Arterial supply of the soleus muscle: anatomical study of fifty lower limbs

Soft tissue defects of the lower limb are a formidable challenge to the plastic surgeon but a soleus muscle flap often provides the solution. Various types of soleus muscle flap have been described, based mainly on the vascular supply. The arterial blood supply of the soleus muscle was studied in 50 cadaveric lower limbs. The blood vessels and their branches to the muscle were dissected. The distance of the origin of the perforators was measured from fixed bony landmarks. Branches of the popliteal artery trunk, the posterior tibial artery, and the peroneal artery supplied the soleus muscle. The number of branches to the soleus muscle from these main arteries were analyzed. The medial part of the muscle was supplied throughout its length by perforators arising from the posterior tibial artery. This constant feature makes the medial part of the muscle reliable as a proximally or distally based flap. The average distances of the lower perforators arising from the posterior tibial artery were 6.5 cm, 11.6 cm, and 16.8 cm from the medial malleolus. The branches of the peroneal artery were mostly distributed in the upper half of the muscle. These large pedicles allow a composite transfer of the soleus muscle with the fibula. Lower perforators were demonstrated to arise from the peroneal artery in 60% of the limbs but the scarcity of perforators in this region limits the clinical usefulness of an inferiorly based lateral hemisoleus flap. The study demonstrates the distribution of arteries entering the soleus muscle and how the information may be used in the design of soleus muscle flaps. The average numbers of the perforators arising from the vessels and their distribution have been highlighted.     

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 arterial supply of the long head of biceps tendon: Anatomical study with implications for tendon rupture

Zones of hypovascularity are thought to exist in several tendons of the shoulder, contributing to localized tendon weakness and subsequent rupture in clinical practice. Although these zones have been demonstrated in many frequently ruptured tendons, the existence of a similar area in the often ruptured long head of biceps (LHB) tendon is largely unknown. Twenty cadaveric upper limb specimens were dissected after injection with either a radio‐opaque lead oxide/milk mixture or India ink, followed by histological sectioning of the tendons. The LHB tendon was consistently supplied via its osteotendinous and musculotendinous junctions by branches of the thoracoacromial and brachial arteries respectively. In two specimens, additional branches from the anterior circumflex humeral artery travelling in a mesotenon vascularized the midsection of tendon. These source arteries divided the LHB tendon into either two or three vascular territories, depending upon the presence of the mesotenon‐derived vascular supply. A zone of hypovascularity was consistently found in the region of the LHB tendon most frequently prone to rupture. This zone covered an area 1.2–3 cm from the tendon origin, extending from midway through the glenohumeral joint to the proximal inter‐tubercular groove. This hypovascular region occurred on the border of two adjacent vascular territories, where reduced caliber choke vessels provide limited arterial supply. While it is probable that the limited arterial supply contributes to the susceptibility of this area to rupture, similar to other tendons the true pathogenesis is likely to be a combination of both vascular and mechanical factors. Clin. Anat. 23:683–692, 2010. © 2010 Wiley‐Liss, Inc.     

跟外侧动脉穿支皮瓣的应用解剖

目的　探讨跟腱区及跟部皮肤软组织的血供解剖学,为跟外侧动脉穿支皮瓣的临床应用提供解剖学基础。 方法　16侧经红色乳胶灌注的成人下肢标本,解剖观察跟外侧动脉“垂直段”及其穿支血管的位置、口径、数目及分布规律。 结果　位于小腿后骨筋膜鞘深部的腓动脉于外踝尖上(6.6±1.1) cm ( 5.5~9.4 cm) 发出腓动脉前穿支和跟外侧动脉,跟外侧动脉下行穿出分隔小腿后骨筋膜鞘浅、深部之小腿后筋膜隔到达外踝后间隙,于腓骨肌腱与跟腱之间移行,继续绕外踝向前下方分布。小腿下段腓动脉、跟外侧动脉穿支数为(3.6±0.7)支,口径为（0.9±0.29） mm,营养跟腱区及跟部皮肤软组织。 结论　研究结果显示跟腱区及跟部皮肤软组织的血供主要来源于腓动脉、跟外侧动脉,为跟外侧动脉的命名、临床应用以及小腿中下段皮瓣的设计和跟部手术提供解剖学基础。     

The arterial supply of the patellar tendon: Anatomical study with clinical implications for knee surgery

