Calcaneal approach, dangerasdsadsdadsadsa.pptx

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1. Posterior
“7 Peroneal

ee, aer Vascular supply
Medi It is essential to understand the vascular supply to the
Pence subcutaneous tissues of the lateral hindfoot as wound-healing
cea | Sus! complications are common after using this approach. The
ES perforating branches of the peroneal artery contribute to the

vascularity of the lateral skin and soft tissue of the foot. The

hee undermining of skin edges runs the risk of skin edge necrosis

peat and therefore full-thickness flaps have to be developed to
bates prevent this complication.
restr tii
err kane banches
Étant AO
peroneal ey Ml The lateral calcaneal artery is responsible for the majority of the

| blood supply to the corner ofthe L-shaped flap of this approach.
The heel pad is mostly supplied from the posterior tibial artery

Later
branches medially.
\ - The sural nerve needs to be protected in the horizontal part of
atera E NEF if the approach.

Foner akan bances al
branches poreror ta onery AO

2. LATERAL APPROACH TO
THE CALCANEUS

"Begin the incision on the lateral margin of the Achilles
‘tendon near its insertion and pass it distaly to a point
4 cm inferior to and 2.5 cm anterior to the lateral malleo-
lus (Fig. 1-28).

"Divide the superficial and deep fascae, isolate the pero-
‘neal tendons, and incise and elevate the periosteum
‘below the tendons to expose the bone.

If necessary, and if no infection is present, divide the
by Z-plasty and repair them later.

LEXTRETR Laver aporonch to cakaneus A, Skin incision 8, Incion in perineum of cakaneus. Calcaneus is expostd. SEE
oor

3. Fibulocalcaneal tendon
Talocalcaneal tendon

Ligaments and tendons

The peroneal tendons are on the lateral side of the calcaneus.
Note the position of the retinaculum and of the fibulocalcaneal
and talocalcaneal ligaments.

In raising the full-thickness L-shaped flap, one detaches the
retinacular attachment as well as that of the fibulocalcaneal and
talocalcaneal ligaments from bone.

4. Subchondral lag screw

‘Once the reduction of the articular surface is achieved, itis
maintained with a subchondral lag screw which runs from lateral
anteromedially into the “constant” medial subchondral fragment.
Thus, when drilling the hole for the lag screw, the drill bit must be
directed carefully in these three directions:

a) Lateral to medial

b) Posterior to anterior

©) Cephalad to caudad

In this way, the threaded portions of the screw will be directed
into the strong medial sustentacular cortical bone.

The surgeon must use caution while inserting the lag screw.

On the medial side is the neurovascular bundle which ends up
frequently at the tip of the subchondral lag screw. If one allows
the drill bit, or the screw, to protrude too far medially, one can
damage the neurovascular bundle or FHL tendon.

5. MEDIAL APPROACH TO
THE IS

TECHNIQUE

Begin the incsion 25 cm anterior to and 4 cm infario to.
‘the medal malleolus, camyng it poster along the
medal surface of the foot to the Achilles tendon.
Dive the fat and fascia and define the inferior margin
of the abductor hall.

= Mobilize the muscle belly and retract it dorsally to expose
‘the medial and inferomedia aspects of the body of the
lcreus.

= Continue the dissection dstally by dvicing the plantar
aporeuross and the muscos attaching tothe calcanaus
of by snpping these from the bone with an osteotome.
(Carefully av0d the medal calcaneal nerve and the nerve
10 the abductor digit minim

)

EEE weciat approach to calcaneus A, Skin incision. asciainiion. € olation of neurovascular bundle (Mode from
Burdeaux 8D: Reduction of calcaneal fractures by the McReynolds medial approach technique and its experimental basis, Clin Orthop Reíat Res
17733. 1985) SEE TECHNIQUE 1-13.

6. U-SHAPED APPROACH
TO THE CALCANEUS

"With the patient prone, support the leg on a large
sandbag.

"= For access to the entire plantar surface of the calcaneus,
make a large U-shaped incision around the posterior four
fifths of the bone (Fig. 1-29).

= After the dissections described, retract a flap consisting
of skin, the fatty heel pad, and the plantar fascia.

-Caleaneus
Plantar
aponeurosis

Incision in ‘and muscles
plantar retracted
ross.

andmusces

© D

shaped approach to cakaneus A Skin incon Peces icon. Icon in plantar aponeuroi and mus.
D, Plantar aponeurosis and muscles are retracted. SEE TECHNIQUE 1-

7. Lateral Approach to the Calcaneus

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1. Open rein nd itera ation of placed
‘chen neues

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Position ofthe Patient
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Dual bode of he Ales ted. Net en.

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lal and the bee spect ofthe Als tendon.

dw nen ar ld lamas
ar discon Fig 1252

Figure 1251. Begin she
deal ib of he meison

SEHE
Sei
=o
Saar
es
Es
mal 610 Sam above the
Enlaces
poe
Bes
distally co meet the first
en
aspect of the os calcis.

8. Deep Surgical Dissection

Incise the periosteum of the lateral wall of the calca-
neus 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 lap prox-
imally. The peroneal tendons will be carried forward

Figure 1252 Decpen the
skin incision through sub-
cutancous tissue, taking
ftp Dinah dis

ps. issect
straight down to the lateral
surface of the caleaneus by
sharp dissection. Nex,
elevate a thick Map
consisting of m
ssbowancots ees and
skin, The peroneal tendons
will be elevaed inthis fap.
Do not attempe to dissect
‘oat layers in this lap.

with the flap. Divide the caleancofibular ligament to
‘expose the subtalar joint. Continue the dissection
proximally co expose the body of the os calcisas well
as the subtalar joint. Distally expose the calca-
ncocuboid joint by incising its capsule. [fat all possi-
ble, ry not to cut into the a
digiti minimac (Fig. 12-53).

I belly of

9. Dangers

Nerves
‘The sural nerve is vulnerable ifthe skin flap is too far
proximal.

The soft tissues are vulnerable during this ap-
proach. The risk of skin necrosis can be minimized if
the flap is clevated as a full thickness flap because the

1253 Continue to de-
velop the anterior Bap. Divide
the calcancofibular ligament to
expose the subtalar joint. Con-
tinue the dissection proximally
to expose the body of the os
cales as well as the subtalar
joint. Distally expose the calca-
neocuboid joint by incising its
capsule.

skin derives its blood supply from the underlying tis-
sues, Dissecting the skin flaps in this arca, which has
always been severely traumatized, is associated with a
significant incidence of wound breakdown. Accurate
assessment of the patients preoperative vascular status
is critical. Most surgery in this arca has to be delayed
for a significant period of time to allow soft-tissue
swelling to diminish before surgery commences,