A case of ischemic osteopathy in a hemodialysis patient with advanced peripheral artery disease.

Peripheral artery disease (PAD) or arteriosclerosis obliterans is a lethal complication highly prevalent in pre-dialysis CKD and dialyzed patients. PAD is driven by atherosclerotic process and causes ischemia of the affected limb. Given that normal bone metabolism is based on sufficient blood supply and PAD decreases intraosseous blood flow of the affected limb, it is probable that PAD can directly cause ischemic osteopathy or osteoporosis in affected limbs. We herein present a 69-year-old female patient receiving 18 years of maintenance hemodialysis therapy was hospitalized for the treatment of bilateral PAD. Angiography showed a diffuse stenosis of the right superficial femoral artery and total occlusion of the left superficial femoral artery. Right ankle brachial index (ABI) was 0.83, whereas left ABI was unmeasurable. Notably, T score of the bone mineral density (BMD) in the right calcaneus measured by quantitative ultrasound was - 1.4, while that in the left calcaneus was - 2.2, showing a huge difference between BMD in the bilateral calcaneus. Metal stent was inserted to the right superficial femoral artery, whereas femoropopliteal bypass surgery was performed for the left limb. After the surgery, her right and left ABI were 0.96 and 0.92, respectively. Our case typically showed the clinical significance of sufficient blood supply to the bone for the normal bone metabolism and reminds us of the potential need to conduct further research on the association between PAD and ischemic osteopathy in patients with CKD.

Subtalar Distraction Arthrodesis.

The subtalar joint can be altered in its anatomy and biomechanical behavior. It is important to know how to assess the talar declination angle in order to assess the deformity at the subtalar joint. Consider a straight posterior approach to the subtalar joint and remain liberal in the use of z-shaped Achilles tendon lengthening. A structural bone graft should be used to elevate the talus. Positioning screws should be used to lock the construct.

Anatomy of medial plantar superficial branch artery perforators: Facilitation of medial plantar superficial branch artery perforator (MPAP) flap harvesting and design for finger pulp reconstruction.

BACKGROUND: Medial plantar artery perforator (MPAP) flap was proposed as proper option for finger pulp reconstruction. To provide the previously unavailable vessel information required for this small flap design, this study aimed to gather all necessary anatomy of MPA, MPAP, and their territories of blood supply to apply in clinical MPAP flap reconstruction minimizing perforator injury. METHODS: Dissection of 30 Thai cadaveric feet for visualizing superficial branch of MPA and its perforators (MPAP) using acrylic dye cannulation were performed. Diameter, length, number of branches, course, distributing areas of these vessels, and also their areas of blood supply were recorded in relation to specified landmarks, eg, C-MTH line; medial calcaneal tuberosity to plantar side of the first metatarsal head and S point; emerging point of superficial branch of MPA from deep fasciae into subcutaneous layer. RESULTS: Average diameter of MPA at its origin and total length are 1.63 ± 0.3 and 52.8 ± 16.1 mm, respectively. It provides 1-3 perforators, with an average size and length of 0.36 ± 0.11 and 23.2 ± 5.47 mm, respectively. Its distribution is mostly in the posteromedial quadrant within 50 and 30 mm from the midpoint of C-MTH line and the S point, respectively. The estimated perforator flap area is 2.5 cm × 1.5 cm and 4.5 cm × 2.5 cm for single and double perforators, respectively. CONCLUSIONS: MPAP flap was proved as another ideal option for finger pulp reconstruction. Its limitation is small size of perforators but this can be overcome by using MPA for microsurgical anastomosis instead.

Quantitative and Qualitative Assessment of the Relative Arterial Contributions to the Calcaneus.

