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

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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

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Figure 1 Figure 2

Photograph of a cadaver specimen demonstrating the orientation of the Lisfranc (ie, interosseous) ligament and the plantar oblique ligament. (Reproduced with permission from Panchbhavi VK, Molina D IV, Villareal J, Curry MC, Andersen CR: Three- dimensional, digital, and gross anatomy of the Lisfranc ligament. Foot Ankle Int 2013;34[6]:876-880.)

Abduction or torsional mechanisms may lead to fracture of the second metatarsal base with subsequent lateral displacement of the lesser metatarsals. Two common mechanisms are theorized to occur in the athletic population.21 A direct axial force on the hindfoot, with the foot plantarflexed and the metatarsophalangeal joints in maximal dorsiflexion (ie, as typically observed in a falling player), leads to dorsal tension failure. Abduction injury may occur with the hindfoot fixed and sudden rotation A, Illustration of the Roman arch architecture of the metatarsal bases with the about the midfoot. This mechanism second metatarsal as the keystone. The interosseous (C1-M2) and plantar oblique ligaments (pC1-M2M3) are shown. B, Coronal T2-weighted MRI sequence can occur in persons who have the demonstrating the Roman arch configuration of the metatarsal bases. C, Axial foot anchored in a strap, such as long-axis CT cut. The arrow highlights the recessed position of the second equestrians or windsurfers, or with metatarsal in the mortise. C1 = medial cuneiform, C3 = lateral cuneiform, M1 = first athletes who suddenly change direc- metatarsal, M2 = second metatarsal, M3 = third metatarsal, M4 = fourth metatarsal, M5 = fifth metatarsal, Nav = navicular, pC1 = plantar medial cuneiform. tion on a planted foot. (Panels B and C reproduced with permission from Siddiqui NA, Galizia MS, Almusa E, Omar IM: Evaluation of the tarsometatarsal joint using conventional radiography, CT, and MR imaging. Radiographics 2014;34[2]:514-531.) Diagnosis been proposed, these injuries vary The weaker dorsal ligaments typically Physical Examination depending on the position of the foot fail under tension, leading to dorsal Subtle disruptions of the TMT joint and the direction of force applied. displacement of the metatarsals. complex are challenging to diagnose.

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Figure 3 Figure 4

AP bilateral weight-bearing radiograph of the feet demonstrating lateral subluxation of the second metatarsal base and intercuneiform widening of the right foot.

Clinical photograph demonstrating plantar arch ecchymosis suggestive bearing, symptoms can be elicited oblique views of the foot. For visu- of Lisfranc injury. during attempts at a single-limb alization of the TMT joints on pro- stance on the forefoot. file, the AP view should be taken Although the diagnosis may be with the x-ray beam 15° off the Patients typically have difficulty with obvious in patients with high-energy vertical plane. weight bearing; in subtle injuries, injuries, careful attention should be Certain radiographic landmarks however, patients may experience directed to the soft-tissue envelope. should be scrutinized on each image pain only during strenuous activity. Closed injuries with fracture blisters to rule out Lisfranc injury. On the AP Swelling is typically located over the signify a substantial soft-tissue insult view, the medial border of the second dorsomedial midfoot. When present, that may benefit from delayed man- metatarsal should align with the plantar arch ecchymosis is highly agement or staged fixation.23 Tense medial border of the middle cunei- associated with Lisfranc injury22 swelling and increasing pain should form. On the oblique view, the medial (Figure 3). Pain may be reproduced alert the clinician to the possibility of border of the fourth metatarsal and with direct palpation of the compartment syndrome.24 the medial border of the cuboid TMT joints as well as with passive should be collinear. The lateral view abduction stress of the midfoot while should demonstrate alignment of the the transverse tarsal joint is stabi- Imaging dorsal and plantar cortices of the lized. Dorsal and plantar translation Lisfranc injuries are commonly metatarsals with the cuneiforms and of the midfoot may reveal sub- missed when diagnosis is based on the cuboid. Contralateral images luxation at the level of the TMT radiographic imaging. Initial imaging should be obtained for comparison joint. In patients who are weight should consist of AP, lateral, and 30° with the patient’s normal anatomy.

