JFAS TECHNIQUES GUIDE

First Metatarsal-Cuneiform Arthrodesisfor the Treatment of First Ray Pathology:A Technical GuideGregory A. Mote, DPM,1 Daniel Yarmel, DPM,2 and Amber Treaster, DPM, AACFAS3

The first tarsometatarsal arthrodesis is a powerful procedure often utilized in the correction of first raypathology. It is primarily used to correct moderate to severe hallux abducto valgus deformity. Theauthors present this review as a summation of the classic and recent literature while offering a detailedillustrated technique guide for the first tarsometatarsal arthrodesis. (The Journal of Foot & Ankle Surgery48(5):593–601, 2009)

Key Words: lapidus, hallux abducto valgus, arthrodesis, bunion, fusion

The first tarsometatarsal arthrodesis (TMA) is a powerful

procedure often utilized in the correction of first ray

pathology. Although primarily used to correct moderate to

severe hallux abducto valgus (HAV) deformity, it may be

used in a variety of first ray and medial column pathology,

including juvenile HAV, revisional HAV surgery, hallux

limitus, hallux rigidus, met primus varus, met primus eleva-

tus, arthrosis of the first metatarsal-cuneiform joint (TMJ),

and medial column instability. Since its inception in the early

1900s, there have been many modifications used to enhance

outcomes and minimize complications. Many of these

advances are related to the advent of modern internal and

external fixation. Although the incidences of complications

are relatively low, the most common complication after

infection is nonunion.

Address correspondence to: Gregory A. Mote, DPM, Delaware Footand Ankle Group. Glasgow Medical Center, 2600 Glasgow Ave, Ste 107,Newark, DE 19702. E-mail: gamote@comcast.net.

1Attending Surgeon, Private Practice, Delaware Foot and Ankle Group,Glasgow Medical Center, Newark, DE (research conducted while PGY-4at PENN Presbyterian Medical Center, Philadelphia, PA).

2Attending, Pinnacle Health System, Harrisburg, PA; private practice:Harrisburg Foot and Ankle Center, Harrisburg, PA (research conductedwhile PGY-4 at PENN Presbyterian Medical Center, Philadelphia, PA).

3Attending, Pinnacle Health System, Harrisburg, PA; private practice:Harrisburg Foot and Ankle Center, Harrisburg, PA.

Financial Disclosure: None reported.Conflict of Interest: None reported.Copyright � 2009 by the American College of Foot and Ankle Surgeons1067-2516/09/4805-0015$36.00/0doi:10.1053/j.jfas.2009.05.009

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The authors present this review as a summation of the

classic and recent literature while offering a detailed illus-

trated technique guide for the first TMA.

Classic Literature Review

Although originally introduced by Albrecht in 1911 (1)

and further described by Truslow in 1925 (2) and Kleinberg

in 1932 (3), the first TMA did not gain acceptance until popu-

larized by Paul W. Lapidus in 1934 (4). Lapidus believed that

an ‘‘atavistic’’ foot type and ‘‘arrest of ontogenic develop-

ment’’ led to an excessively adducted first metatarsal at the

first TMJ and subsequent hallux valgus (Figure 1). Lapidus

originally recommended patients who were ‘‘young and

robust,’’ with ‘‘fixed’’ deformity at the first TMJ as surgical

candidates (5). Additionally, a first intermetatarsal angle of

15� or higher was regarded as the radiographic threshold

for performing the first TMA.

The procedure Lapidus first described included arthrodesis

of the first TMJ, arthrodesis of the first and second metatarsal

bases, and medial capsulorrhaphy of first metatarsophalan-

geal joint (MTPJ). Fusion sites were prepared with drill holes

and fixation was accomplished with cat gut suture (5). After

25 years, Lapidus reported his experience and described the

first TMA useful in ‘‘properly selected cases,’’ reserving the

procedure for significant hypermobility and deformity (5).

