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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_708_Библиотеки_им_академика_М_И_Перельмана
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The skin in this area is quite thin, thus skin breakdown is not uncommon.
Because of this, the skin flap should not be mobilized widely. It is better to
use a slightly longer incision than forcibly retract the skin edges. Areas of
skin that are stretched may necrose.
Ligate any veins that cross the operative field. The sural nerve runs
down the lateral side of the hind part of the foot. In thin individuals, the
nerve can be felt as a ridge under the skin if it is put under stretch by full
plantar flexion of the foot. The nerve lies superficial to the peroneal
retinaculum and parallel to the peroneal tendons. The nerve is therefore
very close to the skin incision. Take care to identify and preserve the nerve.
Open the deep fascia in line with the skin incision, taking care not to
damage the tendons of the peroneal muscles, covered by the inferior
peroneal retinaculum. Palpate the peroneal tubercle—a bony lump of
variable size—in the middle of the incision and identify the peroneal
tendons running beneath the inferior peroneal retinaculum (Fig. 12-3).
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Figure 12-3. Open the deep fascia in line with the skin incision, taking care not
to damage the tendons of the peroneal muscles. They will be covered with the
inferior peroneal retinaculum. The peroneal tubercle—a palpable bony lump of
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variable size—will be found in the middle of the incision, with the peroneal
tendons nearby.
Deep Surgical Dissection
Divide the inferior peroneal retinaculum overlying the peroneal tubercle.
The tubercle separates the tendons of peroneus brevis and the peroneus
longus. The common synovial sheath that covers the two tendons proximal
to the tubercle divides into two slips to individually enclose the peroneal
tendons at the tubercle and beyond. The peroneus brevis lies superior to the
tubercle and the peroneus longus lies inferior to the tubercle.
Palpate the tendons as they lie within their sheaths and identify the
peroneal tubercle. Carefully incise the soft tissues lying over the peroneal
tubercle to expose the bone (Fig. 12-4). Try to preserve the soft tissue
attachments of the tendons to avoid problems with tendon function in the
postoperative phase.
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Figure 12-4. Carefully incise the inferior peroneal retinaculum and the soft
tissues lying over the peroneal tubercle to expose the bone.
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Dangers
Skin Flaps
Exposures in this area are notorious for producing necrosis. Therefore, skin
flaps should be cut as thickly as possible and be full thickness in nature.
Stripping and retraction should be kept to a minimum, and sharp curves in
the skin incision should be avoided. It is better to create a longer incision
than to apply significant retraction to the edges of a small one.
Nerve
The sural nerve runs distally downward almost directly in line with the skin
incision. It is variable in its course. By dissecting carefully, it can be seen
and should be protected. Even small branches should be preserved, as sural
nerve neuromas are painful if the nerve is injured during this approach.
How to Enlarge the Approach
This is not a classically extensile approach. It does not follow an
internervous plane. However, it can be extended somewhat distally over the
calcaneal cuboid joint and somewhat proximally along the line of the
peroneal tendons. In each instance, the sural nerve must be carefully
protected.
To enlarge the approach, extend the incision proximally, curving it along
the inferior border of the fibula and then along the posterior border of the
fibula. By developing a plane between peroneal muscles and the flexor
muscles, the entire length of the fibula can be exposed. In practice, this
extension is rarely required. The incision can also be extended posteriorly
and proximally to reach the Achilles tendon.
REFERENCE
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1. Grice DS. An extra-articular arthrodesis of the subastragalar joint for
correction of paralytic flat feet in children. J Bone Joint Surg Am.
1952;34A(4):927–940.
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13
Lateral Approach to the Posterior
Talocalcaneal Joint
Position of the Patient
Landmarks and Incision
Landmarks
Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
How to Enlarge the Approach
Local Measures
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Introduction
The lateral approach to the posterior talocalcaneal joint exposes the
posterior facet of the talocalcaneal joint more extensively than the
anterolateral approach. It is mainly used for exposure or arthrodesis of
the talocalcaneal joint.
Position of the Patient
Place the patient supine on the operating table with a sandbag under the
buttock of the affected side to bring the lateral malleolus forward. Place a
support on the opposite iliac crest, then tilt the table 20 degrees to 30
degrees away from the surgeon to improve access still further. Exsanguinate
the limb either by elevating it for 3 to 5 minutes or by applying a soft
rubber bandage, then inflate a tourniquet (see Fig. 7-1).
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Figure 13-1. Make a curved incision 10 to 13 cm long on the lateral aspect of
the ankle.
Landmarks and Incision
Landmarks
The lateral malleolus is the subcutaneous distal end of the fibula. The
peroneal tubercle is a small protuberance of bone on the lateral surface of
the calcaneum that separates the tendons of the peroneus longus and brevis
muscles. It lies distal and anterior to the lateral malleolus.
Incision
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Make a curved incision 10 to 13 cm long on the lateral aspect of the ankle.
Begin about 4 cm above the tip of the lateral malleolus on the posterior
border of the fibula. Follow the posterior border of the fibula down to the
tip of the lateral malleolus, and then curve the incision forward, passing
over the peroneal tubercle parallel to the course of the peroneal tendons
(Fig. 13-1).
Internervous Plane
No internervous plane exists in this approach. The peroneal muscles, whose
tendons are mobilized and retracted anteriorly, share a nerve supply from
the superficial peroneal nerve. The approach is safe because the muscles
receive their supply at a point well proximal to it.
Superficial Surgical Dissection
Mobilize the skin flaps minimally, taking care not to damage the sural nerve
as it runs just behind the lateral malleolus with the short saphenous vein.
Begin incising the deep fascia in line with the upper part of the skin incision
to uncover the two peroneal tendons. The tendons of the peroneus longus
and peroneus brevis muscles curve around the back of the lateral malleolus.
The peroneus brevis tendon, which is closest to the lateral malleolus, is
muscular almost down to the level of the malleolus itself (see Fig. 10-8).
Continue incising the deep fascia, following the tendons and dividing the
superior peroneal retinaculum as it runs from the tip of the lateral malleolus
to the calcaneum. The inferior peroneal retinaculum is a band of fascia
attached to the peroneal tubercle (trochlea) and the calcaneum above and
below the peroneal tendons. Incise the inferior peroneal retinaculum in line
with the tendon of peroneus brevis (Fig. 13-2). Next, incise that portion of
the inferior peroneal retinaculum that covers the peroneus longus tendon.
The retinaculum must be repaired during closure to prevent tendon
dislocation (Fig. 13-3). When both peroneal tendons have been mobilized,
retract them anteriorly over the distal end of the fibula (Fig. 13-4).
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