Lateral Plantar Artery Research Articles

Curved Retrograde TTC Fusion Nails

Category: Hindfoot Introduction/Purpose: Retrograde intramedullary nailing is an established surgical procedure for tibiotalocalcaneal (TTC) fusion. The clinical incidence of plantar neurovascular damage secondary to TTC is poorly reported. Neurovascular structures at risk include the lateral plantar nerve and artery and first branch of the lateral plantar nerve. Curved TTC nails with lateral entry points theoretically reduce the risk of injury. The purpose of this study was to assess the incidence of iatrogenic injury to the plantar branches of the tibial nerve and posterior tibial artery and to propose a neurovascular safe-zone regarding entry point of retrograde TTC fusion nails. Methods: Ten below-knee thawed fresh-frozen cadaveric specimens were used in the study. None had gross deformity or malalignment of the hindfoot. Ankle and subtalar joints were not prepared before nail insertion but were maintained in neutral dorsiflexion and 5 degrees of valgus of the hindfoot. Surgical technique followed specific technical steps described for the T2 Ankle Arthrodesis Stryker nail (Schonkirchen, Germany), measuring 11 mm diameter and 200 mm long. Shortest distance between the nail and the main plantar neurovascular branches and injured structures were recorded during dissection. We also evaluated the relative position of these branches as they crossed two different lines: a longitudinal line connecting the most posterior point of the plantar surface of the calcaneus (Point A) to the base of the first metatarsal (Point B) and a transverse line connecting point B to the base of the fifth metatarsal (Point C). Results: Shortest distance between the nail and main branches of the plantar neurovascular bundle: medial plantar nerve 21.5 mm (17.7-25.2), lateral plantar nerve 4.7 mm (2.2-7.1), Baxter’s nerve 6.6 mm (2.1-11) and lateral plantar artery 1 mm (0-2.7). Lateral plantar artery was found to be in direct contact with the nail 70% of the time, 30% with a macroscopic laceration. Baxter’s nerve and lateral plantar nerve were injured in 20% of the cadavers. The medial plantar artery and nerve were not injured. Position of the structures in AB line, from proximal to distal: Baxter’s nerve (33.5%), lateral plantar artery (39%), nail (42%), lateral plantar nerve (47%) and medial plantar nerve (63%). Distance from point B in the line BC was respectively 26% and 56% for medial and lateral plantar nerves. Conclusion: Our cadaveric anatomical study shows that the most common structures at risk for iatrogenic injury by lateral curved retrograde TTC fusion nails are the lateral plantar artery, lateral plantar nerve and Baxter’s nerve. The proposition of a true neurovascular “safe-zone” is difficult to ascertain given individual anatomic variations. More lateral entry points would decrease the risk of iatrogenic injury to these structures. We propose that a longer plantar longitudinal approach (4-5 cm) and blunt dissection performed deeper to the plantar fascia would decrease risk of plantar neurovascular structure injury by the nail.

Neurovascular Structures at Risk With Curved Retrograde TTC Fusion Nails.

The purpose of this study was to assess the risk of iatrogenic injury to plantar neurovascular structures of the foot during insertion of a curved retrograde tibiotalocalcaneal (TTC) fusion nail. Ten below-knee thawed fresh-frozen cadaveric specimens underwent curved retrograde nailing of the ankle. The shortest distance between the nail and the main plantar neurovascular branches and injured structures were recorded during dissection. We also evaluated the relative position of these structures along 2 lines (AB, connecting the calcaneus to the first metatarsal, and BC, connecting the first and fifth metatarsal). The lateral plantar artery was found to be in direct contact with the nail 70% of the time, with a macroscopic laceration 30% of the time. The Baxter nerve was injured 20% of the time, as was the lateral plantar nerve. The medial plantar artery and nerve were never injured. The most proximal structure to cross line AB was the Baxter nerve followed by the lateral plantar artery, the nail, the lateral plantar nerve, and the medial plantar nerve. Our cadaveric anatomic study found that the most common structures at risk for iatrogenic injury by lateral curved retrograde TTC fusion nails were the lateral plantar artery and nerve, and the Baxter nerve. Determination of a true neurovascular safe zone is challenging and therefore warrants careful operative dissection to minimize neurovascular injuries.

