Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_708_Библиотеки_им_академика_М_И_Перельмана
.pdf
This approach is used for release of the medial band of the plantar
fascia. The main neurovascular bundle to the foot could be endangered
by this approach, thus it must be performed with great care.
Position of the Patient
Place the patient supine on the operating table with a sandbag under the
buttock of the opposite limb (see Fig. 3-1). The sandbag rotates the
operative limb externally, causing the medial side of the foot to face the
ceiling. Exsanguinate the limb, then apply a tourniquet to the mid-thigh.
Landmarks and Incision
Palpate the subcutaneous surface of the medial side of the calcaneum
inferiorly and the medial malleolus superiorly. The neurovascular bundle
runs down behind the medial malleolus.
Make a 2-cm longitudinal incision in line with the long axis of the foot
directly over the subcutaneous medial surface of the calcaneum. Begin
approximately 4 cm below and 2 cm posterior to the tip of the medial
malleolus. The incision is over the medial tubercle of the calcaneum, where
the origin of the plantar fascia lies (Fig. 22-1). The medial tubercle of the
calcaneum lies at the inferior border of the proximal end of the calcaneum
and cannot be felt as a discrete lump. The incision should be small and
tissue flaps should be full thickness and not undermined.
https://t.me/medicina_free
Figure 22-1. Make a 2-cm longitudinal incision in line with the long axis of the
foot directly over the medial tubercle of the calcaneum, where the origin of the
plantar fascia lies.
Internervous Plane
There is no true internervous plane because the dissection is being
performed down to a subcutaneous bone.
Superficial Surgical Dissection
Identify and preserve any branches of the medial calcaneal nerve exposed
by the skin incision. Elevate full-thickness flaps to expose the periosteum of
the medial aspect of the calcaneum (Fig. 22-2). Ensure hemostasis to allow
good visualization. Identify the medial tuberosity of the calcaneum by
palpation. The tubercle is at the posterior end of the medial side of the bone.
https://t.me/medicina_free
Deep Surgical Dissection
Several structures arise from the medial tubercle of the calcaneum. The
abductor hallucis, flexor digitorum brevis, and part of the abductor digiti
minimi all arise from the tubercle. Superficial to these muscles, the plantar
aponeurosis is attached to bone. The abductor hallucis is covered by a
fascial layer. Incise the fascia and retract the abductor hallucis muscle in a
cephalad direction (Fig. 22-3). Remain on the surface of the calcaneum and
extend the dissection medially to the underside of the calcaneum. Remain
strictly on the bone, as the neurovascular bundle lies just distal to the field
of dissection and is potentially at risk if dissection strays from the
epiperiosteal plane.
https://t.me/medicina_free
Figure 22-2. Elevate full-thickness flaps to expose the periosteum of the medial
aspect of the calcaneum.
https://t.me/medicina_free
Figure 22-3. Incise the fascia and retract the abductor hallucis muscle in a
cephalad direction.
Dangers
Nerves
https://t.me/medicina_free
The neurovascular bundle is vulnerable if the skin incision is too far
anterior or proximal. By staying immediately over the medial tuberosity of
the calcaneum, the neurovascular bundle is protected by the flexor
retinaculum and the flexor hallucis longus. Superficially, small medial
calcaneal nerves should be identified and preserved.
Vessels
Occasionally, terminal branches of the posterior tibial artery or lateral
plantar artery are very close to the calcaneum and may inadvertently be
divided. It is best to deflate the tourniquet before closure to ensure
hemostasis.
How to Enlarge the Approach
Extensile Measures
Proximal Extension
The incision may be extended proximally toward the posterior border of the
calcaneum, being aware that the skin in this area is always vulnerable to
necrosis.
https://t.me/medicina_free
23
Hindfoot Nailing for Subtalar and
Ankle Joint Fusion (Plantar
Approach)
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
First Layer of Muscles
Second Layer of Muscles
Dangers
Nerves and Vessels
Skin
How to Enlarge the Approach
https://t.me/medicina_free
Introduction
This approach is used for hindfoot fusions that are to be treated by
nailing. This technique is usually used for salvage of badly diseased or
fractured joints of the hindfoot to restore anatomic alignment.1 The
procedure is often accompanied by a fibular osteotomy and removal of
ankle or subtalar joint surfaces.
The skin of the sole of the foot is highly specialized, tough, and
resilient. It responds to abnormal stresses by hypertrophying in the
keratinized layer. The heel skin is especially thick. The approach for
hindfoot nailing involves small incisions on the plantar aspect of the
foot, carefully planned and usually performed on patients with endstage diseases of the hindfoot and ankle. Here, the skin may be
atrophic, especially with patients who have ischemic or neuropathic
conditions.
Position of the Patient
Place the patient supine on the operating table (see Fig. 1-1). Partially
exsanguinate the foot, either by elevating for a few minutes or by applying
a soft rubber bandage loosely to the foot and binding it firmly to the calf.
Then inflate a thigh tourniquet.
Landmarks and Incision
This approach is minimally invasive, and the small skin incision needs to be
very accurately placed. Palpation of bony landmarks is insufficient and
image intensification is usually used to help identify the internal bony
architecture. To achieve a true lateral radiograph of the foot, roll the limb
https://t.me/medicina_free
externally. To achieve a true anteroposterior radiograph of the ankle ensure
that the foot is in a fully dorsiflexed position (see Fig. 1-1).
Minimally invasive surgery demands careful preoperative planning,
patient positioning, and very accurate skin incisions. Determine the position
of the incision by using a lateral fluoroscopic image, an axial heel view, and
an anteroposterior image. The starting point for the incision is determined
by the intersection of two lines on the sole of the foot. The first line is
drawn longitudinally through the ankle and hindfoot on the lateral image.
This line runs through the center of the tibial medullary canal along its axis.
The line crosses the talus and calcaneum to exit through the sole of the foot
(Fig. 23-1A). The second line runs over the lateral column of the calcaneum
and is determined on the longitudinal plantar view (Fig. 23-1B).
It is often easiest to mark a longitudinal line on the sole of the foot using
the longitudinal plantar view, followed by a second line on the sole of the
foot using the lateral image. The cross-section of these two lines on the sole
of the foot will be the entry point (see Fig. 23-1B). Make a 2- to 3-cm
longitudinal incision on the sole of the foot centered on this entry point
(Fig. 23-1C).
The exact position of the skin incision is dictated by the design of the
nail to be used for the fusion procedure. Different nails have different
offsets. A careful study of the technique guide for the selected implant is
advised.
https://t.me/medicina_free
Figure 23-1. A: The starting point for the incision is determined by the
intersection of two lines on the sole of the foot. The first line is drawn
longitudinally through the ankle and hindfoot on the lateral image. This line runs
through the center of the tibial medullary canal along its axis. The line crosses
the talus and calcaneum to exit through the sole of the foot. B: The second line
runs over the lateral column of the calcaneum and is determined on the
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана