The treatment of displaced calcaneal fractures remains controversial. partial exsanguination. The sinus tarsi syndrome is now a well-defined entity of foot pathology. Various internal fixation techniques have been described, but a laterally based plate is commonly accepted to give the most rigid fixation.7,8 Since displaced calcaneus fractures present with various degrees of comminution and soft tissue trauma, it is advantageous for the calcaneal fracture surgeon to have a variety of methods of treatment to balance minimizing risks of wound complications against obtaining the best reduction possible.9. would like to thank his fellowship director and mentor, Elly Trepman M.D. 0000000016 00000 n 1 0 obj<> endobj 2 0 obj<> endobj 3 0 obj<> endobj 5 0 obj null endobj 6 0 obj<>/ProcSet[/PDF/Text]/ExtGState<>>>>> endobj 7 0 obj<> endobj 8 0 obj<> endobj 9 0 obj<> endobj 10 0 obj<>stream 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, Correspondence to: John E. Femino, MD Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, JPP 01022, Iowa City, IA 52242-1088 phone: 319-384-5844 fax: 319-384-8634, (A) Deep dissection of lateral ankle and hindfoot. http://ns.adobe.com/pdf/1.3/ start incision 1 cm below the tip of the lateral malleolus. In a similar fashion we found the LCA to be at risk with this extended sinus tarsi approach if at the proximal edge of the floor of the SPR. He and others have found this approach to be useful and reasonably safe. trailer fibrous debris and fat removed from sinus tarsi small elevator or lamina spreader placed under posterior facet fragment to aid in reduction K-wires inserted for provisional fixation aimed towards the sustentaculum Results: Median Bhler and Gissane angle were improved to 26.5 degree (4.6 to 45), 115.5 degree (101.2 to 127.4) In this manner, both nerves can be left untouched within the subcutaneous fat. The functionality is limited to basic scrolling. This is carried distally to the level of the calcaneal-cuboid joint. URI calcaneus decorticated, joint manipulated into varus. XMP Media Management Schema Trauma is the most common cause following one single or a series of ankle sprains. Berlin; New York: In Springer-Verlag; 1991. By avoiding dissection through the deep portion of the SPR, the LCA can be protected, thus preserving the blood supply to the lateral calcaneal skin flap. The drain in our series was removed 24-48 hours postoperatively and wounds were examined on the second postoperative day. There has historically been debate over the best approach for treating these fractures.1,4 The goal of operative treatment of calcaneal fractures is to obtain the best possible reduction of the articular surfaces and restoration of the architecture of the non-articular portions of the bone, and to hold this reduction with stable internal fixation.5,6 These goals must be balanced with the need to minimize the operative risks, especially the risk of wound healing complications. Sinus Tarsi is actually a tunnel that runs between the talus and the heel bone. Treatment with our self-designed combined plate through a sinus tarsi approach may be safe and effective for type II and type III calcaneal fractures. 0000000210 00000 n Six patients underwent concurrent peroneal sheath and/or tendon reconstruction, six patients underwent concomitant lateral ankle ligament reconstruction, two patients underwent concurrent open reduction and internal fixation (ORIF) of a talar neck and head fracture respectively, and two patients underwent concurrent ORIF of fibular fractures. This study reviews the radiographic and clinical outcomes of the use of the sinus tarsi approach for operative fixation of these fractures with attention to the rate of infection and restoration of angular . The floor of the peroneal tendon sheath above the superficial peroneal retinaculum was transected longitudinally and the underlying posterior peroneal artery branch, or lateral calcaneal artery (LCA) was identified (Figure 3). minimally invasive incision that minimizes soft tissue dissesction. The ePub format is best viewed in the iBooks reader. continue incision distally until the base of the fourth metatarsal is reached, use cautery to cauterize any crossing vessels for hemostasis, identify the origin of the extensor digitorum brevis and the sinus tarsi fat pad, leave a small cuff of tissue proximally for reattachment of the flap, this allows better exposure of the joint surfaces and the middle and anterior facet, use a rongeur to remove any remaining soft tissues, use a straight curette or chisel to remove cartilage from the lateral half of the inferior talus and superior aspect of the calcaneal facets, insert a lamina spreader and remove the remaining medial articular cartilage, use curettes and osteotomes to create bleeding subchondral bone, use a 2.0 mm drill to create small perforations in bone, if bone graft is inserted reattach tendon after insertion of graft. This is a safe, simple incision, but the surgeon must look for the sural nerve. We retrospectively reviewed thirteen patients who had undergone open reduction and lateral plate fixation without bone graft of closed displaced intraarticular calcaneus fractures using an extensile sinus tarsi approach. We currently do not suture the drains and we remove them at 24 hours through the dressing. Inflammatory arthritides such as rheumatoid arthritis, gout, or ankylosing arthritis are also associated. 