Over the last 75 years, there has been much controversy

and debate on the use of the first TMA procedure and its indi-

cation for correction of HAV, with particular focus on the

59348, NUMBER 5, SEPTEMBER/OCTOBER 2009

role of the hypermobile first ray. Yet, despite the lack of

consensus on its indications and use, the first TMA still

remains one of the most common procedures utilized for

correction of first ray pathology. Considering the number

of years that have elapsed since the first report in the litera-

ture, it is surprising to find that the number of prospective

outcome studies reported is quite low. Although there have

been multiple retrospective studies (6–15), prospective

studies are less plentiful. Coetzee et al in 2003 (16) prospec-

tively evaluated 26 patients who underwent a first TMA for

failed HAV surgery. Their procedure included arthrodesis

of the first TMJ and arthrodesis of the first and second meta-

tarsal bases utilizing screw fixation. They reported a signifi-

cant reduction in the postoperative VAS (visual analog scale)

(6.2 to 1.4) and an improved American Orthopaedic Foot and

Ankle Society (AOFAS) score (47.6 to 87.9). No ‘‘dissatis-

fied’’ patients were reported. Faber et al in 2004 (17) per-

formed a prospective randomized trial in 101 feet,

comparing the Lapidus procedure with the Hohman proce-

dure. Similar to Coetzee’s report, their outcomes included

pain scores using the VAS and the AOFAS clinical scoring

system. In addition, they identified a subset of ‘‘hypermobile

FIGURE 1 Preoperative clinical photograph.

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feet’’ to compare the effectiveness of the procedures in that

subgroup. Their results showed statistically significant

improvements in both VAS and AOFAS postoperatively,

with no difference between procedures or subgroups. The

only differences found were radiographic in that the Lapidus

procedure demonstrated greater plantarflexion of the first

metatarsal, whereas the Hohman procedure showed greater

shortening of the first metatarsal. Finally, in 2004 Coetzee

and Wickum (18) reported prospectively on 105 feet in 91

patients that were followed up for an average of 3.7 years.

Similar to previous findings, the AOFAS score increased

from 52 preoperatively to 87 postoperatively. There were

significant reductions in both the intermetatarsal and hallux

abductus angles. They also reported their complications,

stating there were 7 (6.7%) nonunions that required revision.

In summation, although well-defined indications for use of

the Lapidus procedure are unclear, the literature supports

the use of the Lapidus procedure for correction of first ray

deformities with and without hypermobility.

Technique Guide

Anesthesia may be achieved with either a general inhala-

tion anesthetic or monitored anesthesia care. Local anesthesia

is recommended in either case, as decreased exposure to

FIGURE 2 Incisional approach.

systemic agents is preferred. The agent used for local

blockade is under the discretion of the surgeon. Positioning

of the patient is in the supine position, with the heel at the

end of the operative table. The operative foot should be placed

in a rectus position. An ipsilateral bump placed under the

buttock may be necessary to achieve desired positioning.

There have been multiple incisional approaches described

in the literature. These include 3, 2, and 1 incisional

approaches. The 3-incisional approach includes an incision

over the first TMJ, the medial first MTPJ, and the first inter-

space. The 2-incisional approach includes the first TMJ inci-

sion, and the first MTPJ incision. Finally, the single-incision

approach extends from the mid portion of the medial cunei-

form to the mid portion of the hallux proximal phalanx.

This is the preferred approach of the authors (Figure 2). The

incision courses along the dorsomedial foot, just medial to

the extensor hallucis longus tendon. Sharp dissection is

carried through the epidermis and dermis, with blunt dissec-

tion with scissor or hemostatic forceps being used for subcu-

taneous tissues. The dissection of the first MTPJ is undertaken

FIGURE 3 Anatomic relationship of extensor hallucis longus (blackline), extensor hallucis capsularis (blue line), and placement of peri-

osteal/capsular incision (red line).

