跟骨内外侧经皮置针安全区解剖学研究

目的 划定国人跟骨内、外侧外固定针进针位置解剖学相对安全区.方法 解剖14具正常成年人足踝部标本.于跟骨内侧取跟骨最内下后点为A点,内踝最下点为B点,足舟骨结节为C点.解剖出跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、胫后动脉、足底外侧动脉和足底内侧动脉.根据各结构行经AB、AC线的位置,确定跟骨内侧的相对安全区;于跟骨外侧取跟骨最外下后点为D点,外踝最下点为E点,解剖出跟骨外侧神经、腓肠神经、小隐静脉主干,同理确定跟骨外侧的相对安全区.结果 跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、胫后动脉分别行经AB线后下22%、50%、56%、64%及58%处,跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、足底外侧动脉、足底内侧动脉分别行经AC线后下14%、39%、49%、63%、41%及57%处.跟骨外侧神经、腓肠神经、小隐静脉分别行经DE线后下 19%、65%及61%处.结论 在跟骨内侧,AB线后1/2、AC线后1/3所在圆形区域为经皮置针相对安全区.在跟骨外侧,经DE线中点垂线后方的跟骨为经皮穿针相对安全区.     

Arterial supply of the femoral condyles

INTRODUCTION: The most frequent site for aseptic bone necrosis and osteochondrosis dissecans in the human knee joint is the medial femoral condyle. The aim of this study is to analyze the three-dimensional vascularization of the human knee joint and to find out if there are any differences in the blood supply of the medial and lateral femoral condyles which may explain the preponderance of aseptic bone necrosis in the medial side. MATERIAL AND METHODS: The femoral arteries of 14 unfixed lower extremities have been injected with epoxy resin. After documentation of the extraosseous course of the blood vessels the bone was macerated with 10% formic acid. The insertions of tendons and ligaments were investigated by light microscopy and immunohistochemistry. RESULTS: The arterial supply of the lateral femoral condyle originates from the upper lateral geniculate artery, the terminal ends of which penetrate the bone from lateral. Branches of the middle geniculate artery reach the bone from the medial wall of the intertubercular notch. The subchondral bone of the medial femoral condyle draws its blood supply mainly from the descending geniculate artery. Branches of the middle geniculate artery penetrate the medial femoral condyle only in the posterior part of the intercondylar fossa. These posterior vessels do not contribute to the supply of the subchondral bone. In the anterior part of the medial wall of the intercondylar fossa there is the wide femoral insertion of the posterior cruciate ligament. Injection techniques and immunohistochemical investigations show that the fibrocartilage of the chondral apophyseal insertion of the posterior cruciate ligament is avascular and acts as banier which impedes blood vessels to penetrate the bony surface in this region. The subchondral bone adjacent to the femoral insertion of the posterior cruciate ligament receives its blood supply from vessels that penetrate the bone at the medial wall of the medial femoral condyle. The blood vessels which supply the lateral parts of the medial condyle have the longest intraosseous course. The density of vessels within this region is largely reduced. CONCLUSIONS: The region adjacent to the femoral insertion of the posterior cruciate ligament is the most frequent site for osteochondrosis dissecans in the knee joint. Our results show that the arterial supply of the subchondral bone may be considered as a cofactor for the etiology of osteochondrosis dissecans.     

The arterial supply of the lesser metatarsal heads: a vascular injection study in human cadavers

The possibility of avascular changes of the metatarsal heads following forefoot surgery has been previously documented. The aim of this study was to investigate the arterial supply of the lesser metatarsal heads with regard to osteotomies of these bones. We used epoxy resin injections and a modified Spalteholz technique in human cadaveric specimens to demonstrate the intraosseous and extraosseous blood supply of the lesser metatarsals. The metatarsal heads had two arterial sources: 1. The dorsal metatarsal arteries, which arose from the dorsalis pedis artery, and 2. The plantar metatarsal arteries, which are branches of the posterior tibial artery. These two vessels typically anastomosed at two sites about the metatarsal heads, forming a vascular ring and provided an extensive extraosseous arterial network around the metatarsal heads. Small arterial branches of this network run distally on the metatarsal cortex to enter the bone of the metatarsal head. The nutrient arteries traversed the cortex of the metaphysis close to the capsular and ligamentous insertions to provide multiple branches for the supply of the subchondral bone. Extensive capsular stripping during metatarsal head osteotomies results in damage to the medial and lateral head vessels.     

