ORIGINAL ARTICLES Location of the Deep Plantar Artery A Cadaveric Study James H. Whelan, DPM* John P. Lazoritz, DPM* Caroline Kiser, DPM† Vassilios Vardaxis, PhD‡ Downloaded from http://meridian.allenpress.com/japma/article-pdf/110/6/Article_4/2679579/i8750-7315-110-6-article_4.pdf by guest on 28 September 2021 Background: 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. Methods: 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% confi- dence intervals (CIs) were calculated for all of the measurement parameters. Results: We found that the origin of the D-PL artery was located at a mean 6 SD of 11.5 6 3.9 mm (95% CI, 4.5–24.7 mm) distal to the first metatarsal base and 18.6% 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. Conclusions: 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. (J Am Podiatr Med Assoc 110(6): 1- 5, 2020) Procedures performed in the proximal first inter- The D-PL artery is one of the terminal branches of metatarsal space pose risk of injury to important the dorsalis pedis artery that originates in the structures in the area, including the deep plantar (D- proximal first intermetatarsal space. The dorsalis PL) artery.1-5 There are several elective and non- pedis artery divides into the first dorsal metatarsal elective surgical procedures performed in the area artery (FDMA) and the D-PL artery, which passes to treat deformity, trauma-related pathology, and between the first and second metatarsal bones in a infection. A better understanding of the positional dorsal proximal to plantar distal direction.6-9 The D- anatomy of the D-PL artery will aid meticulous PL and lateral plantar arteries form the D-PL arterial dissection and may serve as a guide for fixation arch, which supplies blood to the plantar arch and techniques. forefoot structures.8 In addition, it has an extensive *Foot and Ankle Center of Nebraska and Iowa, Omaha, vascular contribution to the proximal first metatar- NE. Dr. Whelan is now with Beloit Health System, Beloit, WI. sal.10 Dr. Lazoritz is now with Clarinda Regional Health Center, Procedures performed at the proximal first Clarinda, IA. metatarsal to address severe bunion deformity, †Kentucky/Indiana Foot and Ankle Specialists, Bowling Green, KY. Dr. Kiser is now with The Jackson Clinic, including base osteotomies and first metatarsocu- Jackson, TN. neiform joint arthrodeses, and other arthrodeses of ‡Physical Therapy/Academic, Des Moines University, Des the medial column for isolated degenerative joint Moines, IA. disease or medial column collapse pose a risk of Corresponding author: James H. Whelan, DPM, Beloit Health System, 1905 E Huebbe Parkway, Beloit, WI 53511. disruption of the D-PL artery. In addition, open (E-mail: [email protected]) reduction and internal fixation techniques and Journal of the American Podiatric Medical Association Vol 110 No 6 November/December 2020 1 arthrodeses for Lisfranc tarsometatarsal joint frac- year. The skin and soft tissue were degloved and ture-dislocation render the D-PL artery at risk. Some removed to allow for identification of the D-PL authors advocate for fixation placement in an artery located in the proximal first intermetatarsal intermetatarsal manner between the first and space at its point of branching plantarward from the second metatarsals.11,12 An understanding of the dorsalis pedis artery. Meticulous dissection of the positional anatomy could guide fixation place- subcutaneous tissue was performed to avoid alter- ment.13 Iatrogenic injury to the D-PL artery has ation of the natural anatomical position of the D-PL been reported in the literature in one case involving artery for image capture and measurement. The first first metatarsocuneiform joint arthrodesis with metatarsal was isolated and the first metatarsocu- resultant pseudoaneurysm formation.3 In addition, neiform joint was exposed. A pin was placed at the short partial first-ray and transmetatarsal amputa- most proximal aspect of the D-PL artery at its point tions pose concern. The clinical sequela after of origin from the dorsalis pedis artery as a Downloaded from http://meridian.allenpress.com/japma/article-pdf/110/6/Article_4/2679579/i8750-7315-110-6-article_4.pdf by guest on 28 September 2021 interruption of the D-PL artery in cases of trans- reference for image measurements. metatarsal