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Surgical Exposures in Foot & Ankle Surgery The Anatomic Approach (PDF)
Surgical Exposures in Foot & Ankle Surgery The Anatomic Approach (PDF)
Surgical Exposures in Foot & Ankle Surgery The Anatomic Approach (PDF)
Exposures in
Foot and
Ankle Surgery
The Anatomic
Approach
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Surgical
Exposures in
Foot and
Ankle Surgery
The Anatomic
Approach
Piet deBoer
Richard Buckley
Stanley Hoppenfeld
Illustrations by Hugh A. Thomas
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Dedication
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Preface
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viiiPreface
The introduction to each approach describes indications and points out the major advantages and disadvantages of the proposed approach.
The position of the patient is critical to clear exposure as well as to the comfort of the operating surgeon and the safety of the patient.
Surgical landmarks form the basis for any incision;
they are described with instructions on how to find
them. The incision follows these clear landmarks.
Because many approaches in foot and ankle surgery
are limited and carried out through small incisions,
x-ray control is often necessary to ensure precise siting of these incisions.
The surgical dissection is usually divided into
superficial and deep surgical dissection for teaching purposes to reinforce the concept that each layer must
be developed fully before the next layer is dissected.
For many approaches in foot and ankle surgery, however, this concept is not valid; exposure consists of
direct approaches to the bone, elevating tissue as a
single block to avoid problems with skin healing.
When this technique is to be employed, it is clearly
stated in the text.
The dangers of each approach are listed under four
headings: Nerves, Vessels, Muscles and Tendons, and
Special Points. The dangers are presented, along with
how to avoid them.
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Because most foot and ankle approaches are targeted at specific areas for treatment of individual
pathologies, extension of the approach is rarely
required. When such exposure is necessary, it is
described in a section entitled How to Enlarge the
Approach. There are two ways in which exposure can
be enlarged: Local measures include extending skin
incisions, repositioning retractors, detaching muscles, or even adjusting the light source; extensile measures are the ways in which an approach can be
extended to include adjacent bony structures.
Anatomic and surgical illustrations are drawn from
the surgeons point of view whenever possible, with
the patient on the operating table, so that the surgeon can see exactly how the approach should look
during the procedure.
We hope that this book will be as successful as its
parent in helping surgeons around the world, often
working in difficult and emergency situations. We
believe that this book plays an important part in the
commitment shared by both authors and readers to
improve patient care.
Piet deBoer, M.A., F.R.C.S.
Richard Buckley, M.D., F.R.C.S.C.
Stanley Hoppenfeld, M.D.
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Acknowledgments
To Hugh Thomas,
Deceased
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who has kept the rooms and cadaver material for us.
To the fellow physicians who have participated in
teaching the Anatomy course over these many years:
Uriel Adar, M.D., Russell Anderson, M.D., Mel
Adler, M.D., Martin Barschi, M.D., Robert Dennis,
M.D., Michael DiStefano, M.D., Henry Ergas,
M.D., Aziz Eshraghi, M.D., Madgi Gabriel, M.D.,
Ralph Ger, M.D., Ed Habermann, M.D., Armen
Haig, M.D., Steve Harwin, M.D., John Katonah,
M.D., Ray Koval, M.D., Luc Lapommaray, M.D.,
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x Acknowledgments
Al Larkins, M.D., Mark Lazansky, M.D., Shelly
Manspeizer, M.D., Mel Manin, M.D., David Mendes,
M.D., Basil Preefer, M.D., Leela Rangaswamy, M.D.,
Ira Rochelle, M.D., Art Sadler, M.D., Jerry Sallis,
M.D., Eli Sedlin, M.D., Lenny Seimon, M.D., Dick
Selznick, M.D., Ken Seslowe, M.D., Rashmi Sheth,
M.D., Bob Shultz, M.D., Richard Seigel, M.D.,
Norman Silver, M.D., Irvin Spira, M.D., Moe
Szporn, M.D., Richard Stern, M.D., Jacob Teladano,
M.D., Alan Weisel, M.D., and Charles Weiss, M.D.
To the residents who have participated in the
Orthopaedic Anatomy course at the Einstein, who have
been a continual course of stimulation and inspiration.
To Frank Ferrieri,
To Leon Strong,
To Muriel Chaleff,
whose great fund of anatomy and comparative anatomy was passed on to many of us while we were residents. His presence is still felt.
To Dave Murphy,
To Marie Capizzuto,
my long-term secretary and friend, for her professional help in making this book possible.
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Contents
Preface vii
Acknowledgments ix
ANKLE
1 Anterior Approach to the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Lateral Approach to the Ankle with Fibular Osteotomy
for Ankle Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3 Anterior and Posterior Approaches to the Medial Malleolus . . . . . . . . . . . . . 13
4 Approach to the Medial Side of the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
5 Posteromedial Approach to the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6 Posterolateral Approach to the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
7 Lateral Approach to the Lateral Malleolus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
8 Ankle Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
9 Anterolateral Approach to the Ankle and Hind Part of the Foot . . . . . . . . . . 51
HINDFOOT
10 Lateral Approach to the Hind Part of the Foot . . . . . . . . . . . . . . . . . . . . . . . . . 57
11 Lateral Approach to the Hindfoot (Posterior Part of Grice) . . . . . . . . . . . . . . 63
12 Lateral Approach to the Posterior Talocalcaneal Joint . . . . . . . . . . . . . . . . . . 67
13 Anterolateral Approach to the Talar Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
14 Anteromedial Approach to the Talar Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
15 Direct Lateral Approach to the Lateral Process of Talus . . . . . . . . . . . . . . . . . 83
16 Posteromedial Approach to the Posterior Process of the Talus . . . . . . . . . . . 87
17 Posterolateral Approach to the Posterior Talus . . . . . . . . . . . . . . . . . . . . . . . . . 93
18 Lateral Approach to the Calcaneus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
19 Lateral Approach for Osteotomy of the Calcaneus
(Vertical Portion of the Calcaneal Incision) . . . . . . . . . . . . . . . . . . . . . . . . . . 101
20 Posteromedial, Posterolateral, and Posterior Midline Approaches
for Excision of Calcaneal Exostosis (Haglunds Deformity) . . . . . . . . . . . . . 105
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xii Contents
21 Lateral Approach to the Os Peroneum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
22 Medial Approach to the Plantar Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
23 Hindfoot Nailing for Subtalar and Ankle Joint Fusion
(Plantar Approach) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
24 Medial Approach to the Sustentaculum Tali . . . . . . . . . . . . . . . . . . . . . . . . . 123
25 Applied Surgical Anatomy of the Approaches to the Ankle . . . . . . . . . . . . 127
26 Applied Surgical Anatomy of the Approaches to the Hind
Part of the Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
MIDFOOT
27 Midfoot: Approach to the Cuboid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
28 Approach to the Navicular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
29 Direct Medial Approach for Midfoot Collapse for Bony Planing
and Skin Ulcer Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
30 Dorsomedial Approach to Lisfrancs Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
31 Dorsolateral Approach to Lisfrancs Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
32 Dorsal Approaches for Isolated Midfoot Joints . . . . . . . . . . . . . . . . . . . . . . . 161
33 Plantar Approach for Plantar Fibromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
34 Dorsal Approaches to the Middle Part of the Foot . . . . . . . . . . . . . . . . . . . . 169
FOREFOOT
35 Dorsal Approach to the Metatarsophalangeal Joint of the Great Toe . . . . 175
36 Dorsomedial Approach to the Metatarsophalangeal Joint
of the Great Toe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
37 Dorsolateral Approach for Bunion Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 183
38 Dorsomedial Approach to the First Metatarsal . . . . . . . . . . . . . . . . . . . . . . . 187
39 Medial Approach to the First Metatarsal Bone for Excision
of the Medial Sesamoid Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
40 Plantar Approach to the Lateral Sesamoid Bone . . . . . . . . . . . . . . . . . . . . . 195
41 Dorsal Approach to the Fifth Metatarsal Head for Bunionette . . . . . . . . . . . . . 199
42 Lateral Approach to the Fifth Metatarsal Head for Bunionette . . . . . . . . . . . . . 203
43 Lateral Approach to the Base of the Fifth Metatarsal . . . . . . . . . . . . . . . . . . 207
44 Dorsal Approach to the Second to Fifth Metatarsal Bones . . . . . . . . . . . . . 211
45 Dorsal Approach to the Metatarsophalangeal Joints of the
Second, Third, Fourth, and Fifth Toes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
46 Dorsal Approach for Mortons Neuroma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
47 Plantar Approach for Recurrent Mortons Neuroma . . . . . . . . . . . . . . . . . . . 223
TOES
48 Dorsolateral Approach to the Flexor Sheathes of the Second to
Fifth Toes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
49 Transverse Approach for Surgery to a Hammer Toe . . . . . . . . . . . . . . . . . . . 231
50 Longitudinal Approach to the Proximal Interphalangeal Joint of the
Second to Fifth Toes for Hammer Toe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
51 Approach for Nail Bed Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Index 247
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One
Anterior Approach
to the Ankle
Position of the Patient 2
Landmarks and Incision 2
Landmarks 2
Incision 2
Dangers 5
Nerves 5
How to Enlarge the Approach 5
Extensile Measures 5
Internervous Plane 2
Superficial Surgical Dissection 4
Deep Surgical Dissection 4
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Incision
Make a 15-cm longitudinal incision over the anterior
aspect of the ankle joint. Begin about 10 cm proximal
to the joint, and extend the incision so that it crosses
the joint about midway between the malleoli, ending
on the dorsum of the foot. Take great care to cut only
the skin; the anterior neurovascular bundle and
branches of the superficial peroneal nerve cross the
ankle joint very close to the line of the skin incision
(Fig. 1-2A). Alternatively, make a 15-cm longitudinal
incision with its center overlying the anterior aspect
of the medial malleolus (see Fig. 1-2).
Place the patient supine on the operating table. Partially exsanguinate the foot either by elevating it for 3
to 5 minutes or by applying a soft rubber bandage
loosely to the foot and binding it firmly to the calf.
Then, inflate a thigh tourniquet. Partial exsanguination allows the neurovascular bundle to be identified,
because the venous structures will appear blue. Some
continuous vascular oozing must be expected, however (Fig. 1-1).
Internervous Plane
Landmarks
The medial malleolus is the bulbous, subcutaneous,
distal end of the medial surface of the tibia.
The lateral malleolus is the subcutaneous distal end
of the fibula.
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Medial
malleolus
Lateral
malleolus
Superficial
peroneal
nerve
Incise
retinaculum
Extensor
digitorum longus
Extensor
hallucis longus
Extensor
retinaculum
C
Figure 1-2 A: Make a longitudinal incision over the anterior aspect of the ankle joint.
B: Identify and protect the superficial peroneal nerve. Incise the extensor retinaculum
in line with the skin incision. C: Identify the plane between the extensor hallucis lon-
gus and the extensor digitorum longus, and note the neurovascular bundle between
them.
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Extensor
hallucis longus
neurovascular bundle adheres to the underlying tissues and requires mobilization (Fig. 1-3A).
Alternatively, in pilon fractures, incise the deep
fascia to the medial side of the tibialis anterior tendon
(Fig. 1-4), and expose the underlying surface of the
tibia together with the anteromedial ankle joint
capsule.
Extensor
digitorum longus
Extensor
hallucis longus
Extensor
digitorum longus
Extensor
retinaculum
Distal tibia
Joint capsule
of ankle
Dome of talus
Distal tibia
Dome of talus
Neurovascular
bundle
Joint capsule
of ankle
Extensor
retinaculum
Figure 1-3 A: Retract the tendon of the extensor hallucis longus medially with the
neurovascular bundle. Retract the tendon of the extensor digitorum longus laterally.
Incise the joint capsule longitudinally. B: Retract the joint capsule to expose the ankle
joint.
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Extensor
retinaculum
Tibialis
anterior
Tibialis anterior
under extensor
retinaculum
Distal tibia
Joint capsule
of ankle
Figure 1-4 A: Alternately, incise the extensor retinaculum on the medial side of the
tibialis anterior tendon. B: Retract the tibialis anterior laterally to expose the anterior
surface of the ankle joint.
don of the extensor hallucis longus crosses the bundle. The plane between the tibialis anterior and the
extensor hallucis longus can be used as long as the
neurovascular bundle is identified and mobilized so
as to preserve it (see Fig. 25-6).
Dangers
Nerves
Cutaneous branches of the superficial peroneal nerve
run close to the line of the skin incision just under the
skin. Take care not to cut them during incision of the
skin (see Fig. 1-2A).
The deep peroneal nerve and anterior tibial artery
(the anterior neurovascular bundle) must be identified and preserved during superficial surgical dissection. They are in greatest danger during the skin incision, because they are superficial and run close to the
incision itself (see Figs. 25-5 and 25-6).
Above the ankle joint, the neurovascular bundle
lies between the tendons of the extensor hallucis longus and tibialis anterior muscles at the joint; the ten-
Extensile Measures
Although this approach does not descend through an
internervous plane, on occasion it can be extended
proximally to expose the structures in the anterior
compartment. To expose the proximal tibia, use the
plane between the tibia and the tibialis anterior muscle (see Fig. 1-4). Distal extension to the dorsum of
the foot is possible, but rarely, if ever, required (see
Fig. 25-6).
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REFERENCE
1. Colonna PC, Ralston EL. Operative approaches to the
ankle joint. Am J Surg. 1951;82:44.
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Two
Lateral Approach
to the Ankle with
Fibular Osteotomy
for Ankle Fusion
Position of the Patient 8
Landmarks and Incision 8
Internervous Plane 8
Superficial Surgical Dissection 8
Deep Surgical Dissection 9
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Dangers 9
Nerves 9
Vessels 11
How to Enlarge the Approach 11
Extensile Measures 11
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approach provides access to about 90% of the articular surface of the ankle joint, facilitating the excision of the articular cartilage of the joint needed to
perform a successful fusion.
San
Internervous Plane
There is no internervous plane; the dissection is performed down to a subcutaneous bone.
db
ag
Figure 2-1 Position of the patient for exposure of the lateral malleolus.
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Chapter 2 Lateral Approach to the Ankle with Fibular Osteotomy for Ankle Fusion
Figure 2-2 Make a 10-cm longitudinal incision along the anterior margin of the
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Dangers
Nerves
The sural nerve is vulnerable at the distal end of
the approach if the skin flaps are mobilized too far
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Posterior
inferior
tibiofibular
ligament
Tibia
Distal fibula
rotated out
of talar articulation
Divided
interosseous
ligament
Posterior
talofibular
ligament
Lateral articular
surface of talus
Articular
surface of
lateral malleolus
Calcaneofibular
ligament
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Chapter 2 Lateral Approach to the Ankle with Fibular Osteotomy for Ankle Fusion
11
Dome of talus
exposed with
plantarflexion
of ankle
Ankle Plantarflexed
Vessels
Occasionally, the terminal branches of the peroneal
artery lie immediately deep to the medial surface of
the distal fibula. They can be damaged if dissection is
extensive. The damage may not be noticed until the
tourniquet is released and a hematoma forms. That is
why is best to deflate the tourniquet before closure
and ensure hemostasis.
