J Clin Orthop Trauma. 2020 May-Jun; 11(3): 399–405.
Published online 2020 Mar 8. doi: 10.1016/j.jcot.2020.03.002
PMCID: PMC7211829
PMID: 32405198
Midfoot arthritis- current concepts review
Harish Kurup∗ and Nijil Vasukutty
Abstract
Midfoot arthritis causes chronic foot pain and significant impairment of daily activities.
Although post traumatic arthritis and primary osteoarthritis are the most common
pathologies encountered, surgeons need to rule out inflammatory causes and neuropathic
aetiology before starting treatment. Steroid Injections are invaluable in conservative
management and have diagnostic value in guiding surgical treatment. For the definitive
surgical option of fusion there are a variety of fixation devices available. A successful union
is linked to a satisfactory outcome which most authors report to be in the range of 90%
following the key principles of careful patient selection, pre-operative planning, adequate
joint preparation and a stable fixation.
Keywords: Midfoot, Arthritis, Lisfranc, Fusion, Tarso-metatarsal joint
1. Introduction
Midfoot arthritis is a challenging problem causing chronic foot pain and significant
impairment of daily activity. There is little written about this subject in literature and is often
not well known by orthopaedic surgeons in general. In this review we describe the anatomy
of midfoot, pathology of midfoot arthritis, examination and diagnosis, investigations
followed by treatment options.
2. Anatomy
:
Midfoot includes Tarso-metatarsal (TMT) joints and naviculo-cuneiform joints (NCJ). Talonavicular joint (TNJ) and calcaneocuboid joint (CCJ) are considered to be part of hindfoot
along with sub-talar joint. Tarso-metatarsal joints are divided into three columns
anatomically: the medial column (First Tarsometatarsal joint), the middle column (second
and third TMT joints) and the lateral column (Fourth and Fifth TMT or Metatarsocuboid
joints). TMT joints are collectively known as Lisfranc joints as well.
The navicular has three facets distally each of which articulates with the three cuneiforms.
Cuboideonavicular joint is a fibrous joint reinforced by ligaments but in some cases a true
synovial joint may be present.1 In the coronal plane the TMT joints are arranged in the form
of a roman arch (Fig. 1). The cuneiforms are wedge-shaped, with their narrow portions being
plantar, thus allowing for the arch configuration. Metatarsal bases also have a similar shape.
The second metatarsal base assumes the position of keystone because of the unique slightly
more proximal positioning of second TMT joint than the first and third TMT joints
effectively wedging it between the five neighbouring bones. This geometry gives the midfoot
it’s inherent stability. Metatarsal bases are connected together by strong interosseous
ligaments except between the first and second. Instead, the Lisfranc ligament goes obliquely
plantarwards from the medial cuneiform to the base of the second metatarsal. This is the
strongest ligament of all in the Lisfranc joints. In addition to strong ligamentous support, the
entire configuration also receives soft-tissue support from the peroneus longus tendon, the
attachments to which allow it to function as a strong tie beam for this transverse metatarsal
arch.2
Fig. 1
:
Roman arch structure of cuneiforms- Coronal CT.
3. Biomechanics
The function of the midfoot is to connect the hindfoot to the forefoot and hence it is less
mobile compared to the other joints. The midfoot functions as a beam, transforming the
flexible foot at heel strike to a rigid lever arm at toe-off. At toe-off, the foot is supinated,
locking the transverse tarsal joint. Locking of the transverse tarsal joint allows the midfoot to
transfer the force generated during gait from the hindfoot to the forefoot for locomotion.3 The
peak weight distribution in the standing barefoot adult is 60.5% at the heel, 7.8% at the
midfoot, 28.1% at the forefoot, and 3.6% at the toes.4 The medial tarsometatarsal joints
provide <7° of sagittal plane motion, the more mobile lateral fourth and fifth TMT joints
provide balance and accommodation on uneven ground. These small constrained TMT joints
also provide stability and translate the forward propulsion motion of the hindfoot and ankle
joint to the forefoot metatarsophalangeal joints from heel rise to toe-off.5
Ouzounian and Shereff6 quantified midfoot motion in fresh-frozen amputation specimens.
Dorsiflexion/plantar flexion motion was greatest at the fourth/fifth TMT joints (means, 9.6°
and 10.2°, respectively), followed by the navicular-middle cuneiform (mean, 5.2°) and the
navicular-medial cuneiform articulation (mean, 5.0°). Supination & Pronation movements
also followed a similar trend. The second TMT joint had the least motion in
dorsiflexion/plantar flexion (mean, 0.6°) and supination/pronation (mean, 1.2°). The limited
motion at the second TMT joint is again thought to be limited by the strong Lisfranc
ligament and the geometry of the second metatarsal as the keystone in the transverse arch.
