Metatarsal Artery Research Articles

Feasibility study of MR time-resolved imaging of contrast kinetics sequence in evaluation of the dorsalis pedis artery and the first dorsal metatarsal artery

Objective To investigate the feasibility of MR angiography of the dorsalis pedis artery (DPA),the first dorsal metatarsal artery (FDMA) and the branches at the first toe web by threedimensional time-resolved imaging of contrast kinetics (TRICKS) sequence.Methods Forty three patients with suspected or known soft tissue diseases of the ankle and foot were examined retrospectively by MR TRICKS sequence.Two experienced radiologists independently evaluated the visualization performance of DPA,FDMA and its branches with maximum intensity projection.Kappa analysis was performed for the image evaluation of the two radiologists.Consensus scores were obtained if the two radiologists had different scores.Clinical classification of FDMA was carried out for patients with scores equal to,or more than 2 points after imaging evaluation.FDMA was categorized according to its location (superficial,intramuscular,infra-muscular,absent),diameter (large,medium and small) and branching pattern at the toe web (ramifying type,main trunk type and fine small branch).Results The scoring results of the two radiologists indicated a high agreement (Kappa value =0.895,P ＜ 0.05).TRICKS images can clearly show the arterial filling of DPA,FDMA and its branches.The final consensus scores were as follows:8 patients had 4 grade and 22 patients 3 grade,8 patients 2 grade and 5 patients 1 grade.Clinical classification of FDMA for 38 patients(arterial scales ≥2 point):(1) Location:superficial (8 patients),intramuscular (23 patients),intramuscular (7 patients) ; (2) Diameter at the midpoint of FDMA:large (2 patients),medium (25 patients),and small (11 patients); (3)Branching pattern at the toe web:ramifying type (11 patients),main trunk type (5 patients),fine branch (14 patients).Conclusion MR TRICKS sequences are valuable in the evaluation of the DPA and FDMA and its branches,which can provide useful anatomical information for classification of FDMA. Key words: Dorsal artery; Magnetic resonance angiography ; Image processing, computerassisted

Anatomical Classification of the First Dorsal Metatarsal Artery and Its Clinical Application

Vascularized tissue transfer pedicled with the first dorsal metatarsal artery is commonly used in the microsurgical reconstruction of tissue defect. However, there are great anatomical variations of the artery. In this study, the authors classified the artery based on its origin (from where it arises), branches, and course. The significance of this classification system related to harvesting a first dorsal metatarsal artery-based tissue transfer is also discussed. Fresh tissue dissection (n = 48) and cast specimens (n = 30) were studied. Three-dimensional reconstruction (n = 5) was performed based on the computed tomography angiogram of the adult feet. Ultrasound color Doppler imaging was performed on 340 feet. The anatomy of first dorsal metatarsal artery was also studied in patients (n = 148) who had surgery on the first web space. The intramuscular type of the artery described by Gilbert was not found in any of the study specimens. The most common type was found in the space between the dorsal interosseous muscle and the first metatarsal. The authors thus propose a new classification system for the first dorsal metatarsal artery: the arises (origin), branch, and course (ABC) classification system. The arises (origin), branch, and course classification system can help a surgeon to better understand the anatomical variations of the first dorsal metatarsal artery and harvest vascularized tissues based on the artery.

Free toe transplantation for finger reconstruction

Objective To investigate the effect of free toe transplantation in finger reconstruction.Methods Free toe transplantations were performed in 164 patients (185 fingers) suffering from finger defection.There were 134 males and 30 females,aged at 12-83 years [mean (44.8 ± 11.2)years].Finger deletion severity was classified as grade Ⅰ in one case,grade Ⅱ in 18,grade Ⅲ in 23,grade Ⅳ in 49,grade Ⅴ in 54,and grade Ⅵ in 19.According to Gilbert standards,dorsal metatarsal arteries were classified as type Ⅰ in 68 cases,type Ⅱ in 84,and type Ⅲ in 12.Survival ratio of the transplanted fingers and hand function rehabilitation were observed.Results The transplanted toe survived in 160 cases (173 fingers).They composed of all the cases of grade Ⅰ-Ⅴ finger deletion and 15 cases of grade Ⅵ finger deletion; all the cases of type Ⅰ dorsal metatarsal arteries,83 cases of type Ⅱ dorsal metatarsal arteries and nine case of type Ⅲ dorsal metatarsal arteries.Transplantation failed in four cases (12 fingers) of grade Ⅵ finger defection including one case of Gilbert Ⅱ dorsal metatarsal arteries and three cases of Gilbert Ⅱ dorsal metatarsal arteries.Postoperative results were excellent in 110 cases and good in 50.Conclusions Toe transplantation is helpful to restore the finger shape and function and the outcome is satisfactory.Anatomic deformation of dorsal metatarsal arteries is the main cause for the failure of finger reconstruction. Key words: Finger injuries ; Toe Joint ; Transplantation

