Digital technology in repair of soft tissue defect in hand by anterior tibial artery perforator flap / 中华显微外科杂志

Objective:To investigate the clinical value of digital technology in repair of soft tissue defect in hand by anterior tibial artery perforator flap.Methods:From January 2015 to February 2021, 9 patients with soft tissue defects in hand were repaired with anterior tibial artery perforator flap assisted by digital technology in flap design, including 6 males and 3 females aged from 19 to 63 years with a mean age of 33 years. The size of defects varied from 2.0 cm×1.5 cm to 4.0 cm×3.0 cm, with exposed bones or tendons. Preoperative CTA scan of lower limb was performed and three-dimensional image was reconstructed with Mimics 20.0. The anterior tibial artery perforator flap was designed according to the shape and size of the defect, then the resection of flap was digitally simulated. The flap based on the digital design was harvested and the defect was repaired in the operation. The size of flap was 2.5 cm×2.0 cm~4.5 cm×3.5 cm. Outpatient clinic follow-up was performed to evaluate the survival of flaps. Disability of Arm, Shoulder and Hand(DASH) was used for function evaluation.Results:All flaps were harvested successfully and all donor sites were closed directly. After surgery, 8 flaps survived completely. One flap developed venous occlusion that showed partial necrosis of the flap, and it was rescued after exploration and re-anastomosis. The follow-up period ranged from 6 to 21 months, with an average of 13 months. The DASH scores of the affected limb were 2 to 15 points at the last follow-up, with an average of 6.4 points. Mild scar hyperplasia occurred at donor site in 1 case without sensory abnormality.Conclusion:The digital technology is able to accurately locate the perforators by allowing an individualised design of the anterior tibial artery perforator flap. The flap is suitable for repair of small and medium-sized soft tissue defect in hand, and the digital technology has certain value in clinical application.

Endovascular revascularization of chronic total arterial occlusion of the lower limb using the SAFARI technique / Revascularização endovascular utilizando a técnica SAFARI em casos de oclusão arterial total do membro inferior

Abstract The SAFARI technique or Subintimal Arterial Flossing with Antegrade-Retrograde Intervention is an endovascular procedure that allows recanalization of Chronic Total Occlusive (CTO) lesions when conventional subintimal angioplasty is unsuccessful. Retrograde access is usually obtained through the popliteal, anterior tibial, dorsalis pedis artery, or posterior tibial arteries and may potentially provide more options for endovascular interventions in limb salvage. The case of an 81-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and dyslipidemia is presented. He presented with a cutaneous ulcer on the right lower limb with torpid evolution and poor healing. The Doppler ultrasound and arteriographic study revealed a CTO lesion of the popliteal artery that was not a candidate for antegrade endovascular revascularization, but was successfully treated using the SAFARI technique. The patient had no perioperative complications, the wound showed better healing, and he was discharged with an indication of daily dressings and control by an external outpatient clinic.

Resumo A técnica SAFARI, ou Subintimal Arterial Flossing with Antegrade-Retrograde Intervention, é um procedimento endovascular que permite a recanalização de lesões por oclusão total crônica (OTC) em caso de fracasso da angioplastia subintimal convencional. O acesso retrógrado é geralmente obtido através da artéria poplítea, tibial anterior, pediosa ou tibial posterior e pode fornecer mais alternativas de intervenções endovasculares para o salvamento do membro. É apresentado o caso de um homem de 81 anos com histórico de hipertenção não controlada, diabetes melito e dislipidemia. Ele apresentava uma lesão ulcerativa cutânea no membro inferior direito com evolução tórpida e má cicatrização. O ultrassom Doppler e o estudo arteriográfico revelaram uma lesão por OTC na artéria poplítea. O paciente não era candidato a revascularização endovascular anterógrada; sendo assim, esta foi realizada com successo utilizando a técnica SAFARI. O paciente não apresentou complicações perioperatórias e recebeu alta com indicação de cuidados diários com a ferida e controle em um ambulatório externo. Além disso, a ferida apresentou melhor cicatrização.

