O presente estudo objetivou analisar a relação do índice do arco plantar com o equilíbrio postural e com a frequência do uso do salto alto entre mulheres de diferentes faixas etárias. Participaram do estudo 60 mulheres, 20 no grupo jovem (GJ), 20 no grupo adulto (GA) e 20 do grupo idoso (GI), as quais foram separadas em subgrupos com 10 indivíduos cada de acordo com a frequência do uso do salto alto. A avaliação da frequência do uso do sapato de salto alto foi realizada através do número de vezes que o indivíduo utilizava esse tipo de calçado. Para o cálculo do índice do arco plantar (IAP) utilizou-se o método de impressão plantar, por meio de um pedígrafo. Para a aquisição dos dados referentes ao equilíbrio postural foi utilizada uma plataforma de força AMTI; as variáveis utilizadas a partir do Centro de Pressão (COP) foram: amplitude de deslocamento ântero-posterior do centro de pressão (COPap), amplitude de deslocamento médio-lateral do COP (COPml), velocidade média de deslocamento do COP (COPvel) e área da elipse (elipse). Os resultados apontam que não houve correlações entre as variáveis do COP (COPap, COPml, velocidade e elipse) e o IAP na condição de olhos abertos e olhos fechados. Ao se tratar da faixa etária, houve diferença estatisticamente significativa entre o índice do arco plantar do GJ e GI e do GA e GI, indicando que o grupo de mulheres idosas possui um maior índice do arco plantar, ou seja, um rebaixamento no arco longitudinal medial. Com relação à frequência do uso do salto alto, não houve diferença estatisticamente significativa do índice do arco plantar entre os grupos. Concluiu-se que o índice do arco plantar não altera o controle postural em mulheres jovens, adultas e idosas deste estudo e que o grupo idoso apresenta um rebaixamento do arco longitudinal medial quando comparado com o grupo jovem e adulto. / The present study aimed to analyze the relationship between plantar arch index and postural balance and the frequency of use of high-heeled shoes among women of different age groups. The study included 60 women, 20 in the young group (GJ), 20 in the adult group (GA) and 20 in the elderly group (GI), which were separated into groups with 10 individuals each according to frequency of use of high-heeled shoes. The evaluation of the frequency of use of the high heel shoe was performed using the number of times that the person use this kind of footwear. To obtain the plantar arch index (IAP) was used the method of printing plant, with a plantar foot pressure. For acquisition of postural balance data was used a AMTI force plate and variables from the center of pressure (COP) used were: range of anteroposterior displacement of the center of pressure (COPap), range of displacement of the medial-lateral COP (COPml) and average speed of displacement of the COP (COPvel). The results showed that there were no correlations between the variables of COP (COPap, COPml, speed and ellipse) and IAP on eyes opened and eyes closed conditions. When dealing with the age group, there were statistically significant differences between the plantar arch index of the GJ and GI and of the GA and GI, indicating that the group of older women have an increased plantar arch index or a presents lower medial longitudinal arch. It was concluded that the plantar arch index does not alter postural control in young, adult and elderly people and that the elderly group presents lower medial longitudinal arch when compared with the young adult group showing.

O presente estudo objetivou analisar a relação do índice do arco plantar com o equilíbrio postural e com a frequência do uso do salto alto entre mulheres de diferentes faixas etárias. Participaram do estudo 60 mulheres, 20 no grupo jovem (GJ), 20 no grupo adulto (GA) e 20 do grupo idoso (GI), as quais foram separadas em subgrupos com 10 indivíduos cada de acordo com a frequência do uso do salto alto. A avaliação da frequência do uso do sapato de salto alto foi realizada através do número de vezes que o indivíduo utilizava esse tipo de calçado. Para o cálculo do índice do arco plantar (IAP) utilizou-se o método de impressão plantar, por meio de um pedígrafo. Para a aquisição dos dados referentes ao equilíbrio postural foi utilizada uma plataforma de força AMTI; as variáveis utilizadas a partir do Centro de Pressão (COP) foram: amplitude de deslocamento ântero-posterior do centro de pressão (COPap), amplitude de deslocamento médio-lateral do COP (COPml), velocidade média de deslocamento do COP (COPvel) e área da elipse (elipse). Os resultados apontam que não houve correlações entre as variáveis do COP (COPap, COPml, velocidade e elipse) e o IAP na condição de olhos abertos e olhos fechados. Ao se tratar da faixa etária, houve diferença estatisticamente significativa entre o índice do arco plantar do GJ e GI e do GA e GI, indicando que o grupo de mulheres idosas possui um maior índice do arco plantar, ou seja, um rebaixamento no arco longitudinal medial. Com relação à frequência do uso do salto alto, não houve diferença estatisticamente significativa do índice do arco plantar entre os grupos. Concluiu-se que o índice do arco plantar não altera o controle postural em mulheres jovens, adultas e idosas deste estudo e que o grupo