Angiology
Shahan K. Sarrafian
Armen S. Kelikian
ARTERIES
The arterial blood supply to the ankle and the foot (Fig. 7.1) is provided by three arteries: posterior tibial, anterior tibial, and peroneal.
The tibial arteries are the major suppliers of the foot, but the peroneal artery may predominate when the anterior and posterior tibial arteries are atrophic or absent in their distal segments. As described by Dubreuil-Chambardel, the anterior branch of the peroneal artery or perforating branch may supply the dorsalis pedis artery, or the posterior branch of the peroneal artery may be the only supplier of the plantar arteries.1 When the terminal segments of the posterior and anterior tibial arteries are absent simultaneously, the peroneal artery with its anterior and posterior branches is the sole supplier of the dorsal and plantar arterial network (Fig. 7.2).
The posterior tibial artery may be greatly attenuated or absent (Table 7.1). Adachi reports the absence of the posterior tibial artery as being nearly 2% (10 cases in 486 feet).2 Dubreuil-Chambardel has never encountered a complete absence of the posterior tibial artery.1
The anterior tibial artery may be a very thin vessel distally or may terminate in the midleg, thus leaving the entire supply of the dorsum of the foot to the perforating branch of the peroneal artery. Such a variation occurs with the frequency shown in Table 7.2.
The peroneal artery is diminished in volume with the frequency shown in Table 7.3. Dubreuil-Chambardel has never seen this artery completely absent.1 Edwards mentions that “either of its two terminal branches—the perforating or the posterior lateral malleolar—may be missing.”3
Dorsal Arterial Network of the Foot and Ankle
The dorsal arterial network of the foot is extremely variable, but these variations can be superimposed almost constantly on a general pattern termed “a very constant pattern,” “a potential arterial pattern,” or “a grundform.”1, 2, 3, 4 As Huber points out, “any part of that network might be encountered as a vessel of significant size.”4
The general pattern of this network is shown in Figure 7.3.4 At the ankle joint interline, the anterior tibial artery is continued by the dorsalis pedis artery, which extends along an axis drawn from the middle of the transverse bimalleolar axis to the tip of the first intermetatarsal space. The dorsalis pedis artery gives origin at the level of the ankle to the anterior malleolar arteries, both medial and lateral. During its pedal course, the dorsalis pedis artery provides the following branches from its lateral side: artery to the sinus tarsi, lateral tarsal artery, artery to the proximal segment of the second intermetatarsal space, arcuate artery, and artery to the first intermetatarsal space.
The artery of the sinus tarsi may arise directly from the dorsalis pedis artery at the level of the talar neck. Directed transversely, it enters the sinus tarsi.
The lateral tarsal artery also originates at the level of the talar neck; it courses obliquely laterally and distally to the dorsum of the cuboid, and divides into three longitudinal branches reaching the proximal segments of intermetatarsal spaces 2, 3, and 4.
The medial tarsal arteries, proximal and distal, as described by Huber (see Fig. 7.3) emanate from the medial aspect of the dorsalis pedis artery.4 The proximal medial tarsal artery branches off from the dorsalis pedis artery at the level of the navicular and courses transversely. The distal medial tarsal artery originates from the dorsalis pedis artery at the level of C2 and runs obliquely to the dorsum of C1.
The artery to the proximal segment of the second intermetatarsal space takes off at the level of the middle cuneiform. It crosses the base of the second metatarsal and reaches the second intermetatarsal space. This longitudinal branch is connected to the first division branch of the lateral tarsal artery with a transverse branch on the dorsum of the lateral cuneiform.
The arcuate artery originates at the level of the first tarsometatarsal joint and transversely crosses the bases of the second, third, and fourth metatarsals. The arterial arcade is joined by the previously described longitudinal branches of the lateral tarsal artery. The arcuate artery gives origin to the proximal perforating arteries in intermetatarsal spaces 2, 3, and 4 and to the second, third, and fourth dorsal metatarsal arteries. The latter give a set of perforating branches proximal to the corresponding metatarsal heads and farther distally in the web space they divide into the dorsal digital arteries. They give a perforating branch in the axis of the web space and a dorsoplantar anastomotic branch on the side of the corresponding proximal phalanx.
The first intermetatarsal artery or the first dorsal metatarsal artery continues the direction of the dorsalis pedis artery. At the base of the first intermetatarsal space, it plunges plantarward and forms the first proximal perforating artery. The first dorsal metatarsal artery provides two lateral
branches to the first metatarsal and one anastomotic branch to the medial aspect of the second metatarsal neck. Farther distally, at the level of the web space, the artery divides into the dorsal digital artery of the big toe—providing both its dorsolateral and dorsomedial branches—and the dorsomedial artery of the second toe. The first dorsal metatarsal artery finally gives the first distal perforating artery. From its medial side, the dorsalis pedis artery provides two medial tarsal arteries taking off at the level of the navicular and the first cuneiform.
branches to the first metatarsal and one anastomotic branch to the medial aspect of the second metatarsal neck. Farther distally, at the level of the web space, the artery divides into the dorsal digital artery of the big toe—providing both its dorsolateral and dorsomedial branches—and the dorsomedial artery of the second toe. The first dorsal metatarsal artery finally gives the first distal perforating artery. From its medial side, the dorsalis pedis artery provides two medial tarsal arteries taking off at the level of the navicular and the first cuneiform.
 Figure 7.1 Arterial tree of the foot, corrosion study. (1, dorsalis pedis artery; 2, posterior tibial artery; 3, lateral plantar artery; 4, medial plantar artery; 5, plantar arc, deep; 6, first proximal perforating artery; 7, first dorsal interosseous artery; 8, second dorsal interosseous artery; 9, first plantar interosseous artery; 10, plantar metatarsal arteries; 11, dense arterial network of lateral border of foot; 12, anastomotic network at level of pulp of big toe.) (From Hyrtl J. Die Corrosions—Anatomie und lhre Ergebnisse. Wien: Braumüller; 1873:249.) |
TABLE 7.1 FREQUENCY OF ABSENT OR VERY THIN POSTERIOR TIBIAL ARTERY | |||||||||||||||||||||||||||||||||
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TABLE 7.2 FREQUENCY OF ABSENT OR VERY THIN ANTERIOR TIBIAL ARTERY | ||||||||||||||||||||||||||||||||
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The perforating branch of the peroneal artery crosses the distal segment of the tibiofibular interspace, passes over the anterior aspect of the tibiofibular syndesmosis, contours the anterior border of the lateral malleolus, and establishes communication with the lateral malleolar and lateral tarsal arteries.
The previously described standard pattern of distribution of the branches of the dorsalis pedis artery occurs in 5.5%.4 Huber, in a study of 200 feet, grouped the possible variations of pattern according to the level of origin of the arcuate artery and the number of dorsal metatarsal arteries provided by the latter. The individual arrangements are classified into the following four categories.
Group A (35%) (Fig. 7.4): Arcuate artery arising at about the level of the first tarsometatarsal joint and giving rise to the following dorsal metatarsal arteries.
Group A1 (16.5%): Dorsal metatarsal arteries 2, 3, and 4
Group A2 (9%): Dorsal metatarsal arteries 2 and 3
Group A3 (9.5%): Dorsal metatarsal artery 2.
Group B (19%) (see Fig. 7.4): Arcuate artery arising at about the level of the cuneonavicular joint, with the subgroups similar to those of group A.
Group B1 (9%)
Group B2 (6.5%)
Group B3 (3.5%).
TABLE 7.3 FREQUENCY OF VERY THIN PERONEAL ARTERY
Author
Number of Feet
Frequency (%)
Quain
208
2.8
Dubreuil-Chambardel
103
3.8
Figure 7.2 Variations of the arteries of the leg and foot. (A) Habitual pattern. (1, popliteal artery; 2, anterior tibial artery; 3, tibioperoneal arterial trunk; 4, posterior tibial artery; 5, peroneal artery; 6, anterior peroneal artery; 7, posterior peroneal artery; 8, dorsalis pedis artery; 9, dorsal metatarsal arteries; 10, perforating artery of first interspace; 11, lateral plantar artery; 12, medial plantar artery; 13, deep plantar arterial arc; 14, first plantar metatarsal artery.) (B) The dorsalis pedis artery (8) is provided by the anterior peroneal artery (6). (5, peroneal artery; 7, posterior peroneal artery.) (C) The posterior peroneal artery (7) supplies the lateral and medial plantar arteries (11 and 12). (4, posterior tibial artery, incomplete; 5, peroneal artery, well developed; 6, anterior peroneal artery.) (D) The peroneal artery (5) supplies the dorsalis pedis artery (8) through the anterior peroneal artery (6) and the plantar arteries (11 and 12) through the posterior peroneal artery (7). The anterior tibial artery (2) and the posterior tibial artery (4) are incomplete or absent. (From Dubreuil-Chambardel L. Variations des Artères du Pelvis et du Membre Inférieur. Paris: Maison; 1902:246.)