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Three
Anterior and Posterior
Approaches to
the Medial Malleolus
Position of the Patient 14
Incisions 14
Internervous Plane 14
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Incisions
Two skin incisions are available.
1. The anterior incision offers an excellent view of
medial malleolar fractures. It also permits inspection of the anteromedial ankle joint and the
anteromedial part of the dome of the talus.
Make a 10-cm longitudinal curved incision on
the medial aspect of the ankle, with its midpoint
just anterior to the tip of the medial malleolus.
Begin proximally, 5 cm above the malleolus and
Internervous Plane
No true internervous plane exists in this approach,
but the approach is safe because the incision cuts
down onto subcutaneous bone.
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15
Long saphenous
vein and
saphenous nerve
Anterior aspect of
medial malleolus
Figure 3-2 Keep the incision just anterior to the tip of the medial malleolus.
Anterior Incision
Gently mobilize the skin flaps, taking care to identify
and preserve the long saphenous vein, which lies just
anterior to the medial malleolus. Accurately locating
the skin incision will make it unnecessary to mobilize
the skin flaps extensively. Next to the vein runs the
saphenous nerve, two branches of which are bound to
the vein. Take care not to damage the nerve; damage
leads to the formation of a neuroma. Because the
nerve is small and not easily identified, the best way
to preserve it is to preserve the long saphenous vein,
a structure that on its own is of little functional significance (Fig. 3-3).
Posterior Incision
Mobilize the skin flaps. The saphenous nerve is not
in danger (see Fig. 3-7).
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Anterior Incision
Incise the remaining coverings of the medial malleolus
longitudinally to expose the fracture site. Make a small
incision in the anterior capsule of the ankle joint so
that the joint surfaces can be seen after the fracture is
reduced (Fig. 3-4). This is especially important in vertical fractures of the medial malleolus where impaction
at the joint surface frequently occurs. The superficial
fibers of the deltoid ligament run anteriorly and distally downward from the medial malleolus; split them
so that wires or screws used in internal fixation can be
anchored solidly on bone, with the heads of the screws
covered by soft tissue (Fig. 3-5; see Fig. 25-3).
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Extensor
retinaculum
Long saphenous
vein and saphenous
nerve
Extensor retinaculum
and joint capsule
Deltoid ligament
Medial articular
surface of talus
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17
Anterior aspect of
medial malleolus
Deltoid ligament
(partially detached)
Medial articular
surface of talus
Posterior Incision
Incise the retinaculum behind the medial malleolus
longitudinally so that it can be repaired (Figs. 3-6 and
3-7). Take care not to cut the tendon of the tibialis
posterior muscle, which runs immediately behind the
medial malleolus; the incision into the retinaculum
permits anterior retraction of the tibialis posterior
tendon. Continue the dissection around the back of
the malleolus, retracting the other structures that
pass behind the medial malleolus posteriorly to
reach the posterior margin (or posterior malleolus) of
the tibia. The exposure allows reduction in some
fractures of that part of the bone.
Note that, although this approach will allow visualization of most fractures using appropriate reduction forceps, the angle of the approach is such that
the displaced fragments cannot be fixed internally
from this approach. Separate anterior approaches are
required to lag any posterior fragments back. It
always is advisable to obtain an intraoperative radiograph showing the displaced fragment fixed temporarily with a K-wire before definitive fixation is
inserted. Reduction in these fragments is difficult
because of limited exposure, and inaccurate reduc-
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Medial
malleolus
Fascia over
tibialis posterior
Fascia over flexor
digitorum longus
Tendon of tibialis
posterior
Incision in flexor
retinaculum
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19
Septum between
tibialis posterior and
flexor digitorum
Flexor retinaculum
(detached)
Tibialis
posterior
Posterior aspect of
medial malleolus
and distal tibia
Figure 3-8 Anteriorly retract the tibialis posterior. Free up and retract the remaining
structures around the back of the malleolus posteriorly to expose the posterior aspect
of the medial malleolus.
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tibia. Subperiosteal dissection exposes the subcutaneous and lateral surfaces of the tibia along its entire
length.
The exposure can be extended distally to expose
the deltoid ligaments and the talocalcaneonavicular
joint.
Reference
1. Gatellier J, Chastang. Access to the fractured malleolus
with piece chipped off at back. J Chir (Paris). 1924;
24:5B.
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Four
Approach to the
Medial Side of
the Ankle
Position of the Patient 22
Dangers 23
Internervous Plane 22
Superficial Surgical Dissection 23
Deep Surgical Dissection 23
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Incision
Make a 10-cm longitudinal incision on the medial
aspect of the ankle joint, centering it on the tip of the
medial malleolus. Begin the incision over the medial
surface of the tibia. Below the malleolus, curve it forward onto the medial side of the middle part of the
foot (Fig. 4-1).
Internervous Plane
Landmark
The medial malleolus is the palpable distal end of the
tibia.
The approach uses no internervous plane. Nevertheless, the surgery is safe because the tibia is subcutaneous and all dissection stays on bone.
Medial malleolus
First cuneiform
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23
Incision in flexor
retinaculum over
tibialis posterior
Incision in
anteromedial
ankle joint
capsule
Laciniate ligament
Tibialis posterior
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Dangers
The saphenous nerve and the long saphenous vein
should be preserved as a unit, largely to prevent damage to the saphenous nerve and subsequent neuroma
formation.
The tendon of the tibialis posterior muscle is in particular danger during this approach, because it lies
immediately posterior to the medial malleolus. Preserve the tendon by releasing and retracting it while
performing osteotomy of the malleolus (see Figs. 4-2
and 4-3A). The tendons of the flexor hallucis longus
and flexor digitorum longus muscle, together with the
posterior neurovascular bundle, lie more posteriorly
3/15/12 7:28 PM
Tibia
Tibialis
posterior
Score lines
along site
of osteotomy
Site of
osteotomy
Drill hole
Head of talus
B
Figure 4-3 A: Retract the tibialis tendon posteriorly. Drill and tap the medial malleolus, and score the potential osteotomy site for future alignment. B: The line of the
osteotomy and the score marks for the reattachment of the medial malleolus.
Distal tibia
Medial articular
surface of talus
Anteromedial
joint capsule
Deltoid ligament
Osteotomized
medial malleolus
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25
Dome of talus
Figure 4-5 Forcefully evert the foot to bring the dome of the talus and the anterior
LWBK1066-C04-p21-26.indd 25
REFERENCE
1. Koenig F, Schaefer P. Osteoplastic surgical exposure of the
ankle joint: 41st report of progress in orthopaedic surgery.
Chir. 1929;215:196.
3/15/12 7:28 PM
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Five
Posteromedial
Approach to
the Ankle
Position of the Patient 28
Dangers 32
LWBK1066-C05-p27-32.indd 27
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Figure 5-1 Place the patient supine on the operating table with the knee and the hip
LWBK1066-C05-p27-32.indd 28
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29
Achilles tendon
Incision
Make an 8- to 10-cm longitudinal incision roughly
midway between the medial malleolus and the
Achilles tendon (Fig. 5-2).
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Deep fascia
Deep fascia
Fascia over
deep flexor
compartment
Tibial nerve
Muscle fibers of
flexor hallucis
longus
Fibrous pulley
over flexor
hallucis longus
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31
Tibialis posterior
Tibialis anterior
Dome of talus
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Dangers
The posterior tibial artery and the tibial nerve (the
posterior neurovascular bundle) are vulnerable during the approach. Take care not to apply forceful
retraction to the nerve, as this may lead to a neurapraxia. Note that the tibial nerve is surprisingly large
LWBK1066-C05-p27-32.indd 32
REFERENCE
1. Ruedi TP, Murphy WM. AO principles of fracture management. Thieme. 2001.
3/15/12 7:29 PM
Six
Posterolateral
Approach to the Ankle
Position of the Patient 34
Dangers 36
Internervous Plane 34
Superficial Surgical Dissection 34
Deep Surgical Dissection 36
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The posterolateral approach is used to treat conditions of the posterior aspect of the distal tibia
and ankle joint. It is well suited for open reduction
and internal fixation of posterior malleolar fractures. Because the patient is prone, however, it is
not the approach of choice if the fibula and medial
malleolus have to be fixed at the same time. In
such cases, it is better to use either a posteromedial approach or a lateral approach to the fibula,
and to approach the posterolateral corner of the
tibia through the site of the fractured fibula.
Neither of these approaches provides such good
visualization of the bone as does the posterolateral
approach to the ankle, but both allow other surgical procedures to be carried out without changing
the position of the patient on the table halfway
through the operation. Its other uses include the
following:
1. Excision of sequestra
2. Removal of benign tumors
3. Arthrodesis of the posterior facet of the subtalar
joint
4. Posterior capsulotomy and syndesmotomy of the
ankle
5. Elongation of tendons
Internervous Plane
The internervous plane lies between the peroneus
brevis muscle (which is supplied by the superficial
peroneal nerve) and the flexor hallucis longus muscle
(which is supplied by the tibial nerve; Fig. 6-3).
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35
Lateral malleolus
Tendon of Achilles
Peroneus brevis
(superficial peroneal nerve)
Flexor hallucis longus
(tibial nerve)
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Muscle fibers of
flexor hallucis longus
Peroneus brevis
muscle fibers
Peroneus longus
tendon
Superior peroneal
retinaculum
(incised)
Figure 6-4 Mobilize the skin flaps. Incise the deep fas-
cia of the leg in line with the skin incision. Identify the
two peroneal tendons as they pass around the ankle.
whereas the peroneus longus is tendinous in the distal third of the leg (see Figs. 26-1 and 26-2).
Incise the peroneal retinaculum to release the tendons, and retract the muscles laterally and anteriorly
to expose the flexor hallucis longus muscle (Fig. 6-5).
The flexor hallucis longus is the most lateral of the
deep flexor muscles of the calf. It is the only one that
is still muscular at this level (see Fig. 26-2).
LWBK1066-C06-p33-38.indd 36
Dangers
The short saphenous vein and the sural nerve run close
together. They should be preserved as a unit, largely
to prevent the formation of a painful neuroma (see
Fig. 26-1).
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37
Fascia of peroneal
compartment over
peronei
Muscle fibers of
flexor hallucis longus
Flexor hallucis
longus (detached)
Incise muscle
along origin
Posterior tibia
(incise periosteum)
Posterior inferior
tibiofibular ligament
Transverse tibiofibular
ligament
Superior peroneal
retinaculum
(incised)
Posterior joint
capsule of ankle
Posterior talofibular
ligament
Reference
1. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics:
The Anatomic Approach. 4th ed. Philadelphia: Lippincott
Williams & Wilkins; 2004:601607.
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Seven
Lateral Approach
to the Lateral
Malleolus
Position of the Patient 40
Landmarks and Incision 40
Landmarks 40
Incision 40
Internervous Plane 40
Superficial Surgical Dissection 42
Deep Surgical Dissection 42
LWBK1066-C07-p39-44.indd 39
Dangers 42
Nerves 42
Vessels 42
How to Enlarge the Approach 42
Extensile Measures 42
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The approach to the lateral malleolus is used primarily for open reduction and internal fixation of
San
Incision
Make a 10- to 15-cm longitudinal incision along the
posterior margin of the fibula all the way to its distal
end and continuing for a further 2 cm (Fig. 7-3A). In
fracture surgery, center the incision at the level of the
fracture.
Internervous Plane
There is no internervous plane, because the dissection is being performed down to a subcutaneous
bone. For higher fractures of the fibula, the internervous plane lies between the peroneus tertius muscle
(which is supplied by the deep peroneal nerve) and
the peroneus brevis muscle (which is supplied by the
superficial peroneal nerve).1
db
ag
Figure 7-1 Position of the patient for exposure of the lateral malleolus.
LWBK1066-C07-p39-44.indd 40
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41
Figure 7-2 An alternate position for exposure of the lateral malleolus. Place the patient
prone or on his or her side, with a sandbag under the pelvis of the affected side.
Lateral
malleolus
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Fascia
over
peronei
Fascia over
peroneus
tertius
Periosteum
Incise
periosteum
Lateral
malleolus
Sheath over
peronei
C
Figure 7-3 (Continued) B: Incise the periosteum on the subcutaneous surface of the
fibula longitudinally. C: Expose the distal fibula subperiosteally.
Dangers
Nerves
The sural nerve is vulnerable when the skin flaps are
mobilized. Cutting it may lead to the formation of a
painful neuroma and numbness along the lateral skin
of the foot, which, although it does not bear weight,
does come in contact with the shoe. The nerve also is
valuable as a nerve graft. Preserve it if possible (see
Fig. 25-8).
LWBK1066-C07-p39-44.indd 42
Vessels
The terminal branches of the peroneal artery lie
immediately deep to the medial surface of the distal
fibula. They can be damaged if dissection is extensive.
The damage may not be noticed during surgery
because of the tourniquet, but a hematoma may form
after the tourniquet is taken off. That is why it is best
to deflate the tourniquet before closure to ensure
hemostasis; then, the wound can be drained with a
suction drain (see Fig. 26-1).
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LWBK1066-C07-p39-44.indd 43
43
Reference
1. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics:
The Anatomic Approach. 4th ed. Philadelphia: Lippincott
Williams & Wilkins; 2004:607611.
14/03/12 12:49 PM
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Eight
Ankle Arthroscopy
Position of the Patient 46
Incision and Landmarks 46
Dangers 49
Nerves 49
Vessels 49
Surgical Dissection 48
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Ankle arthroscopy has become much more popular in the last 10 years. The development of
noninvasive distractors and smaller arthroscopes
has greatly increased the indications and scope
for ankle arthroscopy. The technique was originally used only for diagnostic purposes and
removal of loose bodies. More recently, a variety
of arthroscopic surgical procedures have become
possible. This chapter will describe only the
two most commonly used arthroscopic portals:
anteromedial and anterolateral. Surgeons wishing to carry out more complex procedures should
refer to the original journal articles describing
them.
Indications include the following:
1. Removal of loose bodies or osteochondral fragments
2. Synovectomy
3. Removal of soft tissue and osteophytes in case of
impingement syndrome
4. Treatment of osteochondritis dissecans
5. Microfracture
Place the patient supine on the operating table. Palpate the anterior neurovascular bundle as it runs
across the anterior aspect of the ankle joint, just lateral to the tendon of the extensor hallucis longus, and
mark its position on the skin. Exsanguinate the limb
using a soft rubber bandage, then inflate a mid-thigh
tourniquet.
