New Advances With The Tarsometatarsal Arthrodesis

Given the consequences of misdiagnosis of Lisfranc pathology, these authors emphasize thorough pre-op evaluation and sound surgical planning, and offer step-by-step pearls for performing tarsometatarsal joint arthrodesis to address end-stage degenerative joint disease.

The tarsometatarsal complex or Lisfranc joint is named after Jacques Lisfranc, a French surgeon who served in Napoleon’s army. Lisfranc originally described an amputation through the tarsometatarsal joint.^1,2 Acute pathology to the tarsometatarsal complex often goes misdiagnosed or physicians miss it completely in 20 percent of cases, which leads to delayed treatment.³ These injuries can lead to an acceleration of degenerative joint disease with subsequent deformity.

Much of the literature on surgical management of the tarsometatarsal complex discusses treatment and outcomes of acute traumatic injuries.^1-5 The tarsometatarsal complex consists of the cuboid, three cuneiforms, five metatarsals and their respective ligamentous complex. The etiology of tarsometatarsal arthritis includes primary, inflammatory and post-traumatic etiologies.⁴ Osteoarthritis of the tarsometatarsal complex is not uncommon and initial treatment should focus on non-operative therapy. These patients often experience pain, disability and poor quality of life. Consider surgical management in those patients failing non-operative care.^6-8

Keys To Effective Preoperative Evaluation

One should perform open and closed kinetic chain evaluation as well as a gait examination for patients with tarsometatarsal degenerative joint disease. Visual inspection often reveals dorsal and medial bony prominences with secondary bursitis. Percussion about the dorsal cutaneous nerves in this region may demonstrate a positive Tinel’s sign. Identify specific movements that aggravate or reproduce symptoms. These activities may include toe walking, squatting and ascending stairs as well as any passive or active movement that stresses the midfoot.

Obtain weightbearing radiographs of the foot and ankle. It is at the physician’s discretion whether to obtain bilateral films for comparison. One can appreciate transverse plane tarsometatarsal deformity by evaluation of the long axis of the second metatarsal relative to its articulation with the middle cuneiform. Joint space narrowing and subchondral sclerosis can be visible on both AP and oblique views. The lateral view can assess dorsal spurring as well as any hindfoot deformity. One can evaluate suprastructural deformity with long-leg axial and hindfoot alignment views.

Advanced imaging can be helpful for some patients. Magnetic resonance imaging (MRI), computed tomography (CT) and diagnostic ultrasound can help one assess cartilaginous, ligamentous and tendinous structures surrounding the tarsometatarsal joint. Advanced imaging can provide a more intimate view of the tarsometatarsal joint complex and provide a three dimensional assessment of the underlying deformity. Advanced imaging, however, is not necessarily required for tarsometatarsal arthrodesis.

A Guide To Surgical Planning

The primary goal with tarsometatarsal joint surgery is a plantigrade foot. The surgeon should consider the patient’s current activity level, occupation and foot type during the planning process. Note the preoperative activity level. High-demand occupations that require restricted shoe gear (i.e., dress shoes or steel-toed boots) might influence hardware selection.

Equinus contracture of the gastrocnemius or gastrocnemius-soleus complex can cause increased midfoot as well as forefoot pressures.⁹ One should address varus or valgus hindfoot as well. Joint-sparing procedures such as a calcaneal displacement osteotomy are ideal for reducible deformities whereas hindfoot arthrodesis might be more appropriate for fixed deformities.

We perform tarsometatarsal arthrodesis to include the first, second and third tarsometatarsal joints. However, we virtually never include the fourth or fifth tarsometatarsal joints. Patients who lose the lateral column as a mobile adapter seem to have poor clinical outcomes.

How To Perform The Surgical Technique

After ensuring a thigh tourniquet and the use of general inhalation anesthesia for the patient, proceed to perform the procedure. Place a bump under the ipsilateral hip so the toes point toward the ceiling. Additionally, placing the operating table in a reverse Trendelenburg position also provides comfortable access to the dorsal midfoot and enhances the ease of intraoperative imaging. Intraoperative views that are necessary often include AP and lateral views of the foot as well as calcaneal axial images. We will sometimes use a Doppler ultrasound to identify and mark out the neurovascular bundle in a larger foot prior to incision placement.

We often perform ancillary procedures prior to tarsometatarsal arthrodesis. These procedures might include posterior muscle group lengthening, harvest of regional bone graft, calcaneal osteotomy, lateral column lengthening, hindfoot arthrodesis, posterior tibial tendon repair, tendon transfers and hardware removal from previous open reduction internal fixation (ORIF). We often perform some of these procedures prior to tourniquet insufflation to preserve tourniquet time for the tarsometatarsal arthrodesis.

