Arthrodesis of the Tarsometatarsal Joint

J. Chris Coetzee, MD, FRCSC

Pascal Rippstein, MD

Dr. Coetzee or an immediate family member has received royalties from Arthrex, DePuy, and MMI; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex and Tornier; serves as a paid consultant to or is an employee of Arthrex, Tornier, Zimmer, and Allosource; has stock or stock options in Tornier; has received research or institutional support from DePuy, Zimmer, and Allosource; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Foot & Ankle Society and the American Academy of Orthopaedic Surgeons. Dr. Rippstein or an immediate family member has received royalties from DePuy; is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy; and serves as a paid consultant to or is an employee of DePuy.

INTRODUCTION

Anatomy

The unique anatomy of the tarsometatarsal (TMT) joint complex, also called the Lisfranc joint, contributes to the spectrum of injury patterns. The stability of the TMT joint complex is maintained by a combination of the wedge-shaped configuration of the metatarsal bases and their corresponding cuneiform articulations, as well as by ligamentous support (Figure 1).

The Lisfranc ligament is composed of three portions, running from the medial cuneiform to the base of the second metatarsal. The strongest part is the plantar portion of the ligament, which is the main stabilizing component of the first and second metatarsal interspace. There is very little motion at the second and third TMT joints, 10° to 20° at the fourth and fifth metatarsal-cuboid, and 5° to 10° at the first TMT joint.

The second TMT joint is recessed between the medial and lateral cuneiforms. The strong plantar ligaments “lock” the metatarsals to the midfoot.

A very important factor to remember is that Lisfranc joints have no inherent stability. The joints are flat on flat surfaces and rely on ligamentous stability to maintain reduction (compared with the inherent stability of a ball-and-socket joint).

PATIENT SELECTION

Indications

TMT arthrodesis, or fusion, can be indicated for a variety of problems, including acute fracture or instability, but most of these procedures are done for chronic deformity and pain.¹ Chronic deformity and pain can be secondary to prior Lisfranc injury; they also can be due to primary degenerative changes or Charcot neuroarthropathy.

Indications for primary fusions of TMT joints include (1) major ligamentous disruptions with multidirectional instability/dislocation of the Lisfranc joints, (2) comminuted intra-articular fractures at the base of the first or second metatarsal, and (3) crush injuries of the midfoot with intra-articular fracture-dislocation.²^,³

Indications for secondary TMT fusions include (1) posttraumatic degenerative joint disease (DJD) after Lisfranc injuries, (2) idiopathic/primary TMT DJD, (3) rheumatoid arthritis, and (4) stable/chronic Charcot neuroarthropathy or other complications of diabetes.⁴^,⁵^,⁶

Figures 2, 3, 4 show three different scenarios where a TMT fusion is indicated. Each creates a different challenge in treatment, but the surgical principles stay the same.

Contraindications

Contraindications for fusion of the TMT joints are (1) skeletal immaturity/open physes; (2) acute Charcot neuroarthropathy (relative); (3) simple, incomplete ligamentous injuries; and (4) active infection. Charcot neuroarthropathy can be approached with care; it should be dealt with acutely only if there is impending skin breakdown.

FIGURE 1 CT scan demonstrates the configuration of the Lisfranc complex, which mimics a “Roman arch,” in which the stability is dependent upon the bony configuration and ligament stability. There is no inherent joint stability.

FIGURE 2 AP (A) and lateral (B) radiographs of an acute traumatic Lisfranc fracture-dislocation with signs of intra-articular fractures.

PROCEDURE

Surgical Technique

The surgical approach for a TMT fusion is exactly the same as the approach commonly used for an open reduction and internal fixation of a Lisfranc injury. A calf or thigh tourniquet is used and inflated to 250 mm Hg. Depending on the number of TMT joints involved in the injury or arthritic process, one or two dorsal, longitudinal incisions are made.

FIGURE 3 AP (A) and lateral (B) radiographs show severe deformity in the sagittal and coronal planes secondary to an untreated or poorly treated Lisfranc injury 15 years earlier.

The first incision is made between the first and second metatarsals (Figure 5). This will allow access to the first TMT joint and most of the second. Pathology involving
only the medial two TMT joints can be corrected with this single incision. If there is any concern about the accuracy of the reduction, it is advisable to do a second, more lateral incision to facilitate exposure and visualization of the joint.²

FIGURE 4 AP (A) and lateral (B) radiographs demonstrate severe deformity in all planes secondary to Charcot neuroarthropathy in patient with type 1 diabetes.

If there is a reason to fuse the third TMT joint, a second lateral incision should always be made. We believe that it is advisable to be liberal with the use of a two-incision approach; adequate exposure of the lateral corner of the second metatarsal base and the lateral cuneiform through a single dorsomedial incision can be very hard to obtain.

FIGURE 5 Intraoperative photograph shows the surgical approaches for a tarsometatarsal joint fusion in a left foot. The medial incision is between the first and second metatarsals, just lateral to the extensor hallucis tendon. The lateral incision is at least 4 cm farther lateral, overlying the fourth metatarsal.

It is extremely rare that the fourth and fifth TMT joints would need to be fused. The only time when it is reasonable is in severe deformities secondary to Charcot neuroarthropathy, where the lateral border of the foot needs to be elevated.

The second incision is centered over the fourth metatarsal; in reality it is much farther lateral than what is appreciated. The most common mistake is to make the incision too far medial. Incision placement may be aided by fluoroscopic guidance and the identification of the intended bony targets. The foot should be internally rotated to obtain an end-on view of the fourth metatarsal. If the radiograph is taken with the foot in a neutral position, there is too much overlap between the third, fourth, and fifth metatarsals to accurately determine the position of the fourth ray.

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