The patient is positioned supine on a radiolucent cantilever-operating table (Figure 2-1).

The patient is brought to the foot end of the bed for unrestricted access to medial and lateral sides and sole of the foot.

Opposite leg bony prominences are padded, including greater trochanter, fibular head (common peroneal nerve), and elbow (ulnar nerve).

A small bolster is placed under ipsilateral hip to position the ipsilateral patella neutral and pointing directly up.

Anteroposterior, lateral, and oblique fluoroscopic views are obtained throughout the procedure.

Thigh or calf tourniquet (when applied low, particularly Esmarch-type, constricts the extensor tendons and may exaggerate correction)

Regional block with sedation or general anesthesia is used for the procedure.

The affected extremity is prepped and draped from mid-calf (if calf tourniquet is used; Figure 2-2) or mid-thigh downward (with thigh tourniquet).

Three- to 6-cm dorsal longitudinal incision is made centering over the first tarsometatarsal joint (TMTJ) to approach the joint through the sheath of the extensor hallucis longus (EHL) tendon.

The EHL tendon is retracted laterally, protecting the dorsalis pedis artery and the deep peroneal nerve.

Longitudinal dorsal capsulotomy of the first TMTJ is made initially.

The capsule of the first TMTJ is incised and elevated along the articular borders of the metatarsocuneiform articulation to visualize the articular surfaces medially, dorsally, and plantarly.

A pin distractor (Hintermann or Weinraub) may then be used to pry open the metatarsocuneiform articulation after inserting 2.0-mm K-wires in the cuneiform and first metatarsal (MT) base.

Osteophytes, if present, are removed with rongeurs and the articular cartilage is removed with a combination of small straight and angled curettes. Utmost care is taken to avoid removing subchondral bone and unnecessarily cause first ray shortening.

The first TMTJ may extend up to 3 cm plantarly, and thorough inspection and cartilage removal is essential for optimal preparation of the articulating surfaces for fusion. Adjusting the pin distractor and using an additional lamina spreader for adequate visualization are critical in this step of the procedure. Caution should be exercised when using a teethed lamina spreader to avoid crushing the bone surfaces.

Once the MT base and the cuneiform are denuded of articular cartilage, the subchondral bone is fenestrated with a 2-mm K-wire or 2-mm drill bit. A 4-mm curved osteotome is then used to connect the perforations to allow bleeding from the cancellous bone.

The frontal plane deformity is addressed next and the hallux is derotated out of valgus into a varus direction to get the nail plate parallel to the ground while stabilizing the hindfoot. Once this is achieved, the hallux metatarsophalangeal joint (MTPJ) is dorsiflexed, initiating the windlass mechanism, to compress the first TMTJ while simultaneously plantarflexing the first MT. All this is done while maintaining correction in the transverse plane.

Additionally, the surgeon can use thumb pressure to manually reduce and maintain the first IMA in the transverse plane.