idoso apresenta um rebaixamento do arco longitudinal medial quando comparado com o grupo jovem e adulto. / The present study aimed to analyze the relationship between plantar arch index and postural balance and the frequency of use of high-heeled shoes among women of different age groups. The study included 60 women, 20 in the young group (GJ), 20 in the adult group (GA) and 20 in the elderly group (GI), which were separated into groups with 10 individuals each according to frequency of use of high-heeled shoes. The evaluation of the frequency of use of the high heel shoe was performed using the number of times that the person use this kind of footwear. To obtain the plantar arch index (IAP) was used the method of printing plant, with a plantar foot pressure. For acquisition of postural balance data was used a AMTI force plate and variables from the center of pressure (COP) used were: range of anteroposterior displacement of the center of pressure (COPap), range of displacement of the medial-lateral COP (COPml) and average speed of displacement of the COP (COPvel). The results showed that there were no correlations between the variables of COP (COPap, COPml, speed and ellipse) and IAP on eyes opened and eyes closed conditions. When dealing with the age group, there were statistically significant differences between the plantar arch index of the GJ and GI and of the GA and GI, indicating that the group of older women have an increased plantar arch index or a presents lower medial longitudinal arch. It was concluded that the plantar arch index does not alter postural control in young, adult and elderly people and that the elderly group presents lower medial longitudinal arch when compared with the young adult group showing.

O presente estudo objetivou analisar a relação do índice do arco plantar com o equilíbrio postural e com a frequência do uso do salto alto entre mulheres de diferentes faixas etárias. Participaram do estudo 60 mulheres, 20 no grupo jovem (GJ), 20 no grupo adulto (GA) e 20 do grupo idoso (GI), as quais foram separadas em subgrupos com 10 indivíduos cada de acordo com a frequência do uso do salto alto. A avaliação da frequência do uso do sapato de salto alto foi realizada através do número de vezes que o indivíduo utilizava esse tipo de calçado. Para o cálculo do índice do arco plantar (IAP) utilizou-se o método de impressão plantar, por meio de um pedígrafo. Para a aquisição dos dados referentes ao equilíbrio postural foi utilizada uma plataforma de força AMTI; as variáveis utilizadas a partir do Centro de Pressão (COP) foram: amplitude de deslocamento ântero-posterior do centro de pressão (COPap), amplitude de deslocamento médio-lateral do COP (COPml), velocidade média de deslocamento do COP (COPvel) e área da elipse (elipse). Os resultados apontam que não houve correlações entre as variáveis do COP (COPap, COPml, velocidade e elipse) e o IAP na condição de olhos abertos e olhos fechados. Ao se tratar da faixa etária, houve diferença estatisticamente significativa entre o índice do arco plantar do GJ e GI e do GA e GI, indicando que o grupo de mulheres idosas possui um maior índice do arco plantar, ou seja, um rebaixamento no arco longitudinal medial. Com relação à frequência do uso do salto alto, não houve diferença estatisticamente significativa do índice do arco plantar entre os grupos. Concluiu-se que o índice do arco plantar não altera o controle postural em mulheres jovens, adultas e idosas deste estudo e que o grupo idoso apresenta um rebaixamento do arco longitudinal medial quando comparado com o grupo jovem e adulto. / The present study aimed to analyze the relationship between plantar arch index and postural balance and the frequency of use of high-heeled shoes among women of different age groups. The study included 60 women, 20 in the young group (GJ), 20 in the adult group (GA) and 20 in the elderly group (GI), which were separated into groups with 10 individuals each according to frequency of use of high-heeled shoes. The evaluation of the frequency of use of the high heel shoe was performed using the number of times that the person use this kind of footwear. To obtain the plantar arch index (IAP) was used the method of printing plant, with a plantar foot pressure. For acquisition of postural balance data was used a AMTI force plate and variables from the center of pressure (COP) used were: range of anteroposterior displacement of the center of pressure (COPap), range of displacement of the medial-lateral COP (COPml) and average speed of displacement of the COP (COPvel). The results showed that there were no correlations between the variables of COP (COPap, COPml, speed and ellipse) and IAP on eyes opened and eyes closed conditions. When dealing with the age group, there were statistically significant differences between the plantar arch index of the GJ and GI and of the GA and GI, indicating that the group of older women have an increased plantar arch index or a presents lower medial longitudinal arch. It was concluded that the plantar arch index does not alter postural control in young, adult and elderly people and that the elderly group presents lower medial longitudinal arch when compared with the young adult group showing.

