Clinical Anatomy 27:915–919 (2014)
ORIGINAL COMMUNICATION
Redefining the Surface Anatomy of the Saphenofemoral Junction In Vivo S. ALI MIRJALILI, JILL C. MUIRHEAD,
AND
MARK D. STRINGER*
Department of Anatomy, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
The surface anatomy of the saphenofemoral junction (SFJ) is especially relevant to surgeons. It is variably described in contemporary anatomy and clinical texts but is usually stated to lie 2.5–4 cm below and lateral to the pubic tubercle. The aim of this study was to map the SFJ accurately in healthy adults using ultrasound. One hundred healthy adults (mean age 27 years; 64 men) were scanned by an experienced sonographer using a 13–5 MHz linear probe. The center of the SFJ was recorded bilaterally in relation to the most superficial point of the pubic tubercle. The SFJ was readily identified in all participants. Its center was a mean of 2.4 6 0.6 cm lateral (range 1–4.5 cm) and 1 6 0.9 cm inferior to the pubic tubercle (range 2.5 above to 4 cm caudal to it). The junction was inferior to the pubic tubercle in 90% of lower limbs and at or above that level in 10%. In men, the SFJ was a mean of 2.6 cm lateral to the pubic tubercle and 1.2 cm inferior to it, compared with 2.2 and 0.6 cm, respectively, in women (P < 0.001). The SFJ was also slightly nearer the pubic tubercle in younger and thinner participants (P < 0.01). The center of the SFJ lies in a square extending 1–4 cm lateral and up to 3 cm below the pubic tubercle in >90% of adults. The junction is slightly closer to the pubic tubercle in women. These results provide a more robust guide to the surface anatomy of the normal SFJ. Clin. Anat. 27:915–919, 2014. VC 2014 Wiley Periodicals, Inc. Key words: surface anatomy; saphenofemoral junction; varicose veins
INTRODUCTION It is estimated that varicose veins affect the lower limbs in more than 25% of adults (Beebe-Dimmer et al., 2005; Kelleher et al., 2012). In addition to cosmetic concerns, varicose veins cause symptoms that adversely affect quality of life and predispose to serious complications such as deep vein thrombosis and venous ulceration. Although endovenous ablation is becoming increasingly popular, surgical high ligation of the great saphenous vein (GSV) close to the saphenofemoral junction (SFJ) is still widely performed as part of the surgical management of the condition (Nesbitt et al., 2011). Long-term recurrence rates after surgery have been reported to be as high as n and 45% (Sarin et al., 1992; Negus, 1993; Nelze Fransson, 2013). Reasons for recurrence include failure to ligate the GSV close to the SFJ and failure to ligate and divide all GSV tributaries in that region (Donnelly et al., 2005; Vaz et al., 2013). Accurate knowledge of the surface anatomy of the SFJ and its
C V
2014 Wiley Periodicals, Inc.
variability is therefore important when operating on this junction. Anatomical variations of the tributaries of the GSV have been well documented using ultrasound in normal adults and by dissection in patients with varicose veins and in cadavers (Donnelly et al., € hlberger et al., 2009; Hemmati et al., 2012; 2005; Mu
*Correspondence to: M.D. Stringer; Department of Anatomy, Otago School of Medical Sciences, University of Otago, P.O. Box 913, Dunedin, New Zealand. E-mail: [email protected] Disclosure: The authors have no conflict of interest. Preliminary results presented at the 30th Annual Meeting of the American Association of Clinical Anatomists, Denver, Colorado, USA, July 9–13, 2013. Received 29 September 2013; Revised 24 January 2014; Accepted 1 February 2014 Published online 20 March 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ca.22386
916
Mirjalili et al.