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.

Variant anatomy of the dorsalis pedis arteries and their topographo-anatomical relationships with the bones and joints of the foot

With 60 lower limbs of adults studied angioarchitectonics of the dorsalis pedis artery and its main branches. We distinguished 3 variants of the dorsalis pedis artery angioarchitectonics – straight, with the medial and lateral bends. Moreover, for each of them can be characterized by specific topographo-anatomical relationships of their branches to the bones and joints of the foot. It was proved that the location of the dorsalis pedis artery trunk influence on the levels of it divergence and the amount of its branches. The morphometrical study shows a wide range of differences between the minimal and maximal values of the internal diameters of both the dorsalis pedis artery and its main branches. The average values of cured inner diameters of arteries were indicated. Grossly visible anastomoses between the branches of the dorsalis pedis artery are normally absent except for the well pronounced anastomosis revealed only between plantar branch of the dorsalis pedis artery and the lateral plantar artery.

The Lateral Plantar Artery as Recipient Vessel for Microsurgical Lateral Plantar Forefoot Reconstruction: Case Report

Division of the lateral plantar artery does not jeopardize the foot circulation because of anastomosis of the lateral plantar artery with the dorsalis pedis artery at the first intermetatarsal space. However, care should be taken with patients with peripheral artery occlusive disease and the flow of dorsalis pedis artery should be confirmed before surgery. Given the advantages of sizable vessel, easy dissection, and proximity to the defect, we believe that the lateral plantar artery might be a valuable option as recipient vessel for lateral plantar forefoot reconstruction.

Reconstruction of Calcaneous Region after Melanoma Excision with Extended Medial Plantar Flap: Case Report

Introduction: Acral melanoma has some distinct characteristics of the other melanoma subtypes as a higher frequency of local involvement. This leads to surgical treatment with wide margins of deep and peripheral resection, causing significant tissue loss with frequent exposure of the bone ends. The medial plantar flap uses the skin of the plantar cavus area, an ideal tissue for reconstruction of the calcaneous area. Objective: To report a case of calcaneal region reconstruction with medial plantar flap after melanoma excision. Case report: Patient, female, had a lesion diagnosed on the right foot in medical consultation due to unicomycosis. There were no complaints related to the injury. The biopsy revealed malignant acral lentiginous melanoma with a Breslow thickness of 1.9 mm, surgical margins free of neoplastic involvement and T2NxMx pathological staging. After the anatomopathological result, a 2 cm margin magnification was programmed with extensive resultant defect. The plastic surgery team opted for immediate reconstruction with ipsilateral extended medial plantar flap and graft of the donor area. Conclusion: The medial plantar flap provides adequate coverage for the calcaneal region, resistant to local inherent traumas of the region, with low morbidity in the donor area, good esthetic effect, rare complications, easy reproducibility and satisfactory functional recovery. It can be extended including a lateral plantar artery depending on the case, besides being able to remove the graft from the flap itself to avoid an increase in morbidity in other areas.

Anatomical basis and design of the distally based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone: a cadaveric dissection.