Perform arthrodesis of the first through the third tarsometatarsal joints with a two-incision technique. Address the first tarsometatarsal joint through a medial incision and access the second and third tarsometatarsal joints through a dorsal-lateral incision. We typically begin with a long linear incision over the second and third tarsometatarsal joints. Sometimes, the surgeon can modify this incision to accommodate severe abduction or adduction deformity from previous trauma or congenital deformity.

Obtaining a fluoroscopic AP image prior to tourniquet insufflation can be helpful when anatomic landmarks are difficult to appreciate. This can aid in incision placement and avoid inadvertent placement of the incision too medial, which can result in difficulty accessing the third tarsometatarsal articulation. This incision should be long to avoid overzealous retraction, which might predispose the wound to breakdown.

Use double-prong skin hooks for superficial retraction but superficial retraction should be limited as wound dehiscence can occur in this region, especially in patients with arterial compromise, poorly controlled diabetes mellitus, tobacco users or those patients on medications that might predispose them to poor healing. Additionally, patients with a compromised soft tissue envelope from previous ORIF are also at risk for wound problems.

Take care to identify and protect dorsal cutaneous branches of the superficial peroneal nerve along the proximal part of the incision. The extensor digitorum brevis and extensor hallucis brevis muscle bellies are immediately visible in the proximal aspect of the incision. Identify the neurovascular bundle and retract it medially. Identify the juncture between these two muscle bellies and make a periosteal incision at this level. All dissection is subperiosteal. Release soft tissues from the second and third tarsometatarsal joints. All scars from previous injury or surgery must have adequate release to allow joint access and realignment. Complete mobilization of these joints is essential for realignment.

We will consider release of the fourth and fifth tarsometatarsal joints through an ancillary lateral incision if we feel scar tissue from previous injury is an impediment to complete reduction. After a prior injury, there are often large osteophytes and hypertrophic bone in the affected area, and one should completely remove these to allow joint visualization. Additionally, this hypertrophic bone is often responsible for the dorsal bursitis and neuritis that some patients experience following injury. Decompression of this area through evacuation of hypertrophic bone will often result in symptomatic relief.

Furthermore, removing this bone provides a flat surface for plate application. Plates should sit flat prior to screw fixation. Compression of a plate to an uneven surface can result in elevation of the metatarsal to the plate, especially with more rigid devices. We will often morselize this resected bone, if the quality is reasonably good, for later use as bone graft.

Utilize a pin distractor with 5/64 Steinmann pins to distract the joint. Larger pins (7/64) might be necessary for severely scarred joints. However, using these larger diameter pins results in large holes that can compromise plate fixation. The second and third tarsometatarsal joints will distract as a single unit. Therefore, one should place pins in areas that don’t obstruct the surgeon’s vision or instrument access. We exclusively use contour resection. Planal or wedge resection techniques have a higher incidence of sagittal plane malalignment and shortening that can result in overload to adjacent metatarsal heads with subsequent metatarsalgia.

Surgeons can use a combination of small osteotomes and curettes to resect the articular cartilage. It is especially important to focus on the plantar aspect of the joint. Otherwise, remaining cartilage in this area can result in metatarsal head elevation. Rongeurs are useful in situations in which there is no cartilage but rather sclerotic subchondral bone and scar tissue. There can sometimes be substantial bone deficits following debridement, especially in situations following prior trauma. This will often require bone graft and/or some type of orthobiologic.

Prepare the joints with a combination of fenestration using a small diameter drill (2.0 mm or 2.5 mm) and fish scaling with a small osteotome. One can also use a burr but thermal necrosis is always a concern with this technique.

Additionally, we will debride and prepare the medial intercuneiform joint, the area between the medial second metatarsal base and medial cuneiform, as well as the area between the second and third metatarsal bases to increase the fusion mass and impart greater stability. We delay fixation of the second and third tarsometatarsal joints until we reduce and fixate the first tarsometatarsal joint.

Make an incision along the medial midfoot, staying in the interneural plane between the dorsal and plantar nerves to access the first tarsometatarsal joint. One can extend this incision further proximally if the naviculocuneiform joint also requires arthrodesis. Carry dissection down to the deep fascia and release the fascia. Identify the tibialis anterior tendon and partially release it to provide room for a low profile plate. Avoid overzealous resection to the tibialis anterior tendon. Make a medial incision into the remainder of the deep fascia and periosteum, and carry subperiosteal dissection across the dorsal and plantar aspects of the joint. Then utilize a pin distractor and use the same aforementioned techniques for joint debridement and preparation. Place a combination of bone graft and orthobiologics in the arthrodesis site.