Figure 7.3 The arterial network of the dorsum of the foot, general or potential pattern. (1, anterior tibial artery; 2, dorsalis pedis artery; 3, anterior or perforating peroneal artery; 4, anterior lateral malleolar artery; 5, anterior medial malleolar artery; 6, lateral tarsal artery; 7, arcuate artery; 8, first proximal perforating artery; 9, dorsal metatarsal arteries; 10, dorsal digital arteries; 11, medial tarsal arteries.) (From Huber JF. The arterial network supplying the dorsum of the foot. Anat Rec. 1941;80:373. By permission of Alan R. Liss, Inc., Publisher.)
Group C (34%) (Fig. 7.5): No arcuate artery present.
Group D (12%) (see Fig. 7.5): Dorsalis pedis artery practically absent.
Adachi describes the “grundform” of the rete of the dorsalis pedis (Fig. 7.6) as formed transversely by the proximal lateral tarsal artery, the distal lateral tarsal artery, and the arcuate artery. These transverse or oblique components are anastomosed by three sagittal or longitudinal arteries, forming a complex network. The longitudinal arteries run parallel to the dorsalis pedis artery; they may be very thin, or one or two branches may be missing. These arteries continue as the dorsal metatarsal arteries and give off the proximal or posterior perforating arteries. The distal lateral tarsal artery is usually insignificant in size. When the sagittal arteries are thin, the supply to the dorsal metatarsal arteries is provided by the proximal perforating arteries. When the dorsal metatarsal arteries are thin, the proximal perforating arterial branches are also rudimentary.
Dorsalis Pedis Artery
At the level of the ankle joint interline, the anterior tibial artery is continued by the dorsalis pedis artery, which runs along a line extending from the middle of the transverse malleolar line to the proximal end of the first intermetatarsal
space. During its course, the artery passes across the talus, the navicular, the second cuneiform, and the base of the second metatarsal. It penetrates the first intermetatarsal space limited anteriorly by the arch formed by the first dorsal interosseous muscle and posteriorly by the base of the first and second metatarsals. It terminates by inosculation with the lateral plantar artery after making two 90-degree turns—one vertical and one horizontal-lateral. This standard course of the artery occurs in 73.5%.4
space. During its course, the artery passes across the talus, the navicular, the second cuneiform, and the base of the second metatarsal. It penetrates the first intermetatarsal space limited anteriorly by the arch formed by the first dorsal interosseous muscle and posteriorly by the base of the first and second metatarsals. It terminates by inosculation with the lateral plantar artery after making two 90-degree turns—one vertical and one horizontal-lateral. This standard course of the artery occurs in 73.5%.4
 Figure 7.4 Variations of the arterial pattern on the dorsum of the foot. (Group A) Arcuate artery (7) arising at about the level of the first tarsometatarsal joint and giving rise to the dorsal metatarsal arteries 2, 3, and 4 (9). (1, anterior tibial artery; 2, dorsalis pedis artery; 3, anterior peroneal artery; 6, lateral tarsal artery; 9′, first dorsal metatarsal artery.) (Group B) Arcuate artery (7) arising at about the level of the cuneonavicular joint and providing the dorsal metatarsal arteries 2, 3, and 4 (9). (From Huber JF. The arterial network supplying the dorsum of the foot. Anat Rec. 1941;80:373. By permission of Alan R. Liss, Inc., Publisher.) |
Variations
From a study of 200 feet, Huber reports the absence of the dorsalis pedis artery in 12% (see Fig. 7.5).4 Adachi, from a group
of 230 feet, reports a very thin dorsalis pedis artery in 3% (Fig. 7.7).2
of 230 feet, reports a very thin dorsalis pedis artery in 3% (Fig. 7.7).2
 Figure 7.5 Variations of the arterial pattern on the dorsum of the foot. (Group C) Absent arcuate artery (7). (1, anterior tibial artery; 2, dorsalis pedis artery; 3, anterior peroneal artery; 3′, anastomotic branch between anterior tibial artery and anterior peroneal artery; 6, lateral tarsal artery providing dorsal metatarsal arteries 2, 3, and 4 (9); 9′, first dorsal metatarsal artery.) (Group D) Practically absent dorsalis pedis artery (2). (1, anterior tibial artery; 3, anterior peroneal artery; 6, lateral tarsal artery; 9, dorsal metatarsal arteries 2, 3, and 4; 9′, absent first dorsal metatarsal artery.) (From Huber JF. The arterial network supplying the dorsum of the foot. Anat Rec. 1941;80:373. By permission of Alan R. Liss, Inc., Publisher.) |
Lateral deviation of the artery occurs in 5.5%.4 Such cases are also described by Dubreuil-Chambardel (1.8%) and Adachi (0.4%) (Fig. 7.8A).1, 2
Medial deviation of the artery occurs in 3.5%.4
In about 5% (as mentioned previously), the tibialis anterior artery is absent or filiform in the distal segment, and the dorsalis pedis artery is supplied by the perforating branch of the peroneal artery (Fig. 7.9A).
The lower end of the anterior tibial artery is in the position of the perforating peroneal artery in 1.5% (Fig. 7.9B).4
 Figure 7.6 “Grundform” of the rete of the dorsalis pedis artery formed by the transversely oriented proximal, distal, and lateral tarsal arteries and the arcuate arteries connected by longitudinally oriented anastomotic branches and the dorsalis pedis artery. (From Adachi B. Das Arteriensystem der Japaner. Kyoto: Maruzen; 1928:251.) |
 Figure 7.7 Very thin dorsalis pedis artery (1) and absent first dorsal metatarsal artery (2). (3, dorsal metatarsal arteries 2, 3, and 4.) (From Adachi B. Das Arteriensystem der Japaner. Kyoto: Maruzen; 1928:246, 248.) |
 Figure 7.8 (A) Lateral deviation of the dorsalis pedis artery. (B) General pattern of arterial distribution on the dorsum of the foot. (1, anterior tibial artery; 2, dorsalis pedis artery; 3, first dorsal interosseous artery; 4, arcuate artery; 5, medial tarsal artery; 6, lateral tarsal artery; 7, dorsal metatarsal arteries 2, 3, and 4; 8, first proximal perforating artery; 9, anterior peroneal artery; 10, anterior lateral malleolar artery; 11, anterior medial malleolar artery.) (From Adachi B. Das Arteriensystem der Japaner. Kyoto: Maruzen; 1928:243.) |
 Figure 7.9 Variations of the arterial pattern on the dorsum of the foot. (A) Absent or filiform anterior tibial artery (1). The dorsalis pedis artery (2) is supplied by the anterior peroneal artery (3). (6, lateral tarsal artery; 7, arcuate artery supplying the dorsal metatarsal arteries 2, 3, and 4 (9); 9′, first dorsal metatarsal artery.) (B) The lower end of the anterior tibial artery (1) is in the position of the perforating peroneal artery. (2, dorsalis pedis artery; 6, lateral tarsal artery supplying the dorsal metatarsal arteries 3 and 4; 7, arcuate artery supplying second dorsal metatarsal artery [9]; 10, first dorsal metatarsal artery.) (From Huber JF. The arterial network supplying the dorsum of the foot. Anat Rec. 1941;80:373. By permission of Alan R. Liss, Inc, Publisher.) |
The artery arises equally from the anterior tibial and the perforating peroneal artery in 0.5% (Fig. 7.10A).4
In very rare instances, the dorsalis pedis artery is formed by a branch of the posterior tibial artery passing around the medial malleolus and reaching the dorsum of the foot. This vessel is anastomosed by a transverse branch on the dorsum of the scaphoid, with the perforating branch of the peroneal artery supplying, in turn, the second, third, and fourth dorsal metatarsal arteries (Fig. 7.11).1
Caliber
The usual diameter of the dorsalis pedis artery is 2 to 3 mm, and in 6% of 50 feet it was very small, not exceeding 1.5 mm.5
The average diameter of the same artery at the upper limit of the extensor retinaculum is given as 2.79 mm.6
The average diameter of the same artery at the upper limit of the extensor retinaculum is given as 2.79 mm.6
 Figure 7.10 Variations of the arterial pattern on the dorsum of the foot. (A) The dorsalis pedis artery (2) arises equally from the anterior tibial artery (1) and the perforating peroneal artery (3). (6, lateral tarsal artery; 7, arcuate artery; 9, dorsal metatarsal arteries 2, 3, and 4; 9′, first dorsal metatarsal artery.) (B) The lateral tarsal artery (6) is in continuity with the perforating peroneal artery (3). (2, incomplete dorsalis pedis artery; 9, dorsal metatarsal arteries 2, 3, and 4 supplied by 6; 12, absent first dorsal metatarsal artery.) (From Huber JF. The arterial network supplying the dorsum of the foot. Anat Rec. 1941;80:373.) |
Lateral Tarsal Arteries
The lateral arteries are two, rarely three: it is the exception to have more than three.2 The proximal lateral tarsal artery is the strongest. The second lateral tarsal artery is not significant and may be represented by only a connecting thin artery extending from the proximal lateral tarsal artery to the dorsalis pedis artery (Fig. 7.12).