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Markers of instability include wid- Figure 5 ening of .2 mm between the first metatarsal-medial cuneiform and the second metatarsal compared with the contralateral side, .2mmof joint subluxation of the TMT joint, or any dorsal displacement of the metatarsal on the lateral view.3 An avulsion fracture off the base of the second metatarsal or medial cuneiform, known as the fleck sign, sig- nifies disruption of the Lisfranc ligament.20 Signs of instability may not be present on initial radiographs. In patients with suspected midfoot injury, weight-bearing radiographs should be obtained to place physiologic stress on the TMT joint complex. An AP weight-bearing radiograph of both feet on the same cassette is particularly useful for evaluating subtle instability (Figure 4). In patients who are unable to bear weight, a pronation-abduction stress A, AP non2weight-bearing radiograph of the foot in a patient with a mechanism radiograph25 may be adequate to and physical examination findings suspicious for Lisfranc injury. B, AP stress radiograph during pronation-abduction of the midfoot demonstrating instability, diagnose instability (Figure 5). In the including lateral subluxation of the first and second tarsometatarsal joints. office setting, stress radiographs may cause major patient discomfort. In patients with a mechanism of injury, plantar oblique ligament visible on Although this classification system examination results, and static MRI was highly predictive of intra- does not predict outcome, it provides images suspicious for TMT joint operative instability a framework for understanding complex injury, stress views obtained patterns of injury, including patterns under anesthesia allow appropriate of instability that may extend to the evaluation of midfoot instability. Classification intercuneiform or naviculocunei- Advanced imaging can also play a Several classification systems have form joints. Importantly, it implies role in the management of TMT joint been proposed for TMT joint that the energy dissipates in different injuries. CT is useful for delineating injuries. Myerson et al20 developed directions as it enters and exits the areas of articular comminution and the most commonly used system, midfoot. This is analogous to the nondisplaced fracture lines in high- which incorporates the prior work of tension and compression sides of energy injury patterns. Axial, thin- Quenu and Guss28 and Hardcastle failure in fracture patterns and may cut CT slices may also be reformatted et al29 (Figure 6). The classification have implications for selection of in multiple axes to match the coronal, scheme divides injuries in terms of exposure and type of implant. sagittal, and transverse planes of the joint congruity, location of involve- Nunley and Vertullo30 proposed a TMT joint complex.26 However, CT ment, and direction of instability. classification system to guide treat- is not dynamic, and normal osseous Type A injuries have total joint ment of low-energy, athletic injury relationships may be present in the incongruity. Type B injuries are patterns. Injuries are differentiated setting of ligamentous instability. subdivided into injuries involving the according to examination, radio- MRI may be particularly valuable in medial column in isolation (ie, B1) graphic, and bone scintigraphy find- depicting subtle ligamentous injuries and those involving the lateral rays ings. Stage I injuries have pain with normal radiographic parame- (ie, B2). Type C injuries represent isolated to the TMT joint complex, ters. For example, Raikin et al27 divergent patterns with either partial normal weight-bearing radiographs, demonstrated that disruption of the (ie, C1) or total (ie, C2) incongruity. and increased uptake on bone scan.

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Figure 6

Illustration demonstrating the classification of tarsometatarsal joint injuries. The shaded areas represent the injured or displaced portion of the foot. A, Type A represents total incongruity, which involves displacement of all five metatarsals with or without fracture at the base of the second metatarsal. The usual displacement is lateral or dorsolateral. These injuries are homolateral. B, In type B injuries, one or more articulations remain intact. Type B1 represents partial incongruity with medial dislocation. Type B2 represents partial incongruity with lateral dislocation; the first tarsometatarsal joint may be involved. C, Divergent injury pattern, with either partial (C1) or total (C2) displacement. The arrows in C2 represent the forces through the foot leading to a divergent pattern. (Reproduced from Watson TS, Shurnas PS, Denker J: Treatment of Lisfranc joint injury: Current concepts. JAmAcadOrthopSurg 2010;18[12]:718-728.)

Stage II injuries demonstrate 1 to examination but showing normal Management 5 mm of widening between the first results on weight-bearing radiographs and second metatarsals on weight- should either be followed closely with Nonsurgical bearing views without evidence of serial examinations and imaging or height loss in the longitudinal arch. Nonsurgical management of TMT be further evaluated with advanced Stage III injuries have .5mmof joint complex trauma is reserved for imaging. When a high index of suspi- widening of the intermetatarsal space patients who have a stable injury pat- cion remains with equivocal findings as well as longitudinal arch collapse. tern or are unable to tolerate surgical on advanced images, an examination Although these classification sys- intervention. The key to successful under anesthesia should be per- tems provide a common descriptive nonsurgical management of Lisfranc formed. Patients should be counseled language, none has been useful injuries is to rule out subtle instability. and should provide consent for surgi- in predicting outcomes following Midfoot injuries suspicious for cal fixation if the examination dem- Lisfranc injury. instability by history and physical onstrates instability.

