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ORIGINAL ARTICLE
Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649
A DESCRIPTION OF THE SIZE AND DISTAL BRANCHING
PATTERN OF THE DORSALIS PEDIS ARTERY: A CADAVERIC
STUDY
Lané Prigge1,2, Nanette Briers2
1
Department of Anatomy, School of Pathology and Pre-Clinical Sciences, Faculty of Health Sciences,
Sefako Makgatho Health Sciences University, Pretoria, South Africa.
2
Department of Anatomy, Section of Clinical Anatomy, School of Medicine, Faculty of Health
Sciences, University, Pretoria, South Africa.
Correspondence to: L Prigge Department of Anatomy, School of Pathology and Pre-Clinical
Sciences, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, PO Box 232
Medunsa 0204, Republic of South Africa. Email: [email protected].
ABSTRACT
Detailed knowledge of the dorsalis pedis artery (DPA) on the dorsum of the foot is required for
reconstructive surgery, especially when a dorsalis pedis flap is utilised. The aim of this study was to
determine the size and branching pattern of the DPA. Within the anterior tarsal tunnel of 40
cadaveric ankles, the size and branches of the DPA were measured, while the relationship of the
branches of the DPA to the inferior extensor retinaculum (IER) was noted. The thickness and the
locations of the DPA and its branches provided statistically significant data (p>0.05) that the DPA
does not divide into equal diameter branches at the level of the ankle joint. The branching pattern
of the DPA can be divided into three categories: 27.5% of the arteries arise proximal to the IER,
62.5% of the branches deep to the IER and 10% of the terminal branches distal to the IER. The
measurements and locations of the branches noted should assist and inform surgeons of variations
during vascular and reconstructive surgery.
Key words: Neurovascular anatomy; reconstructive surgery; bifurcation; foot dorsum; inferior extensor
retinaculum
INTRODUCTION
The anterior tibial artery extends distally as
the dorsalis pedis artery (DPA), at the lower
end of the tibia, midway between the malleoli
(Sinnatamby, 2011). The DPA passes deep to
the inferior extensor retinaculum (IER) and is
responsible for the majority of arterial blood
supply to the dorsum of the foot (Moore and
Dalley, 2006). The DPA gives rise to a lateral
tarsal artery and two- to three medial tarsal
arteries. It then travels to the proximal end of
the first intermetatarsal space, where it turns
to the sole of the foot to form part the plantar
arch (Standring, 2008). The pulse of the DPA
can be palpated lateral to the tendon of the
extensor hallucis longus, where it is located
next to the deep fibular nerve, between the
tendons of the extensor hallucis longus and
the tendons of the extensor digitorum longus
(Sinnatamby, 2011).
In a case report by Kim and colleagues
(2011), a first web space free flap was used
to reconstruct both the upper and lower
eyelid defects of a patient. The first dorsal
metatarsal artery, a branch of the dorsalis
pedis artery, was used to form an
anastomosis with the frontal branch of the
superficial temporal artery. Eo and co-workers
Submitted 29th August 2015, corrected 16th October 2015. Published online 18th February 2016. To cite: Prigge L, Briers
N. 2016. A Description of the Size and Distal Branching Pattern of the Dorsalis Pedis Artery: A Cadaveric Study.
Anatomy Journal of Africa. 5: 644 – 649.
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Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649
(2006) emphasize the importance of the
knowledge and appreciation of the anatomy
of the donor sites. They state that this will
ensure accurate microsurgical reattachment of
the severed blood vessels at the recipient site,
which can be achieved by correctly resecting
the free flap with the blood vessels.
dorsalis pedis artery will impact on the
knowledge of the anatomy of this area and
the approach to surgical procedures on this
structure.
During reconstructive flap surgery, the
dorsalis pedis flap is widely used for
reconstructions pertaining to the orbital area,
intra-oral region and hand- and palm
reconstructions (Chitra, 2009). The dorsalis
pedis artery, as well as the deep fibular nerve,
is contained within this flap, emphasizing the
importance of both these anatomical
structures (Strauch and Vasconez, 1990; Tang
and Chen, 1990; Dong et al., 2003; Chitra,
2009).
Some authors describe the termination of the
DPA more of a bifurcation rather than a vessel
branching into branches (Pomposelli et al.,
1995; Allen, 1997). According to Menin
(2010), the term “bifurcation” describes an
abrupt change in pattern. It then follows that
in order for the distal termination of an artery
to be considered a bifurcation, it must exhibit
a drastic pattern change such as seen in the
bifurcation of the common carotid artery,
abdominal aorta and common iliac artery.