Application of three-dimensional reconstruction images of the first metatarsal dorsal artery CT in thumb reconstruction

Objective To investigate the application of three-dimensional reconstruction images of the first metatarsal dorsal CT in thumb reconstruction.Methods From August 2008 to March 2011,fifty-six patients were applied thumb reconstruction.There were 3 males and 19 females,with average age of 26.5 years(range from 18 to 45 years).The injured thumbs were reconstructed by using the combined great toe-nail flap,the great toe-nail phalanx flap or second toe transplantation.All patients received the 64 row helical CT scanning in order to carry out 3-D reconstruction image before the operation.According to the CT three-dimensional reconstruction images of the first metatarsal dorsal artery,designed the operation scheme.During the operation,the dorsalis pedis artery and the first dorsal metatarsal artery were exposed.The first dorsal metatarsal artery were classified into three types according to the classification of Gilbert.The route of first dorsal metatarsal artery and the relative relationship between the first dorsal metatarsal artery and the first dorsal interosseous muscle were observed.The coincidence degree was determined between the intraoperative findings and the preoperative CT examination results.Results There were 30 cases whose first dorsal metatarsal artery were Gilbert type Ⅰ,tuentyone cases in type Ⅱ,four cases in type Ⅲ and 1 cases with variation of dorsalis pedis artery.Intraoperative findings and preoperative CT examination results were completely consistent.All of the 56 fingers survived completely,and 6 fingers underwent second-stage plastic surgeries.Followedup 16 months to 4 years after surgery,all the reconstructed fingers had realistic configurations,and the two-point discrimination of the finger pulps ranges from 5 mm to 8 mm.The functions such as grabbing,grasping,nipping were restored.Conclusion 3D CT images of the first dorsal metatarsal artery is intuitive and reliable.It can provide an anatomical evidence for the design of operation on reconstruction of thumb and assist to get the situation of which artery of the foot is variable.This is especially applicable to the patients whose pulse of the first dorsal metatarsal artery can not be felt with fingers or can not be detected by Doppler flowmetry and Color Doppler ultrasound. Key words: First metatarsal dorsal artery; CT; Three-dimensional reconstruction images; Thumb; Reconstruction

Comparison of invasive versus noninvasive blood pressure measurements before and after hemorrhage in anesthetized greyhounds using theSurgivetV9203

To determine the agreement between blood pressure obtained with a noninvasive technique and direct technique using the Surgivet V9203 at varying blood pressure levels created using a canine hemorrhage model. Experimental study. University Teaching Hospital. Twenty-nine greyhounds with an average weight of 30 kg. Approval from the Murdoch University Animal Ethics Committee was obtained (R228609). Arterial blood pressure (BP) was measured noninvasively (NIBP) via a cuff placed over the dorsal metatarsal artery and via a catheter in the contralateral dorsal metatarsal artery (IBP). Retrospectively the blood pressure measurements recorded were divided into various BP categories. A total of 84 paired readings were obtained. The data were further analyzed with respect to heart rate [<120/min and >120/min]. Comparison of the measurements was performed using the Bland-Altman method. For all categories, BP measurements were generally lower when recorded using the oscillometric technique [Systolic (Sys) bias 4.20 kPa (31.54 mm Hg), mean bias 0.52 kPa (3.93 mm Hg), and diastolic bias 1.04 kPa (7.83 mm Hg)]. Mean arterial BP had the least bias and greatest precision in the hypotensive group (bias 0.174 kPa (1.3063 mm Hg), precision 0.79 kPa (5.89 mm Hg)), low BP group (bias 0.62 kPa (4.67mm Hg) and precision 0.89 kPa (6.67mm Hg)) and normotensive group [bias 0.76 kPa (5.71 mm Hg) and precision 1.16 kPa (8.73 mmHg)]. The results demonstrate that the agreement between NIBP measurements and IBP, are within the limits of agreement recommended by the American College of Veterinary Internal Medicine Hypertension Consensus Panel for all pressures except Sys BP. This suggests that mean and diastolic NIBP using the Surgivet V9203 are a clinically acceptable alternative of IBP in hypovolemic hypotensive dogs.

