DEFINITION

This is a procedure to definitively treat midfoot arthrosis with or without deformity.

 

 

ANATOMY

 

Midfoot articulations include the following:

 

 

 

Tarsometatarsal (TMT) joints Naviculocuneiform joints

 

In the coronal plane, the midfoot may be viewed as three columns:

 

 

Medial column (the first ray)

 

 

Middle column (the second and third rays) Lateral column (the fourth and fifth rays)

 

 

These articulations form an arch in both the longitudinal plane and the transverse plane. The second cuneiform is the keystone to the transverse arch.

 

Anatomic alignment in the longitudinal plane is rather simple to assess on weight-bearing radiographs of the foot.

 

 

In both the anteroposterior (AP) and lateral planes, the talo-first metatarsal axis should be congruent.

 

Physiologically, the medial and middle columns (first through third rays) have congruent joints and tight ligaments, leaving little motion.

 

 

This is important to ensure the midfoot serves as a rigid lever during the gait cycle's stance and push-off.

 

In contrast, the lateral column (fourth and fifth rays) is relatively supple.

 

 

This is important to allow the foot to accommodate to various surfaces.

 

Given that the midfoot's medial and middle columns are physiologically stiff, arthrodesis of these joints in physiologic alignment creates few functional deficits. However, arthrodesis of the lateral column is generally contraindicated, as the midfoot's ability to accommodate to various surfaces is forfeited.

 

PATHOGENESIS

 

When the compact and stable midfoot anatomy is compromised, the talo-first metatarsal relationship is disrupted and the foot loses its mechanical advantage during the stance and push-off phases of gait.

 

In the sagittal (lateral) plane, this leads to loss of the longitudinal arch at the midfoot, with a midfoot sag.

 

 

In the extreme case, the arch will reverse and become a “rocker bottom deformity.” In the coronal (AP) plane, the forefoot drifts into abduction relative to the hindfoot.

 

A plantigrade foot balances relatively evenly on the weightbearing surfaces of the first and fifth metatarsals and

the heel. When the midfoot collapses, this balance is disrupted and weight bearing eventually may be on the midfoot as well.

 

With progressive midfoot deformity, the hindfoot may eventually lose its physiologic alignment, typically with greater than physiologic valgus.

 

 

This typically leads to shortening of the Achilles tendon and equinus contracture.

 

 

In extreme cases, the ankle may become incongruent as well. Causes include the following:

 

 

Posttraumatic arthritis (chronic Lisfranc fracture-dislocation) Primary arthritis

 

 

Inflammatory arthropathy (rheumatoid arthritis) Charcot neuroarthropathy

NATURAL HISTORY

 

An injury to the midfoot articulations or the ligaments, particularly the “Lisfranc ligament” between the base of the second metatarsal and the first cuneiform, leads to destabilization of the midfoot's architecture and a tendency toward gradual progressive arch collapse and forefoot abduction.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

History

 

 

Often (but not always), midfoot trauma is reported. Primary and inflammatory arthritis may be responsible without trauma. Also, a patient with neuropathy may develop midfoot destabilization but without recollection of trauma or with a history of what appeared to be only a minor trauma.

 

 

Patients experience pain with weight bearing, especially with push-off during the gait cycle. They may also note a fallen arch and difficulty with shoe wear.

 

Physical examination

 

 

The patient must be examined while weight bearing. Comparison to the uninvolved contralateral foot is sometimes useful as a baseline of the patient's physiologic alignment.

 

 

With advanced disease, loss of the longitudinal arch and forefoot abduction are present.

 

Midfoot tenderness and pain with stress

 

 

 

Tenderness is typically focused on the midfoot. Stress of the midfoot produces midfoot pain.

 

The “piano key test” isolates the focus of the pathology to the specific TMT joint.

 

 

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Neurologic examination

 

If there is a concern for neuropathy, the Semmes-Weinstein monofilaments should be used to determine protective sensation.

 

 

If the patient can sense the 5.07 monofilament, protective sensation is deemed intact.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

 

Weight-bearing radiographs of the foot are obtained: AP, oblique, and lateral views. Rarely is computed tomography (CT) required for assessment or preoperative planning.

 

If there is a question of which midfoot articulations may be symptomatic, selective or diagnostic injections may be useful.

