- Email: [email protected]
Transverse Incisions to Approach the Metatarsophalangeal Joints
Transverse Incisions to Approach the Metatarsophalangeal Joints WILLARD E. DOTTER, M.D.
The object of this paper is to present the technique of the surgical approach to the metatarsophalangeal joint area by means of a transverse incision. History
A single transverse plantar incision just behind the toe web area was mentioned by Hoffman2 in 1911. In 1961 Lidstrom3 suggested use of the same incision. Claytonl in 1960 advised a dorsal transverse incision at the bases of the toes to approach the metatarsal head areas. Indications
In general, the use of a transverse incision to approach the metatarsophalangeal area is indicated if more than one digital base is to be exposed. Assuming the plantar surface of the metatarsal heads is to be attacked, a transverse incision should be considered especially if the ball of the foot is scarred from chemical, thermal, or radiation burns. The plantar transverse incision may be warranted also if the weight-bearing area has longitudinal surgical scars, hyperkeratotic fissures, or neurotrophic ulcers and scars. On the dorsal surface of the foot, exposure of the extensor tendons and metatarsophalangeal joints through a single transverse incision makes visualization of the structures much more efficient. This is especially so if severe hammertoe or clawtoe deformity exists. Lateral retraction of the edges of a longitudinal incision to expose a dorsal dislocation of a metatarsophalangeal joint often results in excess trauma to the soft tissues, unusual edema, and delay in healing with possible skin necrosis; poor visualization of the joint area before resection is common. However, plantar flexion of the dorsally dislocated hammertoe or clawtoe spreads the edges of the transverse incision, providing unsurpassed exposure of the operative field. Clayton2 preferred to operate on all such deformed toes through one dorsal transverse incision at the bases of the toes since the contour of the distal metatarsals could easily be adjusted as desired after the heads were 775
776
WILLARD
E.
DOTTER
removed. Dense scars or callosities are seldom encountered on the dorsal surface of the foot. Thus, the need to avoid such scars or weight-bearing points is not as important as on the plantar surface of the foot.
Theoretical Considerations The plantar incision follows the skin creases at the bases of the toes. It avoids by a considerable margin the bony prominences involved in weight-bearing in a shoe. If used on the dorsal surface of the foot the incision avoids areas which are subject to pressure from the shoe uppers or any folds in the toe caps. These folds will often pinch a longitudinal scar as the patient walks. Since one incision is adequate to expose all metatarsophalangeal joints if necessary, possible maceration from excessive retraction of single or multiple longitudinal incisions is avoided. The transverse incision closes easily; it is necessary only to approximate the skin edges with small mattress sutures. A neat, thin, movable cutaneous scar usually results. OPERATIVE TECHNIQUE
Dorsal Transverse Incision The toenails are trimmed as short as possible; the foot and toes are shaved if necessary, and then the foot is scrubbed thoroughly with surgical soap. With the patient in a supine position under general or spinal anesthesia the leg is elevated and wrapped snugly with an elastic bandage. A pneumatic tourniquet about the proximal third of the thigh is inflated to a pressure of 250 ffiffi. of mercury. The elastic bandage is then removed and the leg is draped in such a manner as to permit exposure of the foot in a sterile operative field. The skin incision (Fig. 1) starts from the medial side of the dorsal surface of the first metatarsal head and extends distally to the first metatarsophalangeal joint. It then curves sharply laterally, passing X' inch proximal to the four interdigital folds to the level of the fifth metatarsophalangeal joint, then curving sharply proximally to the dorsal aspect of the neck of the fifth metatarsal. Care must be taken to avoid extending the skin incision to the medial or lateral sides of the metatarsal heads where the scar would be subject to pressure from a shoe. Plantar flexion of the toes causes the skin edges to separate widely, permitting incision of the subcutaneous tissues in line with the skin incision. The extensor tendons can be isolated and the metatarsophalangeal joint capsules exposed by gentle retraction of the tendons. Small subcutaneous vessels may be encountered with the use of this incision; however, the neurovascular bundles to the toes are deep in the wound, well on the plantar side of the intermetatarsal areas.