The Intraosseous and Extraosseous Vascular Supply of the Fifth Metatarsal

Osteotomies of the fifth metatarsal may disrupt the nutrient artery and result in nonunion. The location of the nutrient artery foramen relative to the location of common osteotomies has not been described. The goal of this study was to describe the vascular supply of the proximal fifth metatarsal, including the artery of origin of the nutrient artery and the location of the nutrient artery foramen. Fifty-six adult cadaver specimens were amputated below the knee. The anterior tibial, posterior tibial, and peroneal arteries were injected with India ink and Ward's Blue Latex. The specimens were frozen for 48 hours and then thawed to room temperature. The soft tissues were débrided with sodium hypochlorite, and the extraosseous vascularity was recorded. The fifth metatarsal was then removed and the intraosseous vascular anatomy elucidated using a modified Spälteholz technique. The dorsalis pedis, posterior tibial, and peroneal arteries branch in predictable patterns to supply the fifth metatarsal. The nutrient artery arose from the fourth plantar metatarsal artery in 100% of specimens and inserted into the plantar medial diaphysis in 83% of specimens. The nutrient artery foramen was an average of 26.8 mm (range, 19-40) from the medial aspect of the base of the fifth metatarsal. When an operative approach to the fifth metatarsal is planned, care should be taken to avoid stripping the bone on the plantar and medial aspects. Osteotomies placed within the proximal 40 mm of the bone carry a risk of disrupting the nutrient artery, resulting in possible nonunion.

Extreme Below-the-Knee Interventions: Retrograde Transmetatarsal or Transplantar Arch Access for Foot Salvage in Challenging Cases of Critical Limb Ischemia

To describe advanced retrograde access (transmetatarsal or transplantar arch) for endovascular treatment of critical limb ischemia (CLI) and foot salvage. From September 2011 to March 2012, 28 CLI patients (24 men; mean age 71.9 ± 10.6 years) being treated for foot salvage had failed antegrade recanalization, and percutaneous retrograde access at the pedal or plantar artery was unavailable. Advanced retrograde access techniques were required to recanalize the target vessel to restore blood flow to the compromised tissue. After local administration of verapamil to control spasm, the first dorsal metatarsal artery was preferentially accessed with a 21-G needle. When the first metatarsal artery was occluded and not fluoroscopically viewable, the plantar arch was punctured directly. After puncture, a 0.018- or 0.014-inch guidewire and microsheath were inserted for retrograde recanalization of the foot and tibial arteries with balloons sized to the target vessels. Retrograde transmetatarsal artery access was performed in 25 cases and direct transplantar arch access in 3. Technical success (ability to deliver the balloon across the lesion and inflate it at nominal pressure) was achieved in 24 (86%) cases, with <50% residual stenosis and no complications. The 4 technical failures were due to spasm or no true lumen re-entry after successful transmetatarsal (n=3) and transplantar arch access. During a mean 5-month follow-up (range 1-8), clinical improvement was obtained in the patients having technically successful tibial and foot artery recanalization; the transcutaneous pressure improved from 12.5 ± 6.7 to 49.8 ± 9.5 mmHg. There were no major and only 8 minor amputations. Amputation-free survival estimated by Kaplan-Meier analysis was 71% at 6 months. In patients with failed advanced access, the clinical condition did not improve. The advanced retrograde access technique appears feasible and beneficial as a rescue strategy in challenging patients with a failed antegrade approach who are unsuitable for retrograde pedal/plantar access.