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In patients with stable injury pat- Figure 7 Figure 8 terns, treatment consists of non– weight-bearing immobilization in a CAM boot or short leg cast for 4 to 6 weeks. Once the immobilization has been removed, patients can progress to weight bearing with a full-length arch support orthotic as tolerated. A course of physical therapy focusing on gait and balance can expedite recovery. Return to function and resolution of pain and swelling may take 4 to 6 months.

Initial Surgical Management Surgical intervention is indicated Illustration of lateral views of the first when there is evidence of instability tarsometatarsal joint demonstrating a of the TMT joint complex. Most burred trough in the dorsal cortex of the first metatarsal. This allows injuries are initially managed with retrograde screw placement across splint immobilization until soft-tissue Clinical photograph of a patient with the tarsometatarsal joint perpendicular a high-energy fracture-dislocation to the joint, minimizes screw head swelling resolves. Midfoot disloca- following biplanar external fixation. tions require a closed reduction prominence, and prevents breakage The reduction did not remain closed, in the dorsal cortex.) to minimize soft-tissue compromise. and the soft tissues were not When left unreduced, these injuries amenable to definitive fixation. (Courtesy of Robert Marsh, DO, can lead to continued soft-tissue Tulsa, OK.) needed to address instability or damage and even full-thickness skin associated fractures of the cunei- necrosis. Certain high-energy injury fixation. We routinely assess for forms or navicular bone. Branches of patterns may require a staged equinus contracture while the patient the superficial peroneal nerve cross approach.23 Provisional reduction is under anesthesia and perform a the extensor hallucis longus in the using Kirschner wires and/or an gastrocnemius recession when a proximal portion of this incision external fixator can maintain align- major contracture is found.31 and are easily injured if not pro- ment and facilitate soft-tissue man- Exposure, reduction, and fixation tected. The dorsalis pedis artery and agement until definitive fixation can generally proceed from proximal to vein and deep peroneal nerve are be achieved (Figure 7). distal and from medial to lateral. mobilized laterally and are pro- Careful attention should be paid to tected. The interval between the Definitive Surgical the intercuneiform joint for signs of extensor hallucis longus and exten- Management instability. We directly visualize the sorhallucisbrevisiscommonlyex- The goal of surgical treatment is to dorsal ligaments of the intercunei- ploited; however, several intervals restore the functional anatomy of the form joint for evidence of injury. can be used to expose the affected foot. However, definitive manage- When the evidence is unclear, we joints.32 The dorsal-lateral incision ment is delayed until the soft-tissue perform dorsal-plantar translation is centered over the fourth meta- envelope is appropriate for open and axial loading across the first ray tarsal and can help visualize the approaches and the pattern of insta- to identify occult intercuneiform lateral aspect of the second TMT bility and involved joints is clearly instability. For three-column injuries, joint, as well as the third and fourth understood. Rigid fixation is used to a two-incision dorsal approach is TMT joints. The common extensor recreate the stability of the medial necessary to adequately visualize the tendons are mobilized medially, and middle columns, whereas flexible involved joints. The dorsal-medial and the muscle belly of the extensor temporary fixation is used for the incision, centered between the first digitorum brevis is split in line with mobile lateral column. If relative and second rays, can help visualize its fibers to gain exposure of the ankle equinus is not addressed, it can the first TMT joint and the medial affected joints. lead to increased loading of the mid- aspect of the second TMT joint. This Once adequate exposure has been foot and theoretically to failure of incision can be carried proximally as obtained, anatomic reduction is

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Figure 9

A, Preoperative AP radiograph of a foot demonstrating a Lisfranc injury with major impaction of the articular surface of the fourth metatarsal base. B, Postoperative AP radiograph of the same foot. Dorsal plating was used for the comminuted third and fourth metatarsal base fractures. Arthrodesis was performed for the first, second, and third tarsometatarsal joints. C, AP weight-bearing radiograph of the same foot obtained after the patient had the fourth tarsometatarsal bridge plate removed at 3 months postoperatively.

