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The dorsolateral approach for bunion surgery allows access to those
structures present on the lateral aspect of the metatarsophalangeal joint
of the hallux. It is used almost exclusively for soft tissue corrective
procedures in cases of hallux valgus.1 Its uses include the following:
Tenotomy of the adductor hallucis tendon
Release of the lateral (fibular) sesamoid bone and, rarely, excision of
that bone
Division of the transverse metatarsal ligament
Soft tissue procedures in hallux valgus are often accompanied by
other surgical procedures: classically, first metatarsal osteotomies.
This surgical approach, therefore, is often combined with dorsomedial
approaches to the metatarsophalangeal joint of the hallux.
Soft tissue procedures, in isolation, are contraindicated in advanced
arthrosis of the metatarsophalangeal joint, spasticity of any type, and
when the distal metatarsal proximal phalangeal angle is greater than 15
degrees. As with all procedures on the distal part of the foot, a
preoperative assessment of the vascularity of the foot is mandatory.
Position of the Patient
Place the patient supine on the operating table. After exsanguination, use a
tourniquet placed on the middle of the thigh. Alternatively, use a soft rubber
bandage to exsanguinate the foot, then wrap the leg tightly just around the
ankle (see Fig. 1-1).
Landmarks and Incision
Palpate the head of the first metatarsal bone and the metatarsophalangeal
joint on the ball of the foot and along its medial border. Palpate the extensor
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hallucis longus tendon on the dorsum of the foot. If you flex the toe
passively in the plantar direction, the tendon stands out, making
identification easier.
Make a 4- to 5-cm longitudinal incision on the dorsal aspect of the foot
in the first web space. Center the incision between the first and second
metatarsal heads. The incision should extend some 2 cm beyond the
metatarsophalangeal joints of the hallux and second (index) toe (Fig. 39-1).
Figure 39-1. Make a 4- to 5-cm longitudinal incision on the dorsal aspect of the
foot in the first web space. Center the incision between the first and second
metatarsal heads.
Internervous Plane
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There is no internervous plane. The only muscle involved in the approach—
adductor hallucis—receives its nerve supply well proximal to the surgical
field, thus the muscle is not denervated by the approach. Terminal branches
of the deep peroneal nerve supply skin in the region of the first web space.
Care must be taken to preserve these nerves so as not to denervate the skin,
creating an area of anesthesia postoperatively.
Superficial Surgical Dissection
Deepen the incision in the line of the skin incision through subcutaneous
tissue and fat. Continue dissection to expose and then incise the
adventitious bursa present between the first and second metatarsal heads
(Fig. 39-2).
Deep Surgical Dissection
Insert a self-retaining retractor between the first and second metatarsal
heads. Identify the tendon of adductor hallucis as it inserts jointly into the
lateral sesamoid bone and the lateral aspect of the proximal phalanx of the
hallux (Fig. 39-3). Using a knife blade, develop a plane between the
metatarsal head dorsally and the lateral (fibular) sesamoid bone plantarly
(Fig. 39-4A). Develop this plane until the blade strikes the base of the
proximal phalanx. Turn the blade laterally and plantarward to release the
adductor tendon from the base of the proximal phalanx. Withdraw the blade
in the same plane between the metatarsal head and the sesamoid, dividing
the remainder of the capsule running between the sesamoid bone and the
metatarsal. Identify the cut end of the adductor hallucis tendon and dissect it
carefully, proximally, until the muscle fibers of the adductor hallucis are
found. At this stage, you will be able to see the lateral (fibular) sesamoid
clearly (Fig. 39-4B).
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Figure 39-2. Deepen the incision in the line of the skin incision through
subcutaneous tissue and fat. Continue dissection to expose and then incise the
adventitious bursa present between the first and second metatarsal heads.
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Figure 39-3. Insert a self-retaining retractor between the first and second
metatarsal heads. Identify the tendon of adductor hallucis as it inserts jointly
into the lateral sesamoid bone and the lateral aspect of the proximal phalanx of
the hallux.
Reinsert the self-retaining retractor deeply, spreading the first and second
metatarsal heads apart. This places the transverse metatarsal ligament,
which passes from the second metatarsal bone into the lateral (fibular)
sesamoid, under tension. Carefully divide the ligament with sharp
dissection, noting that the common digital nerve and the artery to the first
web space are immediately underneath the structure.
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Figure 39-4. A: Using a knife blade, develop a plane between the metatarsal
head dorsally and the lateral (fibular) sesamoid bone plantarly. B: Identify the
cut end of the adductor hallucis tendon and dissect it carefully, proximally, until
the muscle fibers of the adductor hallucis are found. At this stage, you will be
able to see the lateral (fibular) sesamoid clearly.
Dangers
Terminal branches of the deep peroneal nerve may be injured in superficial
surgical dissection. Staying in the midline of the web space will reduce the
risk of injuring these important cutaneous nerves.
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Careless incision of the transverse metatarsal ligament may injure the
digital nerve that lies immediately underneath. This risk can be minimized
if the structure is identified and stretched using the self-retaining retractor.
How to Enlarge the Approach
This approach cannot be usefully extended either proximally or distally. Its
use is exclusively confined to soft tissue procedures on the lateral aspect of
the metatarsophalangeal joint of the hallux.
1
REFERENCE
1. Easley ME, Trnka HJ. Current concepts review: hallux valgus part ii:
operative treatment. Foot Ankle Int. 2007;28(6):748–758.
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40
Medial Approach to the First
Metatarsal Bone for Excision of the
Medial Sesamoid Bone
Position of Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Extend the Approach
Introduction
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The flexor hallucis brevis muscle inserts into the medial and lateral
sides of the base of plantar surface of the proximal phalanx of the
hallux via two sesamoid bones—medial and lateral. This surgical
approach is used almost exclusively for partial or total excision of the
medial (tibial) sesamoid bone.1 It may also be used for bone grafting
of medial sesamoid nonunion.
Two structures are at risk during this surgical procedure. The
medial plantar sensory nerve lies just dorsal to the medial sesamoid
and must be identified and preserved to avoid postoperative anesthesia
in weight-bearing areas. The flexor hallucis longus tendon is also at
risk during excision of the medial sesamoid bone.
Position of Patient
Place the patient supine on the operating table. After exsanguination, place
a tourniquet on the middle of the thigh. Alternatively, use a soft rubber
bandage to exsanguinate the foot, then wrap the leg tightly just above the
ankle (see Fig. 1-1).
Landmarks and Incision
Palpate the head of the first metatarsal bone and the metatarsophalangeal
joint on the ball of the foot and along its medial border.
Make a 3- to 4-cm longitudinal incision on the medial aspect of the foot.
Begin just distal to the metatarsophalangeal joint of the hallux overlying the
plantar border of the joint. Extend the incision proximally to follow the
plantar border of the first metatarsal bone (Fig. 40-1).
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Figure 40-1. Make a 3- to 4-cm longitudinal incision on the medial aspect of the
foot. Begin just distal to the metatarsophalangeal joint of the hallux overlying the
plantar border of the metatarsophalangeal joint. Extend the incision proximally
to follow the plantar border of the first metatarsal bone.
Internervous Plane
There is no true internervous plane. The two muscles encountered during
the approach—the abductor hallucis and the flexor hallucis longus—receive
their nerve supply well proximal to the field of dissection, therefore neither
muscle can be denervated by this procedure.
Superficial Surgical Dissection
Incise the subcutaneous tissue in the line of the skin incision. Take care to
identify and preserve any cutaneous nerves that may cross the field. Deepen
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