Lateral Column Arthroplasty
Thomas J. Chang
Lateral column pathology has not been discussed in much detail in the literature, although there have been discussions regarding calcaneal-cuboid joint syndrome and lateral Lisfranc arthritis. Kinematic studies have documented triplanar motion at the lateral Lisfranc area, which is different from its medial counterparts (1). It may also be helpful to consider lateral column pain in relationship to various foot types. The neutral to slightly supinated foot will tend to overload the lateral column and can be more at risk for these lateral pathologies.
Over the past years, many patients have undergone fourth and fifth metatarsal cuboid arthrodesis from Lisfranc fracture/dislocations, traumatic arthritis, and intra-articular pain. The result has been a pain-free area that feels very stiff and uncomfortable. The current recommendation for end-stage arthrosis of the lateral joints is to perform a joint arthroplasty versus an arthrodesis to hopefully avoid this stiffness.
Patients with end-stage arthrosis of the lateral Lisfranc joint are prime candidates for this approach. This is the result of direct trauma to the joint or Lisfranc fracture dislocations. Relocation and stabilization or fusion of the medial three joints may still leave significant pathology at the fourth and fifth metatarsal-cuboid joints.
Diagnostic injections at the joint level can be helpful in proper diagnosis of intra-articular joint pain. If this relieves the majority of the symptoms, then surgical arthroplasty is a viable option to consider. Since the cuboid forms a common synovial space with two bones, it is often important to consider treatment of both joints when either one appears to be involved.
CRITERIA/SELECTION OF PROCEDURE/CONTRAINDICATIONS
Orthopaedic and biomechanical studies have documented the triplanar movement noted at the lateral Lisfranc joint. The motion in both the frontal and sagittal planes are almost two to three times their medial counterparts. Komenda et al (2) and Mann et al (3) have both commented on the discomfort patients relate after lateral column arthrodesis at the distal joint.
Berlet et al have discussed the “anchovy procedure” as an interpositional spacer after joint resection. In this procedure, the extensor tendon is rolled up into a ball and inserted between the resected joint margins (4). Recently, Shawen has described the placement of a ceramic sphere into this space after joint resection. A similar implant was used initially in the hand for tarsometacarpal arthritis, but this has fallen out of favor due to subsidence of the implant (5).
The incision should allow the surgeon to access the two lateral metatarsal bases and stay above the peroneus brevis tendon and sural nerve. This is located by palpating the fourth and fifth metatarsal-cuboid joint and extending the incision several centimeters proximally and distally from this anatomic location (Fig. 82.1A). Dissection is then carried out through the subcutaneous tissues down to the deep fascia covering the metatarsal bases. If the neurovascular bundle is seen, then it can be retracted plantarly with the soft tissue envelope (Fig. 82.1B). Often, the peroneus brevis tendon is seen along the inferior aspect of the incision as it attaches to the fifth metatarsal base.