Anatomic study of the superficial sural artery and its implication in the neurocutaneous vascularized sural nerve free flap

Combined extended nerve and soft tissue defects of the upper extremity require nerve reconstruction and adequate soft tissue coverage. This study focuses on the reliability of the free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap within this indication. An anatomical study was performed on 26 cadaveric lower extremities that had been Thiel fixated and color silicone injected. Dissection of the fasciocutaneous posterior calf flap involved the medial sural nerve and superficial sural artery (SSA) with its septocutaneous perforators, extended laterally to include the lateral cutaneous branch of the sural nerve and continued to the popliteal origin of the vascular pedicle and the nerves. The vessel and nerves diameter were measured with an eyepiece reticle at 4.5× magnification. Length and diameter of the nerves and vessels were carefully assessed and reported in the dissection book. A total of 26 flaps were dissected. The SSA originated from the medial sural artery (13 cases), the popliteal artery (12 cases), or the lateral sural artery (one case). The average size of the SSA was 1.4 ± 0.4 mm. The mean pedicle length before the artery joined the sural nerve was 4.5 ± 1.9 cm. A comitant vein was present in 21 cases with an average diameter of 2.0 ± 0.8 mm, in 5 cases a separate vein needed to be dissected with an average diameter of 3.5 ± 0.4 mm. The mean medial vascularized sural nerve length was 21.2 ± 8.9 cm. Because of inclusion of the vascularized part of the lateral branch of the sural nerve (mean length of 16.7 ± 4.8 cm), a total of 35.0 ± 9.6 cm mean length of vascularized nerve could be gained from each extremity. The free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap pedicled on the SSA offers a reliable solution for complex tissue and nerve defect. Clin. Anat. 26:903–910, 2013. © 2012 Wiley Periodicals, Inc.     

Variations of the superficial brachial artery in Korean cadavers

The superficial brachial artery (SBA), a branch of the axillary artery, is one of the most common arterial variations in this area. While it is more vulnerable to accidental arterial injection or injury, it could be useful for the nourishment of a medial arm skin free flap. To analyze the relationship between the SBA of axillary origin and segmental variation of the axillary artery, we dissected 304 arms of Korean cadavers. We found an SBA of axillary origin in 12.2% of cadaveric arms. Unilateral occurrence was detected in 16 cadavers and bilateral in 10. SBAs gave rise to radial and ulnar arteries in the cubital fossa (8.9%), continued in the forearm as the radial artery (2.3%), or ended in the upper arm (1.0%). The SBA ended as ulnar artery was not found in any of the cadavers. The bifurcation of the SBA into the radial and ulnar arteries, presence of an SBA that ends in the upper arm, and the lack of continuation as the ulnar artery are characteristics of SBAs in Korean cadavers.     

Cutaneous innervation of the ankle: An anatomical study showing danger zones for ankle surgery

Three nerves innervate the skin in the foot and ankle region: the saphenous, sural, and superficial peroneal nerves. Because they are close to the medial and lateral malleoli, these nerves are at significant risk during orthopedic interventions. The aims of this study were to investigate the distal courses of the three cutaneous nerves of the ankle and to determine their exact relationships with easily identifiable bony landmarks. Ten freshly frozen and 40 embalmed lower extremities of adults were dissected. The positions of the superficial peroneal, sural, and saphenous nerves were determined using reference lines based on easily palpable osseous landmarks. The frequencies and distributions of all three nerves and their branches were converted into absolute numbers. A danger zone for each nerve was established on the basis of the distribution of crossings between the nerves and the different reference lines. Determination of the exact orientation of the nerves around the ankle should help minimize the nerve injury rate during surgical approaches in this area. Using this easily translatable new grid system, the course and danger zones of each cutaneous nerve around the ankle can be estimated clinically. Clin. Anat. 653–658, 2014. © 2013 Wiley Periodicals, Inc.     

带尺侧上副动脉尺神经转位的解剖及临床意义

目的为临床上带血管蒂的尺神经移植在健侧颈7移位治疗臂丛根性撕脱伤中的应用提供解剖学依据。方法取新鲜经动脉灌注红色乳胶的成人上肢标本22侧进行显微解剖,观察尺神经外部营养动脉的来源。另取患骨肿瘤而截肢新鲜成人上肢6侧作仅保留尺侧上副动脉的尺神经游离,采用动脉灌注墨汁和尺神经组织切片的方法,观察尺侧上副动脉对尺神经内部血供营养的范围。结果尺神经在腋部由胸外侧或腋动脉的分支供应,在内侧肌间隔后方由尺侧上副动脉供应,在尺神经沟由尺侧上副动脉与尺侧返动脉后支的吻合支供应,在前臂由尺侧返动脉和尺动脉的分支供应。尺侧上副动脉灌注墨汁后,尺神经腕部、手背支及腋部的神经束内微血管被墨汁充填。结论以尺侧上副动脉的起始处为血管蒂部旋转点,尺神经可提供平均为(46.5±2.6)cm的有血供的移植长度,可经胸前皮下隧道逆向转位与对侧颈7神经根吻合。以尺侧上副动脉为血供的尺神经移植的设计是合理的。     