TABLE 1. Textbook Descriptions of the Surface Marking of the Saphenofemoral Junction References
Surface marking(s)
Schwartz’s Principles of Surgery (Brunicardi, 2009)
“. . .approximately 4 cm inferior and lateral to the pubic tubercle.” “. . .1 cm above and parallel to the groin crease. This location provides . . . most reliable access to the saphenofemoral junction.” “. . .3 cm lateral to a point just distal to the pubic tubercle” 3 or 3.5 cm “below and lateral to the pubic tubercle” “. . .3.75 cm lateral and 3.75 inferior to the pubic tubercle” “. . .3–4 cm inferior and just lateral to the pubic tubercle” “. . .2.5 cm below the inguinal ligament . . . immediately medial to the femoral pulse”
Rutherford’s Vascular Surgery (Cronewett and Johnston, 2010) Gray’s Anatomy (Standring, 2008) Last’s Anatomy (Sinnatamby, 20111) Clinically Oriented Anatomy (Moore et al., 2013) Surface Anatomy (Lumley, 2008) Clinical Anatomy (Ellis and Mahadevan, 2012)
Dickson et al., 2013; Vaz et al., 2013), but the surface anatomy of the SFJ has been neglected. The surface marking of the SFJ is variably described in contemporary texts on general surgery (Brunicardi et al., 2009), vascular surgery (Cronewett and Johnston, 2010), and anatomy (Lumley, 2008; Standring, 2008; Drake et al., 2010; Sinnatamby, 2011; Ellis and Mahadevan, 2012; Moore et al., 2013). In some texts, the SFJ is stated to lie 3 or 3.5 cm “below and lateral to the pubic tubercle” (Sinnatamby, 2011) or “approximately 4 cm inferior and lateral to the pubic tubercle” (Brunicardi, 2009), but whether these descriptions refer to a diagonal distance or a point that is both 3–4 cm below and 3–4 cm lateral to the pubic tubercle is not clear. Other descriptions are summarized in Table 1. One text cites the femoral pulse as a guide (Ellis and Mahadevan, 2012), another the groin skin crease (Cronewett and Johnston, 2010), whereas another simply describes the general vicinity of the SFJ as just inferior to the medial end of the inguinal ligament (Drake et al., 2010). Early descriptions date back to the early nineteenth century and were probably based on cadaver dissections. For example, Quain 1828 described the junction as lying “an inch and a half [3.5 cm] below Poupart’s [inguinal] ligament.” The aim of this study was to map the SFJ in healthy adults using ultrasound to provide a more reliable evidence-based surface marking.
Mouse” sign (Fig. 1). The vascular structures were then confirmed using color Doppler imaging. The center of the SFJ and the most superficial point of the pubic tubercle were identified using ultrasound and marked on the skin, after which the following three measurements were recorded using a flexible linen tape measure: the craniocaudal distance between the pubic tubercle and the SFJ; the horizontal distance between the pubic tubercle and the SJF; and the diagonal distance between the pubic tubercle and the SFJ (Fig. 2). The relationship between the SFJ and groin skin crease was also noted. Data were analyzed using SPSS Statistics version 20.0.0 (SPSS, Chicago, IL). Differences between left and right sides were analyzed using a paired-samples t-test, differences between sexes using an independent-samples t-test, and associations with age and BMI by Pearson correlations. Intra-rater repeatability was assessed in 15 subjects by rescanning after an interval of at least 4 weeks with the researchers blinded to the original results. Intra-class correlation coefficients (ICCs) were calculated and graded according to the following criteria: poor agreement, 90% of healthy adults.
The authors thank the participants in this study and Robbie McPhee, medical illustrator and graphic artist, for assistance with Figures 2 and 3.
