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Scientific Articles   |    
Digital Vascular Mapping of the Integument About the Achilles Tendon
Horacio Yepes, MD1; Maolin Tang, MD2; Christopher Geddes, MD, MSc2; Mark Glazebrook, MD, FRCS(C)3; Steven F. Morris, MD, MSc, FRCS(C)4; William D. Stanish, MD, FRCS(C)3
1 Department of Orthopaedic Surgery, Faculty of Medicine, Dalhousie University, 1487 George Street, Sydney, NS B1P 1P2, Canada. E-mail address: yepeshoracio@yahoo.ca
2 Department of Anatomy and Neurobiology and Department of Surgery, Faculty of Medicine, Dalhousie University, Sir Charles Tupper Building, 13th Floor, Halifax, NS B3H 4H7, Canada
3 Fenwick Medical Centre, 5595 Fenwick Street, Suite 311, Halifax, NS B3H 4M2, Canada
4 QEII Health Sciences Centre, 1796 Summer Street, Room 4443, Halifax, NS B3H 3A7, Canada
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Queen Elizabeth II Research Foundation, Halifax, Nova Scotia. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Anatomy and Neurobiology and the Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 May 01;92(5):1215-1220. doi: 10.2106/JBJS.I.00743
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: 

Soft-tissue coverage and vascularity likely play a vital role in the genesis of wound complications and infections during open Achilles tendon repair. Planning an appropriate surgical approach might decrease the prevalence of these complications.

Methods: 

Five adult cadavers underwent whole-body arterial perfusion with a mixture of lead oxide, gelatin, and water. The skin of the foot and ankle was dissected, and the vascular supply was evaluated with angiography. All angiograms were analyzed with use of statistical software.

Results: 

We constantly identified three vascular zones: (1) the medial vascular zone, which had the richest blood supply; (2) the lateral vascular zone, in which the density of vascularity was good and much better than that in the posterior zone; and (3) the posterior vascular zone, which showed the poorest blood supply.

Conclusions: 

The richest vascular zones of the skin covering the Achilles tendon are located toward the medial and lateral aspects of the Achilles tendon. On the basis of the present study, we recommend using a medial or lateral incision in the integument covering the tendon, as the posterior incision will be located in a less vascular zone.

Clinical Relevance: 

The present study should help the surgeon to plan the surgical approach to the Achilles tendon by designing skin incisions in a more vascular zone.

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    References

    Accreditation Statement
    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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    Horacio Yepes, MD
    Posted on June 27, 2010
    Dr. Yepes responds to Dr. Kraemer and colleagues
    Dalhousie University, Halifax,, Nova Scotia, Canada

    Soft tissue coverage over the Achilles tendon continues to be an important issue for the orthopaedic and plastic surgeon. In our personal experience, we have seen more complications when we used a posterior approach compared with a medial approach, supporting our hypothesis that there may be different vascular zones in the skin covering the Achilles tendon. As we published in our paper (1), we have found three different vascular zones with the posterior zone the least vascular and more prone to wound complications. The lateral and medial zones have more blood supply, with the medial zone having the most.

    With great enthusiasm we have read Dr. Kraemer's letter supporting our study. We want to thank Dr. Kraemer for his input and congratulate him for his own research (2). Dr. Kraemer used a real-time non-invasive combined laser doppler and near-infrared photospectroscopy at different locations of the Achilles tendon and skin demonstrating a better pattern of blood supply on the medial aspect of the medial paratendon and skin covering the Achilles tendon.

    Peer review is a valuable way to forward scientific knowledge and keep the highest standards in research. We had the opportunity of reviewing his article (2) and noted how we reached a similar conclusion.

    We agree in recommending a surgical approach on the medial paratendinous side, which represents the richest vascular zone of the integument covering the Achilles tendon.

    We would like to take the opportunity to thank Dr. Kraemer for his supportive letter.

    References

    1. Yepes H, Tang M, Geddes C, Glazebrook M, Morris SF, Stanish WD. Digital vascular mapping of the integument about the Achilles tendon. J Bone Joint Surg Am. 2010;92:1215-20.

    2. Knobloch K, Kraemer R, Lichtenberg A, Jagodzinski M, Gossling T, Richter M, Zeichen J, Hufner T, Krettek C. Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes. Am J Sports Med. 2006;34:92-7.

    Robert Kraemer
    Posted on May 30, 2010
    Medial Paratendinous Approach in Achilles Tendon Surgery
    Hannover Medical School, Germany

    To the Editor:

    We read with great interest the recent report from Yepes and coworkers about the evaluation of vascularity of the skin covering the Achilles tendon (1). We would like to comment on some observations and conclusions made by the authors.

    Yepes stated that the richest vascular zones of the skin covering the Achilles tendon are located toward the medial and lateral aspects of the Achilles tendon. Yepes recommended using a medial or lateral incision in the integument covering the tendon, as the posterior incision would be located in a less vascular zone.

    Typically, Achilles tendon infections are the reason for soft tissue problems subsequent to open, seldom after minimal-invasive surgical repair of the torn Achilles tendon. From a plastic surgeons’ point of view, soft tissue coverage in the ankle region is often challenging and often necessitates free flap transfer. Therefore, we recently performed a similar study to evaluate the soft tissue microcirculation in the Achilles region with potential implications for the surgical approach as well. Using a distinct technology involving spectrophotometry and Laser-Doppler flowmetry, we could demonstrate equivalent results to the findings of Yepes et al. (2).

    For microcirculatory mapping of skin perfusion we used real-time non-invasive combined laser Doppler and near-infrared photospectroscopy at 24 locations at the Achilles tendon (Oxygen-to-see, LEA Medizintechnik,Giesen, Germany).

    We found that skin oxygen saturation medial paratendinous to the Achilles tendon was significantly higher than lateral but equivalent to skin covering the Achilles tendon. Medial paratendinous capillary blood flow was higher than capillary blood flow at the skin covering the Achilles tendon and covering the lateral paratendon. The lateral paratendon had higher postcapillary venous filling pressures than medial indicating impaired venous blood clearance at the lateral aspect of the Achilles tendon.

    As a conclusion, we found better microcirculatory values at the medial aspect of the Achilles tendon in contrast to the skin covering the Achilles tendon and the lateral paratendinous area. According to Yepes et al. we would support and recommend a paratendinous approach to the Achilles tendon, at best on the medial aspect. We would like to congratulate the authors for their inspiring work.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Yepes H, Tang M, Geddes C, Glazebrook M, Morris SF, Stanish WD. Digital vascular mapping of the integument about the Achilles tendon. J Bone Joint Surg Am. 2010;92:1215-20.

    2. Knobloch K, Kraemer R, Lichtenberg A, Jagodzinski M, Gossling T, Richter M, Zeichen J, Hufner T, Krettek C. Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes. Am J Sports Med. 2006;34:92-7.

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