BACKGROUND: The purpose of this study was to quantitatively and qualitatively assess relative arterial contributions to the calcaneus. METHOD: Fourteen cadaveric ankle pairs were used. In each specimen, the posterior tibial artery, peroneal artery, and anterior tibial artery were cannulated and used for contrast-enhanced magnetic resonance imaging (MRI) and computed tomography (CT). Quantitative MRI analysis of the pre- and postcontrast MRI scans facilitated assessment of relative arterial contributions. In addition, postcontrast MRIs were used to measure all perfused arterial entry points and scaled to a 3-dimensional calcaneus model. Contrast-enhanced CT imaging was assessed to further delineate the extraosseous arterial course. Two pairs underwent infusion of diluted BaSO4 through a constant-pressure pump using extended infusion duration. RESULTS: Quantitative MRI findings indicated the peroneal artery provided 52.6% of the calcaneal arterial supply, 31.6% from the posterior tibial artery, and 15.8% from the anterior tibial artery. The cortical entry points were found in fairly consistent patterns along calcaneal cortical surfaces. All specimens demonstrated intraosseous anastomoses between lateral and medial entry points at common locations. CONCLUSIONS: The peroneal artery was found to provide the largest calcaneal arterial contribution, followed by the posterior tibial artery and anterior tibial artery. A rich anastomotic arterial network was found supplying the calcaneus. CLINICAL RELEVANCE: This study provides quantitative and qualitative findings of the relative arterial contribution of the calcaneus. This knowledge can help expand our understanding of calcaneal vascularization, demonstrate the vascular impact of calcaneal fracture and surgery, and facilitate future research on the arterial anatomy of the calcaneal soft tissue envelope.

The lateral calcaneal artery as an alternative recipient vessel option for heel and lateral foot reconstruction.

BACKGROUND: Clinical outcomes of consecutive use of the lateral calcaneal artery (LCA) as a recipient vessel for microsurgical reconstruction have not been reported. This study aimed to evaluate the feasibility and safety of the LCA as a recipient vessel for microsurgical foot reconstruction based on anatomical study of CT angiography and clinical results of using this vessel as the recipient. METHODS: Anatomic study was performed using CT angiography of 61 lower extremities (31 patients). The emerging point, course, and diameter of the LCA were evaluated using 3-D reconstructed images. The LCA was used as the recipient artery in 17 consecutive patients with a mean age of 59 years (range: 23-77 years). Thoracodorsal artery perforator flap was used in most cases (16 of 17), and clinical outcomes were evaluated. RESULTS: The LCA emerged 31.1 ± 9.8 mm proximal and 14.7 ± 5.0 mm posterior to the tip of the fibula and traversed 13.9 ± 2.7 mm posterior to the posterior margin of the lateral malleolus. The accompanying vein was used for venous outflow in five patients and the small saphenous vein was used in the remaining cases. Emergent re-operation was performed in one case due to venous thrombosis, and salvage was successful. All flaps except for one with partial flap necrosis completely survived. During a mean follow-up of 13 months, all but one of the patients were able to wear shoes and walk. CONCLUSIONS: The LCA may be safely used as a recipient vessel for microsurgical heel and lateral foot reconstruction. LEVEL OF EVIDENCE: IV.

Anatomic structures at risk: curved hindfoot arthrodesis nail--a cadaveric approach.

Retrograde intramedullary nailing of the hindfoot and ankle is an established procedure for salvage of severe foot and ankle deformity, arthritis, tumor, and instability. In the present study, retrograde hindfoot (tibiotalocalcaneal) arthrodesis nailing was performed using a standardized technique on 7 cadaver specimens by trained senior surgeons. The specimens were then dissected to determine the distance of the subcalcaneal structures at risk from the insertion point of the nail. The findings showed that the distance of the lateral neurovascular bundle from the edge of the nail was 6.5 (range 3.5 to 8, 95% confidence interval 5.9 to 7.1) mm. No neurovascular bundle was compromised, and all were within a previously described "safe window."

Low Wound Complication Rates for the Lateral Extensile Approach for Calcaneal ORIF When the Lateral Calcaneal Artery Is Patent.