Apply a noninvasive distractor to the dorsum of
the foot. Distractors usually consist of a calcaneal
component and a dorsal containment strap. If possible, ensure that the calcaneal strap of the distractor is placed so that the foot is elevated. This ensures
that you will be able to get access to the posterolateral aspect of the ankle if required during the
procedure (Fig. 8-1). Drop the foot of the table
30 degrees to aid access to the anterior aspect of the
ankle joint.
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47
Figure 8-1 Apply a noninvasive distractor to the dorsum of the foot. Distractors usu-
LWBK1066-C08-p45-50.indd 47
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Anteromedial
port
Trochar
Fibular
articular
surface
Talar
dome
Anterior
tibiofibular
ligament
Anterior tibiotalar
joint
Arthroscope
Lateral
gutter
Anterior
talofibular
ligament
Deep
deltoid
ligament
Medial
gutter
Anterior
talar
sulcus
Figure 8-2 Carefully dissect down to the ankle joint capsule using blunt dissection
with a pair of mosquito forceps. Although the saphenous nerve should be well medial
to this approach, its position is variable; using this technique will allow you to
identify the nerve and preserve it if it is in an abnormal position.
Surgical Dissection
Carefully dissect down to the ankle joint capsule
using blunt dissection with a pair of mosquito forceps. Although the saphenous nerve should be well
medial to this approach, its position is variable; using
this technique will allow you to identify the nerve and
preserve it if it is in an abnormal position (Fig. 8-2).
Dorsiflex the foot to place it in the neutral position. This will bring the talar dome away from the
distal tibia and open up the anterior aspect of the
joint. Enter the ankle joint using a trocar. Ensure that
the trocar is angled laterally by approximately 60
degrees. Insert the arthroscope. Working from
medial to lateral, identify the following structures
(see Figs. 8-2 and 8-3).
1. Deep deltoid ligament
2. Medial gutter
3. Anterior tibiotalar joint
4. Anterior talar sulcus
5. Anterior talofibular ligament
6. Anterior tibiofibular ligament
7. Lateral gutter
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49
Scope in
anterolateral
port
Dangers
Nerves
The superficial peroneal nerve crosses the anterior
aspect of the ankle joint, just medial to the anterior
aspect of the lateral malleolus. Its course is variable
and it frequently divides into terminal branches above
the ankle joint. Because of its variable position, sharp
dissection of the anterolateral portal is not recommended (see Fig. 25-5).
The deep peroneal nerve, which supplies skin in the
first interspace, runs down the anterior aspect of the
ankle joint together with the anterior tibial artery.
The anterior tibial artery becomes the dorsalis pedis
artery on the dorsal aspect of the foot. To avoid damage to this neurovascular structure, identify it by palpation prior to inflation of the tourniquet and mark
its position on the skin (see Fig. 25-5).
LWBK1066-C08-p45-50.indd 49
Vessels
The anterior tibial artery runs on the anterior aspect
of the ankle joint. It crosses the ankle roughly in the
midline and is easily palpable prior to inflation of
the tourniquet (see Fig. 25-5). This structure should
not be at any risk during the creation of the anteromedial, anterolateral, and posterolateral portals, but
it is potentially at risk if accessory anterior portals
are used, for example, in the treatment of anterior
osteophytes.
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Nine
Anterolateral Approach
to the Ankle and
Hind Part of the Foot
Position of the Patient 52
Landmarks and Incision 52
Landmarks 52
Incision 52
Internervous Plane 52
Superficial Surgical Dissection 52
Deep Surgical Dissection 52
Dangers 52
How to Enlarge the Approach 52
Extensile Measures 52
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Internervous Plane
The internervous plane lies between the peroneal muscles (which are supplied by the superficial peroneal
nerve) and the extensor muscles (which are supplied by
the deep peroneal nerve; see Figs. 25-5 and 25-8).
LWBK1066-C09-p51-56.indd 52
Dangers
The deep peroneal nerve and anterior tibial artery cross
the front of the ankle joint. They are vulnerable if
dissection is not carried out as close to the bone as
possible (see Fig. 25-5).
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Chapter 9 Anterolateral Approach to the Ankle and Hind Part of the Foot
53
Distal tibia
Lateral
malleolus
Styloid process of
fifth metatarsal
Figure 9-1 Incision for the anterolateral approach to the ankle. Make a 15-cm slightly
curved incision on the anterolateral aspect of the ankle. Begin approximately 5 cm proximal to the ankle joint and 2 cm anterior to the anterior border of the fibula. Curve the
incision downward to cross the ankle joint 2 cm medial to the tip of the lateral malleolus, and continue onto the foot, ending about 2 cm medial to the fifth metatarsal.
LWBK1066-C09-p51-56.indd 53
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Superior extensor
retinaculum
Inferior extensor
retinaculum
Superficial
peroneal nerve
Extensor
retinaculum
Anterior inferior
tibiofibular
ligament
Tendons of extensor
digitorum longus
Sinus tarsi
fat pad
Tendon of
peroneus tertius
LWBK1066-C09-p51-56.indd 54
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Distal tibia
Interosseous
membrane
Extensor
retinaculum
Distal fibula
Anterior inferior
tibiofibular
ligament
Joint capsule
of ankle
Anterior talofibular
ligament
Extensor digitorum
brevis
Extensor
retinaculum
Distal tibia
Interosseous
membrane
Anterior inferior
tibiofibular ligament
Dome of talus
Lateral malleolus
Anterior
talofibular ligament
Cervical ligament
Posterior
talocalcaneal
joint
LWBK1066-C09-p51-56.indd 55
Talonavicular
joint
Sinus tarsi
fat pad
Calcaneocuboid
joint
Extensor digitorum
brevis
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Ten
Lateral Approach to
the Hind Part of
the Foot
Position of the Patient 58
Landmarks and Incision 59
Landmarks 59
Incision 59
Internervous Plane 59
Superficial Surgical Dissection 59
Deep Surgical Dissection 59
LWBK1066-C10-p57-62.indd 57
Dangers 59
Skin Flaps 59
How to Enlarge the Approach 59
Local Measures 59
Extensile Measures 62
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of the ankle and hind part of the foot forward. Further increase internal rotation by tilting the table
away from you. Exsanguinate the limb either by elevating it for 5 minutes or by applying a soft rubber
bandage, and then inflate a tourniquet (see Fig. 7-1).
Lateral
malleolus
Neck of talus
Navicular
Lateral
calcaneus
Figure 10-1 Make a curved incision starting just distal to the distal end of the lateral
malleolus and slightly posterior to it. Continue distally along the lateral side of the
hind part of the foot and over the sinus tarsi. Then, curve the incision medially
toward the talocalcaneonavicular joint.
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59
Extensor
retinaculum
Incision
Make a curved incision starting just distal to the distal
end of the lateral malleolus and slightly posterior to
it. Continue distally along the lateral side of the hind
part of the foot and over the sinus tarsi. Then, curve
medially, ending over the talocalcaneonavicular joint
(Fig. 10-1).
Internervous Plane
The internervous plane lies between the peroneus tertius tendon (which is supplied by the deep peroneal
nerve) and the peroneal tendons (which are supplied by
the superficial peroneal nerve).
LWBK1066-C10-p57-62.indd 59
Dangers
Skin Flaps
Exposures in this area are notorious for producing
necrosis of skin flaps. Therefore, skin flaps should be
cut as thickly as possible, stripping and retraction
should be kept to a minimum, and sharp curves in the
skin incision should be avoided.
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Tendons of extensor
digitorum longus
Extensor
retinaculum
Peronei
Peroneus
tertius
Extensor
retinaculum
Sinus tarsi
fat pad
Peronei
Extensor digitorum
brevis
tendons medially.
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61
Anterior talofibular
ligament
Sinus tarsi
fat pad
Cervical ligament
Bifurcate ligament
Peronei
Joint capsule of
calcaneocuboid joint
Anterior talofibular
ligament
Sinus tarsi
fat pad
Talonavicular
joint
Posterior
talocalcaneal
joint
Peronei
Cuboid navicular
joint
Calcaneocuboid
joint
Extensor digitorum
brevis
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Peroneal tendons
Posterior
talocalcaneal
joint
Inferior peroneal
retinaculum
Extensile Measures
To enlarge the approach proximally, continue the
incision, curving it along the posterior border of the
fibula. By developing a plane between the peroneal
muscles and the flexor muscles, the entire length of
the fibula can be exposed.1 In practice, however, this
extension is required rarely, if ever.
LWBK1066-C10-p57-62.indd 62
Reference
1. Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics:
The Anatomic Approach. 4th ed. Philadelphia: Lippincott
Williams & Wilkins; 2004:607611.
14/03/12 12:53 PM
Eleven
Lateral Approach
to the Hindfoot
(Posterior Part
of Grice)
Position of the Patient 64
Landmarks and Incision 64
Internervous Plane 64
Superficial Surgical Dissection 64
Deep Surgical Dissection 64
LWBK1066-C11-p63-66.indd 63
Dangers 66
Skin Flaps 66
Nerve 66
How to Enlarge the Approach 66
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Internervous Plane
There is no true internervous plane with this
approach. It is a direct approach in line with the peroneal tendons. These muscles receive their nerve
supply well proximal to the surgical field.
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65
Lateral
malleolus
Lateral
process
of talus
Peroneus
brevis
Peroneus
longus
Incision centered
over peroneal
tubercle
Cuboid
Styloid
process
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Peroneal
retinaculum
Peroneus
longus &
brevis
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Retinaculum
divided and
retracted
lum and the soft tissues lying over the peroneal tubercle to
expose the bone.
Dangers
Skin Flaps
Exposures in this area are notorious for producing
necrosis. Therefore, skin flaps should be cut as thickly
as possible and be full thickness in nature. Stripping
and retraction should be kept to a minimum, and
sharp curves in the skin incision should be avoided. It
is better to create a longer incision than to apply hard
retraction to the edges of a small one.
Nerve
The sural nerve runs distally downward almost
directly in line with the skin incision. It is variable in
its course. By dissecting carefully, it can be seen and
should be protected. Even small branches should be
preserved, as sural-nerve neuromas are painful if the
nerve is injured during this approach.
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Twelve
Lateral Approach
to the Posterior
Talocalcaneal Joint
Position of the Patient 68
Landmarks and Incision 68
Landmarks 68
Incision 69
Dangers 71
Nerves 71
How to Enlarge the Approach 71
Local Measures 71
Internervous Plane 69
Superficial Surgical Dissection 69
Deep Surgical Dissection 69
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Landmarks
The lateral malleolus is the subcutaneous distal end of
the fibula. The peroneal tubercle is a small protuberance of bone on the lateral surface of the calcaneus
that separates the tendons of the peroneus longus and
brevis muscles. It lies distal and anterior to the lateral
malleolus.
Small (short)
saphenous vein
Sural nerve
Lateral malleolus
Peroneal
tubercle
Figure 12-1 Make a curved incision 10 to 13 cm long on the lateral aspect of the ankle.
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Incision
Make a curved incision 10 to 13 cm long on the lateral
aspect of the ankle. Begin some 4 cm above the tip of
the lateral malleolus on the posterior border of the fibula. Follow the posterior border of the fibula down to
the tip of the lateral malleolus, and then curve the incision forward, passing over the peroneal tubercle parallel to the course of the peroneal tendons (Fig. 12-1).
Internervous Plane
No internervous plane exists in this approach. The
peroneus muscles, whose tendons are mobilized and
retracted anteriorly, share a nerve supply from the
superficial peroneal nerve. The approach is safe
because the muscles receive their supply at a point
well proximal to it.
69
malleolus. The peroneus brevis tendon, which is closest to the lateral malleolus, is muscular almost down
to the level of the malleolus itself (see Fig. 25-8).
Continue incising the deep fascia, following the
tendons. The peroneus brevis is covered by the inferior peroneal retinaculum distal to the tip of the fibula. Incise it in line with the tendon (Fig. 12-2). The
peroneus longus is covered by a separate fibrous
sheath of its own; incise that sheath in line with the
tendon as well. These ligaments of the retinaculum
must be repaired during closure to prevent tendon
dislocation (Fig. 12-3). When both peroneal tendons
have been mobilized, retract them anteriorly over
the distal end of the fibula (Fig. 12-4).
Superior peroneal
retinaculum
Lateral malleolus
Sheath over
peroneus brevis
Inferior peroneal
retinaculum
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Sheath over
peroneus longus
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Peroneus
longus
Lateral
malleolus
Incise posterio
talocalcaneal
joint capsule
Peroneus
brevis
Peroneal
tubercle
Calcaneofibular
ligament
Posterior
talocalcaneal
joint
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Dangers
Nerves
The sural nerve is vulnerable when the skin flaps are
mobilized. Cutting it may lead to the formation of a
painful neuroma and numbness along the lateral skin
of the foot, which, although it does not bear weight,
does come in contact with the shoe. The nerve also is
valuable as a nerve graft.
71
it inferiorly by sharp dissection. To see the talus better, cut the calcaneofibular ligament and the capsule
of the talocalcaneal joint superiorly to uncover its
lateral border.
Exposure of the articular surfaces of the joint can
be achieved only by inverting the foot. Forcible
inversion does not open up the joint if the anterior
part of the talocalcaneal (talocalcaneonavicular) joint
remains intact.
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Thirteen
Anterolateral
Approach to the
Talar Neck
Position of the Patient 74
Dangers 76
Internervous Plane 74
Superficial Surgical Dissection 75
Deep Surgical Dissection 75
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Internervous Plane
Superficial
branch of
peroneal
nerve
Incision
Styloid
process
Fourth
ray
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75
Superior
extensor
retinaculum
Inferior
extensor
retinaculum
Fascia over
extensor tendons
Anterior
inferior
tibiofibular
ligament
Extensor
digitorum
longus
Anterior
talofibular
ligament
Fat pad
in sinus
tarsi
LWBK1066-C13-p73-78.indd 75
Figure 13-3 Identify the extensor digitorum longus tendons and retract them
medially.
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Anterior inferior
tibiofibular ligament
Anterior
joint capsule
Dome of talus
Talar neck
Anterior
talofibular
ligament
Cervical
ligament
Dangers
The deep peroneal nerve and anterior tibial artery
cross the front of the ankle joint, medial to the
LWBK1066-C13-p73-78.indd 76
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77
Talar neck
and dome
rotated into
better view
Invert
Plantarflex
Figure 13-5 Forceful inversion and plantar flexion of the foot improves visualization
of the talus.
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LWBK1066-C13-p73-78.indd 78
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Fourteen
Anteromedial
Approach to
the Talar Neck
Position of the Patient 80
Landmarks and Incision 80
Internervous Plane 80
Superficial Surgical Dissection 81
Deep Surgical Dissection 81
LWBK1066-C14-p79-82.indd 79
Dangers 81
Nerves 81
Vessels 81
How to Enlarge the Approach 81
Extensile Measures 81
Special Surgical Points 82
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lateral approach to the talar neck to accurately visualize talar neck fractures. It is generally thought that
two incisions are the best approach to deal with this
difficult clinical scenario. The two approaches together
provide excellent visualization of talar neck fractures
for their reduction and fixation.
