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Midfoot Arthritis
Updated: Oct 4 2016

Tarsalmetatarsal Arthrodesis

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating

  • triplanar radiographs of the foot
  • CT scan
  • determines configuration of the Lisfranc complex


Execute surgical walkthrough

  • describe the steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • K wires
  • 3,4 or 5 mm cortical screws
  • plating systems(optional)


Room setup and equipment

  • standard OR table
  • bring fluoroscopy from the contralateral side


Patient positioning

  • supine position
  • align sole of the foot with the end of the bed
  • place tourniquet around the upper thigh



Mark and make incision

  • inflate thigh tourniquet.
  • mark the first incision between the first and second metatarsal to access the first TMT joint and most of the second
  • make a 6 cm incision just lateral to the EHL tendon
  • if needed make the second incision centered around the over the fourth metatarsal


Identify neurovascular structures

  • identify and protect the superficial and deep peroneal nerves as well as the dorsalis pedis artery with a retractor
  • the distal 3 cm of the incision should be centered around the TMT joint
  • cauterize the vein that is found crossing the field

Joint Preparation


Expose the the TMT joint

  • evacuate the hematoma for exposure and visualization


Determine the joint instability

  • determine the joints which are involved in the instability pattern by using fluoroscopy
  • stabilize the hindfoot while the forefoot is manipulated with abduction and adduction followed by plantarflexion and dorsiflexion stress
  • when DJD is present there is often significant deformity of the TMT joints with lateral abduction as well as dorsiflexion
  • perform significant soft tissue release around the involved joints to mobilize the joint for reduction in all planes

Arthordesis Preparation


Debride the joint of all loose pieces of cartilage

  • remove the articular cartilage from the opposing surfaces of the joints using a rongeur, curettes and osteotome
  • the goal is to remove only cartilage and exposed subchondral bone


Fully expose joint

  • place a small laminate spreader to allow visualization of the entire joint
  • if the full joint is not exposed there is a tendency to fuse the joint in dorsiflexion


Create a vascular channel

  • use a small diameter drill or small osteotomes on the opposing surfaces to create vascular channels


Perform reduction

  • secure and reduce the first TMT joint
  • check alignment with fluoroscopy


Temporarily place a K wire to stabilize the joint




Stabilize medial column

  • place a 3,4 or 5 mm cortical screw from the medial cuneiform into the first metatarsal
  • this stabilizes the medial column as a foundation for the remaining metatarsals to be secured


Reduce the second metatarsal into the keystone position

  • use a clamp to pull the metatarsal base onto the lateral aspect of the first metatarsal and adjacent cuneiform
  • check alignment radiographically


Place second cortical screw

  • insert the second screw from the medial cuneiform into the base of the second metatarsal
  • placement of remaining fixation and placement is dependent on the individual situation
  • placement of one more point of fixation is needed
  • the simplest method is to use compression staples

Treat Intraoperative and Immediate Postoperative Complications


Step 1 in treating intraoperative complications


Step 2 in treating intraoperative complications


Wound Closure


Irrigation, and hemostasis

  • ensure hemostasis using cautery


Superficial closure

  • use 3-0 nylon for skin


Deep closure

  • use 2-0 vicryl for the subcutaneous layer


Dressing and immediate immobilization

  • place in well padded non-weightbearing short leg plaster cast
  • split cast in recovery room to allow for post op swelling
Postoperative Patient Care
Private Note

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