BACKGROUND: Historically, the lateral extensile approach for calcaneal fracture osteosynthesis has had relatively high rates of wound healing problems. The vascular territory (angiosome) of the lateral foot is now known to be dependent upon the lateral calcaneal branch of the peroneal artery (LCBP artery). We postulated that patency of the LCBP artery may have a profound positive impact on incisional wound healing for calcaneal open reduction and internal fixation (ORIF). METHODS: Ninety consecutive calcaneal fractures that met operative criteria were preoperatively evaluated for the presence of a Doppler signal in the LCBP artery and were followed for the development of wound healing problems. RESULTS: Among these 90 fractures, 85 had a positive preoperative Doppler signal along the course of the LCBP artery (94%) and 5 had no Doppler signal (6%). All patients underwent ORIF via a lateral extensile approach. Overall, incisional wound healing problems occurred in 6 of 90 calcaneal incisions (6.5%). All 5 feet that exhibited an absent Doppler signal in the LCPB artery developed an incisional wound healing complication (5/6, approximately 83%): 2 large apical wounds and 3 major dehiscence/slough. However, among the 84 feet that possessed a positive preoperative Doppler signal in the LCBP artery, there was only 1 (1/84, approximately 1%) incisional wound healing problem (P < .0001, Fischer's exact test). Smokers with a positive Doppler signal in the LCBP artery did not develop a wound healing complication. CONCLUSIONS: This study suggests a strong link to low incisional wound healing complications for the lateral extensile approach to the calcaneus when a preoperative Doppler signal is present in the LCBP artery. We believe this simple examination should be routinely performed prior to calcaneal ORIF. LEVEL OF EVIDENCE: Level III, comparative case series.

Skin demarcation and amputation level for foot gangrene following meningococcal septicemia.

UNLABELLED: A case report of a 55-year-old woman who was being considered for bilateral below knee or Syme's amputations after gangrene at the level of both forefeet due to meningococcal septicaemia is described. An expectant approach for 6 months revealed that the tissues deep to the necrotic skin were viable and she was subsequently able to mobilize independently with normal footwear after bilateral toe amputations at the metatarsophalangeal joint levels. This case and a literature review suggest that the demarcation of healthy skin from necrotic skin (eschar) should not dictate the level of amputation in dry gangrene of the foot following meningococcal septicemia. Magnetic resonance imaging can overestimate the degree of muscle necrosis. Treatment should be individualized for each patient, but advice should include the option of prolonged conservative treatment to preserve limb length and function. LEVEL OF EVIDENCE: Therapeutic, Level IV: Case study.

[Minor amputations: a maxi task : Part 2: From transmetatarsal amputation to hindfoot amputation]. / Minor-Amputationen - eine "Maxi-Aufgabe" : Teil 2: Von der transmetatarsalen Amputation bis zur Rückfußamputation.

The definitive aim of a minor amputation is limited resection with retention of feet and legs resulting in a completely loadable extremity, in contrast to the lower leg stump. A shift in the amputation level in the sense of a shortening is inevitably accompanied by a reduction in the stand area, an increase in axial pressure and a disruption of muscle equilibrium in the extent of movement of the rest of the foot. This knowledge forms the central issue for further treatment of minor amputations in addition to the subtle treatment of the skin of the sole for coverage of a tension-free tip of the stump. Advantageous are longitudinal partial amputations of the forefoot and midfoot.

A simple method to detect human intraosseous vascular structures: using the calcaneus as an example.

BACKGROUND: Intraosseous vessels play an important role in regeneration of bone. However, the anatomy of the intraosseous vessels in humans has not been clearly delineated due to inadequate method of stereoscopically investigating vessels surrounded by bone tissues. PURPOSE: This study was to investigate the feasibility of simple CT scanning with barium sulphate perfusion to detect intraosseous vessels in humans. METHODS: Two freshly obtained feet from a patient who required a double amputation were used in this study. One foot was perfused with barium sulfate and then scanned by CT (CT method). The other foot was processed using vascular corrosion casting (traditional method). Intraosseous vessels in both specimens were compared. RESULTS: The anatomical distributions of the calcaneal intraosseous vessels were similar as assessed by the CT and traditional methods. However, in comparison to traditional method, the CT method allows the preservation of the surrounding bone tissue, which is important for analyzing the relationship between intraosseous vessels and the surrounding bone structures, and the visualization of a special vascular structure called the sinusoid cluster. CONCLUSION: Simple CT scanning with barium sulfate perfusion may be a practical and adequate method for stereoscopically detecting the morphology and distribution of the intraosseous vessels.