Síndrome do aprisionamento da artéria tibial anterior bilateral pelo retináculo extensor do tornozelo: relato de caso / Bilateral anterior tibial artery entrapment by the ankle extensor retinaculum: case report

Resumo Os aprisionamentos vasculares são raros. Nos membros inferiores, geralmente são assintomáticos, mas podem causar claudicação intermitente atípica em indivíduos jovens sem fatores de risco para aterosclerose ou doenças inflamatórias. O vaso mais frequentemente acometido é a artéria poplítea, causando a síndrome do aprisionamento da artéria poplítea (SAAP), com sintomas na região dos músculos infrapatelares. Quando o desconforto ao esforço é mais distal, deve-se pensar em outros locais de aprisionamento arterial, como a artéria tibial anterior. Neste trabalho, é relatado o caso de um paciente com claudicação intermitente nos pés devido ao aprisionamento da artéria tibial anterior (AATA) bilateral, causado pelo retináculo dos músculos extensores e diagnosticado pela ultrassonografia vascular e angiotomografia durante flexão plantar. O paciente foi tratado cirurgicamente, evoluindo com melhora dos sintomas clínicos.

Abstract Vascular entrapment is rare. In the lower limbs it is generally asymptomatic, but may cause atypical intermittent claudication in young people without risk factors for atherosclerosis and inflammatory diseases. The most common type of compression involves the popliteal artery, causing symptoms in the region of the infra-patellar muscles. When discomfort is more distal, other entrapment points should be considered, such as the anterior tibial artery. This article reports the case of a patient with intermittent claudication in both feet due to extrinsic compression of the anterior tibial artery bilaterally by the extensor retinaculum of the ankle, diagnosed by vascular ultrasonography and angiotomography during plantar flexion maneuvers. The patient was treated surgically, resulting in improvement of clinical symptoms.

Anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap for foot and ankle defect / 中国修复重建外科杂志

Objective: To investigate the clinical application of the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap in repair of foot and ankle defects. Methods: Between October 2014 and October 2018, 18 cases with foot and ankle defects were treated. There were 12 males and 6 females with an average age of 32.8 years (range, 8-56 years). There were 11 cases of traffic accident injuries, 3 cases of falling from height injuries, and 4 cases of heavy objects injuries. The wound was at the dorsum of the foot in 9 cases, the heel in 4 cases, the lateral malleolus in 5 cases. The time from injury to flap repair was 7-34 days (mean, 19 days). The size of wound ranged from 6.0 cm×2.5 cm to 11.0 cm×6.0 cm. The foot and ankle defects were repaired with the peroneal artery terminal perforator propeller flap in size of 6 cm×3 cm-18 cm×7 cm, which donor site was repaired with the anterior tibial artery perforator propeller flap in size of 8 cm×3 cm-16 cm×6 cm. Results: One patient had a hemorrhagic swelling in the peroneal artery terminal perforator propeller flap, and survived after symptomatic treatment. All recipient and donor sites healed by first intention. Eighteen patients were followed up 6-15 months (mean, 12.5 months). At last follow-up, the shape, color, texture, and thickness of the flaps in the donor sites were similar with those in the recipient sites. There were only linear scars on the donor sites. The two-point discrimination of the peroneal artery terminal perforator propeller flap ranged from 10 to 12 mm (mean, 11 mm). According to American Orthopaedic Foot and Ankle Society (AOFAS) score criteria, the results were excellent in 15 cases and good in 3 cases, with an excellent and good rate of 100%. Conclusion: The foot and ankle defects can be repaired with the anterior tibial artery perforator propeller flap relay peroneal artery terminal perforator propeller flap. The procedure is not sacrificing the main vessel and can avoid the skin grafting and obtain the good ankle function.