 Figure 7.11 Dorsalis pedis artery (4) formed by a branch of the posterior tibial artery (2) passing around the medial malleolus and reaching the dorsum of the foot. (1, anterior peroneal artery; 3, anastomotic branch between 1 and 4; 5, first dorsal metatarsal artery.) (From Dubreuil-Chambardel L. Variations des Artères du Pelvis et du Membre Inférieur. Paris: Maison; 1902:225.) |
Proximal
The proximal lateral tarsal artery originates from the dorsalis pedis at the level of the talar head, 0.5 cm proximal to this level (occasionally), or 0.5 cm distal (rarely).2 This arterial branch courses obliquely in a lateral and distal direction, crosses the calcaneonavicular junction and the dorsum of the cuboid, reaches the lateral border of the cuboid, passes under the peroneus brevis tendon, and anastomoses with the lateral plantar artery. At the level of the talar head, the proximal lateral tarsal artery provides arterial branches to the talar head and to the lateral anterior aspect of the talar body. In 21.7% to 32%, the artery provides direct origin to the artery of the sinus tarsi or forms with the perforating peroneal artery an arterial loop that gives origin to the artery of the sinus tarsi.1, 2, 7 The artery forms an arterial anastomotic network in the tarsal sinus with contributions from the anterior lateral malleolar artery and the perforating peroneal artery. It also participates in the formation of the lateral malleolar arterial rete. At the level of the cuboid, the proximal lateral tarsal artery provides two, rarely three, longitudinal anastomotic branches with the arcuate artery; in some cases, these branches are large enough to continue distally as the fourth and third dorsal metatarsal arteries or, rarely, as the fourth, third, and second metatarsal arteries. The origin of the proximal lateral tarsal artery is variable and occurs at the following sites as reported by Huber in 200 feet: from the level of the junction of the talar head and neck, 58%; almost at the level of the ankle joint, 19.5%; from below the talonavicular joint, 19%; absent artery, 1.5%; extremely small artery, 1.5%; a continuation of the perforating peroneal artery, 0.5%.4
 Figure 7.12 Lateral tarsal arteries. (1, anterior tibial artery; 2, dorsalis pedis artery; 3, proximal lateral tarsal artery; 4, distal lateral tarsal artery; 5, dorsal metatarsal arteries 2, 3, and 4.) (From Adachi B. Das Arteriensystem der Japaner. Kyoto: Maruzen; 1928:245.) |
Gilbert et al.,8 in a comprehensive study, described the proximal lateral tarsal artery originating from the dorsalis pedis artery at the level of the talar neck in all 20 specimens. On the dorsum of the proximal-medial aspect of the cuboid the proximal lateral tarsal divides into two branches:
A longitudinal branch to the third intermetatarsal space
A transverse pedicle branch (unnamed previously)
The transverse pedicle branch courses the dorsum of the cuboid toward the groove for the peroneus longus tendon
(Figs. 7.13 and 7.14). The artery provides an average of 15 nutrient vessels (range, 8 to 20 nutrient vessels) to the cuboid. It anastomoses at the lateral edge of the cuboid with the vertical descending segment of the anterior lateral malleolar artery and/or a branch of the lateral plantar artery. The division point of the longitudinal branch to the third intermetatarsal space and the transverse pedicle branch occurred, on average, 2 mm (range, 0 to 6 mm) lateral to the cuboid-third cuneiform joint. The average length of the proximal lateral tarsal artery from its origin from the dorsalis pedis to its division into the transverse pedicle branch and the longitudinal branch to the intermetatarsal space was 38 mm (range, 28 to 55 mm). The proximal lateral tarsal artery establishes communication with the second through fourth dorsal metatarsal
arteries by way of three longitudinal branches to the second, third, and fourth intermetatarsal space. The longitudinal branch of the second intermetatarsal space anstomosed over the third cuneiform with the longitudinal branch to the second intermetatarsal space from the distal lateral tarsal artery (Fig. 7.15).
(Figs. 7.13 and 7.14). The artery provides an average of 15 nutrient vessels (range, 8 to 20 nutrient vessels) to the cuboid. It anastomoses at the lateral edge of the cuboid with the vertical descending segment of the anterior lateral malleolar artery and/or a branch of the lateral plantar artery. The division point of the longitudinal branch to the third intermetatarsal space and the transverse pedicle branch occurred, on average, 2 mm (range, 0 to 6 mm) lateral to the cuboid-third cuneiform joint. The average length of the proximal lateral tarsal artery from its origin from the dorsalis pedis to its division into the transverse pedicle branch and the longitudinal branch to the intermetatarsal space was 38 mm (range, 28 to 55 mm). The proximal lateral tarsal artery establishes communication with the second through fourth dorsal metatarsal
arteries by way of three longitudinal branches to the second, third, and fourth intermetatarsal space. The longitudinal branch of the second intermetatarsal space anstomosed over the third cuneiform with the longitudinal branch to the second intermetatarsal space from the distal lateral tarsal artery (Fig. 7.15).
 Figure 7.13 Overview of the extraosseous blood supply to the foot and ankle. (A, anterior tibial artery; B, anterior medial malleolar artery; C, anterior lateral malleolar artery; D, dorsalis pedis artery; E, proximal lateral tarsal artery; F, proximal medial tarsal artery; G, distal medial tarsal artery; H, distal lateral tarsal artery; I, arcuate artery; J, first dorsal metatarsal artery; K, artery of sinus tarsi; L, longitudinal branch to second intermetatarsal space; M, longitudinal branch to third intermetatarsal space; N, longitudinal branch to fourth intermetatarsal space; O, transverse pedicle branch; P, posterior tibial artery; Q, medial plantar artery; R, lateral plantar artery; S, fibular metaphyseal artery; T, perforating peroneal artery.) (From Gilbert BJ, Horst F, Nunley JA. Potential donor rotational bone graft using vascular territories in the foot and ankle. J Bone Joint Surg. 2004;86-A(9):1859, Figure 1.) |
 Figure 7.14 (A) The dorsal extraosseous blood supply to the cuboid. (1, third cuneiform; 2, cuboid; 3, calcaneus; 4, os perineum; A, proximal lateral tarsal artery; B, longitudinal branch to the third intermetatarsal space; C, transverse pedicle branch; D, longitudinal branch to the second intermetatarsal space; E, longitudinal branch to the fourth intermetatarsal space; F, vertical descending branch of the anterior lateral malleolar artery.) (B) The dorsal extraosseous supply to the cuboid in another specimen, with the vascular territory supplied by the transverse pedicle branch of the proximal lateral tarsal artery outlined in green. (From Gilbert BJ, Horst F, Nunley JA. Potential donor rotational bone graft using vascular territories in the foot and ankle. J Bone Joint Surg. 2004;86-A(9):1861, Figure 3.) |
Distal
The origin of the distal lateral tarsal artery is very variable; it is often found on the dorsum of the second cuneiform or, occasionally, more proximal at the level of the cuneo2-navicular joint.2 The proximal lateral tarsal artery is usually larger than the distal, and Adachi provides the following information concerning their sizes in 230 feet: in 84%, the proximal lateral tarsal artery is larger; in 6%, the distal lateral tarsal artery is larger; in 10%, both are equal.2
The distal lateral artery as described by Gilbert et al.8 was present in all 20 specimens. It originates over the proximal half of the second cuneiform in 80% (16 specimens) and more proximally between the level of midnavicular and second cuneonavicular joint in 20% (4 specimens). From its origin, it courses across the dorsum of the second cuneiform (see Fig. 7.15) and provides its first branch medially, as the “lateral hook of the necklace to the second cuneiform,” originating an average of 4 mm (range, 0 to 8 mm) medial to the articulation of the second and third cuneiforms. The distal lateral tarsal artery continues anterolaterally over the dorsomedial aspect of C3 and divides into three branches:
A plantar perforating branch
A transverse branch to C3
A longitudinal branch to the second intermetatarsal space.
