https://doi.org/10.1177/1071100718802255 Foot & Ankle International® 1–7 © The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1071100718802255 journals.sagepub.com/home/fai Article Joint depression calcaneal fractures usually require open reduction and internal fixation. Currently, common lateral approaches for calcaneal fractures include the extensile lat- eral calcaneus approach (ELCA) and sinus tarsi (STA). ELCA is an extensive approach which provides good expo- sure to the lateral aspect of the calcaneus, including the pos- terior facet, anterior process, lateral wall, and calcaneal tuberosity. However, ELCA has a high rate of infection and skin necrosis. 3 In addition, patients with diabetes or who smoke are also at higher risk of wound complications after ELCA. 8 STA is a limited lateral calcaneal approach 802255FAI XX X 10.1177/1071100718802255Foot & Ankle InternationalSirisreetreerux et al research-article 2018 1 Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand 2 Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 3 Excellence Center in Osteology Research and Training Center (ORTC), Chiang Mai University, Chiang Mai, Thailand Corresponding Author: Theerachai Apivatthakakul, MD, Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, 110 Intavararot road, Chiang Mai, 50200, Thailand. Email: tapivath@gmail.com Location of Vertical Limb of Extensile Lateral Calcaneal Approach and Risk of Injury of the Calcaneal Branch of Peroneal Artery Norachart Sirisreetreerux, MD 1 , Paphon Sa-ngasoongsong, MD 1 , Noratep Kulachote, MD 1 , and Theerachai Apivatthakakul, MD 2,3 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