 

NONOPERATIVE MANAGEMENT

 

Activity modification

 

 

 

Nonsteroidal anti-inflammatory drugs (NSAIDs) Intra-articular corticosteroid injection Mechanical support

 

Longitudinal arch support

 

Stiffer-soled shoe with or without a slight or low-profile rocker bottom modification

 

 

With limited deformity and midfoot arthritis, a rocker may be placed on a sensible regular shoe; it need not be a big cumbersome shoe.

 

However, with greater deformity, the shoe may need to be accommodative.

 

Bracing

 

 

Stiffer-soled shoe with rocker modification in combination with a double upright brace or ankle-foot orthosis (AFO)

 

Diabetics with neuropathy or neuroarthropathy will require the stiffer-soled shoe with rocker modification in combination with a total contact insert.

 

SURGICAL MANAGEMENT

 

Surgical management is warranted with failure of nonoperative measures.

 

Procedures may include arthrodesis in situ or arthrodesis in combination with realignment midfoot osteotomy. Occasionally, adjunctive hindfoot procedures and Achilles tendon lengthening may be warranted.

 

Preoperative Planning

 

Preoperative weight-bearing radiographs of the foot are essential to determine the preoperative plan.

 

 

 

The goal is to restore congruency in the AP and lateral talo-first metatarsal alignment. The deformity must be studied to determine the optimal method for realignment.

 

The degree of destruction or distortion of the midfoot anatomy (particularly with erosive changes of an inflammatory arthropathy) is important and factors in how to best reconstruct the midfoot.

 

Associated hindfoot deformity may need to be addressed as well.

 

Equinus contracture

 

 

The preoperative assessment should include the condition of the Achilles tendon.

 

Often, Achilles lengthening, either with a triple cut or gastrocnemius -soleus recession, is necessary to realign the foot and may serve to unload stresses on the midfoot.

 

Equipment

 

 

 

Various screw and plating systems, some even dedicated to the midfoot, are available. Depending on the planned reconstruction, the following options exist:

 

 

 

Standard screws and plates Locking midfoot plates Intramedullary screws

 

Compression staples or compression plates

 

Positioning

 

 

The patient is positioned supine on the operating table. We routinely use a tourniquet.

Approach

 

Dual longitudinal approach over the midfoot

 

 

 

One dorsal and one medial Most common

 

Transverse approach

 

Has been used by many surgeons but is not universally accepted

TECHNIQUES

• Screw and Compression Plate Fixation

Background

The patient was a 38-year-old woman with posttraumatic arthritis after chronic Lisfranc fracture-dislocation.

She also had a “nutcracker” injury to her cuboid with some lateral column degenerative change (TECH FIG 1).

Exposure and Joint Preparation

Dual dorsal longitudinal incisions with adequate skin bridge Medial incision

Extensor hallucis brevis exposed (TECH FIG 2A)

Deep neurovascular bundle deep to extensor hallucis longus muscle-tendon (TECH FIG 2B) First and second TMT joint preparation

Particularly deep joint (2.5 to 3.0 mm)

Essential to remove all plantar prominences and cartilage to avoid dorsiflexion malunion (TECH FIG 2C)

 

 

It is important to remove scar tissue between base of second metatarsal and first cuneiform to allow reduction of second metatarsal base (TECH FIG 2D).

 

Penetrate the subchondral bone to promote fusion (TECH FIG 2E).

 

Lateral incision (with adequate skin bridge) (TECH FIG 2F)

 

Protect the superficial peroneal nerve branch or branches (TECH FIG 2G).

 

Third TMT joint preparation: Remove residual cartilage and penetrate subchondral bone (TECH FIG 2H,I).

 

Add bone graft as necessary.

 

 

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TECH FIG 1 • Preoperative radiographs of 38-year-old woman with postoperative midfoot arthritis secondary to chronic Lisfranc injury. A. AP view. B. Oblique view (note distortion to cuboid: chronic nutcracker injury). C. Lateral view.

 

 

 

TECH FIG 2 • Dorsal medial approach. A. Extensor hallucis brevis (EHB) muscle elevated. B. Immediately deep to EHB is the deep neurovascular bundle. C-E. Preparing medial aspect of TMT joints. C. Sharp elevator for first TMT joint. (Note: toes at top of A to C) D. Rongeur in junction between base of second metatarsal and first cuneiform (it is important to be sure the second metatarsal fully reduces). E. Drill to penetrate subchondral bone. The second TMT joint is prepared in a similar manner. Dorsolateral approach. (continued)

 

 

67

 

 

 

TECH FIG 2 • (continued) F. Interval identified. G. Superficial peroneal nerve branches are identified and protected. H,I. Preparation of third TMT joint. H. Sharp elevator to remove residual cartilage. I. Drilling subchondral bone. (Note: toes at right side of F to I)

Reducing the Deformity

 

The “windlass” mechanism may be useful in reducing the TMT joints and particularly in avoiding dorsiflexion malunion. Moreover, it compresses the joints (TECH FIG 3A).