TRANSVERSE INCISIONS TO ApPROACH THE METATARSOPHALANGEAL JOINTS
777
Fig. 1 Fig. 2 Fig. 3 Figure 1. Outline of the dorsal incision in its entirety. If the surgical task does not require an exposure as extensive as this, only the appropriate section is used. Figure 2. The plantar incision as outlined preoperatively. Figure 3. A photograph of the plantar surface of the foot taken when weightbearing demonstrates that the incision scar is not in a weight-bearing area during the stance pbase.
If only two or three metatarsophalangeal joint areas are to be exposed, that appropriate portion of the skin incision may be used.
Plantar Transverse Incision Surgical preparation and position of the foot and patient are the same as described for the dorsal incision. The plantar incision (Fig. 2) begins at a point ~ inch proximal to the first metatarsophalangeal joint flexion crease at the junction of the plantar and medial skin surfaces. It extends distally to a point ~ to U inch proximal to the first metatarsophalangeal joint flexion crease and then curves sharply laterally, passing ~ inch proximal to all of the metatarsophalangeal joint flexion creases of the toes. At the lateral side of the fifth metatarsophalangeal flexion crease the incision curves sharply proximally just lateral to the weight-bearing surface of the fifth metatarsal head terminating at the neck area. The toes then can be dorsiflexed, separating the skin edges and permitting section of the metatarsal fat pad in line with the skin incision. The neurovascular bundles, flexor tendons, metatarsal heads and metatarsophalangeal joint capsules are readily visualized on gentle traction of the pad and proximal skin flap. Again, only a portion of
778
WILLARD
E.
DOTTER
the incision need be used if desired exposure is limited to two or three metatarsophalangeal joints. Closure of either the dorsal or plantar wound is easily accomplished with the use of simple sutures or vertical mattress sutures. After closure of the wound, the tourniquet is released and a light pressure dressing is applied to the foot. The incision usually heals readily, permitting removal of sutures in seven days. Postoperative edema is dependent upon the operative procedure which is carried out, but is not considered unusual.
DISCUSSION
A transverse incision on the plantar surface of the foot permits adequate exposure of the metatarsophalangeal joints, proximal phalanges and metatarsal heads as well as the soft tissues in this area. This incision has been used to excise plantar neuromas, plantar fibromas, xanthomas of the flexor tendon sheaths, and condyles of metatarsal heads. Since the healed incision scar is well away from any weight-bearing point (Fig. 3) on the ball of the foot in either stance or push-off phase of gait, the ball of the foot is not jeopardized in tight, pointed shoes with thin soles, that is, stylish shoes. This incision bypasses any scars on the ball of the foot. The dorsal transverse incision has been used to excise metatarsal heads, remove the bases of proximal phalanges, extensor tenorrhaphies and recessions of toe extensor tendons into the necks of the metatarsals. The healed incision scar here blends well with skin lines. It does not produce a contracted keloid as often occurs with a longitudinal incision in this area. It is readily apparent that a combination of these two incisions makes an excellent incision for amputation of all toes or toes and metatarsals through a level as far proximal as the midpoint of the shafts.
CONCLUSIONS
A dorsal or plantar transverse incision at the bases of the toes facilitates surgical exposure of the metatarsophalangeal joint area. The incision heals well. Weight-bearing or shoe pressure does not irritate the scar.
REFERENCES 1. Clayton, M. L.: Surgery of the forefoot in rheumatoid arthritis. Clin. Orthop. 16:
136-140, 1960. 2. Hoffman, P.: An operation for severe grades of contracted or clawed toes. Am. J. Orthop. Surg. 9: 441-450 (Feb.) 1911. 3. Lidstrom, A.: Excision of metatarsal heads for pain under the anterior arch of the foot with weight-bearing. Acta orthop. 8candinav. 31: 329-336, 1961.
