Insertion of the abductor hallucis muscle in feet with and without hallux valgus

Textbooks of human anatomy present different opinions on the insertion of the abductor hallucis muscle which is concerned in etiology as well as in therapy of hallux valgus. In plastic and reconstructive surgery the muscle is taken as a graft for flap-surgery. In this study 109 feet (58 right, 51 left) were examined, 18 of these with clinical hallux valgus. The tendon of the muscle may attach to the tendon of the medial head of the short flexor hallucis muscle where a subtendineous bursa can be found. At the head of the first metatarsal bone the joint capsule is reinforced by fibres arising from the medial sesamoid bone which may be called "medial sesamoidal ligament." The tendon passes the first metatarsophalangeal joint plantarily to its transverse axis. Three types of insertion could be distinguished: type A, insertion at the proximal phalanx (N = 42); type B, insertion at the medial sesamoid ligament and at the medial sesamoid bone (N = 65); type C, insertion at the medial sesamoid bone (N = 2). In all types superficial fibres of the tendon extended to the medial and plantar sides of the base of the proximal phalanx, running in a plantar to dorsal direction. Statistical analysis exposed neither significant differences between both sides nor significant difference between normal feet and feet with hallux valgus. Therefore, a specific pattern of insertion of the abductor hallucis muscle in hallux valgus cannot be stated.     

足韧带的解剖学研究及其临床意义

目的:研究足韧带的解剖学特点,探讨其临床意义。方法:30侧成人足标本解剖观测各韧带起至、走行和比邻,分析其作用。结果:距舟背侧韧带分为内、外两束。楔舟背侧韧带分为内、中、外、斜4束。足横弓和纵弓交汇处为足底最凹点,足底长短韧带、腓骨长肌腱、胫骨后肌腱为"外三角",楔舟足底韧带、楔骰足底韧带、跟舟足底韧带为"内三角",维系该凹点。跟舟足底韧带承托距骨头部,是将踝压力分向第1跖骨头和足跟的首要韧带。各楔骨、楔骰骨间韧矢状面上都位于关节前侧,不规则形,质地强韧,维系足横弓。结论:足部韧带分为足背、足底和骨间3个系统,结构复杂,其功能及其在创伤外科中的意义有待深入研究。     

Fetal development of the first metatarsophalangeal joint complex with special reference to the intersesamoidal ridge

In most individuals, plantar to the first metatarsal head, a more or less well developed crest separates the two furrows for the medial and the lateral sesamoid bones. In some instances, the absence of this crest has been observed in a previous study. This observation may be related to a pathological and/or an ontogenetic development. For the present examination, we have assumed the ontogenetic hypothesis. Twenty-two feet were examined at different developmental stages from week 12 to 38. The feet were prepared for examination using methods of plastination-histology. Sesamoids have already developed from the joint capsule by the first stage (12th week). Attachment bundles of collagenous fibers have deeply penetrated the cartilage of the sesamoids on their capsular side. Only some inner fibers of the muscular tendons join the sesamoids on their plantar side. The intersesamoid ligament is blended into the synovial tendon sheath of the flexor hallucis longus. The plantar crest has already developed in the fetal cartilage of the first metatarsal head as a strong ridge. With further growth, the surfaces become inwardly tapered on both sides of the ridge through the sesamoid bones, so that in the end the ridge results in a more or less clear crest. If the tapering of the furrows for the sesamoid bones proceeds too briskly or too far, this can result in an absence of the plantar crest. If the absence of this crest stands in relation to the formation of a Hallux valgus, this result would be a first indication of an developmentally based cause for this wide-spread disease of the foot.     