Zusammenfassung Gefäßerkrankungen und Diabetes mellitus nehmen als Krankheiten der modernen Zivilisation zu. Sie gehen oft mit dem Risiko einer Amputation einher. Trotz verbesserter Therapie aufgrund des medizinischen Fortschritts steigen die Amputationsraten. Besonders gefährdet sind Patienten mit Diabetes mellitus. Aufgrund des besonderen Atherosklerosebefallsmusters mit Verschluss der kruralen Gefäße bei relativer Aussparung der Oberschenkel- und Fußarterien erzielen pedale Bypässe bei diabetischen Patienten besonders gute Ergebnisse im Hinblick auf die Wiederherstellung der Fußdurchblutung. Ein pedaler Bypass kann eine drohende Amputation oft verhindern. Voraussetzungen für eine pedale Bypass-Operation sind umfassende anatomische Kenntnisse über die Variabilität der Arterien im Operationsgebiet. Die vorliegende Arbeit befasst sich mit den Gefäßvariationen an Unterschenkel und Fuß. Mit unterschiedlichen Methoden wurden Alkohol-fixierte (n=12) und Thiel-fixierte (n=10) Beinpräparate auf arterielle Variabilität untersucht. Die Alkohol-fixierten Präparate wurden makroskopisch präpariert und fotografisch dokumentiert, außerdem erfolgte eine Probenentnahme zur histologischen Untersuchung der Atherosklerosegrade in verschiedenen Gefäßregionen (n=32) und die Herstellung von zwei Dauerpräparaten. An Thiel-fixiertem Material wurde die Digitale Subtraktionsangiographie (DSA) getestet. Folgende Fragestellungen waren zu beantworten: 1. Welche Variationen der Blutgefäße finden sich für den Unterschenkel und Fuß? Wie kommunizieren die Gefäße zwischen Fußsohle und Fußrücken? 2. Wie können kleinste Gefäße am Fuß präpariert und fotografisch dokumentiert werden? 3. Lässt sich an fixiertem Leichenmaterial eine Digitale Subtraktionsangiographie durchzuführen? 4. Zeigen proximale und distale Blutgefäße des Beines einen unterschiedlichen Befall der Atherosklerose? 5. Welche Bedeutung hat die Herstellung von Dauerpräparaten für den studentischen Unterricht? 6. Welche Bedeutung hat die makroskopische Anatomie für die Klinik? Die Ergebnisse und Schlussfolgerungen sind: 1. Während der makroskopischen Präparation fanden sich folgende Variationen: Trifurkation, Truncus tibiofibularis anterior mit hohem Abgang der A. tibialis posterior und Abgang der A. tibialis anterior aus der A. fibularis, eine sehr dominante A. fibularis bei schwach ausgeprägter A. tibialis posterior, ein Arcus plantaris durch den zweiten intermetatarsalen Spalt laufend, kräftig ausgebildete A. plantaris profunda, kräftiger tiefer Ast der A. plantaris medialis, stark ausgeprägte A. arcuata. Die den Arcus plantaris versorgenden Arterien, vor allem die A. plantaris lateralis und die A. plantaris profunda, variieren stark in ihrer Ausprägung. Sie sind Teil der „Ringanastomose”, die eine Durchblutung des Fußes über die Verbindungen verschiedener Gefäße zwischen Fußsohle und Fußrücken gewährleistet. Neben der A. plantaris profunda, die auch als Ramus perforans I bezeichnet wird, gibt es zwischen den Aa. metatarsales plantares und dorsales Verbindungen, die Rr. perforantes II-IV, die bei schwach ausgeprägter A. plantaris profunda die Gefäßversorgung sicherstellen und entsprechend stärker ausgebildet sein können. Die A. fibularis kann über ihre kommunizierenden Äste, dem Ramus perforans zur A. dorsalis pedis oder dem Ramus communicans zur A. tibialis posterior, an der arteriellen Versorgung der Fußsohle beteiligt sein. Bei schwacher Ausbildung der A. tibialis posterior und/oder A. tibialis anterior kann diese durch die A. fibularis als phylogenetisch ältestes und damit konstantestes Gefäß der drei Unterschenkelarterien sogar teilweise oder vollständig ersetzt werden. Die „Ringanastomose“ hat für die Gefäßchirurgie eine große Bedeutung. Beim popliteodistalen Bypass orientiert sich die Wahl des distalen Anschlussgefäßes daran, über welches Gefäß sich der Arcus plantaris angiographisch füllt. Eine Kollateralbildung beim Erwachsenen infolge atherosklerotischer Veränderungen über ursprünglich embryologische Gegebenheiten ist denkbar. 2. Die makroskopische Präparation kleinster Gefäße am Fuß wird durch die Injektion der roten Injektionslösung Microfil® erleichtert. Zur fotografischen Dokumentation ist eine Farbmarkierung der Arterien von außen notwendig, um den Gefäßverlauf sichtbar zu machen. 3. Digitale Subtraktionsangiographie an Leichenmaterial ist nur an Thiel-fixiertem Material möglich, da diese Methode die Gewebeverhältnisse in ihrer natürlichen Konsistenz erhält. Das Einbinden der Schleusen und die Injektion von Kontrastmittel in das Gefäßsystem sind durchführbar, weil die Gefäßlumina durchgängig bleiben. Alkohol- oder Formaldehyd-fixiertes Material ist für diese Zwecke ungeeignet, da das Gewebe aushärtet und in den Gefäßen befindliche Blutreste koagulieren. Dadurch wird eine Kontrastmittel-Injektion unmöglich. 