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to release joint contracture and resect the prominent medial

eminence if necessary. Blunt reflection of deep fascial tissues

along the medial aspect of the first MTPJ is performed with

attention directed to neurovascular structures of the medial

foot. In contrast to distal osteotomies, there is less dissection

about the medial eminence secondary to the absence of an os-

teotomy in the distal metatarsal. Next, attention is directed to

the first metatarsal interspace in which blunt dissection allows

for a lateral capsule release if desired. The decision to perform

a lateral release and which structures should be released is

under the discretion of the surgeon. The authors perform

a sequential release of the adductor tendon, metatarsal sesa-

moidal ligament, and sesamoidal phalangeal ligament as

necessitated by the deformity. A periosteal-capsular incision

is made along the dorsomedial first MTPJ in the interval

between the extensor hallucis longus and extensor hallucis

capsularis (Figure 3). The extent of the incision should allow

for exposure to the medial eminence. The authors use an ‘‘L’’

type capsulotomy for exposure of the eminence, which is

subsequently resected with power instrumentation with care-

ful attention to maintain the sagittal groove. Once the contrac-

tures about the first MTPJ are released and the hallux is

FIGURE 4 Subcutaneous dissection with the course of the medialdorsal cutaneous nerve (red arrow) traveling from lateral to medial

within the incision.

59548, NUMBER 5, SEPTEMBER/OCTOBER 2009

mobilized, it is manually reduced while an abductory force is

placed upon the first metatarsal to assess realignment. Once

satisfactory, dissection of the first TMJ is undertaken, and

special attention must be paid to the course of the medial

dorsal cutaneous nerve, which often crosses from lateral to

medial within the incision (Figure 4). A periosteal-capsular

incision is made dorsally from the midpoint of the medial

cuneiform traveling distally to approximately 1 to 1.5 cm

distal to the first TMJ (Figure 5A). Perisoteal dissection is

continued plantarly (Figure 5B). Other authors have

purported a vertical capsulotomy at the first TMJ to decrease

the amount of periosteal reflection, thereby reducing the

chance of bone healing complications. The authors have not

found their periosteal dissection to be problematic as long

as careful layer dissection and closure are used. When dissect-

ing the lateral aspect of the first TMJ, attention must be given

to the course of the dorsalis pedis artery laterally and the

perforating artery plantarly just distal to the conjunction of

the first and second metatarsals. Once the first TMJ is

released, a Weinraub retractor is placed to further open the

arthrodesis site and joint resection may be undertaken. The

authors utilize osteotomes (Figure 6), although it is recog-

nized that curettage or use of power instrumentation may

produce similar results. The base of the first metatarsal is

resected, removing just cartilage. The plane of the cut is

perpendicular to the long axis of the first metatarsal. The

resection is from a medial to lateral direction, with caution

taken when approaching the lateral aspect of the metatarsal

to avoid the aforementioned neurovascular structures as

well as the second metatarsal base. If wedge resection is

desired, then the osteotomy may be directed to allow for

plantar and laterally based wedges off the metatarsal to create

FIGURE 5 (A) Periosteal/capsulardissection at the first tarsometatar-

sal joint. (B) Plantar and medial

dissection at the first TMJ.

FIGURE 6 Cartilage removal with osteotome.

FIGURE 7 Use of rongeur for plantar and lateral bone adhered tosoft tissue.

596 THE JOURNAL OF FOOT & ANKLE SURGERY

greater abduction and plantarflexion of the first metatarsal.

Once the metatarsal cartilaginous base has been resected,

the medial cuneiform cartilage may now be resected. The

cuneiform cartilage is also resected from medial to lateral.

The orientation of the bone cut is perpendicular to the long

axis of the cuneiform. Because of the commonly present

obliquity of the articular surface, the osteotomy often creates

a laterally based wedge resection. Particular attention must be

paid to the lateral and plantar aspects of the fusion site because

these often retain cartilaginous remnants. Often, the insertion

of peroneus longus is encountered at the plantar lateral aspect

of the first metatarsal base and the flare of the metatarsal is

firmly adhered. A rongeur may be used to remove the adhered

bone (Figure 7). If the lateral flare of the metatarsal is promi-

nent, then it may be resected within the sagittal plane to

narrow the metatarsal to allow for translation. Once appro-

priate joint resection (with or without wedging) is complete,

then preparation of the arthrodesis site is undertaken. This

may be performed with subchondral drilling using 0.035- to

0.045-inch Kirschner wire (K-wire) (Figure 8) or

a �1.5-mm drill bit. ‘‘Fish scaling’’ was performed with an

osteotome or microfracture technique. The authors prefer

the microfracture technique with the use of a small awl or

pick and mallet. The goal of arthrodesis site preparation is

to achieve a healthy bleeding substrate. This can be identified

by the presence of pinpoint bleeding at the osteotomy site,

also known as the ‘‘paprika sign.’’ The metatarsal may be

transposed laterally and plantarly as needed. If wedge resec-

tion is used, transposition may not be necessary. Next,

FIGURE 8 Arthrodesis site preparation with use of 0.035-in K-wire.

