Extensile Lateral Approach to Calcaneus

• Allows visualization of the lateral calcaneus and subtalar joint
  
• Indications
  • calcaneus fractures
  • calcanectomy

• No true internervous or intermuscular plane

• 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

• 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