amputation has been studied.4 Attinger and colleagues4 found that compromised communi- Measurements cation between the D-PL artery and the plantar arch can cause differential flap failure in the presence of The specimen foot length measurements were taken underlying peripheral vascular disease. They found at the time of dissection. Foot length was deter- that the dorsal flap of the transmetatarsal amputa- mined using a ruler, with length determined as the tion is at risk for failure when disruption of the D-PL measurement between the most distal aspect of the artery occurs and the posterior tibial artery is the longest toe and the most posterior aspect of the predominant arterial supplier. On the contrary, the heel. Digital images of the dissected specimens plantar flap is at risk for failure when disruption were taken by one of us (J.P.L.) closely paralleling occurs and the anterior tibial artery is the predom- the transverse plane. The images included a ruler inant artery.4 and were saved for measurement using in-house– Consideration of potential injury to the D-PL artery and the risk of surgical complications related written software in MATLAB 8.6 (The MathWorks to proximal metatarsal procedures and amputation Inc, Natick, Massachusetts). A linear length of 50 warrant a closer look at the vascular positional mm was used on each image to calibrate measure- anatomy in this area. Previous studies have inves- ments from each specimen. The foot length mea- tigated the location of the D-PL artery and have surement and specimen axial image measurements provided general guidelines to surgeons.1,2,5 The were independently taken by two of us (J.H.W. and present study was, therefore, undertaken to obtain a J.P.L.). The digital image measurements included 1) more detailed understanding of the anatomical the distance between the most proximal aspect of relationship of the D-PL artery to the first metatarsal the D-PL artery and the most proximal lateral aspect with the aim of developing and providing cautionary of the base of the first metatarsal and 2) the length guidelines to aid surgeons when dissecting in the of the first metatarsal (Fig. 1). region of the proximal first intermetatarsal space and for fixation placement. This knowledge may Statistical Analysis decrease the potential for iatrogenic, intraoperative vascular injury. Descriptive statistics were calculated for foot length, metatarsal length, and location of the D-PL Methods artery in all of the specimens. The means, standard deviations, and 95% confidence intervals (CIs) were Cadaveric Dissection calculated for all of the measurement parameters and are reported by sex and as pooled data. Two of us (J.H.W. and J.P.L.) performed dissections Interrater reliability of the measurements was on 43 embalmed feet (23 male [53%] and 20 female estimated using the intraclass correlation coeffi- [47%]) from 27 cadavers (14 male [52%] and 13 cient for single measurement, with values of 0.60 or female [48%]) (age: mean, 81.8 years; range, 61–96 greater accepted as fair reliability, 0.75 or greater as years). All of the cadaveric specimens were good reliability, and 0.90 or greater as high procured by the Department of Anatomy, College reliability.14 All of the descriptive analyses were of Osteopathic Medicine, Des Moines University performed in IBM SPSS Statistics for Windows, (Des Moines, Iowa), during the 2012–2013 academic Version 19.0 (IBM Corp, Armonk, New York). 2 November/December 2020 Vol 110 No 6 Journal of the American Podiatric Medical Association 1); however, sex differences did not appear in the absolute or relative distance for the origin of the D- PL from the base of the first metatarsal. The average interrater reliability, estimated using the intraclass correlation coefficient, across all of the measure- ments was 0.945 (range, 0.900–0.970). This value is rated high per Landis and Koch.14 Discussion The purpose of the present study was to improve our understanding of the anatomical relationship of Downloaded from http://meridian.allenpress.com/japma/article-pdf/110/6/Article_4/2679579/i8750-7315-110-6-article_4.pdf by guest on 28 September 2021 the D-PL artery with respect to the first metatarsal and to provide surgeons with a reference when dissecting in the region of the proximal first Figure 1.