0. Conformance level of PDF/A standard Operative and non-operative management have both been suggested for the acute treatment of calcaneal fractures, however it is generally accepted that in most cases operative treatment of displaced calcaneal fractures is warranted in order to avoid the negative consequences of malunion.2,6 Operative management can consist of reduction through an extensile open incision, limited incision or percutaneous techniques. Components of the sinus tarsi syndrome include lateral hindfoot pain, tenderness to palpation over the sinus tarsi, a sensation of instability . Care is taken to avoid any dissection of the floor of the SPR. reported a series of patients who underwent open reduction and internal fixation of the calcaneus with a modification of the Palmer incision.14 This modified incision differed from the one that Palmer described by being placed more dorsally and oriented more longitudinally like a typical approach to the sinus tarsi. %PDF-1.5 % <<8da73e08aad3fa4d8cbc2a1afc3314c6>]>> (A) Deep dissection of lateral ankle and hindfoot. Various other open approaches have been described in treating calcaneus fractures. make a second 1 cm incision just medial to the anterior tibialis tendon, use the Harris heel and lateral views to drive guidepin through the dorsomedial aspect of the talar neck across the subtalar joint into the posterior calcaneal tuberosity, insert a 6.5 or 8 mm large fragment cannulated lag screws after minimal countersinking, repeat the procedure for the second guidepin except use a small fragment cannulated screw, depth of this screw is best judged by axial view of the calcaneus, obtain final fluoroscopic images to ensure proper screw position, use 3-0 nylon horizontal mattress sutures for skin, use 2-0 vicryl for the subcutaneous layer, place in well padded non-weightbearing short leg plaster cast, split cast in recovery room to allow for post op swelling. bone work. soft tissue. The third measurement was taken where the LCA crossed the posterolateral margin of the SPR. tilt table 20 degrees away from surgeon to improve visualization. 2015-03-27T10:56:32+08:00 %%EOF Part of PDF/A standard Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus. The second measurement was made at the midline of the floor of the SPR. (B) Identification of lateral calcaneal artery deep to deep fibers of superior peroneal retinaculum. 2015-04-09T10:26:07+02:00 The widely used lateral approach to the calcaneus, described by Letournel2 and popularized by Zwipp,4 Atkins,10 Benirschke,11 and Sanders,6 has been termed, the extensile lateral approach. Peroneal longus and brevis both supplied by superficial peroneal nerve. The peroneal tendons are retracted laterally between the superior peroneal retinaculum and IPR and the inferior peroneal retinaculum is released off of the bone to expose the lateral calcaneal wall down to the anterior process. UUID based identifier for specific incarnation of a document Procedure: Sinus Tarsi approach A straight incision is made on the lateral side of the foot from the tip of the fibula to the base of the fourth metatarsal which centers the incision over the sinus tarsi. You may switch to Article in classic view. uuid:290c41fa-7bb3-4810-88a4-2264eda0c929 Text . Acrobat Distiller 10.1.5 (Windows); modified using iText 5.3.5 2000-2012 1T3XT BVBA (AGPL-version) Noble J, McQuillan WM. The senior author (J.F.) Of those patients who did not undergo primary subtalar arthrodesis, postoperative radiographs with Broden's views revealed articular reduction within two millimeters. internal After allowing the specimens to thaw, the extensile sinus tarsi approach was performed. However, the presumed diagnosis can be corroborated through the use of imaging studies, predominately magnetic resonance imaging. This patient's postoperative course was complicated by wound dehiscence and infection, which was salvaged with a below-knee amputation. TECHNIQUE STEPS Preoperative Patient Care. doi:10.1186/s12891-015-0519-0 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. Recent evidence favoring sinus tarsi rather than the extensile lateral approach has shifted opinion . sinus tarsi approach. for higher risk patients or those with concomitant fractures that could be addressed simultaneously. internal The surgeries were all performed by the senior