Potential donor rotational bone grafts using vascular territories in the foot and ankle

BACKGROUND: An improved understanding of the extraosseous and intraosseous blood supply of the distal aspect of the tibia, distal aspect of the fibula, cuboid, and cuneiforms should identify vascular territories that would enable surgeons to perform rotational vascularized pedicle bone-grafting procedures in the foot and ankle. METHODS: We investigated the blood supply of twenty cadaveric lower extremities using two vascular injection techniques. In order to define the extraosseous and intraosseous arterial anatomy in this region, ten specimens were sequentially subjected to injection with Batson's compound, soft-tissue digestion, and bone-clearing according to a modified Spalteholz technique. To further characterize the extraosseous vascular anatomy, the other ten specimens were injected with latex and dissected. RESULTS: We identified a consistent and previously unnamed blood supply to the distal aspect of the tibia, distal aspect of the fibula, cuboid, and cuneiforms. Four vessels, each present in all of our specimens, provided distinct vascular territories to bone. A branch of the proximal lateral tarsal artery supplied a consistent vascular territory in the cuboid with an average of fifteen nutrient vessels. Similarly, a branch of the distal medial tarsal artery to the first cuneiform supplied an average of nine nutrient vessels superior to the tibialis anterior tendon insertion. A branch of the anterior lateral malleolar artery to the fibula supplied an average of seven nutrient vessels to the lateral malleolus. A branch of the distal lateral tarsal artery provided the midsection of the third cuneiform with an average of seven nutrient vessels. In the latex-injected specimens, harvesting of the vascularized pedicle bone grafts designed from these data demonstrated their anatomic plausibility and arcs of rotation. CONCLUSIONS: Four new rotational vascularized pedicle bone grafts have been identified in the foot and ankle. These grafts were present in all of our specimens, were well vascularized, had wide arcs of rotation, and were relatively easy to harvest.     

Percutaneous pin placement in the medial calcaneus: is anywhere safe?

OBJECTIVE: To redefine the medial calcaneal anatomic safe zone for pin placement with respect to reproducible palpable landmarks. DESIGN: Anatomic study. SETTING: Medical school anatomy laboratory. INTERVENTIONS: Thirty-three fresh-frozen adult cadaveric feet were used. Three palpable anatomic landmarks were identified on each ankle and labeled as Point A (posteroinferior medial calcaneus), Point B (inferior medial malleolus), and Point C (navicular tuberosity). The medial neurovascular bundle was carefully dissected, and the medial calcaneal nerve, the most posterior branch of the lateral plantar nerve, the lateral plantar nerve, the medial plantar nerve, and the posterior tibial artery were identified. These structures were recorded at the point at which they transected a line from Point A to B and from Point A to C. Based on the findings of the first thirty-three feet, two pins were placed percutaneously into the medial calcaneus of ten additional feet. Pin 1 was placed one half the distance from Point A to B. Pin 2 was placed one third the distance from Point A to C. The neurovascular structures were then dissected and identified in relation to the pin position. RESULTS: The medial calcaneal, most posterior branch of the lateral plantar, and lateral plantar nerves are at significant risk for abutting the pins or being directly injured at the margins of these relative safe zones. CONCLUSION: The medial calcaneus provides a small window for safe percutaneous pin placement. Posterior to the halfway point from Point A to B and posterior to the one-third mark from Point A to C remain the relatively safest regions; a more posterior placement in the safe zone is safest. Careful blunt dissection and the use of cannulas may help to avoid neurovascular injury.     