跗跖关节韧带的解剖观测及其意义

目的　观察跗跖关节韧带的走行和分布。 方法　解剖观察跗跖关节的韧带,测量相关数据。 结果　 跗跖关节背侧的韧带扁而薄,相邻骨骼间呈纵行,横行或斜行分布。除第1、2跖骨间无骨间韧带外,相邻跖骨间、楔骨间、外侧楔骨与骰骨间和内侧楔骨与第2跖骨基底部之间均有韧带相连。在跗跖关节的跖侧,胫骨后肌腱向远端延伸的纤维连接3块楔骨和第1~4跖骨基底部,形成一个韧带群;内侧楔骨与第1、2跖骨基底部各有韧带相连;外侧楔骨和骰骨与第3~5跖骨基底部有一横行韧带相连。 结论　跗跖关节的韧带数量众多,分布广泛,是维持跗跖关节稳定的主要结构。     

Arterial anatomy of the hallucal sesamoids

The aim of this study was to analyze the arterial supply of the sesamoid bones of the hallux. Twenty‐two feet from adult cadavers were injected with epoxide resin or an acrylic polymer in methyl methacrylate (Acrifix®) and subsequently processed by two slice plastination methods and the enzyme maceration technique. Afterwards, the arterial supply of the sesamoid bones was studied. The first plantar metatarsal artery provided a medial branch to the medial sesamoid bone. The main branch of the first plantar metatarsal artery continued its course distally along the lateral side of the lateral sesamoid and supplied it. The supplying arteries penetrated the sesamoid bones on the proximal, plantar, and distal sides. The analysis and cataloging of the microvascular anatomy of the sesamoids revealed the first plantar metatarsal artery as the main arterial source to the medial and lateral sesamoid bones. In addition, the first plantar metatarsal artery ran along the lateral plantar side of the lateral sesamoid bone, suggesting that this artery is at increased risk during soft‐tissue procedures such as hallux valgus surgery. Clin. Anat. 22:755–760, 2009. © 2009 Wiley‐Liss, Inc.     

A proposal for a new classification for the tendon of insertion of tibialis posterior

Although the tendon of the tibialis posterior muscle (TPM) is high morphological variability, its insertion is not well defined in anatomy discussions. The aim of the work is to systematize the classification of tibialis posterior tendon insertion by anatomical dissection. Classical anatomical dissection was performed on 80 lower limbs (40 female, 40 male) fixed in 10% formalin solution. The morphology of the insertion of the tendon was evaluated, and the muscle was subjected to appropriate morphometric measurements. Four types of insertion were observed, the most common being Type III (35 cases – 43.75%): a triple distal attachment where the main tendon inserts to the navicular bone and the medial cuneiform bone, and two accessory bands insert to the medial, lateral, or intermediate cuneiform bone or to the metatarsal bones (II, III, IV, V) depending on subtypes (A–C). The second most common type was Type II (18 cases: 22.5%): a double distal attachment. Type IV (14 cases: 17.5%) was characterized by quadruple distal attachment and was also divided into three subtypes (A–B). The rarest type was Type I (13 cases: 16.25%), which was characterized by a single band: the main tendon inserts to the navicular bone and the medial cuneiform bone. The tendon of the TPM presents high morphological variability. Knowledge of the four particular types of insertions is essential for both clinicians and anatomists. Clin. Anat. 32:557–565, 2019. © 2019 Wiley Periodicals, Inc.     

Variations of the plantar tarsometatarsal ligaments

This study investigated the morphological variations of the plantar tarsometatarsal ligaments of the foot by classifying them based on their ligamentous components. Fifty embalmed feet from 27 adult Korean cadavers were used. The plantar tarsometatarsal ligaments comprised nine components (medial cuneiform‐first metatarsal, pCn1‐M1; medial cuneiform‐second metatarsal, pCn1‐M2; medial cuneiform‐second and third metatarsals, pCn1‐M2,3; median cuneiform‐second metatarsal, pCn2‐M2; lateral cuneiform‐third metatarsal, pCn3‐M3; lateral cuneiform‐fourth metatarsal, pCn3‐M4; lateral cuneiform‐third and fourth metatarsals, pCn3‐M3,4; cuboid‐fourth metatarsal, pCb‐M4; and cuboid‐fifth metatarsal, pCb‐M5). pCn1‐M2 was newly observed in the present study. The number of the bands composing the ligament was one in the pCn1‐M2, pCn2‐M2, pCn3‐M3, and pCn3‐M4 components, and one or two in the pCn1‐M1, pCn1‐M2,3, pCn3‐M3,4, pCb‐M4, and pCb‐M5 components. The plantar tarsometatarsal ligaments were classified into five types based on the combination of their components. The pCn1‐M1, pCn1‐M2,3, and pCn2‐M2 components were consistently observed in types I–IV (88%), along with pCn3‐M3,4 in type I, pCn3‐M4 and pCb‐M5 in type II, and pCn3‐M3 in type IV. In type V (12%), the pCn1‐M1 and pCb‐M5 components were consistently present. Improved comprehension of the variations in plantar tarsometatarsal ligament anatomy is expected to help diagnose diverse injuries to this region, better understand the structural pathomechanism of the injuries, and contribute to successful treatment. Clin. Anat. 32:699–705, 2019. © 2019 Wiley Periodicals, Inc.     

