Achilles’ death

The Achilles tendon is the most frequently ruptured tendon in the lower limb and accounts for almost 20% of all large tendon injuries. Despite numerous published studies describing its blood supply, there has been no uniformity in describing its topography. The current study comprises a detailed anatomical study of both the intrinsic and extrinsic arterial supply of the Achilles tendon, providing the detail sought from studies calling for improved planning of surgical procedures where damage to the vascularity of the Achilles tendon is likely. A dissection, microdissection, histological, and angiographic study was undertaken on 20 cadaveric lower limbs from 16 fresh and four embalmed cadavers. The Achilles tendon is supplied by two arteries, the posterior tibial and peroneal arteries. Three vascular territories were identified, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. The midsection of the Achilles tendon was markedly more hypovascular that the rest of the tendon. The Achilles tendon is at highest risk of rupture and surgical complications at its midsection. Individuals with particularly poor supply of the midsection may be at increased risk of tendon rupture, and approaches to the tendon operatively should consider the route of supply by the peroneal artery to this susceptible part of the tendon.

The Achilles tendon is the strongest and thickest tendon in the human body. It is also the commonest tendon to rupture. It begins near the middle of the calf and is the conjoint tendon of the gastrocnemius and soleus muscles. The relative contribution of the two muscles to the tendon varies. Spiralisation of the fibres of the tendon produces an area of concentrated stress and confers a mechanical advantage. The calcaneal insertion is specialised and designed to aid the dissipation of stress from the tendon to the calcaneum. The insertion is crescent shaped and has significant medial and lateral projections. The blood supply of the tendon is from the musculotendinous junction, vessels in surrounding connective tissue and the osteotendinous junction. The vascular territories can be classified simply in three, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. This leaves a relatively hypovascular area in the mid-portion of the tendon where most problems occur. The Achilles tendon derives its innervation from the sural nerve with a smaller supply from the tibial nerve. Tenocytes produce type I collagen and form 90% of the cellular component of the normal tendon. Evidence suggests ruptured or pathological tendon produce more type III collagen, which may affect the tensile strength of the tendon. Direct measurements of forces reveal loading in the Achilles tendon as high as 9 KN during running, which is up to 12.5 times body weight.

Objectives The main factor in the healing of foot ulcers in diabetic patients is adequate perfusion. There is no consensus on whether direct or indirect revascularization is more effective in leg revascularization. At the centre of that debate, there is a disagreement about whether collateral circulation is sufficient or not. Our aim is to evaluate collateral circulation activity between angiosomes in the feet of diabetic patients by evaluating the level of occlusion in leg arteries and comparing the angiosome regions that have necrosis. Methods The study included 61 patients. All had undergone CT angiography to the lower extremity prior to any revascularization of the leg arteries between September 2014 and September 2016. Stenosis was evaluated on the anterior tibial artery, the posterior tibial artery and the peroneal artery up to the level of the ankle. The opening of the vessel wall at the narrowest part of the vessel was determined as a percentage. The areas with necrosis were determined according to the angiosomes of the posterior tibial artery, anterior tibial artery and peroneal artery vessels. Results Necrosis of the foot was most common in the posterior tibial artery angiosome. Necrosis in the posterior tibial artery angiosome was independent of the level of posterior tibial artery occlusion; however, it was associated with the occlusion of the anterior tibial artery ( p < 0.05). It was found that anterior tibial artery occlusion over 15% resulted in necrosis in the posterior tibial artery angiosome. Conclusions Collateral circulation between the anterior tibial artery and posterior tibial artery is active and there is almost always occlusion in the posterior tibial artery branches. The posterior tibial artery angiosome is fed by the collateral arteries of the anterior tibial artery even if there is no occlusion of posterior tibial artery at the level of the leg, so indirect revascularization on the anterior tibial artery is sufficient to provide foot circulation.

Research Type:Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studiesIntroduction/Purpose:The risk of vascular injury is a significant concern in posterior malleolus surgery, especially with the commonly used posterolateral approach. Anatomical variations of the peroneal artery, such as the presence of a communicating branch to the posterior tibial artery, may heighten this risk. This study investigates the prevalence of this communicating branch and its implications for surgical decision-making, advocating for the medial-posteromedial approach as a safer alternative.Methods:To identify the presence of a communicating branch between the peroneal and posterior tibial arteries, a retrospective analysis of 916 lower limb computed tomography angiographies (CTA) was performed. Patient data were stratified based on clinical indication for imaging, laterality, and the presence or absence of the communicating branch.Results:A communicating branch was identified in 289 (31.6%) of the cases. The prevalence was significantly higher in patients with PVD (n = 227) compared to those imaged for trauma (n = 18), free fibula graft assessment (n = 16), or other vascular concerns (n = 28). Notably, in cases where the communicating artery was present, 40% had an atretic proximal posterior tibial artery, making the peroneal artery, with its communicating branch, the primary blood supply to the medial plantar arch of the foot. This anatomical variation poses a substantial risk of arterial compromise if the posterolateral approach is used, as it necessitates ligation of these branches.Conclusion:Our findings reinforce the existing anatomical literature regarding the variability of peroneal artery branching and underscore the potential hazards of a posterolateral approach to the posterior malleolus. Inadvertent ligation of the communicating branch may lead to ischemic complications, such as flexor hallucis longus contracture. Given the high prevalence of this variation, particularly in patients with PVD, the posterolateral approach should be approached with caution. The medial-posteromedial approach provides a safer alternative, preserving vascular integrity while ensuring more than adequate surgical exposure for posterior malleolus fracture fixation.

