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Management of Tarsometatarsal Joint Injuries

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Management of Tarsometatarsal Joint Injuries Review Article Management of Tarsometatarsal Joint Injuries Abstract Brian M. Weatherford, MD Joint disruptions to the tarsometatarsal (TMT) joint complex, also John G. Anderson, MD known as the Lisfranc joint, represent a broad spectrum of pathology from subtle athletic sprains to severe crush injuries. Although injuries Donald R. Bohay, MD, FACS to the TMT joint complex are uncommon, when missed, they may lead to pain and dysfunction secondary to posttraumatic arthritis and arch collapse. An understanding of the appropriate anatomy, mechanism, physical examination, and imaging techniques is necessary to diagnose and treat injuries of the TMT joints. Nonsurgical management is indicated in select patients who maintain reduction of the TMT joints under physiologic stress. Successful surgical management of these injuries is predicated on anatomic reduction and stable fixation. Open reduction and internal fixation remains the standard treatment, although primary arthrodesis has emerged as a viable option for certain types of TMT joint injuries. he tarsometatarsal (TMT), or these injuries often result in painful TLisfranc, joint complex is com- posttraumatic arthritis and arch posed of the TMT, intertarsal, and collapse. Early diagnosis and main- proximal intermetatarsal joints.1 The tenance of anatomic reduction of the unique osseous anatomy of the TMT joints are necessary to maxi- midfoot along with the stout liga- mize patient function. JAAOS Plus Webinar mentous support allows effective Nevertheless, appropriate initial Join Dr. Weatherford, Dr. Anderson, force transfer from the hindfoot to treatment of TMT injuries is contro- and Dr. Bohay for the interactive the forefoot during ambulation. versial. A variety of techniques have JAAOS Plus Webinar discussing “Management of Tarsometatarsal Joint Injuries to the TMT joint complex are been described for the management Injuries,” on Tuesday, July 11, 2017, at rare, accounting for only 0.2% of all of TMT injuries, but rates of post- 8 pm Eastern Time. The moderator will fractures, with a reported incidence of traumatic arthritis following surgical be Christopher P. Chiodo, MD, the 2 treatment still range from 27% to ’ 1 per 55,000 persons. When they do Journal s Deputy Editor for Foot and 4,5 Ankle topics. Sign up now at occur, TMT injuries represent a 94%. Recently, primary arthrodesis http://www.aaos.org/jaaosplus. broad spectrum of pathology ranging of the TMT joints has shown favor- from low-energy, subtle ligamentous able results for certain injury 6,7 disruptions to high-energy crush patterns. Despite these promising From the Illinois Bone and Joint injuries with associated soft-tissue results, the role of arthrodesis in the Institute, Glenview, IL compromise. management of TMT injuries has yet (Dr. Weatherford) and Orthopaedic to be clearly defined. Associates of Michigan, Grand Given the uncommon occurrence Rapids, MI (Dr. Anderson and of TMT joint disruptions, as well as Dr. Bohay). the potential for subtle presentation Anatomy J Am Acad Orthop Surg 2017;25: and a lack of familiarity with the 469-479 injury among treating physicians, up The combined ligamentous and DOI: 10.5435/JAAOS-D-15-00556 to 20% of TMT injuries are missed osseous anatomy of the TMT joint initially.3 A high index of suspicion is complex is essential for maintenance Copyright 2017 by the American Academy of Orthopaedic Surgeons. necessary when evaluating suspected of the transverse and longitudinal midfoot trauma. Left untreated, arches of the foot. The TMT joint July 2017, Vol 25, No 7 469 Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Management of Tarsometatarsal Joint Injuries complex is composed of the TMT, second metatarsals. Instead, a series The functional anatomy of the intertarsal, and proximal inter- of dorsal, interosseous, and plantar TMT joint complex is best under- metatarsal joints.8 The first, second, oblique ligaments secure the medial stood by dividing the midfoot into and third metatarsals articulate with cuneiform to the recessed second medial, middle, and lateral col- the medial, middle, and lateral metatarsal to maintain the crucial umns.1,16 The medial column is cuneiforms, whereas the fourth and mortise relationship.8 Of these, the composed of the medial cuneiform fifth metatarsals articulate with sep- interosseous ligament is the strongest and first metatarsal, whereas the arate facets of the cuboid. restraint of the TMT joint complex middle column consists of the middle Several unique aspects of the osse- and is commonly referred to as the and lateral cuneiform bones and the