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Authors of section


Khairul Faizi Mohammad, Brad Yoo

Executive Editors

Markku T Nousiainen, Richard Buckley

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Arthrodesis of metatarsals 1–3 (length unstable)

1. General considerations

If fragmentation is such that the joint cannot be reconstructed, the options are:

  • Nonoperative treatment
  • Primary fusion

None of these options are ideal.

The results may be unsatisfactory because of the fracture’s intraarticular nature, and the patient may complain of pain and stiffness.

As fusion is permanent, the decision to perform fusion should be considered for only significantly damaged articular surfaces.

Plates are used in cases with bone loss where maintenance of length is desirable.

A dorsal plate is less prominent than a medially placed plate (first metatarsal).

Associated midfoot instability is common and should be identified if present.

Arthrodesis of a TMT joint with a plate and bone graft
Note on illustrations - To illustrate this procedure, a fractured 1st metatarsal is shown. The principles and the step-wise procedure are identical for the second and third metatarsals.

Anatomical considerations

Proper alignment of the metatarsal heads is a critical goal in restoring the forefoot mechanics.

A normal curved “cascade” (Lelièvre’s parabola) appearance, which is symmetric with the other foot, is mandatory on the AP view. See illustration. This symmetry ensures that the normal length of the metatarsal is restored.

It is also critical to restore the metatarsals in their axial or horizontal plane so that all the metatarsal heads are on the same level in the axial view.

Any malalignment, particularly flexion, will recreate focally high pressure during the stance phase and toe-off, resulting in pain and subsequent callus formation.

The sesamoids, rather than the first metatarsal head, bear weight in the first row. Therefore, one must look at the sesamoid level in establishing the alignment in the axial or horizontal plane of the first metatarsal.

Anatomical alignment of the metatarsal heads

Timing of surgery

The timing of surgery is influenced by the soft tissue injury and the patient's physiologic status.

timing of surgery

2. Temporizing measures

Medial and lateral external fixation (with a distractor device to restore columnar length) may be applied as soon after the injury as possible to stabilize the foot and decrease further injury to the soft tissues.

Percutaneous K-wires can be used to reduce displaced fragments and left as temporary fixation.

3. Patient preparation

This procedure is typically performed with the patient placed supine with the knee flexed at 90°.

Patient position supine for surgical treatment of the foot

4. Approach

Selection of approach

Fractures of the first metatarsal can be approached through a medial or a dorsal approach:

Any single metatarsal injury in metatarsals 2–3 can be approached through the following dorsal approach:


A medial-column distractor may be used to restore the length of the medial column.

If the medial distraction creates an abduction deformity, applying a lateral distractor may help minimize the angulation.

It is helpful to have comparative x-rays from the uninjured side, allowing proper length and morphology to be judged.

The proximal pin is inserted into the neck of the talus through a stab incision. Image intensification can ensure correct pin placement outside the articular surfaces. The correct insertion point is often located 1–2 cm posterior to the navicular tubercle.

The distal pin is inserted in the first metatarsal.

Medial- and lateral-column distractor applied to improve visualization of a length unstable proximal 1st metatarsal fracture

5. Irrigation and debridement

Irrigate the fracture site using a syringe.

Irrigation of a proximal articular fracture of the 1st metatarsal

Displaced fracture fragments are debrided and mobilized with a dental pick or Freer elevator. Debrided cancellous fragments should be kept and used as bone grafts at the end of the procedure.

Once adequate visualization has been achieved and the joint thoroughly irrigated, examine the extent of articular surface involvement to validate the preoperative plan of primary fusion versus ORIF.

If joint fragmentation is not extensive and tarsometatarsal instability is absent, it may be possible to perform fixation.

Debridement of a proximal articular fracture of the 1st metatarsal

6. Preparation of joint for fusion

Preparation of joint for fusion

Remove the cartilage from the adjacent bone using a curette.

Cartilage removal of the adjacent bone for arthrodesis of the 1st TMT joint

Penetrate the subchondral bone using a high-speed burr to promote bone growth.

Promoting bone growth by penetrating the subchondral bone for arthrodesis of the 1st TMT joint

7. Fixation of arthrodesis

Plate contouring

Contour a T-plate to fit the bone surface.

For the first TMT joint, a 3.5 mm plate can be used, which allows for three-screw fixation in the distal and proximal segments.

For the second and third TMT joint, a 2.7 mm T-plate can be used, which allows for two screws in the proximal and three screws in the distal segment.

Plate contouring for arthrodesis of a TMT joint


Insert screws in neutral mode after appropriate length, alignment, and rotation have been verified.

Arthrodesis of a TMT joint with a plate

The remaining bone defect should be grafted using cancellous or corticocancellous bone graft for structural support harvested from the distal or proximal tibia.

Arthrodesis of a TMT joint with a plate and bone graft

8. Aftercare

An appropriate well-padded dressing should be applied to protect the surgical incision. Compression will help control swelling.

If present, the skin-pin interface should be similarly well-padded but with dressings that can be readily removed to inspect for pin site infection.

Immediate postoperative treatment is rest, ice, and elevation.

The patient should restrict weight-bearing for six weeks until signs of radiographic healing are present. After this, patients can be weight-bearing as tolerated.

Patients must exercise their ankle and subtalar joints out of the orthosis to prevent stiffness (eg, by stretching their Achilles).

X-ray the metatarsals at six weeks to confirm satisfactory union and remove K-wires if present. Once the fracture is united, the orthosis may be gradually discontinued.

A gastrocnemius release may need to be performed in cases with postoperative gastrocnemius contracture. This occurs more typically in the mid- and hindfoot.

If the gastrocnemius muscle has been released, a splint or cam walker can be used to protect the surgical site.