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The medial plantar artery flap (MPAF) presents both unique value as well as significant challenges. As the plantar foot has specific anatomy, the use of the MPAF to recreate this highly specialized area may provide improvements in durability and rates of limb salvage. The purpose of this study is to establish the anatomic course of the branching patterns of the medial plantar artery (MPA) and provide a foundation for MPA flap nomenclature as it is related to design and elevation. Thirty-seven fresh frozen cadaver feet were used for dissection: 20 right and 17 left sided limbs. Anatomic measurements recorded included: branching pattern of the MPA, bifurcation distance of the superficial branch (SB) and deep branch (DB) from the origin of the MPA, distance from the MPA origin to the anterior colliculus of the medial malleolus, and the distance from the SB and the DB to the navicular tuberosity. The MPA was found to bifurcate into SB and DB in 30 (81%) specimens; 6 (16%) specimens had only a SB, whereas 1 (3%) specimen had only a DB, which had not been previously described. The distance from the anterior colliculus to the MPA was 3.0 cm, MPA to the distal bifurcation was 2.9 cm, and navicular tuberosity to the SB and DB was 2.2 cm and 1.3 cm, respectively. Minimizing the complexity of the dissection with the use of more reliable landmarks and a deeper understanding of the anatomy may reduce complications and allow for more reproducible outcomes when utilizing the MPAF., (Copyright © 2024 the American College of Foot and Ankle Surgeons. All rights reserved.)

Medial plantar artery-based flaps have great value in healing full-thickness wounds of the foot and ankle. The goal of this study was to identify a common location for the origin of the medial plantar artery. Recognition of this anatomic marker will help improve incision placement and increase the success of preserving the artery when performing the medial plantar artery fasciocutaneous flap. This study examined the location of the origin of the medial plantar artery in 40 fresh cadavers. Results were obtained by dissection and macroscopic analysis to document the distance of the origin of the medial plantar artery from the intercollicular groove of the medial malleolus in centimeters. The mean distance was determined to be 3.2 ± 0.4 cm (range 2.7 to 4.5), with a low standard error of 0.0621. This suggests a high statistical probability that the common origin of the medial plantar artery is found 3.2 cm distal to the intercollicular groove of the medial malleolus in the general population., (Published by Elsevier Inc.)

The angiosome concept of foot perfusion was conceived based on anatomical studies of arterial circulation and used for planning surgical procedures, tissue reconstruction, and amputation. Its application is relevant in diabetic patients with critical limb ischemia and nonhealing foot ulcer or amputation. An understanding of foot angiosome anatomy is useful for predicting healing and planning arterial revascularization. A review of the literature, including the most recent systematic reviews and meta-analyses, indicates improved wound healing is achieved when the angiosome concept is followed. The greatest value of angiosome-based revascularization is in patients with lesion(s) limited to a single angiosome, or to achieve optimal healing of amputation sites. Future research should focus on proper identification of (imaging) modalities to determine the hemodynamic and functional changes before and after revascularization, thus identifying the "real" angiosome and directing optimal therapy., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

The history of the recognition and surgical treatment of lower limb ischemia dates back to the Middle Ages. The twin Saints Comas and Damian were ascribed to have saved a gangrenous limb in the 13 th century and became patrons of future surgeons. The physicians that followed developed the theories of blood flow, anatomy of the arterial circulation, and recognition that occlusive disease was the cause of limb ischemia and gangrene. Innovative physicians developed the techniques of arterial surgery and bypass grafting to restore limb blood flow and allow healing of lesions. In the 1960s, the era of endovascular intervention by the pioneering work of Charles Dotter, who developed techniques to image diseased arteries during a recanalization procedure. The development of guide wires, angioplasty balloons, and stents quickly followed. Management of lower limb ischemia and the diabetic foot will continue to evolve, building on the history and passion of preceding physicians and surgeons., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The pathophysiology of the diabetic foot ulcer and soft-tissue infection is due to neuropathy, trauma, and, in many patients, concomitant peripheral artery occlusive disease. Diabetic neuropathy results in foot deformity, leading to increased skin pressure with walking. Once a foot ulcer develops, the limb is at high risk for invasive infection and, when combined with peripheral artery occlusive disease, the patient should be considered to have critical limb ischemia. A multidisciplinary approach to care for the diabetic foot is recommended, which includes annual (3-month intervals in high-risk patients) assessments by a primary care physician and referral to a podiatrist and vascular surgeon for diabetics with a foot ulcer for evaluation of foot arterial perfusion and off-loading therapy to reduce plantar skin pressure with walking. When invasive foot infection develops and tissue beneath the fascia is involved, inpatient care is recommended for systemic antibiotic therapy, vascular laboratory testing of artery limb perfusion, and surgical debridement of infected tissue. The goals of treatment are to achieve a healed foot and keep the patient ambulatory., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Traditional incision techniques for midfoot amputation might not provide immediate soft tissue coverage of the underlying metatarsal and tarsal bones in the presence of a large plantar soft tissue defect. Patients undergoing transmetatarsal and Lisfranc amputation frequently have compromised plantar tissue in association with neuropathic ulcers, forefoot gangrene, and infection, necessitating wide resection as a part of the amputation procedure. Open amputation will routinely be performed under these circumstances, although secondary healing could be compromised owing to residual bone exposure. Alternatively, the surgeon might elect to perform a more proximal lower extremity amputation, which will allow better soft tissue coverage but compromises function of the lower extremity. A third option for this challenging situation is to modify the plantar flap incision design to incorporate a medial or lateral plantar artery angiosome-based rotational flap, which will provide immediate coverage of the forefoot and midfoot soft tissue defects without excessive shortening of the bone structure. A plantar medial soft tissue defect is treated with the lateral plantar artery angiosome flap, and a plantar lateral defect is treated with the medial plantar artery angiosome flap. Medial and lateral flaps can be combined to cover a central plantar wound defect. Incorporating large rotational flaps requires knowledge of the applicable angiosome anatomy and specific modifications to incision planning and dissection techniques to ensure adequate soft tissue coverage and preservation of the blood supply to the flap. A series of 4 cases with an average follow-up duration of 5.75 years is presented to demonstrate our patient selection criteria, flap design principles, dissection pearls, and surgical staging protocol., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Calcaneal osteotomies are used to correct hindfoot alignment. Traditional open procedures have been plagued with complications. Various minimally invasive techniques have been described but are laborious and time-consuming. A percutaneous technique using a side cutting "Shannon" burr offers a simple and reliable alternative; however, little evidence is available to address the safety concerns. The aim of the present study was to quantify the risk posed to the medial and lateral neurovascular structures using this technique. The study was performed at the anatomy department, University of Sussex, using 13 fresh-frozen, below-the-knee cadaveric specimens during a training session held by WG Healthcare UK, Ltd. (Letchworth, Herts). The participants were 11 consultant orthopedic surgeons, who were inexperienced in minimally invasive surgery, and 2 demonstrators. Each performed a chevron calcaneal osteotomy using a Shannon burr by way of a lateral percutaneous approach under fluoroscopic guidance. The authors subsequently dissected the specimens to identify the neurovascular structures, describe their anatomic relations and proximity to the burr, and note any damage incurred. No evidence was found of significant neurovascular injury. Two very small proximal branches of the sural nerve were transected, the nerve itself passing safely 9 to 21 mm anterosuperior to the entry point. The medial neurovascular bundle crossed the path of the osteotomy in 4 specimens but was protected by the medial head of the quadratus plantae muscle. In conclusion, the Shannon burr for calcaneal osteotomy has the potential to minimize the surgical morbidity and maximize surgical efficiency without compromising safety in all patients with normal anatomy of the quadratus plantae muscle., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