Internervous Plane
No internervous plane is used. The approach is safe
because the incision cuts down onto bone, which is
subcutaneous both proximally and distally.
Medial
malleolus
Tibialis
anterior
Anteromedial
talar dome
Extensor
retinaculum
Incision
Anteromedial
navicular
LWBK1066-C14-p79-82.indd 80
Deltoid
ligament over
medial talar
neck
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81
Extensor
retinaculum
Deltoid
ligament
Incision
Figure 14-2 Visualize the extensor retinaculum and incise it in the line of the skin
incision.
LWBK1066-C14-p79-82.indd 81
Dangers
Nerves
The saphenous nerve runs with the saphenous vein
and is close to the medial edge of the approach. If cut
it may form a neuroma, causing numbness on the
medial side of the dorsum of the foot. Preserve the
nerve by identifying and preserving the long saphenous vein.
Vessels
The long saphenous vein that runs just anterior to
the medial malleolus is at risk and should be protected.
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Deltoid
ligament
retracted
Medial talar
neck
Talonavicular
joint
Figure 14-3 Extend the capsular incision distally to expose the talar neck and the
LWBK1066-C14-p79-82.indd 82
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Fifteen
Direct Lateral
Approach to the
Lateral Process
of Talus
Position of the Patient 84
Landmarks and Incision 84
Internervous Plane 84
Superficial Surgical Dissection 84
Deep Surgical Dissection 84
LWBK1066-C15-p83-86.indd 83
Dangers 84
Nerves 84
How to Enlarge the Approach 84
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window, it is mainly used for fixation of lateral process fractures or debridement of this part of the
talocalcaneal joint.
Internervous Plane
There is no internervous plane for this approach.
The peroneal muscles, whose tendons are retracted
plantarward, share a nerve supply from the superficial
peroneal nerve. The approach is safe because the
muscles receive their nerve supply at a point well
proximal to the surgical field.
Dangers
Nerves
The sural nerve lies distal and posterior to the approach,
thus should not be at risk. The superficial branch of the
peroneal nerve runs more anteriorly. A small incision
should not endanger either of these nerves.
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85
Lateral
malleolus
Lateral
process
of talus
Incision
Calcaneus
Peroneal
tubercle
an anterior direction. This will allow you to visualize more of the subtalar joint. Posteriorly, this incision can be extended a few centimeters only before
running into the sural nerve and the tendons
behind the fibula. To see the talus better, cut the
calcaneal fibular ligament and the capsule of the
Calcaneofibular
ligament
Lateral
talocalcaneal
joint capsule
Peroneal
tendons
Peroneal
retinaculum
and peroneal
tubercle
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Lateral
process
of talus
Peroneal
tendons
retracted
Subtalar
joint
incised
Lateral process
of talus
Posterior
calcaneal
articular
surface
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Calcaneus
inverted
Ankle inverted
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Sixteen
Posteromedial
Approach to the
Posterior Process
of the Talus
Position of the Patient 88
Dangers 91
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Posterior tibial
a. and tibial n.
89
Posterior dome
of talus
Fascial
incision
Achilles
tendon
Deep
fascia
Incision
Medial
malleolus
Talus
Calcaneus
Flexor
hallucis
longus
retracted
Flexor
hallucis
longus
Tibial n.
Posterior
ankle joint
capsule
opened
Flexor
hallucis longus
retinaculum
Posterior
tibiotalar
joint
A
Figure 16-3 A: At the lateral border of the flexor hallu-
LWBK1066-C16-p87-92.indd 89
Flexor hallucis
longus retinaculum
released
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Flexor
digitorum
longus
Posteromedial
ankle joint
Neurovascular
bundle
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LWBK1066-C16-p87-92.indd 91
91
Dangers
The posterior tibial artery and the tibial nerve (the
posterior nerve vascular bundle) are vulnerable during
the approach. Take care not to apply forceful retraction to the nerve, as this may lead to neuropraxia.
Take care to identify all structures in the area before
dividing any tendons or definitively cutting structures.
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Seventeen
Posterolateral
Approach to the
Posterior Talus
Position of the Patient 94
Dangers 96
Internervous Plane 94
Superficial Surgical Dissection 94
Deep Surgical Dissection 95
LWBK1066-C17-p93-96.indd 93
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The posterolateral approach is used to treat pathology of the posterior aspect of the talus and ankle
joint. It is well suited for open reduction and internal
fixation of posterior talar fractures. Because the
patient is prone, however, it is not the approach of
choice if other surgery requires an anterior approach.
In such cases, it is often better to use either a pos-
Internervous Plane
The internervous plane lies between the peroneus
brevis muscle (which is supplied by the superficial
peroneal nerve) and the flexor hallucis longus muscle
(which is supplied by the tibial nerve).
Incision
Short saphenous
v. and sural n.
Lateral
malleolus
Lateral
border of
Achilles
tendon
Talus
LWBK1066-C17-p93-96.indd 94
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Posterior
inferior
tibiofibular
ligament
Transverse
tibiofibular
ligament
Peroneus
longus and
brevis
Posterior
peroneal
retinaculum
Posterior ankle
joint capsule
Posterior
talofibular
ligament
Posterior
talocalcaneal
joint capsule
LWBK1066-C17-p93-96.indd 95
95
Flexor
hallucis
longus
Posterior
ankle joint
capsule
Peroneal
tendons
retracted
Posterior
peroneal
retinaculum
released
Posterolateral
talus
Posterior
ankle joint
capsule
opened
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Dangers
The short saphenous vein and the sural nerve run
close together just behind the peroneal tendons.
They should be preserved as a unit during the superficial surgical dissection.
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Eighteen
Lateral Approach to
the Calcaneus
Position of the Patient 98
Landmarks and Incision 98
Landmarks 98
Incision 98
LWBK1066-C18-p97-100.indd 97
Internervous Plane 98
Superficial Surgical Dissection 99
Deep Surgical Dissection 99
Dangers 100
Nerves 100
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neuropathy and smoking, are relative contraindications to this surgery approach. The indications for
the surgical approach include the following:
Incision
The skin incision has two limbs. Begin the distal limb
of the incision at the base of the fifth metatarsal and
extend it posteriorly, following the junction between
the smooth skin of the dorsum of the foot and the
wrinkled skin of the sole. Make a second incision
beginning approximately 6 to 8 cm above the skin of
the heel, halfway between the posterior aspect of the
fibula and the lateral aspect of the Achilles tendon.
Extend this second incision distally to meet the first
incision overlying the lateral aspect of the os calcis
(Fig. 18-1).
Place the patient in the lateral position on the operating table. Ensure that the bony prominences are well
padded. Place the leg that is to be operated on posteriorly with the under leg anterior. Exsanguinate the
limb either by elevating it for 3 to 5 minutes or by
applying a soft rubber bandage. Inflate a tourniquet.
Internervous Plane
No internervous planes are available for use. The dissection consists of a direct approach to the subcutaneous bone.
Sural n.
Cuboid
Calcaneus
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Base of
fifth metatarsal
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99
Peroneal
tendons
Calcaneofibular
ligament
Subtalar
joint
capsule
Cuboid
Calcaneus
Subtalar
joint
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Dangers
Nerves
The sural nerve is vulnerable if the skin flap is too far
proximal.
The soft tissues are vulnerable during this approach.
The risk of skin necrosis can be minimized if the flap
is elevated as a full-thickness flap because the skin
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Nineteen
Lateral Approach for
Osteotomy of the
Calcaneus (Vertical
Portion of the
Calcaneal Incision)
Position of the Patient 102
Landmarks and Incision 102
LWBK1066-C19-p101-104.indd 101
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Place the patient in the lateral position on the operating table (Fig. 19-1). Ensure that the bony prominences are well padded. Position the image intensification unit in front of the patient or at the foot of the
table. Place the leg that is to be operated on posteriorly with the under leg anterior.
Internervous Plane
There is no true internervous plane for this incision.
The dissection consists of a direct approach to the
subcutaneous calcaneal bone.
Dangers
Figure 19-1 Place the patient in the lateral position on
LWBK1066-C19-p101-104.indd 102
Nerves
The sural nerve is vulnerable if the skin incision is
too far anterior or if extensive skin flaps are developed.
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103
Sural
nerve
Achilles
tendon
Incision
Calcaneus
Talus
Sural
nerve
Calcaneus
Calcaneus
LWBK1066-C19-p101-104.indd 103
Full thickness
flap
the calcaneus and develop a full-thickness flap consisting of periosteum, subcutaneous tissues, and skin. Be
aware that the sural nerve lies in the anterior flap.
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Twenty
Posteromedial, Posterolateral,
and Posterior Midline
Approaches for Excision of
Calcaneal Exostosis
(Haglunds Deformity)
Position of the Patient 106
Landmarks and Incision 106
Internervous Plane 106
Superficial Surgical Dissection 106
Deep Surgical Dissection 106
LWBK1066-C20-p105-108.indd 105
Dangers 108
Nerves 108
How to Enlarge the Approach 108
Extensile Measures 108
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Achilles
tendon
Internervous Plane
The approach uses no true internervous plane, being
an incision down onto a subcutaneous bone.
LWBK1066-C20-p105-108.indd 106
Lateral
incision
Medial
incision
Posterior
incision
Calcaneus
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107
Lateral aspect
of calcaneus
Medial aspect
of calcaneus
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Tendon divided
and retracted
Incision
through
tendon
Calcaneus
Figure 20-4 A: Divide the tendon in the midline and incise the anterior paratenon.
B: Retract the cut edges of the tendon and paratenon to reveal the posterior aspect of
the calcaneus.
Dangers
Nerves
Cutaneous branches of the sural nerve run close to
the line of a lateral incision. A lateral incision close to
the Achilles tendon may expose the nerve that should
be identified and preserved to prevent neuroma formation. The tibial nerve runs near the medial
approach but runs more medially behind the medial
malleolus.
Extensile Measures
Although this approach does not utilize an internervous plane, on occasion it can be extended proximally
to expose more of the Achilles tendon or distally to
expose more of the calcaneus.
LWBK1066-C20-p105-108.indd 108
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Twenty one
Lateral Approach to the
Os Peroneum
Position of the Patient 110
Landmarks and Incision 110
Dangers 111
Nerves 111
LWBK1066-C21-p109-112.indd 109
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the base of the fifth metatarsal and extend it posteriorly, following the junction between the smooth skin
of the dorsum of the foot and the wrinkled skin of the
sole (Fig. 21-1). The exact length of the incision is
determined by the pathology to be treated.
Place the patient in the lateral position on the operating table (see Fig. 19-1). Ensure that all bony prominences are well padded. Place the leg that is to be
operated on posteriorly, with the under leg anterior.
Exsanguinate the limb either by elevating it for a few
minutes or by applying a soft rubber bandage. Inflate
a tourniquet on the mid-thigh.
Internervous Plane
No internervous planes are available for use. The dissection consists of a direct approach to the fifth metatarsal bone, which is subcutaneous.
Sural n.
Peroneus
longus
and brevis
Incision
Styloid
process of
5th metatarsal
Figure 21-1 Make a 3- to 4-cm longitudinal incision on the lateral aspect of the foot.
Begin the incision at the base of the fifth metatarsal and extend it posteriorly, following the junction between the smooth skin of the dorsum of the foot and the wrinkled
skin of the sole.
LWBK1066-C21-p109-112.indd 110
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111
Peroneus
longus in
cuboid
groove
Peroneus
brevis
Styloid
process of
5th metatarsal
Dangers
Nerves
The sural nerve is vulnerable during the superficial
surgical dissection. Take care to identify and preserve
it. The soft tissues are vulnerable during this approach
as well, as the risk of skin necrosis is ever present. This
risk can be minimized if the skin incision is full thickness and there is no undermining of soft tissue.
Calcaneocuboid joint
capsule
Extensor
digitorum
brevis
Cuboid
5th metatarsocuboid joint
capsule
Peroneus
longus
LWBK1066-C21-p109-112.indd 111
Peroneus
brevis
Styloid
process of
5th metatarsal
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LWBK1066-C21-p109-112.indd 112
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Twenty two
Medial Approach to
the Plantar Fascia
Position of the Patient 114
Landmarks and Incision 114
Internervous Plane 114
Superficial Surgical Dissection 114
Deep Surgical Dissection 114
LWBK1066-C22-p113-116.indd 113
Dangers 116
Nerves 116
Vessels 116
How to Enlarge the Approach 116
Extensile Measures 116
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Internervous Plane
There is no true internervous plane because the dissection is being performed down to a subcutaneous
bone.
Medial and
lateral plantar n.
Abductor
hallucis
Plantar
fascia
LWBK1066-C22-p113-116.indd 114
Incision
Medial
calcaneal
tubercle
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115
Abductor
hallucis
Medial
calcaneal
tubercle
Plantar
fascia
Abductor
hallucis
retracted
Undersurface
of calcaneus
Figure 22-3 Incise the fascia and retract the abductor hallucis
LWBK1066-C22-p113-116.indd 115
Plantar
fascia
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Dangers
Nerves
The neurovascular bundle is vulnerable if the skin
incision is too far anterior or proximal. By staying
immediately over the medial tuberosity of the calcaneus, the neurovascular bundle is protected by the
Extensile Measures
Proximal Extension. The incision may be extended
proximally toward the posterior border of the
calcaneus, being aware that the skin in this area
is always vulnerable to necrosis.
LWBK1066-C22-p113-116.indd 116
Vessels
Occasionally, terminal branches of the posterior tibial artery are very close to the calcaneum and may
inadvertently be divided. It is best to deflate the tourniquet before closure to ensure hemostasis.
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Twenty three
Hindfoot Nailing
for Subtalar and Ankle
Joint Fusion (Plantar
Approach)
Position of the Patient 118
Dangers 121
Nerves and Vessels 121
Skin 121
LWBK1066-C23-p117-122.indd 117
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LWBK1066-C23-p117-122.indd 118
Internervous Plane
No internervous plane is available for use. The
approach consists of a direct approach through subcutaneous tissues to the plantar surface of the calcaneum, and no muscles are involved.
3/15/12 7:32 PM
Chapter 23 Hindfoot Nailing for Subtalar and Ankle Joint Fusion (Plantar Approach)
119
Tibia
Longitudinal
line along
tibial shaft
Talus
Calcaneus
Plantar
fascia
Line along
lateral column
of calcaneus
Calcaneus
Bone
(calcaneus)
Intersection
of lines on
sole of foot
Incision
at intersection
of lines
Exposed
bone
Plantar
fascia
incised
E
D
Figure 23-1 A: The starting point for the incision is determined by the intersection
of two lines on the sole of the foot. The first line is drawn longitudinally through the
ankle and hindfoot on the lateral image. This line runs through the center of the tibial medullary canal along its axis. The line crosses the talus and calcaneum to exit
through the sole of the foot. B: The second line runs over the lateral column of the
calcaneus and is determined on the longitudinal plantar view. CE: Make a 2- to 3-cm
longitudinal incision on the sole of the foot centered on this entry point.
