|Year : 2023 | Volume
| Issue : 1 | Page : 42-45
Variations of branching pattern of the dorsalis pedis artery: A cadaveric study
Dinesh K Patel, Amol Ashok Shinde
Associate Professor, Department of Anatomy, Dr. D. Y. Patil Vidyapeeth and Medical College, Pune, Maharashtra, India
|Date of Submission||07-Dec-2022|
|Date of Decision||20-Jan-2023|
|Date of Acceptance||30-Jan-2023|
|Date of Web Publication||21-Feb-2023|
Amol Ashok Shinde
B-1004 Westside County Society, Near HP Gas Godown, Pimple, Gurav, Pune - 411 061, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Dorsalis pedis artery (DPA) is the chief artery of foot. It provides nutrition to the dorsum of the foot. Palpation of DPA is essential for the diagnosis of peripheral vascular diseases. Cutaneous flaps supplied by branches of DPA are used in various reconstruction surgeries. Methodology: 50 meticulously dissected lower limbs of both sides and known sex were observed for morphometry, asymmetry and sexual dimorphism of DPA and its branches. Variations like absent arcuate artery and extra lateral tarsal arteries were looked for. Results: Absent arcuate artery was seen in 12%. Three tarsal metatarsal arteries and two tarsal metatarsal arteries were seen in 4% and 16%, respectively. An extremely rare case of U-shaped loop joining two tarsal metatarsal arteries was seen in two limbs. Conclusion: Rare variations like multiple tarsal arteries joined by U-shaped loop and absent arcuate artery seen in our study are of importance for reconstruction surgeries using DPA flaps.
Keywords: Arcuate artery, dorsalis pedis artery, island flap, musculocutaneous flap, reconstructive surgery
|How to cite this article:|
Patel DK, Shinde AA. Variations of branching pattern of the dorsalis pedis artery: A cadaveric study. Natl J Clin Anat 2023;12:42-5
|How to cite this URL:|
Patel DK, Shinde AA. Variations of branching pattern of the dorsalis pedis artery: A cadaveric study. Natl J Clin Anat [serial online] 2023 [cited 2023 Mar 20];12:42-5. Available from: http://www.njca.info/text.asp?2023/12/1/42/370143
| Introduction|| |
The dorsalis pedis artery (DPA) is the continuation of the anterior tibial artery in the dorsum of the foot at the mid-malleolar point. It continues as a deep plantar and 1st dorsal metatarsal artery. The arterial pulse can be palpated between the extensor hallucis longus tendon and extensor digitorum longus tendon. Loss of this pulse is seen in cases of thromboangitis obliterans and peripheral vascular diseases. The deep fibular nerve is located lateral to the artery.
The branches of DPA are the arcuate artery, medial and lateral tarsal arteries, deep plantar artery, and 1st dorsal metatarsal artery. Cutaneous flaps supplying the dorsum of the foot between the extensor retinaculum and 1st webspace or intermetatarsal space between digits are formed by the cutaneous branches of 1st dorsal metatarsal artery. This skin flap can be useful for various reconstruction surgeries, like vascular surgeries in diabetic foot patients requiring amputation.
A hypothesis that the location of DPA is at the mid-malleolar point has been mentioned, but some studies have contradicted this hypothesis. Variations like absent DPA, absent arcuate artery, and multiple lateral tarsal arteries have been mentioned in earlier studies. Studies have reported variation in the origin of DPA from the peroneal artery., Preoperative angiography to look for anomalous branching is highly recommended in musculocutaneous flap surgeries for cases of nonhealing diabetic foot ulcers.
Knowledge about the variation of branches of DPA is important for facial reconstruction surgeries such as lip reconstruction and oral cavity reconstruction for cancer patients. Dorsalis pedis fascial flap is used in soft-tissue reconstruction. Axial or Island flaps supplied by DPA are used for reconstruction at the heel. Revascularisation in diabetic foot patients is helped by knowledge of variation before procedure.
This study is undertaken to determine the morphometry and asymmetry of DPA and its branching pattern in the Pune region of Maharashtra.
| Materials and Methods|| |
Fifty lower limbs used for normal 1st MBBS dissection classes were used for this study. Twenty male and five female cadavers were dissected meticulously to determine the morphometry, asymmetry and observe for variations of DPA. Twenty-five right-sided and 25 left-sided lower limbs were observed. Branching pattern of the DPA was noted. Any anomalous branching, morphological asymmetry, and sexual dimorphism were looked for. Sexual dimorphism of the morphometry and branching pattern variations was undertaken as a pioneer study. Arteries with variation were colored and photographed. The length of DPA and distance of the branches from the malleoli were measured using Vernier caliper. Ethical clearance for this study was taken from the Institutional Ethical Committee.