Realign the first tarsometatarsal by dorsiflexing the hallux to engage the windlass mechanism. This maneuver will restore sagittal plane alignment. Provisional fixation occurs with smooth pins that are part of a cannulated screw system. We prefer percutaneous delivery of a compression screw from plantar to dorsal and a medial locking plate. However, there are many options for fixation and this is based on surgeon preference. Multiple compression screws as well as plates located plantar or dorsal are also reasonable options. Relatively long implants are preferable to disperse axial load over a greater surface area.

Redirect attention to the dorsal incision for reduction and fixation of the second and third tarsometatarsal joints. If autogenous bone graft is necessary, harvest it at this time and place the graft directly into all arthrodesis sites, including the medial intercuneiform and metatarsal base region, particularly the area between the second metatarsal base and medial cuneiform. We typically harvest bone from the calcaneus or distal tibia.

Reduce the second and third tarsometatarsal joints into anatomic alignment under image intensification. One can ensure transverse plane realignment by having the medial aspect of the second metatarsal collinear to the medial aspect of the intermediate cuneiform. Sagittal plane realignment is acceptable when the dorsal cortices of the second and third metatarsals are parallel to the dorsal cortex of the first metatarsal on lateral and oblique images.

Additionally, evaluate the metatarsal heads and monitor them with the foot in neutral position during fixation to ensure appropriate sagittal plane alignment.

Key Pointers On Fixation And Closure

Fixation options include axial compression screws placed distal to proximal, compression staples, individual locking plates that provide compression across each joint and larger locking plates that compress the second and third tarsometatarsal complex as one unit. We prefer a single low-profile locking plate that provides compression across both joints. These plates are typically anatomically congruent and have options for both locking and non-locking screws. The plates should be well contoured to the bone prior to fixation to avoid elevation of the metatarsals. Otherwise, there is a risk of overload to adjacent metatarsals with subsequent metatarsalgia, which is difficult to manage. Realignment and fixation of all joints occurs with image intensification.

We will also consider an ancillary screw directed from the medial aspect of the medial cuneiform to the second metatarsal base to enhance the stiffness of the construct. However, this is not always possible if locking screws that secure the plate to the bone are too proximal in the metatarsal. Using longer plates along the second metatarsal base will keep locking screws further distal from the joint, which can preserve space for the medial-lateral screw.

Then perform closure of the subcuticular and skin layers. Deeper tissues are often scarred and require removal. We don’t perform subcutaneous closure to avoid potential nerve injury. Then perform ancillary procedures. Apply standard dressings with a layered compression dressing. Patients wear a posterior splint with a neutral ankle position immediately following the procedure, which will accommodate postoperative edema. Popliteal and common peroneal nerve blocks are routine unless contraindicated. Perform these with the patient under anesthesia and use ultrasound guidance away from the surgical site in order to avoid compartment syndrome. Patients typically transition into a short leg cast, placed with a neutral ankle in order to prevent shortening of the posterior muscle group. Often, we apply a short-leg cast the following day.

How To Modify Surgery For Longstanding Deformity

We will modify our approach for severe, longstanding deformities that require significant transverse plane realignment. Transverse plane manipulation and translation are often not adequate to reduce the deformity in these cases due to the magnitude or rigidity. Komenda and colleagues have recommended wedge resection in cases demonstrating > 15 degrees of transverse plane deformity or 3 mm of sagittal plane displacement.¹⁰

We will consider an extensile medial approach to access the tarsometatarsal complex for longstanding deformity. Perform a medial ostectomy to identify the first tarsometatarsal joint. Then resect a medially- and plantarly-based wedge through the first to third tarsometatarsal complex. The specific anatomy dictates the amount of resection in both planes. Place small diameter wires as cutting guides under image intensification to control the size and depth of the wedge. Use small saws and osteotomes to perform the osteotomies. Then resect the bone wedge and prepare the arthrodesis site in standard fashion. Close the osteotomy by dorsiflexing the hallux and adducting the first metatarsal. Fixation occurs with a combination of locking plates and screws.

Unfortunately, significant first ray shortening can result following wedge resection. Keeping wedge resection to a minimum will limit shortening but might result in undercorrection. We will medially translate the metatarsals on the cuneiforms in these cases. Additionally, we often place a bone marrow aspirate-enhanced structural allograft into the first tarsometatarsal joint to maintain length in cases of severe shortening. Reserve this technique for the most severe cases of tarsometatarsal arthritis and deformity.

What You Should Know About Ancillary Procedures

There are invariably a number of ancillary procedures that are necessary during tarsometatarsal arthrodesis. This depends on the severity of the deformity, the presence and magnitude of lateral column shortening, the need for bone graft, the presence of secondary adult-acquired flatfoot and whether this deformity is reducible or fixed, the presence of degenerative changes in more proximal midfoot articulations and/or tritarsal complex, and equinus deformity. The ultimate goal is a plantigrade foot that is well aligned in all planes.

