Dorsal Approach to the Metatarsophalangeal Joint of the Great ToeThe dorsal approach can be employed for most of the surgeries to the metatarsophalangeal joint of the great toe for the treatment of bunions or hallux rigidus.
Its use includes the following:
Excision of metatarsal exostosis (bunionectomy)
Distal metatarsal osteotomy
Excision of the proximal part of the proximal phalanx
Soft-tissue correction of hallux valgus, including reefing procedures, tenotomies, and muscle reattachments
Arthrodesis of the metatarsophalangeal joint
Insertion of total joint replacements
Dorsal wedge osteotomy of the proximal phalanx in cases of hallux rigidus
The skin overlying a bunion may be red, thin, and inflamed. In extreme cases, frank ulceration with associated infection may occur. A careful assessment of the skin and vascular state of the foot is mandatory as part of the preoperative workup.
Position of the Patient
Place the patient supine on the operating table. After exsanguination, use a tourniquet placed mid-thigh. Alternatively, used a soft rubber bandage to exsanguinate the foot, then wrap the leg tightly just above the ankle (see Fig. 1-1).
Landmarks and Incision
Palpate the head of the first metatarsal bone and the metatarsophalangeal joint, which are on the ball of the foot and its medial border. In cases of bunion, the metatarsal head is prominent medially.
Palpate the extensor hallucis longus tendon on the dorsum of the foot. When it is tight, it stands out when the great toe is passively flexed in the plantar direction. In most cases of hallux valgus, it is displaced laterally.
Begin the dorsal incision just proximal to the interphalangeal joint and just medial to the tendon of the extensor hallucis longus muscle. Extend the incision proximally, parallel, and just medial to the tendon of the extensor hallucis longus. Finish about 2 to 3 cm proximal to the metatarsophalangeal joint. Note that the final incision is straight (Fig. 35-1).
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