import { OnePagerSummary, ContentSection, ExamWarning, InfoCardGrid, InfoCard, EvidenceCard, ComparisonTable, VivaScenario, MnemonicCard, ExamCheatSheet, Tab, Tabs } from '@/components/mdx' # Lateral Extensile Approach to Calcaneus: Comprehensive Examination Guide ## Introduction and Clinical Context The **lateral extensile approach to the calcaneus** (Benirschke-Sangeorzan technique) is the GOLD STANDARD surgical approach for achieving direct visualization and anatomic reduction of **displaced intra-articular calcaneal fractures** (Sanders type II-IV), providing comprehensive exposure of the **posterior facet** (subtalar joint articular surface), **calcaneocuboid joint**, **lateral calcaneal wall**, and **calcaneal body** through a full-thickness L-shaped flap that preserves neurovascular structures and minimizes skin/soft tissue complications when proper technique and timing employed. ### Historical Development and Surgical Evolution Open reduction and internal fixation (ORIF) of calcaneal fractures via lateral extensile approach was pioneered by **Palmer (1948)** and refined by **Stephenson (1987)** and **Benirschke & Sangeorzan (1993)**, who described the modern full-thickness flap technique. Calcaneal fracture management remains CONTROVERSIAL - multiple randomized controlled trials comparing ORIF vs nonoperative management show CONFLICTING results, with some studies demonstrating improved anatomic and functional outcomes with surgery (Buckley 2002: ORIF superior outcomes in Sanders II-III, working patients) while others show no difference or even worse outcomes in high-risk patients (operative group wound complications 25% negating benefits - Folk 1999). Current evidence-based consensus: **SELECTIVE operative management** for displaced intra-articular fractures (Sanders II-III) in HEALTHY patients (non-smokers, non-diabetic, good soft tissue envelope) with surgeon expertise in technique, while nonoperative management preferred for: (1) Non-displaced fractures, (2) Sanders IV (severely comminuted - poor outcomes regardless), (3) High-risk patients (smokers, diabetics, peripheral vascular disease - wound complication risk 30-50%), (4) Elderly/low-demand patients. The lateral extensile approach's PRIMARY advantage is **COMPLETE exposure** of posterior facet (allows anatomic reduction under direct visualization), but at cost of **HIGH wound complication rate** (10-25% infection/dehiscence/necrosis even with proper technique) - this complication risk drives patient selection criteria and has led to development of **minimally invasive alternatives** (sinus tarsi approach, percutaneous reduction) for selected fracture patterns. ## Surgical Anatomy and Key Landmarks ### Surface Anatomy and Planning **Skin incision landmarks:** - **Posterior limb**: Begins midline Achilles tendon (8-10cm proximal to tuberosity insertion), curves laterally at level of superior tuberosity - **Horizontal limb**: Extends anteriorly along lateral foot (parallel to plantar surface), ends at calcaneocuboid joint level - **L-shaped configuration**: Two limbs meet at ~90° angle at posterolateral corner of calcaneus **Palpable landmarks:** - **Lateral malleolus**: Superior landmark, marks fibula (avoid injury during dissection) - **Peroneal tendons**: Run posterior to lateral malleolus, palpable as cords (protect during approach) - **Calcaneocuboid joint**: Palpable anteriorly (junction of calcaneus and cuboid - anterior limit of incision) - **Achilles tendon**: Posterior midline landmark (posterior limb starts here, curves lateral) - **Tuberosity**: Palpable posteriorly (fracture often extends through tuberosity) **"Wrinkle sign" (CRITICAL timing indicator):** - **Definition**: Skin wrinkles visible when ankle plantar/dorsiflexed (indicates edema resolved) - **Clinical test**: Passively move ankle - if skin on lateral hindfoot shows wrinkles, edema resolved (SAFE to proceed) - **If absent**: Persistent edema, skin tight (HIGH wound complication risk - delay surgery further) - **Timeline**: Usually 10-14 days post-injury (range 7-21 days depending on injury severity, patient factors) ### Layer-by-Layer Anatomic Dissection **Layer 1 - Full-Thickness Flap (Skin + Subcutaneous + Periosteum):** - **CRITICAL CONCEPT**: Lateral extensile approach uses FULL-THICKNESS FLAP elevated as single unit - **Composition**: Skin, subcutaneous fat, periosteum all elevated TOGETHER (NOT separate layers) - **Rationale**: Preserves blood supply to skin (subcutaneous plexus and periosteal vessels feed skin from deep) - **Consequences of thin flap**: If periosteum separated from skin/subcutaneous tissue, skin blood supply compromised (necrosis risk 15-25%) **Incision Technique:** 1. **Posterior limb incision**: - Start 8-10cm proximal to calcaneal tuberosity (midline Achilles tendon) - Incise through skin ONLY (not deeper yet) - Curve laterally at level of superior tuberosity (avoiding direct posterior approach over Achilles) - **Sural nerve and lesser saphenous vein** run IN posterior limb path (identify and protect OR intentionally divide - see below) 2. **Horizontal limb incision**: - From lateral curve of posterior limb, extend anteriorly along lateral foot - Position incision ~1cm superior to lateral plantar skin junction (avoids plantar weight-bearing surface) - End at calcaneocuboid joint level (palpable joint line anteriorly) - Incise through skin ONLY initially **Layer 2 - Flap Elevation (Subperiosteal):** 1. **Deepen incision through subcutaneous tissue TO periosteum** (full thickness cut) 2. **Elevate flap from inferior to superior** (like turning page of book): - Start at plantar edge (inferior), insert periosteal elevator between periosteum and calcaneus bone - Elevate in SUBPERIOSTEAL PLANE (periosteum stays WITH flap, elevated OFF bone) - Work inferiorly to superiorly (flap hinges along superior border near peroneal tendons) 3. **Protect neurovascular structures during elevation**: - **Sural nerve**: Runs in subcutaneous tissue in posterior limb (address during flap elevation - see Neurovascular Anatomy section) - **Peroneal tendons**: Superior to horizontal limb (stay inferior to tendons during elevation) - **Lateral calcaneal artery branches**: Ligate small vessels during subperiosteal elevation **Layer 3 - Fracture Exposure:** - With full-thickness flap elevated superiorly, entire lateral calcaneal wall exposed - Remove fracture hematoma, irrigate - Identify key fracture fragments: - **Lateral wall**: Usually displaced laterally (widened calcaneus) - **Posterior facet**: Intra-articular fragments (subtalar joint surface) - **Sustentaculum tali**: Medial fragment (usually intact - serves as reduction reference) - **Tuberosity**: Posterior fragment (varies with fracture pattern) ### Neurovascular Anatomy and Relationships **Sural Nerve (HIGHEST RISK STRUCTURE):** - **Course**: Descends in posterior calf (between gastrocnemius heads), pierces deep fascia 10-15cm proximal to lateral malleolus, runs subcutaneously with lesser saphenous vein along posterior leg/lateral foot - **Position relative to incision**: Runs DIRECTLY IN PATH of posterior limb of incision (unavoidable) - **Innervation**: Lateral foot and heel sensation (pure sensory nerve - no motor) - **Management options**: 1. **Identification and protection** (IDEAL): - Identify nerve in subcutaneous tissue during posterior limb dissection - Gently retract anteriorly with flap (preserve nerve) - Outcomes: 5-10% temporary numbness (neuropraxia from retraction), 85-90% normal sensation long-term - Challenge: Small nerve (2-3mm diameter), multiple variations in course, easily injured even with careful dissection 2. **Intentional division and burial** (ALTERNATIVE): - Divide nerve sharply, bury proximal stump in muscle (prevents traction neuroma at skin level) - Outcomes: 100% permanent lateral foot/heel numbness (expected), 5-10% painful neuroma despite burial - Rationale: Accepts permanent numbness to avoid inadvertent nerve traction injury (numbness less bothersome than painful neuroma) - Many surgeons prefer this approach (predictable outcome, faster dissection, less nerve-related complications) 3. **Inadvertent injury** (COMPLICATION): - Nerve injured during dissection without identification (transection, stretch, cautery burn) - Outcomes: Variable - numbness, dysesthesias, painful neuroma (15-20% bothersome symptoms) - Worse than intentional division (uncontrolled injury site, nerve ends at skin level risks neuroma) - **Injury rate**: 10-20% permanent numbness regardless of approach (Bennett 1999) **Lesser Saphenous Vein:** - Accompanies sural nerve (runs parallel) - Can be ligated if needed for exposure (collateral venous drainage adequate) - Avoid excessive cautery near vein (thermal injury to adjacent sural nerve) **Peroneal Tendons:** - **Course**: Run posterior to lateral malleolus in retrofibular