The usefulness of minimal F-wave latency and sural/radial amplitude ratio in diabetic polyneuropathy

The possibility of whether minimal F-wave latency and a simple ratio between the sural and superficial radial sensory response amplitudes may provide a useful electrodiagnostic test in diabetic patients was investigated in this report. To evaluate the diagnostic sensitivity of minimal F-wave latency, the Z-scores of the minimal F-wave latency, motor nerve conduction velocity (MCV), amplitude of compound muscle action potentials (CMAP), and distal latency (DL) of the median, ulnar, tibial, and peroneal nerve were compared in 37 diabetic patients. For the median, ulnar, and tibial nerves, the Z scores of the minimal F-wave latency were significantly larger than those of the MCV. In addition for all four motor nerves, the Z scores of the minimal F-wave latency were significantly larger than those for the CMAP amplitude. Furthermore, 19 subjects showing abnormal results in the standard sensory nerve conduction study had a significantly lower sural/radial amplitude ratio (SRAR), and 84% of them had an SRAR of less than 0.5. In conclusion, minimal F-wave latency and the ratio between the amplitudes of the sural and superficial radial sensory nerve action potential are sensitive measures for the detection of nerve pathology and should be considered in electrophysiologic studies of diabetic polyneuropathy.     

吻合血管的尺神经转位治疗截瘫

目的：重建胸段脊髓横断致伤完全性截瘫患者的部分周围神经功能。方法：在４例截瘫病人将一侧的尺神经自腕部切断,以骨间前神经旋前方肌支吻接远端尺神经深支,取一桡神经浅支的分支与尺神经浅支吻接,自皮下隧分段游离尺神经至腋窝起始处,分离过程中保护尺侧上副血管。于皮下将尺神经及其尺侧上副血管引人侧胸壁隧道。显露胸背动,静脉,将尺侧上副血管与其行端端吻合。在臂部分离出阴部神经、股后皮神经和坐骨神经,用带筋膜蒂股     

Easily identifiable bony landmarks as an aid in targeted regional ankle blockade

Regional anesthesia around the ankle joint is well suited to a large number of surgical procedures of the foot. Previous studies have alluded to the variable nerve distribution of the foot, which may result in incomplete blocks. The aim of the study was to determine the position of the nerves in relation to the ankle joint to easily identifiable bony and prominent soft tissue landmarks to aid more accurate targeting of these nerves. A number of 94 ankles (47 left; 47 right) were dissected to expose the tibial, sural, deep fibular (peroneal), superficial fibular (peroneal), and saphenous nerves. The distance of the nerves relative to easy to find bony landmarks was measured. A distance (alpha) was measured from the middle of the tibial nerve to the most medial aspect of the medial malleolus. Measurement beta was considered from the inferior tip of the lateral malleolus to the anterior border of the sural nerve on a horizontal plane. Measurement delta was taken from the medial border of the deep fibular (peroneal) nerve to the most anterior aspect of the medial malleolus. epsilon was measured from the middle of the superficial fibular (peroneal) nerve to the most anterior aspect of the medial malleolus on a horizontal plane. The saphenous nerve was measured (gamma) from its medial border to the most anterior aspect of the medial malleolus on a horizontal plane. Factors such as sex, length, and ankle side were also analyzed concerning their influence on the position of the nerves. This study suggests that a greater degree of certainty may possibly be attained when palpable and easy to find bony landmarks are used to determine the position of the nerves around the ankle and ensure a simple to perform, predictable, and selectively targeted block.     

A Study of Complete Superficial Palmar Arches Formed Entirely by Ulnar Artery

Superficial Palmar Arch is an arterial arcade and a dominant vascular structure in the palm. It is defined as the anastomosis between the superficial branch of the ulnar artery and supericial palmar branch of the radial artery. In ulnar dominant complete superficial palmar arch, the ulnar artery does not anastomose with radial artery and it terminates by supplying thumb and index finger. In the present study, this type of variation was found in 50% of the hands. This is in contrast to the classical superficial palmar arch normally described where the arch is completed on the radial side by superficial palmar branch of radial artery. In accordance with the present study, a feature that is present in 50% of the specimens cannot be called as a variation. In these cases, without an efficient collateral circulation, ulnar artery occlusion may cause claudication and gangrene in the digits and has clinical significance.     

