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Transcript
EM El-Saeed et al.
Alexandria Bulletin
557
ANATOMICAL STUDY OF THE DORSALIS PEDIS ARTERY AND ITS SURGICAL
IMPORTANCE IN RECONSTRUCTIVE SURGERY
Ebrahim M. El-Saeed, Amal Abd El-monsif, Madiha A. El-Sayed,
Nancy M. Aly, Naser A. Gezlan*
Anatomy Department, Plastic and Reconstructive Surgery Department*,
Faculty of Medicine, Alexandria University
ABSTRACT
Introduction: The anatomical study of the arteries of the foot is necessary for further advances in arterial
reconstruction. Such reconstruction often avoids amputation in cases of arterial trauma resulting from industrial
and automobile accidents, as well as in patients with diabetes and severe ischemia of the lower limbs. The dorsalis
pedis flap is one of the most common used foot flaps. There is still little detailed information on the arterial supply
of the dorsum of the foot. Knowledge of the vascular anatomy is key to ensuring the safety and reliability of flap
surgery.
Aim of the work: The aim of this work was to study the anatomy of dorsalis pedis artery. This included its course,
relations, origin and branches. Variations of its branching distribution pattern were also recorded. The lengths
and diameters of surgically important branches were measured. Their branches to the skin, muscles and bones of
the dorsum of the foot were studied.
Methods: For anatomical study, twenty feet specimens were used. They were obtained from the dissecting room of
the Department of Anatomy, Faculty of Medicine, University of Alexandria. They were injected with a mixture of
50% lead oxide and 50% red latex in the femoral artery, then dissected. Printed photos were taken for the different
stages of dissection. Angiogram was done to confirm the anatomical results obtained from cadaveric dissection.
The clinical study was carried out on 10 patients who were admitted to the Plastic Surgery Unit of the Alexandria
Main University hospital. They were suffering from soft tissue defects of the foot requiring flap coverage.
Results: In all studied specimens the dorsalis pedis artery was present. In 95% of specimens the location of
dorsalis pedis artery was at 1-1.5 cm lateral to the medial edge of the proximal head of the first metatarsal bone,
on the middle of the dorsum of the foot. In one specimen (5%) the dorsalis pedis artery was deviated laterally at
the lateral edge of talus. The first dorsal metatarsal artery was present in 19 specimens (95%) and was absent in
one specimen (5%). The first dorsal metatarsal artery passed either superficial to the first dorsal interosseous
muscle, deep to it or partially embedded in the muscle. The dorsalis pedis artery gave the lateral tarsal artery
which was double (proximal and distal) in 14 specimens (70%) and was single in 6 specimens (30%). In 18
specimens (90%) the medial tarsal artery was doubled (proximal and distal). It arose from the medial aspect of
dorsalis pedis artery .In two specimens (10%) the medial tarsal artery was single. The arcuate artery arose either
directly from dorsalis pedis artery in 18 specimens (90%) or from lateral tarsal artery in 2 specimens (10%). In 17
specimens (85%) the arcuate artery gave off the 2nd, 3rd, 4th dorsal metatarsal arteries and in one specimen (5%) it
gave an additional first dorsal metatarsal artery to the 2nd, 3rd, 4th dorsal metatarsal arteries. In 2 specimens (10%) the
arcuate artery gave only the second dorsal metatarsal artery. The clinical study was carried on 10 patients. They were
admitted to the Plastic Surgery Unit of the Alexandria Main University hospital suffering from soft tissue defects of
foot and ankle requiring flap coverage. Patients with Dermatofibrosarcoma of dorsal aspect of the first metatarsal
head and with unstable scar of posterior and plantar heel were managed with a transposed dorsalis pedis flap.
All flaps survived completely with uneventful healing of both donor and recipient sites.
Conclusions: Awareness of the anatomical variations of the foot arteries is important for angiographers, vascular
surgeons and reconstructive surgeons who operate upon the foot region. The dorsalis pedis artery is excellent for
pedal revascularization since it is the largest artery distal to the ankle joint. Fasciocutaneous flaps have been shown
to be very reliable and versatile for covering defects of the foot.
Key wards: Dorsalis pedis artery, Fasciocutaneous foot flaps, First dorsal metatarsal artery, Arcuat artery.
INTRODUCTION
The foot has been regarded as being one of the
most characteristic functional elements of the human
body. In both classical and scientific literature, its
anatomical peculiarities have been taken to be
unique in relation to man’s erect stance, bipedal gait
and the evolutionary development of the trunk,
upper limbs and nervous system
The arterial system of the foot has attracted the
attention of anatomists and surgeons for many years
because of its importance and extreme variability.(1)
In recent years there has been an intensive
reappraisal of the anatomy of the vasculature of
Bull. Alex. Fac. Med. 44 No.2, 2008.
the skin, muscle and fascia. This anatomic
revolution has been stimulated by the evolution of
the microvascular free flap, the revival of the
musculocutaneous flap, and the introduction of the
fasciocutaneous flap.(2)
The dorsum of the foot is supplied by the dorsalis
pedis artery. It is the continuation of the anterior
tibial artery at the level of the ankle joint. It follows
the tibial side of the dorsum of the foot to the
proximal end of the first intermetatarsal space,
where it turns into the sole between the two heads of
the first dorsal interosseous muscle to complete the
plantar arch. At this junction it provides the first
ISSN 1110-0834
558
Anatomical Study of the Dorsalis Pedis Artery.
(3,4)
planter metatarsal artery.
Flaps are the basic building blocks of
reconstructive surgery that enable the surgeon to
restore form and function with safety and reliability.
Each flap had distinct features that reflect
predetermined anatomic characteristics; these
include location, size, type of tissues, thickness and
texture, pattern of circulation, blood supply, nerve
supply and function.(5)
A classification system provides a frame work for
decision making in reconstructive surgery. A flap is
generally classified according to its component
parts, vascular anatomy, and its size. These three
parameters are the basis for flap selection.(5,6)
The vascular anatomy is the pivotal factor in
ensuring flap viability. Moving tissue to a new
site requires preservation of arterial and venous
connections or the immediate reestablishment
of vascular connections at a distant site by
microsurgical techniques. Therefore, knowledge of
the vascular anatomy is key to ensuring the safety
and reliability of flap surgery. This information is
critical for flap design and surgical techniques for
flap elevation and inset.(6,7)
The dorsalis pedis flap is one of the most common
used foot flaps. There is still little detailed
information on the arterial supply of the dorsum of
the foot.(8) The aim of this work was to study the
anatomy of dorsalis pedis artery. This included its
course, relations, origin and branches. Variations of
its branching distribution pattern were also recorded.