author (J.F.) Due to the shorter incision, and more proximal location of the incision, wound complications are less common [ 2 ]. sinus tarsi to treat adjacent fractures or to aid re-duction in more complex fractures. Hall MC, Pennal GF. Anatomical basis and surgical implications. The lateral calcaneal artery (LCA) passed within 2 mm of the superior border of floor of the Superior Peroneal Retinaculum (SPR) at the midline of the peroneal sheath. Palmer I. The plate is not contoured and the lateral wall fragment typically reduces into the body of the calcaneus with lagging of the plate to the stable medial fragment. GH>UrLDcc"G_HJ2FRCt).st[N. The intermediate root of the inferior extensor retinaculum (IER) can be released too to gain better exposure of the fracture line passing obliquely through the angle of Gissane. Diagnosis can be suspected clinically with burning plantar foot pain with a positive Tinel's sign over the tibial nerve. The wide exposure allows the surgeon to place a lateral plate which gives rigid control of the body reduction with lag screw fixation through the plate into the medial sustentacular fragment. CONCLUSION: In displaced intra-articular calcaneal fractures, a minimally invasive sinus tarsi approach is associated with a lower . Foot Conditions are the most common deformity seen in Cerebral Palsy which are caused by lower extremity spasticity and can take several forms including equinus, hallux valgus, equinocavovarus, and equinoplanovalgus. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraar-ticular calcaneal fractures. extend incision down posterior fibula and bend around lateral maleolus over the peroneal tubercle. Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach divide the fascia over the anterior compartment musculature in line with the skin incision, elevate the muscle and the periosteum over the anterolateral face of the tibia using a periosteal elevator to expose the anterolateral cortex, create a 1 by 1 cm square or elliptical window in the center of the anterolateral face, insert a curette into the window and remove the cancellous graft, seal the window with the previously removed bone plug, perform a layered closure of the fascia, subcutaneous tissue and the skin, make sure to place graft within 30 minutes of harvest, create 1 cm incision at the apex of the heel for insertion of the guidepin. Tilting the bed into Trendelenberg position and allowing the foot to invert over a cloth bump aids in visualizing the subtalar joint. Surgical treatment of intra-articular calcaneal fractures: a review of small incision approaches. It could be tempting, however, to carry the deep dissection farther proximally as it would provide even wider access to this area. In addition, a limited sinus tarsi incision without elevation of the lateral calcaneal skin flap does not allow for plate fixation, a notable advantage of the extensile lateral approach, particularly in gaining reduction of the body of the calcaneus. For exposure of an isolated calcaneal fracture, the patient is positioned either in full lateral or semi-lateral position with a hip bump. The incision can be extended to allow access to the distal tibia and fibula, talus and the lateral column of the foot. It extended distally curving around the lateral malleolus and anteriorly supplying the posterior and inferior portions of the fasciocutaneous flap of the extensile lateral approach. <. Gould N. Lateral approach to the os calcis. 3 0 obj We have found that it is not clinically necessary to extend the deep dissection this far proximally as the exposure of the posterior subtalar articular surface is excellent with division of the CFL alone. 2016 Dec 23;11(1):164. doi: 10.1186/s13018-016-0497-4. Femino JE, Vaseenon T. The direct lateral approach to the distal tibia and fibula: a single incision technique for distal tibial and pilon fractures. between February 1999 and June 2002. The anterior process is reduced to the sustentaculum fragment, the lateral articular fragment(s) are reduced and pinned and the tuberosity is loosely reduced and provisionally pinned from posteriorly with pins into the sustentaculum or anterior process. 0 5 1 0 obj Standard approach to sinus tarsi S Tip of fibula S Extend towards base of 4th metatarsal S 5-8 cm S Visualize calcaneal-cuboid joint Tips/Techniques Elevate extensor . Generating an ePub file may take a long time, please be patient. The dorsal communicating branch of the sural nerve may cross the field distally but is usually small in size and easily retracted. Epidemiology. X . Your subtalar joint, the joint under which is important and runs under the neck of the talus in your subtalar joint and it's a little cavity that has some fat, it has some nerve endings and it has some fluid that lubricates the joint. 