The anatomical basis of the vascularized fibularis brevis grafts / Base anatómica de los injertos vascularizados del músculo fibularis brevis

Fibularis brevis grafts have been extensively used, especially as distally-based grafts, to cover defects in the lower leg and foot. The study has contributed to analyze the blood supply of the fibularis brevis muscle and the vascular basis of its possible different grafts. Both legs of twelve preserved cadavers, without congenital vascular anomalies, were utilized in the study. Fibularis brevis was exposed in all selected legs along with the verification of different arterial pedicles. The total means and standard deviations of the length and width of the muscle together with diameters of major vessels were calculated. Total length and width of middle portion of fibularis brevis were at means of 28.7±0.4 cm and 3±0.02 cm respectively. The upper and middle portions of the muscle were supplied by the fibular and the anterior tibial artery. The middle portion was supplemented by the upper perforating branch of the posterior tibial artery. The lower portion of the muscle was supplied by the lower perforating branch of the posterior tibial and the periosteal arteries. The muscle could be used as a proximally or distally based flap, free vascularized muscle graft, free vascularized osteo-muscular flap, and distally-based split flap. It can be split completely into two flaps; each of which can be used as a proximally or distally.

Los injertos de músculo fibularis brevis son usados ampliamente, especialmente como injertos de base distal, para cubrir defectos en la parte inferior de la pierna y el pie. El objetivo de este estudio fue analizar el suministro de sangre del músculo fibularis brevis y la base vascular de los posibles diferentes injertos. Para el estudio se utilizaron ambas piernas de 12 cadáveres preservados, sin anomalías vasculares congénitas. El músculo fibularis brevis fue encontrado en todas las piernas junto con los diferentes pedículos arteriales. Se calcularon las medias totales y las desviaciones estándar de la longitud y el ancho del músculo, junto con los diámetros de los vasos principales. La longitud y el ancho totales de la porción media del músculo fibularis brevis fueron de 28,7±0,4 cm y 3±0,02 cm, respectivamente. Las partes superior y media del músculo estaban suplidas vascularmente por la arteria fibular y la arteria tibial anterior. La parte media se complementó con la rama perforante superior de la arteria tibial posterior. La parte inferior del músculo fue suplida por una rama perforante inferior de la arteria tibial posterior y las arterias periósticas. El músculo podría usarse como un colgajo de base proximal o distal, injerto de músculo vascularizado libre, colgajo osteomuscular vascularizado libre y colgajo dividido distal. Se puede dividir por completo en dos colgajos; cada uno de estos puede ser utilizado como proximal o distal.

Anatomy study and clinical application of periosteal perforator bone-skin fiap of proximal lateral tibial / 中华显微外科杂志

Objective To provide anatomical information and clinical application of periosteal perforator bone-skin flap of proximal lateral tibia. Methods From March, 2015 to March, 2017, 15 fresh cadavers who underwent injected with imaging technology and dissected with layer by layer. The origins, branches, distribution and anastomosis of periosteal perforator vessels in the proximal lateral tibial were observed. Sixteen patients of composite tissue defect in hands and feet were repaired with the method of free transplantation of this flap from March, 2015 to March, 2017. Injured area was from 3.0 cm × 0.8 cm to 6.0 cm × 5.5 cm. Bony defect size was from 1.7 cm × 1.5 cm × 1.0 cm to 5.0 cm × 1.0 cm × 1.0 cm. The bone-skin flap size ranged respectively from 3.0 cm × 0.8 cm to 6.0 cm × 5.5 cm and 1.6 cm ×1.0 cm × 0.8 cm to 5.0 cm×1.0 cm × 1.0 cm. Postoperative followed-up was done termly. Results The diameter and superficial length of the main perforators respectively were 0.5 to 1.2 mm and from 2.5 to 4.3 cm. The followed-up time was from 6 to 24 months in 14 cases, with the results of the bone-skin flaps presented favourable contours and good functions. The healing time of bone flap was 2 to 4 months. The function of shank was normal. Conclusion The periosteal perforator of proximal lateral tibia has favourable appearance, constant vascular pedi-cle, reliable blood supply and large diameter. The free transplantation of this flap offers a satisfactory alternative for repairing the small and medium-sized area of composite tissue defects of hands and feet.

Coil Embolization of a Pseudoaneurysm of the Anterior Tibial Artery: A Case Report / 대한족부족관절학회지

Development of a pseudoaneurysm around the ankle is an uncommon complication after surgery. We experienced a case of a pseudoaneurysm, which developed from the anterior tibial artery. A 44-year-old woman had sustained painful swelling of her right ankle after the removal of implants for a distal fibular fracture. The pseudoaneurysm was confirmed by ultrasonography and angiography. The patient was treated with an intervention using a coil and recovered without further complaints. This case report aims to increase the awareness of this complication with review of literature.

