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46
Plantar Approach for Recurrent
Morton’s Neuroma
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 plantar approach for a digital neuroma gives excellent exposure of
the common plantar digital nerve. The approach can be extended
proximally to expose more of the nerve. The major disadvantage of the
incision is that it creates a plantar scar. Healing time is often longer
than the dorsal approach. Plantar scars are occasionally sensitive.
The alternative surgical approach—the dorsal approach—divides
the deep transverse metatarsal ligament, which may be an important
source of pathology in the creation of Morton’s neuroma. For that
reason, the plantar approach for Morton’s neuroma is usually reserved
for exploration of a recurrent neuroma rather than as the primary
procedure for treating this pathology.
Position of the Patient
Place the patient supine on the operating table. Apply a tourniquet either at
the midpoint of the thigh or just above the ankle after the leg has been
exsanguinated. Alternatively, use a soft rubber bandage to exsanguinate the
foot, then use the bandage as a tourniquet at the ankle (see Fig. 1-1).
Landmarks and Incision
To palpate each metatarsal head, place the thumb on the plantar surface and
the index finger on the dorsal surface of the foot. The skin under the
metatarsal heads may be thickened; this may also be used as a landmark.
Make a 4- to 5-cm longitudinal incision from the plantar aspect of the
sole of the foot overlying the interspace to be explored. Begin the incision
just distal to the level of the metatarsophalangeal joint and proceed
proximally (Fig. 46-1).
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Figure 46-1. Make a 4- to 5-cm longitudinal incision from the plantar aspect of
the sole of the foot overlying the interspace to be explored. Begin the incision
just distal to the level of the metatarsophalangeal joint and proceed proximally.
Internervous Plane
There is no internervous plane. The tendon of flexor digitorum longus that
is exposed during the approach receives its nerve supply well proximal to
the site of surgery.
Superficial Surgical Dissection
Deepen the approach in the line of the skin incision (Fig. 46-2) and identify
the flexor tendons running to the two affected toes. Using blunt dissection
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between the flexor tendons, develop a surgical plane.
Deep Surgical Dissection
Identify the common plantar digital nerve running with its artery between
the flexor tendons. When using the approach for revision surgery, start by
identifying the common plantar digital nerve well proximal to the previous
surgical field away from the scarring caused by the primary surgery. Trace
the nerve from proximal to distal, identifying its bifurcation (Fig. 46-3).
When excising the neuroma, ensure that the proximal section of the nerve is
proximal to the metatarsal heads. Excision of the neuroma, particularly in
revision surgery, should always be confirmed histologically.
Figure 46-2. Deepen the approach in the line of the skin incision, dividing the
plantar fascia.
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Figure 46-3. Identify the common plantar digital nerve running with its artery
between the flexor tendons. When using the approach for revision surgery,
identify the common plantar digital nerve proximally well away from the previous
field of surgical dissection. Trace the nerve from proximal to distal, identifying its
bifurcation.
Dangers
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The long flexor tendons of the toes are easily identifiable in the superficial
surgical dissection. The artery running with the common plantar digital
nerve can be sacrificed during excision of the digital nerve.
The danger of the approach lies in the creation of a plantar scar. The
approach should be avoided when atrophic skin is present as well as in
cases of peripheral vascular disease, most notably diabetes mellitus.
How to Enlarge the Approach
The approach is specifically designed for exploration of digital neuroma,
thus cannot be extended. The key to adequate exposure is to identify the
nerve proximally well away from the site of previous surgery, then trace it
into the area of the previous surgery, where there will be extensive scarring.
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47
Dorsolateral Approach to the
Flexor Sheathes of the Second to
Fifth Toes
Position of the Patient
Landmarks and Incisions
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Exposure
Introduction
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The dorsolateral approach to the second to fifth toes provides safe
access to the flexor sheath and its contents. It is used mainly for flexor
tenotomy or flexor-to-extensor tendon transfer in the treatment of
flexible hammer toe deformity (curly toes). The deformity must be
correctible by passive manipulation. The approach lies dorsal to the
neurovascular bundle and therefore does not endanger this vital
structure.
Position of the Patient
Place the patient supine on the operating table (see Fig. 1-1). Good lighting
and a good exsanguinating bandage and tourniquet are essential. The
tourniquet may be placed on the mid-thigh. Alternatively, use a soft rubber
bandage to exsanguinate the foot, then wrap the leg tightly just above the
ankle. The use of a toe tourniquet is not advised, as this will interfere with
the incision and tether the tendons.
Landmarks and Incisions
Palpate the proximal interphalangeal joint of the toe by passively flexing
and extending the joint to confirm its position. The key surgical landmark is
the junction between the wrinkled dorsum and the smooth plantar skin on
the side of the toe.
Make a 2-cm longitudinal incision on the lateral aspect of the toe
running along the junction between the wrinkled dorsum and the smooth
plantar skin. Center this incision over the proximal interphalangeal joint
(Fig. 47-1).
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Figure 47-1. Make a 2-cm longitudinal incision on the lateral aspect of the toe
running along the junction between the wrinkled dorsum and the smooth plantar
skin. Center this incision over the proximal interphalangeal joint.
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Internervous Plane
There is no true internervous plane because no intermuscular interval is
utilized. The sensory nerve supply to the toe comes from two sources: the
dorsal digital nerve and the plantar digital nerve. Because the skin incision
marks the division between these two supplies, it causes no significant area
of hypoesthesia.
Superficial Surgical Dissection
Develop a slight plantar skin flap by incising the subcutaneous flap in line
with the skin incision. The flap overlying the proximal interphalangeal joint
itself is quite thin; take care not to incise the joint itself (Fig. 47-2).
Continue the dissection toward the midline of the toe, aiming slightly in a
plantar direction. The main neurovascular bundle lies in the plantar flap.
Expose the sheath covering the flexor tendons.
Deep Surgical Dissection
Incise the fibrous flexor sheath longitudinally to expose the underlying
tendons (Fig. 47-3). At the level of the proximal interphalangeal joint, the
superficial flexor tendon splits into two and wraps around the long flexor
tendon. If a flexor tenotomy or flexor-to-extensor transfer is to be
performed, take a blunt hook and insert it around the long flexor tendon.
Putting the hook toward you will passively flex both the proximal and distal
interphalangeal joints and allow the long flexor tendon to be divided well
distal to the site of the dissection (Fig. 47-4). If a flexor-to-extensor transfer
is to be carried out, develop an epiperiosteal plane around the base of the
middle phalanx, following the bone around onto its dorsal surface. The
common extensor tendon can then easily be visualized.
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