A previously unreported variation related to the insertion of the tibialis anterior muscle and the superficial fibular (peroneal) nerve

During dissection classes in 2003 in the Department of Anatomy at Ege University Faculty of Medicine, an unexpected variation of the insertion of the tibialis anterior tendon was determined on the right side of a formalin-fixed cadaver of a 40-year-old man without any trace of scars, adhesions or signs of trauma or operation. The insertion of the tibialis anterior tendon was very abnormal, not on the medial side of the foot but on the lateral side. The tibialis anterior is an important muscle because of its function and use in tendon transfer as a treatment of recurrent congenital clubfoot and paralytic equinovarus foot deformities in cerebral palsy and arthroscopy, as discussed herein.     

Anatomical study of human adductor hallucis muscle with respect to its origin and insertion

The adductor hallucis muscle (ADH) is evolutionally and functionally important, but no detailed morphological data about this muscle in the human body is available. In the present study, we examined the origin and insertion of the oblique and transverse heads of the ADH. Forty-five feet (20 right, 25 left) of 34 cadavers (13 men, 21 women, average age of 80 years old) were used in the present study. The origin, insertion and nerve supplies of the oblique and transverse heads of the ADH were macroscopically examined in detail. Most commonly, the oblique head of the ADH arose from the bases of the 2nd, 3rd and 4th metatarsal bones, the plantar metatarsal ligaments spanned between the bases of the 2nd, 3rd and 4th metatarsal bones, the lateral cuneiform bone, the fibrous sheath of the tendon of the peroneus longus muscle and the long plantar ligament, and inserted into the lateral sesamoid bone of the great toe and the capsule of the 1st metatarsophalangeal joint. Most commonly, the transverse head of the ADH originated from the capsules of the 3rd and 4th (and occasionally 5th) metatarsophalangeal joint and the deep transverse metatarsal ligaments, and inserted into the lateral sesamoid bone of the great toe, the capsule of the 1st metatarsophalangeal joint and lateral surface of the base of the 1st proximal phalanx. This muscle was classified into four types based on the origin of its oblique head and was classified into three types based on the origin of its transverse head. The percent ratio of the weight of the oblique head to the total weight of all the intrinsic muscles of the foot was 9.4% ± 1.5, and the transverse head was 1.5% ± 0.6 (n = 14). The transverse head of ADH tends to be reduced in size in the human, but the oblique head is well developed with no sign of reduction.     

Structure of the human tibialis anterior tendon

The structure and vascular pattern of the human tibialis anterior tendon was investigated using injection techniques, light and transmission electron microscopy and immunohistochemistry. From the well vascularised peritenon, blood vessels penetrate the tendon tissue and anastomose with a longitudinally oriented intratendinous network. The distribution of blood vessels within the tibialis anterior tendon was not homogenous. The posterior part of the tendon had a complete vascular network that extends from the musculotendinous junction to the insertion at the first metatarsal and medial cuneiform bones. In the anterior half, the tissue was avascular in a zone with a length of 45–67 mm. This zone was covered by a single layer (∼30 μm) of oval shaped cells. Transmission electron microscopy showed that these cells have the characteristics of chondroid cells. This region was stained by Alcian blue at pH 1 which indicates a high concentration of acid glycosaminoglycans and immunohistochemical staining for chondroitin-4-sulphate, chondroitin-6-sulphate and aggrecan was positive. However, immunostaining for the typical cartilage specific type II collagen within this zone was negative. The location of the avascular zone corresponds to the region where the tibialis anterior tendon wraps around the superior and inferior retinacula which serve as fibrous pulleys. This is the region where most spontaneous ruptures of the tibialis anterior tendon occur. The presence of fibrocartilage within gliding tendons is a functional adaptation to compressive and shearing forces. In contrast to reports from the literature about the structure of gliding tendons wrapping around a bony pulley, the gliding zone of the tibialis anterior tendon has only a narrow layer of chondroid cells and proof of type II collagen is lacking.     