A segmental hypoplastic anterior tibial artery coexisting with a hypertrophied perforating fibular artery a case report and clinical implications / Coexistencia de una arteria tibial anterior hipoplásica segmentaria con una arteria fibular perforante hipertrofiada. Reporte de caso e implicancias clínicas

Vascular injuries of the lower limb, especially from penetrating gunshot wounds, and peripheral arterial diseases are on the increase and management of these and many other lower limb injuries involve increasing usage of vascular interventions like by-pass surgery, per-cutaneous transluminal angioplasty, arterial cannulation, arterial bypass graft or minimally invasive measures like percutaneous trans-arterial catheterization, among others. A thorough knowledge of infrapopliteal branching most especially their pathways and luminal diameters are important to surgeons in selecting appropriate surgical interventions or procedures. We report the case in which one of the 3 terminal branches of the popliteal artery (PPA), the anterior tibial artery (ATA) of good caliber size at origin became hypoplastic in the anterior leg region after giving off numerous muscular branches. Continuing as an almost attenuated dorsalis pedis artery (aDPA) in the dorsum of the foot, the latter was reinforced by an enlarged hypertrophied fibular artery. This case illustrates yet the importance of the fibular artery as the dominant of the 3 infrapopliteal branching arteries, reinforcing or replacing the posterior tibial artery (PTA) when it is weak or absent by a strong communicating branch or, reinforcing a weak ATA and dorsalis pedis artery (DPA) by a strong perforating fibular artery as being reported. The PTA however travelled a normal course yielding the medial and lateral plantar arteries posterior to the abductor hallucis muscle. This case demonstrates the importance of collateral communications and reinforcements from other infrapopliteal arteries, whenever one of its members or subsequent branches are absent or hypoplastic. A very sound knowledge of the various branching patterns of the PPA can be gained via pre-operatively vascular angiography, designed to guide the surgeon in the selection of appropriate surgical interventions, adding value to patients care in helping to reduce iatrogenic surgical vascular complications and reduction in total number of limb loss.

Las lesiones vasculares de los miembros inferiores, especialmente las heridas penetrantes por arma de fuego y enfermedades arteriales periféricas, están en aumento. Su manejo, así como el de otras lesiones en los miembros inferiores, implican un mayor uso de intervenciones vasculares como la cirugía de by-pass, angioplastía transluminal percutánea, canulación arterial, injerto de derivación arterial o medidas mínimamente invasivas como el cateterismo transarterial percutáneo, entre otros. El conocimiento profundo de las ramificaciones infrapoplíteas, muy especialmente sus vías y diámetros luminales son importantes para los cirujanos en la selección de las intervenciones o procedimientos quirúrgicos apropiados. Presentamos un caso en el cual, una de las 3 ramas terminales de la arteria poplítea (APP), la arteria tibial anterior (ATA), de buen calibre en su origen se hizo hipoplásica en la región anterior de la pierna después de un desprendimiento de numerosas ramas musculares. Continuó como una arteria dorsal del pie (ADP) casi atenuada en el dorso del pie; esta última se vio reforzada por una amplia arteria fibular hipertrofiada. Este caso ilustra la importancia de la arteria fibular como dominante de las 3 ramificaciones de las arterias infrapoplíteas, un refuerzo o sustitución de la arteria tibial posterior (ATP) cuando es débil o está ausente, por una fuerte rama comunicante, o bien refuerzo de una débil ATA y ADP por una fuerte arteria fibular perforante como en el caso reportado. La ATP sin embargo tenía un trayecto con un curso normal generando las arterias plantares medial y lateral, posterior al músculo abductor del hállux. Este caso demuestra la importancia de las comunicaciones colaterales y refuerzos de otras arterias infrapoplíteas, cada vez que uno de sus componentes o ramas posteriores están ausentes o hipoplásicas. Un conocimiento detallado de los diferentes patrones de ramificación de la APP puede ser adquirido a través de una angiografía vascular previo a la cirugía, diseñada para guiar al cirujano en la selección de las intervenciones quirúrgicas adecuadas, agrega valor a la atención de los pacientes, ayuda a disminuir las complicaciones vasculares quirúrgicas iatrogénicas y reduce el número total de pérdidas de miembros inferiores.

