Deep Plantar Research Articles

Evaluation of Healing Potential in Diabetic Foot Ulcer With Pedal Acceleration Time

Predicting wound healing in diabetic patients is challenging owing to the presence of incompressible arteries. Recently, it has been shown that patients with diabetes mellitus are more likely to have calcification of the pedal arteries. The calcification can lead to spuriously high toe pressures, leading to a false assurance that the patient's ulcer will heal. Another limitation of toe pressures is that they cannot be measured in patients with toe amputations or painful toe ulcers. We studied the pedal acceleration time (PAT) as a predictive tool for healing potential. We identified 19 patients with diabetic foot ulcers. All 19 patients had undergone duplex ultrasound with a GE logic E9 linear probe scanner and high-resolution scanner (GE Healthcare, Chicago, Ill). Patients with aortoiliac occlusive disease were excluded. The imaged pedal arteries included the arcuate, lateral plantar, medial plantar, deep plantar, and dorsal metatarsal arteries. Patients with a PAT of <180 ms were assigned to best medical therapy and wound care and given a 4- to 6-week follow-up appointment for close monitoring. Patients with a PAT of >180 ms were considered for endovascular or surgical revascularization with a 4-week follow-up visit to document clinical progress and the postprocedure PAT. Nineteen patients were enrolled in the present study. Of the 19 patients, 11 were treated conservatively because of a PAT of <180 ms. After 4 to 6 weeks of follow-up, the ulcers of 10 of the 11 patients had healed. One patient had not completely healed and osteomyelitis of the great toe was diagnosed. Eight patients had had a PAT of >180 ms and were assigned to the intervention group. Two of these patients had undergone surgical bypass and their ulcers healed, and six had undergone endovascular intervention. Of the latter six patients, one had died of an unrelated cause. The ulcers of the remaining five patients had healed after endovascular intervention. The PAT can predict the healing potential of diabetic foot ulcers.

Percutaneous Saphenous Vein Arterialization

Purpose In patients with no-option critical limb-threatening ischemia, venous foot arterialization can be considered the last chance before major amputation. Up until now, a really significant limitation of endovascular arterialization compared with surgery was the possibility to obtain arterial flow into the foot only through the deep plantar network. Technique Two 5-mm snares are placed: one in the proximal tibial artery and the other in the great saphenous vein. After passing through these snares with a needle and a guidewire and closing the snares, the guidewire is pulled through the proximal arterial sheath and the distal venous sheath. Thus, the arterial-venous connection is created. A covered stent is, then, placed between the artery and the vein to avoid leakage. Conclusions Based on our knowledge, this is the first described totally percutaneous arterialization of the superficial dorsal venous foot system, through reverse flow in the great saphenous vein.

Bridging the Gap: Innovative Use of Disposable Syringe and Platelet-rich Fibrin for Treating Planter Fissures.

Deep plantar fissures are a common, painful condition, which are often recalcitrant to multiple modalities. Autologous platelet-rich fibrin is a reservoir of supraphysiological concentration of platelets housing various growth factors shown to accelerate wound healing. This unique form factor affords a novel advantage of its ability to be applied over and within these fissures under occlusion. We report the innovative use of disposable syringes to fashion platelet-rich fibrin casts for management of these deeper fissures.

Fresh Cadaveric Study of the Distances between the Deep Plantar Arch and the Lesser Metatarsals at Risk During Osteotomy of the Lesser Metatarsals

Category:Midfoot/ForefootIntroduction/Purpose:Osteotomy of the lesser metatarsals is useful to treat forefoot deformity. Although there is the possibility that some arteries supplying the lesser metatarsals are injured during osteotomy, there are few informations about the distances from the deep plantar arch to the lesser metatarsals. This study aimed to identify the distances from the deep plantar arch to the lesser metatarsals and to reveal how osteotomy of the lesser metatarsals might injure the deep plantar arch.Methods:Twenty fresh cadaveric feet were injected with barium through the external iliac artery, and enhanced computed tomography images were assessed. The distance between the deep plantar arch and each lesser metatarsal was measured on both axial and sagittal images.Results:The distances between the deep plantar arch and the second, third, and fourth metatarsals on the axial plane were 0.5, 2.2, and 2.8 mm, respectively. The distances from the distal epiphysis to the line passing through the deep plantar arch perpendicular to the longitudinal axis of the lesser metatarsal on the sagittal plane were 47.0, 45.7, and 46.4 mm, respectively, and those from the proximal epiphysis were 23.0, 21.0, and 18.6 mm, respectively. The deep plantar arch coursed at the level of the middle third, proximal to this third in 11/20 (55.0%), 7/20 (35.0%), and 5/16 (31.2%) feet, respectively.Conclusion:This study suggested that overpenetration into the medial-plantar direction of the second metatarsal or the proximal-plantar direction of the fourth metatarsal during the shaft or proximal osteotomy might injure the deep plantar arch easily. This study also suggested that on the plantar aspect, the shaft or proximal osteotomy about 45-47 mm proximal to the distal epiphysis of the lesser metatarsal or 18-23 mm distal to the proximal epiphysis might damage blood flow of the deep plantar arch.