Streptozotocin-induced diabetes differentially affects sympathetic innervation and control of plantar metatarsal and mesenteric arteries in the rat

In humans neural control of arterial vessels supplying skin in the extremities is particularly vulnerable to the effects of diabetes. Here the streptozotocin (STZ) rat model of type 1 diabetes was used to compare effects on neurovascular function in plantar metatarsal arteries (PMAs), which supply blood to skin of hind paw digits, with those in mesenteric arteries (MAs). Twelve weeks after STZ (60 mg/kg ip), wire myography was used to assess vascular function. In PMAs, lumen dimensions were unchanged but both nerve-evoked contractions and sensitivity to α(1) (phenylephrine, methoxamine)- and α(2) (clonidine)-adrenoceptor agonists were reduced. The density of perivascular nerve fibers was also reduced by ~25%. These changes were not observed in PMAs from STZ-treated rats receiving either a low dose of insulin that did not greatly reduce blood glucose levels or a high dose of insulin that markedly reduced blood glucose levels. In MAs from STZ-treated rats, nerve-evoked increases in force did not differ from control but, because lumen dimensions were ~20% larger, nerve-evoked increases in effective transmural pressure were smaller. Increases in effective transmural pressure produced by phenylephrine or α,β-methylene ATP in MAs from STZ-treated rats were not smaller than control, but the density of perivascular nerve fibers was reduced by ~10%. In MAs, the increase in vascular dimensions is primarily responsible for reducing effectiveness of nerve-evoked constrictions. By contrast, in PMAs decreases in both the density of perivascular nerve fibers and the reactivity of the vascular muscle appear to explain impairment of neurovascular transmission.

Microsurgical repair of many places and polymorphous skin defects of hands

Objective To discuss the clinical effects of the many kinds of combined skin flaps of foot which used for repairing of many places and polymorphous skin defects of hands.Methods This study included 18 patients (15 male and 3 female) with a mean age of 32.6 years (range 15-56 years) between September 2003 and January 2012.The skin defect of hand were 2-3 places and the size of the defect ranged 1.5 cm × 2.0 cm-2.5 cm × 13.0 cm.All of them with bones and tendons exposure or defect.These 18 patients with many places and polymorphous skin defects of hands were treated with combined anterosuperior malleolusdorsalls pedis flaps (6 cases),three-leaf flap of dorsum of foot (2 cases),combined the first dorsal metatarsal artery island flap and toe back flap (5 cases)and combined toe back flaps (5 cases).Meanwhile,deep peroneal nerve was used to repair defect of digital nerve or dorsal digital nerve and long extensor tendon of toes was used to repair digital flexor tendon or digital extensor tendon.Results Eighteen patients with 32 flaps survived.In the follow-up of 4 months-2 years,the fingers and skin flaps were in good shape and normal color.The sensation of the hands of the patients with nerve repaired was restored to S2-S3 and the two-point discrimination was 8-10 mm.The motor function of the hands of the patients with tendons repaired was good,which can be competent to daily life and work.Conclusion Many kinds of combined skin flaps of foot were used to repair many places and polymorphous skin defects of hands. Key words: Hand; Foot; Surgical flap; Microsurgey

