ABSTRACT
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.
Subject(s)
Humans , Arteries/anatomy & histology , Surgical Flaps , Muscle, Skeletal/blood supply , Fibula/blood supply , CadaverABSTRACT
The study has contributed to evaluate the tibial nerve and its vasculature anatomically. Ten preserved cadavers (5 male, 5 female) have been used for this study. Each cadaver was injected with red latex and through incisions the tibial nerve was exposed at the level of bifurcation of sciatic nerve. The tibial nerve in 85 % cadavers was located between middle and lower thirds at upper angle of popliteal fossa; whereas, in 15 % cadavers it was present below the piriformis muscle in gluteal region. The total length of the tibial nerve was at a mean of 65.26±14.42 cm in males and 64.79±67.61 cm in females, without significantly different. Its total diameter was at a mean of 5.51±1.55 mm, with a mean of 4.11±0.88 mm at the popliteal fossa and a mean of 3.24±0.81mm at its termination deep to the flexor retinaculum in male cadavers. In female; the means were 5.11±0.21 mm, 3.97±1.78 mm and 3.14 ± 0.03 mm respectively without significance difference. It was concluded that tibial nerve has sufficient and good blood supply. Moreover, it can be utilized as allogeneic vascularized nerve graft to repair sizable nerves after limb salvage.
El estudio ha contribuido a evaluar anatómicamente el nervio tibial y su vasculatura. Se han utilizado diez cadáveres preservados (5 hombres, 5 mujeres) para este estudio. Cada cadáver fue inyectado con látex rojo y a través de incisiones el nervio tibial fue expuesto al nivel de la bifurcación del nervio ciático. El nervio tibial en el 85 % de los cadáveres se localizó entre los tercios medio e inferior en el ángulo superior de la fosa poplítea; mientras que en el 15 % de los cadáveres estaba presente debajo del músculo piriforme en la región glútea. La longitud total media del nervio tibial fue de 65,26±14,42 cm en hombres y 64,79±67,61 cm en mujeres, sin diferencias significativas. Su diámetro total se situó en una media de 5,51±1,55 mm, con una media de 4,11±0,88 mm en la fosa poplítea y una media de 3,24 ± 0,81 mm en su terminación profunda al retináculo flexor en cadáveres masculinos. En mujeres; Las medias fueron 5,11±0,21 mm, 3,97±1,78 mm y 3,14±0,03 mm, respectivamente, sin diferencia significativas. Se concluyó que el nervio tibial tiene suficiente y buen suministro de sangre. Además, se puede utilizar como injerto de nervio vascularizado alogénico para reparar nervios importantes después de la recuperación de miembros.
Subject(s)
Humans , Male , Female , Tibial Arteries/anatomy & histology , Tibial Nerve/blood supply , Cadaver , Fibula/blood supplyABSTRACT
Objective@#To report operative techniques and clinical results of free sural cutaneoadipofascial flap containing the neurovascular axis based on a dominant peroneal perforating artery (DPPA, with a caliber≥0.8 mm) and its concomitant veins for reconstruction of dorsal forefoot soft tissue defects.@*Methods@#The flap was applied in 32 cases with middle to large soft tissue defects in the dorsal forefoot from Aug. 2009 to Dec. 2014. DPPAs arising from the posterolateral intermuscular septum was located and assessed preoperatively with color Doppler flow image and computed tomography angiography. According to the location, size, and shape of the defects, one of these DPPAs was chosen for flap planning. The flap was harvested from the posterolateral aspect of the leg. The neighboring neurovascular axis (one or more of that of the sural nerve, the medial cutaneous nerve, the lateral cutaneous nerve of calf and the sural communicating nerve) was included to ensure vascular supply. According to skin laxity of the donor site, the width of the full harvesting part which should be able to cover the region of the recipient site where pressure and friction force were prominent while wearing shores was decided; the rest was harvested as an adipofascial flap (without skin) to get enough size. After transfer to recipient site, the flap was revascularized by anastomosing the perforating artery and its venae comitantes with appropriate recipient vessels, and reinnervated (antegrade or retrograded methods). Skin grafting was performed on the adipofascial surface of the flap primarily or secondarily. The defects in donor site of the leg was closed directly.@*Results@#All flaps (ranged from 7.5 cm×5.0 cm to 23.0 cm×13.0 cm) were transplanted successfully, and no vascular or donor site problems occurred. All primary skin grafts (19 cases) was partially lost, but only 2 of them need a second grafting. Adipose necrosis occurred in 4 of 13 cases receiving secondary grafting but only needed wound care before surgery. Following up for 11-26 months showed both satisfactory functional and cosmetic results without problems of shoe wearing. Flap sensibility restored at least to the degree of S3.@*Conclusions@#The cutaneoadipofascial flap combines the advantages of perforator, neurocutaneous axis, free and adipofascial flaps leaving only suture scar in the donor leg, and is a satisfactory method for free-style and acute coverage of dorsal forefoot defects.