距骨的血液供应及其临床意义

本文观察了２４侧尸体足标本，均无已知临床血管疾病。在死后３６～４８小时之间行动脉灌注ＡＢＳ填充剂，以化学腐蚀和手工剔除的方法清除软组织。距骨的血供来自小腿下部三根主要动脉的分支，即跗骨管动脉和三角支、近端和远端跗骨窦动脉、颈上支及后结节血管丛。跗骨管动脉常发自足底内侧动脉，而三角支多单独自胫后动脉发出；跗骨管动脉通常比三角支和跗骨窦动脉都来得细小。以上的这些动脉相互吻合，形成了一个骨膜血管网，覆盖于全部的距骨非关节面上。而且，环绕着跗骨管、跗骨窦、距骨颈的上面和距骨体部的内侧面，由三角支、跗骨管动脉、跗骨窦动脉、颈上支及其相互之间的吻合血管网形成了一个不定形的距骨动脉环。本文还讨论了距骨缺血性坏死与动脉环的可能关系，距骨骨折脱位或手术后的缺血性坏死是由于距骨动脉环的毁损或功能受影响所致。三角支在距骨骨折脱位时具有重要意义，手术或手法复位时应注意保护。     

Radio-anatomical study of the arteries of the foot]

30 Cadaveric feet were injected with minium by 3 catheters, one in each foot artery. The A. tibialis posterior is the most voluminous. It branches off in A. plantaris lateralis, main artery of the sole of the foot and A. plantaris medialis, small artery terminating on the medial edge of the big toe (in fact, in most cases (60%), it divides into 3 branches). The third branch has a double destiny, it vascularizes the shell of the calcaneus and it anastomoses with the posterior fibular artery. The A. dorsalis pedis, in 80% of the cases rejoins the lateral plantar artery in the first space. Among the 5 classical branches, the lateral tarsal artery and the dorsal metatarsal artery are constant. The other branches are more uncommun. But some anastomoses are frequent: - with the posterior fibular artery, (20%); - with the anterior fibular artery (10%). The A. fibularis is divided over the talo-tibial joint. Only the posterior branch is always injected. It gives three anastomoses: - The supra-malleolar artery with the posterior tibial artery, of great value because it is able to inject all the foot arteries. - The two others are narrower, the supracalcanean artery with the posterior tibial artery, and the medial supratarsal artery with the lateral tarsal artery. It ends in the sole of the foot after having given the vascularisation of the external face of the calcaneus. It is possible to oppose: The parts with a good vascularisation: - sole of the foot, - internal face of the calcaneus, - external face of the big toe, - internal face of the last 4 toes; The parts with a poor vascularisation: - dorsal face of the foot, - external face of the calcaneus, - internal face of the big toe, - external face of the last 4 toes.     

Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study

OBJECTIVE: To describe the extraosseous blood supply of the tibia and how the blood supply of the distal tibia is influenced by different plating techniques. DESIGN: Microdissection of cadaveric adult hip disarticulation specimens following sequential arterial injections of india ink and Ward's Blue Latex was performed. Readily identifiable arterioles measured approximately 0.5 mm in diameter. Their artery of origin was identified, and their position along the medial, lateral, and posterior aspects of the tibia was documented relative to the tibial plafond. Additionally, six matched pairs of limbs were used to assess the effects of different plating techniques on the extraosseous blood supply along the medial aspect of the distal tibia. SETTING: University anatomy laboratory. PATIENTS/PARTICIPANTS: Nine matched pairs ( = 18) of randomly obtained, adult cadaveric hip disarticulation specimens. INTERVENTION: India ink followed by Ward's Blue Latex was injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system. The skin, subcutaneous tissue, and muscles were dissected from the leg, exposing the arterial system and the extraosseous vessels of the tibia. MEAN OUTCOME MEASUREMENTS: The extraosseous blood supply of each aspect of the tibial diaphysis was determined. Each extraosseous arteriole was identified, and the locations of each documented relative to the tibial plafond. Changes in the filling of these vessels along the medial aspect of the distal tibia were documented in a separate group of specimens ( = 12), which had undergone two different plating techniques. RESULTS: The proximal metaphysis of the tibia was found to have a rich extraosseous blood supply provided primarily from vessels from the popliteal artery, the anterior tibial artery (ATA) laterally, and the posterior tibial artery (PTA) medially. In comparison, the tibial diaphysis was found to have relatively few extraosseous vessels and a considerably hypovascular region, posteriorly. Branches of the ATA were found to supply the posterior aspect of the diaphysis with these branches passing through the interosseous membrane. The diaphysis also received a variable contribution from the PTA. The lateral aspect of the diaphysis was supplied by branches of the ATA. An anastomotic network of arteries from the ATA and PTA formed the rich extraosseous blood supply of the medial distal aspect of the tibia. Open plating of the medial aspect of the distal tibia caused a statistically significant ( < 0.05) greater disruption of the extraosseous blood supply of the metaphyseal region than did percutaneously applied plates. In each specimen, open plating prevented filling of each periosteal vessel in the region as opposed to percutaneous plates, which permitted filling of the extraosseous vessels up to the edge of the plate. CONCLUSIONS: The proximal and distal metaphyseal areas of the tibia have a rich extraosseous blood supply provided primarily by branches of the ATA and the PTA. Open plating of the medial aspect of the distal tibia caused a greater disruption of this extraosseous blood supply than did percutaneously applied plates. Disruption of these extraosseous vessels following fracture and subsequent operative stabilization may slow healing and increase the risk of delayed union and nonunion. These findings support current efforts to develop less invasive methods and implants for operative stabilization of distal tibia fractures.     

Circular frame fixation for calcaneal fractures risks injury to the medial neurovascular structures: A cadaveric description

AimThere is a risk of iatrogenic injury to the soft tissues of the calcaneus and this study assesses the risk of injury to these structures in circular frame calcaneal fracture fixation.Materials and methodsAfter olive tip wires were inserted, an L-shaped incision on the lateral and medial aspects of 5 formalin fixed cadaveric feet was performed to expose the underlying soft tissues. The calcaneus was divided into zones corresponding to high, medium and low risk using a grading system.ResultsStructures at high risk included the posterior tibial artery, posterior tibial vein and posterior tibial nerve on the medial aspect. Soft tissue structures on the lateral side that were shown to be at lower risk of injury were the small saphenous vein and the sural nerve and the tendons of fibularis longus and fibularis brevis.ConclusionThe lateral surface of the calcaneus provides a lower risk area for external fixation. The risk of injury to significant soft tissues using a circular frame fixation approach has been shown to be greater on the medial aspect.Clinical relevanceThis study highlights the relevant anatomical relations in circular frame fixation for calcaneal fractures to minimise damage to these structures.     

Blood supply of the knee joint. A microangiographic study in children and adults

The knee joint blood supply is derived from a rich anastomosis of the five major constant arteries, namely, the superior medial and lateral, the middle (posterior), and the inferior medial and lateral genicular arteries. Anastomosis also occurs with descending genicular arteries and the anterior tibial recurrent artery. These branches form anastomoses in and around the knee joint, while each major vessel was noted to provide the respective major blood supply to specific areas. The most obvious difference between vascularization of child and adult knees was the separation of vessels and relative avascularity of epiphyseal plate areas; such persisted until closure of the epiphyseal plate. The regions representing the seals of plate closure had less rich vascularization. A rich intraosseous blood supply was defined in the femoral and tibial condyles and the patella. Similarly, the adjacent and superficial soft tissues, including major ligaments and peripheral parts of the menisci, were richly vascularized. Areas of separated vascularization in children may have relevance to epiphyseal injury, growth deformity, Osgood-Schlatter disease, and hematogenous osteomyelitis. In adults, such information may be relevant to high tibial osteotomy, meniscus and cruciate ligament repair, and surgery utilizing the semitendinosus tendon, fascia lata, or patella tendon grafts.     

