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branches of the posterior tibial artery (deltoid branches) that enter the bone
from its medial side. Therefore, safe access to the body of the talus involves
a medial malleolar osteotomy rather than a direct approach through the
deltoid ligament. Hinging the osteotomized medial malleolus downward,
preserving the deltoid ligament, preserves the blood supply. The deltoid
branches supply the medial talar neck and body.
The artery of the tarsal canal is formed by an anastomosis of branches of
the posterior tibial artery from the medial side and branches of the peroneal
artery from the lateral (Fig. 25-5). Branches of the dorsalis pedis artery and
the peroneal artery supply the neck and the lateral side of the body.
1
Figure 25-5. Vascular supply of the talus.
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REFERENCE
1. Fernández Á, Poggio D, Llusá M, et al. Graphic representation of
intraosseous and extraosseous talus blood supply. Illustrated anatomy.
Rev Esp Cir Ortop Traumatol (Engl Ed). 2021;S1888-4415(21)00074-6.
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26
Midfoot: Approach to the Cuboid
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
How to Enlarge the Approach
Introduction
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The midfoot consists of the navicular, cuboid, and cuneiform bones,
their joints, and the four powerful muscles that insert into the midfoot
that are responsible for controlling inversion and eversion of the foot.
The muscles are the tibialis anterior, which inserts into the medial
surface and undersurface of the medial cuneiform bone and into the
adjoining part of the base of the first metatarsal bone; the peroneus
longus, which inserts into the lateral side of the medial cuneiform
bone; the peroneus brevis, which inserts into the base of the lateral
side of the fifth metatarsal bone; and the tibialis posterior, which
inserts into the tuberosity of the navicular bone, the inferior surface of
the medial cuneiform, the intermediate cuneiform, and bases of the
second, third, and fourth metatarsal bones.
Proximally, the midfoot begins at the calcaneal cuboid joint
laterally and the talonavicular joint medially. Distally, it ends at the
joint between the cuboid and the lateral metatarsals laterally and the
joint between the cuneiforms and the medial metatarsals medially.
The lateral part of the midfoot is flexible and mobile. The medial
part is more rigid and is vital for the stability of the foot.
All bones of the midfoot are superficial and can be approached
directly by dorsal, medial, and lateral approaches. The middle part of
the foot is the target of various specialized procedures for the
treatment of muscle imbalance, mobile flat foot, accessory navicular
bone, as well as fracture care.
This approach is used mainly for the treatment of cuboid fractures.
1
These injuries are frequently associated with other midfoot and
hindfoot fractures; thus, this approach is often combined with other
surgical approaches. Careful assessment of the skin and associated soft
tissue injuries is essential before considering surgery. Procedures may
have to be delayed to allow swelling to subside and soft tissue injuries
to heal.
Position of the Patient
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Place the patient on the operating table in the lateral position (see Fig. 12-
1). Ensure that all bony prominences are well padded and that the patient is
stabilized, using a bean bag or kidney rest. It is best to have the under leg
flexed at the knee with the top leg more extended if fluoroscopy is needed.
After exsanguination, apply a tourniquet to the mid-thigh.
Landmarks and Incision
To palpate the cuboid, first palpate the styloid process of the fifth
metatarsal, which can be felt laterally in the midfoot. The cuboid is
immediately proximal and dorsal to the styloid process and anterior to the
peroneal tendons. It lies in a small divot located between the calcaneum and
the styloid process of the fifth metatarsal.
Make a 3- to 4-cm longitudinal incision over the dorsolateral aspect of
the cuboid (Fig. 26-1). This dorsolateral incision will expose both the
calcaneocuboid and cuboid metatarsal joints as well as the base of the fifth
metatarsal.
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Figure 26-1. Make a 3- to 4-cm longitudinal incision over the dorsolateral
aspect of the cuboid.
Internervous Plane
There are no internervous planes in this approach. The peroneus brevis
muscle receives its nerve supply well proximal to the approach and will not
be denervated by it.
Superficial Surgical Dissection
Deepen the skin incision through subcutaneous tissue, taking care to
identify and preserve any cutaneous nerves that are terminal branches of the
sural nerve. Make sure that skin flaps are full thickness and that they are not
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undermined. Identify the peroneus brevis tendon as it runs across the
operative field to insert into the base of the fifth metatarsal bone (Fig. 26-2).
Deep Surgical Dissection
Palpate the calcaneocuboid joint immediately dorsal to the peroneus brevis
tendon. If access to the joint is needed make an incision through the capsule
of the joint to open it. To expose the body of the cuboid, identify the lateral
border of the extensor digitorum brevis muscle and elevate it from the
dorsal surface of the bone. Continue the epiperiosteal dissection distally,
staying on the anterior surface of the bone to reach the joints between the
distal end of the cuboid and the bases of the fourth and fifth metatarsals. To
expose the cuboid metatarsal joints, incise the joint capsule and supporting
ligamentous structures in line with their fibers (Fig. 26-3).
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Figure 26-2. Deepen the skin incision through subcutaneous tissue, taking care
to identify and preserve any cutaneous nerves that are terminal branches of the
sural nerve. Make sure that skin flaps are full thickness and that they are not
undermined. Identify the peroneus brevis tendon as it runs across the operative
field to insert into the base of the fifth metatarsal bone.
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Figure 26-3. Identify by palpation the calcaneocuboid joint immediately dorsal
to the peroneus brevis tendon. If needed, make an incision through the capsule
of the joint to open it. To expose the body of the cuboid, identify the lateral
border of the extensor digitorum brevis muscle and elevate it from the dorsal
surface of the bone. Continue the epiperiosteal dissection distally to reach the
joints between the distal end of the cuboid and the bases of the fourth and fifth
metatarsals. To expose the cuboid metatarsal joints, incise the joint capsule and
supporting ligamentous structures in line with their fibers.
How to Enlarge the Approach
This approach can be extended proximally following the dorsal aspect of
the peroneal tendons toward the distal and lateral sides of the ankle joint.
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Such extension allows exposure of the subtalar joint and the lateral process
of the talus.
REFERENCE
1. van Raaij TM, Duffy PJ, Buckley RE. Displaced isolated cuboid
fractures: results in four cases with operative treatment. Foot Ankle Int.
2010;31:242–246.
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