A modified free muscle transfer technique to effectively treat chronic and persistent calcaneal osteomyelitis.

UNLABELLED: Successful management of chronic calcaneal osteomyelitis presents a major challenge for the plastic and reconstructive surgeon, especially in cases involving soft-tissue defects. This article describes a modified free muscle transfer technique to effectively eradicate chronic and persistent calcaneal osteomyelitis. METHODS: Between February 2009 and September 2009, 3 male patients with persistent calcaneal osteomyelitis were treated in our clinic. All 3 had purulent drainage for a minimum of 6 months and a maximum of 23 years. Multiple surgical debridements and vacuum-assisted closure had been used in the past, but the infection remained. We used a therapeutic protocol of repeated and radical surgical debridement with removal of nearly all cancellous bone and preservation of the cortical shell of the calcaneus. After the final debridement, the bone cavity was plugged by a free gracilis muscle flap from the contralateral side. A meshed split thickness skin graft was applied. Culture-specific antibiotics were administered for 2 weeks. RESULTS: All flaps healed uneventfully except for a minor hematoma that was treated conservatively. All 3 patients were able to return to ambulatory status with regular foot apparel. At last follow-up evaluation, they had no clinical, laboratory, or radiologic signs of osteomyelitis. CONCLUSION: This modified free muscle transfer technique seems to be successful in managing chronic and persistent calcaneal osteomyelitis. Infected and healthy cancellous bone of the calcaneus is removed to eradicate all possible foci that maintain inflammation. The resulting bony defect after the aggressive surgical debridement is sufficiently filled with a well-vascularized muscle that ensures a good wound healing. We consider this method to be a promising treatment option, which needs to be supported by further cases.

Assessment of medial and lateral neurovascular structures after percutaneous posterior calcaneal displacement osteotomy: a cadaver study.

A prospective investigation of the effects on the medial and lateral neurovascular structures of the rearfoot after percutaneous posterior calcaneal displacement osteotomy was performed using 20 below the knee fresh frozen cadaver specimens. This anatomic study aimed to examine the medial and lateral neurovascular structures to determine whether they were jeopardized during execution of the osteotomy. After completion of the osteotomy, the medial plantar, lateral plantar, medial calcaneal, sural, and posterior tibial neurovascular structures, along with their respective branches, were inspected for iatrogenic injury. Our findings demonstrated that the percutaneous, subperiosteal osteotomy minimized trauma to the local soft tissue envelope and protected the adjacent neurovascular structures. Because no iatrogenic injury was observed in the cadaveric specimens, we postulated that percutaneous calcaneal displacement osteotomy is a safe, predictable, and advantageous alternative compared with open techniques for osteotomy and could result in reduced postoperative complications. The results of this investigation remain to be confirmed in the clinical setting.

Boyd amputation in adults.

BACKGROUND: Foot ulcerations resulting in amputation are one of the most devastating consequences of diabetes mellitus and peripheral arterial disease. In foot amputations, Boyd amputation has been even less accepted than Syme amputation due to its dependence on calcaneotibial osseous union in adults. METHODS: Fifteen Boyd amputations were performed for 14 adults. The indications for amputation were diabetic ulceration of the foot in eight patients, ischemic disease of the lower extremity in four and salvage of the deformed foot due to peripheral neuropathy in one patient. One patient with scleroderma had bilateral amputations due to digital ischemic necrosis. RESULTS: Complete wound healing was documented in seven feet of six patients. Further revisions to a more proximal amputation level were required in seven patients. CONCLUSION: Despite the high failure rate, we believe Boyd amputation is still a good option in some patients to try to preserve length.

