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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_708_Библиотеки_им_академика_М_И_Перельмана
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18
Lateral Approach to the
Calcaneum
Position of the Patient
Landmarks and Incision
Landmarks
Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
Introduction
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The lateral approach to the calcaneum 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.
1
Diabetes, especially with associated neuropathy and smoking, are
relative contraindications to this surgery approach. The indications for
the surgical approach include the following:
Open reduction and internal fixation of displaced calcaneal fractures
Treatment of other lesions or malunions 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
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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.
18-1).
Figure 18-1. 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
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No internervous planes are available for use. The dissection consists of a
direct approach to the subcutaneous bone.
Superficial Surgical Dissection
Deepen the skin incision through subcutaneous tissue, taking care not to
elevate any flaps. Distally, dissect straight down to the lateral surface of the
calcaneum by sharp dissection (Fig. 18-2).
Deep Surgical Dissection
Incise the periosteum of the lateral wall of the calcaneum 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 possible, try not to cut into the muscle belly of abductor digiti
minimae (Fig. 18-3).
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Figure 18-2. Deepen the skin incision through subcutaneous tissue, taking care
not to elevate any flaps. Distally dissect straight down to the lateral surface of
the calcaneum 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.
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Figure 18-3. 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.
Dangers
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.
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The lateral calcaneal artery is the main blood supply to this extensile
flap.2 By waiting a few days after a fracture, the blood supply is more
assured to the flap from the other two smaller branches if the incision
compromises the lateral calcaneal artery.
REFERENCES
1. Bibbo C, Ehrlich DA, Nguyen HML, et al. Low wound complication
rates for the lateral extensile approach for calcaneal ORIF when the
lateral calcaneal artery is patent. Foot Ankle Int. 2014;35(7):650–656.
2. Borrelli J Jr, Lashgari C. Vascularity of the lateral calcaneal flap: a
cadaveric injection study. J Orthop Trauma. 1999;13:73–77.
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19
Lateral Approach for Osteotomy of
the Calcaneum (Vertical Portion of
the Calcaneal Incision)
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
Introduction
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This approach is used for calcaneal osteotomies in cases of calcaneal
malunion. It also may be used for excision of bony lumps on the
calcaneum that are producing pressure symptoms. 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 surgical approach.
Position of the Patient
Place the patient in the lateral position on the operating table (Fig. 19-1).
Ensure that the bony prominences are well padded. Position the image
intensification unit in front of the patient or at the foot of the table. Flex the
knee so that the leg that is to be operated on lies posteriorly with the under
leg anterior.
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Figure 19-1. Place the patient in the lateral position on the operating table.
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