When undertaking surgical maneuvers about the midfoot, caution must be used to avoid injury to the dorsalis pedis artery, which courses along the dorsum of the foot on the dorsolateral aspect of the tarsal navicular. In an effort to better understand the relationship of the course of the dorsalis pedis artery relative to the tarsal navicular, 128 embalmed feet (31 [48.4%] female and 33 [51.6%] male cadavers aged 15 to 91 years) were measured. The dorsalis pedis artery was dissected from its origin to its termination (i.e., the first dorsal metatarsal artery and the deep plantar perforating artery), and the distance from the medial cortex of the navicular tuberosity to the medial margin of the artery and the location of the artery as a percentage of the medial-to-lateral width of the navicular were measured. In the male cadaver specimens, the distance from the navicular tuberosity to the dorsalis pedis was 23.75 ± 3.1 mm, the width of the navicular was 37.41 ± 5.0 mm, and the location of the artery as a percentage of the width of the navicular was 64.34% ± 13.1%. In the female cadaver specimens, the distance from the navicular tuberosity to the dorsalis pedis was 22.81 ± 5.5 mm, the width of the navicular was 36.11 ± 4.0 mm, and the location of the artery as a percentage of the width of the navicular was 63.29% ± 9.9%. For the right foot specimens, the distance from the navicular tuberosity to the dorsalis pedis artery was 20.29 ± 3.3 mm, and the width of the navicular was 37.21 ± 4.4 mm. For the left foot specimens, the distance from the navicular tuberosity to the dorsalis pedis was 21.40 ± 2.5 mm, and the width of the navicular was 35.92 ± 4.4 mm. The statistical comparisons between the males and females showed no statistically significant differences. In contrast, those between the right and left feet showed significant differences in the distance from the navicular tuberosity to the dorsalis pedis artery and the location of the dorsalis pedis artery as a percentage of the width of the navicular. Knowledge of these distances and the location of the dorsalis pedis artery relative to the width of the tarsal navicular should aid surgeons in preparation for, and during, dissection of the midfoot., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Although discussed as an alternative to triple arthrodesis for hindfoot correction, the published data surrounding the medial double arthrodesis, or fusion of the subtalar and talonavicular joints, has not addressed the proximity of the anatomic structures at risk. A total of 10 cadaver specimens were used to examine the risk of damage to the neurovascular and tendinous structures of the posterior medial hindfoot when performing the medial double arthrodesis. The distance of the reviewed structures was measured in relation to the standardized point of the middle facet of the calcaneus (mean ± standard deviation and range). The proximity of the middle facet to the posterior tibial tendon was 1.88 ± 2.65 (range 0 to 6.65) mm, to the flexor digitorum longus tendon was 5.34 ± 4.79 (range -3.14 to 12.79) mm, to the flexor hallucis longus tendon was 19.08 ± 4.84 (range 13.04 to 27.31) mm, and to the neurovascular bundle was 21.19 ± 7.84 (range 8.36 to 34.26) mm. At the level of the middle facet, the posterior tibial tendon was the largest tendon, measuring 7.14 ± 2.21 (range 3.31 to 10.23) mm by 2.95 ± 0.88 mm (range 1.86 to 4.24 mm; area 22.37 ± 12.23 mm(2), range 6.16 to 43.38 mm) followed by the flexor digitorum longus tendon at 4.25 ± 1.25 (range 1.74 to 5.95) mm by 2.25 ± 0.96 mm (range 1.41 to 4.79 mm; area 8.88 ± 2.62 mm(2), range 6.12 to 14.52 mm) and flexor hallucis longus tendon at 5.75 ± 2.05 (range 2.27 to 8.91) mm by 2.75 ± 0.82 mm (range 1.35 to 4.13 mm; area 16.81 ± 10.05 mm(2), range 4.81 to 36.80 mm). During dissection for the medial double arthrodesis, one can encounter critical anatomic structures, including artery, vein, nerve, and tendon. Our cadaveric investigation found a mean safe distance of more than 2 cm between the middle facet of the talocalcaneal articulation and the inferiorly located neurovascular bundle using the medial double arthrodesis approach., (Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