The lengths and diameters of these branches were
measured. Their branches to the skin, muscles and
bones of the dorsal aspect of the foot were studied.
The resulting fasciocutaneous flaps based on the
dorsalis pedis artery and their branches were
demonstrated.
METHODS
This study was carried on twenty feet of human
cadaveric specimens obtained from the dissecting
room of the Anatomy Department Faculty of
Medicine, University of Alexandria. They were
injected and dissected to study the distribution
pattern of the dorsalis pedis artery.
Ten patients admitted to the Plastic and
Reconstructive Unit, Department of Surgery,
Alexandria Faculty of Medicine was used. Those
patients were undergoing reconstructive surgery of
the foot by using fasciocutaneous flaps.
This study included an anatomical and a clinical
study.
I- Anatomical study:
Twenty injected foot specimens (18 male, 2
female) were used in this study.
The femoral artery in the upper third of the thigh
just below the inguinal ligament was exposed.
• After exploration, the artery was cannulated,
Bull. Alex. Fac. Med. 44 No.2, 2008.
EM El-Saeed et al.
proximally ligated and irrigated with 10%
ammonium chloride to dislodge blood clots.
• A mixture of 50% lead oxide and 50% red latex
was injected under a moderately maintained
pressure.
The
latex
component
allows
identification of the most minute pedicles, while
the lead oxide provides a radioopaque contrast for
radiography. Injection was maintained until
resistance was felt or back flow of the dye
occurred.
The injected specimens were subjected to X-ray
and then dissected 24 hours after injection to allow
the radiographic mixture to set to give a firm
rubbery consistency. The cadavers were then
dissected to demonstrate the distribution pattern of
the dorsalis pedis artery. The length and external
diameters of the dorsalis pedis artery and its main
branches supplying the dorsum of the foot were
measured using Vernier Swiss caliber. Printed
photos were taken for the different stages of
dissection.
II- The clinical study:
The study was carried out on 10 patients who were
admitted to the Plastic Surgery Unit of the
Alexandria Main University hospital. They were
suffering from soft tissue defects of the foot. Patients
were included regardless of age and sex. The
different indications for reconstruction were crush
and degloving injuries with exposed bone,
compound fractures with skin loss, post-traumatic
deformities, adherent scars and ulcers, post-burn
scars, contractures and ulcerations, chronic
osteomyelitis, chronic non-specific ulcers, and
defects following tumour resection.
All patients included in this study were subjected to
the following:
1- Careful history taking
• Personal history: Name, age, sex, occupation.
• Present history: Aetiology and duration of the
defect. Any previous treatment and surgical
interventions.
• Past history: Diabetes mellitus, coronary heart
disease, deep venous thrombosis, lower limb
ischaemia.
2- Thorough clinical examination
• General examination: General condition, vital
signs, systemic review of the different body
systems.
• Local examination:
- Site, size and nature of the defect, presence of
infection.
- Pre-existing scars, evidence of underminings or
other traumas.
- Vascular examination: To detect the state of the
limb vessels (arteries and veins).
- Neurological examination (motor and sensory).
- Orthopaedic examination.
EM El-Saeed et al.
Alexandria Bulletin
3- Routine laboratory investigations: including
• Complete blood picture.
• Bleeding and coagulation times.
• Urine analysis.
• Fasting blood sugar, urea and creatinine for
patients above the age of 40 years.
4- Plain X-ray
(A-P and lateral) of the affected limb for assessment
of the condition of the bony skeleton.
5- Doppler study
A Doppler probe (5 MHz) [Echo-Saunder ES2000R, Arusu, Inc. Japan] was used in each case
preoperatively to evaluate the condition of the limb
vessels and to identify the presence and sites of the
perforators upon which the flaps will be based.
Surgical technique
General measures
According to the site and size of the defect, the
various flaps that can be used to cover that defect
were evaluated. With the aid of the Doppler probe,
the perforators upon which these flaps will be based
were identified and localised. The most appropriate
flap to cover a particular defect was then chosen and
planning in reverse (according to the size of the
defect) was performed.
We used fasciocutaneous dorsalis pedis flap for the
indicated cases.
Fasciocutaneous dorsalis pedis flap
Flap markings:
The skin on the dorsum of the foot extending from
the ankle joint to the metatarsophalangeal joints may
be included with this flap. The boundaries include
the junction of the toes with the dorsal foot skin
distally. Proximally it is the anterior surface of the
ankle joint. The lateral border is 1 cm beyond the
lateral border of the dorsal venous arch of the foot.
The medial boundary is 1 cm medial to the medial
border of the dorsal venous arch of the foot. If the
dorsal venous arch is not immediately apparent, a
venous tourniquet at the level of the ankle will
immediately demonstrate these borders.
Pedicle location
The dorsalis pedis artery enters the dorsum of the
foot deep to the extensor retinaculum and just lateral
to the extensor hallucis longus tendon. In this
location it is easily identified by palpation.
Incisions:
A distal incision is made for identification of the
first dorsal metatarsal artery with subsequent
retrograde dissection of the flap.
Flap elevation:
After the distal incision is made, the first dorsal
metatarsal artery and branches of the deep peroneal
nerve to the first web space are divided. The branches
of the superficial peroneal nerve are similarly
identified laterally and divided. The dissection
Bull. Alex. Fac. Med. 44 No.2, 2008.
559
continues from distal to proximal in a plane just deep
to the deep peroneal nerve and the first dorsal
metatarsal artery. This is a plane deep to the vessels,
deep the extensor hallucis brevis tendon, and just
above the peritenon of all the extensor tendons. The
tendon of the extensor hallucis brevis is detached and
the tendon and muscle should be included in the flap
as the muscle passes between the dorsalis pedis artery,
first dorsal metatarsal artery, and overlying skin. This
dissection is continued proximally up to the proximal
head of the metatarsal.
At that level the deep perforating branch of the
dorsalis pedis artery is encountered. The medial
incision is then made and the medial side of the flap
elevated with the greater saphenous vein and the
dorsal venous arch included in the flap.
The dissection proceeds just over the tendon of
the extensor hallucis longus, preserving the
peritenon to that tendon. As dissection proceeds
from medial to lateral over the tarsal bones the
dorsalis pedis artery is easily identified and traced
down to the deep perforating branch. At this level
the dorsalis pedis artery, first dorsal metatarsal
artery, and deep perforating branch should all be
clearly demonstrated. The deep branch is then
divided and the rest of the skin incision completed.
With the upper incision completed, the extensor
retinaculum is opened and the dorsalis pedis artery,
its two venae comitantes, and nerves are identified.
