Dorsal Approach to the Metatarsophalangeal Joints of the Second, Third, Fourth, and Fifth Toes

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 weight-bearing skin, violating a basic surgical principle.

The uses for the approach include the following:

Excision of metatarsal heads
Distal metatarsal osteotomy
Partial proximal phalangectomy
Fusion of metatarsophalangeal joints (rare)
Capsulotomy of metatarsophalangeal joints
Muscle tenotomy
Neurectomy

Position of the Patient

Place the patient supine on the operating table. Position a bolster under the thigh to flex the knee and allow the foot to lie with its plantar surface on the table (Fig. 45-1).

Landmarks and Incision

Landmarks

To palpate each metatarsal head, place a thumb on the plantar surface and an index finger on the dorsal surface of the foot. Skin callosities under the heads indicate that the area concerned is bearing an unaccustomed amount of weight and indicating pathology in the weight distribution around the foot.