A paucity of published studies and clinical recommendations are available regarding ankle fracture and its association with vascular injury, likely because of the lower incidence relative to the more commonly seen popliteal artery injury after knee dislocation. In the present case report, we describe a previously healthy patient who experienced a pilon type ankle fracture (AO 43C2) with fibular and syndesmotic involvement, followed by a subacute presentation of vascular ischemia weeks after the initial injury and repair, ultimately leading to a major amputation. The failure to identify an occult, vascular injury can have devastating consequences. Guidelines regarding the identification and management of displaced ankle fracture-associated vascular injury, drawing evidence from other traumatic injury complexes, could improve the clinical outcomes. We aim to raise awareness of the association of vascular embarrassment secondary to ankle fracture by proposing a clinical practice algorithm to aid clinicians in recognizing traumatic vascular injury at the earliest and most treatable stage., (Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Significant progress in limb salvage for patients with peripheral arterial disease and critical limb ischemia has occurred in the past 2 decades. Improved patient outcomes have resulted from increased knowledge and understanding of the disease processes, as well as efforts to improve revascularization techniques and enhance patient care after open and endovascular procedures. An imaging modality that is noninvasive, fast, and safe would be a useful tool for clinicians in assessing lower-extremity perfusion when planning interventions. Among the current and emerging regional perfusion imaging modalities are transcutaneous oxygen monitoring, hyperspectral imaging, indocyanine green dye-based fluorescent angiography, nuclear diagnostic imaging, and laser Doppler. These tests endeavor to delineate regional foot perfusion to guide directed revascularization therapy in patients with critical limb ischemia and foot ulceration., (Copyright © 2014 Elsevier Inc. All rights reserved.)

For generations, the use of techniques to defer skin pressure and protect the lower-extremity wound has been a cardinal goal to achieve therapeutic success and healing. Choosing the appropriate postoperative offloading device or shoe is often difficult, as it is challenging to merge optimal mechanical protection with clinical realities and patient needs. The gold standard for offloading remains the total contact cast, yet it receives minimal utilization in the clinical setting. Other devices have shown benefit, including the removable cast walker, instant total contact cast, and depth inlay shoes, for preventative measures. Ultimately, any plantar, lower-extremity wound must receive some form of external pressure reduction to reach acceptable rates of healing. Future technologies will aid these measures by providing body-worn constant monitoring systems and more effective offloading via patient-specific exoskeletons. This review is a supplemental update on the available wound offloading modalities based on logic-driven research regarding pressure relief across the diabetic neuropathic or impaired perfusion foot., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The diagnosis of critical limb ischemia, first defined in 1982, was intended to delineate a patient cohort with a threatened limb and at risk for amputation due to severe peripheral arterial disease. The influence of diabetes and its associated neuropathy on the pathogenesis-threatened limb was an excluded comorbidity, despite its known contribution to amputation risk. The Fontaine and Rutherford classifications of limb ischemia severity have also been used to predict amputation risk and the likelihood of tissue healing. The dramatic increase in the prevalence of diabetes mellitus and the expanding techniques of arterial revascularization has prompted modification of peripheral arterial disease classification schemes to improve outcomes analysis for patients with threatened limbs. The diabetic patient with foot ulceration and infection is at risk for limb loss, with abnormal arterial perfusion as only one determinant of outcome. The wound extent and severity of infection also impact the likelihood of limb loss. To better predict amputation risk, the Society for Vascular Surgery Lower Extremity Guidelines Committee developed a classification of the threatened lower extremity that reflects these important clinical considerations. Risk stratification is based on three major factors that impact amputation risk and clinical management: wound, ischemia, and foot infection. This classification scheme is relevant to the patient with critical limb ischemia because many are also diabetic. Implementation of the wound, ischemia, and foot infection classification system in critical limb ischemia patients is recommended and should assist the clinician in more meaningful analysis of outcomes for various forms of wound and arterial revascularizations procedures required in this challenging, patient population., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Magnetic resonance imaging (MRI) has been recognized as the most accurate imaging modality for the detection of diabetic foot osteomyelitis. However, how accurately MRI displays the extent of diabetic foot osteomyelitis in the presence of ischemia is still unclear. We retrospectively compared the preoperative MRI findings with the results of histopathologic examinations of resected bones and studied the efficacy of MRI in the diagnosis of diabetic foot osteomyelitis of different etiologies. A total 104 bones from 18 foot ulcers in 16 diabetic patients (10 men and 6 women; age range 42 to 84 years) treated by surgical intervention from 2008 to 2012 was examined. In 8 neuropathic ulcers, 29 bones were accurately diagnosed in detail using MRI, even those with severe soft tissue infection. Of 75 bones in 10 ischemic ulcers, only 7 bones evaluated by MRI after revascularization were diagnosed accurately; the other 68 could not be diagnosed because of unclear or equivocal MRI findings. On histopathologic examination, all the bones were found to be infected through the bone cortex by the surrounding infected soft tissue, not directly by articulation. Overall, preoperative MRI is effective in the diagnosis of neuropathic ulcers, but less so of ischemic ones., (Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Coverage of the weightbearing heel poses a unique technical challenge to the reconstructive surgeon. In the present study, we share our clinical experience with the use of the medial plantar artery-based flap for coverage of tissue defects around the heel. Eighteen medial plantar artery flaps performed from January 1996 to December 2009 were included. All the procedures were performed by 2 surgeons at Aga Khan University and Hospital (Karachi, Pakistan) and Bahawal Victoria Hospital (Bahawalpur, Pakistan). Of the 18 patients, 16 were male and 2 were female. The indications were traumatic loss of the heel pad in 13, pressure sores in 2, and unstable plantar scars in 3. All the flaps were raised as sensate fasciocutaneous pedicled flaps based on the medial plantar artery. All the flaps healed uneventfully without major complications. The donor site was covered with a split-thickness skin graft, and we had partial graft loss in 1 case. The sensate flaps had slightly inferior protective sensation compared with the normal side. From our results, we suggest that the medial plantar artery flap is a good addition to the existing armamentarium. It provides tissue to the plantar skin with a similar texture and an intact protective sensation. The technique is easier to master compared with free microvascular flaps and has less risk of any functional donor site morbidity., (Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Successful foot and ankle reconstructions require a detailed knowledge of vascular anatomy. This knowledge becomes all the more important in diabetic patients because of healing complications and high incidence of peripheral vascular disease; it allows foot and ankle surgeons to design safe exposures and vascular surgeons to choose effective revascularization strategies. The angiosome concept separates the body into distinct threedimensional blocks of tissue fed by source arteries. This article focuses on the surgical implications of angiosomes of the foot and ankle and their arterial-arterial connections., (2010 Elsevier Inc. All rights reserved.)