ABSTRACT
Objective@#To investigate the therapeutic effect of propeller flap with low peroneal artery perforator for defects at ankle and heel.@*Methods@#From January 2009 to March 2016, 28 cases with skin defects at ankle and heel were treated with propeller flap pedicled by low peroneal artery perforator, including 15 cases of car accidents, 8 cases of pressure injury, 3 cases of wring injury and 2 cases of electricity shock injury. Defects size ranged from 3 cm×3 cm to 4 cm×6 cm. The fibular was divided into 9 segments from head to external ankle. Doppler ultrasound was used to locate the low peroneal artery perforator from the lower 6-9 segments. The flap pivot point was at perforator point at skin surface, with the peroneal artery as flap axis. The length of big blade was the distance from rotate point to distal end of defects. The flap width was half of the length. The ratio of big blade length to width should not exceed 2∶1. The flaps size was from 3 cm×5 cm to 4 cm×10 cm, based on the defect size. The defects at donor site could be closed with small blade directly.@*Results@#Partial necrosis happened in 1 case due to veneous crisis, which healed after dressing. All the other 27 flaps survived completely. During the follow-up period, the flaps had good match in color and thickness. No secondary operation was needed.@*Conclusions@#The optimization of propeller flap with low peroneal artery perforator is an idealmethod for defects at ankle and heel, which can avoid the necrosis at distal end of flap.
ABSTRACT
Abstract The posterior tibial artery normally arises from tibial-fibular trunk at the popliteal fossa, together with the fibular artery. The classic course of the posterior tibial artery is to run between the triceps surae muscle and muscles of the posterior compartment of the leg before continuing its course posteriorly to the medial malleolus, while the fibular artery runs through the lateral margin of the leg. Studies of both arteries are relevant to the fields of angiology, vascular surgery and plastic surgery. To the best of our knowledge, we report the first case of an anastomosis between the posterior tibial artery and the fibular artery in their distal course. The two arteries joined in an unusual “X” format, before division of the posterior tibial artery into plantar branches. We also provide a literature review of unusual variations and assess the clinical and embryological aspects of both arteries in order to contribute to further investigations regarding these vessels.
Resumo A artéria tibial posterior e a artéria fibular se originam do tronco tibiofibular, na fossa poplítea. A trajetória clássica da artéria tibial posterior é correr entre o tríceps sural e os músculos do compartimento posterior da perna, e, então, seguir posteriormente ao maléolo medial. Já a artéria fibular corre na margem lateral da perna, seguindo profundamente aos músculos. O estudo dessas artérias é relevante para o campo da angiologia, cirurgia vascular e cirurgia plástica. O presente trabalho é o primeiro relato de caso de uma anastomose entre ambas artérias, na porção distal de suas trajetórias. Tais artérias se anastomosaram em formato de “X”, antes da divisão da artéria tibial posterior em ramos plantares. Foi feita uma revisão de literatura das variações de tais artérias, dando ênfase ao aspecto clínico e embriológico, de modo a contribuir para novas investigações sobre esses vasos.
Subject(s)
Humans , Male , Anatomic Variation/physiology , Popliteal Artery/abnormalities , Tibial Arteries/abnormalities , Cadaver , Dissection/classificationABSTRACT
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.
Subject(s)
Humans , Popliteal Artery/abnormalities , Tibial Arteries/abnormalities , Vascular Malformations , CadaverABSTRACT
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.