A study7 of contact mechanics of the normal tarsometatarsal joints in cadaveric feet found
that the second/third tarsometatarsal joints bore the majority of the force in all positions of
the foot compared with the first and fourth/fifth tarsometatarsal joint articulations. The force
transferred from the second/third tarsometatarsal joints to the first and fourth/fifth
tarsometatarsal joints was greatest in plantar flexion. This appears to be the mechanism by
which the midfoot limits pressure on the second/third tarsometatarsal joints and allows the
midfoot to adapt to varying loads and repetitive stresses. This would explain why second and
third TMT joints are the most common joints to develop arthritis in midfoot (even in the
absence of any history of previous injury).
4. Pathology
Mid foot arthritis is usually caused by one of the following aetiologies.
:
•
•
•
•
Degenerative
Post traumatic
Inflammatory
Neuropathic
• Post hindfoot fusion
Post-traumatic arthritis is common in midfoot following both fractures and the more subtle
ligamentous Lisfranc injuries. Primary degenerative arthritis can appear spontaneously, but
most patients may still describe an injury which has been overlooked. Inflammatory arthritis
typically affects multiple joints and so does neuropathic Charcot. Ankle or Hindfoot fusion
can transfer stresses to midfoot leading to secondary arthritis in later life.
5. Diagnosis
The diagnosis of a Lisfranc pathology must be made on the basis of the history, physical
examination, and radiographic evaluation of the foot. History helps to rule out diabetes and
inflammatory arthritis. Most patients recall history of a past injury which they themselves
may have overlooked.
Pain typically gets worse when using stairs or on uneven grounds. Symptoms are due to lack
of stability, altered mechanics and loading on the inflamed joint. Eventually midfoot collapse
occurs leading to a rigid flatfoot deformity, forefoot abduction and varus, longitudinal arch
collapse (midfoot break usually becomes more apparent on weight bearing), and osteophyte
formation.8 Patients usually have shoe-wear difficulty secondary to residual deformity.
6. Clinical assessment
Passive manipulation of the midfoot involves abduction of the forefoot and a pronation stress
test to determine the location of maximal pain. Tenderness across the midfoot is made worse
by this manoeuvre but it cannot stress the TMT joints individually.9 The piano key test
described by Keiserman et al.10 offer better localization of symptomatic joints than
manipulation of the whole midfoot. The midfoot and hindfoot are manually secured and a
plantar force is applied to the individual metatarsal head (as if one were striking a piano key).
An alternative method is to grasp the desired toe to apply the downward force to the
corresponding metatarsal. The metatarsal acts as a lever arm transmitting the force and a
positive test will produce localized pain at the corresponding TMT joint.
The gap sign11 shows an obvious gap between the first and second toes of the affected foot,
which occurred during weightbearing. It occurs as a result of widening of the intercuneiform
joint with disruption of the Lisfranc ligament but without injury to the TMT joints.
:
Injection of a local anaesthetic is an option to determine which joints are painful or
symptomatic. However, some authors8 do not consider this to be sufficiently accurate, as
these joints are small for selective anaesthesia and local anaesthetic can leak from one to
another. If performed use of radiopaque dye is advisable to confirm and document exact
location of the needle and injection (Fig. 2).
Fig. 2
Injection of midfoot joints under fluoroscopy with use of radiopaque dye.
7. Radiology
:
Weight bearing Antero-posterior, lateral and oblique views are the first investigation of
choice in midfoot arthritis. The addition of non-weight-bearing lateral radiographs can help
identify the level of midfoot break, which may be at TMT, NCJ, TNJ or a combination of
these. Radiologically medial border of first metatarsal is aligned with the medical border of
the medial cuneiform. The middle column is aligned when the medial border of the second
metatarsal is aligned with the medial border of intermediate cuneiform. On the lateral side
the medial border of the fourth metatarsal is aligned with the medial border of the cuboid. On
lateral radiographs restoration of arch height and first metatarsal declinational angle are
imperative (Fig. 3, Fig. 4).
Fig. 3
:
AP Radiograph showing alignment of medial and middle columns.
Fig. 4
Lateral Radiograph showing alignment of lateral column.
:
MRI (Magnetic Resonance Imaging) is useful in mapping the degree & extend of arthritis in
midfoot. It is very useful to look for early signs of arthritis in adjacent joints before
considering surgical interventions such as fusion. (Fig. 5, Fig. 6). Technetium bone scan may
be helpful but increased uptake is often noted in joints that are not painful particularly with
respect to the lateral column. Spect-CT may be useful to find out which one of the arthritic
joints is the worst but again has limited value.
Fig. 5
:
Sagittal T1 weighted MR image showing arthritis of second TMT joint.
Fig. 6
Axial T2 weighted MR image showing arthritis of second TMT joint.