The battlefield has provided a multitude of advancements in the management of hemorrhage and vascular repair. Basic understanding of the anatomy and exposures of lower extremity injuries is essential to any surgeon caring for these patients. The techniques of repair and potential adjunctive measures (eg, shunts) available should always be considered when approaching a vascular injury. The most important concept from a vascular standpoint is the fact that a multidisciplinary approach to these complex patients is required with maximal tissue preservation when feasible and safe., (Published by Elsevier Inc.)

A thorough preoperative vascular evaluation should be performed before the initiation of any lower extremity surgical intervention, but particularly in situations of diabetic foot reconstruction with compromised blood flow. The intended emphasis of this brief report is to provide the foot and ankle surgeon with an appreciation for the clinical vascular anatomy of the transmetatarsal amputation through a handheld Doppler examination., (Copyright 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

This report describes the results of 17 metatarsal ray resections performed through a minimal incision in 13 consecutive patients. Each patient underwent minimum-incision metatarsal ray resection for either definitive treatment or as the index incision and drainage procedure followed by transmetatarsal amputation. There were 10 male and 3 female patients with a mean age of 68.8 +/- 8.5 years (range, 59-83 years). Twelve patients had diabetes mellitus and 7 had critical limb ischemia. There were 11 right feet and 6 left feet involved, and 3 second, 3 third, 3 fourth, and 8 fifth minimum-incision metatarsal ray resections performed. Direct primary-incision closure was performed 7 times (1 with adjacent percutaneous metatarsal osteotomy), delayed primary closure was performed 4 times (1 with external fixation), and conversion to a transmetatarsal amputation was performed 2 times. Fourteen of 17 minimum-incision metatarsal ray resections were deemed successful. Two failures occurred when skin necrosis developed from excessive tension along the incision line requiring conversion to a transmetatarsal amputation, and the other occurred in a patient with unreconstructed critical limb ischemia who underwent multiple repeated incision and drainage procedures and vascular bypass with ultimate healing via secondary intent. When properly performed in patients with adequate vascular inflow, minimum-incision metatarsal ray resection as the definitive procedure or in conjunction with an incision and drainage for unsalvageable toe infection or gangrene represents a safe, simple, useful technique., (Copyright 2010 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Management of the septic foot is a challenge in diabetic patients, and this condition often progresses to amputation in an effort to alleviate otherwise incurable infection. We designed and followed a protocol for the management of the septic diabetic foot and, after 2 years (May 2004 through June 2006), we analyzed the data related to 31 septic feet of 139 patients. The treatment protocol consisted of blood glucose control, intravenous antibiotic therapy, controlling comorbidities, revascularization, ulcer drainage and irrigation, systematic debridement, dressing changes and wound care, and amputation if necessary. The outcomes of interest were amputation and limb salvage. The analyses showed that frequent drainage and debridement, along with revascularization when indicated and possible, resulted in 4 (12.9%) major (below-the-knee) amputations and 3 transmetatarsal amputations. Of the 7 amputations, 3 were associated with ischemia, 4 with neuropathy, and 1 with neuropathy and ischemia. In follow-up, 1 patient with a prior history of septic diabetic foot required major amputation. Based on these findings, it is concluded that the septic diabetic foot is not necessarily an indication for amputation, and aggressive management by means of metabolic and surgical care can lead to a favorable outcome., Level of Clinical Evidence: 2.