FIGURE 9 Temporary fixation with 0.062-in K-wire.

FIGURE 10 Temporary stabilization of reduced intermetatarsal

angle with 0.062-in K-wire.

597VOLUME 48, NUMBER 5, SEPTEMBER/OCTOBER 2009

temporary fixation with a 0.062-inch K-wire is used at the

arthrodesis site (Figure 9), and the position is evaluated radio-

graphically. If necessary, a K-wire may be placed between the

first and second metatarsals to ensure intermetatarsal space

reduction (Figure 10). Special attention must be paid to inter-

metatarsal reduction, hallux position, sesamoid position, and

the metatarsal parabola to ensure avoidance of transfer meta-

tarsalgia, recurrence, hallux varus, and other postoperative

complications. Positioning of the arthrodesis site is of para-

mount importance and, in the authors’ opinions, intraopera-

tive fluoroscopy is a necessity (Figure 11). Clinically, the

foot should be balanced, with even weight distributed

between the medial and lateral columns while loading the

forefoot.

Once satisfactory positioning is achieved, the arthrodesis is

stabilized with internal fixation. Many fixation techniques

may be utilized including K-wires, screws (both cannulated

FIGURE 11 Use of intraoperative fluoroscopy.

598 THE JOURNAL OF FOOT & ANKLE SURGERY

and solid core), plating systems (locking and nonlocking),

external fixation (monorail), or a combination. The authors

prefer the use of a locked plating system (typically

a 3.5-mm ‘‘H-plate’’ configuration) combined with an inter-

fragmentary compression screw (typically 3.5-4.0mm). The

compression screw is placed first and is directed from plantar

medial to dorsolateral (Figure 12). The screw will engage the

plantar first metatarsal cortex and the endosteal cortical bone

at the dorsolateral aspect of the medial cuneiform. Positioning

of this screw enables resistance of ground reaction forces. The

plate is then placed in a dorsomedial position. Temporary

fixation of the plate with K-wire or olive wires is recommen-

ded to hold the desired position (Figure 13). Drilling and

measurement are performed in the typical fashion. If further

stabilization is desired, then one can lengthen the plate screws

to enable penetration of the intermediate cuneiform.

Completion of the arthrodesis of the first TMJ is followed

by first MTPJ capsulorrhaphy and closure to maintain a rectus

position of the hallux. The authors perform a dorsally based

rhomboid wedge resection from the medial capsule. The

capsule is closed with 2-0 gauge absorbable suture. Deep

FIGURE 12 Placement of 4.0-mm partially threaded compressionscrew.

capsular closure is on a bias from proximal dorsal to distal

plantar to ensure reduction. The remaining periosteal and

capsular layers are closed with a similar technique, in an

over-and-over interrupted fashion. Subcutaneous tissues are

closed with an absorbable 4-0 gauge suture, in a continuous

running fashion. Finally, skin closure is achieved with a 5-0

gauge absorbable suture in a continuous running fashion. A

dry, sterile dressing is applied, including an ACETM bandage

(Becton, Dickinson and Company, Franklin Lakes, NJ) for

compression. A nonweightbearing short leg cast is applied

for a period of 8 weeks. Cast changes occur at 1, 4, and

8 weeks. Serial radiographs are performed immediately post-

operatively and at 4 and 8 weeks. Typically, transition to

a weightbearing cast occurs at the 8-week interval.

Discussion

The first TMA, popularly known as the Lapidus procedure,

remains a mainstay for the treatment of first ray pathology,

FIGURE 13 Locking plate placement with olive wires.

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with the majority of its use seen in the correction of moderate

to severe HAV deformity with or without hypermobility.