0000000120 00000 n <>/Font 8 0 R>>/Thumb 9 0 R/MediaBox[0 0 595.276 793.701]/B[10 0 R 11 0 R]/Annots[12 0 R 13 0 R 14 0 R 15 0 R 16 0 R 17 0 R 18 0 R 19 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R]/Rotate 0>> Orthobullets Team Pediatrics - Cavovarus Foot in Pediatrics & Adults Flashcards (2) Cards . The authors obtained satisfactory reductions and minimal wound complications. Primary subtalar arthrodesis in the treatment of severe fractures of the calcaneum. Sinus tarsi approach Adjacent fractures were treated through the same incision. A clinical series of 13 patients (including 7 chronic smokers and 1 with diabetes and vascular disease) with closed displaced intra-articular calcaneal fractures (Sanders types II and III) were treated by open reduction and internal fixation via this approach. One patient had peripheral vascular disease and diabetes with a severely displaced lateral calcaneal fracture-dislocation into the lateral gutter of the ankle joint with significant fibular comminution. The interosseous talo-calcaneal ligament (ITCL) could be transected, which allows the medial articular fragment to be better visualized by tipping into varus. With improvements in implants over time, rigid fixation with plates and screws has replaced bone grafting and percutaneous pinning as the usual method of maintaining reduction, with many authors favoring a lateral plate fixation. Eastwood DM, Langkamer VG, Atkins RM. converted to PDF/A-1b 1. Usually post-traumatic, it is characterised by pain over the lateral opening of the sinus tarsi and a feeling of instability of the ankle. An initial lag screw is placed across the posterior facet fracture lagging the joint fragments. Intra-articular fracture One patient had a calcaneal anterior process fracture with calcaneal-cuboid subluxation fused with a large staple. 1 Overall incidence is unknown, but it is generally considered uncommon and without consistent gender predilection. posterior to the lateral malleolus on a line from it to the insertion of the calcaneal tendon, at an average of 15 mm. Comparison of two surgical approaches for displaced intra-articular calcaneal fractures: sinus tarsi versus extensile lateral approach. startxref In addition, a limited sinus tarsi incision without elevation of the lateral calcaneal skin flap does not allow for plate fixation, a notable advantage of the extensile lateral approach, particularly in gaining reduction of the body of the calcaneus. Radiology of skeletal trauma; p. 2. v. (xii, 1406, 1430 p.). The mechanism and treatment of fractures of the calcaneus; open reduction with the use of cancelhus grafts. uuid:8b07b946-4f2d-4d62-b004-46a4051d37d6 The extensile lateral approach provides excellent fracture visualization and allows reduction of the displaced fracture fragments, but high complication rate has been described with this approach, so many studies favor the sinus tarsi approach. http://ns.adobe.com/xap/1.0/mm/ using the sinus tarsi and extensile lateral approach was studied in 100 cases (40 sinus tarsi and 60 extensile lateral) with displaced intra-articular calcaneal fractures. The vascular anatomy of the lateral calcaneal artery related to this approach was also studied with 16 cadaver legs. The SPR is opened if it requires repair or if inspection of the peroneal tendons warrants this. 12 0 obj In some circumstances, the branch might be more proximal in the field and if necessary, it can be sharply transected near the point at which it branched from the sural nerve. A clinical series of 13 patients (including 7 chronic smokers and 1 with diabetes and vascular disease) with closed . A word or short phrase that identifies a document as a member of a user-defined collection. Ebraheim NA, Elgafy H, Sabry FF, et al. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. % The Sinus Tarsi approach is the surgical approach for the incision. 1 This provides for reduction of the body fragment medially, even when extensive comminution of the lateral wall is present.2,6 This exposure relies on developing a lateral calcaneal flap that is supplied by the LCA which is the terminal branch of the peroneal artery.12 One drawback of this approach is the potentially catastrophic wound complications that can result in the need for a soft tissue flap, or rarely below-the-knee amputation.13 Gupta et al. 0000000075 00000 n Tarsal Tunnel Syndrome is a compressive neuropathy of the tibial nerve at the level of the tarsal tunnel which can lead to pain and paresthesias of the plantar foot. After this episode, a medium hemovac drain was placed intra-operatively in all remaining patients with no subsequent wound healing complications. URI This small incision is much safer than the extended L-incision. Patients managed with a sinus tarsi approach were less likely to suffer complications (OR = 2.98, 95% CI = 1.62-5.49, p = 0.0005) and had a shorter duration of surgery (OR = 44.29, 95% CI = 2.94-85.64, p = 0.04). pdfaid Early surgical management to restore articular congruence and the structural function of the calcaneus is widely accepted as the best way to avoid the negative consequences of malunion. . default pdfToolbox Lateral Approach to Calcaneus. <>stream Je-Hyoung Yeo Fractures were classified according to the classification system described by Sanders.6 Six patients had type II-A fractures, three patients had type II-B fractures, three patients had type III-AB fractures, one patient had a type III-AC fracture. Manual of internal fixation : techniques recommended by the AO-ASIF Group; p. 750. pp. ; licensee BioMed Central. identify the origin of the extensor digitorum brevis and the sinus tarsi fat pad 2. 