Lower extremity complications are common in patients with diabetes and include neuropathy, ulceration, infection, and peripheral arterial disease. Foot infections represent the single most common cause of hospitalization and lower extremity amputation in persons with diabetes. Foot ulceration as a result of diabetic peripheral sensory neuropathy, rigid osseous deformities and soft-tissue contractures, repetitive trauma from unprotected ambulation, and peripheral vascular disease can all lead to a limb- or life-threatening infection. Antibiotic therapy for diabetic soft-tissue and osseous infections is usually inadequate as an isolated form of therapy. The mainstay of treatment involves well-planned surgical procedures, including extensive and properly placed incisions to perform adequate drainage of abscesses and débridement of necrotic soft-tissue and osseous structures from which deep cultures are obtained for specific antibiotic coverage. Initial antibiotic therapy should provide broad-spectrum coverage, and when final culture results are available the regimen should be revised to organism-specific coverage. Detailed and timely evaluation of the vascularity of the limb is paramount, followed by timely vascular reconstruction involving various endovascular and open surgical procedures to restore pulsatile flow to the full extent of the limb.

Arteriovenous malformation of the foot is very uncommon, and surgical closure after its treatment with embolization and total excision may be challenging for the foot surgeon, particularly in distally localized lesions. A popular method to cover these difficult wounds is free-tissue transfer, which is a highly demanding procedure. Alternatively, distally based regional flaps have been occasionally reported for clinical use in such distant foot defects. Herein, we present a 36-year-old female patient with a diagnosis of arteriovenous malformation arising in the distal medial plantar and dorsal surfaces of the right foot. After surgical resection of the vascular lesion preceded by a misapplied embolization procedure, an extended lateral supramalleolar flap was successfully transferred to the defect area, covering it completely. Functional and aesthetic outcome was satisfactory after 6 months follow-up. Extended lateral supramalleolar flap is a useful and reliable choice for distal foot reconstructions.

The senior author (N.P.G.) observed that if the foot became dependent in the first 48 hours after foot surgery, the patient had swelling and pain. This effect seemed less after about 48 hours. The authors set out to see if there was a scientific basis for this. Laser Doppler was used to assess blood flow in 14 patients. Flow was recorded in the big toe, at heart level, and on dependency, preoperatively and postoperatively. Postural vasoconstriction was calculated, and time for blood flow to normalize was recorded. Mean postural vasoconstriction preoperatively was 51.31%; postoperative mean at 24 hours was 23.05%, at 48 hours 36.62%, and at 72 hours 44.24%. There was a difference between the preoperative levels and the 24-, 48-, and 72-hour postoperative levels (P < .05). Results showed that it takes longer than 72 hours rather than 48 hours for microcirculation to return to normal. The results emphasized the importance of postoperative foot elevation for at least 48 hours because of this phenomenon.

Soft tissue defects in patients with chronic comorbidities place these patients at high risk for amputation, even when their underlying problems are controlled. The reverse sural artery flap is an effective technique for closing these defects and saving the limb. We retrospectively reviewed 15 consecutive high-risk patients who underwent a sural artery flap procedure between 2003 and 2005 as a final attempt to prevent having a below-the-knee amputation. All of our patients presented with at least 1 comorbidity, with a majority having multiple. Comorbidities in our patient population consisted primarily of diabetes mellitus with neuropathy, critical limb ischemia, end-stage renal disease, and various cardiomyopathies. All patients presented before surgical intervention with a longstanding history of chronic ulcerations that had failed multiple healing strategies. Ulcerations were located at various regions of the foot and ankle such as the heel, lateral malleolus, medial malleolus, and the lateral midfoot. Of those 15 procedures, three failed completely and two had complete dermal necrosis with viable adipose tissue that healed secondarily. The remaining ten flaps healed primarily. We used negative pressure therapy preoperatively in seven patients and postoperatively in five patients. We obtained a success rate of 80%. The reverse sural artery flap has many advantages over free flaps, which has made it a viable treatment option in chronic ulcerations that have failed conservative attempts.

Acute compartment syndrome is most commonly caused by trauma. Although it has been well described in adults, few have addressed this condition in the pediatric patient. The most common causes of acute compartment syndrome of the foot in children are crush syndromes with or without fractures. We present the case of an 8-year-old girl who had a congenital hemangioma on the second toe of her right foot, with persistent pain and swelling of her right lower extremity. On exploration, the limb was cold and swollen, and pulses were timidly palpable. She was admitted with a working diagnosis of cavernous hemangioma with a hematoma that affected the blood flow of the foot. After measuring the compartment pressures, acute compartment syndrome of the right foot was diagnosed and fasciotomy was performed. The current medical literature was reviewed for acute compartment syndromes secondary to hemangiomas. It appears that this could be a new complication of hemangiomas located in limbs with severe consequences if not detected in time.