Flap elevation continues from distal to proximal.
The extensor hallucis brevis muscle is divided at the
level of the extensor digitorum longus to the second
toe. The flap is now isolated on the vascular pedicle.
Proximal dissection of the vessels and nerves is
continued until the desired length of vascular pedicle
is obtained.
RESULTS
I- Anatomical results:
In all studied specimens the dorsalis pedis artery
was present (Fig.1) It was found to be the
continuation of the anterior tibial artery in front of
the ankle joint in all specimens (Fig. 2). It passed
between the tendon of extensor hallucis longus
medially and the tendon of extensor digitorum
longus and extensor hallucis brevis muscle laterally
(Fig.2). The dorsalis pedis artery passed directly
over the dorsum of the talus, navicular, and medial
cuneiform bones and gave direct branches to
supply them (Figs. 3a, 3b) .It was crossed near its
termination by the tendon of extensor hallucis brevis
(Fig. 2). At the proximal end of the first intermetatarsal space, the dorsalis pedis artery was
divided into the deep plantar artery and the first
dorsal metatarsal artery (Fig.4). The diameter of the
deep plantar artery (Table I) ranged from 1.5 to 2
mm with a mean of 1.7±0.4.
In 19specimens (95%) the location of dorsalis
pedis artery was at 1-1.5 cm lateral to the medial
560
Anatomical Study of the Dorsalis Pedis Artery.
edge of the proximal head of the first metatarsal
bone, on the middle of dorsum of the foot(Fig. 2).
The length of the dorsalis pedis artery (Table I)
ranged from 6.2 to 9.4 cm with a mean of 7.6±0.98.
The diameter of the dorsalis pedis artery (Table I)
proximal to the lateral tarsal artery ranged from 3.2
to 4.8 mm with a mean of 3.9±0.51. Its diameter
distal to the lateral tarsal artery ranged from 2.6 to
3.9 mm with a mean of 3.2±0.39.
In one specimen (5%) the dorsalis pedis artery was
deviated laterally at the lateral edge of talus. (Fig. 5)
The skin and subcutaneous tissue of the lateral
part of the dorsum of the skin was supplied by
perforators from lateral malleolar, lateral tarsal and
arcuate arteries (Fig.1).The dorsalis pedis artery
gave 3 perforators for the skin of the central part of
the dorsum of the foot (Fig. 6).
In (95%) the first dorsal metatarsal artery was seen
originating from dorsalis pedis artery (Figs.3a, 4). In
one specimen (5%) out of 20 specimens it was
absent (Fig.7).The point of origin of the first dorsal
metatarsal artery (FDMA) distal to the first
tarsometatarsal joint ranged from 8-10 mm with a
mean of 8.82±1.5. It lied at a distance of 2.1-4.2 mm
with a mean of 2.84±0.76 plantar to the dorsal
surface of the second metatarsal bone. (Table I)
(Fig.8). The diameter of the first dorsal metatarsal
artery (Table I) ranged from 0.5 to 1.5 mm with a
mean of 0.96±0.29.
The first dorsal metatarsal artery passed either
superficial to the first dorsal interosseous muscle in 10
specimens (50%) (Fig.4) or deep to it in 6 specimens
(30%) (Fig.9) or partially embedded in the muscle
in 3 specimens (15%) (Fig.10). The first dorsal
metatarsal artery gave 2 terminal branches (dorsal
digital branches) supplying the adjacent sides of the
big and second toe (Fig. 11). It also gave branches to
the first dorsal interosseous muscle, to the first
metatarsal bone, and to the medial side of the big toe
(Fig. 11).
The dorsalis pedis artery gave the lateral tarsal
artery. The lateral tarsal artery was double (proximal
and distal) in 14 specimens (70%) (Fig.12). In 6
specimens (30%) the lateral tarsal artery was single
(Fig. 9). In all specimens the proximal branch was
larger than the distal one (Figs. 12, 13). The
proximal branch was found to originate 0.2 - 1.5 cm
with a mean of 1.22±0.55 distal to the beginning of
the dorsalis pedis artery above the head of talus
(Fig.3a). It passed laterally deep to the extensor
digitorum brevis muscle. It gave branch to its deep
surface and also to the adjacent bones (talus, cuboid,
and lateral cuneiform) (Figs. 3b, 13).
At the lateral aspect of foot, the proximal lateral
tarsal artery anastomosed with branches of lateral
malleolar artery (branch from the anterior tibial
artery) (Fig.1). The length of the proximal lateral
tarsal artery (Table I) ranged from 1.8 to 3.7 cm with
a mean of 2.7 ± 0.57. The diameter of the proximal
Bull. Alex. Fac. Med. 44 No.2, 2008.
EM El-Saeed et al.
lateral tarsal artery (Table I) at its origin ranged from
1.2 to 2.8 mm with a mean of 2.1 ± 0.59.
The distal lateral tarsal artery (accessory artery) of
the dorsalis pedis artery was smaller than the
proximal lateral tarsal artery (Figs. 12, 13). It passed
deep to extensor hallucis brevis (Fig. 12) supplying
it by direct branches .It gave branch to navicular
bone (Fig. 13). The distal lateral tarsal artery, when
present, arose at a distance ranged from 2.3 - 4.2 cm
with a mean of 2.84±0.70 distal to the origin of the
lateral tarsal artery. The length of the distal lateral
tarsal artery (Table I) ranged from 1.5 to 2.1 cm with
a mean of 1.7 ± 0.24. Its diameter (Table I) at its
beginning ranged from 1.4 to 1.8 mm with a mean of
1.5 ± 0.15.
In 18 specimens (90%) the medial tarsal artery
originated as 2 branches (proximal and distal) from
the medial aspect of dorsalis pedis artery (Fig. 14).
The first branch arose from dorsalis pedis artery at
the level of the proximal edge of talus 2.5cm from
the origin of dorsalis pedis artery .It divided into
smaller branches supplying the medial surface of
talus (Fig.14). It anastomosed with branches from
medial plantar artery (Fig. 14). The second branch
arose 4cm distal to the first one at the level of
navicular bone. It divided into 2 branches supplying
the medial surface of navicular bone (Fig. 14). Out
of this 2 specimens (10%) a third branch arose from
dorsalis pedis artery at the level of medial cuneiform
.It gave branches to the medial surface of medial
cuneiform (Fig. 14).
In two specimens (10%) (Figs. 9) the medial tarsal
artery was single. It originated from the medial
aspect of dorsalis pedis artery at the level of
proximal edge of talus at the ankle joint (Figs. 9).
