The anatomy of the dorsalis pedis artery and the first dorsal metatarsal artery in Vietnamese adults

Nội dung text: The anatomy of the dorsalis pedis artery and the first dorsal metatarsal artery in Vietnamese adults

1. Journal of military pharmaco-medicine n 08-2017 THE 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 reconstruction. There have been studies of the anatomy of the great toe, second toe on cadaver such as study of Murakami The microsurgery technique of transference on Japanese adults; Gilbert ’s [12] study of toes to hand is an intensive technique on French adults. In Vietnam, in 1999, that has been developed in Vietnam since Nguyen Huy Phan [1] published statistics 1995 and has been growing more widely. on the size of some blood vessels and The most difficult problem of the technique their application; however, they did not is the deficiency of blood supply after flap have specific research. We investigated transplantation. The main source of the the anatomy of the dorsalis pedis artery great toe and second toe should be (DPA), the first dorsal metatarsal artery investigated more deeply in order to have (FDMA) and the second dorsal metatarsal a good preparation and attain the best artery (SDMA) basing on the size, origin, result of treatment in complex toe-to-hand * 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 159
2. Journal of military pharmaco-medicine n 08-2017 location and associated arteries. The results A superficial incision was made along helped to describe the morphology of the the medial and lateral malleolus to expose arteries at the microsurgical level, which the inferior extensor retinaculum. This acted as a guideline for the surgery, incision was extended to the head of the increasing the successful rate in complex first metatarsal bone and to the fifth toe-to-hand reconstruction. metatarsal bone. After locating the extensor hallucis longus tendon, it was cut at the SUBJECTS AND METHODS joint of the first metatarsal and the first 1. Subjects. proximal phalanx and reflected. Then, the 30 feet of 18 Vietnamese adult cadavers extensor hallucis brevis was located, cut preserved by formaldehyde embalming at the same junction, and reflected. The fluid were dissected and described in dissection was continued to reach the first Department of Anatomy, Military Medical dorsal metatarsal artery. After dissection University (12 cadavers were dissected both to examine the first metatarsal artery, the dorsal metatarsal ligaments, interosseous of their feet, 6 cadavers were dissected muscles, and metatarsophalangeal joint one foot). The adults with an average age capsules were reflected and the second of 66 years, of which 16 males and 14 metatarsal bone was removed for study. females, were operated from July 2016 to After removal of all meta-tarsal bones, October 2016. the dissection continued to study the * Tool: anatomic variations of the first metatarsal Surgical kits: knives, scissors, flaps, artery in relation to the first dorsal needles, blood vessels; magnifying glass, interosseous muscle. All meta-tarsal bone blood dye. Measuring tools: rulers, palmer specimens were cleaned soft tissues ruler with 0.1 mm precision, camera, computer. using a periosteal elevator and then fixed in 10% neutralized buffered formalin. 2. Methods. Damaged specimens were not included in * Surgical method: 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 Figure 1: Skin incision in the foot. measuring the diameter of the flat (D) and 160
3. Journal of military pharmaco-medicine n 08-2017 calculating the diameter of the circle in The data were analyzed using SPSS terms of the formula: version 21.0 software as a percentage, Circular diameter = 2D/3.1416 x 1.18. averages, and standard deviations. When For: D is the diameter of the artery. specific data from the specimens were 1.18 is the rate of vasoconstriction when available, we compared the data with stored in formol. other studies. RESULTS AND DISCUSSION 1. Dorsal pedis artery (DPA). 16% 14% 14% 12% 12% 10% 8% 6.67% 6.67% 6% 4% 3% 2% 0% Huber Reich Adachi Yamada Our Figure 1: Comparison of the incidence of DPA was very small or absence in the studies. The incidence of absence of dorsalis Origin of DPA: Huber [5] reported that pedis artery: Huber [5] studied 200 cadavers in 1.5% of the specimens, DPA originated resulting in either vacuum or very small from the arterial artery outside the lower leg. arteries in 12% of limbs; 3% in Adachi's Yamada [4], observed this abnormality in study [6]; 14.2% in Reich's study [7], and one of the 30 specimens. This figure was 6.67% in Yamada's study [4]. In this similar to 7.1% found in the study by study, the incidence of DPA was 100%; Adachi [6]. However, in this study, 100% however, two specimens accounted for of the specimens, DPA were derived from 6.67% of the very small DPA, after walking the previous tarsal artery. This can be down the dorsalis, branching and ending explained by the limited number of specimens prematurely. In the upper third of the in our study (30 specimens). It might not dorsalis, two cases of absence of the be possible to detect the others of the origin DPA may also be considered. of DPA. 161