The plantar perforating branch dives plantarward between C2 and C3 to anastomose with the plantar circulation and provide nutrient vessels to both of these bones. In 8 of 10 corrosion cast specimens, this branch originated directly from the distal lateral tarsal artery. In the other two specimens, it originated from the distal lateral longitudinal branch to the second intermetatarsal space.
 Figure 7.15 (A) The extraosseous blood supply to the medial aspect of the first cuneiform. (1, first cuneiform; 2, second cuneiform; 3, navicular; 4, base of first metatarsal; A, proximal medial tarsal artery; B, distal medial tarsal artery; C, superomedial border branch of the distal medial tarsal artery; D, middle pedicle branch of the distal medial tarsal artery; E, inferior communicating branch of the distal medial tarsal artery; F, direct superomedial border branch of the dorsalis pedis artery; G, branch of the medial plantar artery.) (B) The medial view of the extraosseous blood supplies the first cuneiform in another specimen, with the vascular territory supplied by the middle pedicle branch of the distal medial tarsal artery outlined in green. (From Gilbert BJ, Horst F, Nunley JA. Potential donor rotational bone graft using vascular territories in the foot and ankle. J Bone Joint Surg. 2004;86-A(9):1862, Figure 4.) |
The transverse branch crossed over the midsegment of C3 and anastomosed with the longitudinal branch to the third intermetatarsal space (see Figs. 7.13 and 7.15A). This anastomosis was found in all specimens and occurred over the articulation of the cuboid and C3 and provided an average of 7 nutrient vessels (range, 2 to 11 nutrient vessels) to the dorsum of C3. “In seven of the ten corrosion cast specimens, the transverse branch to the third cuneiform divided into two branches over the third cuneiform and then coalesced back into one branch before it united with the longitudinal branch to the third intermetatarsal space.”8
The longitudinal branch to the second intermetatarsal space anastomoses over C3 with the longitudinal branch to the second intermetatarsal space of the proximal lateral tarsal artery and forms the common longitudinal branch to the second intermetatarsal space. This arrangement was found in 8 of the 10 corrosion cast specimens. In the other two, either component was absent.
Medial Tarsal Arteries
Gilbert et al.8 provided a comprehensive study of the medial tarsal arteries, proximal and distal, and their findings were as follows.
Proximal Medial Tarsal Artery
This artery was present in all 20 specimens of their study. The artery originates from the dorsalis pedis artery at the level between the talonavicular and second cuneonavicular joint in 18 specimens. The artery travels nearly transversely along the dorsal aspect of the navicular, toward its inferomedial
apex and bifurcates, uniting with the inferior communicating branch of the distal medial tarsal artery and continues inferomedially to anastomose with branches of the medial plantar artery (Fig. 7.15). “Along its path, the proximal medial tarsal artery provided multiple nutrient vessels to the dorsum of the navicular, as well as a variable number of anastomotic branches to the distal medial tarsal artery.”8 It also sends a “medial recurrent tarsal artery to the talar neck and body.”8 In the remaining two specimens, “the proximal medial tarsal artery originated from the anterior tibial artery at the level of the tibiotalar joint. In one of these specimens, the proximal medial artery and the medial malleolar artery originated from a common trunk.”8 The artery “passed in a straight line from the tibiotalar joint to the medial posteroinferior corner of the first cuneiform” and “united with the inferior communicating branch of the distal medial tarsal artery and anastomosed with branches of the medial plantar artery. They sent a medial recurrent tarsal artery to the talar neck and body.”8
apex and bifurcates, uniting with the inferior communicating branch of the distal medial tarsal artery and continues inferomedially to anastomose with branches of the medial plantar artery (Fig. 7.15). “Along its path, the proximal medial tarsal artery provided multiple nutrient vessels to the dorsum of the navicular, as well as a variable number of anastomotic branches to the distal medial tarsal artery.”8 It also sends a “medial recurrent tarsal artery to the talar neck and body.”8 In the remaining two specimens, “the proximal medial tarsal artery originated from the anterior tibial artery at the level of the tibiotalar joint. In one of these specimens, the proximal medial artery and the medial malleolar artery originated from a common trunk.”8 The artery “passed in a straight line from the tibiotalar joint to the medial posteroinferior corner of the first cuneiform” and “united with the inferior communicating branch of the distal medial tarsal artery and anastomosed with branches of the medial plantar artery. They sent a medial recurrent tarsal artery to the talar neck and body.”8
Distal Medial Tarsal Artery
Gilbert et al.8 described this artery as present in all their 20 specimens. The distal medial tarsal artery originates from the dorsalis pedis artery at the level of the second cuneonavicular joint in 45% (9 of the 20 specimens). It originated more proximally at the level of the anterior half of the navicular in six specimens, and it originated more distally at the level of the posterior half of the second cuneiform in 5 specimens. The distal medial tarsal artery courses anteromedially. “The first main branch of the distal medial tarsal artery occurred over the medial half of the second cuneiform. This previously unnamed branch travelled in a U-shaped loop across the dorsum of the second cuneiform. The loop passed deep to the dorsalis pedis artery and supplied an average of 8 nutrient vessels (range 3 to 14 nutrient vessels) to the dorsum of the second cuneiform. The lateral extent of this U-shaped loop anastomosed with the distal lateral tarsal artery.”8 “This U-shaped loop was an anastomotic necklace that draped down distally over the dorsal surface of the second cuneiform, connected the distal medial tarsal artery to the distal lateral tarsal artery, and provided multiple nutrient vessels to the dorsum of the second cuneiform along the way. This unnamed artery was evident in all specimens and is referred to here as the necklace of the second cuneiform [see Fig. 7.15A].”8 Gilbert et al.8 referred to the “branch point of this artery off the distal medial tarsal artery as the medial hook of the necklace of the second cuneiform. The branch point of this artery off the distal lateral tarsal artery was referred to as the lateral hook to the 2nd cuneiform.” The medial hook of the necklace to the second cuneiform branched off the distal medial tarsal artery an average 3 mm (range, 0 to 6 mm) lateral to the articulation of the first and second cuneiforms. The distal medial tarsal artery crossed the superior border of the first cuneiform and “divided into 2 distinct and previously unnamed branches”:
A superomedial border branch
A middle pedicle branch.
The superomedial border branch was present in 18 of the 20 specimens. It supplied an average of three nutrient vessels (range, one to six nutrient vessels) to the first cuneiform. The middle pedicle branch was present in all specimens. It coursed across the medial aspect of C1 and provided an average of 9 nutrient vessels (range, 4 to 15 nutrient vessels) superior to the insertion of the tibialis anterior tendon. The middle pedicle branch anastomosed with a branch of the medial plantar artery. This occurred in 5 of the 10 corrosion cast specimens. In 3 of the 10 corrosion cast specimens, the middle pedicle branch supplied nutrient vessels to the medial aspect of the base of the first metatarsal. In the remaining two specimens, it anastomosed with the medial plantar artery and supplied nutrient vessels to the medial aspect of the base of M1.
Another previously unnamed artery, termed by Gilbert et al.8 as the inferior communicating branch (see Fig. 7.16) originated from the middle pedicle branch about halfway between the navicular and the first metatarsal articular surface of the first cuneiform. This small vessel was oriented perpendicular to the middle pedicle branch. It coursed over the medial aspect of the first cuneiform, deep to the tibialis anterior tendon, and anastomosed with the proximal medial tarsal artery near the medial apex of the navicular. The inferior communicating branch provided an average of 5 nutrient vessels
(range, 0 to 11 nutrient vessels) to the medial aspect of the first cuneiform.
(range, 0 to 11 nutrient vessels) to the medial aspect of the first cuneiform.