Anatomical contribution to the surgical construction of the sartorius muscle flap

The sartorius muscle (SM) is frequently used as a surgical flap. This study intends to describe sartorius nerve and artery distribution in adult men. Fifty-three specimens obtained from fresh cadavers were prepared as described: 32 specimens were injected with a red-colored gelatin solution through the femoral artery so that intra-muscular arteries and nerves were dissected; six specimens were injected with barium sulfate solution through the femoral artery for radiography; seven specimens were injected with a Chinese ink solution, also through the femoral artery, for diaphanization; seven specimens were injected with a solution of vinyl acetate, through the femoral artery, to obtain an arterial cast and one specimen was cut and colored by Masson’s Trichrome. Sartorius branching patterns of the nerve and artery were schematized. The following measurements were taken for each dissected muscle: total length, arterial pedicle length and distance between each arterial pedicle to the proximal muscle extremity. Five to nine arterial pedicles were found in the sample. In their trajectories, these arteries may give rise to many branches to form a dense and elongated net of anastomoses. Intra- and inter-pedicular anastomoses were observed in the inner part of the muscle. The nerve supply originated from one or two branches, which enter the muscle together with the first or second arterial pedicle. The nerve branches were divided into two or three territorial branches, and then into four or five segmental branches, running longitudinally inside the muscle. The muscles showed an average length of 44.81 cm. SM is a segmented structure and it can be divided into as many as five arterial and nervous segments. In the proximal and middle parts, the muscle has better arterial supply. The segments can be filled by adjacent pedicles, due to an elongated net of anastomoses, which allow a longer arc of rotation in the construction of pedicled flaps.     

Applied anatomy of the musculus flexor carpi ulnaris and its clinical application

The blood vessels and nerves supplying 50 specimens of musculi flexor carpi ulnaris (FCU) in 25 Chinese male adult cadavers were investigated. The majority of the muscles were supplied by four to six blood vessels and by two branches of the ulnar nerve. The diameters of the second to fourth arteries were larger than 0.9 mm, which would allow them to be anastomosed to recipient vessels. As the arteries to the muscle were derived directly and/or indirectly from the ulnar artery, they could therefore be used as the arterial pedicles. The nerves were broad enough (1.18–1.05 mm) to act as nerve pedicles. These findings suggest that the FCU might be suitable for use as a free transplantation flap. Since the vessels and nerves to the FCU enter the muscle in its superior half, transposition in the reversed position is also possible. Eight patients have been treated by reversed transplantation of the FCU to restore lost function of the elbow joint. Follow-up studies showed uniformly good results.     

The superficial ulnar artery: Development and surgical significance

The upper limbs of 72 formalin-fixed human cadavers were examined by dissection for arterial anomalies. In one subject, the ulnar artery was noted to be a branch of the second part of the axillary artery on both right and left sides. It ran a superficial course in the arm, crossed the elbow immediately subjacent to the median cubital vein, and continued its course in the forearm in a subcutaneous position. In the hand it played a dominant role in the formation of the superficial palmar arch. The anomalous ulnar artery was of a smaller caliber than both the radial and common interosseous arteries. Although superficial ulnar arteries have been reported in the literature, the combination of bilateral superficial ulnar arteries originating from the axillary arteries appears to be rare. The developmental and surgical significance of the findings are discussed. © 1996 Wiley-Liss, Inc.     

Similarities and dissimilarities of the blood supplies of the human sciatic,tibial, and common peroneal nerves

The aim was to investigate the arterial supply of the sciatic, tibial, and common peroneal nerves. Thirty‐six lower limbs of 18 human fetuses were studied. The fetuses had been fixed in buffered formalin and the blood vessels injected with barium sulfate. Fetal age ranged from 12 to 28 weeks of gestation. Microdissection of the fetal lower extremities was done under ×5 magnifying lenses. The sciatic nerves of 10 lower extremities were dissected and excised and radiographs taken. The extraneural arterial chain of the sciatic nerve was composed of 2–6 arterial branches of the inferior gluteal artery, the medial circumflex femoral artery, the perforating arteries, and the popliteal artery. The extraneural arterial chain of tibial nerve was composed of 2–5 arteries, which were branches of the popliteal, the peroneal, and the posterior tibial arteries. Radiographs showed the presence of complete intraneural arterial chains in the sciatic and tibial nerves, formed from anastomosing vessels. Dissection showed that, in 97.2% of the specimens, the common peroneal nerve was supplied only by one popliteal artery branch, the presence of which was confirmed radiologically. The sciatic and tibial nerves are supplied by numerous arterial branches of different origins, which provide for collateral circulation. In contrast, the common peroneal nerve is most frequently supplied only by one elongated longitudinal blood vessel, a branch of the popliteal artery. Such a vascular arrangement may make the common peroneal nerve less resistant to stretching and compression. Clin. Anat. 26:875–882, 2013. © 2012 Wiley Periodicals, Inc.     

