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The dorsolateral approach to the lateral part of Lisfranc’s joint is
usually used in conjunction with the medial approach.1 In this area,
full-thickness skin flaps must be made without undermining any soft
tissue. This is most important if two incisions are used (dorsomedial
and dorsolateral). The lateral side of the midfoot is mobile and in cases
of fractures is frequently stabilized on a temporary basis usually using
large K wires. The medial side of the midfoot provides stability.
Treatment of the medial part of this joint, in cases of fracture, often
involves primary fusion.
Position of the Patient
Place the patient supine on the operating room table (see Fig. 7-1). Place a
sandbag underneath the buttock of the affected side to correct the natural
external rotation of the leg. This maneuver will position the foot for both
open and closed procedures, when fluoroscopy is used. Exsanguinate the
leg, then apply a tourniquet to the middle of the thigh.
Landmarks and Incision
Although you can palpate the styloid process of the fifth metatarsal laterally
and the dorsal surface of the fourth metatarsal, fluoroscopy is necessary for
precise anatomic localization of the small bones of the midfoot.
Make a 4-cm longitudinal incision directly over the dorsal aspect of the
fourth metatarsal (Fig. 30-1). The incision may need to be positioned more
medially or more laterally depending on the pathology to be treated and the
technique to be used. An incision over the fourth metatarsal will allow easy
access to the joints between the bases of the fourth and fifth metatarsals and
the cuboid as well as the joint between the base of the third metatarsal and
the lateral cuneiform.
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Figure 30-1. Make a 4-cm longitudinal incision directly over the dorsal aspect of
the fourth metatarsal.
Internervous Plane
There is no internervous plane in this approach. The only muscle involved
—the extensor digitorum brevis—receives its nerve supply proximal to the
approach and cannot be denervated by it.
Superficial Surgical Dissection
Incise the subcutaneous tissue in the line of the skin incision, taking care to
identify and preserve cutaneous nerves. Two structures cover the dorsal
aspect of the lateral part of Lisfranc’s joint—the tendons of the extensor
digitorum longus and the muscle belly of the extensor digitorum brevis
(Fig. 30-2). Identify the tendons of the extensor digitorum longus (Fig. 30-
3). Mobilize the relevant tendon and retract it medially or laterally
depending on the deep structures to be approached. The tendons and belly
of the extensor digitorum brevis are now exposed.
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Figure 30-2. Two major structures cover the dorsal aspect of the lateral part of
Lisfranc’s joint—the tendons of the extensor digitorum longus and the muscle
belly of the extensor digitorum brevis.
Figure 30-3. Identify the tendons of extensor digitorum longus.
Deep Surgical Dissection
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Identify the muscle belly of the extensor digitorum brevis. Incise the muscle
belly in the line of the skin incision to expose the relevant joint (Fig. 30-4).
The extensor digitorum brevis is a large muscle that should be incised
completely. Its fibers run longitudinally and are easily split.
Figure 30-4. Incise the muscle belly of extensor digitorum brevis in the line of
the skin incision to expose the relevant joint.
How to Enlarge the Approach
The approach can be enlarged locally to improve visualization of local
structures by extending the skin incision both distally and proximally. This
will allow you to safely retract the skin flaps and expose the joints of the
cuboid and the fourth and fifth metatarsals as well as the corner of the
lateral midfoot between the cuboid and lateral cuneiform and the cuboid
and third metatarsal.
This approach can be extended proximally and distally. Proximally, the
incision can be extended to the level of the ankle joint by extending the skin
incision proximally along the dorsolateral aspect of the foot and the lateral
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malleolus and dividing the extensor retinaculum. Branches of the
superficial peroneal nerve must be avoided.
To extend the incision distally, continue the longitudinal incision distally
in the line of the fourth metatarsal. Continue the incision of the belly of
extensor digitorum brevis to reveal the underlying fourth metatarsal.
REFERENCE
1. Grewal US, Onubodu K, Southgate C, et al. Lisfranc injury: a review and
simplified treatment algorithm. Foot (Edinb). 2020;45:101719.
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31
Dorsal Approaches for Isolated
Midfoot Joints
Position of the Patient
Landmarks and Incision
Internervous Plane
Surgical Dissection
How to Enlarge the Approach
Introduction
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The commonest reason for using this approach is osteoarthritis of one
or more midfoot joints.1 Removal of osteophytes or fusions is the most
frequent procedure carried out through these approaches. Isolated
midfoot fusions require small, precise approaches. The approaches are
very specific to the requirements of the treatments, and the incisions
need to be carefully planned. Fluoroscopy is often helpful in ensuring
precise localization of the skin incision.
Position of the Patient
Many approaches on the dorsum of the middle part of the foot are possible.
If you wish to access lateral structures, place a sandbag under the buttock of
the affected side to internally rotate the limb (see Fig. 7-1). After
exsanguination, apply a tourniquet to the middle of the thigh.
Landmarks and Incision
One or more dorsomedial or dorsolateral approaches are possible, and the
landmarks needed to position them vary. On the lateral side of the foot, the
styloid process of the fifth metatarsal bone is a reliable landmark. On the
medial side, the base of the first metatarsal is easily palpable. The use of
fluoroscopy is essential if small incisions are to be accurately positioned.
Make a longitudinal incision directly over the area to be exposed. The
length of the incision depends on the procedure to be carried out. Small
dorsomedial incisions are used to expose the talonavicular joint, the
navicular medial cuneiform joint, and the first metatarsal cuneiform joint. A
more dorsal incision is used to expose the navicular cuneiform joint and
more uncommonly, the lateral cuneiform.
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Internervous Plane
No internervous plane is available for use in these approaches. The joints to
be exposed are essentially subcutaneous, thus there is no risk of denervating
any muscle.
Surgical Dissection
Cut down directly onto the structures that are to be exposed, taking care to
avoid any cutaneous nerves that can be identified. The joints of the midfoot
are nearly all subcutaneous. Ensure that the skin flaps are as thick as
possible. Minimize retraction as much as possible. Take care to avoid
damaging the sensory nerves, the extensor digitorum brevis and longus, and
insertions of the four powerful inverters and evertors of the foot: the tibialis
anterior, tibialis posterior, peroneus brevis, and peroneus longus (Fig. 31-1).
Figure 31-1. Cut down directly onto the structures that are to be exposed,
taking care to avoid any cutaneous nerves that can be identified.
How to Enlarge the Approach
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Each of these approaches can be extended proximally and distally as
required. The neurovascular bundle that lies directly over the middle
cuneiform is a key structure to avoid, as are the extensor hallucis longus
tendon and tibialis anterior tendon medially. More laterally, the extensor
digitorum longus tendons lie over their respective rays.
Distally, the incisions can also be extended as required to uncover the
whole of the cuneiform bones proximally and distally, and the cuboid
laterally.
REFERENCE
1. Kurup H, Vasukitty N. Midfoot arthritis: current concepts review. J Clin
Orthop Trauma. 2020;11(3):399–405.
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32
Plantar Approach for Plantar
Fibromatosis
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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