Hypoplastic anterior tibial artery associated with continuation of fibular (peroneal) artery as dorsalis pedis artery: a case report / Arteria tibial anterior hipoplásica asociada con la continuación de la arteria fibular como arteria dorsal del pié: un reporte de caso

Arterial variations of distal parts of lower limb are well documented. However, continuation of fibular artery as dorsalis pedis artery is a rare finding. Unusual course and distribution of the anterior tibial artery and fibular artery were observed during routine anatomical dissection of the right lower limb of an approximately 40-year-old male cadaver. The arteries of the crural region arose from the popliteal artery, as usual. However the anterior tibial artery was hypoplastic. The fibular artery was larger than usual and crossed the lowest portion of the interosseous membrane and continued as dorsalis pedis artery. Posterior tibial artery had a normal course and distally divided into medial and lateral plantar arteries. The awareness of these variations is important to vascular surgeons while performing arterial reconstructions in femorodistal bypass graft procedures, and also to orthopaedic surgeons during surgical clubfoot release.

Las variaciones arteriales de las partes distales de los miembros inferiores están bien documentados. Sin embargo, la continuación de la arteria fibular como arteria dorsal del pie es un hallazgo raro. El curso y distribución inusual de la arteria tibial anterior y la arteria fibular se observaron durante la disección anatómica de rutina en el miembro inferior derecho del cadáver de un hombre de aproximadamente 40 años de edad. Las arterias de la región crural se originaron desde la arteria poplítea como es usual. Sin embargo, la arteria tibial anterior era hipoplásica. La arteria fibular era más grande de lo habitual, cruzó la porción más baja de la membrana interósea y se mantuvo como la arteria dorsal del pie. La arteria tibial posterior tuvo un curso normal; distalmente se dividió en las arterias plantares medial y lateral. El conocimiento de estas variaciones es importante para los cirujanos vasculares al realizar reconstrucciones arteriales en procedimientos de injerto de bypass femorodistal, y también para los cirujanos ortopédicos durante la liberación quirúrgica del pie zambo.

Pseudoaneurysm of Anterior Tibial Artery after Ankle Arthroscopy / 대한족부족관절학회지

Pseudoaneurysm is extremely rare complication after ankle arthroscopy with standard anteromedial and anterolateral portals. We report a case of a pseudoaneurysm of the anterior tibial artery detected at 3 months after ankle arthroscopy in a 16-year-old male. He had sustained painful swelling of his right ankle after the arthroscopic surgery, and referred to our hospital with an MRI checked postoperatively. We failed to make the diagnosis of pseudoaneurysm with the postoperative MRI, thus the patient underwent another arthroscopy which revealed massive hemarthrosis within the joint. The diagnosis was confirmed with an angiography, and the vascular lesion was ligated.

Anatomical review of dorsalis pedis artery flap for the oral cavity reconstruction

The dorsalis pedis artery (DPA) was renamed from the anterior tibialis artery after it passed under the extensor retinaculum, and DPA travels between the extensor hallucis longus and extensor digitorum longus muscle along the dorsum of the foot. After giving off the proximal and distal tarsal, arcuate and medial tarsal branches, DPA enters the proximal first intermetatarsal space via the first dorsal metatarsal artery (FDMA), which courses over the first dorsal interosseous muscle (FDIM). For detailed knowledge of the neurovascular anatomy of a dorsalis pedis artery flap (DPAF) as a routine reconstructive procedure after the resection of oral malignant tumors, the precise neurovascular anatomy of DPAF must be studied along the DPA courses as above. In this first review article in the Korean language, the anatomical basis of DPAF is summarized and discussed after a delicate investigation of more than 35 recent articles and atlas textbooks. Many advantages of DPAF, such as a consistent flap vascular anatomy, acceptable donor site morbidity, and the ability to perform simultaneous flap harvest using oral cancer ablation procedures, and additional important risks with the pitfalls of DPAF were emphasized. This article will be helpful, particularly for young doctors during the special curriculum periods for the Korean National Board of Specialists in the field of oral and maxillofacial surgery, plastic surgery, otolaryngology, orthopedic surgery, etc.