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Guide wire
drilled
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Chapter 23 Hindfoot Nailing for Subtalar and Ankle Joint Fusion (Plantar Approach)
Dangers
Nerves and Vessels
The medial plantar artery and nerve runs medially
and plantarward on the sole of the foot, and must be
avoided. They are normally well clear of the surgical
field, but be aware that severe deformity of the bony
architecture will affect the position of the bundle.
The lateral plantar nerve and artery cross the sole of
the foot from medial to lateral between the first and
second layers of muscle. This occurs distal to the
approach and so these structures should not be in
danger.
LWBK1066-C23-p117-122.indd 121
121
Skin
The incision should be kept small to minimize damage done to the sensitive skin on the sole of the foot.
The incision usually is off of the hard, calloused skin
of the heel and more into the soft, fleshy portion of
the sole of the foot.
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LWBK1066-C23-p117-122.indd 122
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Twenty four
Medial Approach to
the Sustentaculum
Tali
Position of the Patient 124
Landmarks and Incision 124
Internervous Plane 124
Superficial Surgical Dissection 124
Deep Surgical Dissection 125
LWBK1066-C24-p123-126.indd 123
Dangers 125
Nerve 125
Arteries 125
How to Enlarge the Approach 125
Extensile Measures 125
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Tibialis
posterior
tendon
Internervous Plane
This approach does not use an internervous plane.
All of the muscles seen receive their nerve supply well
proximal to the approach and therefore are not denervated by it.
Incision
Medial and
lateral plantar
n. and a.
Flexor
digitorum
longus
tendon
LWBK1066-C24-p123-126.indd 124
Sustentaculum
tali
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Abductor
hallucis
longus
Figure 24-2 Incise the deep fascia in line with the skin
Deltoid
ligament
Flexor hallucis
longus tendon
Sustentaculum
tali
LWBK1066-C24-p123-126.indd 125
125
Dangers
Nerve
The tibial nerve lies very close to the surgical plane
but is protected by the tendon of the flexor digitorum
longus during this approach. It divides into the lateral
and medial plantar nerve immediately posterior to
the surgical field. Awareness of the position of the
nerve is critical to ensure that retractors are safely
positioned. Do not retract the tendon of flexor digitorum longus vigorously as this may cause a traction
lesion of the nerve.
Arteries
The posterior tibial artery runs immediately behind
the flexor digitorum longus. By leaving the retinaculum intact behind the flexor digitorum longus, the
posterior tibial artery is usually not seen, but only
palpated during this approach. By being diligent with
retractors and sharp dissection, the artery can be protected throughout the case. In some instances, the
tourniquet should be released before closure of the
wound to check the integrity of the artery. The tourniquet maybe reinflated if necessary.
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LWBK1066-C24-p123-126.indd 126
digitorum longus, as this protects the nerve and vessel of the neurovascular bundle behind the ankle
medially. Distally, the incision can be extended
without difficulty as the nerves and arteries have penetrated the sole of the foot and are away from the
surgical field (see Fig. 25-2).
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Twenty five
Applied Surgical
Anatomy of the
Approaches to the Ankle
Overview 128
Tendons 128
Neurovascular Bundles 128
Superficial Sensory Nerves 128
Landmarks 131
Bony Structures of the Ankle 131
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Overview
The key structures that cross the ankle joint fall into
specific groups.
Tendons
Three sets of tendons cross the ankle joint in addition
to the Achilles and plantaris tendons, which lie posteriorly in the midline.
1. The flexor tendonsthe tibialis posterior, flexor
digitorum longus, and flexor hallucis longus (which
are supplied by the tibial nerve)pass behind the
medial malleolus.
2. The extensor tendonsthe tibialis anterior, extensor digitorum longus, extensor hallucis longus, and
peroneus tertius (which are supplied by the deep
peroneal nerve)pass in front of the ankle joint.
3. The evertor tendonsthe peroneus longus and peroneus brevis (which are supplied by the superficial
peroneal nerve)pass behind the lateral malleolus.
The tendons are all prevented from bowstringing
around the ankle by thickened areas in the deep fascia
of the leg, called retinacula.
The different nerve supplies of the groups offer
three potential internervous planes through which the
ankle can be approached: medially, between flexors
(tibialis posterior) and extensors (tibialis anterior); posterolaterally, between flexors (flexor hallucis longus)
and evertors (peroneus brevis); and laterally, between
extensors (peroneus tertius) and evertors (peroneus
brevis).
Neurovascular Bundles
Two major neurovascular bundles cross the ankle
joint and supply the foot. They present the major surgical concerns for all approaches around the ankle.
1. The anterior neurovascular bundle crosses the front
of the ankle roughly halfway between the malleoli.
It lies between the tibialis anterior and extensor
hallucis longus muscles proximal to the joint (see
Fig. 25-6) and between the tendons of the extensor hallucis longus and extensor digitorum longus
muscles distal to the joint. The tendon of the
extensor hallucis longus crosses the bundle in a
lateral to medial direction at the level of the ankle
joint (see Fig. 25-5).
The anterior tibial artery, which crosses the front of
the ankle joint before becoming the dorsalis pedis
artery, is palpable on the dorsum of the foot. It also
communicates with the medial plantar artery through
the first metatarsal space. Fractures through the base of
the metatarsal bones and dislocations at the tarsometatarsal joint (Lisfrancs fracture/dislocation*) can damage
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Tibialis anterior
Medial malleolus
Flexor retinaculum
Tendon of Achilles
Fat pad
Flexor retinaculum
(Laciniate ligament)
First metatarsal
Extensor
expansion
Calcaneus
Distal phalanx
of great toe
Abductor
hallucis
(insertion)
Flexor
hallucis
longus
Medial
sesamoid
Medial
belly of
flexor
hallucis
brevis
Tibialis
anterior
(insertion)
Tibialis
posterior
Flexor
digitorum
longus
Abductor
hallucis
Figure 25-1 The superficial structures of the medial aspect of the foot and ankle.
Fibers of the flexor retinaculum cross the neurovascular bundle, binding it to the
medial side of the foot.
Tibialis posterior
Tibia
Medial malleolus
Tibial nerve
Flexor hallucis longus
Deltoid ligament
Tendon of Achilles
Tibialis anterior
Flexor retinaculum
Navicular
First cuneiform
Second cuneiform
Calcaneus
First cuneiform
metatarsal joint
Flexor retinaculum
(Laciniate ligament
insertion)
Extensor digitorum
longus
First metatarsal
Extensor halluci
longus
Extensor
expansion
Lateral plantar
vessels and nerves
Knot of
Henry
Proximal
phalanx of
great toe
Abductor
hallucis
(insertion)
Flexor
hallucis
longus
Medial
sesamoid
Medial
belly of
flexor
hallucis
brevis
Medial plantar
vessels and nerves
Flexor digitorum brevis
Flexor
hallucis
longus
Abductor
hallucis
Figure 25-2 The extensor retinaculum and part of the flexor retinaculum have been
removed to reveal the deeper tendons and the neurovascular bundle. The abductor
hallucis has been detached from its origin to reveal the knot of Henry and the medial
and lateral plantar arteries and nerves.
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Tibialis anterior
Septum of flexor
compartment
Medial malleolus
Deltoid ligament
Navicular
Sustentaculum
tali
Second cuneiform
First cuneiform
Calcaneus
Tibialis anterior
(insertion)
Lateral plantar
vessels and nerves
Fascia over
abductor hallucis
longus
Second metatarsal
First metatarsal
Extensor hallucis
longus
Extensor
expansion
Proximal
phalanx of
great toe
Flexor
hallucis
longus
Abductor
hallucis
(insertion)
Medial
sesamoid
Flexor
Medial hallucis
belly of longus
flexor
hallucis
brevis
Flexor
Tibialis
posterior digitorum
(insertion) brevis
Flexor
digitorum
longus
Spring
ligament
Medial plantar
vessels and nerves
Figure 25-3 The flexor and extensor tendons have been resected to expose the
Fibula
Tibia
Groove for tibialis
posterior
Medial malleolus
Second cuneiform
Calcaneus
Second metatarsal
Sinus tarsi
First
cuneiform
First
metatarsal
Distal phalanx of
great toe
Tubercle
of navicular
Sustentaculum
tali
Medial tubercle of
calcaneus
Proximal phalanx
of great toe
Figure 25-4 Osteology of the medial side of the foot and ankle.
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131
Tibialis anterior
Tibia
Peronei
Tibialis posterior
Superior extensor
retinaculum
Extensor hallucis
Lateral malleolus
Medial malleolus
Anterior tibial a.
Peroneus brevis
Extensor digitorum brevis
Inferior extensor
retinaculum
Extensor hallucis longus
Peroneus tertius
Dorsalis pedis artery
Styloid process
of fifth metatarsal
Sural nerve
Saphenous nerve
Abductor hallucis
Extensor hood
Lateral band
Figure 25-5 The anatomy of the superficial structures of the anterior portion of the
ankle and the dorsum of the foot. At the level of the ankle joint, the neurovascular
bundle lies immediately lateral to the extensor hallucis longus tendon.
Landmarks
Bony Structures of the Ankle
The dome of the talus and the inferior articular surface of the tibia form the articulation that bears
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Cervical ligament
Bifurcate ligament
Navicular
First cuneiform
Calcaneocuboid ligament
Peroneus brevis
Tibialis anterior
(insertion)
First metatarsal
Cuboid
Abductor digiti minimi
Extensor hallucis longus
Extensor digitorum longus
Dorsal interossei
Tibia
Fibula
Medial malleolus
Lateral malleolus
Neck of talus
Calcaneus
Navicular
Cuboid
Styloid process of
fifth metatarsal
First cuneiform
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Fibula
133
Peroneus longus
Superior peroneal
retinaculum
Calcaneus
Inferior
peroneal
retinaculum
Abductor
digiti
minimi
Peroneus
longus
Peroneus
brevis
Extensor
digitorum
brevis
Styloid
process of
fifth metatarsal
Peroneus
tertius
Abductor
digiti
minimi
Figure 25-8 The superficial anatomy of the lateral and dorsolateral aspects of the
foot and ankle. The peroneal tendons are held in place by their superior and inferior
retinacula.
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Fibula
Peroneus brevis
Tibialis anterior
Anterior tibial artery
and deep peroneal nerve
Tendon of Achilles
Flexor hallucis
longus
Lateral malleolus
Superior peroneal
retinaculum
Bifurcate ligament
Anterior
talofibular ligament
Calcaneofibular
ligament
Peroneus tertius
(insertion)
Posterior
talocalcaneal
joint
Cervical
ligament
Peroneal
tubercle
Abductor
digiti
minimi
Peroneus
Cuboid Styloid
longus
Peroneus
Extensor
process
brevis
digitorum
of fifth
(insertion)
brevis
metatarsal
(origin)
Abductor
digiti
minimi
Figure 25-9 The peroneal and extensor tendons have been resected to reveal the
ligaments of the lateral and anterolateral ankle joints. Note the peroneal tubercle
and the resected portion of the inferior peroneal retinaculum, which forms separate
fibroosseous tunnels for the peroneal tendons. The calcaneofibular ligament is visible
deep to the superior peroneal retinaculum.
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135
Tibia
Fibula
Neck of talus
Tibia
Sinus tarsi
Talonavicular joint
Lateral malleolus
Navicular
Posterior talocalcaneal
joint
Second cuneiform
Third cuneiform
Calcaneus
Peroneal
tubercle
Cuboid
Calcaneocuboid
joint
Styloid process
of fifth metatarsal
Figure 25-10 Osteology of the lateral side of the foot and ankle.
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REFERENCE
1. White JW. Torsion of the Achilles tendon: its surgical significance. Arch Surg. 1943;46:784.
14/03/12 1:03 PM
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Twenty six
Applied Surgical
Anatomy of the
Approaches to the
Hind Part of the Foot
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The sinus tarsi contains a tough ligament, the ligamentum cervicis tali, and a large fat pad; the ligament
must be divided and the fat pad mobilized for access
to the sinus and joints. The extensor digitorum brevis
muscle originates from the top of the anterior wall of
the sinus. It must be detached for access to the calcaneocuboid joint.
Behind the tarsal canal lies the posterior part of
the subtalar joint, which consists of a convex superior
facet of the talus and a concave facet of the talus. The
joint line is oblique when viewed from the lateral
(operative) side. To see it better, the peroneal tendons
that overlie it partially must be mobilized and
retracted anteriorly.
Distal to the tarsal canal lies the anterior part of
the subtalar joint and the talocalcaneonavicular joint.
Sural nerve
Peroneus brevis
Flexor hallucis
longus
Peroneus tertius
Peroneal artery
Posterior talofibular
ligament
Cuboid
Superior peroneal
retinaculum
Peroneus
brevis
Styloid process
of fifth
metatarsal
Peroneus
longus
Inferior
peroneal
retinaculum
Abductor
digiti
minimi
Figure 26-1 Superficial anatomy of the posterolateral aspect of the foot and ankle.
Note that the muscle fibers of the peroneus brevis run all the way to the ankle joint
and lie immediately posterior to the lateral malleolus.
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Chapter 26 Applied Surgical Anatomy of the Approaches to the Hind Part of the Foot
Tendon of Achilles
and soleus
139
Deep fascia
Tibial nerve
Peroneus longus
Fascia of deep
flexor compartment
Peroneus brevis
Tibialis posterior
Lateral malleolus
Posterior transverse
tibiofibular ligament
Peroneus tertius
Lateral tubercle
of talus
Peroneus brevis
Peroneus longus
Posterior
talofibular
ligament
Peroneal
tubercle
Calcaneus
Superior peroneal
retinaculum
Calcaneofibular ligament
Figure 26-2 The Achilles tendon and the peroneus muscles have been resected to
reveal the posterolateral aspect of the ankle joint and the deep flexor tendons of the
foot. The flexor hallucis longus is immediately medial to the peroneus brevis. The
fascia investing these muscles is deep to the deep fascia; it separates them into peroneal and deep flexor compartments. The flexor hallucis longus remains muscular
down to the ankle joint.
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Tibia
Lateral tubercle
of talus
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Twenty seven
Midfoot: Approach
to the Cuboid
Position of the Patient 142
Landmarks and Incision 142
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Internervous Plane
There are no internervous planes in this approach.
The peroneus brevis muscle receives its nerve supply
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143
Sural nerve
branches
Incision
Peroneus
brevis
tendon
Cuboid
Figure 27-1 Make a 3- to 4-cm longitudinal incision over the dorsolateral aspect of
the cuboid.
