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.

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.