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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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This approach is used to approach the plantar fascia in the treatment of
plantar fibromatosis, a disease notorious for being of varying severity.
When the disease is very severe, a complete excision may need to be
made over the whole of the sole of the foot, from the posterior aspect
of the heel right into the forefoot. Smaller incisions are usually made
directly down onto the plantar fascia, necessitating isolated smaller
approaches to the sole of the foot.
The thick skin on the bottom of the sole is highly specialized,
tough, and resilient. It should be respected and cut only when
absolutely necessary. (Incisions should be limited where possible. See
Pg 275.)
Position of the Patient
After exsanguination, apply a tourniquet to the middle of the thigh. Then
place the patient prone on the operating table (see Fig. 6-1). Ensure that
bony prominences are well padded around the upper extremities, chest,
pelvis, and lower extremities. Be careful to ensure that ventilation is secure
and that there is no pressure on the genitals.
Landmarks and Incision
Palpate the thick skin of the heel to feel the distal extension of the
calcaneum. More distally palpate the first metatarsal head medially and the
other metatarsal heads sequentially by moving laterally to the fifth
metatarsal head.
Make a longitudinal incision directly over the area to be exposed. The
length of the incision depends on the amount of tissue to be excised (Fig.
32-1). Take care not to penetrate too deeply, as the medial and lateral
plantar nerves lie immediately under the plantar fascia.
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Figure 32-1. Make a longitudinal incision directly over the area to be exposed.
The length of the incision depends on the amount of tissue to be excised.
Internervous Plane
No internervous planes are available in this approach, which consists of an
incision down onto a subcutaneous structure.
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Superficial Surgical Dissection
Cut down directly onto the area of the plantar fascia that needs to be
exposed. Take care to avoid any cutaneous nerves that can be identified. If
possible, try to avoid cutting over the thick, calloused area of the hindfoot
or forefoot. Using sharp dissection, try to define a plane between the skin
and the plantar fascia (Fig. 32-2). This is difficult in advanced cases of
plantar fibromatosis, which is the foot’s equivalent of Dupuytren’s
contracture of the hand.
Deep Surgical Dissection
Make a transverse incision through the plantar fascia using a scalpel (Fig.
32-3). The plantar fascia is much thicker in its central parts, where it is
known as the plantar aponeurosis. Take great care because the lateral and
medial plantar nerves lie immediately under the fascia. Once the fascia has
been divided, the cut ends usually pull apart and the correct plane
underneath the fascia can be easily established (Fig. 32-4).
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Figure 32-2. Define a plane between the skin and the underlying plantar fascia.
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Figure 32-3. Carefully incise the plantar fascia using a scalpel. The incision
should be transverse.
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Figure 32-4. Once the fascia has been divided, the cut ends usually pull apart
and the correct plane underneath the fascia can be easily established.
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How to Enlarge the Approach
This approach can be extended proximally and distally as needed. Often the
medial band of the plantar fascia is most affected, but fibromatosis can
involve the whole of the plantar fascia from its origins on the calcaneum
down to the extended insertions into the metatarsal heads.
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33
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Dorsal Approaches to the Middle
Part of the Foot
Position of the Patient
Landmarks and Incisions
Landmarks
Incisions
Internervous Plane
Surgical Dissection
How to Enlarge the Approach
Introduction
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The middle part of the foot extends from the calcaneocuboid and
talonavicular joints to the tarsometatarsal Lisfranc’s joints. All these
bones and joints are superficial and can be approached directly by
dorsal, medial, and lateral approaches. Operations in this area (which
are performed rarely) usually involve surgery on the insertions of the
four powerful muscles that, together, are responsible for controlling
inversion and eversion of the foot. These muscles are the tibialis
anterior, which inserts into the medial surface and undersurface of the
medial cuneiform bone, and into the adjoining part of the base of the
first metatarsal bone; the peroneus longus, which inserts into the
lateral side of the medial cuneiform bone; the peroneus brevis, which
inserts into the base of the lateral side of the fifth metatarsal bone; and
the tibialis posterior, which inserts into the tuberosity of the navicular
bone, the inferior surface of the medial cuneiform bone, the
intermediate cuneiform bone, and the bases of the second, third, and
fourth metatarsal bones (see Figs. 10-2, 10-5, 10-8, and 10-9).
The middle part of the foot is the target of various specialized
procedures for the treatment of muscle imbalance, mobile flatfoot, and
an accessory navicular bone. It is also approached for open reduction
and internal fixation of fractures in and around Lisfranc’s joint, and for
local tarsal fusion. Only the general surgical approaches are
considered here, because the details of operative technique and
indications are beyond the scope of this book.
Position of the Patient
Place the patient supine on the operating table. Dorsomedial approaches and
medial approaches are carried out with the leg in its natural position of
slight external rotation, whereas dorsolateral approaches require internal
rotation of the limb, which is achieved by placing a sandbag under the
buttock. For all procedures, exsanguinate the limb either by elevating it for
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