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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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36
Lateral Approach to the Base of the
Fifth Metatarsal
Position of the Patient
Landmarks and Incisions
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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The lateral approach to the base of the fifth metatarsal bone gives easy,
safe access to that part of the bone. Its uses include the following:
Basal osteotomy of the fifth metatarsal bone in cases of bunionette.
This procedure is indicated if the intermetatarsal angle between the
fourth and fifth metatarsal bones is abnormal.
Open reduction and internal fixation of fractures or nonunions of the
base of the fifth metatarsal bone. Transverse fractures are much more
likely to result in nonunion than avulsion fractures due to the tenuous
blood supply in that area of the bone.1 Stress fractures may also
occur in athletes.
Position of the Patient
Place the patient supine on the operating table. Fix a support to the opposite
side of the operating table to support the contralateral iliac wing. Next,
place a sandbag under the buttock and tilt the table away from you (see Fig.
7-1). This will ensure internal rotation of the leg and bring the lateral side of
the foot into the operative field. After exsanguination, place a tourniquet on
the middle of the thigh. Alternatively, use a soft rubber bandage to
exsanguinate the foot, then wrap the leg tightly just above the ankle.
Landmarks and Incisions
The styloid process of the base of the fifth metatarsal bone is easily
palpable along the lateral aspect of the foot. Place your fingers over the
styloid process, moving them proximally and superiorly to palpate the
tendon of the peroneus brevis muscle.
Make a 2- to 3-cm incision on the lateral aspect of the foot. For open
reduction and internal fixation of fifth metatarsal fractures, center this
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incision on the styloid process of the fifth metatarsal bone (Fig. 36-1). For
basal osteotomies of the fifth metatarsal bone, make a 2-cm incision
beginning at the styloid process of the fifth metatarsal bone and extending
along the lateral aspect of the foot in line with the fifth metatarsal bone.
Superficial Surgical Dissection
Cut through the subcutaneous fat in the line of the skin incision. Take care
to identify and preserve any small cutaneous branches of the sural nerve
that lie subcutaneously. Identify the tendon of the peroneus brevis muscle as
it inserts into the styloid process of the fifth metatarsal bone (Fig. 36-2).
Deep Surgical Dissection
If the approach is to be used for open reduction and internal fixation of the
basal metatarsal fracture, carefully explore the fracture or nonunion site,
taking care to preserve as much soft tissue attachment to the bone as
possible.
If the approach is to be used for a basal metatarsal osteotomy, carefully
incise the periosteum at the osteotomy site. Some periosteal stripping will
be necessary to perform the procedure, but as with cases of fractures, try to
preserve as much soft tissue attachment to the bone as possible.
Figure 36-1. Make a 2- to 3-cm incision on the lateral aspect of the foot. For
open reduction and internal fixation of basal fifth metatarsal fractures, center
this incision on the styloid process of the fifth metatarsal bone.
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Figure 36-2. Cut through the subcutaneous fat in the line of the skin incision.
Take care to identify and preserve any small cutaneous nerves in the plane.
Identify the tendon of the peroneus brevis muscle as it inserts into the styloid
process of the fifth metatarsal bone.
Dangers
The peroneus brevis muscle is a broad, easily recognized structure. It
should not be in any danger in this approach.
Subcutaneous sensory branches of the sural nerve are present during the
superficial surgical dissection and should be identified and preserved if
possible.
How to Enlarge the Approach
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The approach can be extended distally to expose the entire length of the
fifth metatarsal bone. Such an extension is rarely indicated in fracture
surgery. Extend the incision distally along the line of the fifth metatarsal,
taking care to preserve branches of the sural nerve. Identify the belly of the
abductor digiti quinti muscle, and incise the fascia covering it
longitudinally. Retract the skin and subcutaneous tissue dorsally and the
abductor digiti quinti muscle plantarly to reveal the shaft of the fifth
metatarsal bone (Fig. 36-3). Proximally, the approach may be extended
either into a lateral approach to the os calcis (see Chapter 18) and lateral
approach to the hindfoot (see Chapter 11).
Figure 36-3. Extend the incision distally along the line of the fifth metatarsal,
taking care to preserve branches of the sural nerve. Identify the belly of the
abductor digiti quinti muscle, and incise the fascia covering it longitudinally.