Anomalous tibialis posterior muscle as an etiologic factor of hallux valgus

The role of an anomalous tibialis posterior (TP) tendon in the etiology of hallux valgus (HV) deformity was investigated in four stages: clinical, anatomical, neurological, and operative. In the clinical stage, the patients were instructed to planter flex and invert the foot to contract the TP tendon. Attempts to correct the deformity passively were not possible and resulted in, moderate pain in all patients (197 feet). When the foot was in dorsiflexion and everted (TP tendon was relaxed) the deformity was easily corrected without any pain in 196 feet (99.5%). In the second stage (anatomical), 10 cadavers (20 feet) with HV deformity and 10 cadavers (20 feet) without any foot deformity were dissected. An abnormal expansion of TP tendon into the oblique part of adductor hallucis was found consistently in all HV feet. The tendinous expansion was absent in all normal feet studied. Also when traction was applied to TP tendon, an increase in the metatarsophalangeal (MP) angle of the big toe was observed in all HV feet, but not in the control group. In the third group (neurological), faradic stimulation was applied to the TP muscle in 7 patients with HV deformity and 7 without deformity. The MP angle was increased in HV patients, but no change was observed in the control group. In the fourth stage, 11 patients (18 feet) surgically operated for HV deformity by proximal metatarsal osteotomy and excision of the band anchoring TP tendon to the oblique part of adductor hallucis. The results were excellent in 10 patients (17 feet) even after a minimum 2.5 year follow-up. Also, in two patients who were operated by different procedures with poor results, the TP tendon was lengthened by Z-plasty and they were completely pain free. Our data show the dynamic role of anomalous expansions of the TP tendon into the oblique part of adductor hallucis muscle in HV patients. We suggest this expansion be excised in addition to other operative procedures selected for the surgical treatment of HV patients. © 1994 Wiley-Liss, Inc.     

内侧楔骨与第2跖骨底间韧带的解剖研究及临床意义

目的 测量内侧楔骨至第2跖骨底间韧带的相关参数,为临床治疗Lisfranc损伤提供解剖学依据。 方法 20例新鲜成人足部标本,解剖测量背侧韧带、Lisfranc韧带和跖侧韧带的长、宽,并观测Lisfranc韧带的走行方向和其在内侧楔骨的起点位置。 结果 背侧韧带长为（5.44±0.83）mm,宽为（4.20±0.64）mm;跖侧韧带长为（7.07±1.05）mm,宽为（5.23±1.10）mm;Lisfranc韧带长为（9.33±1.34）mm,宽为（8.00±1.23）mm,其与第2跖骨干中轴近端夹角为（61.45±5.03）°,其在内侧楔骨外侧面起点距关节面背侧（10.89±0.84）mm,跖侧（8.31±0.92）mm,远端（5.35±0.60）mm,近端（12.04±0.85）mm。 结论　Lisfranc韧带最为粗大,跖侧韧带次之,背侧韧带最为薄弱。内固定治疗Lisfranc损伤,可参照Lisfranc韧带起点位置和走行方向的解剖数据。     

克氏针和绷带固定对微创术后拇外翻的生物力学影响

目的研究第1跖骨远端截骨后克氏针和绷带固定对拇外翻的作用效果。方法通过拇外翻的医学影像数据建立完整的三维足部有限元模型,此模型包括足骨、籽骨、软骨、韧带、软组织、跟腱等;分别建立克氏针和绷带固定的模型,分析拇外翻平衡站立时的足部受载特点。结果绷带固定下截骨之间的压应力(14.9 MPa)大于克氏针峰值应力(6.71 MPa)。从背侧、跖侧、内侧、外侧来看,克氏针固定对截骨面的稳定作用都优于绷带固定,更有利于截骨面的稳定。结论绷带固定可减少截骨端的愈合时间,有利于临床上拇外翻术后固定方式的优化选择。     

