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longitudinal plantar view. C–E: Make a 2- to 3-cm longitudinal incision on the
sole of the foot centered on this entry point.
Internervous Plane
No internervous plane is available for use. The approach consists of a direct
approach through subcutaneous tissues to the plantar surface of the
calcaneum, and no muscles are involved.
Superficial Surgical Dissection
Incise the deep fascia of the sole of the foot in line with the skin incision
(Fig. 23-1D). The deep fascia is similar to the deep palmar fascia of the
hand. The fascia is much thicker in its central parts and thinner where it
covers the intrinsic muscles of the toes. Its central part, the plantar
aponeurosis, originates from the medial tubercle of the calcaneum and runs
forward to attach to the proximal phalanges of each toe.
The attachment of the plantar aponeurosis to the medial tubercle of the
calcaneum can often be palpated through the skin.
As this is a percutaneous procedure, sleeves are used for guide wires,
drills, and reamers to ensure that any anatomic structures of significance are
protected.
Deep Surgical Dissection
Insert a K-wire under fluoroscopic control to penetrate the plantar surface
of the calcaneum at the predetermined entry point.
Medial and lateral fibrous septi originate from the medial borders of the
plantar fascia to attach to the first and fifth metatarsal bones. The plantar
fascia and the deep compartments of the foot will be crossed by the K-wires
used for positioning and the reamers used for fusion (Fig. 23-2). Careful
continued fluoroscopic images will assist in ensuring accurate positioning
both in the lateral and axial views.
An understanding of the anatomy of the sole of the foot is essential.
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Figure 23-2. Medial and lateral fibrous septi originate from the medial borders
of the plantar fascia to attach to the first and fifth metatarsal bones. This fibrous
layer will be penetrated and the deep compartments of the foot will be crossed
by the K-wires used for positioning and the reamers used for fusion.
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First Layer of Muscles
The superficial layer of muscles in the sole of the foot consists of three
muscles: the flexor digitorum brevis, abductor hallucis, and abductor digiti
minimi. The flexor digitorum brevis arises mainly from the plantar
aponeurosis and partly from the medial calcaneal tubercle. It divides into
four tendons that insert into the middle phalanx of the lateral four toes and
flexes the toes independent of the position of the ankle. The deep surgical
dissection penetrates this muscle and its surrounding fascia. The abductor
hallucis originates in the medial tubercle of the calcaneum, inserting into
the medial side of the proximal phalanx of the great toe and abducting it.
Second Layer of Muscles
The second layer of muscles consists of the long flexor tendons; the flexor
hallucis longus, flexor digitorum longus, and flexor accessorius. They
maintain the longitudinal arch of the foot. This approach avoids these
muscles and the muscles of the third and four layers which lie more distal to
the approach.
Dangers
Nerves and Vessels
The medial plantar artery and nerve runs medially and plantarward on the
sole of the foot, and must be avoided. They are normally well clear of the
surgical field, but be aware that severe deformity of the bony architecture
will affect the position of the bundle. The lateral plantar nerve and artery
cross the sole of the foot from medial to lateral between the first and second
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layers of muscle. This occurs distal to the approach and so these structures
should not be in danger.
Skin
The incision should be kept small to minimize damage done to the sensitive
skin on the sole of the foot. The incision is usually centered over the soft
fleshy portion of the sole of the foot avoiding the hard calloused skin of the
heel.
How to Enlarge the Approach
This approach is not extensile and should not be taken distally or
proximally. It is meant only for insertion of a fusion nail and not for any
other procedure.
REFERENCE
1. Tarkin IS, Fourman MS. Retrograde hindfoot nailing for acute trauma.
Curr Rev Musculoskelet Med. 2018;11:439–444.
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24
Medial Approach to the
Sustentaculum Tali
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerve
Arteries
How to Enlarge the Approach
Extensile Measures
Introduction
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This approach to the hindfoot provides exposure to the sustentaculum
tali as well as the flexor tendons on the medial side of the foot. The
indications for its use include sustentacular1 fractures, which account
for approximately 10% of calcaneal fractures, and the release of flexor
tendons. The approach is also useful for the debridement of open
fractures of the calcaneum as virtually all wounds occur on the medial
side of the calcaneum where the sustentacular fragment pierces the
medial skin.