The object of this paper is to present the technique of the surgical approach to the metatarsophalangeal joint area by means of a transverse incision. History
A single transverse plantar incision just behind the toe web area was mentioned by Hoffman2 in 1911. In 1961 Lidstrom3 suggested use of the same incision. Claytonl in 1960 advised a dorsal transverse incision at the bases of the toes to approach the metatarsal head areas. Indications
In general, the use of a transverse incision to approach the metatarsophalangeal area is indicated if more than one digital base is to be exposed. Assuming the plantar surface of the metatarsal heads is to be attacked, a transverse incision should be considered especially if the ball of the foot is scarred from chemical, thermal, or radiation burns. The plantar transverse incision may be warranted also if the weight-bearing area has longitudinal surgical scars, hyperkeratotic fissures, or neurotrophic ulcers and scars. On the dorsal surface of the foot, exposure of the extensor tendons and metatarsophalangeal joints through a single transverse incision makes visualization of the structures much more efficient. This is especially so if severe hammertoe or clawtoe deformity exists. Lateral retraction of the edges of a longitudinal incision to expose a dorsal dislocation of a metatarsophalangeal joint often results in excess trauma to the soft tissues, unusual edema, and delay in healing with possible skin necrosis; poor visualization of the joint area before resection is common. However, plantar flexion of the dorsally dislocated hammertoe or clawtoe spreads the edges of the transverse incision, providing unsurpassed exposure of the operative field. Clayton2 preferred to operate on all such deformed toes through one dorsal transverse incision at the bases of the toes since the contour of the distal metatarsals could easily be adjusted as desired after the heads were 775
776
WILLARD
E.
DOTTER
removed. Dense scars or callosities are seldom encountered on the dorsal surface of the foot. Thus, the need to avoid such scars or weight-bearing points is not as important as on the plantar surface of the foot.
Theoretical Considerations The plantar incision follows the skin creases at the bases of the toes. It avoids by a considerable margin the bony prominences involved in weight-bearing in a shoe. If used on the dorsal surface of the foot the incision avoids areas which are subject to pressure from the shoe uppers or any folds in the toe caps. These folds will often pinch a longitudinal scar as the patient walks. Since one incision is adequate to expose all metatarsophalangeal joints if necessary, possible maceration from excessive retraction of single or multiple longitudinal incisions is avoided. The transverse incision closes easily; it is necessary only to approximate the skin edges with small mattress sutures. A neat, thin, movable cutaneous scar usually results. OPERATIVE TECHNIQUE
Dorsal Transverse Incision The toenails are trimmed as short as possible; the foot and toes are shaved if necessary, and then the foot is scrubbed thoroughly with surgical soap. With the patient in a supine position under general or spinal anesthesia the leg is elevated and wrapped snugly with an elastic bandage. A pneumatic tourniquet about the proximal third of the thigh is inflated to a pressure of 250 ffiffi. of mercury. The elastic bandage is then removed and the leg is draped in such a manner as to permit exposure of the foot in a sterile operative field. The skin incision (Fig. 1) starts from the medial side of the dorsal surface of the first metatarsal head and extends distally to the first metatarsophalangeal joint. It then curves sharply laterally, passing X' inch proximal to the four interdigital folds to the level of the fifth metatarsophalangeal joint, then curving sharply proximally to the dorsal aspect of the neck of the fifth metatarsal. Care must be taken to avoid extending the skin incision to the medial or lateral sides of the metatarsal heads where the scar would be subject to pressure from a shoe. Plantar flexion of the toes causes the skin edges to separate widely, permitting incision of the subcutaneous tissues in line with the skin incision. The extensor tendons can be isolated and the metatarsophalangeal joint capsules exposed by gentle retraction of the tendons. Small subcutaneous vessels may be encountered with the use of this incision; however, the neurovascular bundles to the toes are deep in the wound, well on the plantar side of the intermetatarsal areas.
