DCIA (DEEP CIRCUMFLEX ILIAC ARTERY) FLAP

ANATOMY
‡ Hip Bone
± Made of three bones fused in a Y-shaped epiphysis involving acetabulum (hip joint socket), a concave hemisphere ± Pubis and ischium form incomplete bony wall for pelvic cavity, their outer surface gives attachment to the thigh muscles ± Ilium forms a brim between the hip joint and the joint with the sacrum

‡ Anterior 2/3 is thin bone forming iliac fossa, posterior abdominal wall ‡ Posterior 1/3 is thick bone and carries articular surface for sacrum ‡ Ilium is nearly at right angle to other two bones

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‡ Outer surface rises wedge-shaped along anterior border to anterior superior iliac spine ‡ Behind acetabulum, it passes up as a thick bar of weight-bearing bone and curves back to posterior superior iliac spine ‡ It is attachment of muscles of buttock: Gluteus minimus, medius and maximus

has a bold upward convexity and curve from front backward in a sinuous bend ‡ Anterior part is curved outwards and it s external rim has a more prominent convexity behind the anterior superior iliac crest spine. iliac crest.‡ Upper border between anterior and posterior superior iliac spines. the iliac tubercle .

‡ Gluteal surface: ± Convex in front. conforming to curvature of iliac crest ‡ Anterior border: ± Shows a gentle S-shaped bend ± Sartorius muscle is attached a finger breadth below anterior spine ‡ Posterior part of crest is thicker than rest ‡ Inner surface: ± Iliac fossa shows a gentle concavity and is paper thin in its deepest part ± Iliacus muscle and fascia are attached to inner lip of crest over whole area . concave behind.

5 cm.7 cm through tubercle ‡ Bone becomes progressively thinner posterior to tubercle. thickness of crest 2 cm posterior to anterior superior iliac spine is 1. increases to 1. until region of sacroiliac articulation is reached .‡ For an "average" pelvis.

MUSCLES AND LIGAMENTS AROUND THE HIP BONE .

Iliacus ‡ Origin: Anterior inferior iliac spine and inner lip of iliac crest ‡ Insertion: Lesser trochanter of femur ‡ Function: Flexes hip joint ‡ Nerve supply: Femoral nerve .

Gluteus maximus ‡ Origin: Outer surface of ilium behind posterior gluteal line ‡ Insertion: Gluteal tuberosity of femur ‡ Function: Extenses hip joint ‡ Nerve supply: Inferior gluteal nerve (L5. S2) . S1.

S1) .Gluteus medius ‡ Origin: External surface of ilium between anterior and posterior gluteal lines ‡ Insertion: Lateral surface of greater trochanter of femur ‡ Function: Extenses hip joint ‡ Nerve supply: Superior gluteal nerve (L4. L5.

S1) . L5.Gluteus minimus ‡ Origin: External surface of ilium between anterior and posterior gluteal lines ‡ Insertion: Antero-lateral surface of greater trochanter of femur ‡ Function: Extenses hip joint ‡ Nerve supply: Superior gluteal nerve (L4.

S1) .Tensor fascia lata ‡ Origin: Lateral aspect of iliac crest between anterior superior iliac spine and iliac tubercle ‡ Insertion: Ilio-tibial tract ‡ Function: Stabilizes knee during extension ‡ Nerve supply: Superior gluteal nerve (L4. L5.

Internal oblique ‡ Origin: Inguinal ligament. lower border of last 4 ribs ‡ Function: unilateral contraction rotates vertebral column to same side ‡ Nerve supply: Iliohypogastric nerve. Ilioinguinal nerve . iliac crest ‡ Insertion: Xiphoid process of sternum.

providing thoracic and pelvic stability ‡ Nerve supply: iliohypogastric nerve. inguinal ligament ‡ Insertion: Xiphoid process of sternum ‡ Function: Compresses ribs and viscera.Transverse abdominis ‡ Origin: Iliac crest. ilioinguinal nerve .

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NERVES AROUND THE HIP BONE .

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DEEP CIRCUMFLEX ILIAC ARTERY .

