Increasing the safety of minimally invasive hallux surgery-An anatomical study introducing the clock method

Foot Ankle Surg. 2018 Feb;24(1):40-44. doi: 10.1016/j.fas.2016.11.004. Epub 2016 Nov 17.


Background: The purpose of this study is to describe a simple and reproducible method to localize the neurological structures at risk and to describe a safe zone for hallux minimally invasive surgery (MIS) procedures.

Methods: Ten fresh-frozen cadaveric feet were dissected to identify the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) of the first toe. Axial sections were performed at the sites of metatarsal osteotomies. We documented the position of the nerves with respect to the extensor hallucis longus (EHL) tendon using a clock method superimposed on the axial section RESULTS: The DMDN was found at an average of 26.2° medial to the medial border of the EHL tendon. (SD 11.26, range 14.5-45.5), whereas the average distance of the DLDN was 32.3° lateral to the medial border of the EHL tendon. (SD 6.29, range 13.5-40).

Conclusions: Using the clock method the DMDN and DLDN were found consistently between 10 o'clock and 2 o'clock in either right and left feet. The clock method may facilitate avoiding the area where these nerves are located serving as a valuable tool in minimally invasive foot surgery.

Keywords: Anatomy; Arthroscopy; Cadaveric study; Hallux rigidus; Hallux valgus; Iatrogenic nerve injury; Minimally invasive surgical procedures.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cadaver
  • Dissection
  • Female
  • Hallux / anatomy & histology
  • Hallux / innervation*
  • Hallux / surgery*
  • Humans
  • Male
  • Middle Aged
  • Minimally Invasive Surgical Procedures / methods*
  • Minimally Invasive Surgical Procedures / standards*
  • Osteotomy
  • Patient Safety*