Objectives: To describe the characteristics of locations, origins, variation courses of the dorsalis pedis arteries and the first dorsal metatarsal arteries. Material and method: 30 feet of 18 Vietnamese adult cadavers that were preserved by formaldehyde embalming fluid, were dissected and described in Anatomy Department of Military Medical University (12 cadavers were dissected both of feet, 6 cadavers were dissected one of feet).
Trang 1THE ANATOMY OF THE DORSALIS PEDIS ARTERY AND
THE FIRST DORSAL METATARSAL ARTERY
IN VIETNAMESE ADULTS
Tran Ngoc Anh*; Nguyen Trong Nghia**; Nguyen Van Dieu*
SUMMARY
Objectives: To describe the characteristics of locations, origins, variation courses of the
dorsalis pedis arteries and the first dorsal metatarsal arteries Material and method: 30 feet of
18 Vietnamese adult cadavers that were preserved by formaldehyde embalming fluid, were
dissected and described in Anatomy Department of Military Medical University (12 cadavers
were dissected both of feet, 6 cadavers were dissected one of feet) Results: The dorsalis pedis
artery was mostly found between medial and lateral malleolus (86.66%), in 1/3 middle segments
13.33% of the examined dorsalis pedis artery were found in other locations The average
diameter of the dorsalis pedis artery was 2.48 ± 0.82 mm The first dorsal metatarsal artery
arised from the dorsalis artery (93.33%) and the plantar artery (6.67%) The course of the first
dorsal metatarsal artery in intermetatarsal space: A type (80%), B type (10%), C type (10%)
The second dorsal metatarsal artery arised from the plantar artery (60%), the dorsalis pedis
artery (23.33%), the dorsalis pedis artery (13.33%), and the lateral anterior malleolar artery
(3.33%) Conclusion: Due to the variations of origins and courses of the dorsalis pedis arteries
and the first dorsal metatarsal arteries in Vietnames adults, it should be convenient to use them
for toe grafts in toe tranfer surgery
* Keywords: Dorsal pedis artery; Dorsal metatarsal artery; Toe transfer surgery
INTRODCUTION
The microsurgery technique of transference
of toes to hand is an intensive technique
that has been developed in Vietnam since
1995 and has beengrowing more widely
The most difficult problem of the technique
is the deficiency of blood supply after flap
transplantation The main source of the
great toe and second toe should be
investigated more deeply in order to have
a good preparation and attain the best
result of treatment in complex toe-to-hand
reconstruction There have been studies
of the anatomy of the great toe, second toe on cadaver such as study of Murakami
on Japanese adults; Gilbert’s [12] study
on French adults In Vietnam, in 1999, Nguyen Huy Phan [1] published statistics
on the size of some blood vessels and their application; however, they did not have specific research We investigated the anatomy of the dorsalis pedis artery (DPA), the first dorsal metatarsal artery (FDMA) and the second dorsal metatarsal artery (SDMA) basing on the size, origin,
* Vietnam Military Medical University
** Hadong General Hospital
Corresponding author: Tran Ngoc Anh (anhtngoc@gmail.com)
Date received: 09/06/2017
Date accepted: 28/09/2017
Trang 2location and associated arteries The results
helped to describe the morphology of the
arteries at the microsurgical level, which
acted as a guideline for the surgery,
increasing the successful rate in complex
toe-to-hand reconstruction
SUBJECTS AND METHODS
1 Subjects
30 feet of 18 Vietnamese adult cadavers
preserved by formaldehyde embalming
fluid were dissected and described in
Department of Anatomy, Military Medical
University (12 cadavers were dissected both
of their feet, 6 cadavers were dissected
one foot) The adults with an average age
of 66 years, of which 16 males and 14
females, were operated from July 2016 to
October 2016
* Tool:
Surgical kits: knives, scissors, flaps,
needles, blood vessels; magnifying glass,
blood dye Measuring tools: rulers, palmer
ruler with 0.1 mm precision, camera, computer
2 Methods
* Surgical method:
Figure 1: Skin incision in the foot
A superficial incision was made along the medial and lateral malleolus to expose the inferior extensor retinaculum This incision was extended to the head of the first metatarsal bone and to the fifth metatarsal bone After locating the extensor hallucis longus tendon, it was cut at the joint of the first metatarsal and the first proximal phalanx and reflected Then, the extensor hallucis brevis was located, cut
at the same junction, and reflected The dissection was continued to reach the first dorsal metatarsal artery After dissection
to examine the first metatarsal artery, the dorsal metatarsal ligaments, interosseous muscles, and metatarsophalangeal joint capsules were reflected and the second metatarsal bone was removed for study After removal of all meta-tarsal bones, the dissection continued to study the anatomic variations of the first metatarsal artery in relation to the first dorsal interosseous muscle All meta-tarsal bone specimens were cleaned soft tissues using a periosteal elevator and then fixed
in 10% neutralized buffered formalin Damaged specimens were not included in this study
* Calculation of blood vessel size and data processing:
The size of the blood vessels was measured with the Palmer ruler Using a needle to stabilize the blood vessels before carrying out the measurement to avoid displacement, deformity, loss of relevance or severity The relative length
of the blood vessels was calculated from the original commissar to the first major branching Measurement of the circumference
by squeezing the blood vessel and measuring the diameter of the flat (D) and
Trang 3calculating the diameter of the circle in
terms of the formula:
Circular diameter = 2D/3.1416 x 1.18
For: D is the diameter of the artery
1.18 is the rate of vasoconstriction when
stored in formol
The data were analyzed using SPSS version 21.0 software as a percentage, averages, and standard deviations When specific data from the specimens were available, we compared the data with other studies
RESULTS AND DISCUSSION
