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VASCULAR SUPPLY

ARTERIES

Anterior tibial artery

The anterior tibial artery arises at the distal border of popliteus (Figs 83.9, 83.12, 83.13; see Figs 82.1, 82.4, 84.9). At first in the flexor compartment, it passes between the heads of tibialis posterior and through the oval aperture in the proximal part of the interosseous membrane to reach the extensor (anterior) compartment, passing medial to the fibular neck: it is vulnerable here during tibial osteotomy. Descending on the anterior aspect of the membrane it approaches the tibia and, distally, lies anterior to it. At the ankle the anterior tibial artery is midway between the malleoli, and it continues on the dorsum of the foot as the dorsalis pedis artery.

  

Fig. 83.12  Transverse section through the left leg, approximately 6 cm proximal to the tip of the medial malleolus.

  

Fig. 83.13  Magnetic resonance angiogram of major branches of the popliteal artery. 1. Tibiofibular trunk. 2. Anterior tibial artery. 3. Fibular artery. 4. Posterior tibial artery.
(By courtesy of Dr Justin Lee, Chelsea and Westminster Hospital, London.)

The anterior tibial artery may, on occasion, be small but it is rarely absent. Its function may be replaced by perforating branches from the posterior tibial artery or by the perforating branch of the fibular artery. It occasionally deviates laterally, regaining its usual position at the ankle. It may also be larger than normal, in which case its territory of supply in the foot may be increased to include the plantar surface.

Relations

In its proximal two-thirds the anterior tibial artery lies on the interosseous membrane, and in its distal third it is anterior to the tibia and ankle joint. Proximally it lies between tibialis anterior and extensor digitorum longus, then between tibialis anterior and extensor hallucis longus. At the ankle it is crossed superficially from the lateral side by the tendon of extensor hallucis longus and then lies between this tendon and the first tendon of extensor digitorum longus. Its proximal two-thirds are covered by adjoining muscles and deep fascia, its distal third by the skin, fasciae and extensor retinacula. It is accompanied by venae comitantes. The deep fibular nerve, curling laterally round the fibular neck, reaches the lateral side of the artery where it enters the extensor region, is then anterior to the artery in the middle third of the leg, and becomes lateral again distally.

Branches

The named branches of the anterior tibial artery are the posterior and anterior recurrent tibial, muscular, perforating, and anterior medial and lateral malleolar arteries.

Posterior tibial recurrent artery

The posterior tibial recurrent artery is an inconstant branch that arises before the anterior tibial reaches the extensor compartment. It ascends anterior to popliteus with the recurrent nerve to that muscle, anastomosing with the inferior genicular branches of the popliteal artery. It supplies the superior tibiofibular joint.

Anterior tibial recurrent artery

The anterior tibial recurrent artery arises near the posterior tibial recurrent artery. It ascends in tibialis anterior, ramifies on the front and sides of the knee joint and joins the patellar network, anastomosing with the genicular branches of the popliteal and circumflex fibular arteries.

Muscular branches

Numerous branches supply the adjacent muscles. Some then pierce the deep fascia to supply the skin, while others traverse the interosseous membrane to anastomose with branches of the posterior tibial and fibular arteries.

Perforating branches

Most of the fasciocutaneous perforators pass along the anterior fibular fascial septum behind extensor digitorum longus before penetrating the deep fascia to supply the skin.

Anterior medial malleolar artery

The anterior medial malleolar artery arises approximately 5 cm proximal to the ankle. It passes posterior to the tendons of extensor hallucis longus and tibialis anterior medial to the joint, where it joins branches of the posterior tibial and medial plantar arteries.

Anterior lateral malleolar artery

The anterior lateral malleolar artery runs posterior to the tendons of extensor digitorum longus and fibularis tertius to the lateral side of the ankle and anastomoses with the perforating branch of the fibular artery and ascending branches of the lateral tarsal artery.

Posterior tibial artery

The posterior tibial artery begins at the distal border of popliteus, between the tibia and fibula (Fig. 83.13; see Figs 82.1, 82.4). It descends medially in the flexor compartment and divides under abductor hallucis, midway between the medial malleolus and the medial tubercle of the calcaneus, into the medial and lateral plantar arteries. The artery may be much reduced in length or in calibre: the fibular artery then takes over its distal territory of supply and may consequently be increased in size.