TRANSVERSE INCISIONS TO ApPROACH THE METATARSOPHALANGEAL JOINTS
777
Fig. 1 Fig. 2 Fig. 3 Figure 1. Outline of the dorsal incision in its entirety. If the surgical task does not require an exposure as extensive as this, only the appropriate section is used. Figure 2. The plantar incision as outlined preoperatively. Figure 3. A photograph of the plantar surface of the foot taken when weightbearing demonstrates that the incision scar is not in a weight-bearing area during the stance pbase.
If only two or three metatarsophalangeal joint areas are to be exposed, that appropriate portion of the skin incision may be used.
Plantar Transverse Incision Surgical preparation and position of the foot and patient are the same as described for the dorsal incision. The plantar incision (Fig. 2) begins at a point ~ inch proximal to the first metatarsophalangeal joint flexion crease at the junction of the plantar and medial skin surfaces. It extends distally to a point ~ to U inch proximal to the first metatarsophalangeal joint flexion crease and then curves sharply laterally, passing ~ inch proximal to all of the metatarsophalangeal joint flexion creases of the toes. At the lateral side of the fifth metatarsophalangeal flexion crease the incision curves sharply proximally just lateral to the weight-bearing surface of the fifth metatarsal head terminating at the neck area. The toes then can be dorsiflexed, separating the skin edges and permitting section of the metatarsal fat pad in line with the skin incision. The neurovascular bundles, flexor tendons, metatarsal heads and metatarsophalangeal joint capsules are readily visualized on gentle traction of the pad and proximal skin flap. Again, only a portion of
778
WILLARD
E.
DOTTER
the incision need be used if desired exposure is limited to two or three metatarsophalangeal joints. Closure of either the dorsal or plantar wound is easily accomplished with the use of simple sutures or vertical mattress sutures. After closure of the wound, the tourniquet is released and a light pressure dressing is applied to the foot. The incision usually heals readily, permitting removal of sutures in seven days. Postoperative edema is dependent upon the operative procedure which is carried out, but is not considered unusual.
DISCUSSION
A transverse incision on the plantar surface of the foot permits adequate exposure of the metatarsophalangeal joints, proximal phalanges and metatarsal heads as well as the soft tissues in this area. This incision has been used to excise plantar neuromas, plantar fibromas, xanthomas of the flexor tendon sheaths, and condyles of metatarsal heads. Since the healed incision scar is well away from any weight-bearing point (Fig. 3) on the ball of the foot in either stance or push-off phase of gait, the ball of the foot is not jeopardized in tight, pointed shoes with thin soles, that is, stylish shoes. This incision bypasses any scars on the ball of the foot. The dorsal transverse incision has been used to excise metatarsal heads, remove the bases of proximal phalanges, extensor tenorrhaphies and recessions of toe extensor tendons into the necks of the metatarsals. The healed incision scar here blends well with skin lines. It does not produce a contracted keloid as often occurs with a longitudinal incision in this area. It is readily apparent that a combination of these two incisions makes an excellent incision for amputation of all toes or toes and metatarsals through a level as far proximal as the midpoint of the shafts.
CONCLUSIONS
A dorsal or plantar transverse incision at the bases of the toes facilitates surgical exposure of the metatarsophalangeal joint area. The incision heals well. Weight-bearing or shoe pressure does not irritate the scar.
REFERENCES 1. Clayton, M. L.: Surgery of the forefoot in rheumatoid arthritis. Clin. Orthop. 16:
136-140, 1960. 2. Hoffman, P.: An operation for severe grades of contracted or clawed toes. Am. J. Orthop. Surg. 9: 441-450 (Feb.) 1911. 3. Lidstrom, A.: Excision of metatarsal heads for pain under the anterior arch of the foot with weight-bearing. Acta orthop. 8candinav. 31: 329-336, 1961.