Blood supply to the anterior cruciate ligament and supporting structures

The blood supply to the knee arises from a vascular plexus that surrounds the joint. The descending genicular artery, the medial and lateral inferior genicular arteries, the medial and lateral superior genicular arteries, the middle genicular artery, and the anterior and posterior tibial recurrent arteries contribute vessels that supply the various structures of the knee. The intra-articular soft tissues of the knee (the infrapatellar fat pad and synovium) mediate the blood supply to the cruciate ligaments, and preservation and utilization of these tissues should be considered when repair or reconstruction of the anterior cruciate ligament is being performed.     

Vascularized bone graft from the medial calcaneus for treatment of large osteochondral lesions of the medial talus

BACKGROUND: Operative treatment of large osteochondral lesions of the talus is difficult because the blood supply is poor in the talar dome. The purpose of this study was to evaluate the results of a vascularized bone graft transfer from the medial calcaneus to the large osteochondral lesion. METHODS: Four ankles in four patients with medial osteochondral lesions were treated through a medial transmalleolar approach. Vascularized bone graft was harvested from the medial calcaneus using the calcaneal branch of the posterior tibial artery and was placed through a fenestration of the medial aspect of the talar dome. The mean duration of postoperative followup was 34 (range 24 to 48) months. Clinical and radiographic evaluations were made before surgery and at final followup. RESULTS: According to the AOFAS ankle-hindfoot scale, mean pain and function scores improved from 20 to 33 points and 30 to 43 points, respectively. The mean total score improved from 60 to 83 points. Plain radiography at followup showed slight osteosclerosis in all patients, but joint space narrowing was not seen in any patient. Cysts seen preoperatively on MRI or CT resolved after 12 months postoperatively, and MRI or CT did not reveal any findings indicative of osteonecrosis. CONCLUSIONS: Clinical and radiographic results were satisfactory. Vascularized bone grafts harvested from the calcaneus were successful for the treatment of large osteochondral lesions of the medial talus.     

Vascularity of the lateral calcaneal flap: a cadaveric injection study

OBJECTIVE: To describe the arterial blood supply of the subcutaneous tissues of the lateral hindfoot and define the relationships between these arteries and the lateral extensile incision used for open reduction and internal fixation of calcaneal fractures. DESIGN: Human cadaveric lower extremity specimens, doubly injected with India ink and latex, were used to demonstrate the location of the arteries of the subcutaneous tissues of the lateral hindfoot. SETTING: Anatomy laboratory. PATIENTS/PARTICIPANTS: Twenty-four randomly obtained, cadaveric elderly lower extremity specimens. INTERVENTION: India ink and then latex were injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system. Transtibial amputation specimens were manually debrided of the skin and chemically debrided of subcutaneous tissues with sodium hypochlorite to demonstrate the arterial supply to the soft tissues of the lateral hindfoot. MEAN OUTCOME MEASUREMENTS: The location of the three major arteries was determined relative to the lateral malleolus. The proximity of these vessels to the typical extensile lateral incision was determined radiographically with vascular clips applied along each artery and skin staples placed along the path of the typical skin incision. RESULTS: Three arteries, the lateral calcaneal artery, the lateral malleolar artery, and the lateral tarsal artery, were consistently found along the lateral aspect of the hindfoot. The lateral calcaneal artery appeared to be responsible for the majority of the blood supply to the corner of the flap and, because of its proximity to the vertical portion of the typical incision, it appeared most likely to be injured from inaccurate placement of the incision. CONCLUSIONS: The development of wound complications following open reduction and internal fixation of the calcaneus is multifactorial. Disruption of the blood supply to the surgically created flap may play a larger role in the development of wound complications than previously thought. An understanding of the local vascular anatomy may decrease the rate of wound complications during the operative treatment of intraarticular calcaneal fractures.     