It is not clear how soon after bypass surgery tissue perfusion in the ischemic foot is adequate for healing. The purpose of this study was to determine the time interval for tissue to receive adequate oxygenation for healing following limb revascularization. Eleven patients with severe foot ischemia as defined by a transcutaneous oxygen tension (TcPO2) of 30 mm Hg or less were included in the study. TcPO2 measurements were performed prior to the lower extremity bypass and at postoperative day 1, 2, and 3. The mean preoperative value (9.27 mm Hg) was compared with the mean value at postoperative day 1 (17.73 mm Hg), postoperative day 2 (20.36 mm Hg), and postoperative day 3 (36.82 mm Hg) using paired samples t-tests. Statistically significant differences were observed between the mean preoperative TcPO2 measurement and the mean TcPO2 measurement taken on the 3rd postoperative day. The mean TcPO2 level increased from 9.27 mm Hg preoperatively to 36.82 mm Hg by the 3rd postoperative day (p = .001). There was also a statistically significant difference between the mean values on the 2nd (20.36 mm Hg) and 3rd postoperative day (36.82 mm Hg) (p = .002). Despite this finding, 5 of the 11 patients still had individual TcPO2 readings of less than 30 mm Hg on the 3rd postoperative day. Therefore, it can be concluded that in most instances tissue oxygenation reaches an adequate level after waiting at least 3 days following a bypass. Waiting 3 or more days could give adequate time for tissue reperfusion to promote healing of the surgical site.

The study investigated whether the effects of dermal replacement therapy on wound healing are associated with an increase in blood flow at the base of diabetic foot ulcers treated with Dermagraft. Seven full-thickness ulcers were assessed in five patients with type 2 diabetes mellitus and peripheral neuropathy. All lesions had been present for at least 3 months with no recent change in size, despite routine foot care and protective dressings. Dermal replacement therapy was applied weekly to the base of each wound for 8 weeks, after which regular dressing was resumed. Microvascular blood flow was assessed using laser Doppler imaging immediately before and after 2, 5, and 8 weeks of treatment. Blood flow increased by an average of 72% in the base of five out of the seven ulcers studied. Five of the lesions healed by 12 weeks and the other two reduced in size by approximately 25%. The changes in blood flow observed in this pilot study might reflect angiogenesis in the newly formed granulation tissue and/or vasodilatation of existing vessels, processes that are possibly enhanced by the intervention.

Knowing the arterial anatomy of the foot and ankle in addition to understanding the angiosome concept provides the basis for careful and safe planning of incisions. The Doppler allows the surgeon to map out the actual vascular anatomy that exists preoperatively and therefore allows for appropriate adjustment to the planned incisions. If the vascular flow is inadequate for the planned surgery, then the vascular surgeon has to intervene to improve the existing blood flow. If the vascular tree is so compromised that successful revascularization of the affected angiosome is impossible, then the revascularization is likely to fail. Serious consideration to a below-knee amputation should then enter the decision tree at that time. Most of the time, however, the blood flow is adequate or can be sufficiently augmented with vascular surgery. The foot and ankle surgeon can then perform preoperative mapping of the arterial blood supply with the Doppler. By making the necessary adjustments to the planned incision, surgery can proceed safely with uneventful healing.

Vascular problems in the foot are certainly common when one considers only arteriosclerosis on the macrovascular scale. The primary cause of ischemia of the foot undoubtedly is primary arteriosclerosis, whether related to smoking, diabetes, renal failure, or other causes. Vasculitis and vasospasm, in their many forms, are distinctly unusual as a cause of ischemia of the foot. These entities, nonetheless, can cause significant problems from the standpoint of symptoms and even ulceration or gangrene of the foot. This article addresses the pathophysiology of vasculitis and vasospastic problems in the foot and their management.

Soft tissue resurfacing after the ravages of injury or disease continues to be a formidable problem. A thorough understanding of the biomechanics of ambulation and the way in which weight is distributed over the sole of the foot is key to successful outcomes. Soft tissue repair has evolved from the simple filling of holes to a much more sophisticated approach. A plantar-grade foot that distributes the patient's weight in a uniform manner should be the goal. If this can be done without increasing the energy expenditure of ambulation, then surgeons certainly have done our patients an excellent service. Surgeons must not overlook the tendon imbalances and bony deformities that can accompany the effects of disease or trauma. The more complex soft tissue repair may not always be in the patient's best interests. Surgeons should use the simplest approach that can restore the limb to as close to its preinjury level of function as possible. A coordinated approach with plastic surgery, orthopedic surgery, vascular surgery, and podiatric surgery should be the standard of care for patients requiring plantar soft tissue repair.

Aggressive evaluation and treatment of the patient suffering from lower-extremity ischemia is critical. Vascular reconstruction can be performed to enhance healing and to decrease the incidence of major limb amputation and therefore return these patients to active and productive life.

A 5-MHz Doppler probe was utilized to identify the perforating septofasciocutaneous vessels on the plantar aspect of the right and left feet of 10 healthy subjects. Each audible perforator was marked, and each foot was photographed, scanned into a personal computer, and standardized to 8 inches high by 4 inches wide. All 20 feet were then stacked together to create a composite average of all markings. Loupe aided (2.5 x magnification) dissection of a latex cast of the perforating septofasciocutaneous vessels from a fresh frozen cadaveric foot revealed similar location and distribution as the composite average described above. The Doppler probe is capable of accurately identifying the septofasciocutaneous perforating vessels, thereby, creating a vascular map of the plantar aspect of the foot useful for precise planning of advancement flap coverage for full thickness defects. Two representative case examples are presented.