- Distance from medial malleolus (M) – Length from the point on medial malleolus parallel to start of DPA [Figure 1]
- Distance from lateral malleolus (L) – Length from the point on lateral malleolus parallel to start of DPA [Figure 1]
- Length of DPA – Starting from mid-malleolar point to branching of DPA
- Presence of the arcuate artery
- Number of lateral tarsal arteries.
|Figure 1: Tortous dorsalis pedis artery with absence of arcuate artery. A – Dorsalis pedis artery, M – Medial malleolus to DPA and L – Lateral malleolus to DPA|
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Adult lower limbs with no gross damage to DPA and its branches.
Lower limbs with gross damage to DPA and its branches.
| Results|| |
Fifty lower limbs were observed for the morphometry and asymmetry of DPA.
Forty male and 10 female lower limbs were observed for sexual dimorphism.
DPA was present in all the limbs studied. The arcuate artery was absent in six limbs (5 right and 1 left side). Four male and two female limbs showed this variation. 6 limbs showed absent arcuate artery in 50 lower limbs, so in 12%. 8 limbs show 2 lateral tarsal arteries, so in 16%. 2 limbs show 3 lateral tarsal arteries, so in 4%.
Two lateral tarsal arteries were seen in 8 limbs, 5 on the right side and 3 on the left side. Three lateral tarsal arteries were seen in 2 limbs, both on the left side. The presence of 3 and 2 lateral tarsal arteries was seen only in male cadavers. A rare finding of the presence of a rare U-shaped loop formed by the joining of 2nd and 3rd lateral metatarsal arteries was seen in one male body on the left side [Figure 2]. A right-sided limb showed the rare U-shaped loop between 1 and 2 lateral tarsal artery [Figure 3].
|Figure 2: Three lateral tarsal arteries with U shaped loop between 2nd and 3rd Lateral tarsal artery. A – 1st lateral tarsal artery, B – 2nd lateral tarsal artery and C – 3rd lateral tarsal artery|
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|Figure 3: U shaped loop between 1st and 2nd lateral tarsal artery. A – 1st lateral tarsal artery and B – 2nd lateral tarsal artery|
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All results of morphometry of DPA are tabulated in [Table 1], and results of variations in branching pattern are tabulated in [Table 2].
|Table 1: Comparison of observations of the dorsalis pedis artery (cm) with other study|
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|Table 2: Comparison of observation of branching pattern and origin of the dorsalis pedis artery (%) with other studies|
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| Discussion|| |
DPA is of importance for flap transplant surgeries during reconstruction surgeries for conditions such as lacerated wounds in road traffic accidents, venous ulcers due to varicose veins, and burn injuries. The branching pattern of DPA has shown variations in many parts of India and other countries. [Table 1] and [Table 2] show the comparison of our results with earlier studies. We found variations during the meticulous dissection of 50 lower limbs in Pune. The most common variation documented by us was the absent arcuate artery in 12% of limbs. The presence of 3 and 2 lateral tarsal arteries was seen exclusively in male cadavers. A new variation of U-shaped loop between lateral tarsal arteries was found in two cadavers.
Chandani et al. found variations in DPA morphometry in a study at Manipal. The authors reported the average length of DPA as 7.8 cm. Three percentage of limbs showed the absence of arcuate artery by them, while we found 12%. They found the mean distance of DPA from the medial malleolus to be 3.9 and 6 cm from the lateral malleolus. Hence, authors state that DPA is not always at the mid-malleolar point. A comparison of findings of morphometry of DPA is tabulated in [Table 1]. Our study showed findings of 2.86 and 5.72 cm, so we second the view stated by Chandani et al.
As DPA is the largest branch at the ankle, it is most commonly used for pedal revascularisation procedures. In a cadaveric study, Hemamalini and Manjunatha found variations of DPA in 13 out of 40 lower limbs. Rare cases of double DPA and trifurcation of DPA were noted by the authors. Arcuate artery was absent in 7 lower limbs. Our study also showed this finding in 12% of limbs. One lower limb showed tortuous DPA. We also reported this on the right side of a male body. Hemamalini and Manjunatha stated that preoperative angiography for variations in the branching of DPA is indicated before surgical procedures.