Retract the skin and subcutaneous tissue dorsally and the abductor digiti quinti
muscle plantarly to reveal the shaft of the fifth metatarsal bone.
REFERENCE
1. Bušková K, Bartoníček J, Rammelt S. Fractures of the base of the fifth
metatarsal: a critical analysis review. JBJS Rev. 2021;9(10):e21.00010.
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37
Dorsal Approach to the
Metatarsophalangeal Joint of the
Great Toe
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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The dorsal approach can be employed for most of the surgeries to the
metatarsophalangeal joint of the great toe for the treatment of bunions
or hallux rigidus.
Its use includes the following:
Excision of metatarsal exostosis (bunionectomy)
Distal metatarsal osteotomy
1
Excision of the proximal part of the proximal phalanx (Keller’s
arthroplasty)
2
Soft tissue correction of hallux valgus, including reefing procedures,
tenotomies, and muscle reattachments
Arthrodesis of the metatarsophalangeal joint
Insertion of total joint replacements
Dorsal wedge osteotomy of the proximal phalanx in cases of hallux
rigidus
The skin overlying a bunion may be red, thin, and inflamed. In
extreme cases, frank ulceration with associated infection may occur. A
careful assessment of the skin and vascular state of the foot is
mandatory as part of the preoperative workup.
Position of the Patient
Place the patient supine on the operating table. After exsanguination, use a
tourniquet placed mid-thigh. Alternatively, use a soft rubber bandage to
exsanguinate the foot, then wrap the leg tightly just above the ankle (see
Fig. 1-1).
Landmarks and Incision
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Palpate the head of the first metatarsal bone and the metatarsophalangeal
joint, which are on the ball of the foot and its medial border. In cases of
bunion, the metatarsal head is prominent medially.
Palpate the extensor hallucis longus tendon on the dorsum of the foot.
When it is tight, it stands out when the great toe is passively flexed in the
plantar direction. In most cases of hallux valgus, it is displaced laterally.
Begin the dorsal incision just proximal to the interphalangeal joint and
just medial to the tendon of the extensor hallucis longus muscle. Extend the
incision proximally, parallel, and just medial to the tendon of the extensor
hallucis longus. Finish about 2 to 3 cm proximal to the metatarsophalangeal
joint. Note that the final incision is straight (Fig. 37-1).
The dorsal incision avoids cutting through the thin, frequently atrophic
skin overlying the medial aspect of the first metatarsal osteophyte. The
disadvantage of the incision is that more soft tissue dissection is required to
carry out procedures on the medial capsule. Terminal cutaneous branches of
the deep peroneal nerve and saphenous nerve are also more at risk.
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Figure 37-1. Dorsal incision for the approach to the metatarsophalangeal joint
of the great toe. Note that the tendon of the extensor hallucis longus is
displaced laterally and that the sensory nerve to the medial aspect of the great
toe runs parallel to the incision. Note that the great toe is framed by branches of
the saphenous nerve medially and the deep peroneal nerve laterally.
Internervous Plane
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There is no true internervous plane. The bone is subcutaneous; the two
tendons that lie close to the dissection—the extensor hallucis longus and the
adductor hallucis—receive their nerve supply proximal to this approach and
cannot be denervated by it.
Superficial Surgical Dissection
Divide the deep fascia in line with the incision, and retract the tendon of the
extensor hallucis longus muscle laterally. To enter the joint, incise the
dorsal aspect of the joint capsule. The type and position of the capsulotomy
depends on the procedure to be performed (Figs. 37-2 and 37-3).
Deep Surgical Dissection
Incise the periosteum of the proximal phalanx on the first metatarsal bone
longitudinally. Using both sharp and blunt dissections, strip the coverings of
the bone, taking care not to damage the tendon of the flexor hallucis longus
muscle, which lies in a fibro-osseous tunnel on the plantar surface at the
proximal phalanx, between the sesamoid bones. The extent of the deep
dissection depends on the procedure to be carried out. Strip only a
minimum of periosteum of the bone. Do not strip all the soft tissue
attachments off the first metatarsal if the distal osteotomy of that bone is to
be performed, as the metatarsal head may be rendered avascular by
stripping.
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