Objective To compare the difference of high-frequency ultrasound characteristics of lower limb arteries between athletes and normal people, and explore the effect of exercise time on the ultrasonic characteristics of lower limb arteries, so as to guide people to live a healthy lifestyle. Methods A total of 96 professional long-distance runners, short-distance runners, and cyclists who worked in the local sports bureau and the sports college from July 2015 to March 2016 and were engaged in sports training ranging from 5 months to 11 years were selected as an experimental group. Another 108 healthy young people without exercise habits were selected as a control group. The ultrasound diagnostic instrument American GE LOGIQ-7 was used to examine the anterior tibial artery, posterior tibial artery, and peroneal artery of the subjects and measure the blood vessel inner diameter (ID) and intima-media thickness (IMT). SPSS19.0 statistical software package was used for data analysis. The data were tested for normality and homogeneity of variance. Measurement data such as ID and IMT are expressed as the mean ± standard deviation and were compared using the t-test. Count data such as sex composition are expressed as percentages and were compared using the χ2 test. The comparisons of ID and IMT among the experimental subgroups A, B, and C were performed by analysis of variance, followed by pairwise comparisons between groups by the LSD method. Results There were no significant differences in the ID or IMT of the anterior tibial artery, posterior tibial artery, and peroneal artery between the two sides in both groups (P>0.05). The ID and IMT of the tibial artery (t=-3.323, 4.488, all P 0.05). Conclusion Lower limb exercise training can increase the diameter and reduce the intima-middle thickness of the artery. Moreover, when a certain extent of exercise time and intensity are reached, the arterial diameter will gradually increase and intima-middle thickness will gradually decrease with the extension of exercise time, thus delaying the process of atherosclerosis. Key words: Ultrasonography; Athlete; Lower extremity artery; Inner diameter; Intimal medial thickness

To study the distance between the Achilles tendon and the posterior tibial neurovascular bundle via ultrasound (US) - Doppler, with the goal of preventing neurovascular bundle injuries. We studied 36 feet with equinus deformity (18 cases on the right and left side) in children with a mean age of 20.9 months. The distance between the Achilles tendon and the posterior tibial artery was intraoperatively measured using linear US at 10 MHz with Doppler. The measurement was made 1 cm proximal to the calcaneus insertion of the Achilles, where we planned to perform the tenotomy. The patient's weight and height were also recorded. Kolmogorov-Smirnov, t test, and Pearson correlation analyses were applied. Statistical significance was defined as p < 0.05. Mean distance between Achilles tendon and posterior neurovascular tibial bundle was 7.3 mm, and no differences between sexes or sides were observed. The distance was significantly correlated with weight (r = 0.54, p = 0.01) but not height or age. The distance between the Achilles tendon and the tibialis posterior neurovascular bundle is small, and there is a risk of surgical injury during tenotomy of the Achilles tendon.

Objective To investigate the clinical efficiency of perforator pedicled propeller flaps for soft-tissue coverage of the lower leg and foot defects.Methods From July 2007 to December 2011,twentyfive cases with soft-tissue defects of the lower leg and foot were cured by using the perforator propeller flaps.The origins of the perforator were 18 cases from peroneal artery,six cases from posterior tibial artery and 1 case from dorsal foot artery.The minimum of the flap scale was 4-9 cm,and the maximum was 10-33 cm.Results All cases were followed-up from 1 to 26 months.All the flap pedicles were smooth with a satisfied appearance.The donor sites were sutured directly in 9 cases and cured with skin-grafting in 16 cases.Three cases suffered from vein congestion,two cases were cured by incisions in the distal parts of the flaps,one flap had necrosis of the distal 1/3 part and was cured by skin-grafting.Conclusion The perforator pedicled propeller flap is a simple,safe and useful flap.It has more advantages than other pedicled flaps for softtissue coverage of the lower leg and foot defects. Key words: Lower leg and foot; Perforator flap; Propeller flap; Microsurgical operation