groove, turn anteriorly inferior to lateral malleolus, insert on lateral midfoot (peroneus brevis on 5th metatarsal base, peroneus longus crosses plantar foot to medial cuneiform) - **Position relative to incision**: Superior to horizontal limb of incision - **Protection**: Stay inferior to tendons during flap elevation (tendons remain attached to lateral malleolus/fibula, NOT elevated with flap) - **Injury risk**: Low (less than 1%) if flap elevation stays inferior to tendon level **Lateral Calcaneal Artery (branches):** - Branches from peroneal artery, supplies lateral calcaneal wall - Small vessels encountered during subperiosteal elevation (ligate or cauterize) - No major named vessels at risk ## Indications and Contraindications ### Primary Indications (Evidence-Based, SELECTIVE) **ABSOLUTE Indications (Strong Evidence for ORIF):** 1. **Sanders type II-III displaced intra-articular fractures** in HEALTHY patients: - Sanders II: 2 fracture lines in posterior facet (2 major fragments) - Sanders III: 3 fracture lines in posterior facet (3 major fragments) - Displacement criteria: Greater than 2mm articular step-off, Böhler angle less than 20° (normal 25-40°), calcaneal widening greater than 5mm - Patient criteria: Non-smoker, non-diabetic, age less than 60, active/working, good soft tissue envelope - Evidence: Buckley 2002 - ORIF superior to nonoperative in Sanders II-III working patients (SF-36 scores, return to work) **RELATIVE Indications (Selective, Case-by-Case):** 1. **Open calcaneal fractures** (Gustilo I-II) - requires debridement and stabilization 2. **Calcaneal fracture with compartment syndrome** - fasciotomy + ORIF 3. **Bilateral calcaneal fractures** - consider ORIF one side for better functional outcome (patient can mobilize with one good foot) 4. **Young, high-demand patients** with Sanders IV fractures - accept higher complication risk for chance of better outcome (controversial) ### Contraindications **ABSOLUTE Contraindications:** 1. **Active smoking** - wound complication risk 30-40% (Backes 2014: OR 4.8), MUST quit 6-8 weeks before surgery (if refuses, recommend nonoperative management) 2. **Active infection** at surgical site (cellulitis, open wound with contamination) 3. **Severe peripheral vascular disease** (ABI less than 0.7, absent pulses, tissue loss) - healing unlikely 4. **Medical instability** (patient cannot tolerate anesthesia) **RELATIVE Contraindications (High Wound Complication Risk 25-50%):** 1. **Diabetes mellitus** - wound complications 20-30% (vs 10% non-diabetics), especially if poorly controlled (HbA1c greater than 8%) 2. **Age greater than 60 years** - higher complication rate, lower functional demands may not justify surgical risk 3. **Sanders type IV fractures** (severe comminution, 4+ fracture lines) - poor outcomes regardless of treatment (40-50% subtalar arthritis, 50% require fusion) - Debate: Some advocate primary subtalar fusion (avoids attempting ORIF with low success rate) 4. **Significant soft tissue injury** (open fracture Gustilo III, degloving) - wound complications 40-60% 5. **Workers' compensation/litigation** - worse reported outcomes (independent of treatment), higher dissatisfaction rates ## Preoperative Planning and Patient Positioning ### Preoperative Assessment **Clinical Examination:** - **Soft tissue assessment** (MOST IMPORTANT): - **Wrinkle sign**: Passive ankle motion produces skin wrinkles on lateral hindfoot (indicates edema resolved - SAFE to proceed) - Fracture blisters: Clear fluid blisters acceptable (epithelialized), hemorrhagic blisters higher risk (delay further if possible) - Skin quality: Assess for fragility, prior incisions, vascular insufficiency - **Neurovascular examination**: - Dorsalis pedis and posterior tibial pulses (document pre-op - ABI if pulses diminished) - Compartment assessment: Tense compartments (firm on palpation), pain with passive toe motion = compartment syndrome (URGENT fasciotomy) - **Heel position**: Varus/valgus malalignment, heel widening (measure side-to-side heel width) **Radiographic Planning:** - **Lateral X-ray**: - **Böhler angle**: Angle between line from highest point of anterior process to highest point of posterior facet AND line from posterior facet to superior tuberosity (normal 25-40°, fracture often less than 20° or negative) - **Gissane critical angle**: Angle at posterior facet (normal 120-145°, increased with depression) - **Axial (Harris) view**: Heel width, varus/valgus alignment, tuberosity position - **Broden views** (oblique views of posterior facet - historical, largely replaced by CT) - **CT scan** (MANDATORY for operative planning): - **Sanders classification**: Based on coronal CT through posterior facet widest point - Type I: Non-displaced (less than 2mm) - Type II: 2-part fracture (1 fracture line, 2 major fragments) - Type III: 3-part fracture (2 fracture lines, 3 major fragments) - Type IV: 4+ part fracture (3+ fracture lines, severely comminuted) - Assess fracture lines, fragment displacement, articular step-off - Identify sustentaculum tali fragment (usually intact, medial - reduction reference) **Surgical Planning:** - **Implant selection**: Low-profile calcaneal locking plate (lateral wall), screws (interfragmentary compression) - **Reduction strategy**: Plan sequence (typically: restore height/length, reduce posterior facet, correct varus/valgus, fix with plate) - **Soft tissue timing**: Confirm wrinkle sign present, delay if persistent edema ### Patient Positioning **LATERAL DECUBITUS position** (STANDARD): - **Position**: Patient lateral with injured side up - **Support**: - Bean bag or lateral positioners for torso stability - Axillary roll under dependent axilla (protects brachial plexus) - Pillow between knees (protects dependent leg nerves) - All bony prominences padded - **Leg positioning**: - Injured leg supported on bolsters (allows access to lateral hindfoot) - Knee flexed 20-30° (relaxes gastrocnemius, easier ankle manipulation) - Ankle neutral position (foot on lateral surface) - **Advantages**: - Excellent access to lateral hindfoot - Gravity assists with flap retraction (flap falls away from field) - Fluoroscopy easy (C-arm from posterior) - **Tourniquet**: Thigh tourniquet (exsanguinate, inflate to 300-350mmHg for leg) - used selectively (some surgeons prefer tourniquet down to preserve flap perfusion) ## Step-by-Step Surgical Technique ### Step 1: Positioning and Skin Incision **Technique:** 1. **Patient lateral decubitus**, injured side up, ankle neutral position 2. **Exsanguinate and inflate tourniquet** (optional - some surgeons prefer tourniquet down) 3. **Mark incision landmarks**: - **Posterior limb**: Midline Achilles 8-10cm proximal to tuberosity, curve laterally at superior tuberosity - **Horizontal limb**: From lateral curve, extend anteriorly parallel to plantar surface 1cm above plantar skin junction, end at calcaneocuboid joint 4. **Incise skin along marked L-shape**: - Use #10 or #15 blade - Incise through skin ONLY (dermis depth), not deeper yet - Sharp corners at L junction (avoid dog-ear deformity) ### Step 2: Full-Thickness Flap Elevation **Technique:** 1. **Deepen incision through subcutaneous tissue to periosteum**: - Continue through full thickness (skin, subcutaneous fat, periosteum) as SINGLE LAYER - **Identify sural nerve** in posterior limb (runs with lesser saphenous vein): - Option A: Carefully dissect, protect, retract anteriorly with flap (time-consuming, higher inadvertent injury risk) - Option B: Identify, divide sharply, bury proximal stump in gastrocnemius muscle (predictable permanent numbness, lower neuroma risk) - Many experienced surgeons prefer Option B (faster, more predictable outcome) 2. **Elevate flap from inferior to superior** (subperiosteal plane): - Insert wide periosteal elevator (Cobb, Key) at inferior border (plantar edge) - Elevate periosteum OFF calcaneus bone (periosteum stays WITH flap - FULL-THICKNESS concept) - Work from inferior to superior (flap hinges superiorly) - **Gentle handling**: No crushing clamps on flap edges, keep flap moist with saline-soaked sponges 3. **Retract flap superiorly**: - Use Army-Navy retractors or stay sutures through flap margin (distribute tension) - NO Weitlaner or self-retaining retractors on flap edges (excessive pressure causes necrosis) - Expose entire lateral calcaneal wall from anterior process to tuberosity posteriorly, from subtalar joint superiorly to plantar surface inferiorly ### Step 3: Fracture Exposure and Assessment **Technique:** 1. **Remove fracture hematoma**: Irrigate, suction, clear field 2. **Assess fracture pattern** (correlate with pre-op CT): - **Lateral wall**: Usually collapsed and displaced laterally (widened heel) - **Posterior facet**: Depressed and comminuted (intra-articular step-off) - **Sustentaculum tali** (medial fragment): Usually intact - KEY