DISCUSSION
REFERENCES
To our knowledge, this is the first study to map the surface marking of the SFJ in healthy adults. On the basis of these findings, contemporary descriptions of the surface anatomy of the SFJ (Table 1) should be revised. The junction is more accurately represented as lying within a square between 1 and 4 cm lateral and 0–3 cm below the pubic tubercle in more than 90% of individuals (Fig. 3). The SFJ was above the level of the pubic tubercle in fewer than 10% of lower limbs; these were mostly on the left side and in women. Referencing the position of the SFJ to the groin skin crease (Cronewett and Johnston, 2010) is not recommended for several reasons: soft tissue reference points are more variable than bony landmarks, the groin skin crease is not always visible and can vary with adiposity, and whilst the SFJ corresponded to the groin crease in women it was variably related in men. There was no instance of a double or bifid GSV above mid-thigh level in our study, an anatomical variant that ought to be considered during varicose vein surgery (Donnelly et al., 2005). Whether this variant affects the precise position of the SFJ is unknown. Our study has a few minor limitations. The SFJ was scanned in the supine position, which is most surgically relevant. It is unlikely that the position of the SFJ
Brunicardi FC. 2009. Schwartz’s Principles of Surgery. 9th Ed. New York: McGraw-Hill. p 778. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. 2005. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 15:175–184. Cronewett JL, Johnston KW. 2010. Rutherford’s Vascular Surgery. 7th Ed. Philadelphia, PA: Saunders Elsevier. p 861. Dickson R, Hill G, Thomson IA, Van Rij. 2013. The valves and tributary of the saphenofemoral junction: ultrasound findings in normal limbs. Veins and Lymphatics 2:2. URL: http://www.pagepressjournals.org/index.php/vl/article/view/1727, last access: 29/09/2013. Donnelly M, Tierney S, Feeley TM. 2005. Anatomical variation at the saphenofemoral junction, Br J Surg 92:322–325. Drake RL, Vogl AW, Mitchell AWM. 2010. Gray’s Anatomy for Students. 2nd Ed. Philadelphia, PA: Churchill Livingstone. p 542. Ellis H, Mahadevan V. 2012. Clinical Anatomy: A Revision and Applied Anatomy for Clinical Students. 13th Ed. Oxford: Blackwell Publishing. p 264. Hemmati H, Baghi I, Talaei Zadeh K, Okhovatpoor N, Kazem Nejad E. 2012. Anatomical variations of the saphenofemoral junction in patients with varicose veins. Acta Med Iran 50:552–555. Kelleher D, Lane TR, Franklin IJ, Davies AH. 2012. Treatment options, clinical outcome (quality of life) and cost benefit (quality-adjusted life year) in varicose vein treatment. Phlebology 27 (Suppl 1):16–22. Landis JR, Koch GG. 1977. The measurement of observer agreement for categorical data. Biometrics 33:159–174.
Redefining the Surface Anatomy of the Saphenofemoral Junction In Vivo Lumley JSP. 2008. Surface Anatomy: The Anatomical Basis of Clinical Examination. 4th Ed. Edinburgh: Churchill Livingstone. p 100. Moore KL, Dalley AF, Agur AMR. 2013. Clinically Oriented Anatomy. 7th Ed. Philadelphia, PA: Lippincott Williams & Wilkins. p 558. € hlberger D, Morandini L, Brenner E. 2009. Venous valves and Mu major superficial tributary veins near the saphenofemoral junction. J Vasc Surg 49:1562–1569. Negus D. 1993. Recurrent varicose veins: A national problem. Br J Surg 80:823–824. Nesbitt C, Eifell RK, Coyne P, Badri H, Bhattacharya V, Stansby G. 2011. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Syst Rev 10:CD005624. n O, Fransson I. 2013. Varicose vein recurrence and patient Nelze satisfaction 10-14 years following combined superficial and per-
919
forator vein surgery: A prospective case study. Euro J Vasc Endovasc Surg 46:372–377. Quain J. 1828. Elements of Descriptive and Practical Anatomy: For Use of Students. London: W. Simpkin and R. Marshall. p 278. Sarin S, Scurr JH, Coleridge Smith PD. 1992. Assessment of stripping the long saphenous vein in the treatment of primary varicose veins. Br J Surg 79:889–893. Sinnatamby CS. 2011. Last’s Anatomy: Regional and Applied. Edinburgh: Churchill Livingstone Elsevier. p 119. Standring S. 2008. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th Ed. Edinburgh: Churchill Livingstone. p 1344, 1350, 1381. Vaz C, Machado R, Rodrigues G. 2013. Anatomical variation of the saphenofemoral junction—A prospective study in a population with primary superficial venous insufficiency. Angiol Cirurgia Vasc 9:1–5.
