Research Article

Course of the Femoral Artery in the

Mid- and Distal Thigh and
Implications for Medial Approaches
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to the Distal Femur: A CT

Angiography Study
WnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 04/12/2024

Jed I. Maslow, MD
Cory A. Collinge, MD
From the Vanderbilt University
Medical Center, Nashville, TN.
Correspondence to Dr. Maslow:
jed.i.maslow@vanderbilt.edu
Dr. Collinge or an immediate family
member has received IP royalties
from Advanced Orthopaedic
Solutions, Zimmer Biomet, and
Abstract
Introduction: Unfamiliarity with the location of the femoral artery in
the medial thigh has tempered surgeons’ enthusiasm for medial
approaches to the distal femur. The purpose of this study was to
define the relationship of the femoral artery to the mid- and distal
femur to assist in safely approaching the femur for fracture care.
Methods: Fifteen patients undergoing CT with angiography (CTA) of
the lower extremity (CTA) were evaluated. From three-dimensional
CTA images, the distance of the artery at the anterior border,
midsagittal line, and posterior border of the femur from the distal femur
at both the adductor tubercle and medial femoral condyle was
measured.
Results: The average distances of the adductor tubercle to the
femoral artery were 23.2 cm (63.3), 18.8 cm (63.4), and 14.3 cm
(64.1) at the level of the anterior border, midsagittal line, and
posterior border of the femur, respectively. The descending genicular
artery (DGA) originated 10.8 cm (61.3) proximal to the adductor
tubercle.
Discussion: A wide safe zone exists in the medial distal femur. The
artery crosses the midsagittal axis of the medial femur an average of
18.8 cm proximal to the adductor tubercle.

Synthes; serves as a paid consultant
to Zimmer Biomet and Stryker; and
serves as a board member, owner,
officer, or committee member of the
Foundation of Orthopedic Trauma.
Neither Dr. Maslow nor any immediate
family member has received anything
of value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article.
J Am Acad Orthop Surg 2019;27:
e659-e663
DOI: 10.5435/JAAOS-D-17-00700
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
T
he femoral artery travels through
the thigh, branching into the
profunda femoris that supplies the
proximal musculature and the su-
perficial femoral artery that supplies
the leg and foot. As described in
the Hoppenfeld iconic surgical ap-
proaches text, “the artery changes
position in relation to the femur; it
is anterior to it at its upper end,
medial to it at its middle portion,
and behind it at its lower end.”1
Importantly, the superficial femoral
artery (or simply, femoral artery)
travels with the femoral nerve and
the saphenous nerve, which are also
vulnerable to injury. Most ortho-
paedic surgeons can recite detail
that the femoral artery exits from
the “Hunter canal” in the medial
thigh, which runs between the ex-
tensor and adductor compartments
of the thigh, roofed by the Sartorius
muscle and its fascia. We, however,
hypothesized that few surgeons really
understand where the Hunter canal
lies and the course of the artery in the
distal thigh after it exits. The end
result is an appreciation that the
femoral artery may be vulnerable to

July 15, 2019, Vol 27, No 14 e659

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Femoral Artery Course in the Distal Thigh

Figure 1 Figure 2
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Radiographs showing the distance measured to the femoral artery from the
adductor tubercle (A) and medial joint line (B) at the anterior femoral cortex, the
midsagittal point, and the posterior femoral cortex.

invasive or conventional joint arthro- manipulated into a perfect lateral

Three-dimensional image
manipulated to show a perfect lateral
view of the femur.
injury during medial approaches to
the femur.
Most surgical approaches to the
mid- and distal femur are from the
lateral or anterolateral side. Most
fracture textbooks avoid discussion
of medial approaches to the distal
thigh, although medial approaches to
the knee are described in many Sports
Medicine and Arthroplasty books.
Other than trauma, the clinical sce-
narios requiring knowledge of this
approach and anatomy include
tumor resection and reconstruction,
medial osteotomy for lateral com-
partment arthritis, and minimally
plasty.2-7 In contrast to fracture care,
more extensile approaches cranially
in these settings are rarely indicated.
The purpose of this study is to define
the anatomic relationship of the
femoral artery to the mid- and distal
femur.
Methods
Fifteen consecutive patients under-
going CT with angiography (CTA) of
the bilateral lower extremities from
November 2015 to January 2016
were included. Patients with a pelvic
or thigh fracture, a poor-quality
CTA with inability to visualize vas-
cularity, or age less than 18 years
were excluded. All 30 limbs were
evaluated using two-dimensional
(2D) and three-dimensional (3D)
reconstructions (Philips Brilliance
Workspace 4.0). 3D images were
image to superimpose the femoral
condyles (Figure 1). There were
eight men and seven women with an
average age of 50 years (range, 25
to 80 years).
The distance to the femoral artery
from the adductor tubercle and
the distal aspect of the medial fem-
oral condyle (medial joint line)
at the level of the anterior femoral
cortex, midsagittal line, and poste-
rior femoral cortex as seen on
a medial view was measured
(Figure 2, A and B). At these points,
the perpendicular distance to the
femoral artery from the medial
femoral cortex was measured
(Figure 3). In addition, the distance
to the descending genicular artery
(DGA) branch from the adductor
tubercle was also measured using
perfect AP and medial-lateral views
(Figure 4).

e660 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Jed I. Maslow, MD and Cory A. Collinge, MD