Relations

The posterior tibial artery is successively posterior to tibialis posterior, flexor digitorum longus, the tibia and the ankle joint. Proximally, gastrocnemius, soleus and the deep transverse fascia of the leg are superficial to the artery, and distally it is covered only by skin and fascia. It is parallel with and approximately 2.5 cm anterior to the medial border of the calcaneal tendon; terminally it is deep to the flexor retinaculum and abductor hallucis. The artery is accompanied by two veins and the tibial nerve. The nerve is at first medial to the artery but soon crosses behind it and subsequently becomes largely posterolateral.

Branches

The named branches of the posterior tibial artery are the circumflex fibular, nutrient, muscular, perforating, communicating, medial malleolar, calcaneal, lateral and medial plantar, and fibular arteries.

Circumflex fibular artery

The circumflex fibular artery, which sometimes arises from the anterior tibial artery, passes laterally round the neck of the fibula through the soleus to anastomose with the lateral inferior genicular, medial genicular and anterior tibial recurrent arteries. It supplies bone and articular structures.

Nutrient artery of the tibia

The nutrient artery of the tibia arises from the posterior tibial near its origin. After giving off a few muscular branches it descends into the bone immediately distal to the soleal line. It is one of the largest of the nutrient arteries.

Muscular branches

Muscular branches are distributed to the soleus and deep flexors of the leg.

Perforating branches

Approximately five fasciocutaneous perforators emerge between flexor digitorum longus and soleus and pass through the deep fascia, often accompanying the perforating veins that connect the deep and superficial venous systems. The arterial perforators then divide into anterior and posterior branches to supply periosteum and skin. These vessels are utilized in raising medial fasciocutaneous perforator flaps in the leg.

Communicating branch

The communicating branch runs posteriorly across the tibia approximately 5 cm above its distal end, deep to flexor hallucis longus, to join a communicating branch of the fibular artery.

Medial malleolar branches

The medial malleolar branches pass round the tibial malleolus to the medial malleolar network, which supplies the skin.

Calcaneal branches

Calcaneal branches arise just proximal to the terminal division of the posterior tibial artery. They pierce the flexor retinaculum to supply fat and skin behind the calcaneal tendon and in the heel, and muscles on the tibial side of the sole; the branches anastomose with medial malleolar arteries and calcaneal branches of the fibular artery.

Medial plantar artery

The medial plantar artery is the smaller terminal branch of the posterior tibial artery and passes distally along the medial side of the foot, medial to the medial plantar nerve (see Fig. 84.24). At first deep to abductor hallucis, it runs distally between this muscle and flexor digitorum brevis, and supplies both. Near the first metatarsal base, its size, already diminished by muscular branches, is further reduced by a superficial stem that divides to form three superficial digital branches. These accompany the digital branches of the medial plantar nerve and join the first to third plantar metatarsal arteries. The main trunk of the medial plantar artery then runs on to reach the medial border of the hallux, where it anastomoses with a branch of the first plantar metatarsal artery.

Lateral plantar artery

The lateral plantar artery is the larger terminal branch of the posterior tibial artery (see Fig. 84.24). It passes distally and laterally to the fifth metatarsal base, lateral to the lateral plantar nerve. (The medial and lateral plantar nerves lie between the corresponding plantar arteries.) Turning medially with the deep branch of the lateral plantar nerve, it reaches the interval between the first and second metatarsal bases, and unites with the dorsalis pedis artery to complete the plantar arch. As it passes laterally, it is first between the calcaneus and abductor hallucis, then between flexor digitorum brevis and flexor accessorius. Running distally to the fifth metatarsal base, it passes between flexor digitorum brevis and abductor digiti minimi and is covered by the plantar aponeurosis, superficial fascia and skin.

Branches

Muscular branches supply the adjoining muscles. Superficial branches emerge along the lateral intermuscular septum to supply the skin and subcutaneous tissue lateral in the sole. Anastomotic branches run to the lateral border of the foot, joining branches of the lateral tarsal and arcuate arteries. A calcaneal branch sometimes pierces abductor hallucis to supply the skin of the heel.