8. Injection studies
Selective Injection into the affected joints under radiological guidance is the most commonly
used diagnostic test. This also helps in isolating symptoms and most surgeons prefer to do an
injection before offering a fusion to predict success rate. Injection is preferably done with
radiopaque dye to confirm position of the needle within the targeted joint; however it is
common to see it leaking out to the adjacent joints as they are interconnected (Fig. 2).
:
Some surgeons inject in clinic with blind palpation which may not always be accurate, but
this can be improved with the use of ultrasound guidance.12 Drakonaki et al.13 reviewed a
series 59 patients with midfoot joint degenerative changes who received US-guided injection.
The majority of patients had a positive response up to 3 months post-injection (78.4% still
experiencing pain relief at 2 weeks, 57.5% at 3 months and fewer than 15% of patients
further than 3 months post-injection).
9. Management
9.1. Non operative management
Initial management of midfoot degenerative arthritis should always be non-operative. These
include use of analgesics, functional orthoses and local injections.
Mild to moderate symptoms do get better with simple analgesics including non-steroidal
anti-inflammatory tablets. A network meta-analysis of 74 randomised trials of 7 NSAIDs
(Non-steroidal anti-inflammatory Drugs)and paracetamol in people with knee or hip arthritis
has come to the conclusion that NSAIDs were more effective than placebo. Diclofenac at
maximum daily dose of 150 mg/day was more effective than ibuprofen, naproxen and
celecoxib.14 It is reasonable to extrapolate the results of this to the management of
degenerative arthritis of the foot. Paracetamol was not found to be effective at any dose.
Moreover, concern has been raised regarding the adverse cardiovascular effects of selective
COX-2 inhibitors.15 In patients who cannot tolerate oral medication, topical analgesics is an
alternative. However, there is no evidence on literature for the effectiveness of these in foot
arthritis. There are studies showing some efficacy of topical application of Diclofenac,
ketoprofen and capsaicin in knee and hand arthritis.16,17
9.2. Orthoses
Footwear modification and functional orthoses play a key role in most foot pathology and
midfoot arthritis is no exception. For foot arthritis two types of orthosis are mainly used: 1)
shoe stiffening inserts made from flat thin semi rigid material extending the full length of the
shoe and 2) contoured orthoses which contour the arch of the foot and extend just proximal
to the metatarsal heads.18 Individuals with midfoot arthritis have pronated feet and generate
higher loads under the midfoot. Therefore, the orthoses are designed to reduce hindfoot
eversion and support the medial longitudinal arch. A recent randomised control trial showed
improved pain control and function in midfoot arthritis with a semi rigid contoured orthosis
compared to a sham insert over a 12-week period.19 Although both full length and threequarter length inserts are popular among surgeons and orthotists, it has been shown that full
length inserts reduce magnitude and duration of loading under the medial midfoot and thus
better symptom control.20
:
9.3. Injections
Intra articular corticosteroids have been used joint degenerative pathology for their
therapeutic effect. In the foot they have an additional diagnostic benefit in localising the
source of symptoms and targeting any operative intervention effectively. Evidence on the
effectiveness of local injection is sparse in literature with no level 1 studies. Grice and
colleagues21 retrospectively reviewed 365 patients who had image guided foot injections.
86% reported a significant improvement in symptoms and 66% a complete resolution of pain.
The mode time of recurrence of pain was 3 months and 29% were asymptomatic at the 2 year
follow up. They had 24% of patients who had operative intervention within the follow up
period. Although they have not restricted this large series to midfoot pathology it will serve
as a guide to practice and help in patient education and in obtaining an informed consent.
Obesity has been linked to all joint degenerative pathology and the foot is no different.
Investigators from Swansea22 have noted a significant difference in response to corticosteroid
injections for midfoot OA between obese and nonobese patients with their BMI cut-off being
30. They found a statistically significant improvement in post injection Self-reported Foot
and Ankle Scores (SEFAS) at 4 and 12 months in a cohort of 37 patients who had 67
injections.
9.4. Operative management
The decision to operate is usually guided by the level of symptoms and functional
restrictions. Where there are prominent osteophytes or bony prominences, excision of these
is one conservative procedure that would help with pain and make shoe wear more
comfortable however high failure rates have been reported some surgeons anecdotally. A
more definitive treatment option would be arthrodesis of the arthritic joints or columns. The
pain should be localized to the degenerate joint as seen on X-rays. Diagnostic steroid
injections are invaluable in confirming this before going ahead with fusion.23,24 This is
especially true in multi-joint disease.
