First TMT fusion fixation

Indication

First tarsometatarsal (TMT) arthrodesis is indicated for hallux valgus with first-ray hypermobility, post-traumatic arthritis, or planovalgus deformity requiring medial column stabilization. The primary decision point for surgeons is the choice of fixation construct — crossed screws, dorsal or dorsomedial plate-and-screw, plantar (biplanar) plating, or staples — and the postoperative weightbearing regimen each construct permits.

The techniques

• Crossed screws: two solid-core lag screws placed from the medial cuneiform into the first metatarsal base in a divergent pattern.
• Plate and screw (dorsomedial locking plate): a pre-contoured locking plate applied to the dorsomedial aspect of the TMT joint with multiple locking and non-locking screws.
• Biplanar (plantar) plating: a plate applied to the plantar surface of the first TMT joint, often supplemented with dorsal screw(s) for added compression.
• Staples: memory or static staples placed across the joint line, typically two to three per fusion site.

What the evidence says

A meta-analysis of 16 studies (1176 feet) compared three fixation cohorts: screw-only, dorsomedial plating, and plantar plating [1]. No statistically significant differences were found in intermetatarsal angle, hallux valgus angle, or AOFAS score correction between cohorts. Complication rates differed: 24.5% (screw), 19.5% (dorsomedial plate), 13% (plantar plate). Nonunion rates were 5.3% (screw), 1.4% (dorsomedial), and 0.7% (plantar). Time to full weightbearing correlated positively with nonunion (coefficient 0.376, P = .009), and plantar plating was associated with earlier weightbearing. Hardware removal rates were 7.7% (screw), 11.8% (dorsomedial), and 3.6% (plantar). A single-surgeon retrospective equivalence trial (147 feet) compared intraplate compression screw, crossing screws, and single screw with locking plate, all kept non-weightbearing for 4 weeks [2]. Nonunion rates were 2%, 9%, and 5% respectively (not statistically significant); hardware removal was 0%, 12%, and 11%. A systematic review of Lapidus plate systems (14 studies, 738 feet) concluded there is insufficient evidence to determine the optimal plate type or screw configuration [3]. A separate review of minimally invasive Lapidus (5 studies, 162 feet) reported a 12.3% overall complication rate but did not compare fixation constructs [4]. No included source evaluated staples or true biplanar (dual-plate) constructs.

What members see

Members using plantar plating report initiating weightbearing at 2–3 weeks in selected patients, compared with the 4-week non-weightbearing protocol used in the retrospective trial [2] and the weightbearing–nonunion correlation noted in the meta-analysis [1]. How does your nonunion rate with crossed screws compare to the 5.3% pooled figure [1]? What hardware removal frequency do you observe with dorsomedial locking plates versus the 11.8% reported [1]?

Cost and access

The sources do not provide cost data. Factors that drive cost differences include implant price (locking plates > solid screws > staples), operative time (plate contouring vs. percutaneous screw placement), need for a second procedure for hardware removal (highest with dorsomedial plates at 11.8% [1]), and advanced imaging for postoperative assessment.

Open questions

• Does biplanar (dual dorsal + plantar) plating further reduce nonunion below the 0.7% seen with plantar plating alone [1]?
• What is the nonunion and complication profile of staple fixation compared with screw or plate constructs?
• Can a standardized early weightbearing protocol (e.g., 2 weeks) be safely applied to all fixation types, or is it construct-dependent?
• How do patient factors (diabetes, nicotine use, bone quality) modify the fixation–weightbearing interaction?
• What are the long-term functional outcomes (beyond 2 years) and revision rates for each construct?

References

4 of 4 papers retrieved for this room are cited above. The search was limited to systematic reviews, meta-analyses and randomised trials in humans, English, 2016 onwards. Query and full result set: research/raw/first-tmt-fixation.json.

1. 1Lapidus Arthrodesis for Correction of Hallux Valgus Deformity: A Systematic Review and Meta-Analysis. Foot Ankle Spec 2026 · PMID 38483102 Systematic Review, Meta-Analysis
2. 2Evaluation of Fixation Techniques for Metatarsocuneiform Arthrodesis. J Foot Ankle Surg 2017 · PMID 28245975
3. 3Effectiveness of the Lapidus plate system in foot surgery: A PRISMA compliant systematic review. Int Wound J 2022 · PMID 34255939 Systematic Review
4. 4Incidence of Complications After Minimally Invasive Lapidus Surgery. J Am Podiatr Med Assoc 2025 · PMID 40560786 Systematic Review

Back to the comparisons