 

We maintain dorsiflexion of the toes (activates windlass mechanism) while we place the provisional fixation (TECH FIG 3B,C).

 

Using a bone reduction clamp as for open reduction and internal fixation of an acute Lisfranc fracturedislocation may be helpful. After the second metatarsal base is reduced, we place a guide pin to drill with a cannulated drill the path for a classic “Lisfranc screw” (TECH FIG 3D).

 

 

 

TECH FIG 3 • A. Use the windlass mechanism to assist in reduction and promote proper alignment of the TMT joints. Note dorsiflexion of the toes and ankle to tighten plantar soft tissues; this compresses the TMT joints and keeps them from dorsiflexing. B,C. Provisional fixation of first TMT joint. B. Proximal to distal pin. (continued)

Provisional Fixation

 

Guide pins are placed for provisional fixation of the middle column (TECH FIG 4A).

 

Thin guide pins for cannulated drills are fragile. We measure the desired screw length and then pass the wires all the way through the foot. That way, if the guide pin should break, we can retrieve both ends and not leave a pin in the foot that may block my desired screws (TECH FIG 4B,C).

 

Balance of the forefoot is essential. While performing provisional fixation, keep in mind that the metatarsal heads need to be balanced.

 

Typically, that means that the sesamoids are slightly more plantar than the second and third metatarsal heads (TECH FIG 4D).

 

 

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TECH FIG 3 • (continued) C. Distal to proximal pin. Note that the windlass mechanism is still being maintained with dorsiflexion of the toes. D. Large bone reduction clamp to ensure that the second metatarsal base is reduced, much like open reduction and internal fixation of an acute Lisfranc fracturedislocation.

Provisional pin to fix second metatarsal base.

 

Lisfranc Screw Placement

 

The Lisfranc screw stabilizes the base of the second metatarsal and it will limit dorsiflexion of the second TMT joint if a compression plate is used dorsally.

 

We routinely use solid screws but may initiate the drill hole with a cannulated system.

 

For the placement of a solid Lisfranc screw from the first cuneiform to the base of the second metatarsal, we overdrill the guide pin but only to the medial cortex of the second metatarsal base.

 

 

We remove the guide pin and complete the drill hole through the second metatarsal base with a solid drill. We then overdrill the first cuneiform.

 

 

 

TECH FIG 4 • A. Provisional lateral fixation. B,C. Provisional fixation for second metatarsal is the guide pin for the drill for the screw to be placed from the first cuneiform to the second metatarsal base, a traditional Lisfranc screw. B. Clinical view. C. Fluoroscopic view. Note that the guide pin position was checked on fluoroscopy and measured to determine optimal screw length, and then the guide pin was driven fully through the second metatarsal to exit the lateral wound. This way, when the guide pin is drilled and potentially sheared by the drill, both ends of the guide pin may still be retrieved. D. Before placing definitive fixation, the surgeon should check the balance of the forefoot (metatarsal heads). Metatarsal heads should be well balanced, with the sesamoids slightly more plantar than the second and third metatarsal heads.

 

 

We place the solid screw in lag fashion. We typically use a washer for this screw (TECH FIG 5).

Final Fixation

 

We routinely use two lag screws to stabilize the first TMT joint (TECH FIG 6A-F).

 

It is important to use a countersink on the distal to proximal screws so that the dorsal cortex of the first metatarsal base does not fracture when the screw is fully seated (TECH FIG 6E).

 

The middle column may be further stabilized with a lag screw (TECH FIG 6G-J).

 

 

69

 

 

 

TECH FIG 5 • Placing the Lisfranc screw. A. Initiating the drill hole with a cannulated drill over the guide pin.

B. Guide pin is removed and drill hole completed with a solid drill. C. Proximal cortex (first cuneiform) is overdrilled to create lag effect. D. Solid screw is placed. E. Fluoroscopic view.

