Introduction Allows visualization of the lateral calcaneus and subtalar joint Indications calcaneus fractures calcanectomy Planes No true internervous or intermuscular plane Position & Preparation Anesthesia general anesthesia with endotracheal tube Preparation radiolucent table C-arm fluoroscopy tourniquet can be used Position lateral decubitus positioning is necessary slightly flex knee to relax gastrocnemius muscle pull Approach Incision Superficial dissection place the posterior arm of the incision midway between the fibula and the Achilles tendon place the horizontal arm in line with the base of the fifth metatarsal proximal and distal ends of the incision are bluntly spread through until sural nerve is identified full thickness fasciocutaneous flaps are sharply created over calcaneus must not bevel the full-thickness aspect of the incision the vascular supply to the flap is a watershed area. Deep dissection at the corner of the incision, make the incision directly to the bone to ensure that a full thickness flap is created. avoid any undermining of the edges a thick subperiosteal flap is sharply raised off of the lateral wall of the calcaneus until the sinus tarsi, neck, and posterior facet are visualized 1.6mm K-wires can be placed into the talus, fibula, and cuboid the wires are then bent, allowing a "hands-free" retraction technique the peroneal tendons are subperiosteally elevated and reflected in anterior flap calcaneofibular ligament is sharply released from the calcaneus Approach extension can extend proximally to a lateral approach to ankle/fibula if needed distal extension limited by sural nerve Dangers Peroneal tendons risk is minimized with maintenance of access under the anterior flap must evaluate upon closure for instability or laceration(s) Sural nerve risk is minimized with maintenance of access under the anterior flap must dissect out proximal aspect of vertical limb and anterior aspect of horizontal limb to minimize iatrogenic injury Wound dehiscence most common complication of this approach lateral calcaneal artery is responsible for corner of flap careful attention to skin handling and closure with Allgower-Donati suture technique minimizes soft tissue complications