ous anatomy contribute to the sta- Lisfranc ligament13 (Figure 2). The second and third metatarsals. Joint bility of the midfoot. In the coronal Lisfranc ligament may have variable motion for the middle column is plane, the three cuneiforms along anatomy, with both single-bundle limited, with a 0.6° arc of sagittal with their corresponding metatarsal and double-bundle variations plane motion seen at the second bases have a trapezoidal configura- described.14 TMT joint.17 In contrast, the mobile tion, with the middle cuneiform and The plantar oblique ligament, lateral column, which is formed by second metatarsal base serving as the another critical component of the the fourth and fifth TMT joints, keystone of the transverse or Roman TMT ligamentous complex, divides functions as a shock absorber when arch9 (Figure 1). The middle cunei- into deep and superficial bands that the foot encounters uneven surfaces. form is 8 mm proximal to the medial insert on the base of the second and Every effort should be made to main- cuneiform and 4 mm proximal third metatarsals, respectively.10 In tain the mobility of the fourth and fifth relative to the lateral cuneiform, al- general, the plantar ligaments are TMT joints. Arthrodesis of the lateral lowing the second metatarsal base to stronger than the dorsal ligaments, column substantially increases plantar be recessed.10 This mortise configu- which can have important clinical forefoot and calcaneocuboid joint ration confers additional stability implications for the pattern of pressure and can compromise treat- because the second metatarsal has injury.13,15 ment outcomes after TMT injuries.5,18 five separate articulations with the The TMT joint complex is dynam- adjacent cuneiforms and metatar- ically stabilized by the insertions of sals. Anatomic variations of the the tibialis anterior and peroneus Mechanism of Injury second TMT joint may predispose longus tendons. In certain injury certain patients to Lisfranc injuries. patterns, the tibialis anterior tendon Injuries to the TMT joint complex Shorter length of the second meta- becomes entrapped between the can be broadly grouped as direct or tarsal as well as decreased depth of medial and middle cuneiforms, pre- indirect mechanisms. Direct injuries the second TMT mortise have been cluding reduction. The dorsalis typically involve high-energy blunt identified as risk factors for Lisfranc pedis artery and the accompanying trauma, oftentimes a crush injury injury.11,12 deep peroneal nerve cross the TMT to the dorsal aspect of the foot The ligamentous structure of the joint complex and are consistently with substantial soft-tissue disruption. TMT joint complex can be catego- located just lateral to the extensor Crush mechanisms commonly involve rized according to orientation (ie, hallucis brevis tendon. The deep compartment syndrome and open transverse, oblique, longitudinal) and peroneal artery dives between the injuries.19 anatomic location (ie, dorsal, inter- first and second metatarsal bases to Indirect mechanisms account for osseous, plantar).8 The transverse form the plantar arch. The artery most injuries to the TMT complex intermetatarsal ligaments secure the may be avulsed in more severe injury and are typically seen with an axial bases of the second through the fifth patterns, leading to dorsal hema- and/or rotational force applied to a metatarsals; however, no such liga- toma formation or compartment plantarflexed and stationary foot.20 ment exists between the first and syndrome. Although several mechanisms have Dr. Weatherford or an immediate family member serves as a paid consultant to Orthobullets and BESPA Consulting. Dr. Anderson or an immediate family member has received royalties from and is a member of a speakers’ bureau or has made paid presentations on behalf of Stryker; serves as a paid consultant to Zimmer Biomet and Stryker; has stock or stock options held in Pfizer; has received research or institutional support from Stryker; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Foot and Ankle Society. Dr. Bohay or an immediate family member has received royalties from Stryker; is a member of a speakers’ bureau or has made paid presentations on behalf of BESPA Consulting, Zimmer Biomet, and OsteoMed; serves as a paid consultant to BESPA Consulting, Zimmer Biomet, OsteoMed, and Stryker; and has received research or institutional support from the Research and Education Institute at Orthopaedic Associates of Michigan. 470 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Brian M. Weatherford, MD, et al Figure 1 Figure 2 Photograph of a cadaver specimen demonstrating the orientation of the Lisfranc (ie, interosseous) ligament and the plantar oblique ligament. (Reproduced
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