Hemodynamic Change of Anterior Tibial Artery during Acupuncture at Zusanli (ST36) / 中国康复理论与实践

@#Objective To study physiological foundation of acupunctureDeqi.Methods 28 healthy volunteers who never experienced acupuncture were recruited. The right Zusanli (ST36) and a site 1.5 cm beside Zusanli (ST36) (nominated as A) were acupunctured at different time. Shallow and deep acupuncturing was inserted at Zusanli (ST36). Only deep acupuncturing was inserted at A. Hemodynamic parameters of the anterior tibial artery including the peak value in the systolic phase (Vmax), the average blood flow velocity (Vm), and the inner diameter of vessels (Dist) were observed with colored Doppler ultrasound before, at the end of acupuncture, and 3 min afterDeqi response. Results There was significant difference in those parameters between before acupuncture and 3 min after deqi response when deep acupuncturing at Zusanli (ST36) (P＜0.05), but was not significant difference when shallow acupuncturing (P＞0.05). There was significant difference in ΔVmax and ΔVm between acupuncture at Zusanli (ST36) and A points (P＜0.05). Conclusion Arterial haemodynamics variation seems to be associated with acupunctureDeqi.

Effects of Needle Retaining on Haemodynamics of Anterior Tibial Artery During Acupuncture / 中国康复理论与实践

@# Objective To study the relationship between needle retaining anddeqi. Methods Manual acupuncture was performed at the left ST36 of 26 naive healthy adult volunteers. Half of them retained the needles for 6 min and others were put the needle out immediately afterdeqi. Hemodynamic parameters of the anterior tibial artery were observed with color Doppler ultrasonography before and at 0, 1, 2, 3, 4, 5 min after acupuncture. Results There was significant difference in Vmax、Vm、Pi and Dist in anterior tibial artery before and 3 min after acupuncture, but wasn't between needle remaining and not. Conclusion Needle retaining cannot change the regional haemodynamics during acupuncture, which suggest it cannot strengthendeqi.

Pseudoaneurysm of the Anterior Tibial Artery: A Case Report / 대한족부족관절학회지

Pseudoaneurysm of the anterior tibial artery is a rare cause of pain and swelling of the lower leg and the foot following minor sports injuries. When there is no definite musculoskeletal cause of pain, it is important to consider pseudoaneurysm. Early diagnosis and management are essential for the successful outcome. MRI and angiogram are useful for early diagnosis. We report a case of pseudoaneurysm of the anterior tibial artery following minor sports injury. The patient experienced complete relief of the symptoms after resection of the pseudoaneurysm.

Reverse anterior tibial artery flap for the repair of foot skin defect / 中国微创外科杂志

Objective To investigate the feasibility of clinical use of reverse anterior tibial artery flap for the repair of foot skin defect.Methods With the perforating branch of the anterior tibial artery as turning point,a reverse flap was utilized to repair the foot skin defect.The donor site was directly sutured or covered by full-thickness skin grafting.Results The flap and skin graft survived in all the 7 patients.Follow-up observations for 2～24 months(mean,16 months) in 6 patients showed normal color,texture,and appearance of flaps.Conclusions The reverse anterior tibial artery flap can be used for the construction of foot skin defect,with advantages of simple performance and good safety.

Traumatic False Aneurysm: Report of Two Cases / 대한정형외과학회잡지

False aneurysm is one of the complications of untreated arterial injury. Most traumatic aneurysms in the extremities are false, and they are usually caused by penetrating trauma. The pathogenesis of false aneurysm is initiated by a damaged artery that allows hemorrhage into surrounding soft tissue, an encapsulated hematoma is then formed, which undergoes organization, with invasion of fibrin and con-nective tissue, and the endothelialization of its central cavity, which communicates with the arterial defect, forming the false aneurysm. We experienced two cases of traumatic false anerysm of a left anterior tibial artery and a right radial artery, which were treated successfully by end-to-end anastomosis in the former and a saphenous vein graft in the latter.