Detailed investigation of the vasculature of the lateral aspect of the foot has rarely been presented. However, harvesting the flap in this area to cover defects of the foot and hand is highly important. Repair of soft-tissue defects at the forefoot remains a challenge in reconstructive surgery. This study explores the characteristics of the distal-based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone to establish a repair procedure for ulcers or defects in the forefoot region. This study is divided into two parts: anatomical study and simulated operation. Thirty cadavers were utilized in the anatomical study after arterial injection. The tuberosity of the fifth metatarsal bone was used as the anatomical landmark. The lateral plantar artery perforator of the fifth metatarsal bone was identified through dissection. The perforators were dissected under a microscope. The details of the lateral plantar artery perforators, the distribution of the lateral dorsal cutaneous nerve and lateral plantar vein, the anastomosis in the lateral plantar artery perforator of the fifth metatarsal bone, the nutrient vessels of the lateral dorsal cutaneous nerve and lateral plantar vein, and other arteries of the lateral foot were recorded. The flap-raising procedure was performed on three fresh cadavers. The lateral dorsal cutaneous nerve originated from sural nerve, traveled obliquely downward along the anterior lateral margin of the foot, and accompanied by the lateral plantar vein after bifurcation, and was eventually distributed on the lateral aspect of the foot. The nutrifying arteries to the lateral dorsal cutaneous nerve and lateral plantar vein were present segmentally and mainly originated from the lateral plantar artery perforator of the fifth metatarsal bone. These nitrifying arteries constantly originated from the lateral plantar artery in the area of tuberosity of the fifth metatarsal, ran along the medial side of the fifth metatarsal, traveled between the fifth metatarsal bone and the lateral muscle group (the flexor digitorum brevis and the abductor digiti minimi muscles), pierced the aponeurosis, vascularized the skin of the anterior lateral plantar region, and resulted in many minute branches, which anastomosed with the lateral tarsal artery and fourth dorsal metatarsal artery. The anatomical study showed that (1) the vasculature pattern can roughly be classified into three types and (2) constant anastomoses occurred between the above-mentioned arteries in the lateral-dorsum region of the foot. A reliable large- or medium-sized neuro-venocutaneous flap with lateral dorsal cutaneous nerve, lateral plantar vein, and nutrient vessels can be raised using only the perforator of the lateral plantar artery of the fifth metatarsal bone, which is thin, is in the immediate vicinity of the forefoot, and has a reliable retrograde blood supply. This flap can be considered an alternative means to reconstruct soft-tissue defects of the forefoot.

Anatomical basis of the reverse lateral plantar artery perforator flap design.

This study aims to explore the characteristics of the formation and topography of lateral plantar artery perforators to identify a repair procedure for defects in the forefoot region. Thirty-three cadavers were available for this anatomical study. The tuberosity of the fifth metatarsal bone was adopted as the anatomical landmark. The details of the lateral plantar artery perforators and the anastomosis between the lateral plantar artery perforators and other arteries of lateral foot were recorded. The perforators from the base and head of the fifth metatarsal bone constantly originate from the lateral plantar artery in the area of tuberosity of the fifth metatarsal, run along the medial side of the fifth metatarsal, then travel between the fifth metatarsal bone and lateral muscle group, pierce the aponeurosis, vascularize the skin of the anterior lateral plantar region, and finally anastomose with the lateral tarsal artery and the fourth dorsal metatarsal artery. At the point of origin, the mean sizes of the perforator of the fifth metatarsal base and head were 1.3 ± 0.2 and 0.9 ± 0.3 mm (mean ± SEM), respectively. The pedicle lengths were 2.6 ± 0.3 and 3.8 ± 0.5 cm, indicating the possibility of a free perforator flap. The lateral plantar artery perforators are presented constant. The forefoot region can be repaired by the reverse perforator flap harvested pedicled with either the lateral plantar artery perforator from the base or head of the fifth metatarsal bone.

Analysis on optimal protocol of lower extremity MR angiography in patients with diabetic foot