Isolated bone infarct of the calcaneus after fracture.

The calcaneus has a rich vascular supply; therefore, avascular necrosis of the calcaneus is extremely rare. We report the first case of bone infarct of the calcaneus 9 months after a fracture. We also review the literature on osteonecrosis of the calcaneus to offer potential mechanisms for bone infarction in the calcaneus after a fracture.

Modification of the sinus tarsi approach for open reduction and plate fixation of intra-articular calcaneus fractures: the limits of proximal extension based upon the vascular anatomy of the lateral calcaneal artery.

The treatment of displaced calcaneal fractures remains controversial. Early surgical management to restore articular congruence and the structural function of the calcaneus is widely accepted as the best way to avoid the negative consequences of malunion. Concerns remain however regarding the best approach for reducing and maintaining reduction of these complex fractures, while minimizing the risk of surgical complications. The potential for serious wound complications is a major concern, particularly breakdown of the lateral calcaneal skin flap with the extensile lateral approach. Various approaches have been developed to try and balance the need for direct reduction of the articular surface while minimizing the potential for wound complications. Palmer originally described a laterally based approach through the sinus tarsi for direct visualization of the articular surface for reduction. He and others have found this approach to be useful and reasonably safe. At times, however, it may be necessary to extend the limits of a small incision over the sinus tarsi to treat adjacent fractures or to aid reduction in more complex fractures. In addition, a limited sinus tarsi incision without elevation of the lateral calcaneal skin flap does not allow for plate fixation, a notable advantage of the extensile lateral approach, particularly in gaining reduction of the body of the calcaneus. The authors have used an extended sinus tarsi approach to include placement of plate percutaneously beneath the lateral calcaneal skin flap through a sinus tarsi approach, and to treat adjacent fractures and soft tissue injuries. A clinical series of 13 patients (including 7 chronic smokers and 1 with diabetes and vascular disease) with closed displaced intra-articular calcaneal fractures (Sanders types II and III) were treated by open reduction and internal fixation via this approach. Adjacent fractures were treated through the same incision. Two patients developed wound complications. No wound complications occurred in smokers. The vascular anatomy of the lateral calcaneal artery related to this approach was also studied with 16 cadaver legs. The lateral calcaneal artery (LCA) passed within 2 mm of the superior border of floor of the Superior Peroneal Retinaculum (SPR) at the midline of the peroneal sheath. By avoiding dissection through the deep portion of the SPR, the lateral calcaneal artery can be protected, thus preserving the blood supply to the lateral calcaneal skin flap.

Macroscopic and microvascular blood supply of the canine common calcaneal tendon.

Chronic tendinopathy injuries to the canine common calcaneal tendon are relatively common in large breed dogs and typically affect the distal portion of the tendon. In humans, poor blood supply, biomechanical faults, poor training methods and fluoroquinolone administration have all been linked with the development of Achilles tendinopathy. The most common sites for Achilles tendinopathy in humans seem to correspond with areas of poor blood supply within the tendon. The aim of this study was to evaluate the blood supply of the canine common calcaneal (Achilles) tendon to determine if variations occur along the tendon. The null hypothesis was that there would be no difference in the microvascular blood supply at varying points along the tendon. Paired pelvic limbs were collected from 12 large breed dog cadavers. A 50% barium sulphate and 50% saline solution was infused into the femoral artery of one limb from each dog and radiographs were taken to outline the blood supply to the common calcaneal tendon. Indian ink was infused into the contralateral limb. The common calcaneal tendon was removed, fixed and sectioned at 1 cm intervals, from calcaneal insertion to musculotendinous junction. The ink-filled arteries and arterioles in each section were counted. Radiographs revealed fine branches from the caudal saphenous artery entering the mid-body of the tendon along its cranial border. The musculotendinous junction had additional branches from the gastrocnemius muscles. Distally, vessels radiated proximally from the calcaneus 2 to 3 cm into the tendon. Mean total vessel counts at the insertion (138.54 +/- SD 31.06) were significantly higher than all other sections (p <0.001). The mid-body had significantly lower total vessel counts. When the cross sectional area of the tendon was taken into account, only the insertion had a significantly higher mean vessel count/cm2 than the mid-body of the tendon. There were no other significant differences in mean vessel count/cm2. Areas of poorer blood supply did not correspond with the most commonly reported site for chronic common calcanean tendinopathies, suggesting that inherent poor blood supply at the site of injury may not play a role in the pathogenesis. Atraumatic handling and minimal manipulation should be used during the surgical approach and debridement to preserve the remaining blood supply in ruptured tendons.

