Topographic-anatomical characteristics of artery tibialis posterior and its branches in the area of ankle canal

AIM: To clarify peculiarities of the anatomy and topography of the plantar vessels in the area of the ankle canal, to justify access to the bifurcation of the artery tibialis posterior and ultrasound examination of the plantar arteries. The results of anatomical preparations of 10 amputated lower limbs, and of ultrasound duplex angioscanning (DUS) of 30 healthy volunteers without pathology of the vascular system performed using a linear transducer with frequency of 7–12 MHz, were studied. According to the data of anatomical preparation and ultrasound examination, the bifurcation level of the artery tibialis posterior was 1.7 ± 0.4 cm (min 0.5 cm — max 2 cm) below the level of the posterior edge of the medial ankle and was slightly covered by the musculus abductor hallucis. The average diameter of the artery tibialis posterior above the bifurcation level was 2.56 ± 0.4 mm, of the medial plantar artery 1.4±0.44 mm, and of the lateral plantar artery 1.8 ± 0.5 mm. The lateral plantar artery was 90% larger in diameter than the medial plantar artery. In 7% of cases, the medial plantar artery was larger, and in 3% of cases, the diameters of both arteries were equal. When taking the bifurcation of the posterior tibial artery as the central point, the plantar vessels on the DUS can be traced distally down under the abdomen of the musculus abductor hallucis: the medial vessels lie more anteriorly at 2 o’clock position, and the lateral vessels lie somewhat posteriorly at 1 o’clock. Assessment of blood flow at this level gives an idea of the state of the foot vessels. The level of bifurcation of the artery tibialis posterior is located 1.7 ± 0.4 cm below the posterior edge of the medial malleolus, which makes it possible to identify the location of access to it. The location of the DUS probe from this point at 2 o'clock position corresponds to the projection of the medial plantar artery, at 1 o'clock — to the lateral plantar artery on the right lower limb, on the left lower limb — at 10 and 11 o'clock, respectively.

“Like For Like” Reconstruction of Heel Pad with Medial Plantar Artery Flap—Functional and Aesthetic Outcomes in A Series of 19 Cases

Heel pad loss can cause serious problems in weight-bearing and locomotion. The medial plantar artery (MPA) flap is a suitable “like for like” replacement. Nineteen patients whose heels were reconstructed with MPA flap between July 2015 and February 2020 were studied. All patients were assessed based on flap survival, functionality, and patient satisfaction. Loss of heel pad was due to diabetic ulcer (11), trauma (6), tumor (1), and unstable scar (1). The largest flap measured 9 × 7 cm. Sixteen flaps were done as fasciocutaneous flaps and three in combination with abductor hallucis muscle (AbdH). All the flaps survived. The average functional scores at 6, 12, 18, and 24 months were 86.86, 89.62, 89.38 and 97.33 based on AOSAS-AH score. Average patients' satisfaction was 8.7/10. To conclude, the MPA system is a versatile vascular axis providing “like for like” tissue for heel pad reconstruction which is reliable and durable.

Intraadiposal Pedicle Dissection when Performing Free Tissue Transfer: A Means to Address a Short Pedicle

A 77-year-old male patient with a diabetic foot ulcer on his right great toe visited the outpatient clinic. As necrosis of the toe had already progressed, the patient underwent toe amputation to prevent extensive gangrene. With the goal of enabling future ambulation, an anterolateral thigh fasciocutaneous free flap was planned to preserve the metatarsal head and to cover the defect. Subfascial dissection was performed when elevating the fasciocutaneous flap, but the sole healthy perforator was in an extremely proximal area and allowed only a 4-cm-long pedicle. The pedicle had to be at least 8 cm long to ensure secure anastomosis to the medial plantar artery. To overcome this unexpected challenge, we pierced the deep fascia near the perforator and dissected the perforator distally within the deep adipose layer. The necessary additional length of the pedicle was obtained through intraadiposal dissection. The flap survived without any complications, and the foot was reconstructed with successful ambulation. This case demonstrates the value of attempting intraadiposal pedicle dissection when the pedicle turns out to be unmanageably short.

