The extended lateral approach offers a safe surgical approach in the fixation of calcaneal fractures. Lateral plating of the calcaneum could put structures on the medial side at risk. The aim was to identify structures at risk on the medial side of the calcaneum from wires, drills or screws passed from lateral to medial.

Ten embalmed cadaveric feet were dissected. A standard extended lateral approach was performed. The DePuy perimeter plate was first applied and 2mm K-wires were drilled through each of the holes. The medial side was now examined to determine the structures at risk through each hole. The process was repeated with the Stryker plate. The calcaneum was divided into 6 zones, by two vertical lines, from the margins of the posterior facet and a transverse line along the axis of the bone through the highest point of the peroneal tubercle.

The DePuy and the Stryker plates have 12 screw positions, 5 of which are common. With both systems, screw positions in zone 1 risk injury to the medial plantar nerve and zone 3 the lateral plantar nerve. A screw through zone 2 compromises the medial plantar in both. Screws through zone 4 risk the lateral plantar nerve with the DePuy plate. Screws through zone 5 of the DePuy plate risk the medial calcaneal nerve. Zone 5 of the Stryker plate and Zone 6 of both are safe.

There is significant risk to medial structures from laterally placed wires, drills or screws. Subtalar screws have the highest risk and have to be carefully measured and placed. The Stryker plating system is relatively safer than the DePuy perimeter plate with three safe zones out of six.

Talar neck fractures are associated with high complication rates with significant associated morbidity. Adequate exposure and stable internal fixation remains challenging. We investigated the anterior extensile approach for exposure of these fractures and their fixation by screws introduced through the talo-navicular articulation. We also compared the quality and quantity of exposure of the talar neck obtained by this approach, with the classically described medial/lateral approaches.

An anterior approach to the talus between the tibialis anterior and the extensor hallucis tendons protecting both the superficial and deep peroneal nerves was performed on 5 fresh frozen cadaveric ankles . The surface area of talar neck accessible was measured using an Immersion Digital Microscribe and analysed with Rhinoceros 3D graphics package. Standard antero-medial and antero –lateral approaches were also carried out on the same ankles, and similar measurements taken. Seven talar neck fractures underwent operative fixation using the anterior approach with parallel cannulated screws inserted through the talo-navicular joint.

3D mapping demonstrated that the talar surface area visible by the anterior approach (mean 1200sqmm) is consistently superior to that visible by either the medial or lateral approaches in isolation or in combination. Medial malleolar osteotomy does not offer any additional visualisation of the talar neck. 3D reconstruction of the area visualised by the three approaches confirms that the anterior approach provides superior access to the entirety of the talar neck. 5 male and 2 female patients were reviewed. All had anatomical articular restoration, and no wound problems. None developed non union or AVN.

The anterior extensile approach offers superior visualisation of the talar neck in comparison to other approaches for anatomical articular restoration. We argue that this approach is safe, adequate and causes less vascular disruption.