Location of the Deep Plantar Artery: A Cadaveric Study.

The deep plantar (D-PL) artery originates from the dorsalis pedis artery in the proximal first intermetatarsal space, an area where many procedures are performed to address deformity, traumatic injury, and infection. The potential risk of injury to the D-PL artery is concerning. The D-PL artery provides vascular contribution to the base of the first metatarsal and forms the D-PL arterial arch with the lateral plantar artery. In an effort to improve our understanding of the positional relationship of the D-PL artery to the first metatarsal, dissections were performed on 43 embalmed cadaver feet to measure the location of the D-PL artery with respect to the base of the first metatarsal. Digital images of the dissected specimens were acquired and saved for measurement using in-house software. Means, standard deviations, and 95% confidence intervals (CIs) were calculated for all of the measurement parameters. We found that the origin of the D-PL artery was located at a mean ± SD of 11.5 ± 3.9 mm (95% CI, 4.5-24.7 mm) distal to the first metatarsal base and 18.6% ± 6.5% (95% CI, 8.1%-43.4%) of length in reference to the proximal base. The average interrater reliability across all of the measurements was 0.945. This study helps clarify the anatomical location of the D-PL artery by providing parameters to aid the surgeon when performing procedures in the proximal first intermetatarsal space. Care must be taken when performing procedures in the region to avoid unintended vascular injury to the D-PL artery.

Anatomic Limitations of the Transmetatarsal Amputation With Consideration of the Deep Plantar Perforating Branch of the Dorsalis Pedis Artery

The transmetatarsal amputation is considered a durable procedure with respect to limb salvage when managing the consequences of diabetic foot disease. The success of the procedure is, in part, determined by the preoperative appreciation of arterial and functional status. The objectives of the present investigation were to determine the length of the remaining first metatarsal required during transmetatarsal amputation to preserve the anastomotic connection of the deep plantar perforating artery and subsequent “vascular arch” of the foot and the insertion of the tibialis anterior tendon. The primary outcome measure of our investigation was a measurement of the distance between the first metatarsal–medial cuneiform articulation and the distal extent of the deep plantar perforating artery in 85 embalmed lower limbs. As a secondary outcome measure, the insertion of the tibialis anterior tendon was evaluated relative to the deep plantar perforating artery. The most distal extent of the deep plantar perforating artery was observed at a mean ± standard deviation of 15.62 ± 3.74 (range 6.0 to 28.28) mm from the first metatarsal–medial cuneiform articulation. Most (89.41%) of the arteries were found within 20 mm of the first metatarsal–medial cuneiform articulation. The insertion of the tibialis anterior tendon was found to be proximal to the deep plantar perforating artery in all specimens (100.0%). In conclusion, 2.0 cm of remnant first metatarsal might represent an anatomic definition of how “short” a transmetatarsal amputation can safely be performed in most patients when considering the vascular and biomechanical anatomy.

Crossing the Rubicon: A Closer Look at the Pedal Loop Technique

The outcome of peripheral bypass surgery in patients at risk of limb loss is largely influenced by the anatomical integrity of the plantar arch. For this reason, in the last few decades, this area has been considered to be a sensitive territory, rarely approached surgically, and virtually untouchable by any endovascular activities. This hesitance was related to the possible damage to the thin dorsalis pedis, deep plantar, and lateral plantar arteries, together with the crucial metatarsal and digital branches arising from the arch. Twelve years ago, I argued that this area was anatomically very similar to the left anterior descending coronary artery and, thus, suitable for recanalization using standard endovascular coronary technique. Since its initial case, the pedal loop (PL) technique has become a very popular and glamorous procedure, likely performed in thousands of cases worldwide, additionally proving its efficacy in 2 large patient-registry retrospective analyses. Although the procedure is considered quite complex, from a technical point of view, it has almost no reliable alternatives in vascular and endovascular daily practice. However, by focusing attention on 12 well-established key points of the PL technique, it is likely that such may favor its diffusion among vascular surgeons and endovascular specialists.