Objective To evaluate the impact of runoff score on the patency of femoropopliteal artery (FPA) stent in patients with type 2 diabetes mellitus with ultrasonography. Methods A retrospective review of a database of 127 patients with type 2 diabetes mellitus (127 limbs) undergoing femoropopliteal stents in Xuanwu Hospital from January 2016 to July 2018 was made. Demographic characteristics and possible related risk factors were recorded. The extent of FPA disease and the runoff lesions below the knee (anterior tibial artery, posterior tibial artery, and peroneal artery) were preoperative evaluated and regular followed-up by color Doppler ultrasonography (CDU). Femoropopliteal artery lesions were graded according to the Trans-Atlantic Inter-Society Consensus (TASCII), and the runoff lesions below the knee were scored according to the Society for Vascular Surgery (SVS). The patency and the predictors for in-stent restenosis were assessed using a Kaplan-Meier and Cox proportional hazards model. Results Follow up period ranged from 1 month to 24 months.The total patency rates at the 3, 6, 12, 24 months were 91.5%, 70.9%, 45.7% and 31.7%, respectively. Post-procedural runoff score according to SVS criteria: 1-3 scores in 45 limbs, 3.5-5 scores in 37 limbs, 5.5-7 scores in 34 limbs, 7.5-10 scores in 11 limbs. The median runoff score was 4.Patients were stratified according to runoff scores (score ≤4 and >4 groups), and the difference of the patency rates between the two groups was statistically significant by Kaplan-Meier analysis and Log-rank test (χ2=10.825, P=0.001). The runoff score affected patency significantly on COX analysis (RR=1.155, P=0.006, 95%CI: 1.042-1.281). Conclusions Compromised runoff negatively affects the patency of FPA stent. High post-procedural runoff score is a main risk factor related to loss of patency. CDU is a reliable method for monitoring patients with femoropopliteal stenting. Key words: Ultrasonography; Diabetes; Femoropopliteal artery; Runoff score; Stent

The Allen test is used to diagnose the relative contribution of the ulnar and radial arteries to each hand. We modified this test to investigate the relative vascular contributions to distal perfusion of the lower extremity. With the patient supine, a handheld Doppler is used to locate the first dorsal metatarsal artery. The posterior tibial artery (PT) and dorsalis pedis artery (DP) pulses are compressed. A persistent signal indicates collateral flow through the peroneal artery (PA). Sequential decompression is then used to evaluate the relative contribution of the PT and DP to distal circulation. We report a case in which angiography failed to predict reliance on the PT. In this case, performance of the lower-extremity Allen test (LEAT) led to an alternative recipient vessel choice. The LEAT is simple to perform and provides a valuable adjunct to angiographic data.

VH8. Retrograde Angioplasty During a Transtibial Amputation

Achilles, the warrior and hero of Homer's Iliad, lends his name to the Achilles tendon, the thickest and strongest tendon in the human body138. Thetis, Achilles's mother, made him invulnerable to physical harm by immersing him in the river Styx after learning of a prophecy that Achilles would die in battle. However, the heel by which he was held remained untouched by the water and thus Achilles had a vulnerable point. Achilles led the Greek military forces, which captured and destroyed Troy after killing the Trojan prince Hector. However, Hector's brother Paris killed Achilles by firing a poisoned arrow into his heel164. Hippocrates, in the first recorded description of an injury to the Achilles tendon, stated that “this tendon, if bruised or cut, causes the most acute fevers, induces choking, deranges the mind and at length brings death.”26 Ambroise Pare, in 1575, recommended that a ruptured Achilles tendon be strapped with bandages dipped in wine and spices, but advised that the result was dubious27. Operative repair of a ruptured Achilles tendon was advocated in 1888 by another Frenchman, Gustave Polaillon27, although an Arabian physician performed such procedures as early as the tenth century A.D. In the twelfth century, an Italian surgeon, Guglielmo di Faliceto, believed that nature was unable to unite divided tendons and that operative treatment was necessary27. Much research has been performed to elucidate the etiology of a rupture of the Achilles tendon, but its true nature still remains unclear190. Also, the best method of treatment is still fiercely debated. Some physicians advocate operative repair, whereas others insist that an operation is unnecessary and poses an unacceptable risk. The tendinous portions of the gastrocnemius and soleus muscles merge to form the Achilles tendon. The plantaris …