Extensor
digitorum
brevis
Calcaneus
Calcaneo- Cuboid
cuboid joint
capsule
Peroneus
brevis
Figure 27-2 Deepen the skin incision through subcutaneous tissue, taking care to
identify and preserve any cutaneous nerves that are terminal branches of the sural
nerve. Make sure that skin flaps are full thickness and that they are not undermined.
Identify the peroneus brevis tendon as it runs across the operative field to insert into
the base of the fifth metatarsal bone.
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Extensor
digitorum
brevis
Calcaneocuboid joint
Cuboid
Fifth tarsometatarsal
joint
Figure 27-3 Identify by palpation the calcaneal cuboid joint immediately dorsal to
the peroneus brevis tendon. If needed, make a longitudinal incision through the capsule of the joint to open it. By continuing this incision distally and longitudinally, the
whole cuboid can be seen. To expose the cuboid metatarsal joints, incise the joint
capsule and supporting ligamentous structures in line with their fibers.
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Twenty eight
Approach to the
Navicular
Position of the Patient 146
Landmarks and Incision 146
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Internervous Plane
Talar
head
Navicular
First
cuneiform
Tibialis
anterior
Incision
Tibialis
posterior
Figure 28-1 Make a 5- to 6-cm longitudinal incision directly over the area to be exposed.
LWBK1066-C28-p145-148.indd 146
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147
Talonavicular
ligament
Navicularcuneiform
ligament
Tibialis
posterior
Accessary
navicular within
tibialis posterior
tendon
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LWBK1066-C28-p145-148.indd 148
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Twenty nine
Direct Medial
Approach for Midfoot
Collapse for Bony
Planing and Skin
Ulcer Treatment
Position of the Patient 150
Landmarks and Incision 150
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Internervous Plane
Tibialis
posterior
Medial
malleolus
Base of
first
metacarpal
First
cuneiform
Talar
head
Navicular
Incision
Figure 29-1 Make a 4- to 6-cm longitudinal incision directly over the area to be exposed.
The plantar medial incision lies directly over the bony prominence to be removed. The
approach usually runs from the base of the first metatarsal over the navicular.
LWBK1066-C29-p149-152.indd 150
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Chapter 29 Direct Medial Approach for Midfoot Collapse for Bony Planing and Skin Ulcer Treatment
First
cuneiform
Navicular
151
Tibialis
posterior
Figure 29-2 Cut down directly onto the bony prominence to be planed. Preserve any
LWBK1066-C29-p149-152.indd 151
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Thirty
Dorsomedial
Approach to
Lisfrancs Joint
Position of the Patient 154
Landmarks and Incisions 154
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This approach is used for the treatment of pathology of Lisfrancs joint. Generally, two incisions are
made for severe midfoot fractures. Single incisions
may be used for treating isolated dislocations of the
first ray at Lisfrancs joint or other conditions such
as arthritis or fractures.
The midfoot contains a complex array of bony
structures that ensure stability for the medial side
Internervous Plane
First
Tibialis cuneiform
anterior
First
Incision metatarsal
Extensor
hallucis
longus
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Tibialis
anterior
Extensor
hallucis
longus
Deep
peroneal
nerve
155
Dorsal pedal
artery and
vein
Deep peroneal
Extensor nerve and dorsal
hallucis
pedal vessels
longus
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This approach can be enlarged proximally by continuing the dissection between the extensor hallucis
LWBK1066-C30-p153-156.indd 156
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Thirty one
Dorsolateral
Approach to
Lisfrancs Joint
Position of the Patient 158
Landmarks and Incision 158
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side of the midfoot is mobile and in cases of fractures is frequently stabilized on a temporary basis.
The medial side of the midfoot provides stability.
Treatment of this part of the joint in cases of fracture often involves fusion.
Internervous Plane
Extensor
digitorum
longus
Extensor
digitorum
brevis
LWBK1066-C31-p157-160.indd 158
Styloid process
of fifth metatarsal
Fourth
metatarsal
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159
Extensor
digitorum
brevis
Styloid process
of fifth metatarsal
Incision
Fourth
Extensor
digitorum metatarsal
longus
Fourth
metatarsal
LWBK1066-C31-p157-160.indd 159
Extensor
digitorum
brevis
retracted
Fourth
metatarsotarsal joint
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LWBK1066-C31-p157-160.indd 160
the level of the ankle joint by extending the skin incision proximally along the dorsolateral aspect of the
foot and the lateral malleolus and dividing the extensor retinaculum. Branches of the superficial peroneal
nerve must be avoided.
To extend the incision distally, continue the longitudinal incision distally in the line of the fourth metatarsal.
Continue the incision of the belly of extensor digitorum
brevis to reveal the underlying fourth metatarsal.
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Thirty two
Dorsal Approaches for
Isolated Midfoot Joints
Position of the Patient 162
Landmarks and Incision 162
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The approaches are very specific to the requirements of the treatments, and the incisions need to be
carefully planned. Fluoroscopy is often helpful in
ensuring precise localization of the skin incision.
Motor
branch
Tibialis
anterior
Internervous Plane
No internervous plane is available for use in these
approaches. The joints to be exposed are essentially
subcutaneous, thus there is no risk of denervating any
muscle.
Surgical Dissection
Cut down directly onto the structures that are to be
exposed, taking care to avoid any cutaneous nerves
that can be identified. The joints of the midfoot are
nearly all subcutaneous. Try to make sure that skin
flaps are as thick as possible. Minimize retraction as
much as possible. Take care to avoid damaging the
sensory nerves, the extensor digitorum brevis and longus, and insertions of the four powerful inverters and
evertors of the foot: the tibialis anterior, tibialis posterior, peroneus brevis, and peroneus longus (Fig. 32-1).
Extensor
hallucis
longus
Medial dorsal
branch of the
superficial
peroneal
nerve
Intermediate
dorsal branch
of superficial
peroneal nerve
Extensor
digitorum
communis
Extensor
digitorum
brevis
Sural
nerve
Figure 32-1 Cut down directly onto the structures that are to be exposed, taking
LWBK1066-C32-p161-164.indd 162
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LWBK1066-C32-p161-164.indd 163
163
3/15/12 7:45 PM
LWBK1066-C32-p161-164.indd 164
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Thirty three
Plantar Approach for
Plantar Fibromatosis
Position of the Patient 166
Landmarks and Incision 166
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This approach is usually used to approach the plantar fascia. The fascia is much thicker in its central
parts, where it is known as the plantar aponeurosis.
The approach is usually used to treat plantar fibromatosis. This disease is 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. Usually smaller
First
metatarsal
head
Incision
Internervous Plane
Medial and
lateral plantar
nerves
LWBK1066-C33-p165-168.indd 166
Calcaneus
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167
Plantar
fascia
Develop
subfascial
plane as
needed
Figure 33-4 Once the fascia has been divided, the cut
Incise
fascia
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LWBK1066-C33-p165-168.indd 168
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Thirty four
Dorsal Approaches
to the Middle Part
of the Foot
Position of the Patient 170
Landmarks and Incisions 170
Landmarks 170
Incisions 170
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The middle part of the foot extends from the calcaneocuboid and talonavicular joints to the tarsometatarsal Lisfrancs joints. All these bones and
joints are superficial and can be approached directly
by dorsal, medial, lateral, and plantar 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
LWBK1066-C34-p169-174.indd 170
Internervous Plane
There are no internervous planes in these approaches.
Longitudinal incisions avoid damaging cutaneous
nerves. Certain major reconstructive operations, such
as wedge tarsectomy, necessarily cut cutaneous nerves,
leaving portions of the dorsum of the foot partially
anesthetic.
Surgical Dissection
Cut down directly onto the structures that are to be
exposed, taking care to avoid any cutaneous nerves
that can be identified. Try to make sure that skin
flaps are as thick as possible; minimize retraction
as much as possible. The structures of the dorsum
of the foot nearly all are subcutaneous. Take care
to avoid damaging the insertions of the four powerful invertors and evertors of the foot (Figs. 34-2
and 34-4).
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171
Medial malleolus
Head of talus
Navicular
First cuneiform
First metatarsal
Figure 34-1 Incision for exposure of the middle part of the foot. Make a longitudinal
incision directly over the area to be exposed. A dorsomedial incision exposes the talonavicular joint, the navicularmedial cuneiform joint, and the first metatarsocuneiform joint.
Flexor retinaculum
(Laciniate ligament)
Talonavicular joint
Tibialis anterior
First metatarsocuneiform
joint
Navicular first
cuneiform joint
Tibialis
posterior
Figure 34-2 Develop the skin flaps. Note the insertions of the tibialis anterior and posterior muscles. Incise the
joint capsules of the talonavicular joint, the navicularmedial cuneiform joint, and the first metatarsocuneiform
joint according to the demands of the surgery.
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Cuboid
Lateral
malleolus
Styloid process
of fifth metatarsal
Calcaneus
Figure 34-3 A dorsolateral incision exposes the calcaneocuboid joint and the base of
Calcaneocuboid
joint
Peroneus
tertius
Inferior
peroneal
retinaculum
Peroneus
brevis
Styloid process of
fifth metatarsal
Figure 34-4 Develop the skin flaps on the lateral side of the middle part of the foot.
Note the tendon of the peroneus brevis as it inserts into the base of the fifth metatarsal. The joint capsule of the calcaneocuboid joint can be incised, if necessary.
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LWBK1066-C34-p169-174.indd 173
173
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Thirty five
Dorsal Approach to the
Metatarsophalangeal
Joint of the Great Toe
Position of the Patient 176
Dangers 177
LWBK1066-C35-p175-178.indd 175
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Internervous Plane
There is no true internervous plane. The bone is
subcutaneous; the two tendons that lie close to the
LWBK1066-C35-p175-178.indd 176
Deep
peroneal
nerve
Saphenous n.
Dorsal
incision
First
metatarsal
head
3/15/12 7:48 PM
177
Head of first
metatarsal
Bunion and
joint capsule
Bunion
and joint
capsule
Base of proximal
phalanx
fascia in line with the skin incision, and retract the tendon of the extensor hallucis longus laterally.
Dangers
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. 35-2 and 35-3).
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 softtissue 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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Thirty six
Dorsomedial
Approach to the
Metatarsophalangeal
Joint of the Great Toe
Position of the Patient 180
Dangers 181
LWBK1066-C36-p179-182.indd 179
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Internervous Plane
There is no true internervous plane. The bone is subcutaneous; the two tendons close to the dissectionthe
extensor hallucis longus and the abductor hallucis
receive their nerve supply proximal to this approach,
thus cannot be denervated by it.
LWBK1066-C36-p179-182.indd 180
the medial approach to the metatarsophalangeal joint of the great toe. Note the proximity of the dorsal digital nerve to the incision.
14/03/12 1:08 PM
181
flexor hallucis longus muscle, which lies in a fibroosseous 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.
Dangers
The tendon of the extensor hallucis longus muscle,
which lies on the lateral edge of the wound, should not
be cut during the approach. Indeed, in cases of bunion, the tendon bowstrings laterally across the metatarsophalangeal joint and is considerably more lateral
to the incision. Protect the dorsal digital nerve if it can
be seen (see Figs. 35-1 and 36-1).
Flap of bunion
and joint capsule
LWBK1066-C36-p179-182.indd 181
Head of first
metatarsal
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LWBK1066-C36-p179-182.indd 182
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Thirty seven
Dorsolateral
Approach for
Bunion Surgery
Position of the Patient 184
Dangers 186
LWBK1066-C37-p183-186.indd 183
3/15/12 7:47 PM
Internervous Plane
There is no internervous plane. The only muscle
involved in the approachadductor hallucisreceives
its nerve supply well proximal to the surgical field, thus
Incision
Second
metatarsal
head
First
metatarsal
head
LWBK1066-C37-p183-186.indd 184
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185
Adventitious
bursal
the muscle is not denervated by the approach. Terminal branches of the deep peroneal nerve supply skin in
the region of the first web space. Care must be taken to
preserve these nerves so as not to denervate the skin,
creating an area of anesthesia postoperatively.
Transverse head
of adductor
hallucis
Oblique head
of adductor
hallucis
Lateral head
of flexor
hallucis brevis
Lateral first
metatarsophalangeal
joint capsule
First dorsal
interosseous
muscle
Deep
transverse
metatarsal
ligament
Figure 37-3 Insert a self-retaining retractor between the first and second metatarsal
heads. Identify the tendon of adductor hallucis as it inserts jointly into the lateral
sesamoid bone and the lateral aspect of the proximal phalanx of the hallux.
LWBK1066-C37-p183-186.indd 185
3/15/12 7:47 PM
Transverse and
oblique heads
of adductor
hallucis
detached
Lateral
sesamoid
Lateral head
of flexor
hallucis brevis
Intersesamoid
ligament
Deep
transverse
metatarsal
ligament
Figure 37-4 A: Using a knife blade, develop a plane between the metatarsal head
dorsally and the lateral (fibular) sesamoid bone plantarly. B: Identify the cut end of
the adductor hallucis tendon and dissect it carefully, proximally, until the muscle
fibers of the adductor hallucis are found. At this stage, you will be able to see the
lateral (fibular) sesamoid clearly.
Dangers
Terminal branches of the deep peroneal nerve may be
injured in superficial surgical dissection. Staying in
the midline of the web space will reduce the risk of
injuring these important cutaneous nerves.
Careless incision of the transverse metatarsal ligament may injure the digital nerve that lies immediately underneath. This risk can be minimized if the
LWBK1066-C37-p183-186.indd 186
3/15/12 7:48 PM
Thirty eight
Dorsomedial
Approach to the
First Metatarsal
Position of the Patient 188
Dangers 189
LWBK1066-C38-p187-190.indd 187
3/15/12 7:58 PM
1. Drainage of infection
2. Excision of bone tumors affecting the first metatarsal
Internervous Plane
There is no true internervous plane. The bone is subcutaneous.
Saphenous n.
Incision
LWBK1066-C38-p187-190.indd 188
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189
First
metatarsal
Extensor
hallucis
longus
Dangers
The tendon of extensor hallucis longus should lie lateral to the plane of dissection, but may be injured if
the incision is placed too dorsally.
