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

• Upper border between anterior and posterior superior iliac spines, iliac crest, 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, the iliac tubercle

• Gluteal surface:– Convex in front, concave

behind, 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

• For an "average" pelvis, thickness of crest 2 cm posterior to anterior superior iliac spine is 1.5 cm; increases to 1.7 cm through tubercle

• Bone becomes progressively thinner posterior to tubercle, until region of sacroiliac articulation is reached

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, S1, S2)

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)

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, L5, 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, S1)

Internal oblique

• Origin: Inguinal ligament, iliac crest

• Insertion: Xiphoid process of sternum, lower border of last 4 ribs

• Function: unilateral contraction rotates vertebral column to same side

• Nerve supply: Iliohypogastric nerve, Ilioinguinal nerve

Transverse abdominis

• Origin: Iliac crest, inguinal ligament

• Insertion: Xiphoid process of sternum

• Function: Compresses ribs and viscera, providing thoracic and pelvic stability

• Nerve supply: iliohypogastric nerve, ilioinguinal nerve

NERVES AROUND THE HIP BONE

DEEP CIRCUMFLEX ILIAC ARTERY

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

• 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, running along posterior margin of inguinal ligament in a fibrous tunnel formed by line of attachment of transversalis fascia and iliacus fascia

• As it approaches anterior superior iliac spine, 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, and supplies vasculature to the overlying skin

• Average diameter: 2 mm (1.5 - 3 mm)

DCIA FLAP

• Osseomyocutaneous flap• Provides a large concave segment of bone suitable

for reconstruction of upper extremity, 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

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- 2 to 3 mm• Vein caliber- 3 to 5 mm• Pedicle length: 4-7 cm

TECHNIQUE• Anterior superior iliac spine, pubic tubercle and

line of inguinal ligament are marked• Femoral vessels are palpated, 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, and if skin is required, its extent is also marked

• 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, and as anterior superior iliac spine is approached, ascending branch of DCIA is identified, 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

• Both these branches need to be preserved and once identified, 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, 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, appropriate bony cuts can be made to remove bone and flap as required

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

Method of harvesting iliac crest bone graft.Cortical cap is hinged on inner table and

reflected to expose the cancellous bone to be harvested

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