4. Dass histologische Färbungen an langzeitfixiertem Material möglich sind, konnte bestätigt werden. Nach Modifikation der Färbevorschriften erlauben sie die Bewertung des Atherosklerosegrades. Der schwerste Befall mit Grad 4 befindet sich in den Arterien der Kniekehle. Die Fußarterien sind mit Grad 2 geringer befallen. 5. Dauerpräparate verbleiben in der anatomischen Lehrsammlung bzw. im Fundus von Anschauungsmaterial. Sie werden zukünftig zur Demonstration anatomischer Strukturen im Rahmen klinischer Kurse und im Studentenunterricht verwendet. 6. Die Anatomie als Grundlagenfach der Medizin hat in der Lehre einen hohen Stellenwert und in allen Studienabschnitten eine hohe klinische Relevanz. Gemeinsame Lehrveranstaltungen von Anatomie und Klinik wecken bei Studenten großes Interesse und fördern die Motivation. Im Rahmen der ärztlichen Aus- und Weiterbildung werden in klinischen Kursen am Institut für Anatomie beispielsweise Untersuchungsmethoden und Operationsbedingungen simuliert. Kliniker wiederholen, festigen oder vertiefen ihre anatomischen Kenntnisse. Vor allem die chirurgischen Fächer profitieren von diesen praktischen Trainingsmöglichkeiten. Wie die Arbeit am Beispiel der Gefäßchirurgie zeigt, bedingt eine gute Zusammenarbeit zwischen Anatomie und Klinik eine sichere klinische Praxis und eine lebendige Anatomie mit klinischen Bezügen. / Summary Vascular diseases and diabetes mellitus show rising frequency in the Western world and are often accompanied by amputation. The amputation rate is still increasing despite major developments in diagnostics and therapy. Especially patients with diabetes mellitus are at high risk. Because of the special pattern with more severe atherosclerosis in the crural vessels than in the femoral and pedal arteries, the pedal bypass surgery provides excellent vessel patency and limb salvage rates in diabetic patients and can often prevent amputation. A solid knowledge about anatomical variations in the operating area is a precondition for bypass operations. This dissertation deals with variations of arteries from the lower leg and foot. Lower legs from alcohol-fixed and Thiel-fixed cadavers were examined with different methods: The alcohol-fixed legs (n=12) were dissected macroscopically for variations of the arteries and documented by photographes. Samples along the vessel course (n=32) were taken for histological evaluation of the atherosclerotic degrees. Two legs were plastinated with polyethylene glycol. The Thiel-fixed legs (n=10) were tested for digital subtraction angiography (DSA). The following questions had to be answered: 1. Which arterial variations can be found for the lower leg and foot? How do the vessels communicate between the sole and the dorsum of the foot? 2. How are small foot vessels dissected for photographical documentation? 3. Can Thiel-fixed material be used for DSA? 4. Do proximal and distal vessels show different degrees of atherosclerosis? 5. Which relevance does plastination have for the medical education? 6. How important is Gross anatomy for the clinicians? Results and conclusions: 1. The following variations occurred: trifurcation, anterior tibiofibular truncus with high branching from the posterior tibial artery and the anterior tibial artery originating from the fibular artery, dominant fibular artery, plantar arch running through the second interosseus space, dominant deep plantar artery, dominant deep branch of the medial plantar artery, prominent arcuate artery. The arteries for the plantar arch, supplying most of the foot arteries, show a high diversification. They are part of the “ring anastomosis” which assures a good blood supply via different vessels connecting the dorsum and the sole of the foot. Beside the deep plantar artery, also named as “perforating branch I”, there are other connecting branches between the plantar and dorsal metatarsal arteries - the perforating braches II, III and IV. These branches are highly developed in case of an undeveloped deep plantar artery. The fibular artery can be involved in the blood supply of the foot via a communicating branch to the posterior tibial artery and the perforating branch to the dorsalis pedis artery. The fibular artery, which is phylogenetically the oldest crural vessel, can be highly developed in case of inferior anterior tibial artery and/or posterior tibial artery. The “ring anastomosis” is very important for vascular surgery. The inflow and outflow vessels of a popliteodistal bypass are chosen after angiography of the plantar arch showing the vessel for the supply of the plantar arch. 2. Macroscopical dissection of very small foot vessels can be facilitated by injection of a special plastic, Microfil®-solution. The arteries have to be additionally coloured by help of special markers for photographical documentation. 