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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 48-4. Keeping the bone cutters closely applied to the middle phalanx,
push them distally to expose the proximal end of the middle phalanx and excise
the articular surface of the middle phalanx.
Dangers
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This surgical approach should not endanger any significant structures.
Complications can occur if patient selection is poor, particularly with regard
to the vascularity of the toe undergoing surgery.
The digital nerve and vessels should not be at risk as they lie well plantar
to the operative field in these fixed flexed joints.
The tendon of the flexor digitorum longus may be injured if the excision
of the proximal end of the middle phalanx is not performed carefully. The
tendon is closely applied to the plantar aspect of the middle phalanx. Ensure
that bone cutters do not blindly stray in a plantar direction.
How to Enlarge the Approach
The transverse approach cannot be enlarged in any way. Improved
visualization of the joint can be achieved by excising more bone, usually
from the proximal phalanx. However, excise only the amount of bone
required to fully correct the deformity. Excising too much bone may result
in a nonunion of the osteotomy.
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49
Longitudinal Approach to the
Proximal Interphalangeal Joint of
the Second to Fifth Toes for
Hammer Toe
Position of the Patient
Landmarks and Incision
Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
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Introduction
The longitudinal approach to the proximal interphalangeal joint of the
second to fifth toes is used for proximal interphalangeal joint fusion in
the treatment of fixed hammer toe deformities. The longitudinal
midline incision gives excellent access to the extensor tendon and the
underlying proximal interphalangeal joint.
The advantage of the longitudinal incision is that it allows both
proximal and distal extensions if other procedures are to be carried
out. The disadvantage of the longitudinal approach is that following
correction of the fixed flexion deformity, there is often some
redundant skin; wound closure thus must be done carefully to avoid
creating a space under the skin that could be the site of troublesome
postoperative hematoma.
The skin over the dorsal aspect of the interphalangeal joint of a toe
with a hammer toe deformity is often red and thinned. In extreme
cases, frank ulceration with associated infection may occur. The
presence of ulceration is a contraindication to surgery. The skin lesion
should be treated before surgery is considered.
As with all surgical procedures carried out on the foot careful
vascular assessment of the patent is indicated, especially in high-risk
cases such as diabetes mellitus.
Position of the Patient
Place the patient supine on the operating table. The foot normally lies in a
degree of external rotation. If the procedure is to be carried out on the
lateral digits, place a sandbag under the buttock of the affected side to
correct the external rotation and bring the toes more easily into the plane of
the surgical field.
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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. 2-1). The use of a rubber
tourniquet around the toe does restrict access to a minor degree, but has the
advantage that it can be used in conjunction with a ring block local
anesthesia.
Landmarks and Incision
Passively flex and extend the proximal interphalangeal joint to identify its
position.
Incision
Make a 2-cm longitudinal incision on the dorsum of the toe centered on the
proximal interphalangeal joint (Fig. 49-1).
Figure 49-1. Make a 2-cm longitudinal incision on the dorsum of the toe
centered on the proximal interphalangeal joint.
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Internervous Plane
There is no true internervous plane. The extensor digitorum longus tendon
receives its nerve supply well distal to the operative field, thus cannot be
denervated by it.
Superficial Surgical Dissection
Incise the extensor tendon in line with the skin incision (Fig. 49-2).
Carefully retract the divided tendon to expose the dorsal capsule of the
proximal interphalangeal joint. Note that because this capsule is very thin, it
frequently is incised when the extensor tendon is divided.
Deep Surgical Dissection
Flex the proximal interphalangeal joint to cause the proximal end of the
proximal phalanx to protrude through the incised extensor tendon (Fig. 49-
3). If a proximal interphalangeal joint fusion is to be carried out, excise the
distal end of the proximal phalanx, removing approximately 4 to 5 mm of
bone (Fig. 49-4). Apply longitudinal traction to the toe and flex the joint
again, pushing the distal end of the toe proximally and dorsally. The
proximal end of the middle phalanx with its articular surface will now be
visible through the split extensor tendon. Excise the articular surface of the
middle phalanx using sharp bone cutters (Fig. 49-5). Take care not to let the
bone cutters protrude too far in a plantar direction. The tendon of the flexor
digitorum longus is very close to the plantar capsule of the joint, running in
a groove on the plantar surface of the middle phalanx.
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Figure 49-2. Incise the extensor tendon in line with the skin incision.
Figure 49-3. Flex the proximal interphalangeal joint to cause the proximal end
of the proximal phalanx to protrude through the incised extensor tendon.
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Figure 49-4. If a proximal interphalangeal joint fusion is to be carried out,
excise the distal end of the proximal phalanx, removing approximately 4 to 5
mm of bone.
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Figure 49-5. Excise the articular surface of the middle phalanx using sharp
bone cutters.
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Dangers
The tendon of the flexor digitorum longus is in danger during excision of
the articular surface of the proximal end of the middle phalanx. Always
ensure that excision of the articular surface is carried out under direct vision
and do not use sharp bone cutters blindly.
How to Enlarge the Approach
The approach can be enlarged both proximally and distally to expose the
metatarsophalangeal joint and the distal interphalangeal joint of the digit.
Such extension is rarely required, however.
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