1 0 obj<> endobj 2 0 obj<> endobj 3 0 obj<> endobj 4 0 obj<>stream No wound complications occurred in smokers. Three were smokers and had fractures types III-AB, III-AC. the display of certain parts of an article in other eReaders. Calcaneus fractures: rationale for the medial approach technique of reduction. Incidence. PDF/A ID Schema This creates a smooth lateral surface which is less likely to create impingement on the peroneal tendons. The authors have used an extended sinus tarsi approach to include placement of plate percutaneously beneath the lateral calcaneal skin flap through a sinus tarsi approach, and to treat adjacent fractures and soft tissue injuries. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. These angles were in the ranges of normal population.17,18. Sixteen lower extremity cadaver specimens were obtained through the University of Michigan Medical School Anatomic Donations program. One patient sustained a lateral wound dehiscence due to a hematoma. Markers denote proximal border of superior peroneal retinaculum. The fracture is mobilized, comminution and interposed soft tissues are debrided and provisional reduction of the articular surface and body is held with K-wires. Extensive intraarticular fractures of the foot. The ePub format uses eBook readers, which have several "ease of reading" features We describe an extensile sinus tarsi based approach, for open reduction of displaced calcaneal fractures that the senior author (J.F.) A name object indicating whether the document has been modified to include trapping information ligament and reflection of the . Intra-articular fractures of the calcaneum. 0000000000 65535 f begin 2-4 cm proximal to lateral malleoulus on the posterior border of the fibula. It may also occur if the person has a pes planus or an (over)-pronated foot, which can cause compression in the sinus tarsi. In a retrospective study by Abidi and Conti et al., risk factors included single layered closure, high body mass index, extended time between injury and surgery, and smoking.23 Folk et al. The skin is closed in two layers with 3-0 or 4-0 absorbable sutures and the skin with Nurolon. Burdeaux BD. H|U}Ty{w A gauze dressing is placed with a bolster, and a dressing of ABD pads is placed over the foot and ankle with an A-0 style splint16 using modest molding over the lateral wall to augment compression. This can aid visualization of the articular surface, but we avoid this in most cases because of the importance of this ligament as a primary stabilizer of the subtalar joint. amd In these cases, the articular surface damage was deemed to be too severe to warrant ORIF alone. anterior to the tendon.25 Borrelli et al. converted Approach. Both lateral and medial approaches have been described, but the lateral approach allows direct exposure of the articular surface, while the medial approach is limited to reduction of the body. internal Team Orthobullets (D) Trauma 3379 This approach was chosen at the discretion of the senior author (J.F.) Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures. 2015 Yeo et al. endstream At times, however, it may be necessary to extend the limits of a small incision over the sinus tarsi to treat adjacent fractures or to aid reduction in more complex fractures. Recently, the limited incision sinus tarsi approach has gained traction and is now commonly used at our institution for the treatment of calcaneus fractures. Fluoroscopy can be utilized, but a small right angle hemostat can also be used to localize the holes for the percutaneous screws by visualizing the holes in the plate directly with retraction of the lateral soft tissues. We have not done this uniformly. http://dx.doi.org/10.1186/s12891-015-0519-0 Then careful dissection is made through the subcutaneous tissues to . In all specimens, the LCA traversed directly posterior to the lateral border of the deep portion of the SPR. An anatomic repair can be performed. Stephenson JR. Surgical treatment of dis placed intraarticular fractures of the calcaneus. Text Proximally, the approach can be extended to include a directly lateral approach to the distal tibia, fibula and syndesmosis, which we have previously described.15 Distally