4. Journal of military pharmaco-medicine n 08-2017 The size of DPA: Kim J.W [8] reported from deep plantar artery in the two cases the diameter of DPA was about 1.5 to account for 6.67% (two cases of very 2 mm, Barman et al [9] found that the short and small FDMA). According to Lee median size of DPA was 2.25 ± 0.25 mm, J.H, Dauber W [11] 90.6% of all cases of while Yamada [4] studied the results to be FDMA originated from DPA and the rest 2.07 ± 0.77 mm. Nguyen Huy Phan showed from medial tarsal artery in 9.4% cases. that the diameter of the DPA within the Table 2: The origin of FDMA. range of 2.0 to 3.0 mm. Results of our research were 2.48 ± 0.82 mm, 1.2 mm Percentage of origin of FDMA minimum and 4.2 mm maximum, respectively. Author Deep Medial DPA plantar artery tarsal artery Table 1: Diameter of DPA. Lee J.H, 90.6% 0% 9.4% Author Diameter of DPA Dauber W Kim J.M 1,5 - 2 mm This study 93.33% 6.67% 0% Barman 2,25 ± 0,25 mm We found, there was a similarity in the Yamada 2,07 ± 0,77 mm incidence of FDMA from DPA in the two Nguyen Huy Phan 2,0 - 3,0 mm study results. But in the other case, we did not find any case of FDMA originated This study 2,48 ± 0,82 mm from the medial malleolar artery, whereas These results were consistent with the Lee J.H, Dauber W [11] did not find any size of DPA. This artery could be well case of FDMA originated from deep plantar applied to the dorsalis pedis perforator artery. Since the sample sizes for both flap, complex toe-to-hand reconstruction. studies are relatively small (30 cases), However, the surgeons must keep in mind the difference was also relative. that there was very small incidence in the * Origin of second dorsal metatarsal absence of DPA as 02 cases in the study. artery: * Location of DPA: Table 3: The origin of second dorsal Investigate the location of DPA just metatarsal artery. below the ankle, Kim. J.W [8] resulted in Deep Lateral Medial Arcuate the location of the DPA as follows: 1/3 Study plantar DPA tarsal tarsal artery outside is 1.9%, third middle is 94.1%, 1/3 artery artery artery in is 3.9%. Meanwhile, we reported 6.67%, Hamada 57% 25% 0% 12% 6% 86.66%, 6.67%, respectively. The position N et al of DPA helps the surgeons position the This study 60% 13.33% 23.33% 3.33% 0% artery in surgery. There was a consistency in the primary 2. Dorsal metatarsal artery (DMA). incidence of SDMA originated from deep Origin of first dorsal metatarsal artery: plantar artery, but in the remaining cases, this study, FDMA from two sources, from there was a clear difference between our DPA in 28 cases accounted for 93.33%, study and Hamada’ study. In particular, 162
5. Journal of military pharmaco-medicine n 08-2017 we found 23.33% of all cases SDMA incidence of SDMA originated from arcuate originated from DPA while Hamada N's artery and lateral tarsal artery was much study did not detect any cases. While the 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. Type Cases % A 24 80 B 3 10 C 3 10 Total 30 100 A B C Figure 3: FDMA in the first inter-metatarsal space. A. A. A type B. B type C. C type 163
6. Journal of military pharmaco-medicine n 08-2017 - Type A (shallow type): the artery CONCLUSION arises from the top or upper part of deep The DPA and FDMA, SDMA have plantar artery and then falls under a relatively complicated anatomy with many slender arch muscle run to interosseous variations compared to classic descriptions muscle during the whole course. such as the DPA, in addition to classic - Type B (deep type): arteries may arise cases in 1/3 middle dorsalis pedis, there from the lower part of deep plantar artery were cases that are located and 1/3 in, 1/3 or from deep pedal arch to the hindquarters out of two samples together accounted for of first plantar metatarsal artery, then runs 13.33%. There were two small DPA. forward and should be shallowed, and FDMA in two cases accounted for 6.67% then appears above interosseous muscles arising from the common plantar artery, between the ends under the metatarsal with 3 cases of small FDMA (diameter bone I and II. < 1 mm). The SDMA had 4 different - Type C (small arteries or no vessels): origins, of which the largest proportion only one small FDMA with a diameter less was derived from 60% of deep plantar than 1 mm. This artery branch almost artery, the incidence of DPA was only disappeared between the metatarsal bone 13.33%. Basically, the blood vessels along 1 and 2. the DPA - the FDMA most of large size, easy to disclose, good use in making stems The FDMA are mainly in A form with of feeding vessels. However, due to the the number of 24 specimens, accounting variations, clinical examination, ultrasonographic for 80%; the other two types of FDMA are tests, angiography, etc. before the operation B and C both 03 templates, accounting was essential. for 10%. There was no absence of FDMA in our study. REFERANCE Table 5: Proportion of types of FDMA. 1. Nguyen Huy Phan. Microvascular Study Type A Type B Type C microsurgery - experimental neurosurgery and clinical applications. Science and Technology. Nguyen Huy Phan 49% 40% 11% Publishing House. 1999, pp.392-417. This study 80 % 10% 10% 2. Lee J.H, Dauber W. Anatomic study of the dorsalis pedis-first dorsal metatarsal artery. In addition, some authors had different Ann Plast Surg . 1997, 38, pp.50-55. subgroups on the pathway of the FDMA 3. Mark H. Meissner et al . Lower extremity were: Kim. J.W divided into 5 small types venous anatomy. Semin Intervent Radiol . of Ia, Ib, Ic, IIa, IIb as described above. 2015, 22 (3), pp.147-156. The results were very different, due to 4. Yamada et al. Variations of the arterial differences in subjects (race, body or patient), anatomy of the foot. The American Journal of research methods (surgery, ultrasound...). Surgery. 1993, August, Vol 166, pp.130-135. 164
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