Dorsal Approach to the Fifth Metatarsal Head for BunionetteThe dorsal approach to the fifth metatarsal head is used almost exclusively for surgery on bunionettes. This condition, which consists of a lateral prominence of the fifth metatarsal head, is frequently treated by a distal fifth metatarsal osteotomy. The use of distal osteotomy is reserved for this pathology. Lateral bowing of the fifth metatarsal requires a more proximal diaphyseal osteotomy that is usually oblique. Similarly, a bunionette caused by an increased intermetatarsal angle between the fourth and fifth rays is usually treated with a proximal fifth metatarsal osteotomy. Significant varus deviation of the fifth toe often requires an associated soft-tissue procedure.
The approach may also be used for other local pathologies of the fifth metatarsal head, such as drainage of infection and excision of tumors.
As with all distal foot incisions, peripheral vascular disease with an absent pedal pulse is a major contraindication to surgery, and careful examination of the vascular status of the foot is mandatory in the preoperative examination.
Position of the Patient
Place the patient supine on the operating table. After exsanguination, use a tourniquet placed on the middle of the thigh. Alternatively, use a soft rubber bandage to exsanguinate the foot, then wrap the leg tightly just above the ankle (see Fig. 7-1). Place a sandbag underneath the buttock of the affected side to internally rotate the leg and bring the lateral side of the foot into the operative field. Then tilt the table away from side of surgery to further increase internal rotation of the lower limb.
Landmarks and Incision
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