Position of the Patient
Place the patient supine on the operating table with a bump underneath the
opposite side hip. This will roll the foot into external rotation (see Fig. 1-1).
After exsanguination, apply a tourniquet to the mid-thigh.
Landmarks and Incision
The medial malleolus is the bulbous, subcutaneous distal end of the medial
surface of the tibia. Palpate the pulse of the posterior tibial artery
immediately posterior and distal to the medial malleolus before inflating the
tourniquet. Mark its position on the skin with an indelible marker. Next,
palpate the bony tuberosity of the navicular on the medial side of the foot,
just distal and plantarward from the tip of the medial malleolus. Finally,
palpate the sustentaculum tali. It is felt as a bony resistance deep to the
tibialis posterior and flexor digitorum longus immediately distal to the tip of
the medial malleolus.
Make an 8-cm curved incision on the medial aspect of the hindfoot.
Begin the incision starting at the tuberosity of the navicular (Fig. 24-1). The
incision should be 2 cm distal to the medial malleolus and overlie the bony
prominence of the sustentaculum tali. Take great care to cut only the skin,
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as the neurovascular bundle lies directly underneath the skin incision and is
very superficial at this point.
Figure 24-1. Make an 8-cm curved incision on the medial aspect of the
hindfoot. Begin the incision starting at the bony tip of the navicular.
Internervous Plane
This approach does not use an internervous plane. All of the muscles seen
receive their nerve supply well proximal to the approach and therefore are
not denervated by it.
Superficial Surgical Dissection
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Incise the deep fascia in line with the skin incision. Identify and incise the
flexor retinaculum and identify the neurovascular bundle and the tendons of
tibialis posterior and flexor hallucis longus. Find the plane between the
tendons of the tibialis posterior and flexor digitorum longus (Fig. 24-2).
Using this surgical plane ensures that the neurovascular bundle lying
posterior to the tendon of the flexor digitorum longus is not endangered, but
take care when retracting the tendon of flexor digitorum longus as excessive
traction may cause a traction lesion of the nerve.
Deep Surgical Dissection
Develop the plane between the tendons of the tibialis posterior and flexor
digitorum longus. Divide the retinaculum on the lateral side of these
tendons to expose the sustentaculum tali. Confirm the position of this
structure by palpation, then incise the soft tissues covering the bone (Fig.
24-3). The tendon of flexor hallucis longus lies posterior to the
sustentaculum and deeply grooves its undersurface. To get access to the
medial aspect of the calcaneum below the sustentaculum, retract the flexor
hallucis longus tendon to expose the bone.
Knowledge of the anatomy of the neurovascular structures is important
to avoid damaging them. The posterior tibial artery passes behind the flexor
digitorum longus before entering the sole of the foot, where it divides into
the medial and lateral plantar arteries. The tibial nerve passes behind the
medial malleolus with the posterior tibial artery. It gives off a calcaneal
branch to the skin of the heel. After entering the sole of the foot, it divides
into the medial and lateral plantar nerves (see Fig. 10-2).
The incision can be extended both proximally and distally using this
plane carefully. By using the whole length of incision, the medial side of the
calcaneum can be seen, palpated, and any pathology treated. If the approach
is used in fracture surgery, take great care to preserve as much soft tissue
attachments to the bone as possible. Meticulous preoperative planning will
allow smaller, precise incisions with consequent reduction in soft tissue
damage.
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Figure 24-2. Incise the deep fascia in line with the skin incision. Identify and
incise the flexor retinaculum. Find the plane between the tendons of the tibialis
posterior and flexor digitorum longus.
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Figure 24-3. Develop the plane between the tendons of the tibialis posterior
and flexor digitorum longus. Divide the retinaculum on the lateral side of these
tendons to expose the sustentaculum tali. Confirm the position of this structure
by palpation, then incise the soft tissues covering the bone.
Dangers
Nerve
The tibial nerve lies very close to the surgical plane but is protected by the
tendon of the flexor digitorum longus during this approach. It divides into
the lateral and medial plantar nerve immediately posterior to the surgical
field. Awareness of the position of the nerve is critical to ensure that
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