The terminal branches of the saphenous nerve
cross the operative field from lateral to medial. Dam-
LWBK1066-C38-p187-190.indd 189
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LWBK1066-C38-p187-190.indd 190
3/15/12 7:58 PM
Thirty nine
Medial Approach to
the First Metatarsal
Bone for Excision
of the Medial
Sesamoid Bone
Position of Patient 192
Dangers 193
LWBK1066-C39-p191-194.indd 191
3/15/12 7:53 PM
Position of Patient
Internervous Plane
There is no true internervous plane. The two muscles encountered during the approachthe abductor
hallucis and the flexor hallucis longusreceive their
Incision
First metatarsophalangeal joint
Incision
Medial
sesamoid
LWBK1066-C39-p191-194.indd 192
Plantar border
of first metatarsal
3/15/12 7:53 PM
Chapter 39 Medial Approach to the First Metatarsal Bone for Excision of the Medial Sesamoid Bone
193
Abductor
hallucis
Medial tendon
of the flexor
hallucis brevis
Dangers
Superficial cutaneous nerves are in danger during
superficial surgical dissection. They should be identified and preserved. The medial digital nerve lies just
superior to the tendon of the abductor hallucis. Providing dissection is carried out below the abductor
hallucis tendon, it should not be endangered. Damage
to this nerve creates impaired skin sensation in a
weight-bearing area.
Abductor
hallucis
LWBK1066-C39-p191-194.indd 193
Medial tendon
Articular
of the flexor
surface hallucis brevis
of the
medial
sesamoid
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LWBK1066-C39-p191-194.indd 194
3/15/12 7:53 PM
Forty
Plantar Approach
to the Lateral
Sesamoid Bone
Position of the Patient 196
Dangers 198
LWBK1066-C40-p195-198.indd 195
3/15/12 7:38 PM
Incision
Second
metatarsal
Lateral
sesamoid
Internervous Plane
There is no true internervous plane. The two muscles
most involved in the approachthe flexor hallucis
brevis and adductor hallucisreceive their nerve supplies well proximal to the site of the approach, thus
cannot be denervated by it.
LWBK1066-C40-p195-198.indd 196
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197
Lateral
sesamoid
Direct and
oblique heads
of the adductor
hallucis
Common
digital
nerve
Lateral head
of the flexor
hallucis longus
Periosteum
elevated
LWBK1066-C40-p195-198.indd 197
Lateral
sesamoid
3/15/12 7:38 PM
Dangers
The common digital nerve is at risk during both the
superficial and deep surgical dissection. The nerve
must be identified and carefully retracted laterally
away from the operative field before sharp dissection
of structures attached to the lateral sesamoid bone is
carried out.
The tendon of the flexor hallucis longus muscle
lies just medial to the lateral sesamoid and may be
LWBK1066-C40-p195-198.indd 198
3/15/12 7:38 PM
Forty one
Dorsal Approach to the
Fifth Metatarsal Head
for Bunionette
Position of the Patient 200
Dangers 201
LWBK1066-C41-p199-202.indd 199
3/15/12 7:38 PM
Internervous Plane
Bunionette
LWBK1066-C41-p199-202.indd 200
Incision
3/15/12 7:39 PM
Extensor
communis
201
Bunionette
Joint
capsule
Extensor
hood
Joint capsule
retracted
Figure 41-2 A: For the superficial surgical dissection, incise the deep fascia in the
line with the incision. Take care to identify and preserve any cutaneous nerves
encountered during this part of the dissection. Retract the tendon of the extensor
digitorum longus medially to expose the thick capsular structures overlying the fifth
metatarsal head. B: For the deep surgical dissection, divide the capsule longitudinally.
Peel the thick capsular and bursal structures off the fifth metatarsal head.
Dangers
LWBK1066-C41-p199-202.indd 201
3/15/12 7:39 PM
LWBK1066-C41-p199-202.indd 202
3/15/12 7:39 PM
Forty two
Lateral Approach to the
Fifth Metatarsal Head
for Bunionette
Position of the Patient 204
Dangers 205
LWBK1066-C42-p203-206.indd 203
3/15/12 7:39 PM
proximally along the lateral border of the foot. A useful surgical landmark is the junction between the
smooth skin on the dorsum of the foot and the wrinkled skin on the plantar aspect.
Internervous Plane
There is no true internervous plane. The bone is
essentially subcutaneous. The extensor digitorum
longus and flexor digitorum longus tendons to the
little toe receive their nerve supply well proximal to
this approach and cannot be denervated by it.
Incision
Bunionette
LWBK1066-C42-p203-206.indd 204
3/15/12 7:39 PM
205
Extensor
communis
Joint
capsule
Bunionette
Extensor
hood
Joint capsule
incised and
retracted
Figure 42-2 A: For the superficial surgical dissection, cut through subcutaneous
tissue in the line of the skin incision to expose the joint capsule of the metatarso
phalangeal joint of the little 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 superficial surgical dissection; of course, any nerves that
can be identified should be preserved.
LWBK1066-C42-p203-206.indd 205
3/15/12 7:39 PM
LWBK1066-C42-p203-206.indd 206
3/15/12 7:39 PM
Forty three
Lateral Approach to
the Base of the Fifth
Metatarsal
Position of the Patient 208
Dangers 209
LWBK1066-C43-p207-210.indd 207
3/15/12 7:54 PM
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:
1. Basal osteotomy of the fifth metatarsal bone in
cases of bunionette. This procedure is indicated
Peroneus
brevis
Base of fifth
metatarsal
Incision
Figure 43-1 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.
LWBK1066-C43-p207-210.indd 208
3/15/12 7:54 PM
209
Peroneus
brevis
Base of fifth
metatarsal
Figure 43-2 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.
LWBK1066-C43-p207-210.indd 209
3/15/12 7:54 PM
LWBK1066-C43-p207-210.indd 210
3/15/12 7:54 PM
Forty four
Dorsal Approach to
the Second to Fifth
Metatarsal Bones
Position of the Patient 212
Dangers 214
LWBK1066-C44-p211-214.indd 211
3/15/12 7:55 PM
The dorsal approach to the second to fifth metatarsal bones provides safe access for surgery in a number of conditions. Because the metatarsals lie in an
almost subcutaneous position, access is relatively
easy; however, care must be taken to respect the
neurovascular structures on the dorsum of the foot,
especially the cutaneous nerves. Damage to these
nerves may produce hyperesthesia or at worst a
neuroma. Both these complications produce significant postoperative problems for patients. The uses
of the approach include the following:
Extensor
digitorum
longus
tendon
Second
metatarsal
Extensor
digitorum
brevis
tendon
Second
metatarsophalangeal
joint
Incision
LWBK1066-C44-p211-214.indd 212
3/15/12 7:55 PM
Extensor
digitorum
brevis
tendon
Extensor
digitorum
longus
tendon
213
Second
metatarsal
Joint
capsule
Internervous Plane
There is no true internervous plane. These bones are
almost subcutaneous. The tendons of the extensor
digitorum longus and brevis lie in the field of dissection, but these muscles receive their nerve supply
proximal to the approach and the muscles themselves
cannot be denervated by it.
Extensor
digitorum
longus tendon
retracted
Second
metatarsal
Joint
capsule
LWBK1066-C44-p211-214.indd 213
3/15/12 7:55 PM
Metatarsal
head
Metatarsophalangeal
joint
Hyperflex
MP joint
In cases of trauma, try to preserve as much periosteum as possible. Extensive periosteal stripping will
significantly reduce the blood supply to the fracture.
The length and extent of the deep surgical dissection depends on the pathology to be treated and treatment modality selected. For plating of the fractured
metatarsals, the length of the incision will depend on
the plate selected. Plates should be placed in an epiperiosteal plane. Fractures to be treated with wiring
need exposure of the distal end of the affected metatarsal. For wiring, incise the metatarsophalangeal joint
of the affected metatarsal bone. Incision of the dorsal
capsule will allow the proximal phalanx to be flexed,
giving access to the metatarsal head for retrograde
insertion of a wire across the fracture site (Fig. 44-4).
Dangers
The tendon of the extensor digitorum longus muscle
lies directly in line of the skin incision. Take care to
LWBK1066-C44-p211-214.indd 214
3/15/12 7:55 PM
Forty five
Dorsal Approach to the
Metatarsophalangeal
Joints of the Second,
Third, Fourth, and
Fifth Toes
Position of the Patient 216
Landmarks and Incision 216
Landmarks 216
Incision 216
LWBK1066-C45-p215-218.indd 215
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The dorsal approach, which exposes the metatarsophalangeal joints of the second, third, fourth, and
fifth toes, avoids incision of the plantar skin of the
foot. Most plantar approaches scar the weightbearing skin, violating a basic surgical principle.
The uses for the approach include the following:
Incision
Make a 2- to 3-cm longitudinal incision over the dorsolateral aspect of the affected metatarsophalangeal
LWBK1066-C45-p215-218.indd 216
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Chapter 45 Dorsal Approach to the Metatarsophalangeal Joints of the Second, Third, Fourth, and Fifth Toes
Branches of superficial
peroneal nerve
217
Extensor
digitorum
longus
Internervous Plane
There is no true internervous plane for any of these
metatarsophalangeal approaches. The approaches
are well dorsal to the plantar nerves and 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.
LWBK1066-C45-p215-218.indd 217
Tendon of extensor
digitorum longus
Deep fascia
Figure 45-3 Incise the deep fascia in line with the inci-
14/03/12 1:14 PM
Tendon of
extensor
digitorum
longus
Joint
capsule
Base of
proximal
phalanx
metatarsophalangeal joint.
Dangers
heads, beneath the deep transverse metatarsal ligament. As long as the dissection remains on the dorsal
aspect of the ligaments, the nerves are safe. Dissection around the metatarsal heads and proximal
phalanges must be carried out so as to avoid damage
to the nerves and vessel that supply the weightbearing skin of the toes (see Fig. 25-5).
LWBK1066-C45-p215-218.indd 218
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Forty six
Dorsal Approach for
Mortons Neuroma
Position of the Patient 220
Dangers 221
LWBK1066-C46-p219-222.indd 219
14/03/12 1:14 PM
Branches of superficial
peroneal nerve
Sural nerve
Deep peroneal
nerve
Saphenous
nerve
Figure 46-1 Make a dorsal longitudinal incision over the center of the web space
starting at the distal end of the web and extending proximally some 2 to 3 cm beyond
the level of the metatarsophalangeal joints.
LWBK1066-C46-p219-222.indd 220
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221
Dangers
Figure 46-2 Incise the fascia in line with the skin
incision.
Internervous Plane
There is no internervous plane. No muscles or tendons are encountered in the approach.
Deep fascia
Neuroma in nerve
to third web space
Deep
transverse
metatarsal
ligament
Figure 46-3 Incise the deep transverse metatarsal ligament in line with the skin and
LWBK1066-C46-p219-222.indd 221
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LWBK1066-C46-p219-222.indd 222
14/03/12 1:14 PM
Forty seven
Plantar Approach
for Recurrent
Mortons Neuroma
Position of the Patient 224
Dangers 225
LWBK1066-C47-p223-226.indd 223
3/15/12 7:53 PM
Internervous Plane
There is no internervous plane. The tendon of flexor
digitorum longus that is exposed during the approach
receives its nerve supply well proximal to the site of
surgery.
Adjacent
metatarsal
heads
Plantar
fascia
Incision
in interspace
LWBK1066-C47-p223-226.indd 224
3/15/12 7:54 PM
225
Adjacent
flexor
sheaths
Dangers
Common
digital
artery
Common
digital
nerve
nerve running with its artery between the flexor tendons. When using the approach for revision surgery,
identify the common plantar digital nerve proximally
well away from the previous field of surgical dissection. Trace the nerve from proximal to distal, identifying its bifurcation.
LWBK1066-C47-p223-226.indd 225
The long flexor tendons of the toes are easily identifiable in the superficial surgical dissection. The artery
running with the common plantar digital nerve can
be sacrificed during excision of the digital nerve.
The danger of the approach lies in the creation of
a plantar scar. The approach should be avoided when
atrophic skin is present as well as in cases of peripheral vascular disease, most notably diabetes mellitus.
3/15/12 7:54 PM
LWBK1066-C47-p223-226.indd 226
3/15/12 7:54 PM
Forty eight
Dorsolateral Approach
to the Flexor Sheathes
of the Second to
Fifth Toes
Position of the Patient 228
Dangers 230
LWBK1066-C48-p227-230.indd 227
3/15/12 7:57 PM
Metacarpophalangeal
joint capsule
Proximal
interphalangeal
joint
Flexor
sheath
Flexor
sheath
Flexor
digitorum
longus
Flexor
digitorum
brevis
Incision
LWBK1066-C48-p227-230.indd 228
3/15/12 7:57 PM
Chapter 48 Dorsolateral Approach to the Flexor Sheathes of the Second to Fifth Toes
229
Flexor
sheath
Internervous Plane
There is no true internervous plane because no intermuscular interval is utilized. The sensory nerve supply
to the toe comes mainly from two sources: the dorsal
digital nerve and the plantar digital nerve. Because the
skin incision marks the division between these two
supplies, it causes no significant area of hypoesthesia.
Flexor
digitorum
brevis
Flexor
digitorum
longus
LWBK1066-C48-p227-230.indd 229
3/15/12 7:57 PM
Flexor
digitorum
brevis
Flexor
digitorum
longus
Dangers
The plantar digital nerve is endangered if the skin
incision is made too far plantarly. It is also at risk if
LWBK1066-C48-p227-230.indd 230
or flexor-to-extensor transfer is
to be performed, take a blunt
hook and insert it around the
long flexor tendon. Putting the
hook toward you will passively
flex both the proximal and distal
interphalangeal joints and allow
the long flexor tendon to be
divided well distal to the site of
the dissection.
3/15/12 7:57 PM
Forty nine
Transverse Approach
for Surgery to
a Hammer Toe
Position of the Patient 232
Dangers 234
LWBK1066-C49-p231-234.indd 231
3/15/12 7:55 PM
Common
extensor
tendon
Internervous Plane
Incision
LWBK1066-C49-p231-234.indd 232
Proximal
interphalangeal
joint
3/15/12 7:55 PM
233
Ellipse of
common extensor
tendon excised
Distal end
of proximal
phalanx
Distal end
of proximal
phalanx
exposed
Proximal
interphalangeal
joint hyperflexed
Distal end
of proximal
phalanx
excised
LWBK1066-C49-p231-234.indd 233
3/15/12 7:55 PM
Proximal end
of middle phalanx
exposed
Proximal end
of middle phalanx
excised
Dangers
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
LWBK1066-C49-p231-234.indd 234
3/15/12 7:56 PM
Fifty
Longitudinal Approach
to the Proximal
Interphalangeal Joint
of the Second to Fifth
Toes for Hammer Toe
Position of the Patient 236
Landmarks and Incision 236
Incision 236
LWBK1066-C50-p235-238.indd 235
3/15/12 7:58 PM
The longitudinal approach to the proximal interphalangeal joint of the second to fifth toes is used
for the treatment of hammer toe deformities. The
most common procedure that utilizes this approach
is proximal interphalangeal joint fusion.
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
the joint while palpating its dorsal surface can confirm the exact position of the joint.
Incision
Make a 2-cm longitudinal incision on the dorsum of
the toe centered on the proximal interphalangeal
joint (Fig. 50-1).
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.
Extensor
tendon
Incise
extensor
tendon
Incision
Proximal
interphalangeal
joint
LWBK1066-C50-p235-238.indd 236
skin incision.