Lateral calcaneal artery as a recipient pedicle for microsurgical foot reconstruction.

In the microsurgical reconstruction of the foot, anterior tibial artery-dorsalis pedis artery and posterior tibial artery-plantar artery are mainly used as recipient arterial pedicles. These arteries are the main sources for foot circulation and the preservation of these arterial circulations is very important. Although the end-to-side technique or the flow-through technique is selected for the microsurgical anastomosis, the possibility of injury to the circulation of these main arteries exists. We showed the availability of this artery with an angiographic injection study in five fresh cadavers as a reliable recipient artery. We also used the lateral calcaneal artery as a recipient pedicle in foot reconstruction without sacrificing the main circulation in two clinical cases. The diameters at the level of the calcaneus were 1.3 mm and 1.5 mm, respectively.

The lateral calcaneal artery: Anatomic basis for planning safe surgical approaches.

The proximity of the lateral calcaneal artery (LCA) to surgical incisions applied to the lateral hindfoot makes it vulnerable to iatrogenic injury and subsequent postoperative skin necrosis. This study aimed to investigate the course of the LCA and to define anatomical points that can be used by surgeons during lateral approaches to the calcaneus. Thirteen leg-ankle-foot specimens were dissected and the superficial course of the LCA was outlined by three anatomic points: (a) tip of lateral malleolus, (b) the point where it pierces the deep fascia, and (c) the point where it crosses the line connecting the lateral malleolus with the insertion of Achilles tendon. Fifteen healthy volunteers were investigated by color Doppler ultrasound where the diameter and depth of LCA were measured. The LCA pierced the deep fascia at a maximum height of 4.5 cm (mean 3.78) above the midpoint of a line extending from the lateral malleolus to the insertion of Achilles tendon. It crossed the previous line at a maximum distance of 3 cm (mean 2.6) posterior to lateral malleolus. At this point, its mean diameter was 1.75 mm on the right and 1.73 mm on the left sides, while its mean depth was 7.73 mm on the right and 8.0 mm on the left sides. A dangerous triangle that contained the superficial course of the artery was mapped out in the lower lateral part of the leg. This triangle should be considered during surgical approaches applied to the lateral hindfoot to avoid damage of the LCA.

Long-term results of lateral calcaneal artery flap for hindfoot reconstruction.

The purpose of the present study was to analyze our long-term results of lateral calcaneal artery flap transfer for hindfoot reconstruction. A total of four patients (average age, 48 years) underwent lateral calcaneal artery flap transfer. The etiologies were heat injury of the lateral malleolus in one patient and skin necrosis over the Achilles tendon attachment site in three patients due to displaced calcaneal fracture, pyogenic tendinitis of the Achilles tendon, and vascular insufficiency of the wound after Achilles tendon surgery in a patient with Werner syndrome, respectively. The defect sizes ranged from 2 x 2 cm to 4 x 4 cm, and all of the patients had bone or tendon exposure. All of the flaps survived completely without any problems. The donor sites were closed by full-thickness skin grafts. Postoperative complications included delayed wound healing in one patient and transient restriction of ankle motion in another patient. No painful neuroma of the sural nerve was recorded. No recurrence of ulcers at the shoe-contacting area of the flaps was noted. Therefore, lateral calcaneal artery flap transfer is useful for reconstruction of skin and soft tissue defects with bone or tendon exposure over the calcaneus or lateral malleolus.