Objective To explore the optimal protocol of lower-extremity contrast-enhanced MRA(CE-MRA) in the evaluation of diabetic foot. Methods Twenty eight healthy volunteers were scanned by CE-MRA in crus twice with parellel imaging factor (PIF) of 3 or 4. The signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and image quality of popliteal artery, posterior tibial artery, anterior tibial artery and peroneal artery were compared. Twenty patients with diabetic foot underwent CE-MRA by both of protocol 1 and 2 in leg, crus and foot. Protocol 1 was the traditional Care-bolus protocol and protocol 2 was the optimized K-space center filling delay-time protocol. The difference of two protocols in venous aliasing and in display of femoral artery, popliteal artery, posterior tibial artery, anterior tibial artery, peroneal artery, dorsalis pedis artery, medial plantar artery and lateral plantar artery were compared. The SNR, CNR of two different PIF sequences were compared by paired t test, and the display of artery of crus was compared by Wilcoxon. The display of vessels and venous aliasing of 2 protocols of diabetic foot patients were compared by Wilcoxon. Results In the images of healthy volunteers with PIF of 3, the SNR were 267±84,174±51, 147±42;and the CNR were 232±83,139±51,108±39 at popliteal artery, posterior tibial artery and peroneal artery. However, in the images with PIF of 4, the SNR were 239±73,157±53,132±35; and CNR were 206±71, 124±50,103±33, respectively. Both the SNR and CNR were higher in the former than in the latter(t values were 2.31 to 4.11, P 0.05).In the protocol 1 of patients with diabetic foot,the display of popliteal artery, posterior tibial artery, anterior tibial artery, peroneal artery, dorsalis pedis artery, medial plantar artery and lateral plantar artery, the venous aliasing in crus and foot were 3.40±0.82, 2.70±0.80, 2.50±1.00, 2.20±0.77, 2.30±0.92, 2.15±1.04, 1.45±0.60, 2.20±1.01, 2.20±1.06. And in the protocol 2, they were 3.85±0.37, 3.55± 0.69, 3.30±0.92, 2.90±0.79, 3.30±0.92, 3.25±0.79, 1.95±1.10, 3.70±0.47, 3.65±0.49, respectively(P<0.05). All of these parameters of protocol 2 were superior to protocol 1. Conclusion Using a higher PIF properly, setting the personalized K-space center filling delay-time can contribute to improving the image quality of whole lower-extremity MRA in patients with diabetic foot. Key words: Diabetic foot; Magnetic resonance angiography; Lower extremity

Weight-bearing Plantar Reconstruction Using Medial Plantar Flap Vascularized by Reverse-flow Lateral Plantar Artery: Two Case Reports

Weight-bearing Plantar Reconstruction Using Medial Plantar Flap Vascularized by Reverse-flow Lateral Plantar Artery: Two Case Reports

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.

Profuse bleeding from traumatic lateral plantar artery pseudoaneurysm after glass foot injury diagnosed by CT angiography: A case report

Abstract Retained foreign bodies and penetrating injuries to the plantar aspect of the foot are a common childhood problem. Inflammations or infections are common complications whereas vascular injury and pseudoaneurysm' formation are rare. Three cases of post -traumatic lateral plantar artery (LPA) pseudoaneurysms due to foot lacerations by glass have been reported in children. This case is a six year-old boy who presented with two episodes of bleeding after a foot laceration sustained when he stepped on glass. CT angiography showed an LPA pseudoaneurysm that was successfully managed by surgery. It should be recognized that penetrating injuries to the plantar aspect of the foot, may be associated with vascular injury and pseudoaneurysm' formation. Appropriate investigations and management is important to prevent further complications.

Lower Extremity Ulcers

Acknowledging and addressing common features of lower extremity ulcers will allow the surgeon to heal the vast majority of leg ulcers, either surgically or nonsurgically. The involvement of a surgeon interested in lower extremity preservation ensures the patient is offered a comprehensive set of management options. The authors discuss chronic and problem wounds, incidence and epidemiology, anatomic considerations, clinical evaluation and investigative studies, and general and specific management of the main types of leg ulcer (arterial, diabetic, venous, and inflammatory). Tables describe types and causes of lower extremity ulcers, common characteristics, members of the multidisciplinary team, conditions that interfere with healing, angiosomes of the foot, components of a leg ulcer that must be removed by débridement, benefits of hyperbaric oxygen and well-performed débridement, commonly used local pedicled flaps, staging systems for diabetic foot ulcer, and classes of compression stockings. Figures illustrate angiosomes of the anterior tibial, dorsalis pedis, peroneal, posterior tibial, lateral plantar, and medial plantar arteries; interplay between bacterial levels; types of wound dressing; ulcer locations as an indication of etiology; and management of arterial insufficiency ulcers, diabetic foot ulcers, and venous stasis ulcers. This review contains 11 figures, 11 tables, and 138 references.

