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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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Figure 20-3. Careful dissection allows the periosteum to be incised immediately
beneath the skin on the medial aspect of the calcaneum.
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Figure 20-4. A: Divide the tendon in the midline and incise the anterior
paratenon. B: Retract the cut edges of the tendon and paratenon to reveal the
posterior aspect of the calcaneum.
Dangers
Nerves
Cutaneous branches of the sural nerve run close to the line of a lateral
incision. A lateral incision close to the Achilles tendon may expose the
nerve that should be identified and preserved to prevent neuroma formation.
How to Enlarge the Approach
Extensile Measures
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Although this approach does not utilize an internervous plane, on occasion,
it can be extended proximally to expose more of the Achilles tendon or
distally to expose more of the calcaneum.
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21
Lateral Approach to the Os
Peroneum
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
Introduction
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This approach is used primarily for resection of the base of the fifth
metatarsal or for removal of the os peroneum. The peroneal tendons
can also be seen with this incision. An accurate assessment of the
patient’s vascular status is critical before considering surgery owing to
the fact that diseases such as diabetes and vasculopathies (associated
neuropathies and smoking) are relative contraindications to extensive
surgical approaches to the foot.
Position of the Patient
Place the patient in the lateral position on the operating table (see Fig. 19-
1). Ensure that all bony prominences are well padded. Flex the knee to
place the leg that is to be operated on posteriorly, with the under leg
anterior. Exsanguinate the limb either by elevating it for a few minutes or
by applying a soft rubber bandage. Inflate a tourniquet on the mid-thigh.
Landmarks and Incision
Palpate the posterior border of the distal fibula and the lateral border of the
Achilles tendon. Next, identify the styloid process at the base of the fifth
metatarsal bone, which is easily felt along the lateral aspect of the foot.
Make a 3- to 4-cm longitudinal incision on the lateral aspect of the foot.
Begin the incision at the base of the fifth metatarsal and extend it
posteriorly, following the junction between the smooth skin of the dorsum
of the foot and the wrinkled skin of the sole (Fig. 21-1). The exact length of
the incision is determined by the pathology to be treated.
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Figure 21-1. Make a 3- to 4-cm longitudinal incision on the lateral aspect of the
foot. Begin the incision at the base of the fifth metatarsal and extend it
posteriorly, following the junction between the smooth skin of the dorsum of the
foot and the wrinkled skin of the sole.
Internervous Plane
No internervous planes are available for use. The dissection consists of a
direct approach to the fifth metatarsal bone, which is subcutaneous.
Superficial Surgical Dissection
Incise the subcutaneous tissue in the line of the skin incision, taking care
not to elevate any flaps. Distally, dissect straight down to the lateral
projection of the fifth metatarsal. The peroneus brevis inserts onto the
styloid process of the fifth metatarsal (Fig. 21-2).
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Deep Surgical Dissection
Identify the insertion of the peroneus brevis into the styloid process of the
fifth metatarsal. Mobilize the lateral border of the extensor digitorum brevis
muscle and retract it medially (Fig. 21-3) to approach the cuboid. Identify
the tendon of the peroneus longus lying against the posterior ridge of the
groove on the cuboid. This is the most common site for an os peroneum,
which is a small growth of sesamoid fibrocartilage.
1
Figure 21-2. Incise the subcutaneous tissue in the line of the skin incision,
taking care not to elevate any flaps. Distally, dissect straight down to the lateral
projection of the fifth metatarsal.
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Figure 21-3. Identify the insertion of the peroneus brevis into the styloid
process of the fifth metatarsal. To approach the cuboid, mobilize the lateral
border of the extensor digitorum brevis muscle and retract it medially.
Dangers
Nerves
The sural nerve is vulnerable during the superficial surgical dissection. Take
care to identify and preserve it. The soft tissues are vulnerable during this
approach as well, as the risk of skin necrosis is ever present. This risk can
be minimized if the subcutaneous tissue is incised without creating skin
flaps and there is no undermining of soft tissues.
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REFERENCE
1. Le Minor JM. Comparative anatomy and significance of the sesamoid
bone of the peroneus longus muscle (os peroneum). J Anat.
1987;151:85–99.
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22
Medial Approach to the Plantar
Fascia
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
Vessels
How to Enlarge the Approach
Extensile Measures
Introduction
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