achieved under direct visualization A variety of implants are available cuboid.33 These injuries require res- and is provisionally held with multiple for fixation; however, most ligamen- toration of lateral column length. Kirschner wires. At this point, the tous injuries can be adequately sta- Contralateral foot radiographs aid surgeon may proceed with either bilized with solid or cannulated small the orthopaedic surgeon in deter- internal fixation or primary arthro- fragment cortical screws. When ret- mining the patient’s anatomic lateral desis on the basis of the injury pattern rograde lag screws are placed across column length. Although simple and surgeon preference. Reduction the TMT joints, making a trough in fractures may be treated with open typically begins with assessment of the the dorsal cortex of the metatarsal reduction and internal fixation intercuneiform joint. If left unad- can be helpful (Figure 8). This allows (ORIF) of the cuboid in isolation, dressed, intercuneiform instability can screw placement perpendicular to many of these injuries require lead to continued pain and recurrence the TMT joint and prevents screw adjunctive bone grafting of the of deformity. When occult instability breakage in the dorsal cortex. Injury cuboid and spanning internal or is a concern, we recommend rigid patterns with metatarsal base frac- external fixation (Figure 10). Span- fixation across the intercuneiform tures may require adjunctive plate ning fixation is typically removed at joint. Reduction of the first TMT joint fixation (Figure 9). When arthrode- 8 to 12 weeks to mobilize the fourth is then performed according to the sis is performed, autograft cancellous and fifth TMT joints. alignment of the dorsal and plantar bone can be placed at the junction of Patients should be counseled that cortices with the corresponding the fusion sites. This forms a rapid recovery can take up to 1 year after medial cuneiform. Reduction of the spot weld that relieves shear strain surgery. Postoperatively, the limb is first metatarsal base allows appropri- across the fixation. immobilized in a well-padded splint, ate placement of the second meta- Certain injury patterns can cause which is then converted to a short tarsal base into the mortise. substantial impaction of the leg non–weight-bearing cast for 8

476 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 weeks. The patient is transitioned to transarticular screw fixation is Figure 10 a walking boot at 8 weeks with lacking; however, comparable rates progressive weight bearing to toler- of complications and functional ance. Most patients return to sup- outcomes have been demonstrated in portive shoe wear with use of an arch a small study.38 support by 3 months after surgery. Once the patient is weight bearing, physical therapy focusing on gait Open Reduction and Internal and edema control is initiated. Fixation Versus Arthrodesis Perhaps the most relevant contro- versy in the management of TMT Controversies and Future joint complex injuries is whether to Direction proceed with ORIF or with primary arthrodesis. The broad spectrum of Joint-sparing Fixation Lisfranc injury patterns and the Transarticular screws are routinely variety of treatments available fur- used for fixation of the TMT joint ther complicate decision making. complex; however, there is concern Modern series examining the out- that drilling and placement of screws comes of ORIF for TMT injuries across the articular surface increases found overall favorable results; rates of posttraumatic arthritis seen however, a relatively high rate of with these injuries. Joint-sparing fix- posttraumatic arthritis occurred ation techniques, including suture despite appropriate reduction. Kuo button constructs and dorsal span- et al39 examined the outcomes of 48 ning plates, have been explored as patients following ORIF of TMT alternatives to transarticular screw injuries at a mean follow-up of 52 Oblique radiograph demonstrating fixation. months. The overall rate of post- open reduction and internal fixation Flexible fixation is an intriguing traumatic arthritis was 25%, with of the cuboid with the use of a bridge alternative to standard screw fixation both arthritis and American Ortho- plate from the calcaneus to the fourth metatarsal to maintain lateral column because it allows some physiologic paedic Foot & Ankle Society mid- length. (Courtesy of Jason Nascone, motion but does not violate the foot scores significantly correlated MD, Baltimore, MD.) articular surface or require a second with the quality of the reduction, P = surgery for implant removal. Recent 0.004 and P = 0.05, respectively. The biomechanical studies in a cadaver authors also found a trend toward rized that the postoperative protocol injury model demonstrated equiva- increased arthritis in patients with of prolonged non–weight-bearing lent stability with suture button purely ligamentous injuries (40%) immobilization (ie, for 3 months) devices compared with screw fixa- despite anatomic reduction and and use of an arch support following tion.34-36 However, suture button suggested that this population may initiation of weight bearing contrib- constructs may not adequately con- benefit from primary arthrodesis. In uted to improvements in the liga- trol multiplanar instability patterns; contrast, Abbasian et al40 found no mentous cohort. in these situations, standard tech- substantial difference in functional Two randomized studies directly niques or hybrid constructs with outcome, pain, return to activity, or compared the results of primary both flexible and rigid fixation are rates of posttraumatic arthritis fol- arthrodesis with those of ORIF for advisable. lowing ORIF in matched cohorts of TMT joint complex injuries. Ly and Spanning plate fixation of the 29 patients each with ligamentous Coetzee6 randomly assigned 41 TMT joints provides rigidity while injuries or osseous injury patterns. patients to either open reduction or preserving the articular surface Radiographic arthritis was seen in primary arthrodesis for ligamentous (Figure 11). In a cadaver model of a 27% of ligamentous injuries com- injury patterns. The arthrodesis ligamentous Lisfranc injury, dorsal pared with 31% of osseous injuries; group had substantially improved plate fixation was biomechanically however, only one patient in each functional outcomes, higher returns equivalent to transarticular screw treatment group (3%) required to preinjury activity levels, lower fixation.37 Direct clinical compari- conversion to arthrodesis during rates of revision surgery, and less son of dorsal plate fixation with the study period. The authors theo- pain at final follow-up. In the group