 

 

 

TECH FIG 6 • A,B. Proximal to distal lag screw across first TMT joint. A. After removal of provisional fixation, overdrilling proximal cortex. B. Solid screw placement. C-F. Distal to proximal screw across the first TMT joint.

C. After removal of provisional fixation, solid drill. D. Overdrill near cortex (first metatarsal). (continued)

 

 

70

 

 

TECH FIG 6 • (continued) E. Countersink (essential so that dorsal first metatarsal cortex does not fracture).

F. Solid screw placement. G-J. Lateral screw placement. G. Overdrill guide pin with cannulated drill (pin is measured and then driven through medial foot so that both ends of the wire may be retrieved should the pin break). H. Drill with solid drill bit. I. Overdrill. J. Solid screw placed.

Dorsal Compression Plate Application

 

We secure the third TMT joint with a dorsal compression plate; with the lag screw already placed, excessive dorsiflexion of the third TMT joint is avoided (TECH FIG 7A-F).

 

 

 

TECH FIG 7 • A-F. Third TMT joint compression plate. A. Plate positioned. B. Locking screws placed (surgeon must be sure plate is flush with the bone before locking the plate). (continued)

 

 

We also use a dorsal compression plate on the second TMT joint (TECH FIG 7G-M). Because the Lisfranc screw has already been placed, dorsiflexion can be avoided.

 

Precontouring the plate also prevents dorsiflexion.

 

 

71

 

 

TECH FIG 7 • (continued) C. View from medial side to show drill towers. D. Compression device placed. E.

Plate in position, now being compressed. F. Final plate position. G-M. Second TMT joint compression plate.

G. Plate before contouring. H. Plate after contouring to match second TMT joint. I. Plate positioned, screw holes drilled. J. Locking screw being inserted. K. Surgeon must be sure that plate is flush with bone before fully seating the locking screws.

 

 

72

 

 

 

TECH FIG 7 • (continued) L. Compression device. M. Final plate position.

Completion

 

Intraoperative fluoroscopy of the construct confirms reduction and that dorsiflexion has been avoided (TECH FIG 8A,B).

 

 

The hardware is often close to the deep neurovascular bundle (TECH FIG 8C). We routinely use a drain for this procedure (TECH FIG 8D).

Postoperative Care

 

Follow-up radiographs suggest satisfactory reduction.

 

 

 

TECH FIG 8 • AP (A) and lateral (B) fluoroscopic views of final construct. Note that first metatarsal is not elevated. C. Deep neurovascular bundle intact but will lie directly on second TMT joint compression plate. Note use of a drain (my preference). D. Wounds closed without tension on skin bridge.

 

 

The patient had some residual lateral column symptoms, so we opted to add a subtalar arthroereisis implant to correct hindfoot alignment and perhaps unload some lateral column stress. Fortunately, that was a satisfactory solution in this case (TECH FIG 9).

 

The first through third TMT articulations have little physiologic motion, so arthrodesing them leaves little functional deficit.

 

To avoid loss of the midfoot's accommodative capacity, we rarely, if ever, fuse the lateral side.

 

 

73

 

 

 

TECH FIG 9 • Final radiographs. A. AP view (note restoration of talo-first metatarsal axis). B. Oblique view. C. Lateral view (also with restoration of talo-first metatarsal axis). Note subtalar arthroereisis. This patient had some residual lateral foot pain and greater than physiologic hindfoot valgus, probably secondary to the injury to the cuboid. Although subtalar arthroereisis does not address this directly, it reoriented the hindfoot adequately to relieve the lateral column stress. D. Clinical view of arch. E. The midfoot articulations normally have limited motion, so fusion of these joints does not restrict the foot substantially.

• Plate Fixation with Dedicated Midfoot Plating System

Background

 

The patient was a 48-year-old woman with midfoot Charcot neuroarthropathy who failed bracing (TECH FIG 10).

 

She had severe distortion of the midfoot anatomy and loss of the longitudinal arch.

Medial Midaxial Approach to Allow for Medial Plating

 

A medial midaxial incision is made and the tibialis anterior is retracted to expose the TMT joint (TECH FIG 11A-C).

 

Should the tendon become detached, it can be sutured securely to the appropriate soft tissues during

closure, and with prolonged immobilization to allow the midfoot to heal, the patient typically will retain full active dorsiflexion.

 

Residual articular cartilage is removed and subchondral bone drilled to prepare the joint and promote fusion (TECH FIG 11D).

