Dorsomedial Approach to the Metatarsophalangeal Joint of the Great Toe

The dorsomedial approach makes possible most surgeries to the metatarsophalangeal joint of the great toe for the treatments of bunions or hallux rigidus.

The dorsomedial skin incision provides access to the exostosis on the metatarsal head without much skin retraction; it does have drawbacks, however. The bursa covering the exostosis may have become inflamed, complicating the surgery. As well, the skin on the medial aspect of the metatarsophalangeal joint is thinner than on the dorsum of the joint, and may not heal as well.

The major advantage of the skin incision is that it gives direct access to the exostosis and is anatomically farther away from the terminal branches of the saphenous nerve.

Its use includes the following:

Excision of exostosis of the first metatarsal (bunionectomy)
Excision of the proximal part of the proximal phalanx of the hallux (Keller’s procedure)
Procedures on the medial joint capsule, including reefing and V-Y plasties
Arthrodesis of the metatarsophalangeal joint
Insertion of total joint replacements
Dorsal wedge osteotomy of the proximal phalanx in cases of hallux rigidus

Position of the Patient

Place the patient supine on the operating table. After exsanguination, place a tourniquet 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. 1-1).

Landmarks and Incision

The head of the first metatarsal bone and the metatarsophalangeal joint are palpable on the ball of the foot and on 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 upon passive flexion of the great toe in the plantar direction.

Figure 36-1 Dorsomedial skin incision for the medial approach to the metatarsophalangeal joint of the great toe. Note the proximity of the dorsal digital nerve to the incision.

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