3/15/12 7:58 PM
Dorsal
joint
capsule
incised
Extensor
tendon
retracted
cause the proximal end of the proximal phalanx to protrude through the incised extensor tendon.
Distal end
of proximal
phalanx
exposed
237
Proximal
interphalangeal
joint
hyperflexed
Distal end
of proximal
phalanx
excised
LWBK1066-C50-p235-238.indd 237
3/15/12 7:59 PM
Proximal end
of middle
phalanx
exposed
Proximal end
of middle
phalanx
excised
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.
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
LWBK1066-C50-p235-238.indd 238
3/15/12 7:59 PM
Fifty one
Approach for Nail
Bed Ablation
Position of the Patient 240
Dangers 242
LWBK1066-C51-p239-242.indd 239
3/15/12 7:56 PM
Internervous Plane
Interphalangeal
joint
Incisions
LWBK1066-C51-p239-242.indd 240
3/15/12 7:56 PM
241
LWBK1066-C51-p239-242.indd 241
Skin
Nail bed
3/15/12 7:56 PM
Nail bed
Nail bed
incised down to
distal phalanx
Distal
phalanx
Wound closure consists of suturing back the elevated flap (Fig. 51-6). It may be transposed 2 to 3 mm
distally to facilitate wound closure.
Dangers
The leading danger in this procedure is leaving part
of the nail bed behind. Take care that you do not
leave any nail bed remnants behind at the level of the
interphalangeal joint at either edge of the wound.
Incision of the interphalangeal joint is potentially
hazardous because the field is frequently contaminated by previous infection. Try to avoid incision of
this joint, if possible.
LWBK1066-C51-p239-242.indd 242
3/15/12 7:56 PM
Fifty two
Applied Surgical
Anatomy of the Foot
Overview 244
Anatomy of the Dorsum of the Foot 244
Nerve Supply 244
Superficial Veins 244
Tendons 244
Deep Artery 244
LWBK1066-C52-p243-246.indd 243
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Overview
Surgery of the foot often is undertaken to correct
bony abnormalities. All the bones of the foot can be
approached dorsally; dorsal approaches usually are
better than plantar approaches for two major reasons:
1. The critical neurovascular structures in the forepart of the foot all are on the plantar side of the
metatarsal bones, so they remain protected.
2. Dorsal incisions avoid cutting through the specialized weight-bearing skin of the sole of the foot.
In pathologic situations in which abnormal skin
lies over bones that protrude (e.g., metatarsalgia), a
plantar approach may have to be used and the abnormal skin excised.
Although the dorsal anatomy is the critical surgical
anatomy of the foot, the plantar anatomy includes its
key neurovascular structures. Knowledge of the latter
allows the surgeon to explore wounds in the sole of
the foot, which do not mimic any described surgical
approach. For these reasons, the anatomy of the sole
of the foot also is described in the following section.
Nerve Supply
Branches of three cutaneous nerves run right under
the skin of the dorsum of the foot: the medial side
houses the branches of the saphenous nerve; most of
the dorsum of the foot is supplied by the dorsal cutaneous branches of the superficial peroneal nerve; and
the lateral side of the foot is supplied by the sural
nerve.
The first web space is supplied by branches of the
deep peroneal nerve. Numbness in the first web space
is the earliest sign of a deep peroneal nerve lesion in
the anterior compartment of the leg (see Figs. 25-5,
36-1, 45-2, and 46-1).
Superficial Veins
The veins are arranged in a dorsal venous arch. The
medial side drains into the long saphenous vein; the
lateral side drains into the short saphenous vein.
Superficial veins, of course, must be on the dorsum of
the foot, because they would collapse under the force
of ordinary weight bearing if they were on the sole.
LWBK1066-C52-p243-246.indd 244
Tendons
Two sets of tendons lie immediately deep to the cutaneous nerves: those of the extensor digitorum longus
and extensor digitorum brevis muscles and those of
the extensor hallucis longus and extensor hallucis
brevis muscles. The extensor digitorum tendons
insert into the dorsal extensor expansion of the
lateral four toes, an arrangement that is identical to
that in the fingers. Frequently, these tendons crosscommunicate in the forepart of the foot. The great
toe, similar to the thumb, has no dorsal extensor
expansion (see Fig. 25-5).
Deep Artery
The artery of the dorsum of the foot, the dorsalis
pedis artery, runs forward beneath the tendon of the
extensor hallucis brevis muscle before disappearing
into the first intermetatarsal space (see Fig. 25-6).
14/03/12 1:17 PM
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245
References
1. Fowler AW. A method of forefoot reconstruction. J Bone
Joint Surg [Br]. 1959;41:507.
2. Kates A, Kessel L. Arthroplasty of the forefoot. J Bone Joint
Surg [Br]. 1967;49:552.
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14/03/12 1:17 PM
Index
Note: Page numbers followed by f indicate figures.
LWBK1066-Ind-p247-252.indd 247
dangers
nerves and vessels, 121
skin, 121
deep surgical dissection, 118120, 120f
internervous plane, 118
landmarks and incision, 118, 119f
muscles
first layer of, 120
second layer of, 120121
patient position, 118
superficial surgical dissection, 118, 119f
Ankle joint
posterolateral approach to
dangers, 96
deep surgical dissection, 9596, 96f
extensile measure, 96
internervous plane, 94
landmarks and incision, 94, 95f
patient position, 94, 94f
superficial surgical dissection,
9495, 95f
posteromedial approach to
dangers, 91
deep surgical dissection, 88, 89f,
90f, 91
extensile measures, 91
landmarks and incision, 88, 89f
patient position, 88, 88f
superficial surgical dissection, 88, 89f
surgical anatomy of
ankle, anterior approach to, 134135
ankle, bony structures of, 131133
ankle, lateral approaches to, 135
ankle, medial approaches to, 133134
deltoid ligament of, 130f
extensor muscles, 134
extensor retinacula, 134135
ligaments of anterior portion of, 132f
neurovascular bundles, 128
osteology of, 132f
superficial anatomy of, 133f
superficial sensory nerves, 128, 131
tendons, 128
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248 Index
Anterior tibial artery, 3f
ankle
anterior approach, 5, 131f, 132f
anterolateral approach, 52, 131f
arthroscopy, 49, 131f
foot, hindpart
anterolateral approach, 52, 131f
Avascular necrosis, 76
LWBK1066-Ind-p247-252.indd 248
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Index
superficial surgical dissection, 208,
209f
Fifth metatarsal head
dorsal approach to
approach enlargement
dangers
deep surgical dissection, 201, 201f
internervous plane, 200201
landmarks and incision, 200, 200f
patient position, 200
superficial surgical dissection, 201,
201f
lateral approach to
approach enlargement, 205
dangers, 205
deep surgical dissection, 204205,
205f
internervous plane, 204
landmarks and incision, 204, 204f
patient position, 204
superficial surgical dissection, 204,
205f
First metatarsal bone
dorsomedial approach to
approach enlargement, 189
dangers, 189
deep surgical dissection, 188189,
189f
internervous plane, 188
landmarks and incision, 188, 188f
patient position, 188
superficial surgical dissection, 188
medial approach to
approach enlargement, 194
dangers, 193194
deep surgical dissection, 192193,
193f
internervous plane, 192
landmarks and incision, 192, 192f
patient position, 192
superficial surgical dissection, 192,
193f
Flexor accessorius, 120
Flexor digitorum brevis, 114, 120, 245
Flexor digitorum longus, 120, 124, 125f,
234
Flexor hallucis brevis, 245
Flexor hallucis longus, 88, 91, 116, 120,
128, 192
ankle
posterolateral approach, 34, 35f
muscle, 95, 177, 182, 198
tendon, 192
Flexor retinaculum, 124, 134
Flexor sheathes, to toes
approach enlargement, 230
dangers, 230
deep surgical dissection, 229230, 229f,
230f
internervous plane, 229
landmarks and incision, 228, 228f
patient position, 228
superficial surgical dissection, 229, 229f
Flexor tendon, 128, 229, 230
Fluoroscopy, 162
Foot
anatomy of dorsum of
deep artery, 244
nerve supply, 244
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249
Great toe
dorsal approach to the
metatarsophalangeal joint of
approach enlargement, 177
dangers, 177
deep surgical dissection, 177
internervous plane, 176
landmarks and incision, 176, 176f
patient position, 176
superficial surgical dissection, 177,
177f
dorsomedial approach to the
metatarsophalangeal joint of
approach enlargement, 182
dangers, 181182
deep surgical dissection, 181
internervous plane, 180
landmarks and incision, 180, 180f
patient position, 180
superficial surgical dissection, 181,
181f
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250 Index
Hindfoot
lateral approach, 6466
dangers, 66
deep surgical dissection, 64, 66f
enlarging, 66
incision, 64, 65f
internervous plane, 64
landmarks, 64
patient position, 64, 64f
superficial surgical dissection, 64, 65f
nailing, for ankle and subtalar joint fusion
approach enlargement, 121
dangers, 121
deep surgical dissection, 118120,
120f
internervous plane, 118
landmarks and incision, 118, 119f
muscles, first layer of, 120
muscles, second layer of, 120121
patient position, 118
superficial surgical dissection, 118,
119f
Incise retinaculum, 3f
Incision, dorsolateral, 170
Inferior extensor retinaculum, 131f, 134135
Internervous plane, 74. See also Talar neck
fractures
Interphalangeal joint, 176, 241, 242f
Ischemia, 128
Isolated midfoot joints, direct tarsal
approaches for
approach enlargement, 163
internervous plane, 162
landmarks and incision, 162
patient position, 162
surgical dissection, 162, 162f
LWBK1066-Ind-p247-252.indd 250
Malleolar osteotomy, 81
Malleolus, lateral
lateral approach to, 4043
dangers, 42, 133f, 138f
deep surgical dissection, 42, 138f
distal extension, 4243, 133f, 134f
incision, 40, 41f
internervous plane, 40
landmarks, 40
patient position, 40, 40f, 41f
proximal extension, 42
superficial surgical dissection, 42
Malleolus, medial. See also Medial
malleolus
anterior and posterior approaches, 1419
anterior incision, 15, 16f, 17, 17f,
129f
anterior incisions, 14, 15f
dangers, 17, 19
deep surgical dissection, 15
enlarging, 19
incisions, 14
internervous plane, 14
patient position, 14, 14f
posterior incision, 15, 17, 18f19f,
19, 129f130f
posterior incisions, 14, 18f
Medial malleolus, 2, 3f, 18f, 22f, 23f, 28,
88, 114
anterior of, 15f, 17f
Medial plantar artery, 121
Medial plantar sensory nerve, 192
Medial sesamoid bone, surgical approach
for
approach enlargement, 194
dangers, 193194
deep surgical dissection, 192193, 193f
internervous plane, 192
landmarks and incision, 192, 192f
patient position, 192
superficial surgical dissection, 192, 193f
Metatarsal bone, 98, 142, 162, 180, 192
Metatarsal cuneiform joint, 162
Metatarsal exostosis, excision of, 176
Metatarsal head, 216
excision of, 216
Metatarsal osteotomy, distal, 176
Metatarsocuneiform joint, 170
Onychogryphosis, 240
Os peroneum, lateral approach to
dangers, 111
deep surgical dissection, 111, 111f
internervous plane, 110
3/15/12 8:02 PM
Index
approach enlargement, 238
dangers, 238
deep surgical dissection, 237238,
237f, 238f
internervous plane, 236
landmarks and incision, 236, 236f
patient position, 236
superficial surgical dissection,
236237, 236f
LWBK1066-Ind-p247-252.indd 251
Retinacula, 128
Royal Air Force (RAF) fusion approach,
811. See also Ankle
251
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252 Index
Surgical dissection (continued)
of lisfrancs joint, 154156, 155f, 158,
159f
of metatarsal bones, 213214, 213f
of middle part of foot, 170, 171f, 172f
of mortons neuroma, 221, 221f,
224225, 224f
of nail bed ablation, 240241, 241f, 242f
of navicular bone, 146147, 147f
of os peroneum, 110111, 111f
of plantar fascia, 114116, 115f
of plantar fibromatosis, 166, 167f
of subtalar and ankle joint fusion,
118120, 119f, 120f
of sustentaculum tali, 124, 125, 125f
of talar neck fractures, 7576, 75f77f,
81, 81f, 82f
of talocalcaneal joint, 69, 69f, 70f
of talus, 84, 85f, 86f
of tibial sesamoid bone, 192193, 193f
of toe, 177, 177f
of toes, 229230, 229f, 230f
Sustentacular fractures, 124
Sustentaculum tali, medial approach to
dangers
arteries, 125
nerve, 125
deep surgical dissection, 125, 125f
extensile measures, 125126
internervous plane, 124
landmarks and incision, 124, 124f
patient position, 124
superficial surgical dissection, 124, 125f
LWBK1066-Ind-p247-252.indd 252
Talonavicular part
of joint, 139
Talus
direct lateral approach to, 84
approach enlargement, 8485, 86f
dangers of nerves, 84
deep surgical dissection, 84, 86f
internervous plane, 84
landmarks and incision, 84
patient position, 84, 84f
superficial surgical dissection, 84, 85f
forceful inversion and plantar flexion
of, 77f
posterior, posterolateral approach to
dangers, 96
deep surgical dissection, 9596, 96f
extensile measure, 96
internervous plane, 94
landmarks and incision, 94, 95f
patient position, 94, 94f
superficial surgical dissection,
9495, 95f
posteromedial approach to
dangers, 91
deep surgical dissection, 88, 89f,
90f, 91
extensile measures, 91
landmarks and incision, 88, 89f
patient position, 88, 88f
superficial surgical dissection, 88,
89f
Tarsal canal, 138
Tarsal metatarsal joints, 76
Tarsal tunnel syndrome, 129f, 134
Tarsometatarsal joint, 128
Tendons, 128
evertor, 128
extensor, 128
flexor, 128
of foot, 244
Tibial artery, 125
anterior, 128
identification of, 90f (see also Ankle joint)
posterior, 128, 129f
Tibialis anterior, 5f, 142, 162, 162f
tendon, 146, 163
Tibialis posterior, 23f, 162, 162f
tendon, 23, 24f
Tibial malleolus, 134
Tibial nerve, 125, 128, 133
identification of, 90f (see also Ankle
joint)
Tibial sesamoid bone, surgical approach for
approach enlargement, 194
dangers, 193194
deep surgical dissection, 192193, 193f
internervous plane, 192
landmarks and incision, 192, 192f
patient position, 192
superficial surgical dissection, 192, 193f
Tibiofibular ligament, 95
Toe, great
dorsal approach to the
metatarsophalangeal joint of
approach enlargement, 177
dangers, 177
deep surgical dissection, 177
internervous plane, 176
landmarks and incision, 176, 176f
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