Dorsal Longitudinal Approach

 

A dorsal longitudinal midfoot incision is made (TECH FIG 12A).

 

The deep neurovascular bundle is immediately deep to the extensor hallucis brevis tendon. It must be identified and protected throughout the procedure (TECH FIG 12B-D).

Joint Preparation

 

Joint preparation can be interesting, given the distortion of the anatomy as a result of the Charcot process.

 

For an acute Lisfranc fracture-dislocation, a bone reduction clamp from the first cuneiform to the base of the second or third metatarsal is helpful (TECH FIG 13).

 

Once the reduction is confirmed fluoroscopically, provisional fixation can be placed.

 

 

74

 

 

 

 

TECH FIG 10 • Preoperative weight-bearing radiographs of 48-year-old patient with midfoot Charcot neuroarthropathy. A. AP view. B. Oblique view. C. Lateral view.

Medial Plating

 

Modern dedicated midfoot fusion plates have a contour that matches, for the most part, physiologic anatomy. If the plate fits well, the reduction is typically acceptable (TECH FIG 14).

 

Also, if the plate is positioned properly on the first cuneiform, the first metatarsal can be reduced to the plate and the reduction is typically satisfactory.

 

A lag screw can be added to the medial column construct, but often there is little room for such a screw and the plate, unless a headless screw is placed deep to the plate.

 

 

 

TECH FIG 11 • Direct medial midaxial approach. A. Exposure. B. Reflecting tibialis anterior tendon to expose first TMT joint. C. Full exposure. D. After removing residual cartilage, subchondral bone is drilled to promote fusion.

Dorsal Plating

 

Dedicated dorsal plating systems are now also available. These locking plates secure the first through third TMT joints (TECH FIG 15A-D).

 

Alternatively, individual plates may be used on each TMT joint; however, if a single plate can be used to stabilize all three TMT joints, the construct tends to be stronger.

 

With the distortion of anatomy from Charcot neuroarthropathy, plates designed for physiologic anatomy sometimes are difficult to place perfectly on all three TMT joints.

 

75

 

 

 

TECH FIG 12 • Dorsal approach. A. Approach. B. EHB tendon directly over deep neurovascular bundle.

C. EHB tendon retracted to expose deep neurovascular bundle. D. Neurovascular bundle protected and second and third TMT joints exposed to prepare for arthrodesis (note eccentric joint deformity secondary to Charcot neuroarthropathy).

 

 

 

TECH FIG 13 • Bone reduction clamp used to reduce medial and middle columns of the foot after joint preparation (and bone grafting) performed.

 

 

 

TECH FIG 14 • A-C. Medial plate. The plate is designed to restore physiologic alignment; therefore, it may be used as a reduction tool. Occasionally, we fix the plate to the first cuneiform and then “bring” the first metatarsal to the plate.

 

 

76

 

 

 

TECH FIG 15 • A-D. Dorsal plate. The plate extends from the first TMT joint to the third TMT joint, so it must be carefully positioned under the deep neurovascular bundle and the extensor tendons.

 

 

Take care to protect the deep neurovascular bundle (in neuropathy, obviously the artery only matters) and the extensor tendons.

Postoperative Care

 

Follow-up radiographs for the patient are shown in TECH FIG 16.

 

 

 

TECH FIG 16 • Follow-up radiographs. A. AP view. B. Oblique view. C. Lateral view. In this patient with Charcot neuroarthropathy, the lateral column of the foot was also arthrodesed. We do not routinely arthrodese the lateral column but make an exception in select cases of Charcot neuroarthropathy where added stability may be needed for preoperative first and fifth TMT joint dislocation.

 

 

In this case of Charcot neuroarthropathy and dislocation of the fourth and fifth TMT joints, we opted to also arthrodese the lateral column.

 

Only in this situation of neuroarthropathy do we attempt to fuse the lateral column. Typically, we do not wish to sacrifice the midfoot's ability to accommodate.

 

77

• External Fixation

Background

 

The patient was a 44-year-old woman with midfoot sag and forefoot abduction deformity failing nonoperative treatment (TECH FIG 17).

Medial Midaxial Approach

 

Medial approach for midfoot biplanar osteotomy is undertaken.

 

Two reference pins serve to mark the desired osteotomy (confirmed fluoroscopically) (TECH FIG 18).

Applying the External Fixator

 

The saw is shown positioned for the osteotomy in TECH FIG 19A; but to maintain stability of the foot, we routinely apply the external fixator first and then complete the osteotomy.

