After marking the surgical site and induction of general anesthesia with a popliteal block for postoperative pain control, the patient was positioned supine on the operating table with the feet at the edge of the bed. A right-thigh tourniquet was applied, intravenous antibiotics were given, and the extremity was prepped and draped in the standard surgical fashion. A time-out was taken to identify the correct patient, operative site, and other items per protocol. The limb was exsanguinated with an Esmarch and the tourniquet was insufflated to 275 mmHg.

An approximately 10 cm incision was made on the dorsum of the right foot and care was taken to protect the crossing branches of the superficial peroneal nerve. The interval between the extensor hallucis brevis and longus was identified and the brevis, along with the neurovascular bundle, was mobilized laterally with the longus taken medially. Significant disruption of the deep capsular structures was noted and hematoma was evacuated. Instability of the entire medial ray was visualized with disruption of the first intermetatarsal space, intercuneiform, and naviculocuneiform joints along with cartilaginous injury in the same. The first and second tarsometatarsal articulations were stable. The fracture of the proximal medial pole of the medial cuneiform was identified, found to be multifragmentary, and excised. Given the amount of instability, cartilage injury, and patient’s age, the decision was made to proceed with arthrodesis of the intercuneiform, medial, and middle naviculocuneiform joints. Residual cartilage on the proximal and medial aspect of the medial cuneiform, lateral and proximal aspect of the middle cuneiform, and distal aspect of the medial and middle facets of the navicular was removed with a ¼” curved osteotomy and small curettes. A small lamina spreader and K-wire distractor were utilized as well to create enough distraction to ensure complete removal of cartilage from the plantar aspects of these joints. The subchondral bone of these articulations was then perforated using a water-cooled 2.0 mm drill bit. A 3 cm incision was made over Gerdy’s tubercle on the right proximal tibia and dissection was carried down through the fascia onto the tubercle. The lateral wall was perforated by hand using a 6.5 mm drill guide and cancellous bone graft was removed using a large pituitary rongeur. The graft was morselized and packed into the interstices of the medial and middle naviculocuneiform, intercuneiform joints, and first intermetatarsal space.

Figure 14.3 shows the disruption of the medial ray as identified in the procedure, as well as provisional reduction obtained using a shoulder hook with an adduction and internal rotation maneuver to the medial ray. Attention should be paid to the restoration of Mills line (a line from the medial navicular to the medial cuneiform extended distally) as it now intersects the first metatarsal. The provisional reduction was held temporarily with 1.6 mm K-wires. An external compression device was utilized with appropriate wires to provide controlled compression of the medial ray. A medial incision was made just proximal to the navicular tuberosity and a 3.5 mm position screw was placed from the navicular into the medial cuneiform. Through the same medial incision, another 3.5 mm screw was placed from the navicular into the middle cuneiform. A clamp was placed across the first intermetatarsal space to compress the base of the second metatarsal to the medial cuneiform and a 3.5 mm position screw was placed through a stab incision medial to the cuneiform into the base of the second metatarsal. Retrograde 3.5 mm position screws were placed from the medial cuneiform into the navicular as well as across the middle cuneiform and into the navicular. A 4-0 burr was used to create dorsal troughs in the navicular and medial/middle cuneiforms for additional strain-relieving bone graft to be packed into the interstices. The stability was tested and found to be excellent. The second MTP joint was held in a concentrically reduced position and a 1.6 mm K-wire was placed percutaneously retrograde from the tip of the toe, across the DIP, PIP, and MTP joints. Reduction and hardware position were checked fluoroscopically in multiple planes as shown in Fig. 14.4. All wounds were copiously irrigated and closed in a layered fashion. Sterile dressings were applied and a well-padded below-knee splint was applied.