Continuous variables were assessed Figure 3

with a Student t-test. For all analyses,
P , 0.05 was considered statistically
significant. Parametric continuous
variables were reported as a mean
6 SD. Nonparametric variables
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were reported as a median and

range.
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Results
The average distance to the femoral
artery from the adductor tubercle
was 23.2 cm (63.3), 18.8 cm (63.4),
and 14.3 m (64.1) at the level of the
anterior, midsagittal, and posterior
femur, respectively (Table 1). The
average distance to the femoral
artery from the distal aspect of the
medial femoral condyle was 27.4 cm
(63.4), 22.7 cm (63.4), and 18.7 cm
(64.6) at the level of the anterior,
midsagittal, and posterior femur, Radiographs showing (A) the perpendicular distance from the medial femoral
respectively. The distance to the cortex to the femoral artery at the afrorementioned anterior, midsagittal, and
femoral artery from the medial posterior femoral cortex points in B.
femoral cortex at these points was an
average of 3.3 cm (60.8), 3.1 cm
(60.8), and 3.1 cm (60.9), respec- Figure 4
tively. In this zone, the femoral artery
is bounded by the vastus medialis,
the sartorius, the adductor longus,
and adductor magnus as it travels
through the adductor hiatus. The
distance to the origin of DGA from
the adductor tubercle was on aver-
age 10.8 cm (61.3). No statistically
significant difference by sex was
found (P = 0.3).

Discussion
A danger zone along the medial
aspect of the thigh can be identified
18.8 cm above the adductor tubercle
where the femoral artery crosses the AP (A) and lateral (B) radiographs of the descending geniculate artery branch
midsagittal axis of the femur. The and measurement to the branch origin from the adductor tubercle.
femoral artery follows an oblique
course from anterior-superior to
posterior-inferior relative to the Kim et al8 assessed 30 patients using course in the thigh, coming closest
femur. The DGA begins 10.8 cm from 2D CTA and found that the femoral (12 mm) when the location was more
the adductor tubercle and can be a artery was .12 mm (range, 12.2 to posterior and distal. They concluded
source of bleeding. 38.0 mm) from the femur along its that the anteromedial aspect of the

July 15, 2019, Vol 27, No 14 e661

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Femoral Artery Course in the Distal Thigh
Table 1
Femoral Artery to Femur Distance
Distance to the Adductor
Anatomic femur level
Anterior femur
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Midsagittal femur
Posterior femur
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Average measured distances (mm) from the femoral artery to bony landmarks at respective anatomical femur levels.
femur can be considered a safe zone
for minimal invasive plate osteosyn-
thesis (MIPO). In addition, Jiamton
and Apivatthakakul9 evaluated 10
cadavers with CTA after the MIPO
technique and noted no disruptions of
the superficial or deep femoral ar-
teries. The plate averaged 16.3 mm
from the femoral artery (range, 8.3 to
27.2 mm). They similarly concluded
that the distal 60% of the femoral
length is safe to approach medially.
Kanawati and Narulla10 performed
a similar examination of the Super-
ficial Femoral Artery using 2D CTA
to describe a relative “danger zone.”
This zone is where the artery travels
medial to the shaft of the femur and
would theoretically be at risk during
medial or lateral fixation of the
femur. Evaluating 41 limbs from 16
men and 6 women, the danger zone
was described as 239.6 mm (639.8)
proximal to the adductor tubercle to
172.5 mm (640.9). Although our
data compared reasonably well,
with a “danger zone” 232.1 mm
(633.0) to 142.6 mm (640.6) prox-
imal to the adductor tubercle, the
larger range may be attributed to a
difference in demographics (more
female and younger age in our study)
or the measurement technique.
Understanding the course of the
femoral neurovascular bundle in the
medial thigh is critical for fracture
care, especially in circumstances
where minimally invasive approaches
are contraindicated or extended to
open approaches.11,12 The adductor
tubercle and medial femoral condyle
e662
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Distance to the medial
Tubercle (mm) joint line (mm)
232.1 6 33.0 273.8 6 34.1
188.0 6 34.2 226.6 6 34.2
142.6 6 40.6 186.7 6 46.3
are landmarks that are palpable or
easy to see on intraoperative fluo-
roscopy. Importantly, if a more
extensile approach to the medial
femur is performed, one can expect
the DGA is approximately 11 cm
proximal to the adductor tubercle
traveling distally. This arterial branch
can be a source of bleeding, and, if
expected, can be appropriately pro-
tected or cauterized.13-15
There are limitations to this study.
We were unable to directly visualize
the femoral nerve and vein using the
3D CTA software, although these
were assumed to travel with the
femoral artery. Some variation can
reasonably be expected in the indi-
vidual course of these structures.
Another limitation is that the position
of the femoral artery in our study is
dependent on an intact femur. In
surgery for fractures, local neuro-
vascular structures may be displaced
from their normal anatomic posi-
tions. As such, surgeons approaching
the medial femur in fracture care
should use these data as a general
reference to the location of the fem-
oral artery but be aware that the true
intraoperative position may differ in
the setting of trauma.
In conclusion, a medial or MIPO
approach to the distal femur may be
performed within a relatively large
safe zone; the artery does not cross
the midsagittal axis of the medial
femur until an average of 19 cm
above the adductor tubercle. The
DGA, a sizable branch of the femoral
artery, branches from the femoral
Journal of the American Academy of Orthopaedic Surgeons
Distance to the medial
femoral cortex (mm)
32.8 6 8.1
31.1 6 7.6
30.7 6 8.7
artery 10.8 cm from the adductor
tubercle and travels distally over the
medial femur toward the vastus me-
dialis: this artery will be encountered
during open medial approaches.
Understanding the anatomy of the
medial thigh will allow surgeons to
approach and treat all variations of
fractures.
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