- Dorsal approach to the midfoot and the metatarsals
These three incisions will be used to approach the midfoot from medial for the first midmetatarsal injury and a second and third incision for the more lateral injuries.
The veins are superficial and should be preserved, especially those which run in the long axis of the metatarsus.
The long tendons lie superficially, while the short tendons are deep. The best approach is in between the long and the short extensor tendons, staying lateral of the EDL.
Branches of the deep peroneal nerve which divides to provide the superficial digital enervation must be identified and protected in this approach.
Dorsal double parallel and medial mini approach
In the forefoot, incisions should be straight, in the axis of the foot and should never be undermined.
The dorsomedial incision is centered over the TMT area, between the extensor hallucis longus tendon (EHL) and extensor hallucis brevis (EHB). This incision allows access to the first TMT and the medial base of the 2nd TMT.
The dorsolateral incision is centered over the TMT area, roughly in line with the fourth metatarsal.
A skin bridge as wide as possible should be maintained. But, as long as the area between the incisions is not undermined, the skin bridge is not compromised.
A third small medial incision (along the medial utility line) is used for screw placement into the midfoot and pointed reduction clamps for reduction.
This image shows a postop picture of approaches to first and second metatarsal base with the dorsomedial incision and approaches to the third and fourth metatarsal base with the dorsolateral incision. A small medial incision was used for reduction and screw placement.
Alternative incision for crush injuries
An alternative approach is the extensile dorsal salvage incision (EDSI/Zwipp).
The EDSI is useful in extreme injuries. It can be used for combined foot and leg injuries. It starts at the base of the second toe and runs straight up the foot to the ankle, and if needed it can be extended proximally along the anterior compartment of the leg. In the foot, it can be used for decompression as well as approach for ORIF. However, much tissue dissection is required when this is used for ORIF and this can lead to soft-tissue complications.
This deep dissection takes the surgeon to the keystone which is the base of the second MT as it articulates with the three cuneiform bones.
This illustration shows the second MT at its base as it articulates with the intermediate, medial cuneiform, and base of first MT. This allows the surgeon to carefully reduce and fix or fuse significant injuries.
The surgeon needs this approach to adequately reduce the fourth and fifth MT to the cuboid and to visualize cuboid fractures.