ORIGINAL COMMUNICATION
Redefining the Surface Anatomy of the Saphenofemoral Junction In Vivo S. ALI MIRJALILI, JILL C. MUIRHEAD,
AND
MARK D. STRINGER*
Department of Anatomy, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
The surface anatomy of the saphenofemoral junction (SFJ) is especially relevant to surgeons. It is variably described in contemporary anatomy and clinical texts but is usually stated to lie 2.5–4 cm below and lateral to the pubic tubercle. The aim of this study was to map the SFJ accurately in healthy adults using ultrasound. One hundred healthy adults (mean age 27 years; 64 men) were scanned by an experienced sonographer using a 13–5 MHz linear probe. The center of the SFJ was recorded bilaterally in relation to the most superficial point of the pubic tubercle. The SFJ was readily identified in all participants. Its center was a mean of 2.4 6 0.6 cm lateral (range 1–4.5 cm) and 1 6 0.9 cm inferior to the pubic tubercle (range 2.5 above to 4 cm caudal to it). The junction was inferior to the pubic tubercle in 90% of lower limbs and at or above that level in 10%. In men, the SFJ was a mean of 2.6 cm lateral to the pubic tubercle and 1.2 cm inferior to it, compared with 2.2 and 0.6 cm, respectively, in women (P < 0.001). The SFJ was also slightly nearer the pubic tubercle in younger and thinner participants (P < 0.01). The center of the SFJ lies in a square extending 1–4 cm lateral and up to 3 cm below the pubic tubercle in >90% of adults. The junction is slightly closer to the pubic tubercle in women. These results provide a more robust guide to the surface anatomy of the normal SFJ. Clin. Anat. 27:915–919, 2014. VC 2014 Wiley Periodicals, Inc. Key words: surface anatomy; saphenofemoral junction; varicose veins
INTRODUCTION It is estimated that varicose veins affect the lower limbs in more than 25% of adults (Beebe-Dimmer et al., 2005; Kelleher et al., 2012). In addition to cosmetic concerns, varicose veins cause symptoms that adversely affect quality of life and predispose to serious complications such as deep vein thrombosis and venous ulceration. Although endovenous ablation is becoming increasingly popular, surgical high ligation of the great saphenous vein (GSV) close to the saphenofemoral junction (SFJ) is still widely performed as part of the surgical management of the condition (Nesbitt et al., 2011). Long-term recurrence rates after surgery have been reported to be as high as n and 45% (Sarin et al., 1992; Negus, 1993; Nelze Fransson, 2013). Reasons for recurrence include failure to ligate the GSV close to the SFJ and failure to ligate and divide all GSV tributaries in that region (Donnelly et al., 2005; Vaz et al., 2013). Accurate knowledge of the surface anatomy of the SFJ and its
C V
2014 Wiley Periodicals, Inc.
variability is therefore important when operating on this junction. Anatomical variations of the tributaries of the GSV have been well documented using ultrasound in normal adults and by dissection in patients with varicose veins and in cadavers (Donnelly et al., € hlberger et al., 2009; Hemmati et al., 2012; 2005; Mu
*Correspondence to: M.D. Stringer; Department of Anatomy, Otago School of Medical Sciences, University of Otago, P.O. Box 913, Dunedin, New Zealand. E-mail: [email protected] Disclosure: The authors have no conflict of interest. Preliminary results presented at the 30th Annual Meeting of the American Association of Clinical Anatomists, Denver, Colorado, USA, July 9–13, 2013. Received 29 September 2013; Revised 24 January 2014; Accepted 1 February 2014 Published online 20 March 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ca.22386
916
Mirjalili et al.