Treatment of volar defects of the finger using dorsal digital–metacarpal flap versus free medial plantar artery flap: a comparative study

Background The treatment of defects on the volar surface of the finger has been scarcely reported, and its utility for digital resurfacing remains unclear. This study compared the outcomes of free medial plantar artery flap (MPAF) and dorsal digital–metacarpal flap (DDMF) in finger reconstruction. Methods This retrospective cohort study included 24 patients with soft-tissue defects on the volar surface of the finger from March 2014 to March 2017. The patients were divided into two groups: the MPAF group and the DDMF group. The operation time, complications, such as flap necrosis, graft loss, infection, paresthesia, and donor-site morbidity, as well as two-point discrimination (2-PD) were carefully recorded. The Michigan Hand Outcomes Questionnaire was used for conduct follow-up assessment. Results After more than 12 months of follow-up, the MPAF group had a longer operative time compared with DDMF group, but there was no significant difference between postoperative complications and 2-PD test result in patients without nerve injury. And in terms of overall function, Modified VSS score and 2-PD test (the patients with nerve injury), There were relatively obvious statistical differences, MPAF was superior to DDMF (p < 0.005). Conclusion MPAF and DDMF are reliable for reconstruction of the volar surface of the finger; however, MPAF offers better functional outcomes and is associated with a lower incidence of postoperative complications.

Treatment of Volar Defects of the Finger using Dorsal Digital–metacarpal Flap Versus Free Medial Plantar Artery Flap: A Comparative Study

Background: The treatment of defects on the volar surface of the finger has been scarcely reported, and its utility for digital resurfacing remains unclear. This study compared the outcomes of free medial plantar artery flap (MPAF) and dorsal digital–metacarpal flap (DDMF) in finger reconstruction.Methods: This retrospective cohort study included 24 patients with soft-tissue defects on the volar surface of the finger from March 2014 to March 2017. The patients were divided into two groups: the MPAF group and the DDMF group. The operation time, complications, such as flap necrosis, graft loss, infection, paresthesia, and donor-site morbidity, as well as two-point discrimination (2-PD) were carefully recorded. The Michigan Hand Outcomes Questionnaire was used for conduct follow-up assessment.Results: After more than 12 months of follow-up, the MPAF group had a longer operative time compared with DDMF group, but there was no significant difference between postoperative complications and 2-PD test result in patients without nerve injury. And in terms of overall function, Modified VSS score and 2-PD test (the patients with nerve injury), There were relatively obvious statistical differences, MPAF was superior to DDMF (p < 0.005).Conclusion: MPAF and DDMF are reliable for reconstruction of the volar surface of the finger; however, MPAF offers better functional outcomes and is associated with a lower incidence of postoperative complications.

Treatment of Volar Defects of the Finger using Dorsal Digital–metacarpal Flap Versus Free Medial Plantar Artery Flap: A Comparative Study

Background: The treatment of defects on the volar surface of the finger has been scarcely reported, and its utility for digital resurfacing remains unclear. This study compared the outcomes of free medial plantar artery flap (MPAF) and dorsal digital–metacarpal flap (DDMF) in finger reconstruction.Methods: This retrospective cohort study included 24 patients with soft-tissue defects on the volar surface of the finger from March 2014 to March 2017. The patients were divided into two groups: the MPAF group and the DDMF group. The operation time, complications, such as flap necrosis, graft loss, infection, paresthesia, and donor-site morbidity, as well as two-point discrimination (2-PD) were carefully recorded. The Michigan Hand Outcomes Questionnaire was used for conduct follow-up assessment.Results: After more than 12 months of follow-up, the MPAF group had a longer operative time compared with DDMF group, but there was no significant difference between postoperative complications and 2-PD test result in patients without nerve injury. And in terms of overall function, Modified VSS score and 2-PD test (the patients with nerve injury), There were relatively obvious statistical differences, MPAF was superior to DDMF (p < 0.005).Conclusion: MPAF and DDMF are reliable for reconstruction of the volar surface of the finger; however, MPAF offers better functional outcomes and is associated with a lower incidence of postoperative complications.