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Figure 11

A, AP stress fluoroscopic image demonstrating instability across the first tarsometatarsal joint and second and third metatarsal base fractures. AP (B) and lateral (C) fluoroscopic images of the foot after a joint-sparing technique was performed with dorsal bridge plating of the first, second, and third tarsometatarsal joints. that underwent open reduction, revision surgery, neither review was arthrodesis, the role of this technique 25% of patients required conversion able to definitively demonstrate the in managing all TMT joint complex to arthrodesis for symptomatic superiority of one technique over the injuries has not been determined. posttraumatic arthritis. Routine other. More recent systematic reviews Further studies are needed to clarify removal of transarticular screws was have highlighted the need for further which injury patterns will benefit not performed in the ORIF group; high-quality randomized studies from primary arthrodesis. however, 16 of 21 patients had screw comparing the two techniques.4,42 removal during the study period at an average of 6.75 months post- Summary References operatively. Results in the ORIF group may have been compromised because TMT joint complex injuries are Evidence-based Medicine: Levels of permanent or prolonged transarticular uncommon and are frequently evidence are described in the table of fixation can lead to painful arthro- missed. A high index of suspicion is contents. In this article, references 6 fibrosis of the affected joints. necessary when evaluating suspected and 41 are level I studies. References 41 Henning et al found no sub- midfoot trauma because missed 4, 19, 27, and 42 are level II studies. stantial difference in either the Short injuries may result in a painful, dys- References 5, 7, 11, 12, and 40 are Musculoskeletal Function Assess- functional foot. Nonsurgical man- level III studies. References 2, 20, 22, ment or Medical Outcomes 36-Item agement is successful in select stable 23, 29-33, 36, 38, and 39 are level IV Short Form scores at 2-year follow- injuries. When surgery is indicated, studies. Reference 28 is level V up in patients undergoing arthrode- anatomic reduction and stable fixa- expert opinion. sis versus ORIF for both ligamentous tion are necessary to restore the References printed in bold type are and combined injury patterns. There functional anatomy of the foot and those published within the past 5 was a substantially higher rate of maximize patient outcomes. years. secondary surgery in the ORIF group; ORIF remains the standard treat- 1. Benirschke SK, Meinberg E, Anderson SA, however, most revision surgeries ment of unstable or displaced injuries Jones CB, Cole PA: Fractures and were for elective implant removal as to the TMT joint complex. However, dislocations of the midfoot: Lisfranc and Chopart injuries. J Bone Joint Surg Am part of the study protocol. posttraumatic arthritis can occur 2012;94(14):1325-1337. Although both studies reported despite appropriate reduction and 2. Cassebaum WH: Lisfranc fracture- slight advantages for arthrodesis in fixation. Although ligamentous dislocations. Clin Orthop Relat Res 1963; terms of functional outcome and injuries have benefited from partial 30(30):116-129.

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