An unique variation of the peroneus tertius muscle

Peroneus tertius (fibularis tertius) is a muscle unique to humans. It often appears to be a part of extensor digitorum longus, and might be described as its "fifth tendon". Although its insertion variation has been reported by many authors, variations of its origin points are not common. A variation of the peroneus tertius muscle was found during routine dissection of a 75-year-old male cadaver. The muscle originated from the extensor hallucis longus. The muscle belly of the extensor hallucis longus arose from the middle two-fourths of the medial surface of the fibula, medial to the extensor digitorum longus, and anterior surface of the interosseous membrane. It lay under the extensor digitorum longus, and lateral to the tibialis anterior muscle. The muscle belly of the extensor hallucis longus divided into medial and lateral parts 17 cm below its origin point. The lateral part, named as peroneus tertius, continued downward to reach the medial part of the dorsal surface of the base of the fifth metatarsal bone. The medial part ran also downward and divided into two tendons reaching the dorsal surface of the base of the distal phalanx of the great toe. This kind of variation may be important during foot or leg surgery.     

Ludloff截骨术治疗踇外翻的三维数字模型研究

目的　建立母外翻足三维数字模型,通过模拟Ludloff截骨手术,比较术前术后各项参数的变化,预测术后疗效及并发症,为临床进行母外翻Ludloff截骨术提供一定的理论支持,尽可能降低手术风险,增加手术安全性,提高疗效。 方法　回顾性调查11例（13足）在本院足踝外科治疗的母外翻患者,模拟手术前后对三维重建模型进行母外翻角（HVA）、第1~2跖间角（IMAI~II）、第1跖骨长度、第2跖骨相对长度、第1~5跖间角（IMAI~V）等数值测量记录,并行统计学分析。 结果 模拟截骨术前后HVA分别为（35.62±6.54）°,（11.43±3.24）°;IMAI~II分别为（16.43±2.41）°,（9.12±3.18）°;第1跖骨长度分别为（63.58±4.17）mm,（59.87±3.83）mm;第2跖骨相对长度分别为（93.74±6.02）°,（86.85±5.36）°;IMAI~V分别为（29.68±3.65）°,（19.45±2.46）°。模拟手术前后上述对应指标改变有统计学意义（P<0.05）。 结论　应用三维数字模型技术对母外翻患者进行模拟Ludloff截骨术及测量相关参数,是一种可以评估Ludloff截骨效果的数字化技术,为制定手术方案提供依据。     

以内踝前血管为蒂胫骨远端内侧骨膜瓣移位术的应用解剖

目的：为内踝前血管胫骨远端内侧骨膜瓣移位术提供解剖学依据。方法：30侧经动脉灌注红乳胶成年下肢标本，观测内踝前动脉的来源、走行、分支分布、邻近吻合及胫骨远端内侧面的骨膜血管结果：内踝前动脉起于胫前动脉或足背动脉，紧邻胫骨前肌腱内侧行向前内，在楔骨内缘与足底内侧动脉浅支．或跗内侧动脉后行支形成吻合。动脉滞途发出3～6支外径为03～1．0mm的内踝骨膜支，分布内踝区骨膜，并与其它来源的胫骨远端内侧而骨膜动脉相吻合。结论：以内踝前血管为蒂的胫骨远端内侧骨膜瓣，顺行移位可修复胫骨远端骨不连，顺行或逆行移位可用于修复距骨颈骨折和距骨体缺血性坏死。     