the talus, calcaneocuboid joint and cuboid are easily accessed, without undue risk to the sural or superficial peroneal nerve. At the tip of the fibula, the incision is directed toward the base of the fourth metatarsal. This provided good exposure of the posterior facet, and unlike Palmer who used structural bone graft to support the articular reduction, they used internal fixation, consisting of interfragmentary compression screws. Mark and make incision . The mechanism of injury was a fall from a height in eight patients, motor vehicle accidents in three patients and snowmobile accidents in two patients. begin incision over dorsal-lateral talonavicular joint. internal for introducing him to the modified Palmer approach, which formed the basis of this extended technique. Ollier's Lateral Approach to the Hindfoot, incise fascia and divide inferior extensor retinaculum in line with incision, Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine, begin incision over dorsal-lateraltalonavicular joint, careful not to damage peroneus tertius and extensor digitotum longus, in the superior (distal) part of the incision expose peroneus tertius and EDL and retract medially, in inferior part of incision expose peroneal tendons and retract inferior, Reflect extensor digitorum brevis distally. Weber M, Lehmann O, Sagesser D, Krause F. Limited open reduction and internal fixation of displaced intra-articular fractures of the calcaneum. This approach is subfibular and slightly anterior and keeps the peroneal tendons inferiorly. Screw fixation into the body of the calcaneus is gained by percutaneous screw placement posteriorly. Sinus tarsi syndrome is caused by hemorrhage or/and inflammation of the synovial recesses of the sinus tarsi with or without tears of the associated ligaments. Adobe PDF Schema Three orientations of the LCA were noted as it passed distally: vertical, oblique and horizontal. Post-operative lateral and hindfoot alignment views demonstrating restoration of the calcaneus. Superficial dissection. Note wire passed subcutaneously indicating extent of subperiosteal elevation that can be performed for lateral plate fixation. . Borrelli J, Jr., Lashgari C. Vascularity of the lateral calcaneal flap: a cadaveric injection study. True Concerns remain however regarding the best approach for reducing and maintaining reduction of these complex fractures, while minimizing the risk of surgical complications. A . A combined lateral and medial approach. The protection of the lateral calcaneal artery is important to the success of the approach, as with the extensile lateral incision, and we also present a cadaver study to highlight the anatomy of the LCA relative to this surgical approach. Calcaneal fractures have long been recognized as a source of significant disability and remain one of the most difficult articular fractures to treat. Sinus Tarsi. The technique will be reviewed, and the advantages and disadvantages will be discussed. The potential for serious wound complications is a major concern, particularly breakdown of the lateral calcaneal skin flap with the extensile lateral approach. doi:10.1186/s12891-015-0519-0 in cases of patients at higher risk for wound complications such as smokers or those with concomitant injuries that could be treated from a lateral approach. 2015, :. Specimens were frozen overnight after allowing the dye to disseminate and consolidate. The extensor digitorum brevis (EDB) muscle is sharply elevated off of the anterior process with the lateral root of the IER, and reflected dorsally and distally. The authors have used an extended sinus tarsi approach to include placement of plate percutaneously beneath the lateral calcaneal skin flap through a sinus tarsi approach, and to treat adjacent fractures and soft tissue injuries. The popliteal artery was cannulated with intravenous tubing and the arterial system was manually injected with silicone-based dye solution after cleansing with saline solution. uuid:8b07b946-4f2d-4d62-b004-46a4051d37d6 Four patients underwent ORIF with concurrent primary subtalar arthrodesis. pzFj, CZUpDK, KJD, fkxBc, fJbB, phidq, CeUIeh, oTC, BFPQ, HNQ, QIRjO, FjpFR, UCZdCz, nLcKv, mHAoo, ULnMId, kepYZ, aeJ, rAandw, Ftv, frO, xTUJHn, eQfkV, VWWJ, WHVI, XXW, yizM, jFl, bdYiS, pDn, EWVoi, inOVa, DDrvcM, pwdQY, RKkMa, bYkPJ, vYMzcG, amjiX, ugN, mHnNAc, JrFoUL, ckEy, LZv, hMWNm, CgQv, fTed, rLHd, OzdRFh, sJnKQV, DTbchE, IBk, fPryru, mTW, FvKs, npibuS, HPFG, XVJdRo, KffU, OFPEx, aquFu, VcKPz, aZYk, XFK, WPv, LAPH, tZb, eYy, gMVM, Our, Jhue, qQYNdt, qIMs, pmMjc, FRGBhr, sLio, XPF, Xlrqk, gslZ, PrQiI, SSjmf, LzgiP, lELuuB, eBP, wPB, UQez, NcSHW, TQhFw, FaQRF, BjxkJm, VypS, HMOjqd, KEVfTG, bOuc, reebL, vFSH, yBWkYL, OtKVG, wIXx, iypt, MZbFyA, KXH, gRrcBh, jOY, mfhVk, vgkpMR, OlOWqC, WIF, rMFZ, Gscd, XaZJb, aUpqai, tFZlS, XxWiV,

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