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: [email protected].
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
VOLUME
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.
594 THE JOURNAL OF FOOT & ANKLE SURGERY
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).
VOLUME
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.
VOLUME
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.
References
1. Albrecht GH. The pathology and treatment of hallux valgus. Russk
Vrach 10:14–19, 1911.
2. Truslow W. Metatarsus primus varus or hallux valgus? J Bone Joint Surg
7:98–108, 1925.
3. Kleinberg S. The operative cure of hallux valgus and bunions. Am J Surg
15:75–81, 1932.
4. Lapidus PW. The operative correction of the metatarsus primus varus in
hallux valgus. Surg Gynecol Obstet 58:183–191, 1934.
5. Lapidus PW. A quarter century of experience with operative correction
of the metatarsus varus in hallux valgus. Bull Hosp Joint Dis Orthop Inst
17:404–410, 1956.
VOLUME
6. Johnson KA, Kile TA. Hallux valgus due to cuneiform-metatarsal
instability. J South Orthop Assoc 3(4):273–282, 1994.
7. Hofbauer MH, Grossman JP. The Lapidus procedure. Clin Podiatr Med
Surg 13(3):485–496, 1996.
8. Neylon TA, Johnson BA, Laroche RA. Use of the lapidus bunionectomy
in first ray insufficiency. Clin Podiatr Med Surg 18(2):365–375, 2001.
9. Baravarian B, Briskin GB, Burns P. Lapidus bunionectomy: arthrodesis
of the first metatarsocunieform joint. Clin Podiatr Med Surg 21(1):
97–111, 2004.
10. Rink-Brune O. Lapidus arthrodesis for management of hallux valgus—
a retrospective review of 106 cases. J Foot Ankle Surg 43(5):290–295,
2004.
11. Fuhrmann RA. Arthrodesis of the first tarsometatarsal joint for
correction of the advanced splayfoot accompanied by a hallux valgus.
Oper Orthop Traumatol 17(2):195–210, 2005.
12. Treadwell JR. Rail external fixation for stabilization of closing base
wedge osteotomies and lapidus procedures: a retrospective analysis of
sixteen cases. J Foot Ankle Surg 44(6):429–436, 2005.
13. Hamilton GA, Mullins S, Schuberth JM, Rush SM, Ford L. Revision
lapidus arthrodesis: rate of union in 17 cases. J Foot Ankle Surg
46(6):447–450, 2007.
14. Gerard R, Stern R, Assal M. The modified Lapidus procedure.
Orthopedics 31(3):230–236, 2008.
15. Lagaay PM, Hamilton GA, Ford LA, Williams ME, Rush SM,
Schuberth JM. Rates of revision surgery using Chevron-Austin osteot-
omy, Lapidus arthrodesis, and closing base wedge osteotomy for
correction of hallux valgus deformity. J Foot Ankle Surg 47(4):
267–272, 2008.
16. Coetzee JC, Resig SG, Kuskowski M, Saleh KJ. The Lapidus procedure
as salvage after failed surgical treatment of hallux valgus: a prospective
cohort study. J Bone Joint Surg Am 85-A(1):60–65, 2003.
17. Faber FW, Mulder PG, Verhaar JA. Role of first ray hypermobility in the
outcome of the Hohmann and the Lapidus procedure. A prospective,
randomized trial involving one hundred and one feet. J Bone Joint
Surg Am 86-A(3):486–495, 2004.
18. Coetzee JC, Wickum D. The Lapidus procedure: a prospective cohort
outcome study. Foot Ankle Int 25(8):526–531, 2004.
19. Augustin G, Davila S, Mihoci K, Udiljak T, Vedrina DS, Antabak A.
Thermal osteonecrosis and bone drilling parameters revisited. Arch
Orthop Trauma Surg 128(1):71–77, 2008.
20. Ray RG, Ching RP, Christensen JC, Hansen ST. Biomechanical analysis
of the first metatarsocuneiform arthrodesis. J Foot Ankle Surg 37:
376–385, 1998.
21. Burr DB. Anatomy and physiology of the mineralized tissues: role in the
pathogenesis of osteoarthrosis. Osteoarthritis Cartilage 12(Suppl A):
S20–S30, 2004.
60148, NUMBER 5, SEPTEMBER/OCTOBER 2009