REFERENCE for reduction - **Tuberosity**: Varus/valgus position, may be separate fragment - **Anterior process**: Check for separate fracture extension 3. **Identify key anatomic landmarks**: - **Posterior facet articular surface**: Clean cartilage from debris (allows anatomic reduction under direct vision) - **Lateral wall cortex**: Will be reduced and fixed with plate - **Angle of Gissane**: Intersection of superior calcaneal surface (posterior facet) and anterior process (forms strut for reduction) ### Step 4: Fracture Reduction (Sequential Steps) **Reduction Sequence (Essex-Lopresti maneuver + direct manipulation):** 1. **Restore calcaneal HEIGHT and LENGTH**: - **Essex-Lopresti maneuver** (if needed): Insert Steinmann pin or Schanz screw through tuberosity (posteriorly), apply traction (pull tuberosity posteriorly and inferiorly) - Disimpacts posterior facet (lifts depressed fragments) - Use bone tamp or elevator to push depressed fragments superiorly (restore height) - Check lateral fluoroscopy: Böhler angle should improve toward 25-40° (from pre-op less than 20°) 2. **Reduce POSTERIOR FACET** (most critical step for outcomes): - Goal: ANATOMIC reduction of subtalar joint articular surface (less than 2mm step-off) - Technique: - Identify major posterior facet fragments (2-3 fragments typically in Sanders II-III) - Reduce fragments to **sustentaculum tali** (medial, usually intact - serves as reduction template) - Use pointed reduction clamps to hold fragments - Check reduction under DIRECT VISION (inspect articular cartilage - should be flush, no step-off) - Provisional fixation: K-wires or small lag screws (2.0-2.7mm) for interfragmentary compression 3. **Correct VARUS/VALGUS malalignment**: - Assess tuberosity position (axial view fluoroscopy) - Varus deformity common (tuberosity tilted medially) - Manipulate tuberosity into neutral alignment (lateralize if varus) 4. **Reduce LATERAL WALL**: - Push lateral wall fragments medially (restore heel width) - Reduces widened calcaneus (narrows heel) - Check axial fluoroscopy: Heel width should approximate contralateral side ### Step 5: Fixation **Technique:** 1. **Temporary fixation with K-wires**: - Maintain reduction while preparing plate - K-wires across posterior facet fragments, tuberosity 2. **Plate application** (lateral wall plate): - Select low-profile calcaneal locking plate (pre-contoured for lateral calcaneal anatomy) - Position plate on lateral wall: - Proximal screws: Into posterior facet/sustentaculum (achieve interfragmentary compression across posterior facet) - Middle screws: Into calcaneal body - Distal screws: Into anterior process (if plate extends anteriorly) - Temporary fixation with clamps or initial screw 3. **Screw insertion**: - **Posterior facet screws**: Lag screw technique for interfragmentary compression (if large enough fragments) - **Tuberosity screws**: Bicortical purchase (engage medial cortex) - **Locking screws** (if using locking plate): Provide angular stability (helpful in osteoporotic bone) 4. **Fluoroscopy confirmation**: - **Lateral view**: Böhler angle restored (25-40°), posterior facet reduced, no intra-articular screw penetration - **Axial view**: Varus/valgus correction, heel width normal, hardware position - **Broden views** (oblique): Posterior facet reduction, screw position relative to subtalar joint 5. **Bone grafting** (if large void after reduction): - Restore height often creates metaphyseal void - Fill with cancellous autograft (iliac crest) or allograft bone chips (structural support) - Calcium phosphate/sulfate bone graft substitute alternative (synthetic) ### Step 6: Closure and Post-operative Care **Technique:** 1. **Deflate tourniquet** (if used), achieve hemostasis (cautery, ligate vessels) 2. **Replace flap**: - Lower flap back to anatomic position (no tension) - Ensure flap edges well-perfused (pink, brisk capillary refill) - DO NOT close under tension (causes flap ischemia) 3. **Deep layer closure**: - Reapproximate periosteum (if possible) with absorbable sutures (2-0 Vicryl) - Minimal undermining (preserves flap blood supply) 4. **Subcutaneous closure**: 3-0 absorbable sutures (Vicryl or Monocryl) 5. **Skin closure**: - **Prefer**: Vertical mattress sutures with nylon (3-0 or 4-0) - everts skin edges, less tension than simple interrupted - **Avoid**: Staples (higher wound complication rate in calcaneal surgery) - Sutures removed 3-4 weeks (delayed vs