This study investigates several physiological measurements for their correlation to the minimal arterial occlusion pressure using the pneumatic ankle tourniquet. Blood pressure (brachial), height, weight, body fat percentage, ankle circumference, and leg circumference measurements were collected from 50 normotensive healthy subjects. Ankle brachial index (ABI) was also compared. A pneumatic ankle tourniquet was applied to the right ankle and inflated until Doppler insonation confirmed that arterial occlusion had occurred. Mean arterial occlusion pressure was 161.7 mm Hg (N = 50, Nmales = 33, Nfemales = 17), and statistically less than 170 mm Hg (p < .05). The authors present a data model to predict the lowest necessary ankle tourniquet pressure for this study group. Forward stepwise linear regression (critical significance = .01) yields two variables, ankle brachial index and systolic blood pressure, which are used to predict occlusion pressure in this study group.

The purpose of this study was to evaluate the effect of galvanic electrical stimulation on vascular perfusion in diabetic patients. Nineteen subjects with diabetes were enrolled. Eleven subjects (57.9%) were diagnosed with impaired peripheral perfusion based upon their initial transcutaneous oximetry values (< 40 mm Hg). The subjects were studied over a 2-day period. On the 1st day, one foot was electrically stimulated for four 60-minute periods by an external electrical stimulation device. Vascular perfusion of both feet was assessed before and after the sessions of electrical stimulation. On the 2nd day, no electrical stimulation was applied and noninvasive vascular measurements were repeated. For the 1st hour, transcutaneous oxygen pressure was measured continuously during stimulation at the lateral aspect of the leg. Subsequently, perfusion between the periods of stimulation was measured on the dorsum of the foot with both transcutaneous oximetry and laser Doppler flowmetry after each stimulation period. In the group with impaired peripheral perfusion, a significant rise in tissue oxygenation as compared to the control measurements was measured during the first 5 minutes of stimulation (p < .040). For those without vascular disease (TcpO2 > 40 mm Hg) however, there was not a significant increase compared to baseline (p = .280). After the periods of stimulation, the stimulated feet did not show any higher perfusion levels than the control feet. Patterns in perfusion during the day, as measured by laser Doppler flowmetry, were similar in the tested feet and in the controls. These data suggest that external subsensory electrical stimulation induces a transient rise in skin perfusion in persons with diabetes and impaired peripheral perfusion.

To determine whether arterialized venous blood obtained from a foot vein could be substituted for arterialized venous blood obtained from a hand vein during studies using the glucose clamp technique, we simultaneously measured glucose concentrations and PO2 in blood samples obtained from the heated hands and feet of five normal volunteers during the euglycemic and hyperglycemic steps of a hyperinsulinemic clamp. Plasma glucose concentrations were found to be virtually identical in arterialized venous blood drawn from the hand and the foot under both euglycemic and hyperglycemic conditions. The correlation between these values was significant (R2 = .99, P < .001). PO2 measurements in blood drawn from the heated hand or foot were not statistically different. We conclude that the glucose concentration measured in arterialized venous blood drawn from the foot is equivalent to the concentration in arterialized venous blood drawn from the hand. These observations will allow investigators to study in vivo glucose metabolism in individuals with poor venous access in the upper extremities and to use protocols that make the arms of the subject inaccessible for blood sampling during the study.

The distal popliteal artery and proximal crural vessels represent common locations for atherosclerotic occlusive disease, especially in the diabetic subpopulation. Symptoms such as pain at rest, distal ulceration, and gangrene are associated with a high risk of limb loss unless arterial flow can be restored. Surgical revascularization is the most appropriate treatment in these patients, using autogenous vein to bypass from the popliteal artery to a crural artery beyond the area of stenosis. The posterior approach is an ideal method with which to achieve this goal. Lesser saphenous vein may be harvested from the same incision used to expose the inflow and outflow vessels. The technique minimizes the length of required conduit and preserves the greater saphenous vein for subsequent use. The wound problems associated with medial vein harvest incisions are less frequent. A through knowledge of the anatomy of the region will allow one to use the posterior approach in selected patients with popliteal and infrapopliteal occlusive disease, providing an additional tool for use in patients with limb-threatening lower extremity ischemia.

Cryoglobulins are composed of cold-sensitive immunoglobulins that precipitate upon cooling. As the cutaneous vasculature of the extremities is commonly exposed to colder temperatures than the body core, this precipitation often occurs in cutaneous, or even digital vessels. Hyperviscosity from the precipitated proteins can incite local thrombosis in otherwise normal vessels, which is manifested clinically as ischemic ulceration. In previously injured vessels, as seen with atherosclerotic occlusive disease, cryoglobulin precipitation can lead to thrombosis of larger vessels, with the consequence being more severe ischemic necrosis. A case of bilateral forefoot ischemia is presented where the precipitating cause of the gangrenous changes appears to be the development of a mixed cryoglobulinemia and a B-cell lymphoma. Tibial angioplasty, plasmaphoresis, and chemotherapy directed at the B-cell lymphoma allowed limb salvage with bilateral transmetatarsal amputations.