Mooney (2009) describes a bifurcation as a
division from a common origin into two equal
parts, e.g. the division of a blood vessel into
two equal-sized vessels. According to Douglas
Harper (2013), the author of the online
etymology dictionary, the term “bifid”
(originating from the Latin bifidus) means to
split into two equal parts. The confusing use
of the term “bifurcation” associated with the
The aims of this study were to quantitatively
measure the size of the DPA and its branches,
and to compare the results between the left
and right, as well as between sexes.
Furthermore, the branching patterns were
evaluated in order to determine the
correctness of the term “bifurcation” in the
description of the branching pattern of the
DPA and to shed more light on the varying
patterns that may complicate microsurgical
reattachment of blood vessels during
reconstructive flap surgery.
MATERIALS AND METHODS
Ethical clearance was obtained from the
Research Ethics Committee of the Faculty of
Health Sciences at the University of Pretoria.
According to the South African National
Health Act, Act 61 of 2003, all cadavers used
in this study were legally obtained and stowed
in the Department of Anatomy for research
and teaching purposes.
externally at the level of the IER with a
Vernier digital calliper (accuracy of 0.01mm),
in order to determine the correctness of the
term “bifurcation” in describing the distal
termination of the DPA.
The statistics package, SPSS version 8, was
used to calculate the frequencies and
percentages. The Student t-test was used to
quantify differences and to establish statistical
significance in the difference in mean size of
the DPA between the sexes.
A total of 40 ankles were dissected, which
involved the removal of the skin and the deep
fascia of the leg, as well as the dorsal fascia
of the foot being incised. An incision was
made through the IER to expose the anterior
tarsal tunnel containing the DPA and its
branches on the dorsum of the foot. The
branching pattern of the DPA in relation to the
IER was noted and documented by making
use of digital photographs. The diameter of
the DPA and its branches were measured
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Intra- and inter-observer error was tested
using a random sample of 27 ankles.
The
first and second authors repeated the
measurements on the size of the DPA. No
significant differences were observed when
comparing the intra- and inter-observer errors
with the collected data.
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Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649
RESULTS
The quantitative data obtained from the
dissections of 40 ankles with regard to the
size and branching pattern of the DPA in
relation to the IER, are reported below.
diameters of the arteries when compared for
the sexes (p > 0.05).
Branching pattern
Prior to the observed branching of the DPA,
several smaller malleolar branches arise from
the stem of the DPA. No statistically
significant difference (p > 0.05) was observed
in the location of these smaller branches,
therefore a combined sample for left and right
sides was analysed. In 62.5% of the observed
cases, the malleolar branches of the DPA
were deep to the IER (Fig. 2), while 27.5%
were found proximal to the IER and 10%
were found distal to the level of the IER. No
significant difference could be demonstrated
between the sexes or the different sides of
the body (p> 0.05).
Diameter in mm
Size
In the majority of cases, the main trunk of the
DPA gave rise to two distinct distal branches
in relation to the IER. The mean size of the
DPA main trunk and its branches, distal to the
level of the inferior extensor retinaculum
(IER) are presented in Figure 1. In order to
determine whether the term “bifurcation”, as
described by Mooney (2009) and Harper
(2013), was applicable to the branching of the
DPA, the diameter of the first branch
(continuation of the dorsal pedal artery) was
compared to the second branch (lateral tarsal
artery). On the left, the diameter of the
continuing DPA was measured at 3.29mm ±
0.2 (mean ± SD), while the lateral tarsal
artery had an average diameter of 2.06mm ±
0.1. On the right, the average diameter of the
continuing DPA was 3.23mm ± 0.2, while the
lateral tarsal artery was measured at 2.46mm
± 0.2. In general, the continuing DPA was
significantly thicker than the lateral tarsal
artery (p < 0.05), indicating that the DPA
gives rise to the lateral tarsal artery, instead
of bifurcating. No statistically significant
differences were observed between the
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Several interesting variations in the branching
patterns of the DPA were observed. In six
cases (15%), the DPA formed a secondary
trunk when branching from the main trunk,
after which the secondary trunk further
branched into smaller arteries (Fig. 3). These
trunks displayed varying lengths, with some
trunks directly dividing while others extended
inferiorly prior to dividing into the branches.