Vascular anatomy of plantar muscles

Many reports on the plantar arteries and the deep plantar arch exist, but none of them focus on the arterial pedicles of the plantar muscles. They mainly discuss the deep plantar arch, its variations, and location. This study plans to determine the location and origin of arterial pedicles of all the plantar muscles as a preliminary study for designing new flaps. The study was carried out on 20 feet from 10 cadavers aged from 35 to 67 years. After an injection of latex via popliteal arteries, dissection of the arteries was carried out under a microscope. Abductor hallucis and flexor hallucis brevis muscles receive their main blood supply from the medial plantar artery; abductor digiti minimi and flexor digiti minimi brevis muscles receive their main blood supply from the lateral plantar artery. The flexor digitorum brevis muscle receives branches from both arteries. Adductor hallucis and plantar interosseous muscles receive branches from plantar metatarsal arteries. Quadratus plantae is directly nourished from a branch of the posterior tibial artery. No distal anastomoses between the medial and lateral plantar arteries were identified, except 1 specimen in which the medial plantar artery made anastomosis with the deep plantar arch. As a result, the arterial pedicles of all the plantar muscles were defined, and based on these findings, new flaps can be planned or existing flaps can be modified.     

Intraosseous Vascularity of the Distal Radius: Anatomy and Clinical Implications in Distal Radius Fractures

This study aimed to describe the intraosseous blood supply of the distal radius and its clinical implications in distal radius fractures. Twelve adult wrists from fresh cadavers (six males, six females, 50–90 years of age, mean 68 years) were injected through the brachial artery with latex. Dissections were performed using magnifying loupes and hands were processed using the Spalteholz technique. The distal radius was supplied by three main vascular systems: epiphyseal, metaphyseal, and diaphyseal. The palmar epiphyseal vessels branched from the radial artery, palmar carpal arch, and anterior branch of the anterior interosseous artery. These vessels entered the bone through the radial styloid process at level of the Lister's tubercle but palmar and sigmoid notch. The dorsal contribution to Lister's tubercle is to the dorsal epiphyseal vessels. The intraosseous point of entry to the dorsal epiphyseal vessels was from the fourth and fifth extensor compartment arteries. In the metaphyseal area, we found numerous periosteal and cortical branches originating deep in the pronator quadratus and the anterior interosseous artery. These branches provided the main supply to the distal radius. Vessels perforated the bone and formed an anastomotic network. In the diaphyseal area, only the nutrient vessel provided intraosseous vascularity in the distal radius. Numerous metaphyseal–epiphyseal branches arise within the pronator quadratus and the anterior interosseous artery and course towards the distal radius. These branches may be fundamental to the healing of the distal radius fractures and make nonunion a rare complication.     

带血管蒂髌骨移位修复胫骨内侧髁上关节面缺损的应用解剖

为探索用带血管蒂髌骨移位的方法，修复肛骨内侧髁上关节在缺损，采用经动脉灌注的成人下肢标本３７侧，经解剖，厚切片或铸型研究髌骨的血管。观察３０块髌骨和胫骨内侧髁上关面的形态和面积。供应髌骨血液的各支动脉先有髌骨周围吻合成髌动脉环，再由该环发支进入髌骨，膝下内动脉和膝降动脉关节支的髌下支在髌骨内下方合并与参与形成髌周动脉环。髌骨的关节面与胫骨内侧髁上关节形态大小相似，根据研究结果，提出用带血管蒂髌骨移     

Radial forearm free flap for coverage of postoperative lateral heel wounds after open reduction and internal fixation of the calcaneus

For intraarticular calcaneus fractures, open reduction and internal fixation has become commonplace for the reduction of morbidity of postinjury arthritis. Despite adequate surgical results, there are often associated postoperative wound complications. The purpose of this study was to describe a unique application of the radial forearm free flap for coverage of lateral postoperative heel defects seen after calcaneal fixation. Seven lateral heel wounds after open reduction of calcaneal fractures in 6 patients were covered with radial forearm free flaps. The technique used involved passage of the pedicle of the laterally placed flap anteriorly to the Achilles tendon so that it can be anastomosed to the posterior tibial artery. Flap application was 100% successful, with good functional and cosmetic results in all patients. The radial forearm free flap provides a quick, reliable, and easily harvested source of coverage for lateral heel wounds seen after open reduction and internal fixation of the calcaneus. Tunneling of the flap pedicle anterior to the Achilles tendon is simple and provides the additional advantages of access to reliable vessels, reduced scarring, and avoidance of further wound problems often seen with incisions used to access the anterior tibial artery.     