3. DSA can just be done with Thiel-fixed material. Thiel-fixation allows DSA because maintained in situ conditions. The blood is not coagulated and the vessels stay patent for contrast medium. Alcohol-fixed or formaldehyde-fixed material is not suitable for DSA because of clotted blood in the vessels impeding injection of contrast agent. 4. It is confirmed that histological examination is possible with long fixed material. After modification of the staining protocol the sections could be used for evaluation of the atherosclerotic degree. The popliteal arteries are more affected with degree 4 in comparison to the foot arteries with degree 2. 5. Plastinates are displayed in the anatomical collection of the Institute for Anatomy. They will be used for anatomical demonstrations in the lessons of students and in clinical courses. 6. Anatomy as basic knowledge is very important for teaching medical students and has a high clinical relevance in every phase of the medical course. Interdisciplinary lessons between anatomy and clinical disciplines awake interest and motivate students. Advanced medical training is obtained at the Institute for Anatomy by simulating endoscopic examination and developing new surgical techniques. Clinicians repeat, stabilize and deepen their anatomical knowledge. Especially surgeons benefit from these training possibilities. Using the example of vascular bypass surgery the present dissertation shows the value of a good cooperation between anatomy and clinic to provide a safe clinical practice and a lively anatomy with clinical references.

Made available in DSpace on 2016-12-06T17:07:16Z (GMT). No. of bitstreams: 1 RUDNEI PALHANO.pdf: 3683877 bytes, checksum: fe25b167aa6def43f3bead628f1850d4 (MD5) Previous issue date: 2008-04-25 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The aim of this correlational study was to analyze the plantar medial longitudinal arch during the stance phase of the gait. Thirty-two subjects of both genders (mean age 25,78±6,75 years) from Vale dos Sinos RS have participated of the research. The specific objectives was to describe the behavior of the plantar medial longitudinal arch during the gait in the initial contact and stance phase; identify the foot s angle with the surface in the initial contact; correlate the medial longitudinal plantar arch with the Ankle s angle during the contact phase; correlate the anthropometry variables with the dynamic behavior of the medial longitudinal plantar arch; correlate the plantar pressure distribution (peak pressure, plantar pressure mean, contact time and mean area) with the dynamic behavior of the kinetics and kinematics variables of the medial longitudinal plantar arch during the stance phase and relate the kinetics and kinematics variables with kinds of medial longitudinal plantar arch. The kinematics data has been acquired by the Spica Technology Corporation video system and for kinetic data was used the Novel Emed-XR system with a sampling rate of 100 Hz and the 3D Scanner INFOOT. Subjects were separate into three groups by the Cavanagh s arch index: Cavus foot; normal foot e planus foot. The variables analyzed were: medial longitudinal plantar arch angle in seated position, initial contact and stance phase, angle of the ankle in seated position and stance phase, plantar pressure of peak, mean plantar pressure, contact area, contact time and mean force. The Kolmogorov-Smirnov test has been applied for the statistical analysis to verify the normality of the data. The ANOVA One-Way test has been used to compare means intra-groups and to verify where were the differences was used the Scheffé`s Post Hoc test. Pearson test has been applied to verify the correlation. The level of significance adopted was p ≤ 0.05. There were no differences statistically significant when inter-groups kinematics and anthropometrics variables had been compared. Only in some regions of the plantar surface has shown differences statistically significant when the kinetics variables were compared inter-group. Analyzing the correlations between the dynamic arch index with kinematics variables, only the medial longitudinal plantar arch angle has shown a moderate correlation statistically