Lateral Approach to Calcaneus

The Lateral Approach to Calcaneus is mainly used for open reduction and internal fixation of the Calcaneal fracture.

The indications for the the Lateral Approach to Calcaneus include the following:

1. Open reduction and internal fixation of displaced calcaneal fractures.
2. Treatment of other lesions of the posterior facet of the subtalar joint and lateral wall of the os calcis.

Calcaneal 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.

For More details, see this video: Calcaneal fractures - Operative techniques (OTA lecture)

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.

Landmarks and Incision

• Landmark:
  1. The posterior border of the distal fibula.
  2. The lateral border of the Achilles tendon.
  3. The styloid process at the base of the fifth metatarsal bone.
• 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.

Internervous plane

• There is No internervous plane for Lateral Approach to Calcaneus.
• The dissection consists of a direct approach to the subcutaneous bone.

Superficial dissection

1. Deepen the skin incision through subcutaneous tissue, taking care not to elevate any flaps.
2. Distally, dissect straight down to the lateral surface of the calcaneus by sharp dissection.

Deep 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 the 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 minimae.

Dangers

The structures at risk during the Lateral Approach to Calcaneus include:

• The Sural nerve.
• The skin:
  • 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.

References

• Surgical Exposures in Orthopaedics book – 4th edition Edition.
• Campbel’s Operative Orthopaedics book 12th edition book.