Arthrodesis of the First Metatarsocuneiform Joint

Abduction of the first metatarsal to correct metatarsus primus varus and hallux valgus was first described by Albrecht in 1911. Lapidus in 1934 advocated fusion of the first and second metatarsals with the first cuneiform. Overall uses of the procedure since its initiation have been dedicated to hallux valgus with a relatively high intermetatarsal angle. Clark, Veith, Sangeorzan, and Hansen have utilized the Lapidus procedure for correction in postadolescent hallux valgus. Bacardi and Saffo have advocated the utilization of the procedure for severe metatarsus primus varus. The procedure has gained popularity in the past 10 years, perhaps because The Association for the Study of Internal Fixation (ASIF) techniques, with more precise placement of the distal first metatarsal and high fusion rates, have been used. Objectives of the procedure include reduction of the high intermetatarsal angle and stabilization of obliquity/hypermobility at the first metatarsocuneiform joint. Previous complications of the procedure included less than optimal position of the first metatarsal head, secondary to elevation, or nonunion, which may produce moderate to severe forefoot instability. Patient selection varies with age; however, most procedures have been targeted to the adolescent-to50-year-old population. In most instances, the patient complains of shoe-fitting difficulties as well as appearance problems, pain, ambulatory difficulties, and impingement syndromes to the lateral forefoot, including formation of metatarsalgia, hammer toes, and Morton's neuroma. Specific indications for the procedure include juvenile hallux valgus with obliquity or hypermobility at the first metatarsocuneiform joint, paralytic hallux valgus (either spastic or flaccid in nature), osteoarthritis, traumatic degenerative joint disease secondary to an old Lisfranc injury, severe adult hallux valgus with intermetatarsal angles exceeding 18° (Fig. 19-1), and as an ancillary procedure for the correction of flatfoot of an idiopathic nature or secondary to a posterior tibial tendon rupture, generalized ligamentous laxity, or medial column instability. The procedure is usually combined with a distal first metatarsal procedure, including exostectomy, sesamoid release, distal or midshaft first metatarsal osteotomy, joint implant and proximal phalangeal techniques, including the modified Keller bunionectomy or Regnauld procedure. Arthrodesis is used less frequently than proximal metatarsal osteotomies or distal osteotomies, which may be secondary to the complications encountered in performing the technique. Excess bone removal or elevation of the distal fragment will cause severe forefoot dysfunction, a result that is less than optimal. Patient selection is of paramount importance in the procedure. The long-term effects of fusion of the first metatarsocuneiform joint in the adolescent population are not specifically known at this time. The incidence of nonunion approaches 10 percent and is also a factor in increasing the complication rate with this procedure. Specific preoperative criteria can be highlighted in three areas: (1) hallux valgus; (2) osteoarthritis of degenerative joint disease of the metatarsocuneiform articulation; and (3) as an adjunct procedure to increase