ORIGINAL ARTICLE Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649 A DESCRIPTION OF THE SIZE AND DISTAL BRANCHING PATTERN OF THE DORSALIS PEDIS ARTERY: A CADAVERIC STUDY Lané Prigge1,2, Nanette Briers2 1 Department of Anatomy, School of Pathology and Pre-Clinical Sciences, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa. 2Department of Anatomy, Section of Clinical Anatomy, School of Medicine, Faculty of Health Sciences, University, Pretoria, South Africa. Correspondence to: L Prigge Department of Anatomy, School of Pathology and Pre-Clinical Sciences, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, PO Box 232 Medunsa 0204, Republic of South Africa. Email: [email protected]. ABSTRACT Detailed knowledge of the dorsalis pedis artery (DPA) on the dorsum of the foot is required for reconstructive surgery, especially when a dorsalis pedis flap is utilised. The aim of this study was to determine the size and branching pattern of the DPA. Within the anterior tarsal tunnel of 40 cadaveric ankles, the size and branches of the DPA were measured, while the relationship of the branches of the DPA to the inferior extensor retinaculum (IER) was noted. The thickness and the locations of the DPA and its branches provided statistically significant data (p>0.05) that the DPA does not divide into equal diameter branches at the level of the ankle joint. The branching pattern of the DPA can be divided into three categories: 27.5% of the arteries arise proximal to the IER, 62.5% of the branches deep to the IER and 10% of the terminal branches distal to the IER. The measurements and locations of the branches noted should assist and inform surgeons of variations during vascular and reconstructive surgery. Key words: Neurovascular anatomy; reconstructive surgery; bifurcation; foot dorsum; inferior extensor retinaculum INTRODUCTION The anterior tibial artery extends distally as extensor hallucis longus, where it is located the dorsalis pedis artery (DPA), at the lower next to the deep fibular nerve, between the end of the tibia, midway between the malleoli tendons of the extensor hallucis longus and (Sinnatamby, 2011). The DPA passes deep to the tendons of the extensor digitorum longus the inferior extensor retinaculum (IER) and is (Sinnatamby, 2011). responsible for the majority of arterial blood supply to the dorsum of the foot (Moore and In a case report by Kim and colleagues Dalley, 2006). The DPA gives rise to a lateral (2011), a first web space free flap was used tarsal artery and two- to three medial tarsal to reconstruct both the upper and lower arteries. It then travels to the proximal end of eyelid defects of a patient. The first dorsal the first intermetatarsal space, where it turns metatarsal artery, a branch of the dorsalis to the sole of the foot to form part the plantar pedis artery, was used to form an arch (Standring, 2008). The pulse of the DPA anastomosis with the frontal branch of the can be palpated lateral to the tendon of the superficial temporal artery. Eo and co-workers Submitted 29th August 2015, corrected 16th October 2015. Published online 18th February 2016. To cite: Prigge L, Briers N. 2016. A Description of the Size and Distal Branching Pattern of the Dorsalis Pedis Artery: A Cadaveric Study. Anatomy Journal of Africa. 5: 644 – 649. www.anatomyafrica.org 644 Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649 (2006) emphasize the importance of the dorsalis pedis artery will impact on the knowledge and appreciation of the anatomy knowledge of the anatomy of this area and of the donor sites. They state that this will the approach to surgical procedures on this ensure accurate microsurgical reattachment of structure. the severed blood vessels at the recipient site, which can be achieved by correctly resecting During reconstructive flap surgery, the the free flap with the blood vessels. dorsalis pedis flap is widely used for reconstructions pertaining to the orbital area, Some authors describe the termination of the intra-oral region and hand- and palm DPA more of a bifurcation rather than a vessel reconstructions (Chitra, 2009). The dorsalis branching into branches (Pomposelli et al., pedis artery, as well as the deep fibular nerve, 1995; Allen, 1997). According to Menin is contained within this flap, emphasizing the (2010), the term “bifurcation” describes an importance of both these anatomical abrupt change in pattern. It then follows that structures (Strauch and Vasconez, 1990; Tang in order for the distal termination of an artery and Chen, 1990; Dong et al., 2003; Chitra, to be considered a bifurcation, it must exhibit 2009). a drastic pattern change such as seen in the bifurcation of the common carotid artery, The aims of this study were to quantitatively abdominal aorta and common iliac