least common shape was the irregular type (2.69%) (Table/Fig 5),(Table/Fig 6)a-d. The most common location of the fovea was found in the posteroinferior quadrant (88.55%) (Table/Fig 7),(Table/Fig 8)a-e. The mean values of the transverse diameter and vertical diameter of the head of the femur were 4.16±0.389 cm and 4.15±0.0217 cm, respectively (Table/Fig 9). A positive correlation was found between the transverse diameter of the fovea and both the transverse diameter of the head of the femur (p-value=0.002) and the vertical diameter of the head of the femur (p-value <0.001). Additionally, a positive correlation was also observed between the transverse and vertical diameters of the head of the femur (p-value <0.001) (Table/Fig 10). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discussion |
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The FCF provides an attachment for the ligamentum teres femoris, through which blood vessels reach the center of the head of the femur and supply it. This was reiterated by the study of Perumal V et al., who observed several vascular foramina at the site of attachment of the ligamentum teres femoris, which conveyed vessels to supply the central part of the head of the femur. Such findings highlight the clinical importance of the FCF (11). Previous studies regarding the morphometry of the FCF and its position in the hip joint have revealed several surgical and clinical implications. In their study, Acar N et al., observed that the diameter of the fovea increased with the ageing process, which might be attributed to the degeneration of the perifoveal thin cartilage accompanying ageing (4). Unlike Acar N et al., the present study failed to demonstrate any association between changes in foveal diameter and the ageing process (4). The study by Boymans TAEJ et al., suggested a mediocaudal shift of the femoral head and neck during ageing (19). Bertsatos A et al., stated in their article that the FCF acted as an important marker during the evaluation of hip dysplasia (15), while the studies of Beltran LS et al., and Luthra JS et al., reiterated an association between hip dysplasia and a higher position of the FCF in the femoral head (5),(20). In the Pipkin classification of femoral injuries, the type of injury (Type I and Type II) is categorised by the position of the fracture in relation to the FCF (21). The localisation of the FCF could guide the rotational position of the femoral head during the fixation of femoral neck fractures (3),(22). The position of the fovea is an important parameter to consider during the management of patients with fractures of the proximal end of the femur. Ross JR and Gardner MJ concluded in their study that conservative treatment was acceptable in cases of fracture of the head of the femur if the reduction of the fracture fragment was achieved and the location of the fracture was below the position of the fovea (2). In the femoral tunnel drilling technique for ligamentum teres femoris reconstruction, the channel passes through the center of the FCF (15),(23). The Hip Rotation Center (HRC) and the localisation of the FCF are important factors in determining the clinical outcome after total hip replacement (24). Gupta M et al., studied 96 intact femora and observed a mean foveal depth of 2.95±0.75 mm, with mean foveal transverse and longitudinal diameters of 11.38±2.35 mm and 15.94±3.37 mm, respectively (13). This observation closely resembles that of the present study; however, the mean transverse diameter of the fovea in the present study was greater than that found in the study by Golpinar M (TD=10.23±1.52 mm) (12). In addition, the present study recorded a remarkable finding in 52 femora (17.5%), where the foveal depth could not be measured using vernier calipers due to its shallow nature. Acar N et al., also observed shallow fovea capitis (depth <2 cm) in 3.2% of examined foveae, which they termed fovea plana (4). The most common shape of the fovea recorded in this study was oval (45.45%). This finding corroborates similar findings from many previous studies, where the most common shape was found to be oval (11),(12),(14). Additionally, the present study observed an irregular shape of the fovea in 2.69% of femora, similar to the findings of Bertsatos A et al., (15). Like the studies by Perumal V et al., Golpinar M, Yarar B et al., (11),(12),(14), the present study revealed that the most common position of the fovea with respect to the femoral head is in the Posteroinferior quadrant. This contrasts with the study by Esra SE et al., where the most common position was found to be the posterosuperior quadrant (7). In the present study, the mean values of the transverse and vertical diameters of the head of the femur were found to be 4.16±0.389 cm and 4.15±0.0217 cm, respectively. These values were less than those found in the study by Chowdhury MS et al., where the transverse and vertical diameters of the head of the femora were 5.82±0.19 cm and 5.84±0.42 cm in males, and 4.21±0.20 cm and 4.06±0.18 cm in females, respectively (25). Their study also revealed sexual variations in the morphometric measurements of the proximal end of the femur. Similar to the present study, the studies by Verma M et al., and Iyem C et al., reported mean values of femoral head diameter to be 42.32±4.11 mm and 48.1±3.7 mm, respectively (16),(26). Contractor JB et al., conducted a study on 94 dry femora in Indian population and revealed the significant variation of different parameters in proximal end of femur and importance of considering racial diversity during selection of implants in total hip arthroplasty for improving the longevity of this procedure (27). Zhao K et al., proved in their study that defective nutrient foramina might be an indicator of Osteonecrosis of the Femoral Head (ONFH) (8). Mukhia R et al., studied a total of 75 femora from the Nepalese population and recorded a mean diameter of 13.05±0.9 cm for the femoral head (28). The results of their study reflected differences in the morphometry of the femoral head among populations in other countries, including the present study population. Additionally, Verma M et al., stated in their study that European data-based prosthesis were mismatched for Indians (16). The exact size of the prosthesis could be determined from established data from the Indian population. Similar previous studies have observed that morphometric measurements of the femoral head are important for obtaining the accurate size of the prosthesis (29),(30). An overview of the different parameters of the femoral head and fovea in the present study, comparing them with other studies conducted in India and international datasets has been depicted in (Table/Fig 11) (11),(12),(13),(14). This table highlights the differences in various parameters of the fovea and the femoral head. Limitation(s) Although the present study had a sample size of 297, the shallow Depth of Fovea (DF) (<0.01 cm) in 52 femora could not be measured with vernier calipers, which presents a major limitation. Additionally, since this study was conducted at a medical college in Kolkata, West Bengal, it may not be representative of the entire Indian population. Therefore, it is recommended that multicentric studies with larger sample sizes be conducted in the future to establish standardised national values. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Acknowledgement |
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The authors would like to extend their heartfelt thanks to the Head of Department of Anatomy, Medical College, Kolkata, for his support during conduction of their research and acknowledge their deep gratitude to all the persons whose body donations made the research possible. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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