Fibular artery

The fibular artery arises from the posterior tibial artery approximately 2.5 cm distal to popliteus and passes obliquely to the fibula, descending along its medial crest either in a fibrous canal between tibialis posterior and flexor hallucis longus or within flexor hallucis longus (Figs 83.9, 83.12, 83.13; see Fig. 82.4). Reaching the inferior tibiofibular syndesmosis, it divides into calcaneal branches that ramify on the lateral and posterior surfaces of the calcaneus. Proximally it is covered by soleus and the deep transverse fascia between soleus and the deep muscles of the leg, and distally it is overlapped by flexor hallucis longus.

The fibular artery may branch high from the posterior tibial artery or may even branch from the popliteal artery separately, giving a true ‘trifurcation’. It may also branch more distally from the posterior tibial artery, sometimes 7 or 8 cm distal to popliteus. Its size tends to be inversely related to the size of the other arteries of the leg. It may be reduced in size but is more often enlarged, when it may join, reinforce or even replace the posterior tibial artery in the distal leg and foot. An enlarged perforating branch may replace the dorsalis pedis artery: the dorsalis pedis pulse will then be absent.

Branches

The fibular artery has muscular, nutrient, perforating, communicating and calcaneal branches.

Muscular branches

Multiple short branches supply soleus, tibialis posterior, flexor hallucis longus and the fibular muscles.

Nutrient artery

The nutrient artery branches from the main trunk approximately 7 cm from its origin and enters the fibula 14–19 cm from the styloid process.

Perforating branches

The main perforating branch traverses the interosseous membrane approximately 5 cm proximal to the lateral malleolus to enter the extensor compartment, where it anastomoses with the anterior lateral malleolar artery. Descending anterior to the inferior tibiofibular syndesmosis, it supplies the tarsus and anastomoses with the lateral tarsal artery. This branch is sometimes enlarged and may replace the dorsalis pedis artery.

Fasciocutaneous perforators from the lateral muscular branches pass along the posterior fibular fascial septum to penetrate the deep fascia and reach the skin. These vessels are utilized in raising fasciocutaneous posterolateral leg flaps (see below).

Communicating branch

The communicating branch connects to a communicating branch of the posterior tibial artery approximately 5 cm proximal to the ankle.

Calcaneal branches

Calcaneal (terminal) branches anastomose with the anterior lateral malleolar and calcaneal branches of the posterior tibial artery.

Perforator flaps in the knee and leg

The perforators which arise from the rich vascular anastomosis around the patella generally traverse the quadriceps tendon to supply the skin over the patella and the peri-patellar region (see Fig. 79.7). The skin flaps based on these perforators may be used as distally based or proximally based flaps to cover defects over the knee and popliteal region. The direct cutaneous branch of the popliteal artery and a superficial sural artery which accompanies the sural nerve provide additional perforators to the skin over the back of the knee. The posterior tibial artery gives out an average of ten perforators to the skin covering the anteromedial and posterior parts of the leg. In the upper third of the leg the perforating vessels are predominantly muscular and periosteocutaneous, while in the lower third, the perforating vessels are mainly direct subcutaneous types. They anastomose with the perforating branches of the anterior tibial artery anteriorly and fibular artery posteriorly. Inferiorly, the posterior tibial artery forms a rich anastomotic circle around the ankle joint with the fibular and anterior tibial arteries. Perforators from these vessels supply the calcaneal tendon and the overlying skin. The posterior tibial artery gives off three direct cutaneous perforators in the lower part of the leg: a distally based skin or adipo-fascial flap based on one of these perforators may be used to reconstruct a defect over the anterior or the posterior aspect of the lower leg. The anterior tibial artery gives off an average of six perforators which supply the antero-lateral part of the leg. They emerge in two longitudinal rows; one perforator is fairly large and accompanies the superficial fibular nerve. A small skin flap based on any one of these perforators may be used to cover small defects over the tibia and a neurocutaneous flap that includes the superficial fibular nerve may be used.

The fibular artery has an average of five perforators. A constant perforator pierces the deep fascia approximately 5 cm above the lateral malleolus and divides into an ascending and descending branch. A vascularized fibula graft based on the fibular artery is now the standard graft used in reconstruction of the mandible, while small fascio-cutaneous and adipo-fascial flaps based on the perforators of the fibular artery are useful in covering soft tissue defects over the heel and proximal part of the foot region.

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