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anatomy section at the end. The idea is for the surgeon to read the approach
and anatomy sections together before attempting a given procedure,
because once the anatomic principles of a procedure are fully understood,
the logic of an approach becomes clear.
One key feature of Surgical Exposure in Orthopaedics—The Anatomic
Approach is the concept that successful surgical approaches exploit
internervous planes. Internervous planes lie between muscles—muscles
supplied by different nerves. Internervous planes are helpful mainly because
they can be used along their entire length without either of the muscles
involved being denervated. These approaches can generally be extended to
expose adjacent structures. Virtually all the classic extensile approaches to
bones use internervous planes, a concept first described by AK. Henry, who
believed that if the key to operative surgery is surgical anatomy, then the
key to surgical anatomy is the internervous plane. Because most muscles in
the foot receive their nerve supply well proximal to the field of dissection,
the concept of the internervous plane is not nearly as important in foot and
ankle surgery as it is in more proximal surgery. Nevertheless, we have kept
the section in describing internervous planes because we believe the
concept to be so important.
The approach sections are structured consistently in a step-by-step
manner to guide the reader through surgical procedure.
The introduction to each approach describes indications and points out
the major advantages and disadvantages of the proposed approach.
The position of the patient is critical to clear exposure as well as to the
comfort of the operating surgeon and the safety of the patient.
Surgical landmarks form the basis for any incision; they are described
with instructions on how to find them. The incision follows these clear
landmarks. Because many approaches in foot and ankle surgery are limited
and carried out through small incisions, x-ray control is often necessary to
ensure precise siting of these incisions.
The surgical dissection is usually divided into superficial and deep
surgical dissection for teaching purposes to reinforce the concept that each
layer must be developed fully before the next layer is dissected. For many
approaches in foot and ankle surgery, however, this concept is not valid;
exposure consists of direct approaches to the bone, elevating tissue as a
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single block to avoid problems with skin healing. When this technique is to
be employed, it is clearly stated in the text.
The dangers of each approach are listed under four headings: Nerves,
Vessels, Muscles and Tendons, and Special Points. The dangers are
presented, along with how to avoid them.
Because most foot and ankle approaches are targeted at specific areas for
treatment of individual pathologies, extension of the approach is rarely
required. When such exposure is necessary, it is described in a section
entitled “How to Enlarge the Approach.” There are two ways in which
exposure can be enlarged: Local measures include extending skin incisions,
repositioning retractors, detaching muscles, or even adjusting the light
source; extensile measures are the ways in which an approach can be
extended to include adjacent bony structures.
Anatomic and surgical illustrations are drawn from the surgeon’s point
of view whenever possible, with the patient on the operating table, so that
the surgeon can see exactly how the approach should look during the
procedure.
We hope that this book will be as successful as its parent in helping
surgeons around the world, often working in difficult and emergency
situations. We believe that this book plays an important part in the
commitment shared by both authors and readers to improve patient care.
Piet deBoer, MA, FRCS
Richard Buckley, MD, FRCSC
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Acknowledgments
This book reflects the accumulated experience of many people over many
decades. We should like to thank those in particular who helped us during
the writing of this book.
To Richard Hutton,
long-term friend and editor, who adds organization and reality to our
writings. His love of the English language is reflected in this book.
To Hugh Thomas,
long-term friend and medical illustrator, who added clarity to the book by
his imaginative original illustrations, which reflect anatomic knowledge and
clinical detail. In preparing the artwork for Surgical Exposures in
Orthopaedics: The Anatomic Approach, and this new foot and ankle
volume, he managed to draw beautifully on two continents.
To J. Stuart Freeman Jr,
former Executive Editor at Lippincott Williams & Wilkins, who has
befriended me over these years and has been a source of positive
suggestions and inspiration.
To Robert Hurley,
Executive Editor at Lippincott Williams & Wilkins, in appreciation of his
friendship and professional help in structuring the Third and Fourth
Editions of the parent book and the Foot and Ankle volume.
To Dave Murphy,
Senior Product Editor at Lippincott Williams & Wilkins, in appreciation of
his expertise in all things editorial and production, including the Brave New
World of electronic content and publishing on the Internet.
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To Dr. Brent Haverstock,
Podiatrist, University of Calgary Department of Surgery.
To Bernie Kida,
Whose distinctive art work has enlivened and elevated the book.
To Grace Caputo,
For her excellent work in editing the manuscript and whose tenacity and
patience ensured the accuracy of the text. A real pleasure to work with.
To Stacey Sebring,
Without whom very little if anything would have happened.
