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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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Superficial Surgical Dissection
Cut through subcutaneous tissue in the line of the skin incision to expose
the joint capsule of the metatarsophalangeal joint of the fifth toe and the
periosteum covering the distal end of the fifth metatarsal bone (Fig. 43-2A).
Deep Surgical Dissection
The extent of the deep surgical dissection will depend on the surgical
procedure to be carried out. For most procedures, the thick capsular and
bursal structures adherent to the fifth metatarsal head will need to be
stripped off the bone (Fig. 43-2B). Take care, however, to preserve as much
soft tissue as possible in cases of distal metatarsal osteotomy to reduce the
risk of delayed union or nonunion.
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Figure 43-2. A: For the superficial surgical dissection, cut through
subcutaneous tissue in the line of the skin incision to expose the joint capsule of
the metatarsophalangeal joint of the fifth toe and the periosteum covering the
distal end of the fifth metatarsal bone. B: For most procedures requiring deep
surgical dissection, the thick capsular and bursal structures adherent to the fifth
metatarsal head will need to be stripped off the bone.
Dangers
The tendon of the extensor digitorum longus lies well superior to the wound
and is not at risk. Minor cutaneous nerves may cross the field during a
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superficial surgical dissection; of course, any nerves that can be identified
should be preserved.
How to Enlarge the Approach
The approach can be extended proximally to the base of the fifth metatarsal
bone. Such an extension may be required for a double osteotomy of the
bone or internal fixation of a fifth metatarsal fracture using a plate. The
incision can be extended distally to give a lateral approach to the flexor
tendons of the fifth toe (see Chapter 47). Such an extension may rarely be
indicated if a flexor tenotomy or flexor-toextensor tendon transfer is to be carried out at the same time as a distal
metatarsal osteotomy.
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44
Dorsal Approach to the
Metatarsophalangeal Joints of the
Second, Third, Fourth, and Fifth
Toes
Position of the Patient
Landmarks and Incision
Landmarks
Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
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Introduction
The dorsal approach is the approach of choice for exposure of the
metatarsophalangeal joints of the second, third, fourth, and fifth toes
because it avoids incision of the plantar skin of the foot. Most plantar
approaches scar the weight-bearing skin, violating a basic surgical
principle.
The uses for the approach include the following:
Excision of metatarsal heads
Distal metatarsal osteotomy and pinning of metatarsal neck fractures
1
Partial proximal phalangectomy
Capsulotomy of metatarsophalangeal joints
Muscle tenotomy
Neurectomy
Position of the Patient
Place the patient supine on the operating table. Position a bolster under the
thigh to flex the knee and allow the foot to lie with its plantar surface on the
table (Fig. 44-1).
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Figure 44-1. Position of the patient for approaches to the toes.
Landmarks and Incision
Landmarks
To palpate each metatarsal head, place a thumb on the plantar surface and
an index finger on the dorsal surface of the foot. Skin callosities under the
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heads indicate that the area concerned is bearing an unaccustomed amount
of weight and indicates pathology in the weight distribution around the foot.
Palpate the tendons of the extensor digitorum longus muscle on the
dorsal aspect of the foot.
Incision
Make a 3-cm longitudinal incision over the dorsolateral aspect of the
affected metatarsophalangeal joint. The incision should run parallel with,
but just lateral to, the long extensor tendon (Fig. 44-2). If two adjacent
joints need to be exposed, make the incision between them. Alternatively, a
transverse dorsal incision may be made over the joints.
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Figure 44-2. Make a 3-cm longitudinal incision over the dorsolateral aspect of
the affected metatarsophalangeal joint.
Internervous Plane
There is no true internervous plane for any of these metatarsophalangeal
approaches. The approaches are well dorsal to the plantar nerves and
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vessels, the key neurovascular structures in this area. Take care to avoid
cutting the dorsal digital nerves, branches of which may cross the operative
field.
Superficial Surgical Dissection
Incise the deep fascia in line with the incision, and retract the long extensor
tendon laterally to reveal the dorsal aspect of the metatarsophalangeal joint
(Fig. 44-3). Often, an extensor tenotomy or lengthening is performed at the
same time as the operation on the joint. In this case, divide the extensor
tendon in a “Z” fashion rather than retracting it. If two joints are being
exposed, retract the tendon laterally to gain access to the adjacent joint.
Deep Surgical Dissection
Incise the dorsal capsule of the metatarsophalangeal joint longitudinally to
enter the joint (Figs. 44-4 and 44-5).
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Figure 44-3. Incise the deep fascia in line with the incision on the medial side of
the long extensor tendon.
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