significant, while others correlations had low relations. / O objetivo deste estudo correlacional foi analisar o Arco Plantar Longitudinal Medial durante a fase de apoio da Marcha. Com objetivos específicos: descrever o comportamento do Arco Plantar Longitudinal Medial durante a marcha nos períodos do Contato Inicial e Apoio Simples; Identificar o Ângulo do pé com a superfície no Contato Inicial; Correlacionar o Ângulo do Arco Plantar Longitudinal Medial com o Ângulo do Tornozelo durante a Fase de Contato; Correlacionar as variáveis antropométricas com o comportamento dinâmico do Arco Plantar Longitudinal Medial; Correlacionar as variáveis da Distribuição de Pressão Plantar (Pico de Pressão Plantar, Pressão Plantar Média, Tempo de contato e Área media) com o comportamento dinâmico das variáveis cinemáticas e cinéticas do Arco Plantar Longitudinal Medial durante a o apoio simples;Verificar diferenças nas variáveis cinemáticas e cinéticas relacionando com os diferentes tipos de Arco Plantar Longitudinal Medial dinamicamente. Participaram do estudo 32 sujeitos da região do Vale dos Sinos RS, ambos os sexos, idade entre 19 e 46 anos (25,78±6,75 anos). Utilizaram-se como instrumentos o Sistema de cinemetria da Spica Technology , Sistema cinético da Novel Emed e o Scanner 3D INFOOT. Os sujeitos foram classificados em três grupos através do Índice do Arco Plantar: Pés Cavos (PC); Pés Normais (PN) e Pés Planos (PP). As variáveis analisadas foram: Ângulo do Arco Plantar Longitudinal Média, na posição sentada, contato inicial e no apoio simples; Ângulo do Tornozelo, na posição sentada e apoio simples; Pico de Pressão Plantar; Pressão Plantar Média; Área de Contato; Tempo de Contato e Força Média. Na análise estatística foi aplicado o teste de Kolmogorov-Smirnov para verificar a normalidade nos dados. Na comparação das médias intra-grupos foi aplicado ANOVA One-Way e para verificar onde as diferenças encontravam foi utilizado o teste de Post hoc de Scheffé. Para verificar as correlações foi aplicado Pearson. O nível de significância adotado foi de p≤ 0,05. Na comparação inter-grupos para as variáveis cinemáticas e antropométricas, não apresentaram diferenças estatisticamente significativas. Apenas na comparação inter-grupos das variáveis cinéticas, em algumas regiões da superfície plantar apresentaram diferenças estatisticamente significativas. Ao analisar as correlações entre o Índice do Arco Plantar dinâmico com as variáveis cinemáticas, somente o ângulo do Arco Plantar longitudinal medial apresentou correlação moderada estatisticamente significativa, as demais variáveis cinemáticas apresentaram correlações baixas.

Zusammenfassung Gefäßerkrankungen und Diabetes mellitus nehmen als Krankheiten der modernen Zivilisation zu. Sie gehen oft mit dem Risiko einer Amputation einher. Trotz verbesserter Therapie aufgrund des medizinischen Fortschritts steigen die Amputationsraten. Besonders gefährdet sind Patienten mit Diabetes mellitus. Aufgrund des besonderen Atherosklerosebefallsmusters mit Verschluss der kruralen Gefäße bei relativer Aussparung der Oberschenkel- und Fußarterien erzielen pedale Bypässe bei diabetischen Patienten besonders gute Ergebnisse im Hinblick auf die Wiederherstellung der Fußdurchblutung. Ein pedaler Bypass kann eine drohende Amputation oft verhindern. Voraussetzungen für eine pedale Bypass-Operation sind umfassende anatomische Kenntnisse über die Variabilität der Arterien im Operationsgebiet. Die vorliegende Arbeit befasst sich mit den Gefäßvariationen an Unterschenkel und Fuß. Mit unterschiedlichen Methoden wurden Alkohol-fixierte (n=12) und Thiel-fixierte (n=10) Beinpräparate auf arterielle Variabilität untersucht. Die Alkohol-fixierten Präparate wurden makroskopisch präpariert und fotografisch dokumentiert, außerdem erfolgte eine Probenentnahme zur histologischen Untersuchung der Atherosklerosegrade in verschiedenen Gefäßregionen (n=32) und die Herstellung von zwei Dauerpräparaten. An Thiel-fixiertem Material wurde die Digitale Subtraktionsangiographie (DSA) getestet. Folgende Fragestellungen waren zu beantworten: 1. Welche Variationen der Blutgefäße finden sich für den Unterschenkel und Fuß? Wie kommunizieren die Gefäße zwischen Fußsohle und Fußrücken? 2. Wie können kleinste Gefäße am Fuß präpariert und fotografisch dokumentiert werden? 3. Lässt sich an fixiertem Leichenmaterial eine Digitale Subtraktionsangiographie durchzuführen? 4. Zeigen proximale und distale Blutgefäße des Beines einen unterschiedlichen Befall der Atherosklerose? 5. Welche Bedeutung hat die Herstellung von Dauerpräparaten für den studentischen Unterricht? 