The arcuate artery arose either directly from
dorsalis pedis artery in 18 specimens (90%) (Figs. 4,
11) or from lateral tarsal artery in 2 specimens
(10%) (Figs. 5, 15). The arcuate artery was
incomplete in one specimen; it gave the 2nd dorsal
metatarsal artery while the 3rd, 4th were originated
from the plantar arch (Figs. 4, 15). The arcuate
artery was found to originate from the dorsalis pedis
artery either at the level of the first tarsometatarsal
joint in 14 specimens (70%) (fig.11) or at the level
of the cuneonavicular joint in 5 specimens (30%)
(Fig.4). In one specimen the arcuate artery arose
from the lateral tarsal artery at the level of the
second tarsometatarsal joint (Fig.5) and gave the
second and the third dorsal metatarsal arteries.
The arcuate artery passed laterally over the bases
of the second, third and fourth metatarsal bones,
deep to the tendons of extensor digitorum brevis
(Fig. 1). The arcuate artery anastomosed with small
branches of the lateral tarsal artery (Fig. 1). In 17
specimens (85%) the arcuate artery gave off the 2nd,
3rd, 4th dorsal metatarsal arteries (Figs.11, 15). In one
specimen (5%) it gave an additional first dorsal
metatarsal artery (Fig. 11). In 2 specimens (10%) the
EM El-Saeed et al.
Alexandria Bulletin
arcuate artery gave only the second dorsal metatarsal
artery (Figs.4, 15).
The 2nd, 3rd and 4th dorsal metatarsal arteries were
located at the upper part of the corresponding
intermetatarsal space (Fig. 11). The dorsal metatarsal
arteries gave off the proximal perforating artery which
passed through the intermetatarsal space at the level
of the metatarsal neck (Fig.16). These arteries passed
from the dorsal to the plantar side of the foot.
The dorsal metatarsal arteries coursed distally on
the corresponding dorsal interosseous muscles to
reach the clefts between the toes (Fig. 11). Each one
was divided into medial and lateral proper plantar
digital arteries to the adjacent sides of toes (Fig.11).
The fourth dorsal metatarsal artery gave off a branch
to the lateral side of the fifth toe (Fig. 11).
Arterial supply of muscles of the dorsum of the
foot:
The extensor hallucis brevis muscle was the
medial part of extensor digitorum brevis muscle
(Fig. 1, 2). It was distinct slip ending in a tendon
which crossed the dorsalis pedis artery (Fig. 1, 2). It
was inserted into the dorsal surface of the base of
the proximal phalanx of the big toe (Figs. 2, 12).
The superficial surface of the muscle is supplied by
3 muscular branches from the lateral aspect of
dorsalis pedis artery (Fig. 17). The deep surface of
the muscle was supplied by a branch from the lateral
aspect of dorsalis pedis artery, divided into two
branches, to enter the deep surface of the muscle
(Fig. 18).
The extensor digitorum brevis muscle was a thin
muscle. It arose from the anterior part of the upper
lateral surface of the calcaneus (Fig.1). It passed
obliquely forwards and medially across the dorsum
of the foot. It ended in four tendons (Fig.2). The
medial part of the muscle was the extensor hallucis
brevis (Figs.2, 12). The other three tendons were
inserted into the lateral sides of the tendons of
the extensor digitorum longus of the second, third
and fourth toe (Fig. 12). The superficial surface of
extensor digitorum brevis received direct branches
from lateral malleolar artery through the superior
Bull. Alex. Fac. Med. 44 No.2, 2008.
561
surface of the muscle (Fig. 17) and from lateral
aspect of dorsalis pedis artery (Fig.17). The deep
surface of extensor digitorum brevis was supplied by
muscular branches arising from lateral tarsal artery
passing deep to the muscle (Fig. 13).
The dorsal interossei were four in number. They
were present between the metatarsal bones. They
were bipennate muscles, each arising by two heads
from the adjacent sides of the metatarsal bones
between which it was placed; their tendons inserted
into the bases of the proximal phalanges, and into
the dorsal digital expansions (Fig.11). The first
was inserted into the medial side of the second toe;
the other three into the lateral sides of the second,
third, and fourth toes (Fig. 11). The dorsal interossei
muscles 2nd, 3rd and 4th were supplied by small direct
branches from 2nd, 3rd and 4th dorsal metatarsal
arteries arising from the arcuate artery (Fig. 11). The
first dorsal interossei muscle was supplied by
branches from first dorsal metatarsal artery (Fig. 11).
In one specimen (Fig. 11) the first dorsal
interosseous muscle was supplied by branches from
the arcuate artery which run superficial to the first
dorsal interosseous muscle (Fig. 11).
II- Radiological results
The anatomical results were confirmed by
angiograms to the examined foots. (Figs.19, 20).
III- Results of the clinical study:
This clinical study included 10 patients with
defects of foot and ankle requiring flap coverage.
Patients were admitted to Plastic and Reconstructive
surgery unit of Alexandria main University Hospital.
Six patients were male and four were females. The
age ranged between 18-67 years with an average age
of 45 years.
The patients suffered from Dermatofibrosarcoma
of dorsal aspect of the first metatarsal head and had
unstable scar of posterior and plantar heel (Figs.21a,
21b) were managed with a transposed dorsalis pedis
flap (Figs.22 a, b, c, d). The donor site was covered
with a split thickness skin graft.
All flaps survived completely with uneventful healing
of both donor and recipient sites.
Anatomical Study of the Dorsalis Pedis Artery.
562
EM El-Saeed et al.
Table I: Summary of the morphometric results regarding the Dorsalis pedis artery and its main branches.
Range
Min.
Max.
Items
- Dorsalis pedis artery
● Length (cm)
● Diameter proximal to lateral tarsal artery(mm)
● Diameter distal to lateral tarsal artery (mm)
Diameter of deep plantar artery(mm)
- First dorsal metatarsal artery
● Origin distal to the first tarso- metatarsal joint (mm)
● Depth from the dorsal surface of the second metatarsal bone(mm)
● Diameter at its origin(mm)
- Lateral tarsal artery (proximal)
● Length (cm)
● Diameter at origin (mm)
- lateral tarsal artery (Distal)
● Length (cm)
● Diameter at origin(mm)
Mean±SD
6.2
3.2
2.6
1.5
9.4
4.8
3.9
2
7.6 ± 0.98
3.9 ± 0.51
3.2 ± 0.39
1.7 ± 0.4
8
2.1
0.5
10
4.2
1.5
8.82±1.5
2.84±0.76
0.96±0.29
1.8
1.2
3.7
2.8
2.7 ± 0.57
2.1 ± 0.59
1.5
1.4
2.1
1.8
1.7 ± 0.24
1.5 ± 0.15
Fig 1: A photograph of the dorsum of right male foot
showing, small perforators (arrows) from lateral malleolar
(LM), lateral tarsal (LT) and arcuate (AR) arteries to the
skin and deep fascia of the lateral aspect of foot. Notice,
dorsalis pedis artery (DP), extensor digitorum brevis (EDB),
extensor hallucis brevis (EHB) and anterior tibial artery
(AT).
