Lateral Approach to the Calcaneus
Lateral Approach to the Calcaneus
The lateral approach to the calcaneus is primarily used for open reduction and internal fixation of calcaneal fractures. Such fractures are always associated with significant soft tissue swelling; it is critical to allow this soft tissue swelling to subside before surgery is carried out to reduce the risk of skin necrosis. An accurate assessment of the vascular status of the patient is critical before undertaking surgery. Diabetes, especially with associated neuropathy and smoking, are relative contraindications to this surgery approach. The indications for the surgical approach include the following:
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Open reduction and internal fixation of displaced calcaneal fractures
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Treatment of other lesions of the posterior facet of the subtalar joint and lateral wall of the os calcis
Position of the Patient
Place the patient in the lateral position on the operating table. Ensure that the bony prominences are well padded. Place the leg that is to be operated on posteriorly with the under leg anterior. Exsanguinate the limb either by elevating it for 3 to 5 minutes or by applying a soft rubber bandage. Inflate a tourniquet.
Landmarks and Incision
Landmarks
Palpate the posterior border of the distal fibula and the lateral border of the Achilles tendon. Next, identify the styloid process at the base of the fifth metatarsal bone, which is easily felt along the lateral aspect of the foot.
Incision
The skin incision has two limbs. Begin the distal limb of the incision at the base of the fifth metatarsal and extend it posteriorly, following the junction between the smooth skin of the dorsum of the foot and the wrinkled skin of the sole. Make a second incision beginning approximately 6 to 8 cm above the skin of the heel, halfway between the posterior aspect of the fibula and the lateral aspect of the Achilles tendon. Extend this second incision distally to meet the first incision overlying the lateral aspect of the os calcis (Fig. 12-51).
Internervous Plane
No internervous planes are available for use. The dissection consists of a direct approach to the subcutaneous bone.
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Figure 12-51 Begin the distal limb of the incision at the base of the fifth metatarsal and extend it posteriorly, following the junction between the smooth skin of the dorsum of the foot and the wrinkled skin of the sole. Make a second incision beginning approximately 6 to 8 cm above the skin of the heel, halfway between the posterior aspect of the fibula and the lateral aspect of the Achilles tendon. Extend this second incision distally to meet the first incision overlying the lateral aspect of the os calcis.
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Figure 12-52 Deepen the skin incision through subcutaneous tissue, taking care not to elevate any flaps. Distally dissect straight down to the lateral surface of the calcaneus by sharp dissection. Next, elevate a thick flap consisting of periosteum subcutaneous tissues and skin. The peroneal tendons will be elevated in this flap. Do not attempt to dissect out layers in this flap.
Superficial Surgical Dissection
Deep Surgical Dissection
Incise the periosteum of the lateral wall of the calcaneus and develop a full-thickness flap consisting of periosteum and all the overlying tissues. Stick to bone and continue to retract the soft tissue flap proximally. The peroneal tendons will be carried forward with the flap. Divide the calcaneofibular ligament to expose the subtalar joint. Continue the dissection proximally to expose the body of the os calcis as well as the subtalar joint. Distally expose the calcaneocuboid joint by incising its capsule. If at all possible, try not to cut into the muscle belly of abductor digiti minimi (Fig. 12-53).
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Figure 12-53 Continue to develop the anterior flap. Divide the calcaneofibular ligament to expose the subtalar joint. Continue the dissection proximally to expose the body of the os calcis as well as the subtalar joint. Distally expose the calcaneocuboid joint by incising its capsule.
Dang
Nerves
The sural nerve is vulnerable if the skin flap is too far proximal.
The soft tissues are vulnerable during this approach. The risk of skin necrosis can be minimized if the flap is elevated as a full-thickness flap because the skin derives its blood supply from the underlying tissues. Dissecting the skin flaps in this area, which has always been severely traumatized, is associated with a significant incidence of wound breakdown. Accurate assessment of the patient’s preoperative vascular status is critical. Most surgery in this area has to be delayed for a significant period of time to allow soft tissue swelling to diminish before surgery commences.