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laterally away from the operative field before sharp dissection of structures
attached to the lateral sesamoid bone is carried out.
The tendon of the flexor hallucis longus muscle lies just medial to the
lateral sesamoid and may be endangered if the dissection of the lateral
sesamoid bone is not carried in a strictly subperiosteal plane.
How to Enlarge the Approach
This approach cannot be extended as it is used exclusively for surgery to the
lateral sesamoid bone.
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42
Dorsal Approach to the Fifth
Metatarsal Head for Bunionette
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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The dorsal approach to the fifth metatarsal head is used almost
exclusively for surgery on bunionettes. This condition, which consists
of a lateral prominence of the fifth metatarsal head, is frequently
treated by a distal fifth metatarsal osteotomy. The use of distal
osteotomy is reserved for this pathology. Lateral bowing of the fifth
metatarsal requires a more proximal diaphyseal osteotomy that is
usually oblique. Similarly, a bunionette caused by an increased
intermetatarsal angle between the fourth and fifth rays is usually
treated with a proximal fifth metatarsal osteotomy. Significant varus
deviation of the fifth toe often requires an associated soft tissue
procedure.
The approach may also be used for other local pathologies of the
fifth metatarsal head, such as drainage of infection and excision of
tumors.
As with all distal foot incisions, peripheral vascular disease with an
absent pedal pulse is a major contraindication to surgery, and careful
examination of the vascular status of the foot is mandatory in the
preoperative examination.
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 above the
ankle (see Fig. 7-1). Place a sandbag underneath the buttock of the affected
side to internally rotate the leg and bring the lateral side of the foot into the
operative field. Then, tilt the table away from side of surgery to further
increase internal rotation of the lower limb.
Landmarks and Incision
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Palpate the head of the fifth metatarsal bone and the metatarsophalangeal
joint of the little toe on the ball of the foot and along its lateral border. In
cases of bunionette, the metatarsal head is prominent laterally. Palpate the
extensor digitorum longus tendon to the fifth toe on the dorsum of the foot.
When it is tight, it stands out when the fifth toe is passively flexed in the
plantar direction.
Make a 3-cm incision on the dorsolateral aspect of the foot beginning at
the level of the metatarsophalangeal joint of the fifth toe, just lateral to the
tendon of the extensor digitorum longus (Fig. 42-1). Extend the incision
proximally. The exact length of the incision will depend on the osteotomy
technique to be used.
Figure 42-1. Make a 3-cm incision on the dorsolateral aspect of the foot
beginning at the level of the metatarsophalangeal joint of the fifth toe, just
lateral to the tendon of the extensor digitorum longus.
Internervous Plane
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There is no true internervous plane. The bone is essentially subcutaneous.
The extensor digitorum longus tendon receives its nerve supply well
proximal to the approach and cannot be denervated by this approach.
Superficial Surgical Dissection
Incise the deep fascia in line with the incision. Take care to identify and
preserve any cutaneous nerves encountered during this part of the
dissection. Retract the tendon of the extensor digitorum longus medially to
expose the thick capsular structures overlying the fifth metatarsal head and
neck (Fig. 42-2A).
Deep Surgical Dissection
Divide the capsule longitudinally. Peel the thick capsular and bursal
structures off the fifth metatarsal head and neck (Fig. 42-2B). These
structures may be quite adherent to bone. Incise sufficient soft tissue to
allow adequate exposure of the distal end of the fifth metatarsal bone and its
associated exostosis while ensuring that sufficient soft tissue attachments to
the bone remain to prevent delayed or nonunion of an osteotomy.
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Figure 42-2. A: For the superficial surgical dissection, incise the deep fascia in
line with the incision. Take care to identify and preserve any cutaneous nerves
encountered during this part of the dissection. Retract the tendon of the
extensor digitorum longus medially to expose the thick capsular structures
overlying the fifth metatarsal head. B: For the deep surgical dissection, divide
the capsule longitudinally. Peel the thick capsular and bursal structures off the
fifth metatarsal head.
Dangers
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The tendon of the extensor digitorum longus muscle lies in the medial flap
of the wound. It is easily identified and should be preserved.
Extensive soft tissue stripping of the fifth metatarsal head may
compromise the blood supply to that bone. If this occurs, delayed or
nonunion of the osteotomy may result.
How to Enlarge the Approach
The approach can be extended proximally along the entire length of the
fifth metatarsal bone. This extension is only rarely required for such
procedures as plating of the fifth metatarsal bone.
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43
Lateral Approach to the Fifth
Metatarsal Head for Bunionette
Position of the Patient
Landmarks and Incisions
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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The lateral approach to the fifth metatarsal head is used almost
exclusively for chevron osteotomies of that bone in the treatment of
bunionettes. The approach can also be used for any other procedure on
the fifth metatarsal head, including the treatment of localized
infection.
Although the approach is made through non–weight-bearing skin,
the skin over a bunionette is frequently red, inflamed, and thin. On
those rare occurrences in which frank ulceration and/or infection have
occurred, nonoperative treatment of the skin must be carried out
before surgery. As with all surgical approaches to the distal part of the
foot, a careful vascular assessment should be done preoperatively,
particularly in at-risk patients who have diabetes mellitus.
Position of the Patient
Place the patient supine on the operating table. Fix a support to the opposite
iliac crest. Place a sandbag underneath the buttock on the affected side to
internally rotate the leg, bringing the lateral border of the foot into the
operative field. Next, tilt the table away from you to further increase the
internal rotation.
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. 7-1).
Landmarks and Incisions
Palpate the head of the fifth metatarsal bone and the fifth
metatarsophalangeal joint along the ball of the foot and along its lateral
border. In cases of bunionette, the metatarsal head is prominent laterally.
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The extensor digitorum longus tendon to the fifth toe is easily palpable
on the dorsum of the foot. When this tendon is tight, it stands out upon
passive flexion of the fifth toe.
Make a 3-cm incision on the lateral side of the foot (Fig. 43-1). Begin
just distal to the metatarsophalangeal joint of the fifth toe and extend the
incision proximally along the lateral border of the foot. A useful surgical
landmark is the junction between the smooth skin on the dorsum of the foot
and the wrinkled skin on the plantar aspect.
Figure 43-1. Make a 3-cm incision on the lateral side of the foot. Begin just
distal to the metatarsophalangeal joint of the fifth toe and extend the incision
proximally along the lateral border of the foot.
Internervous Plane
There is no true internervous plane. The bone is essentially subcutaneous.
The extensor digitorum longus and flexor digitorum longus tendons to the
fifth toe receive their nerve supply well proximal to this approach and
cannot be denervated by this approach.
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