Great toe transfer survival after thrombosis at 7 days

Sir, Survival of a great toe transfer depends on pedicle patency immediately postoperatively, as with all microvascular free flaps. Over time, neovascularisation from the recipient bed and surrounding wound margins into the graft may be sufficient to maintain flap viability independent of the primary vascular pedicle. It is not known how long the flow in the pedicle must persist for the flap to survive and there is no clear consensus regarding when free flaps become completely independent of their pedicle [1, 2]. The time it takes for a great toe transfer to develop its own blood supply from its recipient bed is still unknown. Our case shows that revascularisation can occur very early. We harvested a wrap-around flap from the great toe to reconstruct an amputated left thumb at the base of the proximal phalanx of a 32-year-old male smoker. The distal phalanx was harvested including the nail, most of the pulp, and the dorsal, lateral, and plantar skin of the great toe. An iliac crest bone graft was interposed between the proximal and distal ‘vascularised bone’ segments of the reconstructed thumb. The first dorsal metatarsal artery and accompanying vein were anastomosed at the ‘anatomical snuff box’. Total ischemic time was 2 h. Postoperatively, the patient received low molecular weight dextran (500 ml for 5 days) and aspirin (300 mg for 7 days). The patient was discharged on day 5—thanks to a perfect capillary refill of the reconstructed thumb. On day 7, clinical examination revealed a sluggish capillary refill, no bleeding from pin pricks on the tip of the reconstructed thumb and no Doppler signal at the microvascular anastomosis level. The patient returned to the operating room for re-exploration which showed complete thrombosis of the vascular pedicle (Fig. 1). All attempts at reanastomosis failed due to the extensive thrombosis throughout the vascular system of the flap. The patient was hospitalized and received intravenous heparin and dextran. He was discharged 2 days later without signs of vascular recovery of the thumb. A secondary surgical procedure was then scheduled. Surprisingly, 1 week later, the reconstructed thumb showed a normal capillary refill on the pulp giving us a reason to believe that the thumb was viable despite the present superficial epidermolysis, a small area of necrosis at the distal tip and still no detectable arterial Doppler signal distal to the anastomosis. After 10 months, the transplanted thumb showed satisfactory results (Figs. 2 and 3). Several authors have described clinical cases of free flap survival despite early loss of the pedicle blood supply [3, 4]. These papers suggest that after 12 days, adequate revascularisation from the recipient bed may allow at least partial flap survival. Recent clinical cases even suggest that the time may be further reduced [2, 5, 6] to 6–9 days. However, many authors have described complete loss of free flaps several months after surgery, thus highlighting the dependency of free flaps on their vascular pedicle up to 1 year after free tissue transfer [7, 8]. The process of revascularisation is believed to be dependent upon a variety of factors including type of flap used, flap thickness, quality of recipient site and ischemic time during transfer [2–4]. Free flaps are more likely to survive after vascular thrombosis if they have a sufficient marginal inset of their cutaneous portion and contact with the recipient bed [9]. It is evident, therefore, that the process of neovascularisation varies [2]. As already reported, the current consensus is that a free flap can survive after early interruption of the vascular pedicle. However, the cases reported describe the use of fasciocutaneous [1–5] or muscle free flaps [6], whereas in our case, we transferred a composite osteo-onychocutaneous free flap. Transplanted toes, similar to replanted thumbs, can survive even L. Lazzaro Hand Surgery Department, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy

Reversed plantar metatarsal artery island flap for coverage of the plantar defects at the first and second toes

To investigate the clinical effect of reversed plantar metatarsal artery island flap in repairing the plantar soft tissue defects at the first and second toes. 12 cases with plantar soft tissue defects at the first and second toes were repaired by reversed plantar metatarsal artery island flap which size ranged from 2 cm x 3 cm to 4 cm x 6 cm, including 5 cases at emergency, 5 cases with the donor site defects at great toes after free lateral pulp flap transfer, and 2 cases with the donor site defects at second toes after free medial pulp flap transfer. All the reversed plantar metatarsal artery island flaps at the first and second toes survived uneventfully with desirable appearance and sensation over a 3-35 month follow-up. No complication happened at the donor sites. It is an reliable method to adopt the reversed plantar metatarsal artery island flap for the plantar soft tissue defects at the first and second toes, with the advantages of stable blood vessels, high survival rate, good skin texture and few complications.

Doppler spectrum analysis

It is difficult to determine the safe timing of weight-bearing or reconstructive surgery in patients with Charcot arthropathy of the foot and ankle. In this study the Doppler spectrum of the first dorsal metatarsal artery was used to monitor the activity of the disease activity and served as a guideline for management. A total of 15 patients (seven men and eight women) with acute diabetic Charcot arthropathy of the foot and ankle were immobilised in a non-weight-bearing cast. They were followed at two-week intervals and bilateral Doppler spectra of the first dorsal metatarsal arteries were obtained using a 10 MHz linear ultrasound probe. The patients were allowed to start weight-bearing or undergo surgery after the Doppler spectrum had returned to normal pattern. The Doppler spectra in the unaffected limbs were triphasic in pattern, whereas those in limbs with active Charcot arthropathy showed monophasic forward flow. They returned to normal after a mean of 13.6weeks (6 to 20) of immobilisation. Three patients underwent pan-talar arthrodesis to correct gross instability and deformity. Doppler spectrum analysis of the foot may reflect the activity of the disease in patients with Charcot arthropathy, and may be used as a guide to begin weight-bearing or undergo reconstructive surgery.