Ancillary procedures might include lateral column lengthening, medial displacement osteotomy of the calcaneus, posterior tibial tendon repair, spring ligament repair, flexor digitorum longus tendon transfer, naviculocuneiform joint arthrodesis, hindfoot arthrodesis, peroneus brevis to longus tenodesis, harvest of bone graft, hardware removal and posterior muscle group lengthening. One can perform these procedures at the same session as tarsometatarsal arthrodesis or at a later time. We prefer staging more severe cases, especially when we are combining these procedures with hindfoot arthrodesis, in order to avoid compartment syndrome.

Pearls For A Successful Postoperative Course

The postoperative course for our tarsometatarsal arthrodesis includes non-weightbearing for approximately six to eight weeks. Obtain serial X-rays six weeks after surgery. Complete radiographic consolidation is not always apparent at this time. However, if edema appears to be well controlled and temperatures are similar to the non-surgical foot, we will begin the transition to weightbearing in a controlled ankle motion (CAM) boot. Patients begin a gradual transition from partial weightbearing to full weightbearing over the course of two to four weeks. Patients with persistent edema and warmth wear another short leg cast for an additional four to six weeks. We will measure bilateral temperatures following an arthrodesis if the index of suspicion is high for delayed union. We again obtain serial radiographs at that time and if there is a lack of consolidation with continued edema and warmth, we will consider a CT scan to assess consolidation further prior to weightbearing.  

Patients then transition into a firm soled walking shoe at eight to 12 weeks following surgery. We recommend limited activity for the first several weeks and avoidance of strenuous activity. Laborers, industrial workers and those patients with “high demand” occupations usually return to work at six months following surgery.

We do not routinely remove internal fixation for most patients. Those who have dorsal pain secondary to hardware will require removal but we do not remove hardware earlier than one year following reconstruction. The use of low-profile plates virtually never necessitates removal.

We order physical therapy as needed depending on rehabilitation requirements dictated by ancillary procedures and the individual patient’s needs. Daily activity will often strengthen atrophied musculature and increase range of motion to the adjacent joints. Consider physical therapy for patients who plateau or regress in their overall progress. Physical therapy modalities most often include posterior muscle group strengthening, proprioception exercises, lower extremity strengthening, scar desensitization and gait training.

In Conclusion

End-stage tarsometatarsal osteoarthritis continues to be a challenging pathology to both the physicians as well as the patients. Surgery requires careful perioperative planning and realignment to restore a plantigrade foot. Fully discuss expectations and realities with the patient. Identify suprastructural deformities and address them at the time of surgery. While there is no consensus on arthrodesis constructs, newer low profile plates provide a dependable and reliable form of fixation that provides compression and stiffness.

Dr. Chesser is a third-year resident at Western Pennsylvania Hospital in Pittsburgh.

Dr. Catanzariti is the Director of Residency Training at the Western Pennsylvania Hospital in Pittsburgh. He is a Fellow of the American College of Foot and Ankle Surgeons.

References

1.     Cassebaum WH. Lisfranc fracture- dislocations. Clin Orthop Relat Res. 1963; 30:116-129.
2.     Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. Bone Joint J. 1982; 64(3):349-356.
3.     Goossens M, De Stoop N. Lisfranc’s fracture-dislocations: etiology, radiology, and results of treatment. Clin Orthop Relat Res. 1983; 176:154-162.
4.     Rao S, Nawoczenski DA, Baumhauer JF. Midfoot arthritis: nonoperative options and decision making for fusion: nonoperative options and decision making for fusions. Tech Foot Ankle Surg. 2008; 7(3):188-195.
5.     Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthoped Surg. 2010; 18(12):718-728.
6.     Jung HG, Myerson MS, Schon LC. Spectrum of operative treatments and clinical outcomes for atraumatic osteoarthritis of the tarsometatarsal joints. Foot Ankle Int. 2007; 28(4):482-489.
7.     Mann RA, Prieskorn D, Sobel M. Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma. J Bone Joint Surg Am. 1996; 78(9):1376-85.
8.     Nemec SA, Habbu RA, Anderson JG, Bohay DR. Outcomes following midfoot arthrodesis for primary arthritis. Foot Ankle Int. 2011; 32(4):355-361.
9.     Aronow MS, Diaz-Doran V, Sullivan RJ, Adams DJ. The effect of triceps surae contracture force on plantar foot pressure distribution. Foot Ankle Int. 2006; 27(1):43-52.
10.     Komenda GA, Myerson MS, Biddinger KR. Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am. 1996; 78(11):1665-76.