The middle‐third of the patellar tendon (PT) is well‐established as a potential graft for cruciate ligament reconstruction, but there is little anatomical basis for its use. Although studies on PT vascular anatomy have focused on the risk to tendon pedicles from surgical approaches and knee pathophysiology, the significance of its blood supply to grafting has not been adequately explored previously. This investigation explores both the intrinsic and extrinsic arterial anatomy of the PT, as relevant to the PT graft. Ten fresh cadaveric lower limbs underwent angiographic injection of the common femoral artery with radio‐opaque lead oxide. Each tendon was carefully dissected, underwent plain radiography and subsequently schematically reconstructed. The PT demonstrated a well‐developed and consistent vascularity from three main sources: antero‐proximally, mainly by the inferior‐lateral genicular artery; antero‐distally via a choke‐anastomotic arch between the anterior tibial recurrent and inferior medial genicular arteries; and posteriorly via the retro‐patellar anastomotic arch in Hoffa's fat pad. Two patterns of pedicles formed this arch: inferior‐lateral and descending genicular arteries (Type‐I); superior‐lateral, inferior‐lateral, and superior‐medial genicular arteries (Type‐II). Both types supplied the posterior PT, with the majority of vessels descending to its middle‐third. The middle‐third PT has a richer intrinsic vascularity, which may enhance its ingrowth as a graft, and supports its conventional use in cruciate ligament reconstruction. The pedicles supplying the PT are endangered during procedures where Hoffa's fat pad is removed including certain techniques of PT harvest and total knee arthroplasty. Clin. Anat. 22:371–376, 2009. © 2009 Wiley‐Liss, Inc.     

Operative approach to the calcaneus: A comparison of classical and modified techniques with regard to arterial vascularization

Skin and soft tissue necrosis of the heel are the main problems following operative treatment of calcaneal fractures with the classical medial (McReynolds, 1982), lateral (Palmer, 1948), enlarged lateral, and the bilateral approaches. In order to show how classical approaches harm the vessels supplying the adjacent soft tissues, we studied the vascularization to both the calcaneus and its surrounding soft tissues. Our findings show that the calcaneus is well supplied by a collateral circulation derived from the posterior tibial, peroneal, lateral tarsal, the medial and lateral plantar arteries. The soft tissue supply is less rich. On the medial side, the soft tissue supply comes from the posterior tibial and lateral plantar arteries. On the lateral side, it is supplied by a thin anastomotic arch that runs between the lateral tarsal and peroneal arteries. Based on our anatomical findings we have proposed two modified approaches which minimize damage to the vessels of the adjacent soft tissues and still allow exact reposition of the fractures. © 1993 Wiley-Liss, Inc.     

距骨血供与手术入路关系的应用解剖学研究

目的　探讨距骨血管分布及其与手术入路之间的关系。 方法　20例成人足踝部新鲜尸体标本,红色乳胶血管灌注后进行踝关节分层次解剖和制作血管铸行标本,测量供应距骨主要各动脉起点的外径,观察距骨血供的血管来源、走行、分布,同时了解各动脉之间的吻合情况。 结果　距骨血供主要来自胫后动脉发出的三角支,其管径为(0.98±0.04)mm、后结节支,管径为(0.25±0.06)mm、跗骨管动脉,管径为(1.02±0.1)mm,这些分支主要走行于踝关节的内、后内侧,由胫前动脉发出颈上支,管径（0.3±0.1）mm、跗骨窦动脉,管径（1.08±0.6）mm,分布于踝关节的前侧,由腓动脉发出的跟支细小,管径为（0.42±　0.18）mm、穿支,管径为（0.69±0.12）mm,主要分布于踝关节的后外侧,同时在足踝铸行标本上还发现这些分支之间形成丰富的血管吻合。 结论　踝关节的前内侧入路介于胫前动脉和三角动脉之间,对距骨的血液供应损伤影响最小。     

第二、三跖趾关节移植的应用解剖学

在30只足标本上观察了第二、三跖趾关节的动脉供应,其中20只足标本还观察了关节的神经支配。每个关节规律地有背胫、腓侧,跖胫、腓侧和跖趾关节后五部分动脉关节支。作关节移植时,若以一条跖背动脉为蒂可有胫侧6支以上或腓侧7支以上的动脉关节支供血。神经蒂可选用趾背总神经或趾底总神经。     