Fig 2: A photograph of the dorsum of right male foot
showing, dorsalis pedis artery (DP) at ankle joint between
the tendon of extensor hallucis longus (EHL) medially and
the tendons of extensor digitorum longus (ED) and extensor
hallucis brevis muscle (EHB) laterally. The dorsalis pedis
artery (DP) ends at the base of the first metatarsal bone (1)
by giving first dorsal metatarsal artery (D1). Notice (AT)
anterior tibial artery, (E) extensor retinaculum.
Fig 3a: A photograph of the dorsum of right male foot, after
reflexion of extensor digitorum brevis muscle (ED) showing,
branches (arrows) from dorsalis pedis artery (DP) and
from proximal lateral tarsal artery (LT) supplying the dorsal
aspect of talus (t), navicular (N), cuboid (c), medial (m),
intermediate (i), and lateral (l) cuneiform bones. The
proximal lateral tarsal artery (LT) arising above the head of
talus (t). Notice that the branches of dorsal metatarsal
arteries (D1) supplying the corresponding metatarsal bones.
Fig 3b: A close up view of the previous photograph
showing, branches(arrows) of dorsalis pedis artery (DP) and
proximal lateral tarsal artery (LT) to the talus (t), navicular
(n), cuboid (c), medial (m), intermediate (i), lateral (l)
cuneiform. Notice (ED) extensor digitorum.
Bull. Alex. Fac. Med. 44 No.2, 2008.
EM El-Saeed et al.
Alexandria Bulletin
Fig 4: A photograph of the dorsum of right male foot after
reflexion of extensor digitorum brevis (ED) showing,
dorsalis pedis artery (DPA) giving the arcuate artery (AR).
Dorsalis pedis artery (DP) divides into deep plantar artery
(→) and the first dorsal metatarsal artery (D1) at the
proximal end of the first intermetatarsal space. Notice that
the first dorsal metatarsal artery (D1) passing superficial to
the first interosseous muscle (IM), the arcuate artery (AR)
giving only the second dorsal metatarsal artery (D2) while
the third dorsal metatarsal artery (D3) originates from the
plantar side.
Fig 6: A photograph of the dorsum of male right foot
showing the dorsalis pedis artery (DPA) giving 3 small
perforators (arrows) to the skin of the dorsum of the foot.
Fig 5: A photograph of the dorsum of right male foot after
reflexion of extensor digitorum brevis muscle (EDB)
showing, dorsalis pedis artery (DP) passing laterally at the
lateral edge of talus (t). dorsalis pedis artery (DP) gives
proximal lateral tarsal artery (LTA1) passing deep to
extensor digitorum brevis (EDB), distal lateral tarsal artery
(LTA2) and first dorsal metatarsal artery (D1). The arcuate
artery (AR) arising from the distal lateral tarsal artery
(LTA2) and giving the second (D2) and the third (D3)
dorsal metatarsal arteries. Notice (AT) anterior tibial artery.
Fig 7: A photograph of the dorsum of right male foot
showing, dorsalis pedis artery (DP) at the proximal part of
the first intermetatarsal space giving deep plantar artery
(→) and small branch (arrow head) to the first dorsal
interosseous muscle (IM). Lateral tarsal artery (LTA) and
the second dorsal metatarsal artery (D2) were also seen.
Notice the absence of the first dorsal metatarsal artery.
Fig (8): Schematic drawing of dorsalis pedis artery and its branches.
1Bifurcation of digital artery.
2First dorsal metatarsal artery.
3Beginning point of the FDMA from the DPA.
4First tarso-metatarsal joint.
5Dividing point of the arcuate artery.
6Dividing point of the lateral tarsal artery.
Bull. Alex. Fac. Med. 44 No.2, 2008.
563
564
Anatomical Study of the Dorsalis Pedis Artery.
Fig 9: A photograph of the dorsum of left male foot showing,
dorsalis pedis artery (DP) as a continuation of anterior tibial
artery (AT) at the level of the ankle joint. Dorsalis pedis artery
(DP) gives a single medial (MT) and lateral (LT) tarsal arteries.
(MT) arises at the level of the proximal edge of talus (T). Lateral
tarsal artery (LT) gives branches to the deep surface of extensor
digitorum brevis (EDB). Dorsalis pedis artery (DP) at the
proximal end of the first intermetatarsal space gives deep plantar
artery (→) and the first dorsal metatarsal artery (D1) passing
deep to the first interosseous muscle (IM).
EM El-Saeed et al.
Fig 10: A photograph of the dorsum of left male foot
showing the dorsalis pedis artery (DP) at the proximal
end of the first intermetatarsal space giving the deep
plantar artery (→) and the first dorsal metatarsal artery
(D1) embedded within the first dorsal interosseous
muscle (IM).
Fig 11: A photograph of the dorsum of right male foot showing, the first dorsal metatarsal artery (D1) divides into two
terminal branches (A), (B) to the adjacent sides of the big and second toe and also giving branches (→) to the first
metatarsal bone (1) and to the medial side of the big toe. The second (D2), third (D3), fourth (D4) dorsal metatarsal arteries
arising from the arcuate artery (AR) at the base of corresponding metatarsal bones. The dorsal metatarsal arteries (D2, D3,
and D4) give muscular branches to the dorsal interosseous muscles and digital arteries (white arrow) for the adjacent sides
of the toes. The arcuate artery (AR) gives an additional branch (DII) which runs superficial to first dorsal interosseous
muscle Notice dorsalis pedis artery (DP).
Fig 12: A photograph of the dorsum of right male foot
showing, the dorsalis pedis artery (DP) gives 2 medial tarsal
arteries (M1), (M2). It also gives proximal (LT1) and distal
(LT2) lateral tarsal arteries. The extensor digitorum brevis
(ED), extensor hallucis brevis (EH) and anterior tibial artery
(AT) were also seen.
Bull. Alex. Fac. Med. 44 No.2, 2008.
Fig 13: A photograph of the dorsum of right male foot after
reflection of the extensor digitorum brevis (ED) to show 4
branches (1,2,3,4) from proximal lateral tarsal artery (LT1)
supplying the deep surface of the muscle. The dorsalis pedis
artery (DP) gives a larg proximal lateral tarsal artery (LT1)
and a small distal lateral tarsal artery (LT2). The latter gives
branch (→) to the navicular bone (n). The anterior tibial
artery (AT) gives lateral malleolar artery (LM).