standard 10-14 days - allows longer healing time in high-risk wound) 6. **Dressing**: Bulky compressive dressing, posterior splint (ankle neutral, knee flexed 20-30°) 7. **CRITICAL**: Elevate leg above heart level (prevent dependent edema - #1 cause early wound complications) **Post-operative Protocol:** - **First 48 hours**: STRICT elevation (leg above heart), ice, neurovascular checks - **48 hours**: Remove dressing, INSPECT WOUND (check for viability): - Normal: Pink, warm, dry, no blisters - Concerning: Dusky, cool, blisters, drainage - If concerning: Early intervention (loose sutures, negative pressure wound therapy, surgical debridement if necrosis) - **Weeks 0-6**: NON-weight-bearing (crutches/walker), remove sutures 3-4 weeks, ankle ROM exercises (plantarflexion/dorsiflexion, inversion/eversion to prevent stiffness) - **Weeks 6-12**: Advance to partial weight-bearing (25-50%), wean to full weight-bearing by 12 weeks - **Month 3+**: Physical therapy (gait training, proprioception, strengthening), return to activities gradual - **Long-term**: Expect 6-12 months for maximum improvement, counsel on permanent heel widening/stiffness (even with anatomic reduction) ## Complications and Management ### Intraoperative Complications **1. Sural Nerve Injury (10-20% permanent numbness)** **Recognition:** - Visual injury during flap elevation (transection, excessive stretch, thermal injury) - Post-op: Lateral foot/heel numbness or dysesthesias **Management:** - **INTRAOPERATIVE**: - If inadvertently transected: Bury proximal stump in muscle (prevents neuroma at skin level) - If intact but stretched: Gentle handling, avoid further traction - **POST-OPERATIVE**: - Most numbness from retraction = neuropraxia (recovers 6-12 months) - Persistent dysesthesias: Gabapentin or pregabalin (neuropathic pain management) - Painful neuroma: Neuroma excision + nerve burial (if severe, unresponsive to medical management) **Prevention:** - Option 1: Careful dissection, identify and protect nerve (time-consuming, ~10% injury rate still) - Option 2: Intentional division and burial at start (predictable outcome, minimizes inadvertent injury risk - many surgeons prefer) **2. Flap Ischemia/Necrosis (intraoperative recognition rare, usually early post-op)** **Recognition:** - Flap appears dusky, cool, slow capillary refill during closure **Management:** - **IMMEDIATE**: Release any tension (remove deep sutures if tight), ensure NO pressure on flap edges from retractors - DO NOT proceed with closure if flap non-viable (high risk of complete necrosis) - Consider aborting closure: Negative pressure wound therapy (wound VAC), delayed closure or skin graft once granulation tissue formed **Prevention:** - Full-thickness flap technique (preserves blood supply) - Gentle handling (no crushing, keep flap moist) - Tension-free closure (do NOT force flap edges together if tight) ### Early Post-operative Complications (0-6 weeks) **1. Wound Complications (10-25% incidence - MOST COMMON AND SERIOUS)** **Types:** - **Superficial dehiscence** (wound edges separate but no exposed hardware): 5-8% - **Deep infection** (purulent drainage, exposed hardware): 3-5% - **Flap necrosis** (partial/complete skin loss): 2-5% - **Fracture blisters** (post-op blistering along incision): 3-5% **Risk factors:** - Smoking (OR 4.8 - Backes 2014) - Diabetes (OR 2.5) - Immediate surgery without wrinkle sign (OR 3.1 - Howard 1999) - Poor flap handling (thin flap, tension, excessive retractor pressure) **Management:** - **Superficial dehiscence**: - Local wound care (wet-to-dry dressings, antiseptic solutions) - Oral antibiotics if cellulitis (cephalexin or clindamycin) - Heal by secondary intention or delayed closure (2-3 weeks) - **Deep infection**: - Return to OR for irrigation/debridement - IV antibiotics (vancomycin if MRSA suspected, cefazolin for MSSA) - Hardware removal if infected and fracture healed (if fracture not healed, attempt to salvage hardware with aggressive debridement + antibiotics) - Negative pressure wound therapy (wound VAC) for soft tissue management - **Flap necrosis**: - Early debridement of necrotic tissue (do NOT wait - prevents deep infection) - Negative pressure wound therapy - Coverage options: Healing by secondary intention (small defects less than 2-3cm), skin graft (medium defects 3-5cm), local/free flap (large defects greater than 5cm - rare, salvage) - **Outcomes if wound complications**: 60% poor