 

 

 

TECH FIG 17 • Preoperative weight-bearing radiographs of 44-year-old woman with midfoot deformity leading to forefoot abduction and midfoot sag, failing nonoperative measures. A. AP view. B. Lateral view.

 

 

 

TECH FIG 18 • Medial midaxial approach. A. Exposure. B. Tibialis anterior tendon protected and guide pins in place to mark proposed midfoot biplanar osteotomy. C. Full exposure.

 

 

In this case, a “butt frame” construct was used.

 

The hindfoot component of the frame stabilizes the hindfoot with two U rings.

 

 

The frame is first secured with thin wires (TECH FIG 19B,C). Next, half-pins are added for further stability (TECH FIG 19D).

 

We usually tension the thin wires after the half-pins have been inserted (TECH FIG 19E,F).

 

For the forefoot component, a partial ring is added to the forefoot, which is first stabilized with three tensioned thin wires (TECH FIG 19G).

 

We typically add a half-pin to the forefoot-midfoot after we have performed the osteotomy and then know exactly where the struts connecting the forefoot to the hindfoot rings will be positioned.

 

 

78

 

 

 

TECH FIG 19 • A. Saw blade in position for proposed osteotomy. B,C. Butt frame applied before osteotomy, initially with thin wires. B. Medial view. C. Lateral view. Note U ring like a stirrup in coronal plane to stabilize hindfoot. Attached to this is second U ring to provide further support in tibia. D. Frame stabilized further with half-pins from proximal U ring into tibia. E,F. Tensioning thin wires. G. Applying the forefoot ring, primarily with tensioned thin wires, but we routinely add one smalldiameter half-pin to augment the ring's stability.

Midfoot Osteotomy

 

We use an oscillating saw, but a Gigli saw may be used as well (TECH FIG 20A).

 

We create a biplanar wedge with a medial and plantar base to correct abduction and promote plantarflexion in order to recreate the arch.

 

 

We complete the osteotomy with an osteotome (TECH FIG 20B). Remove the wedge of bone (TECH FIG 20C).

 

The osteotomy can then be closed (TECH FIG 20D,E).

 

If it should not close congruently, protect the soft tissues, place the saw in the osteotomy, close the osteotomy as much as possible, and run the saw gently to remove any irregularities. This trick tends to

make the osteotomy appose well.

 

Through this osteotomy, the forefoot may also be derotated.

 

We often “spin” the forefoot out of varus, a common forefoot deformity associated with a flatfoot.

 

Place the struts to connect the hindfoot frame to the forefoot ring (TECH FIG 20F-I).

 

Add compression. With the system's computer program, further correction can be added now or even postoperatively.

 

We routinely reduce the deformity as much as possible intraoperatively, always ensuring appropriate bony apposition at the arthrodesis site, and then compress further to promote stability and healing.

 

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TECH FIG 20 • A-C. Midfoot biplanar osteotomy at planned osteotomy site after application of external fixator (butt frame). A. Saw cut. B. Completion of osteotomy with an osteotome. C. Removal of bone wedge with a rongeur. D,E. Reducing the deformity. D. Osteotomy open. E. Osteotomy closed medially and plantarly. F,G. Frame in place, with struts attached and osteotomy compressed. F. Medial view. G. Plantar foot view, demonstrating recreation of the arch and correction of abduction deformity. H,I. Dressings placed on wires

and pins. Note the half-pin added to dorsolateral forefoot. H. Lateral view. I. AP view.

 

 

80

Postoperative Care

 

 

Follow-up radiographs with frame in place are shown in TECH FIG 21A-C. Final follow-up after frame removal is shown in TECH FIG 21D-H.

 

 

 

 

TECH FIG 21 • A-C. Postoperative radiographs. A. AP view. B. Oblique view. C. Lateral view. Note supplemental wires placed across osteotomy site for initial stabilization. With external fixation, further correction and compression may be performed after the index procedure. D,E. Clinical and radiographic follow-up after external fixator removal. D. Weight-bearing AP radiograph. E. Clinical view. The first ray appears short, which is common after correction of abduction deformity with internal or external fixation. However, in my experience, provided the first ray is adequately plantarflexed and bears weight, the foot functions well with little risk of transfer metatarsalgia despite a relatively long second metatarsal. F-H. Clinical and radiographic follow-up after external fixator removal. F. Lateral clinical view. G. Lateral weightbearing radiograph (note restoration of arch). H. Hindfoot clinical view (note healed incision for gastrocnemius-soleus recession).