To evaluate medium-long term patency of below-knee bypass on patients who suffered from diabetic lower limb ischemia. Clinical and follow-up data of 51 patients was retrospectively analyzed who underwent 56 below-knee bypass because of diabetes from November 2001 to December 2006. There were 35 male and 16 female with an average age of 68 years. They endured 26 months ischemic time lag in average, and had suffered from diabetes for 11 years. All of the patients were performed bypass to below-knee (posterior tibial, anterior tibial or peroneal) arteries. Kaplan-meier method was applied. The subgroups of different operative methods and different out-flow vessels were compared by Log-rank tests. An average follow-up time of 23 months was achieved, and lost-follow-up rate was 15%. The total 1- and 5-year primary patent rates were 68% and 54% respectively, secondary patent rate were 70% and 60% respectively, limb salvage rates were 69% and 65%, survival rates were 82% and 60%. One year (3 years) of patent rate(s) of operative method subgroups of femoral-popliteal-infrageniculate bypass with composite grafts, femoral/popliteal-infrageniculate bypass with artificial grafts and femoral/popliteal-infrageniculate bypass with autologous veins were 70% (50%), 33% (33%) and 70% (70%) respectively. One year (4 years) of patent rate(s) of out-flow vessel subgroups of posterior tibial artery, anterior tibial artery and peroneal artery were 65% (60%), 80% (53%) and 77% (66%) respectively. However, both subgroups did not show any statistic differences by log-rank tests. Partial or whole autologous veins as bypass grafts should be chosen when infrageniculate bypass is considered in diabetic patients. Considerable patent rates are acceptable no matter what kinds of out-flow vessels are chosen.

We report on 4 patients with the campomelic syndrome (CS) in whom postmortem angiography of the lower limbs was performed. Of the 4 patients, 3 were phenotypic females (2 of them with a 46,XY karyotype) and one was a male with a normal 46,XY karyotype. Three fulfilled the criteria of CS, and one (phenotypically female with a 46,XY karyotype) lacked the lower limb bowing and the talipes equinovarus typical of CS. This infant may constitute a further example of the recently reported CS without campomelia. The results of the angiographic study are compared with 46 postmortem angiographies of normal fetuses and newborn infants at different gestational ages. In the first 3 CS patients the main arterial axis of the lower limb, formed by the superficial femoral and anterior tibial arteries, had smaller diameters than expected while the profunda femoris and posterior tibial arteries had greater diameters than age-matched controls. However, the most striking abnormality was the absence or marked deficiency of the anterior tibial artery. Its terminal branch, the dorsalis pedis artery, was also absent and the plantar arch was abnormally formed by the posterior tibial artery either alone or in conjunction with the peroneal artery. The normal arterial pattern was found in the patient who lacked bowed bones. This finding supports a developmental association between vascular defects and lower limb anomalies in CS. This aberrant arterial pattern in CS may affect or be affected by muscle development. The shortness of the posterior femoral and calf muscles fix the knee and the ankle joints.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective To explore the feasibility and clinical resuhs of the tension skin flap of the pedicle of distally based skin flap or reverse-flow island flap. Methods Nine cases were repaired using reversed island flap pedicled with cutaneous branches of medial supramalleolar of posterior tibial artery in clinic,2 cases using distally based skin flap pedicled with the medial perforator of the posterior tibial artery,8 cases using reversalisland flap of peroneal artery lateral mulleolus skin perfarator 4 cases using reversed island flap pedicled with superficial peroneal nerve and its nutrient vessels. 3 cases using distally based sural neurocutaneous flap,and 2 cases using reversed island flap pedicled with dorsal fascia of hand.The area of the tension flap was 1.0 cm×1.0 cm to 5.0 am×3.5 cm. Results All the flaps completely survived.On the postoperative years follow-up,the texture of the flap was excellent,and primary healing was obtained at the donor site. Conclusion It's effective to design at the pedicle of the distally based flap or reversed island flap a tension skin flap,which can prevent the vessels from compressing or destroying. Key words: Surgical skin flap; Transplantation; Tension skin flap; Microsurgery

The use of standard anterolateral and anteromedial portals in ankle arthroscopy results in reduced risk of vascular complications. Anatomical variations of the arterial network of the foot and ankle might render the vessels more susceptible to injury during procedures involving the anterior ankle joint. The literature, to our knowledge, reports only one case of a pseudoaneurysm involving the peroneal artery after ankle arthroscopy. Here, we report the unusual case of a 48-year-old man in general good health with the absence of the anterior tibial artery and posterior tibial artery. The patient presented with a pseudoaneurysm of the perforating peroneal artery following ankle arthroscopy for traumatic osteoarthritis associated with nonunion of the medial malleolus. The perforating peroneal artery injury was repaired by performing end-to-end anastomosis. The perforating peroneal artery is at higher risk for iatrogenic injury during ankle arthroscopy in the presence of abnormal arterial variations of the foot and ankle, particularly the absence of the anterior tibial artery and posterior tibial artery. Before ankle arthroscopy, surgeons should therefore carefully observe the course of the perforating peroneal artery on enhanced 3-dimensional computed tomography, especially in patients with a history of trauma to the ankle joint.