Our experience and that of others indicate that the number of very distal bypass operations is growing. From the early 1970s, when we performed a few operations per year, our numbers have increased to 60 to 65 operations annually, about 20% of all infrainguinal open revascularizations. Amputation of one leg leaves a patient, should he survive for a few years, with a second limb that is at substantial risk of infection or gangrene. From over 20 years of experience with thousands of diabetic leg problems and approximately 600 paramalleolar bypasses, the following facts have emerged from our clinical practice. Primary pedal arterial arches are virtually never complete. This alone should not deter the surgeon from attempting paramalleolar bypass grafting. Clinical details such as neuropathy, sepsis, and general medical status and even family support should not be overlooked as "risk factors." The order of frequency for pedal distal anastomotic sites will be anterior tibial/dorsalis pedis, posterior tibial/common plantar artery, lateral plantar artery/medial plantar artery, and lateral tarsal artery. In each case the graft should be placed as proximal as possible on the vessel; tibial outflow should be considered. Use short grafts with distal inflow whenever possible. In the rare instance wherein no pedal target site is available, consider the isolated tibial segment. Failure of a very distal bypass procedure seldom results in an amputation that is more proximal than otherwise would have been required if no bypass were attempted. As a corollary, after sepsis is controlled and all lesions and amputations are healed, failure of the graft may spare the limb from further risk of amputation. In diabetics, the presence of a palpable popliteal pulse and absence of foot pulse are tantamount to identifying the paramalleolar bypass graft candidate. Even the presence of palpable pedal pulses does not exclude patients who could achieve limb salvage with pedal bypass. That determination depends upon an angiogram. Pulsation and flow are not equivalent. Just as the obligations of the surgeon who performs an amputation are not discharged until healing and rehabilitation are complete, likewise, the vascular surgeon's duties after paramalleolar bypass must include a return to the ambulatory status. Careful follow-up, ongoing explicit patient and family education about foot care, and orthotics and shoes will enhance the life and life expectancy of the bipedal patient.

In summary, a rational approach to soft-tissue coverage in the ankle and foot should help lower osteomyelitis and bone nonunion rates and yield an excellent functional result. In addition to adequate fixation, it is crucial to first obtain a clean healthy wound by doing as many debridements as necessary. The goal should be to achieve coverage within the first week of injury to avoid the sequelae of a later closure; i.e., a potentially much higher infection rate and nonunion rate. The reconstructive options range from secondary intention, to primary closure, to skin grafts, to local flaps, to microsurgical free flaps. The choice should be dictated by the health of the patient, the existing bony and neurovascular anatomy, and the desired ultimate objective. Given the currently available orthopedic and plastic surgical techniques, it is possible to salvage almost any foot or ankle; however, we should not be carried away by our surgical armamentorium. If the salvaged extremity will take more than a year to heal, will be barely functional, and will be a constant source of pain, then a below-knee amputation should strongly be considered. The challenge in the coming decade comes both in picking the correct extremity to salvage and in applying the techniques described previously to restore it to its preinjury state.

Intravascular papillary endothelial hyperplasia is a rare benign reactive lesion usually found in thrombosed subcutaneous blood vessels. The lesion resembles malignant angiosarcoma clinically and histopathologically, and must be diagnosed correctly to avoid inappropriate treatment. The following is a case presentation involving the foot.

The pathogenesis of foot problems in patients with diabetes mellitus involves multiple factors including macrovascular disease, microvascular disease, abnormalities in blood flow distribution, peripheral neuropathy, autonomic neuropathy, physical stress, and infection. Surprisingly, the role of poor glycemic control in the development of diabetic foot complications has not been well studied. Recently, the Diabetes Control and Complications Trial has provided conclusive evidence that hyperglycemia plays a major role in the development of microvascular complications. Because the etiologic factors that contribute to microvascular complications also play an important role in foot complications, one would expect that tight glycemic control, however achieved, would be effective in both the primary and secondary prevention of diabetic foot problems.

A retrospective study was undertaken to determine the importance of performing noninvasive blood flow studies on the diabetic patient population prior to undergoing elective foot surgery. Thirty diabetic patients, contemplating elective foot surgery, underwent noninvasive blood flow studies. Eighty-seven percent of these patients, with ankle/brachial indices greater than 0.6, successfully healed after surgery was performed.

Vascular malformations are infrequent findings in the foot, especially the plantar medial foot. Deeper vascular malformations may be more difficult to diagnose due to the depth and oblique course of the medial neurovascular structures into plantar aspect of the foot. The authors present an interesting case report of a vascular anomaly mimicking a heel spur syndrome and describe a surgical approach for the resection of this type of lesion with a 10-month follow-up.

The effect of modern "flow material" ski boots on foot circulation was studied. Pressure inside a flow material ski boot was found to be markedly higher than in a conventional ski boot. In some places the pressure exceeded the diastolic pressure in the foot. 113mIndium chloride, which when injected intravenously is bound to transferrin was used for blood pool scanning. In healthy young volunteers the uptake of radioactivity in the two feet--one with and one without a ski boot--was compared. The activity level of the foot with the ski boot was significantly lower than in the other foot. After corrections were made for absorption by the boot, a significant difference remained. Plethysmographic studies were performed with a mercury strain gauge using a ski boot in which a hole was cut over the big toe. No difference was demonstrated between the blood pressure at the leg just above the boot top and at the big toe. The arterial pulse wave at the big toe was altered; i.e., there was an absence of a dichrotic wave. Intramuscular perfusion was studied with 133xenon. The disappearance curve in a foot with a boot was more shallow than that in a bare foot. Unbuckling resulted in an immediate fall in radioactivity, the disappearance curve then becoming identical to that of the bare foot. The results indicate that when flow material ski boots are to be used by skiers who are not in the habit of unbuckling for short intervals, buckle tension should not be too high.

It has been reported that when adequate foot care has been provided for the diabetic patient, the amputation rate could be reduced by as much as 50 to 75 per cent. Patient management and rehabilitation of the patient with diabetes mellitus must consider the individual and unusual needs of patients in more than a biologic or physiologic sense.