:
Midfoot arthrodesis can be challenging especially if multiple joints are involved and
choosing suitable hardware is important. A variety of fixation methods have been used
ranging from Kirschner wires, screws, staples and a selection of plates (Fig. 7, Fig. 8, Fig. 9,
Fig. 10). Filippi, Myerson and team25 have used a novel hybrid plating system which
incorporated locking and non-locking screws and obtained bony union in 67 out of 72
patients. They conclude that hybrid plating system is a reliable alternative for fusion in multi
joint disease. A study from 1996 looked at lag screws for arthrodesis in a series of 32
patients8 and reported improvement of AOFAS (American Orthopaedic Foot and Ankle
Society) scores from 44 to 78. Nemec and co-workers26 report on a large series of 104 feet in
95 patients in whom they achieved a 92% union rate following midfoot arthrodesis of
primary osteoarthritis. They combined this with deformity correction and soft tissue
balancing where applicable. Complications included 8 non unions,3 deep infections and one
case of chronic regional pain syndrome. There were 11 re-operations and 26 symptomatic
hardware removals. AOFAS scores improved from 32 pre-operative to 79 post operatively.
Staples are an effective alternative when the surgeon is concerned about soft tissue quality
and in situations where scarring from previous procedures preclude extensive dissection.
There have been several reports27, 28 of the use of staples although none of these looks
exclusive at their use in midfoot joints. Fixation devices which use principles of both staples
and plate screw construct are also popular, but no clinical studies have looked at their use
exclusively in midfoot (Fig. 11, Fig. 12).
Fig. 7
:
65 year old with symptomatic arthritis of 2nd to 5th TMT joints – AP view (Previous 1st TMT Fusion).
Fig. 8
:
65 year old with symptomatic arthritis of 2nd to 5th TMT joints – Lateral view.
Fig. 9
:
Post-operative Radiographs at 6 months Post Fusion 2nd to 5th TMT joints – AP view.
Fig. 10
:
Post-operative Radiographs at 6 months Post Fusion 2nd to 5th TMT joints – Lateral view.
Fig. 11
Post traumatic arthritis of 2nd TMT joint- Fusion with a Polyaxial Dynamic plating system with locking
:
screws and compression by spreader – AP & Oblique views.
Fig. 12
Post traumatic arthritis of 2nd TMT joint- Fusion with a Polyaxial Dynamic plating system with locking
screws and compression by spreader – Lateral view.
Pre-operative planning should consider whether an in-situ arthrodesis or a corrective fusion
is in the patient’s best interest. Evidence is conflicting in this regard and there have been
reports of this in the setting of post traumatic arthritis. Johnson and Johnson29 report on a
series of 15 patients who had an in-situ dowel graft arthrodesis. At a mean follow up of 37
months 11 out of 13 patients available for follow up, had subjective satisfactory pain relief.
Good to excellent relief was reported in 9 out of the 13 and union was achieved in 10. On the
other hand, Sangeorzan and colleagues30 report results of fusion for failed initial treatment of
Lisfranc injuries and state that reduction is key to a good result. They had 69% good to
excellent results. These researchers tried to determine if fusion of lateral rays was required
and have reported that this is not a factor in determining outcome. We feel that in situ
arthrodesis is acceptable for patients with normal radiographic alignment. In patients with
adult flat foot or cavovarus foot, a deformity correction is required with or without
osteotomies. These would make shoe fitting easier and reduce the risk of the transferring load
to adjacent joints.
:
Medial column fusions are used to correct severe midfoot break or arch collapse that
accompany diffuse midfoot arthritis. These are usually done with anatomically contoured
plates with the option of locking and locking screws and typically span the whole medial
column from talus or navicular to first metatarsal depending on the joints involved Fig. 13,
Fig. 14.
Fig. 13
Medial column fusion (Navicular to 1st metatarsal) with locking plate- AP view.
Fig. 14
:
Medial column fusion (Navicular to 1st metatarsal) with locking plate- Lateral view.
Regardless of aetiology the treatment of the symptomatic lateral TMT joint arthritis is
challenging. These joints are mobile and fusion could lead to non-union, chronic pain and
stress fractures. There have been several reports31,32 of motion sparing procedures like soft
tissue interposition and ceramic interposition arthroplasty. These report varying outcomes
and currently long-term studies are lacking. This is one area where authors would
recommend persisting with non-operative treatment as long as the symptoms are bearable.
Complications following midfoot surgery include wound healing problems, infection (3%),
peripheral nerve injury (9%), non-union (3–8%), painful neuroma formation (7%) and screw
irritation or breakage (9%).33 Arthritis in adjacent joints (4.5%) is a long-term problem that
patients should be made aware of. Stress fractures and CRPS have been reported although
less common.20,26
Midfoot arthritis can be debilitating, and a successful union is linked to a satisfactory
outcome which most authors report to be on the range of 90%. The hardware appropriate for
each case should be carefully chosen but the surgeon should not deviate from the key
principles of careful patient selection, pre-operative planning, adequate joint preparation and
a stable fixation.
Funding
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal
relationships that could have appeared to influence the work reported in this paper.
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