Ludloff截骨术治疗踇外翻的三维数字模型研究

目的　建立母外翻足三维数字模型,通过模拟Ludloff截骨手术,比较术前术后各项参数的变化,预测术后疗效及并发症,为临床进行母外翻Ludloff截骨术提供一定的理论支持,尽可能降低手术风险,增加手术安全性,提高疗效。 方法　回顾性调查11例（13足）在本院足踝外科治疗的母外翻患者,模拟手术前后对三维重建模型进行母外翻角（HVA）、第1~2跖间角（IMAI~II）、第1跖骨长度、第2跖骨相对长度、第1~5跖间角（IMAI~V）等数值测量记录,并行统计学分析。 结果 模拟截骨术前后HVA分别为（35.62±6.54）°,（11.43±3.24）°;IMAI~II分别为（16.43±2.41）°,（9.12±3.18）°;第1跖骨长度分别为（63.58±4.17）mm,（59.87±3.83）mm;第2跖骨相对长度分别为（93.74±6.02）°,（86.85±5.36）°;IMAI~V分别为（29.68±3.65）°,（19.45±2.46）°。模拟手术前后上述对应指标改变有统计学意义（P<0.05）。 结论　应用三维数字模型技术对母外翻患者进行模拟Ludloff截骨术及测量相关参数,是一种可以评估Ludloff截骨效果的数字化技术,为制定手术方案提供依据。     

Morphological description of combined variation of distal attachments of fibulares in a foot

An interesting case of peculiarity of the distal attachment of the three fibular muscles is reported in the left foot of a male adult cadaver of Indian origin. The fibularis brevis, just inferior to the fibular malleolus, gave off an additional slender tendon anteromedial to its main tendon. This was attached to the dorsal digital expansion of the little toe while its main tendon was inserted to the customary bone. The tendon of fibularis longus on the plantar aspect just medial to the cuboid tunnel received a prominent slip of attachment of the tendon of tibialis posterior. The fibularis tertius had two parallel-running tendons attached to the bases of the fourth metatarsal and the fourth and fifth metatarsals respectively. The combined variation of the three fibulares in a single foot has not been reported previously. The more distal attachment of the fibularis brevis in this case is a regression in evolution. Weakness of both the fibularis brevis and fibularis longus is found in pes cavovarus. The former can be used as a rotational graft in soft tissue loss of the leg.     

Correlation between the course of the medial plantar artery and the morphology of the abductor hallucis muscle

The abductor hallucis muscle flap is commonly used as a proximally-based flap in the management of ankle, heel, and midfoot lesions, where it is ideally suited for closing defects. This study investigates the anatomical details of this muscle in 13 fresh male cadavers. The medial plantar artery (MPA) was studied by dissection and macroscopic analyses to document the relationship of its superficial and deep branches with respect to the abductor hallucis muscle (AHM). Three main patterns could be described. In Pattern A (54%) the MPA divides into two branches. The deep branch reaches the deep surface of the AHM, supplying its proximal part, and the superficial branch courses between the AHM and the flexor digitorum brevis, to end as the first plantar metatarsal artery. The latter supplies two to three small branches to the distal part of the AHM. The fibers of the AHM end symmetrically on the two sides of the tendon and the muscle presents an arciform shape. The MPA, in Pattern B (38%), lacks a deep branch and continues along the lateral border of the AHM as a superficial branch that supplies proximal and distal collaterals to the muscle. The muscle fibers of the AHM end mainly on the medial side of the tendon. The muscle belly presents an arciform shape and is located on the medial margin of the foot superomedially with respect to Pattern A. In Pattern C (8%) the MPA continues as a large deep branch on the deep surface of the AHM and ends as the medial collateral artery of the big toe. A smaller superficial branch of the MPA provides a few collaterals to the AHM from its proximal part and to the flexor digitorum brevis in its distal part. The AHM fibers end mainly on the lateral side of the tendon and morphologically the muscle presents a straight line on the sole of the foot compared to Pattern A. Although Patterns B and C, from a surgical point of view, necessitate interruption of the main trunk of the MPA, Pattern A may permit the vascularization of the muscles of the medial side of the sole of the foot by the superficial trunk of the MPA. Because preoperative radiological study of the plantar vessels correlate with the morphological characteristics of the AHM observed during surgery, such imaging may be useful in determining the appropriate flap design based on the patient's unique pattern of MPA branching.