EM El-Saeed et al.
Alexandria Bulletin
565
Fig 14: A photograph of the dorsum of right male foot
(medial side) after removal of tendon of extensor hallucis
longus (EH) showing, dorsalis pedis artery (DP) gives two
medial tarsal arteries (M1), (M2) supplying branches (white
arrows) to talus (t) and navicular (n) bones and a third
branch (→) supplying medial cuneiform (c). The branches
of medial tarsal arteries (white arrows) anastomose with
branches (thick arrows) from the medial plantar artery.
Notice the medial malleolus (M).
Fig 15: Schematic drawing of variations of origin of
dorsal metatarsal arteries.
● First dorsal metatarsal artery (F) always arising from
dorsalis pedis artery (DPA).
a- 2nd, 3rd, 4th dorsal metatarsal arteries arising from arcuate
artery (AR).
b- 2nd, 3rd, 4th dorsal metatarsal arteries arising from arcuate
artery (AR) branching from lateral tarsal artery (LTA).
c- 2nd dorsal metatarsal artery arising from dorsalis pedis
artery (DPA), while 3rd, 4th arising from plantar arch.
Fig 16: A photograph of the dorsum of right male foot
showing, lateral tarsal artery (LTA) giving the arcuate artery
(AR). The arcuate artery (AR) gives the second (D2) and the
third (D3) dorsal metatarsal artery. The proximal perforators
(→) arising from the second (D2) and the third (D3) dorsal
metatarsal arteries. Notice the dorsalis pedis artery (DP).
Fig 17: A photograph of the dorsum of right male foot
showing, muscular branches (1,2, 3) from the lateral aspect
of dorsalis pedis artery (DP) to the superficial surface of
extensor digitorum brevis (ED) and extensor hallucis brevis
(EHB) muscle. lateral malleolar artery (LM) gives muscular
branches (arrow) to the superior surface of extensor
digitorum brevis (ED). lateral malleolus (M), anterior tibial
artery (AT).
Fig 18: A photograph of the dorsum of right male foot
showing, a branch (→) from lateral aspect of dorsalis pedis
artery (DP) dividing into 2 terminal branches (1, 2) to the
deep surface of extensor hallucis brevis (EHB). (L) lateral
malleolus.
Fig 19: Angiogram of left everted foot showing the dorsalis
pedis artery (DP) as a continuation of anterior tibial artery
(AT) at the ankle joint. The dorsalis pedis artery (DP) gives
the lateral tarsal artery (LT)
Bull. Alex. Fac. Med. 44 No.2, 2008.
566
Anatomical Study of the Dorsalis Pedis Artery.
EM El-Saeed et al.
Fig 20: Angiogram of right foot (lateral view), showing the dorsalis pedis artery (DP) giving the first dorsal metatarsal
artery (1), the deep plantar artery (→) and the arcuate artery (AR). The arcuate artery (AR) gives the second (2), third (3)
and the fourth (4) dorsal metatarsal arteries.
Fig 21a: A photograph of male left foot, posterior view
showing unstable scar posterior and plantar heel.
Fig 21b: Template of skin paddle needed.
Fig 22a: The cutaneous flap is marked, with the tourniquet
partially elevated to allow marking of several veins.
Fig 22b: The flap has been incised and is ready for transfer.
Fig 22c: A long proximal vascular pedicle (P) is developed.
Fig 22d: Six-month follow-up shows good contour without
breakdown. The donor site has been closed with skin grafts,
and the patient has full weight bearing without pain.
Posterior view.
Bull. Alex. Fac. Med. 44 No.2, 2008.
EM El-Saeed et al.
Alexandria Bulletin
DISCUSSION
The arterial system of foot has attracted the
attention of anatomists and surgeons due to its
clinical importance and marked variability.
Knowledge of the variations in the anatomy of
the foot arteries is important for the vascular
surgeon.
In the present study, the distribution of the
dorsalis pedis artery on the dorsal aspect of the foot
was studied both anatomically and radiologically.
Length, diameters and variations of clinically
important arteries were reported. Also the arterial
supply of skin, muscles, and bones of dorsal
aspect of the foot were demonstrated. Related
fasciocutaneous flaps based on the dorsalis pedis
artery were also studied.
In the present study, the dorsum of the foot was
supplied by the dorsalis pedis artery, the
continuation of anterior tibial artery. The dorsalis
pedis artery passed between the tendon of extensor
hallucis longus medially and the tendon of extensor
digitorum longus and extensor hallucis brevis
muscles laterally. The dorsalis pedis artery, at the
proximal end of the first inter-metatarsal space,
divided into the deep plantar artery and the first
dorsal metatarsal artery. This result agreed with
those reported in most of the classic anatomic
textbooks (3, 4) and with Bailleul et al.,(9) who found
the normal anatomy of dorsalis pedis artery in 75%
of specimens, while in the rest of specimens, the
dorsalis pedis was divided into medial and lateral
branches.
In the present study only in one specimen, the
dorsalis pedis artery was deviated laterally at the
lateral edge of talus. This finding was in agreement
with those of Hamada et al. (5) who observed that the
dorsalis pedis artery deviated laterally to pass across
the lateral end of the talus. They found this variation
in five feet out of 100 studied feet.
The mean diameter of dorsalis pedis artery
proximal to the lateral tarsal artery was 3.9±0.5 and
its diameter distal to lateral tarsal artery was 3.2
±0.39. Taro et al. (1), found that the mean diameter of
28 dorsalis pedis artery examined 3 cm distal to the
ankle was 2.07±0.77. Barman et al.,(2) reported that
the average size of the dorsalis pedis artery was
2.25±0.25.
Tuncel et al.(10) observed that the anterior tibial
artery in 2 specimens was hypoplastic and
terminated by giving numerous muscular and fascial
branches. The dorsalis pedis originated from the
peroneal artery. The peroneal artery reached the
anterior compartment by piercing the interosseous
membrane at its lower part, and then it had the
course of normal dorsalis pedis artery.
Chiba (11) found 2 specimens of superficial dorsalis
pedis artery in the study of 296 Japanese feet. The
superficial dorsalis pedis artery arose from the
Bull. Alex. Fac. Med. 44 No.2, 2008.
567
anterior tibial artery at the ankle. It penetrated the
inferior extensor retinaculum and run distally
superficial to the deep fascia of the foot.
