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27
Approach to the Navicular
Position of the Patient
Landmarks and Incision
Medial Approach
Dorsomedial Approach
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Medial Approach
Dorsomedial Approach
How to Enlarge the Approach
Medial Approach
Introduction
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This approach is used for the removal of an accessory navicular bone
and for the treatment of fractures of the navicular. Two skin incisions
are described. The medial approach is used for excision of an
accessory navicular, the dorsomedial is used for navicular fracture
surgery.1 The main dangers of these approaches are damage to the
tendon of the tibialis posterior, which inserts onto the navicular, with
the medial approach, and damage to the dorsal neurovascular bundle
with the dorsomedial approach.
Position of the Patient
Place the patient supine on the operating table (see Fig. 1-1). Both the
dorsomedial approach and the medial approach are carried out with the leg
in its natural position of slight external rotation. Exsanguinate the leg, then
apply a tourniquet to the mid-thigh.
Landmarks and Incision
Palpate the first metatarsal cuneiform joint by feeling along the medial
border of the foot from distal to proximal. The first metatarsal flares slightly
at its base to meet the first cuneiform. Continue moving proximally along
the medial border to reach the tubercle of the navicular. The medial side of
the talar head is immediately proximal to the navicular. It can be located by
inverting and everting the forefoot. The motion that occurs between the
talus and the navicular is palpable.
Medial Approach
Make a 5- to 6-cm longitudinal incision directly over the area to be
exposed. Begin 1 cm below and 2 cm distal to the medial malleolus and aim
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the incision toward the medial side of the metatarsophalangeal joint of the
hallux. This incision is part of the medial utility incision of the foot, which
allows access to the talonavicular joint, or distally for access to the
cuneiforms, first metatarsal base, and naviculocuneiform and intertarsal
joints (Fig. 27-1).
Dorsomedial Approach
Make a 3- to 4-cm longitudinal incision directly over the dorsal surface of
the navicular between the tendons of extensor hallucis longus and tibialis
anterior (Fig. 27-2).
Figure 27-1. Make a 5- to 6-cm longitudinal incision directly over the area to be
exposed.
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Figure 27-2. Make a 3- to 4-cm incision over the dorsal surface of the navicular.
Internervous Plane
The medial approach uses the internervous plane between the tibialis
anterior supplied by the deep peroneal nerve and the tibialis posterior
supplied by the tibial nerve. The dorsomedial approach does not utilize an
internervous plane, but the extensor hallucis muscle and the tibialis anterior
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receive their nerve supply well proximal to this approach, making the plane
safe.
Superficial Surgical Dissection
For both approaches, deepen the incision through subcutaneous tissue in the
line of the skin incision. Identify and preserve any cutaneous nerves that
can be distinguished. Make sure that skin flaps are full thickness and avoid
undermining them to prevent flap necrosis.
Deep Surgical Dissection
Medial Approach
Identify by palpation the tendons of the tibialis posterior plantarward and
the tendon of the tibialis anterior tendon anteriorly. Incise the remaining
soft tissues covering the bone, staying between the tendons of the tibialis
anterior and tibialis posterior. Incise the capsules of the talonavicular joint
and navicular and first cuneiform joint to expose the joints if necessary
(Fig. 27-3). The accessory navicular will be found in the distal extent of the
tibialis posterior tendon. Excision of the accessory navicular is carried out
in a subperiosteal plane, shelling out the bone from its tendinous coverings
(Fig. 27-4).
Dorsomedial Approach
Identify the tendons of tibialis anterior and extensor hallucis longus and
develop a plane between the two tendons retracting the tibialis anterior
tendon medially and the extensor hallucis longus tendon laterally. Identify
the dorsal capsule of the talonavicular joint and the periosteum covering the
dorsal aspect of the navicular. Divide these structures longitudinally and
retract the edges medially and laterally to allow wide exposure of most of
the body of the navicular for fracture fixation (Fig. 27-5).
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Figure 27-3. Identify by palpation the tendons of the tibialis posterior
plantarward and the tendon of the tibialis anterior tendon anteriorly. Incise the
remaining soft tissues covering the bone, staying between the tendons of the
tibialis anterior and tibialis posterior. Incise the capsules of the talonavicular
joint and navicular and first cuneiform joint to expose the joints if necessary.
Figure 27-4. The accessory navicular will be found in the distal extent of the
tibialis posterior tendon. Excision of the accessory navicular is carried out in a
subperiosteal plane, shelling out the bone from its tendinous coverings.
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Figure 27-5. Develop a plane between the tibialis anterior tendon on the medial
side of the approach and the extensor hallucis tendon laterally. Divide the
dorsal capsule of the talonavicular joint and the periosteum on the dorsal aspect
of the navicular.
How to Enlarge the Approach
Medial Approach
The medial approach can be extended proximally to expose the medial
malleolus and the medial aspect of the talar neck. To achieve this, extend
the skin incision proximally and curve it to end up just over the medial
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malleolus. Remain anterior to the tendon of tibialis posterior. The proximal
extension of the incision also may expose those structures that pass
posterior to the medial malleolus. Distally, the incision can be extended to
the first metatarsal cuneiform joint and beyond to the first metatarsal. Such
extension may be necessary to treat complex fractures of the midfoot and
forefoot, involving several bones of the first ray.
REFERENCE
1. Rosenbaum AJ, DiPreta JA, Tartaglione J, et al. Acute fractures of the
tarsal navicular: a critical analysis review. JBJS Rev. 2015;3(3):e5.
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Direct Medial Approach for
Midfoot Collapse for Bony Planing
and Skin Ulcer Treatment
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial and Deep Surgical Dissection
How to Enlarge the Approach
Introduction
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This approach is used to treat patients with severe foot deformity
associated with diabetes or in patients with midfoot collapse due to a
Charcot-type neuropathy. A bony prominence through the plantar
surface in patients with neurologic sensory deficits often results in
severe skin ulcerations over the plantar surface. Without removing the
prominence, skin ulceration will continue.
This approach is often used as part of a specialized procedure for
the treatment of muscle imbalance; a mobile, pathologic flat foot, or
midfoot collapse. Timing of surgery is crucial, as these patients often
are diabetic or suffering from neurologic deficiencies creating sensory
loss. Treating local ulceration with nonoperative techniques may be
necessary before surgery to optimize local soft tissue conditions. A
detailed neurologic and vascular examination is mandatory. Specialist
investigations such as angiography may also be indicated in specific
cases.
Position of the Patient
Place the patient supine on the operating table (see Fig. 3-1). The
dorsomedial approach and the longer complete medial approach are carried
out with the leg in its natural position of slight external rotation. If
necessary, a sandbag may be placed beneath the opposite buttock to create
even more external rotation of the affected limb, making the medial aspect
of the forefoot more easily accessible. After exsanguination, apply a
tourniquet to the middle of the thigh. Do not use a tourniquet applied just
above the ankle, as this may create vascular problems postoperatively in
diabetic patients.
Landmarks and Incision
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