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Absent Posterior Tibial Artery Associated with Idiopathic ClubfootA Report of Two Cases
Matthew B. Dobbs, MD1; J. Eric Gordon, MD1; Perry L. Schoenecker, MD1
1 Department of Orthopaedic Surgery, Washington University School of Medicine, One Children's Place, Suite 4S20, St. Louis, MO 63110. E-mail address for M.B. Dobbs: mattdobbs@earthlink.net
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Washington University School of Medicine, St. Louis Children's Hospital, and St. Louis Shriners Hospital for Children, St. Louis, Missouri

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Mar 01;86(3):599-602
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The presence of vascular anomalies in the lower extremities of patients with idiopathic clubfoot has been well documented1-6. Absence or a substantial reduction of the anterior tibial artery occurs in approximately 90% of limbs with clubfoot1,2,4,5,7,8. However, an absent or anomalous posterior tibial artery is a very uncommon finding in patients with clubfoot3,6. In patients in whom the posterior tibial artery is absent and the anterior tibial artery is deficient, the peroneal artery becomes the dominant artery to the foot and therefore must be carefully protected during surgical correction of the clubfoot. We report the cases of two patients in whom the posterior tibial artery was found to be absent at the time of an operative release procedure for clubfoot. We also report the arteriographic appearance of an absent posterior tibial artery associated with clubfoot, which has not been reported previously in the orthopaedic literature, to our knowledge. The families of both of our patients were informed that data concerning the cases would be submitted for publication.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Matthew B. Dobbs
    Posted on May 07, 2004
    Dr. Dobbs responds:
    Washington University School of Medicine

    I would like to thank Dr. Hootnick for his comments and insight regarding this clinical problem as he is a leader in the field of arterial deficiencies in a variety of congenital limb anomalies.

    A good point that was reiterated by Dr. Hootnick was the need to perform arteriography in at least two planes to be able to adequately identify absent or hypoplastic arteries. In addition, renaming the hypoplastic anterior tibial artery that is often seen in the lower limbs of clubfoot patients as suggested by Dr. Hootnick makes good anatomical sense.

    I apologize for omitting the 1968 paper by DeVelasco-Polo as a reference.

    I would like to thank Dr. Hootnick again for his comments and his contribution to our understanding of the vascular pattern of the lower limb in clubfoot patients and its clinical implications.

    David R. Hootnick, M.D.
    Posted on April 26, 2004
    Arterial Deficienies in Club Foot
    SUNY Upstate Medical University - Cell & Developmental Biology Dept.

    To the Editor:

    The recent report (1) of two more cases of absence of the posterior tibial artery (PTA) in idiopathic clubfoot (TEV) demonstrated for the first time two lateral arteriographic views of one affected limb (case two, figures 1-A and 1-B). We have also previously noted a single case of absence of the PTA in a patient (2) (case 3) who developed plantar necrosis postoperatively. Color Doppler was employed to assess the vascular tree in that limb.

    Our analysis of the arteriographic abnormalities in a variety of congenital malformations (3), leads us to suggest renaming the hypoplastic anterior tibial artery in fig 1-A as the popliteal profunda and interosseous embryonic arteries (see fig 8D (3)). Precise identification of absent arteries is certainly best determined by dissection (4). However, arteriography in at least two planes can be acceptably determinative. If the existence of embryonic arteries is already known, color Doppler analysis can be adjunctive but not determinative (5).

    The authors of this paper have omitted DeVelasco-Polo and Davy- Ruiz's seminal 1968 study (6) of arterial deficiencies in clubfoot, which not only contributed a plurality of the limbs counted in estimating the 90% incidence of anterior tibial artery deficiency in TEV but also described the first reported case of necrosis after clubfoot surgery.

    We commend the authors on this publication and believe that they have demonstrated sound physiologic reasons for understanding the labyrinth of arterial embryology.

    (1) Dobbs MB, Gordon JE, and Schoenecker PL. Entitled Absent Posterior Tibial Artery Associated with Idiopathic Clubfoot. J. Bone Joint Surgery AM, 2004; 86-A.

    (2) Hootnick DR, Packard DS, Jr., Levinsohn EM, Wladis AR. Three cases of Necrosis Following Clubfoot Surgery: A proposed Vascular Etiology. In the Clubfoot, The Present, and a View to the Future, George W. Simons, editor, Springer-Verlag. 1994; 442.

    (3) Levinsohn EM, Hootnick DR, and Packard DS, Jr. Consistent Arterial Abnormalities Associated with a Variety of Congenital Malformations of the Human Lower Limb. Invest Radiology. 1991; 26:364-373.

    (4) Pierson HH. Seven Arterial Anomalies of the Human Leg and Foot. The Anatomical Record. 1925; 30:139-145.

    (5) Katz DA, Albanese RN, Levinsohn EM, et al. Pulsed Color Flow Doppler Analysis of Arterial Deficiency in Idiopathic Clubfoot. J. Pedi. Orthop. 2003; 23:84-87.

    (6) DeVelasco-Polo G, Davy-Ruiz G. Reporte Preliminar Al Hallazgode Laausencia Vascular En Enfermus Con Pics Equno Cavo Varo Adducto Congenito. Rev Ort Lainoam 1968; 8:27-34.

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