长伸肌瓣的解剖学基础

在30个成人下肢标本上观察了长伸肌的形态、血供和神经支配。测得肌长23.1cm。该肌由7-17支胫前动脉横向分支供应,肌下份有腓动脉穿支发出补充,动脉主要从肌的内侧入肌。腓深神经约发出2支分支分布该肌,也是从肌内侧进入肌内。根据观察结果我们认为长仲肌瓣倒置治疗小腿中下份慢性骨髓炎及开放性胫骨骨折,似为较理想的供肌。     

趾长伸肌腱及其滑液囊血管的应用解剖

用40例新鲜成人尸体足标本,作巨微解剖.透明标本和组织切片方法,测量了趾长伸肌腱各项数据,详细报道了其系膜的分支及位置.趾长伸肌腱囊外近侧段的血供为肌血管的延伸;滑液囊及肌腱囊内段血供主要来自胫前动脉、跗上外侧动脉和足背动脉;肌腱囊外远侧段血供来自跖骨背侧动脉。临床切取不同部位带血管蒂趾长伸肌腱时可以此为据.本文还特别强调了跗上外侧动脉在切取滑液囊肌腱复合瓣中的作用.     

胫骨前肌瓣的应用解剖

在30个成人下肢上观察了胫骨前肌的形态、血供和神经支配。测得肌长27.0cm.该肌上七分之一由胫前返动脉发支供应,其余部份由胫前动脉横向分支供应。胫前动脉的分支主要由肌的外侧人肌。腓深神经约发出3支肌支分布该肌,从肌的外侧或后方入肌。利用胫骨前肌可制作倒置肌瓣,可剥离部份长13.0cm,蒂部尚有8支左右营养动脉,还可制作向内旋转的分裂瓣,此时可保存肌的功能。     

A study of the perforating arteries of the leg derived from the anterior tibial,posterior tibial and peroneal arteries

IntroductionThe present study deals with dissection of anterior tibial artery (ATA), posterior tibial artery (PTA) and peroneal artery (PA) angiosomes or their vascular territories in both legs of 10 freshly donated cadavers prior to embalming. The study shows the distribution of perforating arteries in their respective angiosomes.MethodsPerforating arteries arising from ATA, PTA and PA and passing through the fascial planes between muscles to the skin and subcutaneous tissues were dissected. The numbers of perforating arteries and their distance from easily recognizable anatomical landmarks was measured. The resultant data was tabulated and the average numbers of perforators in each of these three angiosomes was calculated.ResultsPTA angiosome had the largest number of perforating arteries followed by PA angiosome, the least number of perforators being found in the ATA angiosome. The middle and lower thirds of the leg generally had a greater number of perforators in all three territories. Presence of sural artery perforators arising from peroneal/popliteal artery was an additional supply in the PA angiosome.DiscussionThe knowledge of angiosomes and perforating arteries of the leg is essential for flap repairs and reconstruction for injuries of the leg. Such injuries may occur in accidents, burns and non-healing tissue defects due to ischemic ulcers, varicose veins, leprosy, diabetes and nerve injuries.     

带骨骺的儿童腓骨移植应用解剖学

解剖观察了70侧的儿童腓骨上骨骺的动脉来源、分布和吻合情况。其血供来源共见7种,胫前返动脉和腓浅动脉的腓骨头支是营养骨骺的重要血管。带骨骺儿童腓骨移植应以胫前动脉为血管蒂,腓骨体移植仍以腓血管为蒂。     

两种入路手术治疗闭合性跟腱断裂43例临床分析

目的　总结分析两种跟腱断裂修复手术入路和方式,对术后并发症和疗效的临床影响。 方法　回顾笔者2002.1~2015.12收治的闭合性跟腱断裂手术治疗患者43例,其中传统入路组（25例）术中采用传统的跟腱后部正中偏内侧1 cm处的连续长切口,改良入路组（18例）采用新的踝后约3 cm长的“S”形短斜行切口加近段跟腱边缘处2对纵行小切口组合。跟腱缝合方法均采用Bunnell法。总结分析2种入路术后伤口不愈合、皮神经损伤、跟腱再断的发生率及疗效。 结果 术后随访9个月~5年,传统入路组术后伤口不愈合4例,跟腱再次断裂1例,无皮神经损伤病例。改良入路组术后发现腓肠神经损伤1例,无伤口不愈合及跟腱再次断裂发生。两组术后并发症的发生率比较,传统入路组伤口不愈合的发生率较高（P<0.05）。两组跟腱再次断裂及皮神经损伤发生率无明显差异（P>0.05）。跟腱修复术后6个月时按照Arner-indholm评分标准,改良入路组优良率较高（P<0.05）。 结论　采用改良手术入路,术中沿踝后部皮肤皱褶走向,采用斜跨跟腱的短S形切口,加近段跟腱边缘处成对小切口,术后并发症较少,功能恢复较好。     

