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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 37-2. Develop the skin flaps. Divide the deep fascia in line with the skin
incision, and retract the tendon of the extensor hallucis longus laterally.
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Figure 37-3. Incise the joint capsule dorsally and remove as much of the
capsule as necessary, depending on the procedure to be performed.
Dangers
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The tendon of the extensor hallucis longus muscle, which lies on the lateral
edge of the wound, should not be cut during the approach. In most cases of
bunion, the tendon bowstrings laterally across the metatarsophalangeal joint
and is lateral to the incision. Protect the dorsal digital nerve if it can be seen
along the line of the incision (see Figs. 37-1 and 38-1).
The tendon of the flexor hallucis longus muscle is vulnerable at the base
of the proximal phalanx. The tendon lies in a groove on the plantar surface
of the proximal phalanx so close to the periosteum that, if care is not taken,
it may be damaged during stripping. Note that this tendon is often displaced
laterally in patients with hallux valgus (see Fig. 37-1).
How to Enlarge the Approach
Careful and systematic stripping of the bone provides an adequate view of
the joint. The approach cannot be extended usefully to other joints in the
foot, but may be extended proximally to access the shaft of the first
metatarsal bone.
REFERENCES
1. Easley ME, Trnka HJ. Current concepts review: hallux valgus part II:
operative treatment. Foot Ankle Int. 2007;28(6):748–758.
2. Putti AB, Pande S, Adams RF, et al. Keller’s arthroplasty in adults with
hallux valgus and hallux rigidus. Foot Ankle Surg. 2012;18(1):34–38.
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38
Dorsomedial 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 dorsomedial approach is used for most surgeries to the
metatarsophalangeal joint of the great toe in the treatments of bunions
or hallux rigidus.
The dorsomedial skin incision provides access to the exostosis on
the metatarsal head. The major advantage of the skin incision is that it
gives direct access to the exostosis without much skin retraction and is
farther away from the terminal branches of the saphenous nerve.
It does have drawbacks, however. The bursa covering the exostosis
may be inflamed, complicating the surgery. Note that the skin on the
medial aspect of the metatarsophalangeal joint is thinner than on the
dorsum of the joint and may not heal as well.
Its use includes the following:
Excision of exostosis of the first metatarsal (bunionectomy)
Excision of the proximal part of the proximal phalanx of the hallux
(Keller’s procedure)
Procedures on the medial joint capsule, including reefing and V-Y
plasties
Arthrodesis of the metatarsophalangeal joint
Insertion of total joint replacements
Dorsal wedge osteotomy of the proximal phalanx in cases of hallux
rigidus
1
Position of the Patient
Place the patient supine on the operating table. 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 (see Fig. 1-1).
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Landmarks and Incision
Palpate the head of the first metatarsal bone and the metatarsophalangeal
joint on the ball of the foot and on 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 upon passive flexion of the great toe.
Begin the dorsomedial incision just proximal to the interphalangeal joint
on the medial aspect of the great toe. Curve it over the medial aspect of the
metatarsophalangeal joint, remaining medial to the tendon of the extensor
hallucis longus muscle. Then, curve the incision back by cutting along the
medial aspect to the shaft of the first metatarsal, finishing some 2 to 3 cm
from the metatarsophalangeal joint (Fig. 38-1).
Figure 38-1. Dorsomedial skin incision for the medial approach to the
metatarsophalangeal joint of the great toe. Note the proximity of the dorsal
digital nerve to the incision.
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Internervous Plane
There is no true internervous plane. The bone is subcutaneous; the two
tendons close to the dissection—the extensor hallucis longus and the
abductor hallucis—receive their nerve supply proximal to this approach,
thus cannot be denervated by it.
Superficial Surgical Dissection
Incise the deep fascia in line with the incision. Using sharp dissection,
approach the dorsomedial aspect of the metatarsophalangeal joint. The
dorsal digital branch at the medial cutaneous nerve may be visible in the
upper flap of the wound. Retract it laterally with the skin flap on the lateral
edge of the wound. Next, make an incision into the joint capsule. The
positioning of the incision depends on the surgical procedure to be carried
out. A longitudinal incision or U-shaped incision is standard. Ensure that
you leave the capsule attached to the proximal end of the proximal phalanx
(Figs. 38-2 and 38-3).
Deep Surgical Dissection
Incise the periosteum of the proximal phalanx and the first metatarsal bone
longitudinally. Using sharp and blunt instruments, 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 of the plantar surface of the
proximal phalanx, between the sesamoid bones. The extent of deep
dissection depends on the procedure. Strip only a minimum of periosteum
of the bone. Take great care not to strip all the soft tissue attachments of the
first metatarsal bone if the distal osteotomy of that bone is to be performed,
because the metatarsal head may be rendered avascular by stripping.
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Figure 38-2. Incise the deep fascia. Develop a joint capsule flap. Protect the
dorsal digital branch of the medial cutaneous nerve.
Figure 38-3. Make a U-shaped incision into the joint capsule, leaving the
capsule attached to the proximal end of the proximal phalanx.
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Dangers
The tendon of the extensor hallucis longus muscle lies on the lateral edge of
the wound. Indeed, in cases of bunion, the tendon bowstrings laterally
across the metatarsophalangeal joint and is considerably more lateral to the
incision. It should be identified and preserved during the approach.
The dorsal digital nerve lies close to the line of the skin incision. Try to
preserve it to prevent the development of a painful neuroma. Also, take care
not to incorporate the nerve in sutures used to close the wound (see Figs.
37-1 and 38-1).
The tendon of the flexor hallucis longus muscle is vulnerable as you strip
tissue from the base of the proximal phalanx. The tendon lies in a groove on
the plantar surface of the proximal phalanx so close to the periosteum that,
if care is not taken, it may be damaged during stripping. Note: This tendon
is usually displaced laterally in patients with hallux valgus (see Fig. 10-1).
How to Enlarge the Approach
Careful and systematic stripping of the structures of the bone provides an
adequate view of the joint. The approach cannot be extended usefully to
other joints in the foot, but may be extended proximally for access to the
shaft of the first metatarsal.
REFERENCE
1. Blyth MJ, Mackay DC, Kinninmonth AW. Dorsal wedge osteotomy in
the treatment of hallux rigidus. J Foot Ankle Surg. 1998;37(1):8–10
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39
Dorsolateral Approach for Bunion
Surgery
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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