 

Often, after flatfoot correction for midfoot collapse, the first ray may appear short.

 

In my experience, as long as we plantarflex the first ray adequately and avoid dorsiflexion of the medial column, transfer metatarsalgia is rarely a problem.

 

81

• Additional Case

Background

 

This 32-year-old man had undergone open reduction and internal fixation of a Lisfranc fracture-dislocation and subsequent hardware removal at an outside institution (TECH FIG 22A-C). He had failed further nonoperative measures.

 

We performed a midfoot medial column plantar plating in combination with middle column dorsal plating after attempted deformity correction (TECH FIG 22D-G).

 

 

 

TECH FIG 22 • Preoperative weight-bearing radiographs of a 32-year-old man with chronic Lisfranc fracture-dislocation that had undergone prior open reduction and internal fixation of the injury and subsequent hardware removal. A. AP view. B. Oblique view. C. Lateral view. Revision surgery with medial plantar plating and middle column plating was undertaken through dual longitudinal approaches after

attempted reduction of severe abduction deformity and midfoot collapse. D-F. Screw fixation of medial column plantar plate. Note provisional wire fixation. (continued)

 

 

Follow-up radiographs (TECH FIG 22H-J) show that although his longitudinal arch appears corrected, his forefoot still remains in abduction and he remains symptomatic.

 

Further nonoperative care failed.

Rerevision surgery

 

Medial biplanar wedge osteotomy after hardware removal (TECH FIG 23A-C)

 

Further correction of abduction deformity and more plantarflexion to the medial column

 

 

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TECH FIG 22 • (continued) G. Dorsal approach to middle column for compression plating. H-J. Follow-up weight-bearing radiographs. Although arch is restored, forefoot abduction is incompletely corrected. H. AP view. I. Oblique view. J. Lateral view. Patient was improved but remained symptomatic and failed orthotic management.

 

 

 

We was able to reuse the plantar plate (TECH FIG 23D,E). We performed two adjunctive hindfoot procedures:

 

 

Medial displacement calcaneal osteotomy (TECH FIG 23F) Subtalar arthroereisis (TECH FIG 23G)

Postoperative Care

 

Follow-up weight-bearing radiographs suggest improved alignment, particularly with respect to the talo-first metatarsal axis in the AP plane (TECH FIG 24A,B).

 

 

 

TECH FIG 23 • A-C. Rerevision surgery with removal of plantar plate and medial approach biplanar midfoot osteotomy to correct residual abduction deformity and promote even further plantarflexion of the medial column. A. Saw to create biplanar osteotomy along reference pins marking proposed osteotomy. B. Wedge resected. (continued)

 

 

Clinically, alignment and function were improved. In fact, he had perhaps better alignment in his operated foot than his contralateral foot (remains to be seen if this is advantageous but anecdotally appears to be the case) (TECH FIG 24C-E).

 

83

 

 

TECH FIG 23 • (continued) C. Wedge removed. D. Deformity reduced. E. Plantar plate reapplied. F,G.

Supplemental hindfoot correction. F. Medial displacement calcaneal osteotomy. G. Subtalar arthroereisis.

 

 

 

TECH FIG 24 • A,B. Follow-up weight-bearing radiographs. A. AP view (note correction of abduction) and near-anatomic restoration of congruent talo-first metatarsal axis. B. Lateral view, also with restoration of talo-first metatarsal axis. C-E. Clinical follow-up. C. Lateral view. (continued)

 

 

84

 

 

 

TECH FIG 24 • (continued) D. AP view. E. Hindfoot view. Operated foot is in a more physiologically normal position than contralateral foot.

 

 

 

PEARLS AND PITFALLS

 

 

Deformity correction

• Realign talo-first metatarsal axis in both the AP and lateral planes; undercorrection rarely leads to satisfactory outcome.

   

  TMT joint anatomy

• The TMT joints are quite deep (2.5-3.0 cm).

 

Avoid dorsiflexion or elevated malpositioning.

• Be sure to prepare the TMT joints to their bases; leaving plantar bone and cartilage will lead to a dorsiflexion malunion. Also, do not take any dorsal bone from the TMT joints.

   

  Correct abduction

  • The physiologically normal medial aspect of the medial column of the foot is relatively straight; with severe midfoot deformity, the first metatarsal must really be swung around to align anatomically; then, the lesser metatarsals should follow.