踝足部血管吻合支的研究与吻合胫前或胫后动脉逆行皮瓣的设计

目的：研究胫前动脉、胫后动脉和腓动脉之间在足踝部的吻合支的粗细,为吻合胫前或胫后动脉远端逆行血供皮瓣设计提供解剖学基础。方法：46侧新鲜小腿的动脉灌注红色塑料,制成动脉铸型标本。观察胫前、胫后和腓动脉在踝足部的吻合支的形态,测量血管的内径。结果：胫前、胫后和腓动脉三者之间在足踝部的吻合支丰富,胫后动脉经足底弓、足底深支与胫前动脉的吻合支最粗,内径为2.3mm。结论：胫前、胫后和腓动脉三者之间在足踝部的吻合支丰富,胫前动脉或胫后动脉之一断裂或栓塞时,只要三者之间在踝足部的主要吻合支未遭受破坏,胫前动脉或胫后动脉远端仍可作为皮瓣受区血管被利用。     

Arterial vascularization of occipital scalp: mapping of vascular cutaneous territories and surgical applications

Although the vascular supply of the occipital region of the scalp is usually considered as depending on the occipital arteries, in our clinical experience the importance of the posterior auricular arteries seems to have been underestimated. Most of the authors consider that the occipital artery is the main artery to the vascular supply of this region. The role of the posterior auricular artery has not been clearly investigated. In order to describe the cutaneous territories of these two arteries, 20 occipital areas have been dissected after bilateral injection of coloured latex (40 occipital and 40 posterior auricular arteries studied), and 4 occipital areas have been dissected after selective injection of china ink in the occipital and posterior auricular arteries (4 occipital and 4 posterior auricular arteries injected). The occipital artery was deep from its origin to the arch constituted by the insertions of the trapezius and sternocleidomastoid muscles. Then the occipital artery was becoming superficial while ascending to the vertex. The cutaneous territory of the occipital arteries was paramedian and median (38% of the occipital area). The posterior auricular artery was superficial in the auriculomastoid sulcus and divided into three branches: auricular and mastoid as usually described and also a third terminal branch that we called “transverse nuchal artery”. The posterior auricular arteries supplied the major part of the occipital area of the scalp (62%).     

Unilateral arteria peronea magna associated with bilateral replaced dorsalis pedis arteries

During anatomic dissection, a 59-year-old man presented with an arteria peronea magna that replaced all the branches of the posterior tibial artery as well as the dorsalis pedis artery. Thus, the right popliteal artery terminated into the anterior tibial artery and the enlarged peroneal artery. The right anterior tibial artery ended before it reached the ankle. The right dorsalis pedis artery arose from the peroneal artery through its perforating branch. The left popliteal artery gave rise to a common stem that subdivided into two individual branches replacing the proximal part of the anterior tibial artery, and then divided into the posterior tibial artery and the peroneal artery. As on the right side, the left dorsalis pedis artery also arose from the peroneal artery through its perforating branch. A possible embryologic explanation of these variations is proposed.     

Clinical anatomy of the arterial supply of the human patellar ligament

The arterial supply of the human patellar ligament has been systematized on 20 knee joints. After intravascular injection of colored natural latex, the blood supply to the extensor apparatus of the knee was studied by anatomical dissection and tissue transparentation techniques. Three arterial pedicles (superior, middle and inferior) were observed placed on each side of the patellar ligament. Medial pedicles had their origin from the descending and the inferior medial genicular arteries. The lateral pedicles took their origin from the lateral genicular arteries and the recurrent tibial anterior artery. Two main vascular arches anastomosed with these pedicles: the retropatellar and the supratubercular. Both arterial pedicles and anastomotic arches gave rise to a peritendinous network, characterized by a high vascular density next to poles of the patellar ligament. Only the anastomotic arches gave rise to collateral vessels that pierced the tendon, which revealed two vascular segments in the arterial supply of the patellar ligament (bipolar pattern). The upper segment was supplied by deep vessels from the retropatellar arch, whereas the inferior segment received superficial vessels from collaterals of the supratubercular arch. These intratendinous vessels anastomosed in the middle third of the patellar ligament.