Anterior Tibial Artery Terminating as Tarsal arteries

The anterior tibial artery terminated into medial tarsal and lateral tarsal branches. Dorsalis pedis artery was very thin arising as a branch from medial tarsal artery. The first and second dorsal metatarsal arteries were seen arising from lateral tarsal artery. Arcuate artery was absent. Knowledge of vascular anatomy of foot is essential for arterial reconstruction flap surgeries of the foot. This can avoid amputation of foot in cases of arterial trauma like thromboangitis obliterans, industrial automobile accidents, diabetes and severe ischaemia of lower limb.

Multiple flaps based on one pedicle from the foot to repair multiple skin defects of the hand

Objective To introduce the clinical outcomes of using multiple flaps based on one pedicle from the foot for repairing multiple skin defects of the hand.Methods Eight cases with a total of 19 wounds of the hand were treated with multiple flaps based on one pedicle from the foot.The lateral flaps from the first and second toes based on first plantar metatarsal artery were used to repair 12 wounds in 5 cases.Lateral tarsal flap and the first and second toes lateral flaps based on dorsalis pedis artery were transferred to repair 3 wounds in 1 case.Foot dorsum flap and big toe pulp flap pedicled on dorsalis pedis artery were used to repair 4 wounds in 2cases.Results All 19 flaps in 8 cases survived.Postoperative follow-up periods ranged from 3 to 36 months.Flap appearance was lifelike.Two-point discrimination was 5 to 11 mm.Sweat function recovered.Primary healing of skin grafts was achieved at the donor sites. Conclusion Transfer of multiple flaps based on one pedicle from the foot is an ideal method to repair multiple defects of the hand.It simplifies the surgical procedure and shortens the operation time.Flap selection should be based on the type and area of the injury. Key words: Surgical flaps; Microsurgery; Hand injuries

Donor site repair of great toe-nail flap in finger reconstruction surgery

struction surgery Objective To explore methods of donor repair of the great toe-nail flap in finger recon- Methods From December 1998 to December 2010, various kinds of flaps were used in 511 donor sites to repair the great toe-nail flaps, including： 32 dorsal pedal artery flaps; twenty-four first dorsal metatarsal artery flaps; twenty-one second dorsal metatarsal artery flaps; forteen anterior malleolar flaps; seventeen medial tarsal artery flaps; seventy-nine lateral tarsal artery flaps; one hundred and six plantar metatarsal flaps, seventy-nine flaps from second toe; fifteen flaps from mid/lower leg and 124 freed flaps. Results After postoperative 6 months to 11 years of follow-up, repaired donor sites of great toe-flaps all survived successfully, with ideal outlook and function. Conclusion There are many kinds of methods for donor site repair of the great toe-nail flap, and each kind of method has its own advantages and disad- vantages. Among these flaps, plantar pedal artery flap and free groin flap are amony the best ones. Key words: Great toe-nail flap ; Transplantation ; Finger ; Reconstruction ; Microsurgery

Perivascular sympathetic neuropathy in the streptozotocin type I diabetic rat model

Impaired neural control of arteries is implicated in the etiology of diabetes related complications such as diabetic foot. While there is evidence that diabetes impairs neurovascular transmission in animals, there are no reports that sympathetic axons are lost. Here we investigated the effects of streptozotocin (STZ)-induced type I diabetes on rat plantar metatarsal arteries (PMAs). Rats treated with STZ (60mg/kg, i.p.) received 1unit/day (n=6) or 4units/day (n=7) of insulin. Rats treated with a low-dose of insulin had elevated blood glucose levels (>25mM) whereas those treated with a high-dose maintained blood glucose levels <15mM.

Assessment of cardiac output measurement in dogs by transpulmonary pulse contour analysis