TABLE 1. Textbook Descriptions of the Surface Marking of the Saphenofemoral Junction References
Surface marking(s)
Schwartz’s Principles of Surgery (Brunicardi, 2009)
“. . .approximately 4 cm inferior and lateral to the pubic tubercle.” “. . .1 cm above and parallel to the groin crease. This location provides . . . most reliable access to the saphenofemoral junction.” “. . .3 cm lateral to a point just distal to the pubic tubercle” 3 or 3.5 cm “below and lateral to the pubic tubercle” “. . .3.75 cm lateral and 3.75 inferior to the pubic tubercle” “. . .3–4 cm inferior and just lateral to the pubic tubercle” “. . .2.5 cm below the inguinal ligament . . . immediately medial to the femoral pulse”
Rutherford’s Vascular Surgery (Cronewett and Johnston, 2010) Gray’s Anatomy (Standring, 2008) Last’s Anatomy (Sinnatamby, 20111) Clinically Oriented Anatomy (Moore et al., 2013) Surface Anatomy (Lumley, 2008) Clinical Anatomy (Ellis and Mahadevan, 2012)
Dickson et al., 2013; Vaz et al., 2013), but the surface anatomy of the SFJ has been neglected. The surface marking of the SFJ is variably described in contemporary texts on general surgery (Brunicardi et al., 2009), vascular surgery (Cronewett and Johnston, 2010), and anatomy (Lumley, 2008; Standring, 2008; Drake et al., 2010; Sinnatamby, 2011; Ellis and Mahadevan, 2012; Moore et al., 2013). In some texts, the SFJ is stated to lie 3 or 3.5 cm “below and lateral to the pubic tubercle” (Sinnatamby, 2011) or “approximately 4 cm inferior and lateral to the pubic tubercle” (Brunicardi, 2009), but whether these descriptions refer to a diagonal distance or a point that is both 3–4 cm below and 3–4 cm lateral to the pubic tubercle is not clear. Other descriptions are summarized in Table 1. One text cites the femoral pulse as a guide (Ellis and Mahadevan, 2012), another the groin skin crease (Cronewett and Johnston, 2010), whereas another simply describes the general vicinity of the SFJ as just inferior to the medial end of the inguinal ligament (Drake et al., 2010). Early descriptions date back to the early nineteenth century and were probably based on cadaver dissections. For example, Quain 1828 described the junction as lying “an inch and a half [3.5 cm] below Poupart’s [inguinal] ligament.” The aim of this study was to map the SFJ in healthy adults using ultrasound to provide a more reliable evidence-based surface marking.
Mouse” sign (Fig. 1). The vascular structures were then confirmed using color Doppler imaging. The center of the SFJ and the most superficial point of the pubic tubercle were identified using ultrasound and marked on the skin, after which the following three measurements were recorded using a flexible linen tape measure: the craniocaudal distance between the pubic tubercle and the SFJ; the horizontal distance between the pubic tubercle and the SJF; and the diagonal distance between the pubic tubercle and the SFJ (Fig. 2). The relationship between the SFJ and groin skin crease was also noted. Data were analyzed using SPSS Statistics version 20.0.0 (SPSS, Chicago, IL). Differences between left and right sides were analyzed using a paired-samples t-test, differences between sexes using an independent-samples t-test, and associations with age and BMI by Pearson correlations. Intra-rater repeatability was assessed in 15 subjects by rescanning after an interval of at least 4 weeks with the researchers blinded to the original results. Intra-class correlation coefficients (ICCs) were calculated and graded according to the following criteria: poor agreement, 90% of healthy adults.
The authors thank the participants in this study and Robbie McPhee, medical illustrator and graphic artist, for assistance with Figures 2 and 3.
