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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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Because this incision is used to treat midfoot collapse and foot deformity,
the normal bony landmarks will be distorted. Palpate the medial malleolus
as the bulbous end of the distal tibia. It can nearly always be palpated
proximally and is a reliable bony landmark. Distally palpate the first
metatarsal, which is easily felt on the dorsal aspect of the midfoot. Finally,
palpate the bony prominence of the collapsed midfoot overlying the ulcer.
Make a 4- to 6-cm longitudinal incision directly over the area to be
exposed. The plantar medial incision lies directly over the bony prominence
to be removed. The approach usually runs from the base of the first
metatarsal proximally over the navicular (Fig. 28-1).
Figure 28-1. Make a 4- to 6-cm longitudinal incision directly over the area to be
exposed. The plantar medial incision lies directly over the bony prominence to
be removed. The approach usually runs from the base of the first metatarsal
over the navicular.
Internervous Plane
No internervous plane is available for this approach. The muscles whose
tendons are exposed receive their nerve supply well proximal to the
approach and are therefore not denervated by the approach.
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Superficial and Deep Surgical Dissection
Cut down directly onto the bony prominence to be planed (Fig. 28-2).
Preserve any cutaneous nerves that can be identified. Ensure that skin flaps
are full thickness to minimize the risk of skin necrosis. The structures over
the plantar medial surface of the foot are prominent if the skin changes are
on the plantar surface. The extensive insertion of the tibialis posterior onto
the tuberosity of the navicular, the inferior surface of the medial cuneiform,
and the bases of the second, third, and fourth metatarsals will be visualized.
Great care should be taken to preserve these structures.
Figure 28-2. Cut down directly onto the bony prominence to be planed.
Preserve any cutaneous nerves that can be identified.
How to Enlarge the Approach
This approach can be extended both proximally and distally. Such
extensions are indicated if the local bone excision is to be combined with
other surgical procedures such as tendon lengthening, shortening, or
transfer. Proximally extend the incision up posterior to the medial
malleolus, curving it to a point midway between the medial malleolus and
the Achilles tendon. The incision can also be extended distally in line with
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the first metatarsal. Be aware of the need to identify and preserve cutaneous
nerves to prevent permanent local foot anesthesia.
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29
Dorsomedial Approach to
Lisfranc’s Joint
Position of the Patient
Landmarks and Incisions
Internervous Plane
Superficial and Deep Surgical Dissection
How to Enlarge the Approach
Introduction
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This approach is used for the treatment of pathology of the
tarsometatarsal (Lisfranc’s) joint. Generally, two incisions are made
for severe midfoot injuries.1 Single incision may be used for treating
isolated dislocations of the first ray at Lisfranc’s joint or other
conditions such as arthritis or fractures of the base of the first
metatarsal or medial cuneiform.
The midfoot contains a complex array of bony structures that
ensure stability for the medial side of the midfoot and flexibility for
the lateral side of the midfoot. For this reason, implants used to treat
fractures in this area are more rigid on the medial than the lateral side.
In turn, this means that surgical approaches are usually more extensive
on the medial than the lateral side.
Position of the Patient
Place the patient supine on the operating room table (see Fig. 7-1). Place a
sandbag beneath the buttock of the affected side to counteract the natural
external rotation of the leg and put the foot into a neutral position. After
exsanguination, apply a tourniquet to the mid-thigh.
Landmarks and Incisions
It is very difficult to palpate the medial part of Lisfranc’s joint, therefore
another bony anatomy must be used to locate it. Palpating the prominent
base of the first metatarsal is usually possible, but frequently image
intensification is necessary to identify the underlying bony structures.
Make a 4-cm longitudinal incision in the long axis of the foot (Fig. 29-
1). The incision should be centered over the joint between the first
metatarsal and the medial cuneiform. If needed, make a second 4-cm
incision parallel to the first overlying the base of the fourth metatarsal.
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Figure 29-1. Make a 4-cm longitudinal incision directly over the area to be
exposed. The incision should be centered over the joint between the first
metatarsal and the medial cuneiform.
Internervous Plane
No internervous plane is available for use in this approach. The dissection is
essentially directly down to subcutaneous bones and no muscles can be
denervated.
Superficial and Deep Surgical Dissection
Cut down directly to the structures to be exposed, taking care to avoid any
cutaneous nerves that can be identified (Fig. 29-2). Do not undermine the
skin flaps to preserve the blood supply to the skin bridge between the two
incisions.
Retract the tendons of extensor hallucis longus and tibialis anterior
medially (Fig. 29-3). The neurovascular bundle lies laterally. Deepen the
approach in the line of the skin incision to expose the joint between the first
metatarsal and the medial cuneiform (Fig. 29-4). To expose the joint
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between the base of the second metatarsal and the intermediate cuneiform,
continue the dissection laterally, staying close to the bone. There is
frequently an associated fracture of the base of the second metatarsal in a
Lisfranc’s dislocation. To expose the joint between the medial cuneiform
and the navicular, continue the dissection proximally, again staying close to
the bone. Often in the case of fractures, it is difficult to identify structures
by palpation, thus fluoroscopy should be used to more carefully and
accurately enable the surgeon to pinpoint the exact approach needed.
Figure 29-2. Cut down directly to the structures to be exposed, taking care to
avoid any cutaneous branches of the deep peroneal nerve that can be
identified.
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Figure 29-3. Retract the tendons of extensor hallucis longus and tibialis anterior
medially.
Figure 29-4. Deepen the approach to expose the joint between the first
metatarsal and the medial cuneiform.
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How to Enlarge the Approach
This approach can be enlarged proximally by continuing the dissection
between the extensor hallucis longus and the neurovascular bundle. By
releasing the inferior extensor retinaculum, the ankle joint can be palpated.
The incision can also be taken more distally by continuing the dissection
between the extensor hallucis longus and the neurovascular bundle. This
allows the whole length of the medial and middle cuneiforms to the base of
the first metatarsal to be exposed.
REFERENCE
1. Buckley R, Moran C, Apivatthakakul T. Midfoot and forefoot. In: AO
Principles of Fracture Management. 3rd ed. Vol 1. Thieme; 2017:990–
994.
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30
Dorsolateral Approach to
Lisfranc’s Joint
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
How to Enlarge the Approach
Introduction
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