Lower Extremity Ulcers

Acknowledging and addressing common features of lower extremity ulcers will allow the surgeon to heal the vast majority of leg ulcers, either surgically or nonsurgically. The involvement of a surgeon interested in lower extremity preservation ensures the patient is offered a comprehensive set of management options. The authors discuss chronic and problem wounds, incidence and epidemiology, anatomic considerations, clinical evaluation and investigative studies, and general and specific management of the main types of leg ulcer (arterial, diabetic, venous, and inflammatory). Tables describe types and causes of lower extremity ulcers, common characteristics, members of the multidisciplinary team, conditions that interfere with healing, angiosomes of the foot, components of a leg ulcer that must be removed by débridement, benefits of hyperbaric oxygen and well-performed débridement, commonly used local pedicled flaps, staging systems for diabetic foot ulcer, and classes of compression stockings. Figures illustrate angiosomes of the anterior tibial, dorsalis pedis, peroneal, posterior tibial, lateral plantar, and medial plantar arteries; interplay between bacterial levels; types of wound dressing; ulcer locations as an indication of etiology; and management of arterial insufficiency ulcers, diabetic foot ulcers, and venous stasis ulcers. This review contains 11 figures, 11 tables, and 138 references.

Anatomy of arterial systems reveals that the major function of the heart is not to emit waves associated with the axial blood motion

The CrossTalk articles by Tyberg et al. (2013) and Westerhof & Westerhof (2013) and the comments about the forward and backward pressure waves in the arterial system reveal that most researchers depict the left ventricle as a wave emitter, and all the wave models arise from the axial momentum equation or the Navier–Stokes equations applied to the blood. These models not only have difficulty in defining the reflection sites, they also cannot explain many physiological observations such as that the heart rate is inversely proportional to the size of the animal (Milnor, 1989), that the large arterial vessels have a high distensibility and are subjected to substantial longitudinal stretching in vivo, and that the organs of most mammals have similar structures and connect perpendicularly to the aorta at similar relative positions. Anatomical designs are important elements in the mechanism of blood delivery and therefore a realistic haemodynamic model should be able to provide insight into the underlying physiological effects. Recently, taking those physiological observations into account, we integrated some haemodynamic theories (Lin Wang et al. 2004a,b2004a, 2008) to construct a multi-rank distributed-cyclic-hydraulic-press (DCHP) model (Lin Wang & Wang, 2013) to describe the ventricular–arterial system and provided a quantitative method for exploring its overall behaviour. We proposed that the transportation of blood from the heart to the peripheral arterioles is via hydraulic devices of four different ranks. Since pressure is a continuous parameter, instead of taking the branching points or the side-openings as the reflection sites for waves, we treated them as sites for offering both hydraulic pressure forces and blood flow to the connecting lower rank systems. In this model, the left ventricle is depicted as the hydraulic pressure supplier of the first rank. As the blood is ejected from the left ventricle, it encounters the arch of the aorta, changes its axial velocity dramatically in both magnitude and direction. According to Newton's second law, as the blood changes its momentum, it exerts a force on the arterial wall. Thus, the periodic burst of blood from the left ventricle provides a pulsatile force to the main aorta. This pulsatile force will cause the aorta to conduct a distributed radial oscillatory motion which can be represented and measured either by the distributed radius pulse of the artery R(z,t) or the accompanying pressure pulse P(z,t). The gradient of the pulse pressure also induces an inevitable axial oscillatory motion Q(z,t) of the blood. However, this is not the purpose of the ventricular output. Skalak et al. (1966) and Milnor (1989) reported that most of the energy supplied by the left ventricle is dissipated in the friction of viscous flow, while almost all of the amount of work done in distending the arteries is returned later in each cycle of the heart beat because of the relatively small viscous behaviour of the vascular wall. Along large arteries, there is little attenuation of the pressure pulse; hence the ventricular energy input is mainly delivered via the radial pulsatile motion. To reduce energy dissipation, the axial flow in the large arteries should be as small as possible. The 180 deg bend near the arch of the aorta greatly reduces its axial kinetic energy; the ends of the ulnar artery and the radial artery join together as a loop at the palmar arch. Similarly, the deep plantar artery unites with the termination of the lateral plantar artery to complete the plantar arch (Marieb & Hoehn, 2009). At these arches, the head-on collision between blood approaching from opposite directions eliminates their axial momentum and helps to distribute blood more uniformly to all of the perpendicularly attached side-branches. These arterial structures have the effect of reducing the kinetic energy associated with the axial flow Q to only a few per cent of the energy associated the pressure P. The flow Q is a vector parameter, and is more posture dependent compared with the scalar parameter P; hence downgrading the role of Q in large arteries may also give mammals more freedom to change their postures. Two important concepts are utilized in the multi-rank DCHP model (Lin Wang & Wang, 2013). First, the pressure pulse is not governed by the axial momentum equation or the Navier-Stokes equations, but by the radial momentum equations for the blood and the arterial wall or the low dissipated PR wave equation (Lin Wang et al. 2004b). Second, resonant behaviours between the heart and the main aorta (Lin Wang et al. 2004a, 2008), or between the aorta and different organs (Lin Wang et al. 1991) are plausible. Here we share our model in the expectation that it can be used for physiological and pathological studies of arterial systems in the future.

IRRIGACIÓN ARTERIAL DEL MIEMBRO PÉLVICO DE LA ALPACA (Vicugna pacos)

The aim of this work was to identify and describe the arterial vessels of the pelvic member of the alpaca (Vicugna pacos). Six adult alpacas were dissected (3 females and 3 males). There were no anatomical differences between males and females. The arterial blood supply leading to the pelvic limbs mainly originates from the external iliac artery and to a lesser extent from the internal iliac artery, as described also for the canine, equine, bovine and llama. The external iliac artery is the main arterial channel that runs through the different regions of the pelvic limb, changing the name (femoral, popliteal, cranial tibial, dorsal pedal), giving off several collateral branches during its course. The superficial circumflex iliac, lateral circumflex femoral, saphenous, the proximal and distal caudal femoral arteries arose from the femoral artery as does the medial circumflex femoral artery. In the alpaca, coinciding with the llama, did not present the deep femoral artery as described in other domestic animals such as dog, horse and bovine. The popliteal artery gives off to the descending genicular artery, as the first collateral branch, the sural arteries and other branches that were distributed at the knee. The longer cranial tibial artery and the less developed caudal tibial have a distribution very similar to that described in the llama. At the level of the tarsus, the saphenous artery divides into the lateral plantar and medial plantar arteries. In the hindfoot, the medial plantar artery has a greater anatomical presence, being its contribution vital to the digital blood perfusion, as occurs in the llama. Thus, although in the pelvic limb of the alpaca has been observed several homologous arteries described in the classic texts of anatomy of domestic animals, they mostly followed an arterial pattern similar to that of the llama.

Post-traumatic pseudoaneurysm of the medial plantar artery combined with tarsal tunnel syndrome: two case reports

Pseudoaneurysms in the foot are more often reported in the lateral plantar artery than the medial plantar artery, most likely because of its more superficial location. There are no reports of pseudoaneurysm of the medial plantar artery after trauma. We present two cases of pseudoaneurysm of the medial plantar artery after blunt foot trauma and foot laceration. This pseudoaneurysm compressed a posterior tibial nerve, resulting in tarsal tunnel syndrome. The patients were treated successfully using transcatheter embolization without the need for surgical intervention. The tarsal tunnel syndrome also subsided. Here, the authors report these cases and provide a review of literature.