Clinical Profile of Children with Acute Febrile Encephalopathy in a Tertiary Health Care Center of Nepal

Background: Acute febrile encephalopathy is a common and severe neurological syndrome that is associated with significant morbidity and mortality in children. The etiologies differ according to geographical regions and appropriate and efficient protocols for investigations and management requires proper understanding of various potential etiologies.Methods: In this prospective observational study, 54 children of one month to 14 years presenting to the hospital with acute onset of fever with altered sensorium were clinically evaluated and investigated. Clinical examinations included temperature, pulse rate, heart rate, blood pressure, coma severity by GCS, respiratory pattern and detail systemic and CNS examination. Etiology of acute febrile encephalopathy was based on clinical history, examination and relevant laboratory investigations.Results: The incidence of acute febrile encephalopathy was 5.5% of the total hospital admissions. There were 35(64.8%) boys and 19(35.2%) girls. The maximum number of children 24(44.4%) were between one to five years of age. The most common presenting complains besides fever and altered sensorium were seizures and vomiting which was present in 59.3% and 46.3% of children respectively. Signs of meningeal irritation, hypertonia, brisk deep tendon reflexes and extensor plantar response was present in 50%, 24%, 29.6%, and 44.4% respectively. The diagnosis based on clinical findings and laboratory investigations were viral encephalitis 34(63%), bacterial meningitis 12(22.2%), cerebral malaria 4(7.4), enteric encephalopathy 3(5.6%) and hepatic encephalopathy 1(1.9%).Conclusion: Viral encephalitis and bacterial meningitis are the most common cause of acute febrile encephalopathy. Preventive strategies can be done to decrease the incidence.J Nepal Paediatr Soc 2015;35(3):224-230

Familial Study of Paracentric Inversion in Chromosome 3p

Aims: To describe the familial occurrence of paracentric inversion of chromosome 3. Presentation of Cases: Patient 1: Female, Caucasian, born in Southeast of Brazil, 7 years old. Born at term and asphyxia. Developmental delay; aggressive behavior and tendency toward isolation. Prominent forehead, discrete epicanthal folds, down-slanting palpebral fissures, long philtrum and hypermobility of the four limbs. Karyotype: Research Article British Journal of Medicine & Medical Research, 3(3): 760-770, 2013 761 46,XX,inv(3)(p13p25). Patient 2: Female, Caucasian, born in Northeast of Brazil, 3 years old. Born prematurely by cesarean section, pelvic presentation and asphyxia. Severe developmental delay. Microcephaly, bilateral convergent strabismus, epicanthal folds, wide nasal bridge, micrognathia, high arched palate and nasolabial hemangioma, low set ears, hypoplastic nipples, nucal cafe-au-lait spots, deep plantar fold. Dysgenesis of the corpus callosum. Karyotype: 46,XX,inv(3)(p13p25). Patient 3: Male, Caucasian, born in Southeast of Brazil, 5 years. Born at term, by cesarean section, cephalic presentation. Developmental delay and flexor spasms. Dolichocephalic skull, prominent forehead, ocular hypertelorism, epicanthal folds, disproportioned and low set ears, single palmary crease in the right hand, large and elongated thumbs, hypotonia, and recurrent acute otitis. Karyotype: 46,XY,inv(3)(p13p25). Discussion: Patients presented developmental delay and dysmorphic features, but the relatives that presented the same inversion were asymptomatic. Carriers seem to have a normal reproductive fitness, without differences between males and females. Conclusion: The chromosomal rearrangements, especially balanced chromosomal alterations provide an opportunity to broaden the understanding of the structure and functional organization of chromosomes and to offer better genetic counseling for the families.

Transarterial coil embolization of a symptomatic posttraumatic plantar pseudoaneurysm.

Posttraumatic pseudoaneurysms of the lateral plantar artery are rare. We report the case of a 31-year-old woman with a painful pseudoaneurysm of the lateral plantar artery resulting from a deep plantar cut injury. The pseudoaneurysm was successfully treated by performing a transarterial “frontdoor-backdoor” coil embolization technique, which is a minimally invasive alternative to conventional ligature of the artery.

Anatomic variations of the dorsalis pedis artery: A cadaveric study

The dorsalis pedis artery (DPA), along with its variable branching pattern, was examined in cadaver feet. The occurrence and anatomical relationships of the DPA and its branches is of importance to clinical health care professionals for the vital role it plays in many diagnostic and corrective procedures. The DPA, a direct continuation of the anterior tibial artery, provides a lateral tarsal, a media tarsal and an arcuate branch before terminating in the 1st interosseous space by giving rise to the plantar and the dorsal metatarsal arteries.In this study, the DPA was present in all 18 feet examined as a continuation of the anterior tibial artery. Its first branch, the lateral tarsal, was noted in 94% of the cadaveric feet and originated an average of 22 mm distal to the origin of the DPA. The medial tarsal was found in 89% of the feet and originated an average of 49 mm to the origin of the DPA. The arcuate artery was the most variable branch, being present in 9 of the 18 feet examined. The two terminal arteries (first dorsal metatarsal and deep plantar) were present 94% and 89% of the time. In summary, the arcuate artery was the most variable of those studied, and the lateral tarsal artery was the most consistent branch of the DPA.