The possibility of deep peroneal nerve neurotisation by the superficial peroneal nerve: an anatomical approach

Neurotisation involves transfer of nerves for the restoration of function following injury. A number of nerves have been used in different part of the peripheral nervous system. This study was undertaken to develop a practical and relatively safe surgical approach to the treatment of L4 root lesion's. We examined the effectiveness and safety of neurotisation of the deep peroneal nerve and its branches by the superficial peroneal nerve. Twelve legs of dissected cadavers provided for teaching purposes in the anatomy laboratory were used to display the common peroneal nerve and its branches. Each branch was measured using calipers and analysed to investigate the possibility of neurotisation of the deep peroneal nerve by the superficial peroneal nerve and its branches. It was found that of the measured branches, transposition was possible between those to peroneus longus and tibialis anterior on the basis of their diameter and length. In recent decades, advances in microsurgical reconstruction and understanding of the microanatomy have played major roles in improving the results of surgical treatment of nerve injuries. There is a need for further experimental studies on the feasibility of this surgical approach.     

Variations in sural nerve formation pattern and distribution on the dorsum of the foot

The sural nerve, a cutaneous nerve, is clinically important because it is frequently for nerve conduction testing, biopsy, and harvesting for nerve grafts. This nerve exhibits a wide variety of variation in formation, distribution on the dorsum of the foot, and so on, depending on the population observed. In this study, we examined the variation in the sural nerve in 110 Korean cadavers. Of these cadavers, 86.1% of the sural nerves corresponded to type A, where tibial and peroneal components were united to form the sural nerve. These two components most frequently united (65.9%) in the third quarter of the calf, and when the union position was expressed as a ratio to calf length, it corresponded to 0.408 in men and 0.346 in women, with a statistically significant difference. Due to this sexual dimorphism in addition to shorter calf length in females, the length of the sural nerve was shorter in females (male average length: 14.5 ± 4.8 cm; female average length: 11.4 ± 2.9 cm). In terms of distribution of the lateral dorsal cutaneous nerve, the distal continuation of the sural nerve on the dorsum of the foot, it showed variation in association with the superficial peroneal nerve. The innervation of the sural nerve extended most frequently up to the lateral two and a half toes, solely or in conjunction with the superficial peroneal nerve. Obtaining further information regarding sural nerve variation will be useful for various clinical procedures and interpretation of sural nerve conduction results. Clin. Anat. 30:525–532, 2017. © 2017 Wiley Periodicals, Inc.     

Vascular branches from cutaneous nerve of the forearm and hand: Application to better understanding raynaud's disease

Cutaneous nerves have branches called vascular branches (VBs) that reach arteries. VBs are thought to be involved in arterial constriction, and this is the rationale for periarterial sympathectomy as a treatment option for Raynaud's disease. However, the branching patterns and distribution areas of the VBs remain largely unclear. The aim of the present study was to investigate the anatomical structures of the VBs of the cutaneous nerves. Forty hands and forearms were examined to assess the branching patterns and distribution areas of the VBs of the superficial branch of the radial nerve (SBRN), the lateral antebrachial cutaneous nerve (LACN), the medial antebrachial cutaneous nerve (MACN), and the palmar cutaneous branch of the ulnar nerve (PCUN). VBs reaching the radial and ulnar arteries were observed in all specimens. The branching patterns were classified into six types. The mean distance between the radial styloid process and the point where the VBs reached the radial artery was 34.3 ± 4.8 mm in the SBRN and 38.5 ± 15.8 mm in the LACN. The mean distance between the ulnar styloid process and the point where the VBs reached the ulnar artery was 60.3 ± 25.9 mm in the MACN and 43.8 ± 26.0 mm in the PCUN. This study showed that the VBs of the cutaneous nerves have diverse branching patterns. The VBs of the SBRN had a more limited distribution areas than those of the other nerves. Clin. Anat. 31:734–741, 2018. © 2017 Wiley Periodicals, Inc.     

