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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).
Journal of military pharmaco-medicine n08-2017 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, 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 been growing 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 159 Journal of military pharmaco-medicine n08-2017 location 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 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, 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 Methods * Surgical method: 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: Figure 1: Skin incision in the foot 160 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 Journal of military pharmaco-medicine n08-2017 calculating 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 Dorsal pedis artery (DPA) 16% 14% 14% 12% 12% 10% 8% 6.67% 6.67% Y amada O ur 6% 4% 3% 2% 0% Huber R eic h A dac hi 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 161 Journal of military pharmaco-medicine n08-2017 The size of DPA: Kim J.W [8] reported the diameter of DPA was about 1.5 to 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 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 Deep Medial plantar artery tarsal artery DPA Table 1: Diameter of DPA Diameter of DPA Lee J.H, Dauber W 90.6% 0% 9.4% Kim J.M 1,5 - mm This study 93.33% 6.67% 0% Barman 2,25 ± 0,25 mm Yamada 2,07 ± 0,77 mm Author Nguyen Huy Phan This study 2,0 - 3,0 mm 2,48 ± 0,82 mm These results were consistent with the size of DPA This artery could be well applied to the dorsalis pedis perforator flap, complex toe-to-hand reconstruction However, the surgeons must keep in mind that there was very small incidence in the absence of DPA as 02 cases in the study * Location of DPA: 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 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%, 162 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 Arcuate plantar artery artery Hamada N et al 57% This study 60% 25% DPA 0% Lateral Medial tarsal tarsal artery artery 12% 13.33% 23.33% 3.33% 6% 0% 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, Journal of military pharmaco-medicine n08-2017 we 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 A Type Cases % A 24 80 B 10 C 10 Total 30 100 B C Figure 3: FDMA in the first inter-metatarsal space A A A type B B type C C type 163 Journal of military pharmaco-medicine n08-2017 - 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 mm This artery branch almost disappeared between the metatarsal bone and 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 Nguyen Huy Phan 49% 40% 11% This study 80 % 10% 10% In addition, some authors had different subgroups on the pathway of the FDMA were: Kim J.W divided into 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 ) 164 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 cases of small FDMA (diameter < mm) The SDMA had 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 REFERANCE Nguyen Huy Phan Microvascular microsurgery - experimental neurosurgery and clinical applications Science and Technology Publishing House 1999, pp.392-417 Lee J.H, Dauber W Anatomic study of the dorsalis pedis-first dorsal metatarsal artery Ann Plast Surg 1997, 38, pp.50-55 Mark H Meissner et al Lower extremity venous anatomy Semin Intervent Radiol 2015, 22 (3), pp.147-156 Yamada et al Variations of the arterial anatomy of the foot The American Journal of Surgery 1993, August, Vol 166, pp.130-135 Journal of military pharmaco-medicine n08-2017 Huber J.F et al The arterial network supplying the dorsum of the foot Anat Rec 1941, 80, pp.373-391 Adachi et al B Das Arterien system der Japaner Kyoto: Maruzen Co 1928, pp.242-251 Reich R.S et al The pulses of the foot: their value in the diagnosis of peripheral circulatory disease Ann Surg 1934, 99, pp.613-622 Kim J.W et al Anatomic study of the dorsalis pedis artery, first metatarsal artery and second metatarsal bone for mandibular reconstruction American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 2015, 73, pp.1627-1636 Barman A.A et al Anatomy of dorsalis pedis artery and its use in limb salvage surgery Clin Anat 1992, 5, pp.321-325 10 Hamada N et al Arteries to the great and second toes based on three-dimensional analysis of 100 cadaveric feet Surgical and Radiologic Anatomy 1993, 15 (3), pp.187-192 11 May J.W, Chair L.A, Cohen B.E, O'Brien B.M Free neurovascular flap from the first web of the foot in hand reconstruction J.H and Surg 1977, pp.387-393 12 Gilbert A Composite tissue transfers from the foot: anatomic basis and surgical technique Daniller AI, Strauch B (eds) symposium on microsurgery, 14 CV Mosby, St Louis 1976, pp.230-241 165 ... 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... 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,... 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