Fixation of the Achilles Tendon Insertion Using Suture Button Technology

Background: In the operative treatment of Achilles insertional tendinopathy, no guidelines exist concerning which form of fixation of the Achilles tendon insertion is superior. Hypothesis: Transcalcaneal drill pin passage does not place any major plantar structures at risk, and the addition of a Krackow stitch and suture button to the fixation technique provides a significant increase in ultimate load to failure in Achilles tendon insertional repairs. Study Design: Controlled laboratory study. Methods: The Achilles tendon insertions in 6 fresh-frozen cadaveric ankles were detached, and transcalcaneal drill pins were passed. Plantar dissection took place to evaluate the drill pin relationship to the plantar fascia, lateral plantar nerve and artery, flexor digitorum longus tendon, and master knot of Henry. The Achilles tendons were then repaired with a double-row suture anchor construct alone or with a suture button and Krackow stitch added to the double-row suture anchor construct. The repairs were then tested to maximum load to failure at 20 mm/min. The mode of failure was recorded, and the mean maximum load to failure was assessed using the Student t test for distributions with equal variance. Results: Transcalcaneal drill pin passage did not place any selected anatomic structures at risk. The mean maximum load to failure for the suture bridge group was 239.2 N; it was 391.4 N for the group with the suture button (P = .014). The lateral plantar artery was the structure placed at greatest risk from drill pin placement, with a mean distance of 22.7 mm (range, 16.5-29.2 mm) between the pin and artery. Conclusion: In this laboratory study, transcalcaneal drill pin passage appeared to be anatomically safe, and the use of suture button technology with a Krackow stitch for Achilles tendon insertional repair significantly increased repair strength. Clinical Relevance: Achilles tendon insertional repair with suture button fixation and a Krackow stitch may facilitate the earlier institution of postoperative rehabilitation and improve clinical outcomes.

The Medial Plantar Flap Vascularized by the Reverse Flow Lateral Plantar Artery: A Novel Variation through the Case of Aggressive Digital Papillary Adenocarcinoma of the Sole

Aggressive digital papillary adenocarcinoma (ADPA) is a rare neoplasm of eccrine sweat gland origin that typically presents as a mass on the distal extremities. It is associated with high rates of local recurrence and distal metastasis. Presented here is the case of a 61-year-old male who developed ADPA on his distal sole just above the head of the first metatarsal bone. Wide excision of the tumor involving a 3-cm skin margin from previous surgical scar of biopsy was performed, and sentinel lymph node biopsies were taken from the popliteal fossa and inguinal regions. During this wide excision surgery, the pedicle for the reverse medial plantar flap had to be removed along with the tumor. Reconstructive surgery was performed with a medial plantar flap that was vascularized with a lateral plantar artery in a reverse fashion. This flap successfully covered the defect and the patient can walk without any problems. However, the pedicle crossed the donor site somewhat tightly and the flap became congested for a while. Therefore, it is important to ensure careful handling of the donor site when performing this procedure.

The rotational advancement of medial plantar flap for coverage of foot defect: A case report

This case describes the use of the medial plantar artery flap used to cover a lateral foot wound in a 19-year-old male with a history of spina bifida. The original operative plan was for coverage with a medial plantar flap based distally on retrograde flow through the lateral plantar artery; however, this had to be revised intraoperatively as his vascular anatomy was not adequate to support a flap of this type. Thus, advancement with rotation modification of the conventional medial plantar flap was performed with good results. At 2-month follow-up, the patient's flap had fully healed, he returned to full weight-bearing status, and he had gross sensation in the sole of his foot. This case illustrates the use of the well-described medial plantar flap by rotating and advancing the flap for reconstruction of defects of the foot.