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Contents
Preface
Acknowledgments
ANKLE
Chapter 1 Anterior Approach to the Ankle
Chapter 2 Lateral Approach to the Ankle with Fibular Osteotomy for
Ankle Fusion
Chapter 3 Anterior and Posterior Approaches to the Medial Malleolus
Chapter 4 Approach to the Medial Side of the Ankle
Chapter 5 Posteromedial Approach to the Ankle
Chapter 6 Posterolateral Approach to the Ankle
Chapter 7 Lateral Approach to the Lateral Malleolus
Chapter 8 Anterolateral Approach to the Ankle and Hind Part of the
Foot
Chapter 9 Ankle Arthroscopy
Chapter 10 Applied Surgical Anatomy of the Approaches to the Ankle
HINDFOOT
Chapter 11 Lateral Approach to the Hind Part of the Foot
Chapter 12 Lateral Approach to the Hindfoot (Posterior Part of
Grice)
Chapter 13 Lateral Approach to the Posterior Talocalcaneal Joint
Chapter 14 Anterolateral Approach to the Talar Neck
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Chapter 15 Anteromedial Approach to the Talar Neck
Chapter 16 Direct Lateral Approach to the Lateral Process of Talus
Chapter 17 Posterolateral Approach to the Posterior Aspect of the
Talus
Chapter 18 Lateral Approach to the Calcaneum
Chapter 19 Lateral Approach for Osteotomy of the Calcaneum
(Vertical Portion of the Calcaneal Incision)
Chapter 20 Posteromedial, Posterolateral, and Posterior Midline
Approaches for Excision of Calcaneal Exostosis (Haglund’s Deformity)
Chapter 21 Lateral Approach to the Os Peroneum
Chapter 22 Medial Approach to the Plantar Fascia
Chapter 23 Hindfoot Nailing for Subtalar and Ankle Joint Fusion
(Plantar Approach)
Chapter 24 Medial Approach to the Sustentaculum Tali
Chapter 25 Applied Surgical Anatomy of the Approaches to the Hind
Part of the Foot
MIDFOOT
Chapter 26 Midfoot: Approach to the Cuboid
Chapter 27 Approach to the Navicular
Chapter 28 Direct Medial Approach for Midfoot Collapse for Bony
Planing and Skin Ulcer Treatment
Chapter 29 Dorsomedial Approach to Lisfranc’s Joint
Chapter 30 Dorsolateral Approach to Lisfranc’s Joint
Chapter 31 Dorsal Approaches for Isolated Midfoot Joints
Chapter 32 Plantar Approach for Plantar Fibromatosis
Chapter 33 Dorsal Approaches to the Middle Part of the Foot
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FOREFOOT
Chapter 34 Dorsomedial Approach to the First Metatarsal
Chapter 35 Dorsal Approach to the Second to Fifth Metatarsal Bones
Chapter 36 Lateral Approach to the Base of the Fifth Metatarsal
Chapter 37 Dorsal Approach to the Metatarsophalangeal Joint of the
Great Toe
Chapter 38 Dorsomedial Approach to the Metatarsophalangeal Joint
of the Great Toe
Chapter 39 Dorsolateral Approach for Bunion Surgery
Chapter 40 Medial Approach to the First Metatarsal Bone for
Excision of the Medial Sesamoid Bone
Chapter 41 Plantar Approach to the Lateral Sesamoid Bone
Chapter 42 Dorsal Approach to the Fifth Metatarsal Head for
Bunionette
Chapter 43 Lateral Approach to the Fifth Metatarsal Head for
Bunionette
Chapter 44 Dorsal Approach to the Metatarsophalangeal Joints of the
Second, Third, Fourth, and Fifth Toes
Chapter 45 Dorsal Approach for Morton’s Neuroma
Chapter 46 Plantar Approach for Recurrent Morton’s Neuroma
TOES
Chapter 47 Dorsolateral Approach to the Flexor Sheathes of the
Second to Fifth Toes
Chapter 48 Transverse Approach for Surgery to a Hammer Toe
Chapter 49 Longitudinal Approach to the Proximal Interphalangeal
Joint of the Second to Fifth Toes for Hammer Toe
Chapter 50 Approach for Nail Bed Ablation
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APPLIED SURGICAL ANATOMY
Chapter 51 Approaches for External Fixation and Bridge Plate
Fixation in the Foot and Ankle
Chapter 52 Applied Surgical Anatomy of the Foot
Index
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1
Anterior Approach to the Ankle
Position of the Patient
Landmarks and Incision
Landmarks
Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
How to Enlarge the Approach
Extensile Measures
Introduction
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The anterior approach provides excellent exposure of the ankle joint
for arthrodesis1 and ankle arthroplasty. The approach provides the
widest possible exposure of the joint, facilitating positioning of plates
and screws, but does involve extensive soft tissue stripping. Some
studies suggest a higher rate of complications following open ankle
arthrodesis.
2
The decision to use this approach rather than the lateral transfibular
approach, the medial transmalleolar approach, or the posterior
approach depends on the condition of the skin and the surgical
technique to be used. Arthroscopic techniques have been described,
but these are not appropriate if deformity is to be corrected.
3
Its other uses include the following:
Drainage of infections in the ankle joint
Removal of loose bodies
Part of the approach can be used in the operative treatment of pilon
fractures. The positioning and size of approaches used in the
treatment of these fractures must be carefully planned using x-ray
and CT images
Total ankle arthroplasty
Position of the Patient
Place the patient supine on the operating table. Partially exsanguinate the
foot either by elevating it for 3 to 5 minutes or by applying a soft rubber
bandage loosely to the foot and binding it firmly to the calf. Then, inflate a
thigh tourniquet. Partial exsanguination allows the neurovascular bundle to
be identified, because the venous structures will appear blue. Some
continuous vascular oozing must be expected, however (Fig. 1-1).
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