 Figure 7.16 The extraosseous blood supply to the dorsal surface of the second and third cuneiforms. (1, navicular; 2, second cuneiform; 3, third cuneiform; 4, cuboid; A, dorsalis pedis artery; B, distal medial tarsal artery; C, medial hook of the necklace to the second cuneiform; D, distal lateral tarsal artery; E, lateral hook of the necklace to the second cuneiform; F, transverse branch to the third cuneiform; G, distal lateral tarsal longitudinal branch to the second intermetatarsal space; H, proximal lateral tarsal longitudinal branch to the second intermetatarsal space; I, common longitudinal branch to the second intermetatarsal space; J, proximal lateral tarsal artery; K, longitudinal branch to the third intermetatarsal space; L, transverse pedicle branch of the proximal lateral tarsal artery; M, longitudinal branch to the fourth intermetatarsal space; N, site of anastomosis between the transverse branch of the distal medial tarsal artery to the third cuneiform and the longitudinal branch to the third intermetatarsal space. The ruler markings are in millimeters.) (From Gilbert BJ, Horst F, Nunley JA. Potential donor rotational bone graft using vascular territories in the foot and ankle. J Bone Joint Surg. 2004;86-A(9):1864, Figure 5A.) |
Arcuate Artery
The arcuate artery originates from the dorsalis pedis usually at the level of the first tarsometatarsal joint; it crosses the base of the second, third, and fourth metatarsals almost transversely and provides the dorsal metatarsal arteries 2, 3, and 4 and, occasionally, the artery metatarsi dorsalis fibularis (see Figs. 7.3 and 7.8B).2 The artery is present in only 54%, and the variable origin of the artery occurs at the following sites as reported by Huber in 200 feet: at the cuneo1-metatarsal1 level, 35% (group A); at the cuneonavicular level, 17% (group B); below the cuneonavicular level, 2%.4 The dorsal metatarsal arteries provided by the arcuate artery occur with the following frequency in 200 feet: dorsal metatarsal arteries 2, 3, and 4—16.5% (group A), 9% (group B), 25.5% total; dorsal metatarsal arteries 2 and 3—9% (group A), 6.5% (group B), 15.5% total; dorsal metatarsal artery—9.5% (group A), 3.5% (group B), 13% total.4
First Dorsal Metatarsal Artery, First Plantar Metatarsal Artery, and Arterial Supply of the Big Toe
The first dorsal metatarsal artery originates from the dorsalis pedis artery when the latter dives plantarward at the base of the first intermetatarsal space.
As described by Poirier and Charpy, the artery courses over the dorsum of the first dorsal interosseous muscle and divides into two branches—medial and lateral—at the level of the metatarsophalangeal joint of the big toe (Fig. 7.17).9 The medial branch provides two dorsolateral collaterals to the big toe. The lateral branch terminates as the dorsomedial branch of the second toe.
 Figure 7.17 Arterial supply of the big toe. (1, dorsalis pedis artery; 2, first proximal perforating artery or vertical descending portion of 1; 3, transverse segment or deep plantar arterial arc; 4, first dorsal metatarsal artery; 5, first distal perforating artery or vertical descending portion of 4; 6, medial division branch of first dorsal metatarsal artery, providing two dorsal collateral branches to big toe [8]; 7, lateral division branch of first dorsal metatarsal artery, providing tibial dorsal collateral branch to second toe; 9, first plantar metatarsal artery; 10, lateral division branch of first plantar metatarsal artery; 11, medial division branch of first plantar metatarsal artery; 12, medial plantar division branch of vertical portion of first dorsal metatarsal artery, providing medial [13] and lateral [14] hallucal plantar arteries; 15, lateral plantar division branch of vertical portion of first dorsal metatarsal artery, providing tibial plantar artery of second toe; 16, arterial branch arising from medial plantar artery joins first plantar metatarsal artery; 17, cruciate anastomosis formed by first plantar metatarsal artery and its two division branches joined by hallucal branch of medial plantar artery; 18, deep transverse metatarsal ligament; 19, first dorsal interosseous muscle arising from second metatarsal shaft.) (Diagram drawn in accordance with Poirier and Charpy’s description.9) |
Distally, in the web space, the first dorsal metatarsal artery plunges plantarward and bifurcates into its terminal branches, both medial and lateral. The medial plantar branch forms the plantar hallucal arteries, both fibular and tibial, whereas the lateral branch terminates as the medial plantar artery of the second toe. The lateral branch of the first plantar metatarsal artery joins the first dorsal metatarsal artery at the level of its plantar bifurcation. The plantar tibial hallucal artery crosses transversely between the midsegment of the proximal phalanx and the flexor hallucis longus tendon to reach the medial plantar aspect of the big toe, where it is joined by the medial bifurcation branch of the first plantar metatarsal artery (Fig. 7.18). Poirier and Charpy clearly state that “it is the dorsal interosseous (metatarsal1) and not the plantar interosseous (metatarsal1) that provides the three inner plantar collaterals of the [first and second] toes” (Figs. 7.19 and 7.20).9
The first plantar metatarsal artery is considered a branch of the dorsalis pedis or a terminal branch of the lateral plantar artery. It arises at the level of the inferior border of the second metatarsal from the dorsalis pedis arterial area during its vertical course in the first intermetatarsal space.5 It is directed medially and anteriorly, separated from the first dorsal metatarsal artery by the first dorsal interosseous muscle. It is located deep to the level of the oblique head of the adductor hallucis and the flexor hallucis brevis. Initially applied against the lateral surface of the first metatarsal, the artery passes between the bone and the flexor hallucis brevis muscle. At the level of the distal bifurcation triangle of this muscle, the first plantar metatarsal artery divides into two branches: lateral and medial. The lateral branch courses between the two heads of the flexor hallucis brevis and then passes plantar to the lateral head of the short flexor. It turns around the lateral sesamoid, pierces the deep lateral sagittal septum of the plantar aponeurosis for the big toe, courses on the plantar aspect of the deep transverse metatarsal ligament, and joins the first dorsal metatarsal artery at the point of bifurcation in the first web space. The medial branch of the first plantar metatarsal artery also emerges between the two heads of the short flexors of the big toe, passes around the medial sesamoid or between the two sesamoids, and terminates in the tibial plantar hallucal artery. This medial branch is joined by a thin branch from the medial plantar artery (see Figs. 7.17 and 7.18).
 Figure 7.18 Most common disposition of the first dorsal metatarsal artery. (1, dorsalis pedis artery; 2, transverse plantar arterial arc; 3, first plantar metatarsal artery; 4, first dorsal metatarsal artery; 5, lateral and medial dorsal division branches of first dorsal metatarsal artery, forming dorsotibial collateral branch of second toe and dorsoperoneal collateral branch of big toe; 6, medial division branch of first plantar metatarsal artery; 7, lateral division branch of first plantar metatarsal artery; 8, hallucal branch arising from medial plantar artery and forming cruciate anastomosis [9] with first plantar metatarsal artery and its division branches [6, 7]; 10, descending vertical portion of first dorsal metatarsal artery joined by lateral division branch of first plantar metatarsal artery; 11, common plantar hallucal artery; 12, plantar hallucal arteries, medial and lateral, with their transverse anastomotic branch [13]; 14, tibial and plantar collateral artery of second toe.) (From Gilbert A. In Tubiana R, ed. Chirurgie de la Main. Paris: Masson et Cie; 1976.) |
 Figure 7.19 Dorsal aspect of the first web space of the left foot. Top is proximal. (1, thin dorsalis pedis artery; 2, first proximal perforating artery provided from deep plantar arc and supplying first dorsal metatarsal artery [3]; 4, dorsal collateral arterial branch to second toe; 5, distal portion of first dorsal metatarsal artery; 6, vertical descending portion of first dorsal metatarsal artery; 7, 3, dorsal collateral branches of second and first toes.) |
 Figure 7.20 Relationship of the first dorsal metatarsal artery and the deep terminal branch of the deep peroneal nerve. Dorsal aspect of the first web space of the left foot; the big toe is on the left. (1, medial and lateral branches of deep peroneal nerve innervating first web space, crossing first dorsal metatarsal artery [2] superficially; 3, proximal dorsal collateral arterial branch to second toe; 4, vertical descending branch of first dorsal metatarsal artery; 5, 6, dorsal collateral arterial branches to second and first toe supplied by first dorsal metatarsal artery; dorsal collateral artery to second toe is thin.) |
The description by Gilbert (see Fig. 7.18) of the arterial blood supply of the big toe and second toe is quite similar to that provided by Poirier and Charpy except for some further details and minor variations in interpretation.5, 9 The first dorsal metatarsal artery arises from the dorsalis pedis artery as the latter enters the intermetatarsal space “limited anteriorly by the arch formed by the first dorsal interosseous muscle and posteriorly by the base of the two first metatarsals and their ligaments.”5 The first dorsal metatarsal artery passes under a muscular tunnel (about 15 mm long) formed by a belly of the first dorsal interosseous muscle and runs toward the web space in a subcutaneous position dorsal to the interosseous muscle.5 In the web space, the artery provides a dorsal branch to the big toe and a dorsal branch to the second toe and dives plantarward. It branches into the larger lateral plantar digital artery of the big toe and the thinner medial plantar digital artery of the second toe. By means of a transverse anastomotic branch located between the proximal phalanx of the big toe and the flexor hallucis longus tendon, the lateral plantar artery of the big toe unites with the distal segment of the medial plantar artery and provides the major blood supply to the big toe. At the level of the first metatarsal neck, the first plantar metatarsal artery is joined by the thin medial plantar artery. Two arteries arise from this junction, and a “vascular cross” is formed. As described above, the lateral branch joins the first dorsal metatarsal artery in the web space. The distal medial branch forms the plantar tibial hallucal artery. Occasionally, the latter is formed solely by the medial plantar artery.