The dorsalis pedis was present in all studied
specimens. However Taro et al.(1) reported the
absence of the dorsalis pedis artery in two feet out of
30 feet and the dorsal metatarsal arteries were
supplied by the plantar arteries.
The knowledge of the individual variations of the
foot arteries is to be pointed out by arteriography
before using either extensor digitorum brevis muscle
or the skin of the dorsum of the foot as flaps for
covering cutaneous defects of the foot.
Manktelow;(12)
Greenberg
and
May;(13)
(14)
Gilbert
et
al.;
Kay
and
Wiberg;(15)
(16)
(17)
Van Holder et al.; Yu-dong et al. found that the
first dorsal metatarsal artery was the most widely
used arterial pedicle in toe-to-hand transfers, while
Villen and Julve (18) reported that the first plantar
metatarsal artery is used much more frequently.
Other authors such as Foucher and Moss,(19) Yudong et al.(8) and Gu et al (20) prefer the second dorsal
or plantar metatarsal arteries depending on the
surgical technique.
In the present study the first dorsal metatarsal artery
was a branch from the dorsalis pedis artery, at the
proximal part of the first intermetatarsal space. It was
found in 95% of specimens. It was absent in the rest
of specimens. Hamada et al. (5) reported the presence
of a common trunk for the first dorsal and plantar
metatarsal artery in 54% of the feet studied.
As regards the relation of the proximal half of the
first dorsal metatarsal artery to the interosseous
muscle, it was either superficial in (50% of
specimens), intramuscular in (15%), inframuscular
in (30%), or absent in (5%). This was in agreement
with Gu et al. (20) who observed the same relation but
with different percentage. The artery was superficial
in (18% of specimens), intramuscular in (54%),
inframuscular in (23%), and absent in (5%).
The location of the first dorsal metatarsal artery was
also described by Gilbert and Masquelet (21) as three
types: type I, superficial; type II, deep; and type III, fine
branch or absent.
According to the diameter of the first dorsal
metatarsal artery, in the present study it was large
(1.5mm) in 20% of specimens, small (0.5mm) in
23% of specimens and medium in 57 % of
specimens, and These findings were in agreement
with the classification of Gu et al.(20) who observed:
the large one in (16%), medium in (64%), and small
in (20%). They also added another classification
based on its branching pattern, the artery was
classified into ramifying type in (88%), main trunk
in (4%), and fine branch type in (8%).
Villen and Julve (18) reported that from the surgical
point of view, a superficially located and large
caliber (>1mm) first dorsal metatarsal artery, is ideal
568
Anatomical Study of the Dorsalis Pedis Artery.
in toe-to-hand transfers as it is easy to identify,
resistant to spasm during dissection and rapidly
dissected. While Yu-dong et al.(8) found that the
success of toe-transfer was related to the diameter of
the vessel, not to its anatomical location in the first
interosseous space.
In the present study, the first dorsal metatarsal
artery terminated by dividing into 2 terminal
branches supplying the contiguous sides of the big
and second toe.
Upton (22) postulated another classification based
on 57 clinical dissections of 57 cases undergoing toe
transfers: (1) type A: a large first dorsal metatarsal
artery (47%); (2) type B: a smaller first dorsal
metatarsal artery within the interosseous muscle
(30%) ;(3) type C: a small interosseous first dorsal
metatarsal artery (14%); and (4): type D: an absent
first dorsal metatarsal artery (9%). By angiogram,
Upton (22) observed that the contrast reached the foot
and toes faster by injection of the posterior tibial
artery and plantar arch. He concluded that the
posterior tibial artery is the dominant conduit to the
foot and ankle and, the plantar arch is the major
arterial system to the toes.
This classification was useful in toe to hand
transfer surgical procedure. Toe to hand transfer has
become a widely accepted surgical procedure for
reconstruction of the thumb or for finger loss. The
identification of variations of the first dorsal
metatarsal artery during the dissection and its
isolation was crucial to the success of toe
transplantation.(22)
In the present study, the origin of the first dorsal
metatarsal artery distal to the first tarso-metatarsal
joint ranged from 8 to 10 mm. It lied at a distance of
2.1-4.2 mm plantar to the dorsal surface of the
second metatarsal bone. Lee and Dauber,(23) studied
32 feet, they found the first dorsal metatarsal
artery in all specimens. The first dorsal metatarsal
artery branched from the dorsalis pedis artery 10mm
distal to the first tarso-metatarsal joint and 5.5 mm
plantar to the dorsal surface of the second metatarsal
bone.
In the present study, the lateral tarsal artery was
always double in all specimens, (proximal and
distal). This was in agreement with Cormack and
Lamberty,(6) Hamada et al.,(5) and Gilbert et al.(14) In
the present study the proximal branch was the larger
one. It passed deep to the extensor digitorum brevis
muscle supplying it through its undersurface and
supplying the adjacent bones (talus, cuboid, and
lateral cuneiform).
This result was in consistent with Gilbert et al.(24)
who found a branch of the proximal lateral tarsal
artery giving a consistent vascular territory to the
cuboid in the form of fifteen nutrient vessels. Also
they found a branch of the distal lateral tarsal artery
entering the midsection of the lateral cuneiform in
the form of seven nutrient vessels.
Bull. Alex. Fac. Med. 44 No.2, 2008.
EM El-Saeed et al.
In the present study, the proximal lateral tarsal
artery anastomosed with the lateral malleolar artery,
a branch from anterior tibial artery, at the lateral
aspect of foot. This was in accordance with those of
Cormack and Lamberty,(6) who reported that the
lateral tarsal artery was often double and the
proximal branch was usually the larger. It
anastomosed with the lateral malleolar artery above,
and the arcuate artery below. It sent some fine
branches to the skin in the region of the cuboid and
fifth metatarsal base.
In the present study, the distal lateral tarsal artery
was smaller than the proximal one. It passed deep to
extensor hallucis brevis supplying it and supplying
the adjacent bones (intermediate and medial
cuneiform).It anastomosed with branches from
arcuate artery.
Hamada et al.(5) reported the presence of proximal
and distal tarsal arteries in their study of 100 feet.
The proximal tarsal artery arose above the head of
talus, while the distal arose at the level of
cuneonavicular joint.
In the present study, the proximal and distal medial
tarsal artery was found in 18 (90%) specimens.
While in 2 specimens (10%) the medial tarsal artery
was single. Cormack & Lamberty(6) reported the
presence of several small medial tarsal arteries. The
medial tarsal artery was always arising from the
medial aspect of the dorsalis pedis artery. The
proximal branch arose at the proximal edge of talus,
while the distal branch arose at the level of navicular
bone. A third branch was found at the level of
medial cuneiform. The medial tarsal artery gave
branches to the adjacent bones; the medial surface of
talus, navicular, and medial cuneiform. This agrees
with the results obtained by Gilbert et al.,(24) who
reported the presence of a branch of the distal medial
tarsal artery to the medial cuneiform in the form of
nine nutrient vessels.