The phylogeny of the red panda (Ailurus fulgens): evidence from the forelimb

Within the order Carnivora, the phylogeny of the red panda (Ailurus fulgens) is contentious, with morphological and molecular studies supporting a wide range of possible relationships, including close ties to procyonids, ursids, mustelids and mephitids. This study provides additional morphological data, including muscle maps, for the forelimb of Ailurus, based on the dissection of four cadavers from the National Zoological Park, Washington, DC, USA. The red panda forelimb is characterized by a number of primitive features, including the lack of m. rhomboideus profundus, a humeral insertion for m. cleidobrachialis, the presence of mm. brachioradialis, articularis humeri and coracobrachialis, a single muscle belly for m. extensor digitorum lateralis with tendons to digits III-V, four mm. lumbricales, and the presence of mm. flexor digitorum brevis manus, adductores digiti I, II and V, and abductor digiti I and V. Red pandas resemble Ailuropoda, mustelids and some procyonids in possessing a soft tissue origin of m. flexor digitorum superficialis. In addition, red pandas are similar to ursids and procyonids in having a variable presence of m. biceps brachii caput breve. Furthermore, Ailurus and some ursids lack m. rhomboideus capitis. The forelimb muscle maps from this study represent a valuable resource for analyzing the functional anatomy of fossil ailurids and some notes on the Miocene ailurid, Simocyon batalleri, are presented.

The phylogeny of the red panda (Ailurus fulgens): evidence from the hindlimb

The red panda (Ailurus fulgens) is an endangered carnivore living in the temperate forests of the Himalayas and southern China. The phylogeny of the red panda has been the subject of much debate. Morphological and molecular studies have supported a wide range of possible relationships, including close ties to procyonids, ursids, mustelids, and mephitids. This study provides additional morphological data, including muscle maps, for Ailurus. The hindlimbs of four cadavers from the National Zoological Park were dissected. Red pandas retain a number of muscles lost in other carnivore groups, including muscles and tendons related to their robust and weight-bearing hallux. Three features, including a single-bellied m. sartorius, a proximal insertion for m. abductor digiti V, and an absent m. articularis coxae, are found in all terrestrial arctoids, including Ailurus. In addition, red pandas are similar to ursids and canids in lacking a caudal belly of m. semitendinosus, while they resemble procyonids and mustelids in the degree of fusion observed between mm. gluteus medius and piriformis. Furthermore, Ailurus and procyonids are characterized by numerous subdivisions within the adductor compartment, while red pandas and raccoons share a variable m. semimembranosus, composed of one, two, or three bellies. Lastly, a deep plantar muscle inserting onto the metatarsophalangeal joint of the hallux is described for Ailurus. This muscle has not been previously described and is given the name m. flexor hallucis profundus. Additional dissections of the forelimb and axial musculature of red pandas may shed further light on the phylogeny of this species. In addition, the muscle maps presented here offer a valuable resource for interpreting the functional anatomy of fossil ailurids.

The Diabetic Foot Load Monitor: A Portable Device for Real-Time Subject-Specific Measurements of Deep Plantar Tissue Stresses During Gait

Abstract Elevated stresses in deep plantar tissue of diabetic neuropathic patients were associated with an increased risk for foot ulceration, but only interfacial foot pressures are currently measured to evaluate susceptibility to ulcers. The goals of this study were to develop a real-time patient-specific plantar tissue stress monitor based on the Hertz contact theory. The biomechanical model for stress calculations considers the heel and metatarsal head pads, where most ulcers occur. For calculating stress concentrations around the bone-pad interface, plantar tissue is idealized as elastic and incompressible semi-infinite bulk (with properties measured by indentation), which is penetrated by a rigid sphere with the bone’s radius of curvature (from X-ray). Hertz’s theory is used to solve the bone-pad mechanical interactions, after introducing correction coefficients to consider large deformations. Foot-shoe forces are measured to solve and display the principal compressive, tensile, and von Mises plantar tissue stresses in real time. Our system can be miniaturized in a handheld computer, allowing plantar stress monitoring in the patient’s natural environment. Small groups of healthy subjects (N=6) and diabetic patients (N=3) participated in an evaluation study in which the differences between free walking and treadmill walking were examined. We also compared gait on a flat surface to gait on an ascending/descending slope of 3.5deg and when ascending/descending stairs. Peak internal compression stress was about threefold greater than the interface pressure at the calcaneus region. Subjects who were inexperience in treadmill walking displayed high gait-cycle variability in the internal stresses as well as poor foot loading. There was no statistical difference between gait on a flat surface and gait when ascending/descending a slope. Internal stresses under the calcaneus during gait on a flat surface, however, were significantly higher than when ascending/descending stairs. We conclude that the present stress monitor is a promising tool for real-time patient-specific evaluation of deep tissue stresses, providing valuable information in the effort to protect diabetic patients from foot ulceration. Clinical studies are now underway to identify which stress parameters can distinguish between diabetic and normal subjects; these parameters may be used for establishing injury threshold criteria.