The plantar fibular hallucal artery and the dorsal tibial artery of the second toe are the predominating vessels.3, 5, 10
The dorsal hallucal arteries derive from the first dorsal metatarsal artery, and the medial branch is present only in the distal segment.3, 9 The medial branch may be supplied by the plantar medial hallucal artery through a vertical ascending branch.3
The first dorsal metatarsal artery provides muscular branches to the first dorsal interosseous muscle, articular branches to the metatarsophalangeal joints of the big toe and second toe, and cutaneous branches to the skin of the dorsum of the foot.
The cutaneous branches arise from three main sites: proximal to the dorsal muscular arch of the first dorsal interosseous, distal to the same arch, and at the anterior aspect of the first web space.5
The cutaneous branches arise from three main sites: proximal to the dorsal muscular arch of the first dorsal interosseous, distal to the same arch, and at the anterior aspect of the first web space.5
 Figure 7.21 Diagram of arterial supply of the first web space showing two basic variations of the first dorsal metatarsal artery origin. (DDA, dorsal digital artery; DPA, dorsalis pedis artery; FDMA, first dorsal metatarsal artery; FPMA, first plantar metatarsal artery; PDA, plantar digital artery; TML, transverse metatarsal ligament.) (From May JW Jr, Chait LA, Cohen BE, et al. Free neurovascular flap from the first web of the foot in hand reconstruction. J Hand Surg. 1977;2[5]:387.) |
The caliber of the first dorsal metatarsal artery is 1 to 1.5 mm. The first plantar metatarsal artery is of similar size or smaller.5
Arterial Supply of the First Web Space
May and colleagues studied the neurovascular anatomy of the first web space in 50 fresh cadaver specimens.11 The arterial anatomy was defined in regard to the variations of the first dorsal metatarsal artery and the distal communicating arterial anastomosis.
The first dorsal metatarsal artery was seen in two basic patterns (Fig. 7.21):
Type I (78%): The first dorsal metatarsal artery arises from the dorsalis pedis artery superficially at the base of metatarsals 1 and 2. It courses distally under the tendon of the extensor hallucis brevis, in the subcutaneous tissue. Proximally, it is covered by little or no first interosseous muscle.
Figure 7.22 Patterns of distal communicating artery anastomosing. (DCA, distal communicating artery; DDA, dorsal digital artery; DPA, dorsal plantar artery; FDMA, first dorsal metatarsal artery; FPMA, first plantar metatarsal artery; PDA, plantar digital artery; TML, transverse metatarsal ligament.) (From May JW Jr, Chait LA, Cohen BE, et al. Free neurovascular flap from the first web of the foot in hand reconstruction. J Hand Surg. 1977;2[5]:387.)
Type II (22%): The first dorsal metatarsal artery arises deeply from the descending segment of the dorsalis pedis artery or from the plantar arterial tree. It ascends in the first metatarsal space and courses under or through the first dorsal interosseous muscle.
Both types of first dorsal metatarsal artery pass dorsal to the deep transverse metatarsal ligament and give small branches to the skin, muscle, and adjacent metatarsophalangeal joints. The artery courses distally, gives a small branch to the first and second toes, turns plantarward over the transverse metatarsal ligament, forms the distal communicating artery, and joins the first plantar metatarsal artery. Two large plantar digital arteries arise at the junction site and continue toward the tuft of the corresponding first and second toe. The variation of the anastomosis of the distal communicating artery is as follows (Fig. 7.22).
Type I (38%): The distal communicating artery anastomoses with the first plantar metatarsal artery.
Type II (26%): The distal communicating artery anastomoses with the plantar digital artery of the first toe.
Type III (28%): The distal communicating artery anastomoses with the plantar digital artery of the second toe.
TABLE 7.4 SIZE OF ARTERIES SUPPLYING THE FIRST WEB SPACE OF THE FOOT AND DISTANCE OF THEIR ORIGINS FROM THE WEB EDGE IN 50 SPECIMENS | |||||||||||||||||||||||||||||||||||||||||||||
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In 8% of feet, minor variations to the three major patterns were noted.
The diameters of the arterial branches of the first web space and the distance of the origin from the edge of the web space are indicated in Table 7.4.
Variations of the First Dorsal Metatarsal Artery
The variations of the first dorsal metatarsal artery have been analyzed according to the origin and principal source of supply and the relationship with the first dorsal interosseous muscle.2, 4, 5, 12
Variations Relative to the Source of Supply. With regard to the main source of the first dorsal metatarsal artery, in 230 feet it is reported to be dorsal in 80.8% and plantar in 19.1%; in 200 feet, it is reported as dorsal in 76.5%, plantar in 8.5%, dorsal and plantar in 0.3%, and absent in 12%.2, 4
Variations Relative to the First Dorsal Interosseous Muscle and to the Insertion of the Adductor of the Big Toe. Murakami, in a study of 40 feet, groups the variations of the first dorsal and first plantar metatarsal arteries into eight types (Fig. 7.23).12
Type Ia (5%): The first dorsal and first plantar metatarsal arteries have a common trunk passing deep to the first dorsal interosseous muscle. The trunk reaches the plantar aspect of the first metatarsal bone and divides into the dorsal and plantar branches just proximal to the tendon of the adductor hallucis.
Type Ib (5%): The common trunk is more dorsal and passes close to the plantar aspect of the first dorsal interosseous muscle, and the division occurs just proximal to the adductor hallucis tendon.
Type Ic (12.5%): The common trunk is short, is located under the first dorsal interosseous muscle, and bifurcates, proximal to the distal border of the origin of the muscle, into the first dorsal and first plantar metatarsal arteries.
Type Id (25%): The common trunk bifurcates just distal to the origin of the first dorsal interosseous muscle.
Type II (25%): The dorsal and plantar arteries arise independently. The first dorsal metatarsal artery passes superficially to the first dorsal interosseous muscle, whereas the plantar artery passes deep to the same muscle.
Type III (17.5%): Both arteries arise independently. The dorsal artery passes just under the first dorsal interosseous muscle; the plantar artery descends on the plantar aspect of the first metatarsal bone.
Figure 7.23 Variations in the origin and proximal course of the dorsal and plantar arteries in the first intermetatarsal space. (a, first dorsal metatarsal artery; b, first plantar metatarsal artery; c, deep plantar branch of dorsalis pedis artery; D, medial head of first dorsal interosseous muscle; AF, adductor hallucis and flexor hallucis brevis muscles; P, tendon of peroneus longus muscle.) (From Murakami T. On the position and course of the deep plantar arteries, with special reference to the so-called plantar metatarsal arteries. Okajimas Folia Anat Jpn. 1971;48:295.)
Type IV (7.5%): The first dorsal metatarsal artery pierces the first dorsal interosseous muscle. The plantar artery is more plantar in location.
Type V (2.5%): The common trunk of both arteries passes dorsal to the first dorsal interosseous muscle and bifurcates just proximal to the adductor hallucis insertion.
Variations Relative to the First Dorsal Interosseous Muscle and to the Deep Transverse Metatarsal Ligament. Gilbert, in a study of 50 feet, groups the variations of the first dorsal metatarsal artery into five types (Fig. 7.24).5
Types Ia and Ib (66%): Both metatarsal arteries arise independently. In type Ia, the first dorsal metatarsal artery passes under the small posterior belly of the first dorsal interosseous muscle but remains superficial to the main muscle and to the deep transverse metatarsal ligament. In type Ib, the dorsal artery passes through the first dorsal interosseous muscle.
Types IIa and IIb (22%): The dorsal and plantar metatarsal arteries have a common trunk located under the first dorsal interosseous muscle. The first dorsal metatarsal artery courses deep to the muscle and passes dorsal to the deep transverse metatarsal ligament.
Type IIa : A slender superficial branch is present passing superficially to the muscle and uniting at the anterior part of the web space with the dorsal metatarsal artery.
Type IIb: The superficial arterial branch is not present.
Type III (12%): The first dorsal interosseous artery is slender and passes through the first dorsal interosseous muscle. The first plantar metatarsal artery is well developed.