To determine if metatarsal artery pressure (COmet) is comparable to femoral artery pressure (COfem) as the input for transpulmonary pulse contour analysis (PiCCO) in anesthetized dogs, using the lithium dilution method (LiDCO) as a standard for cardiac output (CO) measurement. Prospective randomized study. University research laboratory. Ten healthy purpose-bred mixed breed dogs were anesthetized and instrumented to measure direct blood pressure, heart rate, arterial blood gases, and CO. The CO was measured using LiDCO and PiCCO techniques. Animals had their right femoral and left distal metatarsal artery catheterized for proximal (COfem) and distal (COmet) PiCCO analysis, respectively. Measurements were obtained from each animal during low, normal, and high CO states by changing amount of inhalant anesthetics and heart rate. Measurements were converted to CO indexed to body weigh (CI(BW) =CO/kg) for statistical analysis. Agreement was determined using Bland and Altman analysis and concordance correlation coefficients. Thirty paired measurements were taken. The LiDCO CI(BW) (± SD) was 68.7 ± 30.3, 176.0 ± 53.0, and 211.1 ± 76.5 mL/kg/min during low, normal, and high CO states, respectively. There was a significant effect of CI(BW) state on bias and relative bias with COmet (P<0.001 and P=0.003, respectively). Bias of the COmet method (± SD) was -116.6 (70.5), 20.1(76.4), and 91.3 (92.0) mL/kg/min at low, normal, and high CI(BW), respectively. Bias of the COfem (± SD) was -20.3 (19.0), 8.6 (70.9), and -2.9 (83.0) mL/kg/min at low, normal, and high CI(BW) , respectively. The mean relative bias for COfem was -6.7 ± 44% (limits of agreements: -81.2 to 67.9%). Compared with lithium dilution, the pulse contour analysis provides a good estimation of CO, but requires femoral artery catheterization in anesthetized dogs.

High Origin of Arcuate Artery- A Case Report

Dorsalis pedis artery on the dorsum of the foot was studied to establish the standard description and any variation from normal in the branching pattern in lower limbs of 30 adult human cadavers. The dorsalis pedis artery was present in all 60 (100%) cases. The branching pattern of the artery had textbook description in 54 (90%) cases. In 6 (10%), variation in branching pattern was observed and typing of branching pattern was done as Type A, B and C. The arcuate artery was present in 55(91.7%) cases. High origin of arcuate artery was seen in 1(1.66%) case. Dorsal metatarsal arteries originated from arcuate artery.

Simultaneous Upper and Lower Eyelid Reconstruction Using a First Web Space Free Flap

The authors present a case of near-total upper and lower eyelid defects treated with a first web space free flap after a chemical burn injury. A first web space free flap was raised from the ipsilateral foot and transferred to the defect with its base turned toward the medial canthal area. The first dorsal metatarsal artery and veins were anastomosed to the superficial temporal artery and veins, respectively. The inner layer of the flap was sutured to the advanced upper and lower palpebral conjunctival flap from conjunctival cul-de-sacs, and the outer layer of the flap was sutured to the defected skin. Flap-debulking procedures were carried out 3 times after the microsurgical procedure. Postoperative aesthetic results were good, except for minor problems that included focal symblepharon and sebum formation. The described method could be used as an alternative for total eyelid reconstruction, especially in patients without available local facial tissue because of burns or trauma.

Causes of necrosis of the donor great toe in toe-to-hand transfer and its preventive measures

Objective To analyze the causes of necrosis of the donor great toe in 3 eases of toe-to-hand transfer and propose the proper preventive measures. Methods Among all the toe-to-hand transfers done from February 1998 to February 2005, partial necrosis of the donor great toe occurred in 3 cases. Blood supply of the transferred toe and the intraoperative vessel occlusion test was reviewed and analyzed to define causes of the necrosis, and propose preventive measures accordingly. Results The dorsal artery of the great toe was type Ⅲ in all 3 cases. Intraoperatively the second toe was harvested based on the dorsalis pedis artery, deep plantar artery, plantar artery of the first toe. Donor great toe necrosis was observed 8 to 21 hours postoperatively. Intraopemtive inadvertent injury of the dorsal great toe fibular artery and fibular plantar metatarsal artery, tight dressing of the donor site after the surgery, and poor postoperative monitoring could have contributed to the toe necrosis. Conclusion Type Ill of the dorsal artery of the great toe, anatomical X cross and resection of the second toe could easily affect blood supply to the donor great toe. Anastomosis of the deep plantar artery and the plantar metatarsal artery, or harvest of the toe based on the dorsalis pedis artery, second dorsal metatarsal artery, digital artery axis can effectively prevent damag of the blood flow. Intra-and post-operative close monitoring of the donor site circulation and timely decompression of the great toe were effective ways to prevent great toe Key words: Hallux; Transplantation; Necrosis; Thumb reconstruction; Preventive measures