An unusual variation of the superficial ulnar artery

Anomalous superficial ulnar arteries were found bilaterally during routine dissection of the upper limbs of a 60-year-old male cadaver. In the left arm, the superficial ulnar artery originated from the axillary artery. It crossed the median nerve anteriorly and ran anteromedial to this nerve and the brachial artery. The superficial ulnar artery was also rudimentary and gave rise to only a narrow muscular branch to the biceps brachii. In the hand, it anastomosed with the radial artery, completing the superficial palmar arch. The radial artery was larger than usual and the deep palmar arch was formed only by the radial artery. In the right arm, the superficial ulnar artery originated from the brachial artery at the level of the inter-epicondylar line. Additionally there were “inverse palmaris longus muscles” bilaterally. This was a rare case in which the superficially ulnar artery originated from a different source on each side accompanied by anomalies of the palmar arches on one side.     

Formation and location of the sural nerve in the newborn

In this study, the location and formation of the sural nerve were examined in 40 legs of new-born cadavers. The sural nerve was formed by the peroneal communicating branch from the common peroneal nerve joining the medial sural cutaneous nerve in 27 of 40 legs (67.5%). It was formed by the peroneal communicating branch from the lateral sural cutaneous nerve joining the medial sural cutaneous nerve in 4 (10%). It was formed by the peroneal communicating branch from the common peroneal nerve and fibers from the posterior femoral cutaneous nerve joining the medial sural cutaneous nerve in 2 (5%). In 5 of 40 legs (12.5%), the medial sural cutaneous nerve was in the place of the sural nerve without joining any other nerve. In one case (5%), the sural nerve was not formed bilaterally.     

吻合血管腓骨及腓骨长肌移植的应用解剖

在51例成年人下肢尸体标本和6例下肢血管铸型标本上,对腓骨和腓骨长肌的形态、血管和神经进行了研究。提出以腓血管或胫前血管和支配腓骨长肌的神经为吻合血管神经蒂,讨论分析了腓骨与腓骨长肌移植的临床应用的有关问题。     

桡,尺动脉肌,皮支的解剖学研究

目的:为手外科提供桡、尺动脉分出的肌、皮支.材料和方法:用福尔马林常规固定的成尸上肢69(男61,女8)侧,解剖观测桡、尺动脉分支的部位、支数及外径.主要结果:从尺、桡动脉壁两侧发出分支,大部分为不对称性分支间距不等,平均(3.0～15.0)mm.桡动脉平均分出15.8支,其中肌支10.3支,筋膜皮支5.5支.尺动脉平均分出12.4支,其中肌支7.6支,筋膜皮支4.8支.结论:桡、尺动脉分出肌、皮支,皮支为前臂筋膜瓣、皮瓣的血管蒂.     

A morphometric study on the superficial palmar arch of the hand

The vascular anatomy of the hand is a complex and challenging area and has been the subject of many studies. Knowledge of the vascular patterns and diameters of the hand gained more importance with improvements in microsurgical techniques in reconstructive hand surgery. We evaluated 50 hands (26 left, 24 right) of 26 formalin preserved cadavers to determine the superficial palmar arch, its branches and contributing vessels with special attention to the diameters. The symmetry of the types was also evaluated in detail for the first time in the literature. Measurements were made with the help of a digital caliper. The diameters of the ulnar, radial and median arteries were taken at the level of the wrist while the common palmar digital arteries, hypothenar branches and the superficial palmar branch of the radial artery were measured at their origin. Two types of superficial palmar arch were found and defined as complete (43/50 hands) and incomplete arches (7/50 hands). The complete arches were divided into four subgroups and incomplete arches into three subgroups. Most cases were found at the complete AI group (17 hands). Comparison of the arterial diameters showed the ulnar artery was the dominant vessel of the palm. The diameters of the common palmar digital arteries were not different with regard to complete or incomplete arches and between both sides. It looks safe to sacrifice one of the radial or ulnar arteries in some arterial interventions including radial artery cannulation, radial forearm flap and radial or ulnar artery harvesting for bypass grafting if the arch is complete. But we still recommend the noninvasive tests like modified Allen test or Doppler ultrasonography, before performing an invasive arterial intervention. We propose the radiologists to incorporate the median artery into the Doppler dynamic test in particular the existence or the absence of anastomoses between radial and ulnar arteries.This study was accepted as an oral presentation in the “IX National Congress of Anatomists, 7–10 September 2005, Kusadasi, Turkey”