Leung and coworkers studied the arterial and venous supply of the first metatarsal web space in 70 feet.13 Five dissections were done on fresh cadaver feet, and sixty-five dissections were carried out in surgery prior to toe transfer operations. The external diameter of the dorsalis pedis artery measured 1.3 mm in average, with a range of 1 to 1.9 mm. Seven types of arterial patterns were identified (Fig. 7.25).
 Figure 7.24 Anatomic variations of first dorsal metatarsal artery found in 50 specimens. (1, descending branch of dorsalis pedis artery; 2, first dorsal metatarsal artery; 3, first plantar metatarsal artery; 4, common trunk to 2 and 3; 5, thin superficial first dorsal metatarsal artery; 6, 7, origin of first dorsal interosseous muscle; 8, deep transverse metatarsal ligament.) (From Gilbert A. In Tubiana R, ed. La Main. Paris: Masson et Cie; 1976.) |
Type I (28.6%): The superficial first dorsal metatarsal artery arises from the dorsalis pedis artery before the latter plunges into the first metatarsal space. The first dorsal metatarsal artery runs superficial to the first dorsal interosseous muscle, passes dorsal to the deep transverse metatarsal ligament, and divides into two branches, one for the big toe and one for the second toe. During the course, the artery gives off one to three small branches. The diameter of the first dorsal metatarsal artery ranges from 0.4 to 0.8 mm.
Type II (25.7%): The intramuscular first dorsal metatarsal artery passes through the first dorsal interosseous muscle and gives off three to five extremely small branches. The diameter of the artery ranges from 0.4 to 0.8 mm.
Type III (14%): The deep first dorsal metatarsal artery arises deep from the dorsalis pedis vertical portion. It runs along the plantar aspect of the first dorsal interosseous muscle, passes above or below the deep transverse metatarsal ligament, and divides into terminal branches to the big toe and second toe. The first dorsal metatarsal artery gives off 6 to 10 large branches to the bone, near the commencement of the artery and near the first metatarsal neck. The division into the terminal digital branches may occur more distally in the web space. The diameter of the artery ranges from 0.6 to 0.8 mm.
Type IV (5%): Deep and superficial first dorsal metatarsal arteries. A small superficial dorsal metatarsal artery branches off the dorsalis pedis artery superficially. This artery measures 0.1 to 0.3 mm in external diameter and terminates in fine branches in the web space without reaching the toes. The deep first dorsal metatarsal artery is similar to type III.
Type V (8%): The first plantar metatarsal artery. The first dorsal metatarsal artery is absent. The first plantar metatarsal
artery has a large diameter (0.6 to 0.8 mm), runs plantar to the bone, and gives off 8 to 10 branches to the big toe. It passes plantar to the deep transverse metatarsal ligament and divides into multiple branches to the two toes. The adjacent plantar digital branches are smaller.
Figure 7.25 Six of the seven patterns of distribution of the dorsalis pedis artery of the first web space of the foot. (In type VII, this artery is absent.) (1 Dl, first dorsal metatarsal artery [dorsal interosseous]; 1P, first plantar metatarsal artery; DP, dorsalis pedis artery; DPA, deep plantar arch; SB, superficial branch; TML, transverse metatarsal ligament.) (From Leung PC, Wong WL. The vessels of the first metatarsal web space. J Bone Joint Surg Am. 1983;65[2]:235.)
Type VI (1%): Absent first metatarsal artery, dorsal or plantar.
Type VII (4%): Absent dorsalis pedis artery.
Variations of the First Plantar Metatarsal Artery
The variations of the first plantar metatarsal artery, as described by Gilbert, involve mainly the origin.5 The artery may branch off from the dorsalis pedis or the dorsal metatarsal artery. In one case in 50 feet, the artery branched from the plantar arterial arch, and in another it branched from the terminal segment of the medial plantar artery.
The distal segment of the artery is fairly constant in its course and anatomic location at the level of the lateral sesamoid bone.
Variations of the Tibial Plantar Hallucal Artery
The tibial plantar hallucal artery has a variable origin. The artery may arise from the first dorsal metatarsal artery, the first plantar metatarsal artery, or the tibial superficial plantar artery.
In a study of 100 feet, Adachi found that the tibial plantar hallucal artery originates from the first dorsal metatarsal artery in 40%; from the first plantar metatarsal artery, fibular branch, in 35%, tibial branch, in 13%, both branches, in 5%; from the tibial superficial plantar artery in 1%; from the first dorsal metatarsal and first plantar metatarsal (tibial branch) arteries in 5%; and from the first dorsal metatarsal artery and the tibial superficial plantar artery in 1% (Fig. 7.26).2
Dorsomedial Hallucal Artery and Variations
The artery dorsalis hallucis tibialis or dorsal medial hallucal artery has a plantar or dorsal origin. As mentioned by Adachi, the artery originating from the first dorsal metatarsal artery and oriented toward the dorsotibial aspect of the big toe does not extend distally beyond the first metatarsophalangeal joint. The distal segment of the dorsomedial aspect of the big toe is supplied by a plantar branch arising from the plantar medial hallucal artery, turning around the proximal phalanx, and reaching the dorsotibial aspect of the big toe.3 Poirier and Charpy describe the distal segment of the dorsotibial hallucal artery as being provided by the first dorsal metatarsal artery.9 The principal source of the dorsomedial hallucal artery is described as plantar in 98.7% of 200 feet and 4.3% of 140 feet; as dorsal in 0.9% of 200 feet and 95.7% of 140 feet; and as plantar and dorsal in 0.4% of 200 feet and 0 of 140 feet.1, 2 The extreme differences are explained by the ethnic background (Japanese versus European).
Dorsal Metatarsal Arteries 2 to 4
The dorsal metatarsal arteries 2 to 4 have a double origin: dorsal and plantar (see Fig. 7.3). The dorsal source arises from the dorsal rete and the plantar source from the proximal or posterior perforating artery. According to the caliber of the supply vessel, one source may be considered to predominate or both sources may be of equal importance.
The respective sources of the dorsal metatarsal arteries 2 to 4 are as shown in Table 7.5. The dorsal source is provided predominantly by the arcuate artery, followed in frequency by the proximal lateral tarsal artery. The plantar source is provided by the proximal or posterior perforating artery.
 Figure 7.26 Variations of the origin of the tibial plantar hallucal artery. The tibial plantar hallucal artery is provided by (A) the first dorsal metatarsal artery (1); (B) the fibular branch of the first plantar metatarsal artery (2); (C) the tibial branch of the first plantar metatarsal artery (3); (D) the tibial superficial artery (4); (E) the first dorsal metatarsal artery (1) and the tibial branch of the first plantar metatarsal artery (3); (F) both branches of the first plantar metatarsal artery (2, 3); (G) the first dorsal metatarsal artery (1) and the tibial superficial metatarsal artery (4). (From Adachi B. Das Arteriensystem der Japaner. Kyoto: Maruzen; 1928:281.) |
Dorsal Digital Arteries
The dorsal digital arteries arise close to the metatarsophalangeal joints from the dorsal metatarsal artery, a branch of the plantar metatarsal artery passing dorsally through the distal part of the intermetatarsal space and forming the distal part of the dorsal metatarsal artery, or equally from the dorsal and plantar sources. The incidence of these sources of supply in 200 Western feet is shown in Table 7.6.
Posterior Perforating Arteries
The posterior perforating arteries (proximal perforating arteries, posterior communicating arteries) pass through the proximal end of the corresponding intermetatarsal spaces and join the dorsal metatarsal arteries.4 They are important contributors to the latter, especially when the dorsal source is deficient. They may be absent in 3% to 5%.4
Anterior Perforating Arteries
The dorsal metatarsal artery gives origin to two dorsal digital arteries in the web space, plunges plantarward, forming the anterior perforating artery, supplies the plantar digital arteries, and is joined by the plantar metatarsal artery.4 In the distal segment of the intermetatarsal space and in the web space, there are five communicating branches between the dorsal and plantar arteries: two arteries that arise from each side of
the dorsal metatarsal artery at the metatarsal neck and course plantarward obliquely to unite with the corresponding plantar metatarsal arteries; one artery that is the continuation of the dorsal metatarsal artery and is usually called the anterior perforating artery; and two small arteries that connect on each side the dorsal and plantar digital arteries at the level of the side of the corresponding proximal phalanx.4 Huber groups all five branches under the heading “anterior communicating branches.”4 The connections between the first dorsal metatarsal artery and the first plantar metatarsal artery are indicated in Figure 7.27.
the dorsal metatarsal artery at the metatarsal neck and course plantarward obliquely to unite with the corresponding plantar metatarsal arteries; one artery that is the continuation of the dorsal metatarsal artery and is usually called the anterior perforating artery; and two small arteries that connect on each side the dorsal and plantar digital arteries at the level of the side of the corresponding proximal phalanx.4 Huber groups all five branches under the heading “anterior communicating branches.”4 The connections between the first dorsal metatarsal artery and the first plantar metatarsal artery are indicated in Figure 7.27.