In a study with the South African population, Ntuli et al. reported 6.06% of limbs with absent DPA. Authors documented nine variations of the branching pattern of DPA. 36.6% showing that normal branching was the most common presentation for them. They state that pulse of DPA got affected by variations in the course and branching.
Chepte and Ambiye noted 10 types of variations in the DPA course and branching. Absence of arcuate artery was noted in 1.66% compared to 12% in our study. They stated that knowledge of various variations of DPA was useful for managing limb salvation procedures.
Knowledge of variations in DPA branching is of prime importance for vascular surgeons. Barot and Koyani found 2.5% absent DPA and 10% absent arcuate artery in a cadaveric study at Rajkot. In our study we did not report the absence of DPA, but we found 12% limbs with absent arcuate artery. Authors stated that a weak or absent pulse of DPA could be a result of not only vascular disease but also anatomical variations.
Vijayalakshmi et al. stated that to differentiate if the absence of pulse of DPA was seen due to vessel thrombosis or variant anatomy like absence of an artery, the knowledge of variations was very important. In a cadaveric study of 50 lower limbs, authors found 2% of limbs with the absence of DPA. The arcuate artery was absent in 6% limbs, while we found it in 12% of limbs.
Rageshwari et al. found a higher incidence of the absence of arcuate artery (16.67%) and DPA (9.52%) They reported an unique variation of the arcuate artery being replaced by an U-shaped loop. This rare variation was seen in 2.38% of lower limbs. This U-shaped loop was formed by proximal and distal lateral tarsal arteries. Similar findings of rare U-shaped loop formed by joining of 1st and 2nd metatarsal arteries on a right-sided limb and 2nd and 3rd lateral metatarsal artery on a left-sided limb is seen in our study (4%).
Luckrajh et al. carried out a cadaveric study of variations in the branching pattern of DPA in Durban, South Africa. Absent arcuate artery was reported in a higher 32.5% limbs as compared to 12% in our study. They also reported the rare U-shaped loop between lateral tarsal arteries in 5% limbs as reported by us in 4% limbs. They conclude that branching variations decide the fate of the DPA-supplied skin flap.
In a cadaveric study of 44 lower limbs at Pondicherry, Vengadesan et al. found normal morphometry of DPA in 90% of cases. They found variations like DPA replaced by perforating branch of the peroneal artery. A variant where the anterior tibial artery was seen on the lateral side of leg. This artery continued to the lateral malleolus as the DPA. Both these variations were found bilaterally. Authors mention that DPA-based musculo-cutaneous flaps are used for reconstructive surgeries. Therefore, knowledge of any variation of DPA is of prime importance for interventional radiologists and plastic surgeons.
DPA palpation in suspected cases of arterial disorders is a gold standard clinical test. Mamatha et al. found variation in the branching of DPA during routine cadaveric dissection. They describe one case of very short course of DPA before dividing into medial and lateral branches. They also mention the absence of arcuate artery in one lower limb. The author states that prior angiography to confirm any aberration in the morphometry of DPA and its branches was always indicated before micro vascular surgeries of the foot.
| Conclusion|| |
Knowledge of DPA morphometry and variations in branching is of prime importance for reconstruction and revascularisation surgeries. Morphometric variations, asymmetry, and sexual dimorphism of DPA were seen. We found variations like the absence of arcuate artery in 12% and the presence of 2 and 3 lateral tarsal arteries in 16% and 4%. The presence of 3 lateral tarsal arteries was found only on the left side, the absence of arcuate artery were seen more on the right side. Multiple lateral tarsal arteries were found exclusively in male cadavers. The DPA was not seen at midpoint of line joining the malleoli. We found a rare U-shaped loop formed by the joining of lateral tarsal arteries in two limbs. Prior angiography to check for such variations is highly beneficial to surgeons for selecting the skin flap in reconstruction procedures.
Body donation is a very noble act. The authors are highly grateful to the donors and their family members who donated their bodies for cadaveric dissection, thus improving medical education. We sincerely thank those who donated their bodies to science so that anatomical research can be performed. This study will surely help in improving patient care and reducing morbidity and mortality. We offer the highest gratitude and respect to wards these donors and their families.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]