Location of Vertical Limb of Extensile Lateral Calcaneal Approach and Risk of Injury of the Calcaneal Branch of Peroneal Artery

Abstract

Background:

The extensile lateral calcaneal approach is a standard method for accessing a joint depression calcaneal fracture. However, the operative wound complication rate is high. Previous studies showed a calcaneal branch of the peroneal artery contributing to the calcaneal flap blood supply. This study focuses on the location of the vertical limb in this approach correlating to the aforementioned artery and flap perfusion.

Methods:

Ten pairs of fresh-frozen cadaveric lower extremities were used. Extensile lateral calcaneal approach (ELCA) was carried out on both calcanei, where the vertical limb was placed at the line between the posterior border of lateral malleolus and lateral edge of the Achilles tendon for the right side (standard ELCA; sELCA) and at the lateral edge of the Achilles tendon for the left side (modified ELCA; mELCA). The identified vessel in the vertical limb incision was ligated and cut, and the horizontal limb of the incision was carried out as usual. After completion of flap elevation, 80°C water was injected into the popliteal vessel. In addition, thermal images were taken pre- and postinjection. Dye was injected subsequently, and perfusion was recorded in video format.

Results:

Mean pre- and postinjection skin flap temperature difference was significantly higher in mELCA (5.36°C vs 0.72°C, P = .0002). Dye perfusion patterns were significantly better in mELCA (P = .0013). The calcaneal branch of peroneal artery was found in the vertical incision in 9 of 10 sELCA, with average distance 22.04 mm anterior to the calcaneal tuberosity and 8.22 mm proximal to superior border of the calcaneus, whereas one was found in mELCA, in which perfusion tests still appeared normal.

Conclusion:

The vertical limb of incision during extensile lateral calcaneal approach should be placed at the lateral edge of the Achilles tendon to avoid injuring the calcaneal branch of peroneal artery, which supplies the lateral calcaneal flap. However, further clinical research might be needed to confirm the results of this study.

Clinical relevance:

This study demonstrates a likely safest position for the proper incision for exposing the lateral calcaneus.

Keywords

extensile lateral calcaneal approach complication calcaneal branch peroneal artery calcaneal fracture

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References

Attinger

Evans

Bulan

Blume

Cooper

Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg. 2006;117(7)(suppl):261S-293S.

Basile

Albo

Via

AG.

Comparison between sinus tarsi approach and extensile lateral approach for treatment of closed displaced intra-articular calcaneal fractures: a multicenter prospective study. J Foot Ankle Surg. 2016;55(3):513-521.

Benirschke

Kramer

PA.

Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18(1):1-6.

Bibbo

Ehrlich

Nguyen

Levin

Kovach

SJ.

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.

Borrelli

Jr Lashgari

Vascularity of the lateral calcaneal flap: a cadaveric injection study. J Orthop Trauma. 1999;13(2):73-77.

Elsaidy

El-Shafey

The lateral calcaneal artery: anatomic basis for planning safe surgical approaches. Clin Anat. 2009;22(7):834-839.

Femino

Vaseenon

Levin

Yian

EH.

Modification of the sinus tarsi approach for open reduction and plate fixation of intra-articular calcaneus fractures: the limits of proximal extension based upon the vascular anatomy of the lateral calcaneal artery. Iowa Orthop J. 2010;30:161-167.

Folk

Starr

Early

JS.

Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. J Orthop Trauma. 1999;13(5):369-372.

Freeman

Duff

Allen

Nicholson

Atkins

RM.

The extended lateral approach to the hindfoot. Anatomical basis and surgical implications. J Bone Joint Surg Br. 1998;80(1):139-142.

10.

Gould

Lateral approach to the os calcis. Foot Ankle Int. 1984;4(4):218-220.

11.

Harvey

Grujic

Early

Benirschke

Sangeorzan

BJ.

Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach. Foot Ankle Int. 2001;22(11):868-73.

12.

Hoppenfeld

DeBoer

Buckley

Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.

13.

Kwon

Gonzalez

Riedel

Nazarian

Ghorbanhoseini

Proximity of the lateral calcaneal artery with a modified extensile lateral approach compared to standard extensile approach. Foot Ankle Int. 2017;38(3):318-323.

14.

Guo

Wang

et al . Less wound complications of a sinus tarsi approach compared to an extended lateral approach for the treatment of displaced intraarticular calcaneal fracture: a randomized clinical trial in 64 patients. Medicine (Baltimore). 2016;95(36):e4628.

15.

Nosewicz

Knupp

Barg

et al . Mini-open sinus tarsi approach with percutaneous screw fixation of displaced calcaneal fractures: a prospective computed tomography-based study. Foot Ankle Int. 2012;33(11):925-933.

16.

Park

Che

JH.

The sinus tarsi approach in displaced intra-articular calcaneal fractures. Arch Orthop Trauma Surg. 2017;137(8):1055-1065.

17.

Qiang

Chen

Jia

et al . Post-operative radiological predictors of satisfying outcomes occurring after intra-articular calcaneal fractures: a three dimensional CT quantitative evaluation. Int Orthop. 2017;41(9):1945-1951.

18.

Schepers

The sinus tarsi approach in displaced intra-articular calcaneal fractures: a systematic review. Int Orthop. 2011;35(5):697-703.

19.

Schepers

Backes

Dingemans

de Jong

Luitse

JSK

. Similar anatomical reduction and lower complication rates with the sinus tarsi approach compared with the extended lateral approach in displaced intra-articular calcaneal fractures. J Orthop Trauma. 2017;31(6):293-298.

20.

Yeo

Cho

Lee

KB.

Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach. BMC Musculoskelet Disord. 2015;16:63.

21.

Zwipp

Tscherne

Wulker

Osteosynthesis of dislocated intra-articular calcaneus fractures [in German]. Der Unfallchirurg. 1988;91(11):507-515.

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