TABLE 7.5 SOURCE OF DISTAL METATARSAL ARTERIES | ||||||||||||||||||||||||||||||||||||||||||
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TABLE 7.6 SOURCES OF SUPPLY TO DORSAL DIGITAL ARTERIES | |||||||||||||||||||||||||||||||||||
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 Figure 7.27 Anastomoses between the dorsal and plantar arteries in the interdigital spaces. (A-C) Examples of the ways in which the continuation of the dorsal metatarsal artery may contribute to the plantar digital arteries. (D) There is a connection between the dorsal and plantar digital arteries. (1, dorsal metatarsal artery; 2, dorsal digital arteries; 3, plantar digital arteries; 4, plantar metatarsal artery; 5, connection between dorsal and plantar digital arteries.) (From Huber JF. The arterial network supplying the dorsum of the foot. Anat Rec. 1941;80:373. By permission of Alan R. Liss, Inc., Publisher.) |
Arteries of the Sinus Tarsi
The artery of the sinus tarsi (perforating vessel of the sinus tarsi, arteria anastomotica tarsi, ramus anastomicus tarsi) has a very variable origin (Figs. 7.28 and 7.29). Frequently, it arises
from the lateral aspect of the dorsalis pedis artery at the level of the talar neck or from an anastomotic loop between the proximal lateral tarsal artery and the perforating peroneal artery.7 The artery is always present. At the level of the talar neck, it gives off a few branches to the head, enters the sinus tarsi, supplies multiple branches to the talar body, and anastomoses with the artery of the tarsal canal emanating from the posterior tibial artery.
from the lateral aspect of the dorsalis pedis artery at the level of the talar neck or from an anastomotic loop between the proximal lateral tarsal artery and the perforating peroneal artery.7 The artery is always present. At the level of the talar neck, it gives off a few branches to the head, enters the sinus tarsi, supplies multiple branches to the talar body, and anastomoses with the artery of the tarsal canal emanating from the posterior tibial artery.
 Figure 7.28 Artery of the sinus tarsi arising from the dorsalis pedis artery. The calcaneus has been removed. (From Wildenauer E. Die bluvesorgung des talus. Z Anat Entwicklungs. 1950;115:32.) |
The caliber of the artery at the entrance of the sinus tarsi is reported by Adachi as being 1 to 1.5 mm and never more than 2 mm.4 The origin of the artery of the sinus tarsi is reported to occur from the dorsalis pedis artery in 52% of 305 feet and 39.2% of 120 feet; from the lateral tarsal artery in 32% of 305 feet and 21.7% of 120 feet; from the anterior lateral malleolar artery in 9% of 305 feet and 11.7% of 120 feet; and from two equally strong arteries in 15.8% of 120 feet (proximal—dorsalis pedis, perforating branch of peroneal artery, 10%; distal—lateral tarsal artery, 5.8%).1, 2
 Figure 7.29 Artery of the sinus tarsi and artery of the canalis tarsi arising from the posterior tibial artery. (From Wildenauer E. Die bluvesorgung des talus. Z Anat Entwicklungs. 1950;115:32.) |
Medial Tarsal Arteries
The medial tarsal arteries are very variable in size and number (see Fig. 7.3). They might be two of equal size arising from the dorsalis pedis, one at the level of the middle of the navicular and the other just below the cuneonavicular articulation.4 At times, there is only one proximal or one distal branch. Rarely are three branches present. These branches occur with the following frequency in 200 feet: two equal, 42%; one proximal, 13%; one distal, 13.5%; short common stem at the level of the proximal medial tarsus, divided into two branches (proximal and distal), 15%; minute branches, 16.5%.4
The medial tarsal arteries anastomose on the medial margin of the foot with the medial plantar artery. Adachi describes a significant anastomosis located on the medial margin of the foot between the first cuneiform and the muscles.2
Anterior Medial Malleolar Artery
The anterior medial malleolar artery originates from the dorsalis pedis artery just below the ankle joint (see Figs. 7.3 and 7.28). As mentioned by Huber, it is “not possible to decide in all cases on any one artery which should be called the anterior medial malleolar artery.”4
The artery is directed transversely medially, passes under the tibialis anterior tendon, and at the level of the anterior border of the medial malleolus divides into two branches: superficial
and deep. The superficial branch crowns the base of the medial malleolus and anastomoses with the terminal thin branch of the posterior medial malleolar artery arising from the posterior tibial artery. The anastomotic network or medial malleolar rete provides small branches penetrating the medial malleolus near the base and coursing in a proximodistal direction. The deep branch of the anterior medial malleolar artery disappears in the deltoid ligamentous complex.
and deep. The superficial branch crowns the base of the medial malleolus and anastomoses with the terminal thin branch of the posterior medial malleolar artery arising from the posterior tibial artery. The anastomotic network or medial malleolar rete provides small branches penetrating the medial malleolus near the base and coursing in a proximodistal direction. The deep branch of the anterior medial malleolar artery disappears in the deltoid ligamentous complex.
The variations occur relative to the origin, number, and size of the artery. The variations of origin are listed in Table 7.7. The anterior medial malleolar artery is absent in 16%, and occasionally it is very insignificant.1 It is usually smaller than the anterior lateral malleolar artery, and according to Adachi, the anterior lateral malleolar artery is larger in 69%, the anterior medial malleolar artery is larger in 7%, and both are equal in 24%.2
Gilbert et al.8 described the anterior medial malleolar artery arising proximal to the tibiotalar joint in 45% (9 specimens) and at the tibiotalar joint in 55% (11 specimens). On the average, when the anterior medial malleolar artery originated from the anterior tibial artery, it arose 4 mm (range, 0 to 9 mm) proximal to the tibiotalar joint. The anterior medial malleolar artery traveled transversely medially, underneath the tibialis anterior tendon, and divided into a deep branch and a superficial branch. The deep branch of the anterior medial malleolar artery was present in all 10 corrosion cast specimens and supplied multiple nutrient vessels to the distal aspect of the tibia around the ankle mortise in 6 of the 10 specimens and provided direct nutrient branches to the neck of the talus in all 10 specimens. The superficial branch of the anterior medial malleolar artery was present in all 10 corrosion specimens. It bifurcated into a talar nutrient branch and a medial malleolar nutrient branch and this bifurcation occurred also in all 10 corrosion cast specimens. In eight specimens, the superficial branch of the anterior medial malleolar artery sent a branch into the deltoid ligament from either the talar nutrient branch or from the medial malleolar nutrient branch. The talar nutrient branch anastomosed with the medial recurrent tarsal artery or another branch of the proximal medial tarsal artery to supply nutrient vessels to the talus. The medial malleolar nutrient branch provided the medial aspect of the medial malleolus with nutrient vessels.
TABLE 7.7 VARIATIONS OF ORIGIN OF THE ANTERIOR MEDIAL MALLEOLAR ARTERY | ||||||||||||||||||||
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Anterior Lateral Malleolar Artery
The anterior lateral malleolar artery originates from the dorsalis pedis just below the ankle joint articular interline, usually 1 to 2 mm below the most common point of origin for the anterior medial malleolar artery (see Figs. 7.3 and 7.51).4
The artery is directed transversely laterally and passes under the tendons of the extensor digitorum longus and the peroneus tertius. At the level of the anterior border of the lateral malleolus, it descends vertically along the anterior border of the lateral malleolus and the lateral border of the tarsus and anastomoses with the proximal lateral tarsal artery and the lateral plantar artery.
The transverse segment of the anterior lateral malleolar artery anastomoses proximally with branches from the perforating peroneal artery and sends a transverse branch over the lateral malleolus. The latter anastomoses with a similar transverse branch emanating from the peroneal artery and contributes to the formation of the perimalleolar transverse arterial loop. The descending retromalleolar branch of the peroneal artery unites with the descending segment of the anterior lateral malleolar artery, forms a sagittal arterial loop, and contributes to the formation of the lateral malleolar arterial rete.
The variations occur relative to the origin, number, and size of the artery. The variations of origin are shown in Table 7.8. The anterior lateral malleolar artery is absent in 8%, may be double in 16%, and in 29% originates not from the dorsalis pedis but from the perforating branch of the peroneal artery.1
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