1 Dorsal pedis artery (DPA)
12%
14%
3%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Figure 1: Comparison of the incidence of DPA was very small or absence in the studies
The incidence of absence of dorsalis
pedis artery: Huber [5] studied 200 cadavers
resulting in either vacuum or very small
arteries in 12% of limbs; 3% in Adachi's
study [6]; 14.2% in Reich's study [7], and
6.67% in Yamada's study [4] In this
study, the incidence of DPA was 100%;
however, two specimens accounted for
6.67% of the very small DPA, after walking
down the dorsalis, branching and ending
prematurely In the upper third of the
dorsalis, two cases of absence of the
DPA may also be considered
Origin of DPA: Huber [5] reported that
in 1.5% of the specimens, DPA originated from the arterial artery outside the lower leg Yamada [4], observed this abnormality in one of the 30 specimens This figure was similar to 7.1% found in the study by Adachi [6] However, in this study, 100%
of the specimens, DPA were derived from the previous tarsal artery This can be explained by the limited number of specimens
in our study (30 specimens) It might not
be possible to detect the others of the origin
of DPA
Trang 4The size of DPA: Kim J.W [8] reported
the diameter of DPA was about 1.5 to
2 mm, Barman et al [9] found that the
median size of DPA was 2.25 ± 0.25 mm,
while Yamada [4] studied the results to be
2.07 ± 0.77 mm Nguyen Huy Phan showed
that the diameter of the DPA within the
range of 2.0 to 3.0 mm Results of our
research were 2.48 ± 0.82 mm, 1.2 mm
minimum and 4.2 mm maximum, respectively
Table 1: Diameter of DPA
Author Diameter of DPA
These results were consistent with the
size of DPA This artery could be well
applied to the dorsalis pedis perforator
However, the surgeons must keep in mind
that there was very small incidence in the
absence of DPA as 02 cases in the study
Investigate the location of DPA just
below the ankle, Kim J.W [8] resulted in
the location of the DPA as follows: 1/3
outside is 1.9%, third middle is 94.1%, 1/3
in is 3.9% Meanwhile, we reported 6.67%,
86.66%, 6.67%, respectively The position
of DPA helps the surgeons position the
artery in surgery
2 Dorsal metatarsal artery (DMA)
Origin of first dorsal metatarsal artery:
this study, FDMA from two sources, from
DPA in 28 cases accounted for 93.33%,
from deep plantar artery in the two cases account for 6.67% (two cases of very short and small FDMA) According to Lee J.H, Dauber W [11] 90.6% of all cases of FDMA originated from DPA and the rest from medial tarsal artery in 9.4% cases
Table 2: The origin of FDMA
Percentage of origin of FDMA Author
plantar artery
Medial tarsal artery Lee J.H,
We found, there was a similarity in the incidence of FDMA from DPA in the two study results But in the other case, we did not find any case of FDMA originated from the medial malleolar artery, whereas Lee J.H, Dauber W [11] did not find any case of FDMA originated from deep plantar artery Since the sample sizes for both studies are relatively small (30 cases), the difference was also relative
* Origin of second dorsal metatarsal artery:
Table 3: The origin of second dorsal
metatarsal artery
Study
Deep plantar artery
Arcuate artery DPA
Lateral tarsal artery
Medial tarsal artery
Hamada
There was a consistency in the primary incidence of SDMA originated from deep plantar artery, but in the remaining cases, there was a clear difference between our study and Hamada’ study In particular,
Trang 5we found 23.33% of all cases SDMA
originated from DPA while Hamada N's
study did not detect any cases While the
incidence of SDMA originated from arcuate artery and lateral tarsal artery was much lower than that of Hamada N
Figure 2: DPA branch FDMA and SDMA
The reach of FDMA in the first inter-metatarsal space was significantly different between studies
Table 4: The reach of FDMA in the first inter-metatarsal space
Figure 3: FDMA in the first inter-metatarsal space
A A A type B B type C C type
Trang 6- Type A (shallow type): the artery
arises from the top or upper part of deep
plantar artery and then falls under a
slender arch muscle run to interosseous
muscle during the whole course
- Type B (deep type): arteries may arise
from the lower part of deep plantar artery
or from deep pedal arch to the hindquarters
of first plantar metatarsal artery, then runs
forward and should be shallowed, and
then appears above interosseous muscles
between the ends under the metatarsal
bone I and II
- Type C (small arteries or no vessels):
only one small FDMA with a diameter less
than 1 mm This artery branch almost
disappeared between the metatarsal bone
1 and 2
The FDMA are mainly in A form with
the number of 24 specimens, accounting
for 80%; the other two types of FDMA are
B and C both 03 templates, accounting
for 10% There was no absence of FDMA
in our study
Table 5: Proportion of types of FDMA
Study Type A Type B Type C
In addition, some authors had different
subgroups on the pathway of the FDMA
were: Kim J.W divided into 5 small types
of Ia, Ib, Ic, IIa, IIb as described above
The results were very different, due to
differences in subjects (race, body or patient),
research methods (surgery, ultrasound )
CONCLUSION
The DPA and FDMA, SDMA have relatively complicated anatomy with many variations compared to classic descriptions such as the DPA, in addition to classic cases in 1/3 middle dorsalis pedis, there were cases that are located and 1/3 in, 1/3 out of two samples together accounted for 13.33% There were two small DPA FDMA in two cases accounted for 6.67% arising from the common plantar artery, with 3 cases of small FDMA (diameter
< 1 mm) The SDMA had 4 different origins, of which the largest proportion was derived from 60% of deep plantar artery, the incidence of DPA was only 13.33% Basically, the blood vessels along the DPA - the FDMA most of large size, easy to disclose, good use in making stems
of feeding vessels However, due to the variations, clinical examination, ultrasonographic tests, angiography, etc before the operation was essential
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