Although the precise indications for its use are under constant

debate, the majority of the literature (primarily retrospective,

with few prospective studies) has been favorable with respect

to the outcome of the procedure. These outcomes include

both radiographic and clinical outcomes.

Pearls

1. When resecting the joint, using a mini-Hohman retractor

or malleable retractor within the first interspace will

protect the neurovascular structures and second meta-

tarsal base.

2. Because of the inherent risk of nonunion, joint prepara-

tion must be performed correctly. Although there are

data to support the onset of osteonecrosis with use of

excessive drilling (19), patient-based comparisons of

FIGURE 14 Radiograph showing alternate fixation construct with

plate screws traversing the intercuneiform and intercuneiform-meta-

tarsal joints.

59948, NUMBER 5, SEPTEMBER/OCTOBER 2009

joint preparation techniques in foot surgery do not exist.

In theory, the use of microfracture or ‘‘fish scaling’’

should decrease the probability of thermal osteonecrosis.

3. Removal of the subchondral bone plate is also debat-

able. Most authors advise leaving the subchondral

bone plate intact (with subchondral bone plate perfora-

tion) to maintain the length and stability of the bone

(8–11, 20). In contrast, subchondral bone has been

described as ‘‘corticalized’’ bone (21). Therefore,

some authors believe that removing the subchondral

bone plate will aid in consolidation of the arthrodesis

site (18). If shortening occurs, then bone grafting can

be utilized. Use of the resected medial eminence has

been described as a suitable bone graft (18). It is the

authors’ opinions that, at the very minimum, significant

perforation of the subchondral bone plate must be per-

formed, if not complete removal.

4. Further wedge resection, if necessary, should be taken

off of the first metatarsal base. The first metatarsal is

the mobile segment and is easier to manipulate. Often,

once the joint surfaces have been resected, the first meta-

tarsal can be swiveled or transposed to reduce the first

intermetatarsal angle, thus reducing the need for wedge

resection.

5. Occasionally, it is necessary to resect the lateral flare of

the first metatarsal base to increase the ability to swivel

or translocate the first metatarsal. Sharp dissection of the

plantar soft tissue attachments may be necessary.

6. Use of a smooth lamina spreader or Weinraub retractor

will aid in visualization of the arthrodesis site.

7. The advent of step-off plating (Wright Medical DARCO

LPS locking plate; Wright Medical Technology, Inc.,

Arlington, TN) allows the surgeon to swivel or trans-

pose the first metatarsal without further bone resection

or plate bending.

8. If plating is used, then one must consider a compression

screw to enhance apposition at the fusion site. Locking

plate and screw systems provide nice stability, but often

do not afford the compression obtained with a compres-

sion screw. The authors recommend 3.5-mm or larger

screws.

9. Stabilization of the medial column can be enhanced with

elongated screws within the plate and/or the compres-

sion screw. Using longer screws that traverse the

FIGURE 15 Preoperative (A) andimmediate postoperative (B) radio-

graphs showing reduction of defor-

mity.

600 THE JOURNAL OF FOOT & ANKLE SURGERY

intercuneiform or intermetatarsal joints will add stability

(Figure 14).

10. Temporary fixation with K-wires or guide pins in

multiple planes can aid in the maintenance of correction

during permanent fixation. Use of a K-wire from the first

to second metatarsal allows for consistent reduction and

maintenance of correction of the first intermetatarsal

angle while plate and screw fixation are applied.

In conclusion, the first TMA is a powerful procedure that

may be utilized in various first ray pathologies (Figure 15).

Complications include nonunion, delayed union, metatarsalgia,

and sesamoiditis. These complications are under control of the

surgeon and may be avoided with proper surgical techniques

such as arthrodesis site preparation, use of temporary fixation,

and intraoperative fluoroscopy. Further prospective studies are

needed to further evaluate the success of the procedure.

Acknowledgments

The authors would like to thank Michael S. Downey, DPM,

FACFAS, Chief of Podiatric Surgery Section, D. Scot Malay,

DPM, FACFAS, MSCE, Director of Research, and Harold

Schoenhaus, DPM, FACFAS, PENN Presbyterian Medical

Center, Philadelphia, PA, for assistance in proofing the manu-

script and for use of intraoperative photographs.

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