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Introduction
  • Extensile Lateral ApproachAllows visualization of the lateral calcaneus and subtalar joint
  • Indications
    • calcaneus fractures
    • calcanectomy
Planes
  • No true internervous or intermuscular plane
Position & Preparation
  • Anesthesia
    • general anesthesia with endotracheal tube
  • Preparation
    • radiolucent table 
    • C-arm fluoroscopy
    • tourniquet can be used
  • Position
    • lateral decubitus positioning is necessary
    • slightly flex knee to relax gastrocnemius  muscle pull
Approach 
  • Incision 
  • Superficial dissection 
    • place the posterior arm of the incision midway between the fibula and the Achilles tendon
    • place the horizontal arm in line with the base of the fifth metatarsal
    • proximal and distal ends of the incision are bluntly spread through until sural nerve is identified
    • full thickness fasciocutaneous flaps are sharply created over calcaneus
    • must not bevel the full-thickness aspect of the incision
    • the vascular supply to the flap is a  watershed area.
  • Deep dissection 
    • at the corner of the incision, make the incision directly to the bone to ensure that a full thickness flap is created.
      • avoid any undermining of the edges
    • a thick subperiosteal flap is sharply raised off of the lateral wall of the calcaneus until the sinus tarsi, neck, and posterior facet are visualized
    • 1.6mm K-wires can be placed into the talus, fibula, and cuboid 
      • the wires are then bent, allowing a "hands-free" retraction technique 
    • the peroneal tendons are subperiosteally elevated and reflected in anterior flap
    • calcaneofibular ligament is sharply released from the calcaneus
  • Approach extension
    • can extend proximally to a lateral approach to ankle/fibula  if needed
    • distal extension limited by sural nerve

Dangers

  • Peroneal tendons
    • risk is minimized with maintenance of access under the anterior flap
    • must evaluate upon closure for instability or laceration(s)
  • Sural nerve 
    • risk is minimized with maintenance of access under the anterior flap
    • must dissect out proximal aspect of vertical limb and anterior aspect of horizontal limb to minimize iatrogenic injury 
  • Wound dehiscence
    • most common complication of this approach
    • lateral calcaneal artery is responsible for corner of flap
    • careful attention to skin handling and closure with Allgower-Donati suture technique minimizes soft tissue complications 
 

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