6. Welche Bedeutung hat die makroskopische Anatomie für die Klinik? Die Ergebnisse und Schlussfolgerungen sind: 1. Während der makroskopischen Präparation fanden sich folgende Variationen: Trifurkation, Truncus tibiofibularis anterior mit hohem Abgang der A. tibialis posterior und Abgang der A. tibialis anterior aus der A. fibularis, eine sehr dominante A. fibularis bei schwach ausgeprägter A. tibialis posterior, ein Arcus plantaris durch den zweiten intermetatarsalen Spalt laufend, kräftig ausgebildete A. plantaris profunda, kräftiger tiefer Ast der A. plantaris medialis, stark ausgeprägte A. arcuata. Die den Arcus plantaris versorgenden Arterien, vor allem die A. plantaris lateralis und die A. plantaris profunda, variieren stark in ihrer Ausprägung. Sie sind Teil der „Ringanastomose”, die eine Durchblutung des Fußes über die Verbindungen verschiedener Gefäße zwischen Fußsohle und Fußrücken gewährleistet. Neben der A. plantaris profunda, die auch als Ramus perforans I bezeichnet wird, gibt es zwischen den Aa. metatarsales plantares und dorsales Verbindungen, die Rr. perforantes II-IV, die bei schwach ausgeprägter A. plantaris profunda die Gefäßversorgung sicherstellen und entsprechend stärker ausgebildet sein können. Die A. fibularis kann über ihre kommunizierenden Äste, dem Ramus perforans zur A. dorsalis pedis oder dem Ramus communicans zur A. tibialis posterior, an der arteriellen Versorgung der Fußsohle beteiligt sein. Bei schwacher Ausbildung der A. tibialis posterior und/oder A. tibialis anterior kann diese durch die A. fibularis als phylogenetisch ältestes und damit konstantestes Gefäß der drei Unterschenkelarterien sogar teilweise oder vollständig ersetzt werden. Die „Ringanastomose“ hat für die Gefäßchirurgie eine große Bedeutung. Beim popliteodistalen Bypass orientiert sich die Wahl des distalen Anschlussgefäßes daran, über welches Gefäß sich der Arcus plantaris angiographisch füllt. Eine Kollateralbildung beim Erwachsenen infolge atherosklerotischer Veränderungen über ursprünglich embryologische Gegebenheiten ist denkbar. 2. Die makroskopische Präparation kleinster Gefäße am Fuß wird durch die Injektion der roten Injektionslösung Microfil® erleichtert. Zur fotografischen Dokumentation ist eine Farbmarkierung der Arterien von außen notwendig, um den Gefäßverlauf sichtbar zu machen. 3. Digitale Subtraktionsangiographie an Leichenmaterial ist nur an Thiel-fixiertem Material möglich, da diese Methode die Gewebeverhältnisse in ihrer natürlichen Konsistenz erhält. Das Einbinden der Schleusen und die Injektion von Kontrastmittel in das Gefäßsystem sind durchführbar, weil die Gefäßlumina durchgängig bleiben. Alkohol- oder Formaldehyd-fixiertes Material ist für diese Zwecke ungeeignet, da das Gewebe aushärtet und in den Gefäßen befindliche Blutreste koagulieren. Dadurch wird eine Kontrastmittel-Injektion unmöglich. 4. Dass histologische Färbungen an langzeitfixiertem Material möglich sind, konnte bestätigt werden. Nach Modifikation der Färbevorschriften erlauben sie die Bewertung des Atherosklerosegrades. Der schwerste Befall mit Grad 4 befindet sich in den Arterien der Kniekehle. Die Fußarterien sind mit Grad 2 geringer befallen. 5. Dauerpräparate verbleiben in der anatomischen Lehrsammlung bzw. im Fundus von Anschauungsmaterial. Sie werden zukünftig zur Demonstration anatomischer Strukturen im Rahmen klinischer Kurse und im Studentenunterricht verwendet. 6. Die Anatomie als Grundlagenfach der Medizin hat in der Lehre einen hohen Stellenwert und in allen Studienabschnitten eine hohe klinische Relevanz. Gemeinsame Lehrveranstaltungen von Anatomie und Klinik wecken bei Studenten großes Interesse und fördern die Motivation. Im Rahmen der ärztlichen Aus- und Weiterbildung werden in klinischen Kursen am Institut für Anatomie beispielsweise Untersuchungsmethoden und Operationsbedingungen simuliert. Kliniker wiederholen, festigen oder vertiefen ihre anatomischen Kenntnisse. Vor allem die chirurgischen Fächer profitieren von diesen praktischen Trainingsmöglichkeiten. Wie die Arbeit am Beispiel der Gefäßchirurgie zeigt, bedingt eine gute Zusammenarbeit zwischen Anatomie und Klinik eine sichere klinische Praxis und eine lebendige Anatomie mit klinischen Bezügen. / Summary Vascular diseases and diabetes mellitus show rising frequency in the Western world and are often accompanied by amputation. The amputation rate is still increasing despite major developments in diagnostics and therapy. Especially patients with diabetes mellitus are at high risk. Because of the special pattern with more severe atherosclerosis in the crural vessels than in the femoral and pedal arteries, the