     

    Forefoot balance

  • When arthrodesing the TMT joints, be sure to check the relative position of the metatarsal heads. The first metatarsal head and sesamoids should be slightly plantar to the lesser metatarsal heads. Palpate this balance as the midfoot is provisionally stabilized.

     

    Tricks to correcting abduction

  • In severe deformity, avoid first metatarsal elevation and attempt to reduce the abduction deformity. Fix the plate to the medial aspect of the first cuneiform, then reduce the first metatarsal to the plate.

  • As for a reduction of a Lisfranc fracture-dislocation, use a large bone reduction clamp to reduce the base of the second metatarsal by spanning the course of the first cuneiform-second metatarsal base.

 

POSTOPERATIVE CARE

 

A splint is used that extends beyond the toes with the ankle in neutral position for 2 weeks.

 

The patient returns to the clinic at 2 weeks for suture removal and application of a short-leg cast with the ankle in neutral position. Touchdown weight bearing only is permitted.

 

The patient returns to the clinic at 6 weeks for radiographs out of plaster (three views of the foot). If progression toward healing is suggested by radiographs, the surgeon should consider placing the patient in a cam boot, but still, only touchdown weight bearing is permitted.

 

At 10 weeks, the patient returns for repeat radiographs (weight bearing, three views of the foot).

 

If progression toward healing is suggested radiographically, weight bearing is gradually added over 3 weeks in the cam boot. Then, the patient gradually transitions into regular shoes. We often recommend a longitudinal arch support and a relatively stiff sole.

 

If no progression toward healing is seen, the patient is returned to the boot, with limited weight bearing, and the boot is used for 3 to 4 weeks.

OUTCOMES

There are limited level IV studies for midfoot arthrodesis, but there are reasonable functional outcomes and improvement in pain scores for midfoot arthrodesis based on the weak literature.

Results are generally better when restoration of physiologically normal alignment is achieved. There are virtually no reported outcomes for modern dedicated midfoot plating systems.

More information and higher level evidence are needed.

 

 

COMPLICATIONS

Undercorrection Overcorrection Infection

Wound dehiscence Nonunion Malunion

Greater than physiologic elevation of one or more metatarsals Imbalance of the metatarsal heads

 

 

 

SUGGESTED READINGS

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1. Coetzee JC, Ly TV. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. Surgical technique. J Bone Joint Surg Am 2007;89(suppl 2, pt 1):122-127.

    

2. Ferris LR, Vargo R, Alexander IJ. Late reconstruction of the midfoot and tarsometatarsal region after trauma. Orthop Clin North Am 1995;26:393-406.

    

3. Greisberg J, Assal M, Hansen ST Jr, et al. Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;(435):197-202.

    

4. Horton GA, Olney BW. Deformity correction and arthrodesis of the midfoot with a medial plate. Foot Ankle 1993;14:493-499.

    

5. Jung HG, Myerson MS, Schon LC. Spectrum of operative treatments and clinical outcomes for atraumatic osteoarthritis of the tarsometatarsal joints. Foot Ankle Int 2007;28:482-489.

    

6. Komenda GA, Myerson MS, Biddinger KR. Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78(11):1665-1676.

    

7. Raikin SM, Schon LC. Arthrodesis of the fourth and fifth tarsometatarsal joints of the midfoot. Foot Ankle Int

    

   2003;24:584-590.

    

    

8. Rammelt S, Schneiders W, Schikore H, et al. Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. J Bone Joint Surg Br 2008;90(11):1499-1506.

    

    

9. Sammarco VJ, Sammarco GJ, Walker EW Jr, et al. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. J Bone Joint Surg Am 2009;91(1):80-91.

    

    

10. Sammarco VJ, Sammarco GJ, Walker EW Jr, et al. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. Surgical technique. J Bone Joint Surg Am 2010;92(suppl 1, pt 1):1-19.

     

     

11. Suh JS, Amendola A, Lee KB, et al. Dorsal modified calcaneal plate for extensive midfoot arthrodesis. Foot Ankle Int 2005;26: 503-509.

     

     

12. Toolan BC. Midfoot arthrodesis: challenges and treatment alternatives. Foot Ankle Clin 2002;7:75-93.

     

     

13. Vertullo CJ, Easley ME, Nunley JA. The transverse dorsal approach to the Lisfranc joint. Foot Ankle Int 2002;23:420-426.