functional outcomes (Folk 1999) - wound complications NEGATE benefits of anatomic reduction **2. Loss of Reduction** **Recognition:** - Radiographs show fracture displacement, loss of Böhler angle, posterior facet step-off - Usually due to hardware failure (screw pull-out) or inadequate fixation **Management:** - **If early (less than 4 weeks)**: Consider revision ORIF (re-reduce, augment fixation, bone graft) - **If late (greater than 4 weeks)**: Early healing may prevent re-reduction - observe, plan subtalar fusion if symptomatic arthritis develops **Prevention:** - Adequate fixation (plate + screws, lag screws across fracture lines) - Bone graft large voids (structural support) - Protected weight-bearing (NWB 6-8 weeks allows healing before loading) ### Late Post-operative Complications (6+ months) **1. Subtalar Arthritis (40-50% long-term)** **Recognition:** - Persistent lateral hindfoot pain, stiffness - Worse with ambulation on uneven ground - Radiographs/CT: Subtalar joint space narrowing, sclerosis, osteophytes, subchondral cysts **Risk factors:** - Residual posterior facet step-off (greater than 2mm articular incongruity) - Sanders IV fractures (severe comminution - poor outcomes regardless of reduction) - Even anatomic reduction: 40-50% still develop arthritis (cartilage injury from initial trauma) **Management:** - **Conservative**: NSAIDs, activity modification, ankle-foot orthosis (AFO), corticosteroid injections (temporary relief) - **Surgical**: Subtalar arthrodesis (fusion) - Indications: Failed conservative management, significant pain limiting function - Technique: Resect articular cartilage, compress with screws (2-3 screws across subtalar joint), bone graft - Outcomes: 90-95% pain relief, 85-90% fusion rate, loss of hindfoot inversion/eversion (ankle motion preserved) - Return to function: 80-85% patients satisfied (better than painful arthritic subtalar joint) **2. Malunion (heel widening, varus/valgus deformity)** **Recognition:** - Persistent heel widening (difficulty with shoe fit) - Varus deformity (lateral foot overload, peroneal tendinitis) - Valgus deformity (medial foot overload, tibialis posterior dysfunction) **Management:** - **Heel widening**: Shoe modifications (extra-wide shoes), lateral wall ostectomy (remove prominent lateral bone - cosmetic, not functional improvement) - **Varus/valgus deformity**: Corrective osteotomy or subtalar fusion in corrected position (complex, variable outcomes 60-70% improvement) **3. Hardware Irritation (10-15% incidence)** **Recognition:** - Palpable/prominent hardware under skin (lateral wall plate) - Pain with shoe wear, direct pressure **Management:** - **Observation** if asymptomatic - **Hardware removal** after fracture union (12-18 months post-ORIF) - Timing: Wait at least 1 year (calcaneal fractures heal slowly, early removal risks re-fracture) - Technique: Remove plate and screws, preserve bone stock - Outcomes: 80-90% symptom relief ## Comparison with Alternative Approaches ## Pearls, Pitfalls, and Expert Tips ### Surgical Pearls (What Separates Good from Great) **Pearl 1: Wait for the wrinkle sign - patience saves wounds** - MANDATORY wait 10-14 days post-injury for soft tissue recovery - Wrinkle sign (skin wrinkles with ankle motion) indicates edema resolved - Immediate surgery (less than 72 hours) = 35% wound complications vs delayed (wrinkle sign+) = 15% (Howard 1999) - Counsel patient on delay rationale (prevents misunderstanding "why are we waiting?") **Pearl 2: Full-thickness flap is NON-NEGOTIABLE** - Elevate skin, subcutaneous tissue, AND periosteum as SINGLE UNIT - Thin flap (periosteum separated from skin) devascularizes skin (necrosis risk 15-25%) - Subperiosteal elevation from inferior to superior (flap hinges along peroneal tendons) **Pearl 3: Sustentaculum tali is the reduction template** - Sustentaculum fragment usually INTACT (medial side, protected from injury) - Reduce all posterior facet fragments TO sustentaculum (reference for anatomic reduction) - Sustentaculum visible on medial side (can palpate through soft tissue or use percutaneous tools if needed) **Pearl 4: Anatomic posterior facet reduction is THE key** - Functional outcome determined by posterior facet reduction quality (less than 2mm step-off goal) - Direct visualization allows precise reduction (check with probe, should feel flush cartilage) - Residual step-off greater than 2mm = 2-3x higher subtalar