pedal bypass surgery provides excellent vessel patency and limb salvage rates in diabetic patients and can often prevent amputation. A solid knowledge about anatomical variations in the operating area is a precondition for bypass operations. This dissertation deals with variations of arteries from the lower leg and foot. Lower legs from alcohol-fixed and Thiel-fixed cadavers were examined with different methods: The alcohol-fixed legs (n=12) were dissected macroscopically for variations of the arteries and documented by photographes. Samples along the vessel course (n=32) were taken for histological evaluation of the atherosclerotic degrees. Two legs were plastinated with polyethylene glycol. The Thiel-fixed legs (n=10) were tested for digital subtraction angiography (DSA). The following questions had to be answered: 1. Which arterial variations can be found for the lower leg and foot? How do the vessels communicate between the sole and the dorsum of the foot? 2. How are small foot vessels dissected for photographical documentation? 3. Can Thiel-fixed material be used for DSA? 4. Do proximal and distal vessels show different degrees of atherosclerosis? 5. Which relevance does plastination have for the medical education? 6. How important is Gross anatomy for the clinicians? Results and conclusions: 1. The following variations occurred: trifurcation, anterior tibiofibular truncus with high branching from the posterior tibial artery and the anterior tibial artery originating from the fibular artery, dominant fibular artery, plantar arch running through the second interosseus space, dominant deep plantar artery, dominant deep branch of the medial plantar artery, prominent arcuate artery. The arteries for the plantar arch, supplying most of the foot arteries, show a high diversification. They are part of the “ring anastomosis” which assures a good blood supply via different vessels connecting the dorsum and the sole of the foot. Beside the deep plantar artery, also named as “perforating branch I”, there are other connecting branches between the plantar and dorsal metatarsal arteries - the perforating braches II, III and IV. These branches are highly developed in case of an undeveloped deep plantar artery. The fibular artery can be involved in the blood supply of the foot via a communicating branch to the posterior tibial artery and the perforating branch to the dorsalis pedis artery. The fibular artery, which is phylogenetically the oldest crural vessel, can be highly developed in case of inferior anterior tibial artery and/or posterior tibial artery. The “ring anastomosis” is very important for vascular surgery. The inflow and outflow vessels of a popliteodistal bypass are chosen after angiography of the plantar arch showing the vessel for the supply of the plantar arch. 2. Macroscopical dissection of very small foot vessels can be facilitated by injection of a special plastic, Microfil®-solution. The arteries have to be additionally coloured by help of special markers for photographical documentation. 3. DSA can just be done with Thiel-fixed material. Thiel-fixation allows DSA because maintained in situ conditions. The blood is not coagulated and the vessels stay patent for contrast medium. Alcohol-fixed or formaldehyde-fixed material is not suitable for DSA because of clotted blood in the vessels impeding injection of contrast agent. 4. It is confirmed that histological examination is possible with long fixed material. After modification of the staining protocol the sections could be used for evaluation of the atherosclerotic degree. The popliteal arteries are more affected with degree 4 in comparison to the foot arteries with degree 2. 5. Plastinates are displayed in the anatomical collection of the Institute for Anatomy. They will be used for anatomical demonstrations in the lessons of students and in clinical courses. 6. Anatomy as basic knowledge is very important for teaching medical students and has a high clinical relevance in every phase of the medical course. Interdisciplinary lessons between anatomy and clinical disciplines awake interest and motivate students. Advanced medical training is obtained at the Institute for Anatomy by simulating endoscopic examination and developing new surgical techniques. Clinicians repeat, stabilize and deepen their anatomical knowledge. Especially surgeons benefit from these training possibilities. Using the example of vascular bypass surgery the present dissertation shows the value of a good cooperation between anatomy and clinic to provide a safe clinical practice and a lively anatomy with clinical references.