Arterial abnormalities in talipes equinovarus as assessed by angiography and the Doppler technique

Preoperative angiography in 30 uncorrected clubfeet demonstrated abnormal vascular patterns in all but two limbs with hypoplasia or premature termination of the anterior tibial and medial plantar arteries in the remainder. Postoperative Doppler studies in nine of the limbs with abnormal vessels indicated that these arteries were present. We suggest that the continuous-wave Doppler technique is less useful for identifying major arteries than either dissection or angiography. Furthermore, arterial dysgenesis may play a role in the etiology of clubfoot. Since the posterior tibial artery usually provides the sole arterial supply to the foot, this vessel must be preserved at surgery and during subsequent ankle dorsiflexion.     

Quantitative assessment of blood vessels of the human Achilles tendon: an immunohistochemical cadaver study

BACKGROUND: The pathogenesis of Achilles tendon rupture remains unclear, but vascular patterns may play an important role. Hypoxia is considered to be an important factor in the aetiology of tendon degeneration. METHODS: Statements from the literature regarding the vascularization of the Achilles tendon are controversial. We determined the vascular density of the Achilles tendon using a new method involving antibodies against laminin, a component of the basement membrane. RESULTS: The blood supply of the Achilles tendon mainly arose from the anterior paratenon of the tendon from which vessels run into the tendon. The proximal part of the tendon was supplied by a recurrent branch of the posterior tibial artery, while the distal part of the tendon was vascularized by the rete arteriosum calcaneare, supplied by the fibular and posterior tibial arteries. An avascular area could be seen close to the insertion of the tendon to the calcaneus. Three regions with different vascular density could be determined in the Achilles tendon. The distal part of the Achilles tendon had a vascular density of 56.6 vessels/cm(2). In the middle part of the tendon, the vascular density was much lower: 28.2 vessels/cm(2). The proximal part of the tendon had a vascular density of 73.4 vessels/cm(2). CONCLUSION: The reduced vascularization in the tendon waist may be a predisposing factor for degeneration and spontaneous rupture of the human Achilles tendon.     

Evaluation of Peripheral Perfusion in the Presence of Plantar Heel Ulcerations Status After Transmetatarsal Amputation With Achilles Tendon Lengthening

The objective of this study is to evaluate peripheral perfusion in patients who developed plantar heel ulcerations status after transmetatarsal amputation and Achilles tendon lengthening. Peripheral perfusion was assessed via contrast angiography of the 3 crural vessels (anterior tibial, posterior tibial, and peroneal arteries), as well as intact heel blush and plantar arch. The secondary objective is to correlate the arterial flow to time to develop heel ulceration and incidence of minor and major lower-extremity amputation. Diagnostic angiography without intervention was performed on 40% of patients (4/10), and interventional angiography was performed on 60% of patients (6/10). In-line flow was present in 0% (0/10) of the peroneal arteries, 60% (6/10) of the anterior tibial arteries, and 70% (7/10) of the posterior tibial arteries. Heel angiographic contrast blush was present in 60% (6/10), and intact plantar arch was present in 60% (6/10). Patients developed heel ulcerations at a mean time of 7.6 months (range 0.7 to 41.2) postoperatively. The incidence of major lower-extremity amputation was 30% (3/10), with a mean time of 5.2 months (range 3.5 to 8.3) from time of heel wound development. No amputation occurred in 6 patients (60%). Among them, intact anterior tibial inline arterial flow was present in 3, intact posterior tibial inline arterial flow was present in 6, and heel blush was present in 5. Our results demonstrate that an open calcaneal branch of the posterior tibial artery is sufficient to heal plantar heel ulcerations to potentially increase rates of limb salvage.