artery. measure the size of the DPA and its branches, Mooney (2009) describes a bifurcation as a and to compare the results between the left division from a common origin into two equal and right, as well as between sexes. parts, e.g. the division of a blood vessel into Furthermore, the branching patterns were two equal-sized vessels. According to Douglas evaluated in order to determine the Harper (2013), the author of the online correctness of the term “bifurcation” in the etymology dictionary, the term “bifid” description of the branching pattern of the (originating from the Latin bifidus) means to DPA and to shed more light on the varying split into two equal parts. The confusing use patterns that may complicate microsurgical of the term “bifurcation” associated with the reattachment of blood vessels during reconstructive flap surgery. MATERIALS AND METHODS Ethical clearance was obtained from the externally at the level of the IER with a Research Ethics Committee of the Faculty of Vernier digital calliper (accuracy of 0.01mm), Health Sciences at the University of Pretoria. in order to determine the correctness of the According to the South African National term “bifurcation” in describing the distal Health Act, Act 61 of 2003, all cadavers used termination of the DPA. in this study were legally obtained and stowed in the Department of Anatomy for research The statistics package, SPSS version 8, was and teaching purposes. used to calculate the frequencies and percentages. The Student t-test was used to A total of 40 ankles were dissected, which quantify differences and to establish statistical involved the removal of the skin and the deep significance in the difference in mean size of fascia of the leg, as well as the dorsal fascia the DPA between the sexes. of the foot being incised. An incision was made through the IER to expose the anterior Intra- and inter-observer error was tested tarsal tunnel containing the DPA and its using a random sample of 27 ankles. The branches on the dorsum of the foot. The first and second authors repeated the branching pattern of the DPA in relation to the measurements on the size of the DPA. No IER was noted and documented by making significant differences were observed when use of digital photographs. The diameter of comparing the intra- and inter-observer errors the DPA and its branches were measured with the collected data. www.anatomyafrica.org 645 Anatomy Journal of Africa. 2016. Vol 5 (1): 644-649 RESULTS The quantitative data obtained from the diameters of the arteries when compared for dissections of 40 ankles with regard to the the sexes (p > 0.05). size and branching pattern of the DPA in relation to the IER, are reported below. Branching pattern Prior to the observed branching of the DPA, Size several smaller malleolar branches arise from In the majority of cases, the main trunk of the the stem of the DPA. No statistically DPA gave rise to two distinct distal branches significant difference (p > 0.05) was observed in relation to the IER. The mean size of the in the location of these smaller branches, DPA main trunk and its branches, distal to the therefore a combined sample for left and right level of the inferior extensor retinaculum sides was analysed. In 62.5% of the observed (IER) are presented in Figure 1. In order to cases, the malleolar branches of the DPA determine whether the term “bifurcation”, as were deep to the IER (Fig. 2), while 27.5% described by Mooney (2009) and Harper were found proximal to the IER and 10% (2013), was applicable to the branching of the were found distal to the level of the IER. No DPA, the diameter of the first branch significant difference could be demonstrated (continuation of the dorsal pedal artery) was between the sexes or the different sides of compared to the second branch (lateral tarsal the body (p> 0.05). artery). On the left, the diameter of the continuing DPA was measured at 3.29mm ± Several interesting variations in the branching 0.2 (mean ± SD), while the lateral tarsal patterns of the DPA were observed. In six artery had an average diameter of 2.06mm ± cases (15%), the DPA formed a secondary 0.1. On the right, the average diameter of the trunk when branching from the main trunk, continuing DPA was 3.23mm ± 0.2, while the after which the secondary trunk further lateral tarsal artery was measured at 2.46mm branched into smaller arteries (Fig. 3). These ± 0.2. In general, the continuing DPA was trunks displayed varying lengths, with some significantly thicker than the lateral tarsal trunks directly dividing while others extended artery (p < 0.05), indicating that the DPA inferiorly prior to dividing into the branches. gives rise to the lateral tarsal artery, instead These secondary trunks, which were observed of bifurcating.