DISCUSSION
REFERENCES
To our knowledge, this is the first study to map the surface marking of the SFJ in healthy adults. On the basis of these findings, contemporary descriptions of the surface anatomy of the SFJ (Table 1) should be revised. The junction is more accurately represented as lying within a square between 1 and 4 cm lateral and 0–3 cm below the pubic tubercle in more than 90% of individuals (Fig. 3). The SFJ was above the level of the pubic tubercle in fewer than 10% of lower limbs; these were mostly on the left side and in women. Referencing the position of the SFJ to the groin skin crease (Cronewett and Johnston, 2010) is not recommended for several reasons: soft tissue reference points are more variable than bony landmarks, the groin skin crease is not always visible and can vary with adiposity, and whilst the SFJ corresponded to the groin crease in women it was variably related in men. There was no instance of a double or bifid GSV above mid-thigh level in our study, an anatomical variant that ought to be considered during varicose vein surgery (Donnelly et al., 2005). Whether this variant affects the precise position of the SFJ is unknown. Our study has a few minor limitations. The SFJ was scanned in the supine position, which is most surgically relevant. It is unlikely that the position of the SFJ
Brunicardi FC. 2009. Schwartz’s Principles of Surgery. 9th Ed. New York: McGraw-Hill. p 778. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. 2005. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 15:175–184. Cronewett JL, Johnston KW. 2010. Rutherford’s Vascular Surgery. 7th Ed. Philadelphia, PA: Saunders Elsevier. p 861. Dickson R, Hill G, Thomson IA, Van Rij. 2013. The valves and tributary of the saphenofemoral junction: ultrasound findings in normal limbs. Veins and Lymphatics 2:2. URL: http://www.pagepressjournals.org/index.php/vl/article/view/1727, last access: 29/09/2013. Donnelly M, Tierney S, Feeley TM. 2005. Anatomical variation at the saphenofemoral junction, Br J Surg 92:322–325. Drake RL, Vogl AW, Mitchell AWM. 2010. Gray’s Anatomy for Students. 2nd Ed. Philadelphia, PA: Churchill Livingstone. p 542. Ellis H, Mahadevan V. 2012. Clinical Anatomy: A Revision and Applied Anatomy for Clinical Students. 13th Ed. Oxford: Blackwell Publishing. p 264. Hemmati H, Baghi I, Talaei Zadeh K, Okhovatpoor N, Kazem Nejad E. 2012. Anatomical variations of the saphenofemoral junction in patients with varicose veins. Acta Med Iran 50:552–555. Kelleher D, Lane TR, Franklin IJ, Davies AH. 2012. Treatment options, clinical outcome (quality of life) and cost benefit (quality-adjusted life year) in varicose vein treatment. Phlebology 27 (Suppl 1):16–22. Landis JR, Koch GG. 1977. The measurement of observer agreement for categorical data. Biometrics 33:159–174.
Redefining the Surface Anatomy of the Saphenofemoral Junction In Vivo Lumley JSP. 2008. Surface Anatomy: The Anatomical Basis of Clinical Examination. 4th Ed. Edinburgh: Churchill Livingstone. p 100. Moore KL, Dalley AF, Agur AMR. 2013. Clinically Oriented Anatomy. 7th Ed. Philadelphia, PA: Lippincott Williams & Wilkins. p 558. € hlberger D, Morandini L, Brenner E. 2009. Venous valves and Mu major superficial tributary veins near the saphenofemoral junction. J Vasc Surg 49:1562–1569. Negus D. 1993. Recurrent varicose veins: A national problem. Br J Surg 80:823–824. Nesbitt C, Eifell RK, Coyne P, Badri H, Bhattacharya V, Stansby G. 2011. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Syst Rev 10:CD005624. n O, Fransson I. 2013. Varicose vein recurrence and patient Nelze satisfaction 10-14 years following combined superficial and per-
919
forator vein surgery: A prospective case study. Euro J Vasc Endovasc Surg 46:372–377. Quain J. 1828. Elements of Descriptive and Practical Anatomy: For Use of Students. London: W. Simpkin and R. Marshall. p 278. Sarin S, Scurr JH, Coleridge Smith PD. 1992. Assessment of stripping the long saphenous vein in the treatment of primary varicose veins. Br J Surg 79:889–893. Sinnatamby CS. 2011. Last’s Anatomy: Regional and Applied. Edinburgh: Churchill Livingstone Elsevier. p 119. Standring S. 2008. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th Ed. Edinburgh: Churchill Livingstone. p 1344, 1350, 1381. Vaz C, Machado R, Rodrigues G. 2013. Anatomical variation of the saphenofemoral junction—A prospective study in a population with primary superficial venous insufficiency. Angiol Cirurgia Vasc 9:1–5.