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SCIA: Superficial Circumflex Iliac Artery .SIEA: Superficial Inferior Epigastric Artery.

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running along posterior margin of inguinal ligament in a fibrous tunnel formed by line of attachment of transversalis fascia and iliacus fascia .‡ Also known as arteria circumflexa iliaca profundata ‡ DESCENDING AORTA ABDOMINAL AORTA COMMON ILIAC ARTERY EXTERNAL ILIAC ARTERY DEEP CIRCUMFLEX ILIAC ARTERY ‡ Arises from lateral surface of external iliac artery just above inguinal ligament ‡ It then passes obliquely upward and laterally in a straight line toward anterior superior iliac spine.

and supplies vasculature to the overlying skin ‡ Average diameter: 2 mm (1.5 . it gives rise to a number of branches ‡ It pierces transversalis fascia and makes a gentle curve as it passes backward along anterior half of inner lip of the iliac crest ‡ It then pierces transversus abdominis muscle to anastomose with iliolumbar. superior gluteal and intercostal arteries.‡ As it approaches anterior superior iliac spine.3 mm) .

DCIA FLAP .

lower extremity and mandible ‡ Can provide a large segment of cancellous bone up to 15 cm long and 6 cm wide ‡ No motor or sensory reconstruction possible .‡ Osseomyocutaneous flap ‡ Provides a large concave segment of bone suitable for reconstruction of upper extremity.

2 to 3 mm ‡ Vein caliber.VASCULAR PEDICLE ‡ Deep circumflex iliac artery from lateral aspect of external iliac artery ± 1-2 cm cephalic to inguinal ligament ‡ Ascending branch of deep circumflex iliac artery supplies internal oblique muscle ‡ Deep circumflex iliac vein: ± 2 venae comitantes ± Can pass either superficial to deep to artery ‡ Artery caliber.3 to 5 mm ‡ Pedicle length: 4-7 cm .

course of iliac vessels is noted and a point 1 cm above inguinal ligament in line of iliac artery acts as surface marker for origin of DCI vessels ‡ A line is then drawn parallel to inguinal ligament towards anterior superior iliac spine to mark course of pedicle.TECHNIQUE ‡ Anterior superior iliac spine. pubic tubercle and line of inguinal ligament are marked ‡ Femoral vessels are palpated. and if skin is required. its extent is also marked .

and as anterior superior iliac spine is approached. which pierces transverse abdominus and internal oblique muscles. and supplies both of them ‡ Main branch continues on iliacus in a groove between it and transversalis fascia . ascending branch of DCIA is identified.‡ A transinguinal approach over external iliac artery allows identification of inferior epigastric artery which acts as a marker for DCIA ‡ Pedicle is identified and followed.

appropriate bony cuts can be made to remove bone and flap as required . lateral dissection completed by dividing origin of fascia lata and attachment of gluteal muscles to reach outer plate of iliac bone ‡ Medially. skin is incised down to external oblique fascia.‡ Both these branches need to be preserved and once identified. which is incised parallel to iliac crest along with internal oblique and transversus muscles ‡ Vascular pedicle lies attached to iliacus and inner plate of iliac bone ‡ Once both sides of iliac bone have been exposed.

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unicortical bone preserves contour of the iliac crest .iliac crest is exposed and ilacus muscle is scored to circumscribe area of bone harvest Full thickness bicortical graft is optional.

Cortical cap is hinged on inner table and reflected to expose the cancellous bone to be harvested .Method of harvesting iliac crest bone graft.

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COMPLICATIONS ‡ Postoperative pain at donor site ‡ Nerve injuries ± Sciatic nerve ± Ilioinguinal nerve ± Femoral nerve ± Superior gluteal nerve ‡ Vascular injuries ‡ Abdominal herniation ‡ Hematoma .

COMPLICATIONS ‡ ‡ ‡ ‡ ‡ ‡ ‡ Infection Pelvic instability Gait disturbance Cosmetic deformity Sacro-iliac joint injury Stress fracture Paralytic ileus .

THANK YOU .

DCIA (DEEP CIRCUMFLEX ILIAC ARTERY) FLAP .