arthritis rate **Pearl 5: Early wound check at 48 hours** - Remove dressing 48 hours post-op, INSPECT wound (do NOT wait 10-14 days) - Early recognition of ischemia/necrosis allows intervention (loose sutures, wound VAC, debridement) - Dusky, cool, blistered skin = impending necrosis (act immediately - salvage may be possible) ### Common Pitfalls (and How to Avoid Them) **Pitfall 1: Operating on smoker without cessation** - **Problem**: Smoking increases wound complications from 10% to 37% (OR 4.8 - Backes 2014), and complications negate surgical benefits (65% poor outcomes) - **Solution**: ABSOLUTE smoking cessation 6-8 weeks pre-op OR recommend nonoperative management if patient unwilling/unable to quit - **Counseling**: Explain risk plainly - "Your smoking puts you at 1-in-3 risk of serious wound problem that will make your outcome worse than not having surgery at all" **Pitfall 2: Operating before wrinkle sign positive** - **Problem**: Persistent edema = tight skin = flap tension = ischemia/necrosis (wound complications 42% if operated before wrinkle sign vs 16% after - Howard 1999) - **Solution**: Test wrinkle sign pre-op (passive ankle motion), delay surgery if absent even if 14+ days post-injury - **Patient education**: Show patient wrinkle sign on good foot ("see how skin wrinkles? Your injured side needs to look like this before safe to operate") **Pitfall 3: Thin flap (separating periosteum from skin/subcutaneous)** - **Problem**: Devascularizes skin (blood supply from deep - periosteal vessels), causes necrosis - **Solution**: Elevate FULL-THICKNESS flap (skin + subcut + periosteum together), subperiosteal plane (elevator stays on bone surface) - **Teaching point**: "If you can see calcaneus bone easily (white cortex) before removing hematoma, your flap is too thin - should elevate periosteum WITH flap" **Pitfall 4: Closing under tension** - **Problem**: Tension on flap edges causes ischemia (necrosis along incision) - **Solution**: If wound edges don't approximate easily - DO NOT force closure, consider: (1) Remove deep sutures if tight, (2) Vessel loops as temporary closure (delayed closure 5-7 days), (3) Skin graft if large gap (better than necrotic full-thickness flap) **Pitfall 5: Not addressing smoker/diabetic CONTRAINDICATION** - **Problem**: Operating on high-risk patient (smoker, diabetic, PVD) = 30-50% wound complications (catastrophic outcomes) - **Solution**: Consider these RELATIVE contraindications (case-by-case decision), lean toward nonoperative management if multiple risk factors, MANDATORY smoking cessation if proceeding ### Expert Tips (From High-Volume Surgeons) **Tip 1: Use Army-Navy retractors, not self-retaining** - Self-retaining retractors (Weitlaner) create excessive pressure on flap edges (ischemia) - Army-Navy retractors allow dynamic adjustment (lighten pressure as needed) - Or use stay sutures through flap edges (distribute tension broadly) **Tip 2: Sural nerve - consider intentional division at start** - Many experienced surgeons divide sural nerve early (bury proximal stump in muscle) - Predictable outcome (permanent lateral foot numbness), lower neuroma risk than inadvertent injury - Patients tolerate numbness well (much less bothersome than painful neuroma) - Counsel pre-op: "You'll have permanent numbness on side of foot, but this is better than risking painful nerve problem" **Tip 3: Vertical mattress sutures for skin closure** - Everts skin edges (better healing than inverted edges) - Less tension per suture than simple interrupted - Remove 3-4 weeks (delayed vs standard 10-14 days - allows longer healing in high-risk wound) **Tip 4: Use Broden views intra-op** - Oblique fluoroscopy views (Broden 1-4: 10°, 20°, 30°, 40° cephalad with foot internally rotated) - Visualize posterior facet articular surface (check reduction quality, screw position relative to joint) - Ensure no intra-articular screw penetration (subtalar joint) **Tip 5: Set realistic expectations - counsel on subtalar arthritis** - 40-50% develop subtalar arthritis long-term EVEN with anatomic reduction - Cartilage damage from initial trauma (not preventable with perfect reduction) - Fusion may be needed years later (80-90% pain relief with subtalar fusion if arthritis symptomatic) - Explain: "Surgery goal is restore heel shape and give you best chance at good function, but cannot guarantee perfect result - you may need fusion down road if arthritis develops"