Gilbert et al.(24) stated that knowing the extra and
intraosseous blood supply of bones of foot; enable
surgeons to perform rotational vascularized pedicle
bone-grafting procedures in the foot.
In the present study the arcuate artery was present
in all specimens. The origin of arcuate artery was in
18 specimens (90%) from dorsalis pedis artery. In 2
specimens (10%) of the arcuate artery originated
from lateral tarsal artery at the level of the second
tarsometatarsal joint. This agrees with Taro et al.,(1)
who found that the arcuate artery arose directly from
the dorsalis pedis artery in 18 out of 30 limbs (60%)
and in 2 limbs(7%) it branched off the lateral tarsal
artery. The arcuate artery was absent in 10 limbs
(33%).
In the present study the arcuate artery arose either
at the level of the first tarsometatarsal joint in 70%
of specimens or at the level of the cuneonavicular
joint in 30% of specimens. This was in agreement
with Dilandro et al.,(25) who defined the arcuate
EM El-Saeed et al.
Alexandria Bulletin
artery as that artery branching off the dorsalis pedis
artery at or below the level of the tarsometatarsal
joint (67%) or at the level of the cuneonavicular
joint (33%).
In the present study the arcuate artery was present
over the bases of the second, third, and fourth
metatarsal bones, deep to the tendons of extensor
digitorum brevis. There were three types of arcuate
artery based on the number of the dorsal metatarsal
arteries arising from it. Type I: in 85% of specimens
the arcuate artery gave rise to the second, third, and
fourth dorsal metatarsal arteries. Type II: in 5% of
specimens the arcuate artery gave an additional first
dorsal metatarsal artery to the 2nd, 3rd, 4th dorsal
metatarsal arteries.Type III: in 10% of specimens the
arcuate artery gave off only the second dorsal
metatarsal artery, while the third and fourth
metatarsal arteries originated from the deep plantar
arch. This was in agreement with Hamada et al.(5)
study who found Type I: in 80% of specimens, type
II: in 15% of specimens, and type III: in 5% of
specimens.
In the present study the dorsal metatarsal arteries
were located at the upper part of the corresponding
intermetatarsal space. They run distally on the
corresponding dorsal interosseous muscles to the
clefts between the toes. Each dorsal metatarsal
artery was divided into medial and lateral plantar
digital arteries to the adjacent sides of toes. The
fourth dorsal metatarsal artery constantly gave
off a branch to the lateral side of the fifth toe. The
2nd, 3rd and 4th dorsal metatarsal arteries were
branches of the arcuate artery in 90% of specimens.
These results agreed with those reported by
Hamada et al.(5)
The results of the present study revealed that in
10% of specimens the 2nd dorsal metatarsal artery
was given by the arcuate artery while the 3rd and 4th
dorsal metatarsal arteries was given by the plantar
arch. Taro et al.(1) observed that, the arcuate artery
gave the second, third and fourth metatarsal arteries
in 50% of the specimens, the second and third dorsal
metatarsal arteries in 27.8%, and only the second
dorsal metatarsal artery in 22.2%. Otherwise, the
second, third, and fourth metatarsal arteries were
branches of the plantar arch.
In the present study the dorsal metatarsal
arteries gave off the proximal perforating artery
which passed through the intermetatarsal space
at the level of the metatarsal neck. These
arteries passed from the dorsal to the plantar side of
the foot.
Hamada et al.(5) described two kinds of perforating
arteries, arising from the dorsal metatarsal arteries.
They anastomosed with the corresponding plantar
metatarsal arteries in their distal courses. One was
the middle perforating artery which passed through
the intermetatarsal space at the level of the
Bull. Alex. Fac. Med. 44 No.2, 2008.
569
metatarsal neck; the other was the distal perforating
artery which was the terminal branch of the dorsal
metatarsal artery. The proximal perforating artery
described in the present study was previously named
by Hamada et al. (5) as the middle perforating artery,
while the distal perforating artery was named as the
terminal part of the dorsal metatarsal artery.
In
agreement
with
other
investigators
Giordano
et
al.,(26)
Gilbstein
et
al.;(27)
(28)
(29)
Baltensperger et al.;
Pinal and Herrero,
the
present study revealed that in all the specimens the
major arterial supply to the extensor digitorum
brevis muscle was provided by the lateral tarsal
artery through its deep surface. Thus, this muscle is
considered by Cormack and Lamberty(6) as type I
vascular pattern, and the flap can live on the dorsalis
pedis artery as a main pedicle. In the present study,
the extensor digitorum brevis muscle also received
direct branches from lateral malleolar artery through
its superior border.
El Sayed (30) reported the presence of distal
lateral tarsal artery (accessory artery) in 35%
of the studied specimens. This artery arose 2.3 - 4.3
cm distal to the origin of lateral tarsal artery.
Bonnel(31) and Bakhach et al.(32) reported the
presence of one to three additional vascular
pedicles supplying the extensor digitorum
brevis muscle. These arteries also originated from
the dorsalis pedis artery distal to the lateral tarsal
artery.
The results of the present work indicated the
presence of a constant and reliable vascularization of
extensor digitorum brevis muscle. This muscle had a
long muscular artery with sufficient diameter. Zuker
and Manktelow,(33) Lee and Dauber(23) concluded
that the vascularization of extensor digitorum
brevis muscle through the anterior tibial artery was
very rich and dependable. Giordano et al.(26) stated
that this artery allowed an arc of rotation wide
enough to include the most frequent lesions around
the ankle joint. Gahhos et al.(34) found that the
extensor digitorum brevis flap can be used to
cover defects along almost the entire tibia, as their
vascular pedicle could be traced as far as the leg.
Gibsten et al.(27) reported also that this muscle may
be used as a reverse flow flap, by dividing the
dorsalis pedis artery proximal to the origin of the
lateral tarsal artery. In this case the arterial supply to
the muscle reached it through the deep plantar arch
from the posterior tibial artery.
Zuker and Manktelow,(33) Lee and Dauber(23)
concluded that the profuse arterial flow was
responsible for the reliability and safety of the
extensor digitorum brevis flap. This good vascularity
around the exposed bones and tendons leads to rapid
healing and a high degree of resistance to infection,
so this flap is considered as the ideal biological
dressing.
570
Anatomical Study of the Dorsalis Pedis Artery.
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