These secondary trunks, which were observed
in six cases, measured greater in mean
3.9 3.9
3.3 3.2
2.5
2.1
M
B1
Branches of DPA
B2
Left foot
Right foot
Figure 1: Mean diameter of DPA and its branches in relation to the IER. M: The main DPA prior to the observed
branching; B1: The continuing DPA; B2: The lateral tarsal artery.
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Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649
diameter than the main DPA. In two (5%) of
the investigated cases, one of the secondary
trunks divided into three dorsal branches (Fig.
4). These branches were identified as
muscular, medial and lateral tarsal branches.
DPA
Figure 3: Variation in branching pattern: DPA trunks
prior to the tarsal branching Figure 4: Variation in branching pattern:
Secondary trunk divides into three branches.
Figure 2: Branches (arrows) of the DPA, prior to its distal
branching, are predominantly located deep to the IER (62.5%).
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Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649
DISCUSSION
The viability of the DPA is of special
significance for a DPA-bypass that is often
used for the treatment of ischemic foot
complications (Pomposelli et al., 2003). The
authors believe that the size of the DPA plays
a vital role in its potential use as an outflow
target artery, as explained by Pomposelli and
co-workers (2003), as well as in the use of
the DPA in arterial cannulation as indicated by
Martin et al. (2001).
The dorsalis pedis artery is a continuation of
the anterior tibial artery, and gives rise to the
lateral and medial tarsal arteries, prior to
travelling distally on the dorsum of the foot
(Standring, 2008). The relation between the
IER and malleolar branches, muscular
branches, medial and lateral tarsal arteries
were noted and categorised. These branches
are commonly found in the vicinity of the IER,
and may arise proximal (27.5%), deep to
(62.5%), or distal (10%) to the IER.
Size
For the term “bifurcation” to be used, the
arterial diameter should be of equal value
indicating that the artery divides into equal
sized branches, as stated by Mooney (2009)
and Harper (2013). In this study, the external
diameter of the distal branches of the DPA did
not branch into equal portions, and therefore
the term “bifurcation” cannot be used to
describe the branching pattern of the artery.
This finding is important in the training of
undergraduate and postgraduate students, as
it is essential to use the proper terminology
and to grasp the correct conceptual basis for
applied surgical disciplines. Additionally, the
terminology also impacts on the surgeon’s
understanding of the anatomy underlying
reconstructive flap surgery where a flap is
usually harvested with its neurovascular
supply intact, in order to provide a viable
graft.
When reconstructive surgery of the leg and
foot is performed, a free flap is harvested and
the neurovascular supply is removed with the
tissue flap to ensure adequate neurovascular
supply at the recipient area (Strauch and
Vasconez, 1990; Tang and Chen, 1990; Dong
et al., 2003; Chitra, 2009). Detailed
knowledge of these neurovascular structures
will limit complications and lead to better
results.
In conclusion, the term “bifurcation” is an
incorrect description for the branching pattern
of the DPA in relation to the IER, as used in
other research studies (Pomposelli et al.,
1995; Allen, 1997). It was found that, based
on the statistically significant differences in
the arterial diameters, the branching of the
lateral tarsal artery from the DPA cannot be
considered as a bifurcation.
The mean diameter of the branches, indicates
that an average difference of 1.23mm was
observed in the diameter of the branches on
the left foot, while the right foot exhibited an
arterial diameter difference of approximately
0.77mm between the respective branches.
From these measurements it is evident that
both the branches of the artery (the
continuing DPA and the lateral tarsal artery)
are not of the same diameter, therefore the
term “bifurcation” cannot be used. This was
further substantiated by a student t-test
indicating that the difference in diameters is
statistically significant (p < 0.05).
The medial tarsal, malleolar and muscular
branches arising from the main trunk of the
DPA, are predominantly found underneath or
deep to the IER. This research study will
assist in future vascular reconstructive
surgeries, based on the knowledge of the
arterial branches of the DPA.
AUTHOR CONTRIBUTIONS
Both authors of this research paper have
directly
participated
in
the
planning,
conduction and final write-up of this paper.
The authors have no conflict of interest to
declare.
Branching pattern
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Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649
The authors appreciate the valuable input and
support of the staff members of the
Department of Anatomy, University of
www.anatomyafrica.org
Pretoria, in the revision of the developing
manuscript.
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Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649
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