Lesser Toe MTP Joint Approach

Lesser Toe MTP joint approach exposes the metatarsophalangeal joints of the second, third, fourth, and fifth toes, it avoids incision of the foot plantar skin.

Lesser Toe MTP Joint Approach uses include the following:

1. Excision of metatarsal heads.
2. Distal metatarsal osteotomy.
3. Partial proximal phalangectomy.
4. Fusion of metatarsophalangeal joints (rare).
5. Capsulotomy of metatarsophalangeal joints.
6. Muscle tenotomy.
7. Neurectomy.

Position of the Patient

Place the patient Supine on operating table with a bolster under the thigh to flex the knee and keep the foot plantigrade on the table.

Landmarks and Incision

• Landmarks:
  • The Metatarsal head of the finger.
  • The tendons of the extensor digitorum longus.
• Incision:
  • Make a 2- to 3-cm longitudinal incision over the dorsolateral aspect of the affected metatarsophalangeal joint. The incision should run parallel with, but just lateral to, the long extensor tendon.
  • If two adjacent joints need to be exposed, make the incision between them. Alternatively, a transverse dorsal incision may be made over the joints.

Internervous plane

• There is no internervous plane for Lesser Toe MTP Joint Approach.
• The approaches are well dorsal to the plantar nerves and vessels, the key neurovascular structures in this area.
• Take care to avoid cutting the dorsal digital nerves, branches of which may cross the operative field.

Superficial dissection

• Incise the deep fascia in line with the incision, and retract the long extensor tendon to reveal the dorsal aspect of the metatarsophalangeal joint.
• Often, an extensor tenotomy or lengthening is performed at the same time as the operation on the joint.
• In this case, divide the extensor tendon in a “Z” fashion rather than retracting it. If two joints are being exposed, retract the tendon laterally to gain access to the adjacent joint.

Deep dissection

Incise the dorsal capsule of the metatarsophalangeal joint longitudinally to enter the joint.

Approach Extension

The approach rarely is enlarged and is used primarily for specific web space pathology.

Dangers

The structures at risk during Lesser Toe MTP Joint Approach include:

1.  Digital nerve and vessel.

References

• Surgical Exposures in Orthopaedics book – 4th Edition
• Campbel’s Operative Orthopaedics book 12th