Dislocation and Relocation of the Tarsometatarsal Joint as an Approach for Resection of the Deep Plantar Fibromatosis: Case Report

Dislocation and Relocation of the Tarsometatarsal Joint as an Approach for Resection of the Deep Plantar Fibromatosis: Case Report

Deep Veins

The deep veins of the leg and their associated perforating veins provide the major conduits for the return of blood from the legs to the heart. In health intrinsic valves maintain a one-way flow of blood from distal to proximal leg. To describe and illustrate the different deep veins, their relationship to each other, and to the superficial venous system. Of particular interest is the demonstration of the deep plantar plexus and its relationship to the anterior and posterior tibial veins and to the greater and lesser saphenous veins. The valvular system, which protects them from the effects of gravity, is also illustrated. The various deep veins as well as their tributaries and perforating veins are described in detail and illustrated with simple line drawings. These depictions help clarify the relationships between the paired veins and the higher single veins. Hopefully this unified approach to the various groups of deep veins will allow a better understanding of their form and function. The deep venous system is an integrated group of veins beginning in the deep venous plexus of the foot and terminating in the lower pelvis. Following contraction of the foot, calf, and thigh muscles the blood flows from a multitude of high pressure veins to a single low pressure vein.

Delineation of the costello syndrome

We present a 15-year-old girl with mental retardation, short stature, coarse face, unusually thick, loose skin of the hands and feet, deep plantar and palmar creases, and nasal papillomata. Her history and physical findings are compared to those of 2 children initially reported by Costello and to 1 child recently reported by Der Kaloustian et al.

On the position and course of the deep plantar arteries, with special reference to the so-called plantar metatarsal arteries.

The arterial system of the deep planta was studied in forty feet of Japanese adult cadavers. Results obtained are as follows.I. Besides the deep plantar arch lying on the p lantar surfaces of the interosseous muscles, another deeper arch formation, which corresponds to a part of Pars profundus of Arcus plantaris profundus of Koch (1939) and Catella plantaris proximalis of Nishi (1943) in the foot of the monkey, was found, though only in two feet, on the plantar surface of the fourth metatarsal bone or in the fourth intermetatarsal space deep to the plantar surfaces of the interosseous muscles.II. The so-called plantar metatarsal arteries can be classified, as in the so-called palmar metacarpal arteries (Murakami,1969), into four arteries different in position and course (sM arteries descending along the lateral four metatarsal bones on the plantar surfaces of the interosseous muscles, dM arteries descending along these bones deep to the plantar surfaces of the muscles, sI arteries descending in the lateral intermetatarsal spaces on the plantar surfaces of the muscles and dI arteries descending in these spaces deep to the plantar surfaces of the muscles), although they often take abnormal oblique courses in proportion to the increment of the contribution of the dorsalis pedis artery to the deep plantar 'arch. Out of them, the sM arteries are the most fundamental in occurrence and also in contribution to the arte rial supply of the toes.III. Deep to the first dorsal interosseous muscle there occasionally occur three descending arteries. We arbitrarily call the artery descending close to the plantar surface of the muscle sI1, the artery descending along the medial side of the first metatarsal bone dI1 and the artery descending on the plantar aspect of the bone dM1. The dM1 is usually well developed to supply the toes. A rare faint artery lying dorsal to the long flexor tendon of the first toe is referred to as sM1.IV. We show ideal distributions of arteries near the meta t arsophalangeal joints. Various patterns of arteries to the toes can be considered as the results of the alterations whereby some of the normally existing small arteries or their branches are unusually well developed while others are reduced or wanting in turn.

The Deep Plantar Tendons in the Puff-Birds, Jacamars and Their Allies

The Deep Plantar Tendons in the Puff-Birds, Jacamars and Their Allies