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Updated: Jul 22 2023

Midfoot Arthritis

  • summary
    • Midfoot Arthritis is defined as arthritis of the midfoot which includes the following joints: naviculocuneiform joint, intercuneiform joints, and metatarsal cuneiform joints.
    • Diagnosis is made with plain radiographs of the foot often showing joint space narrowing and dorsal osteophyte formation in the midfoot.
    • Treatment can be nonoperative or operative depending on patient age, patient activity demands, severity of arthritis, and presence of midfoot deformity.
  • Etiology
    • Pathophysiology
      • etiology
        • idiopathic (primary)
          • osteoarthritis is most common form of midfoot arthritis
        • posttraumatic
        • inflammatory
      • pathoanatomy
        • large forces seen by joints that have limited motion
        • soft tissues that support joints see abnormally high forces over time
        • results in midfoot collapse
  • Presentation
    • Symptoms
      • midfoot pain (and in arch) with toe off
    • Physical exam
      • inspection
        • deformity shows
          • longitudinal arch collapse with weight bearing
          • midfoot collapse (look like PTTI)
          • forefoot abduction
          • hindfoot valgus
          • equinuus contracture of achilles tendon
          • halux valgus
      • palpation
        • palpation of arch/midfoot leads to pain
  • Imaging
    • Radiographs
      • lateral
        • loss of co-linearity between talus-1st MT (Meary's line)
          • apex of deformity is at the level of the midfoot
        • may show collapse of longitudinal arch
      • AP
        • arthritic signs in midfoot
        • inflammatory etiology consistent with symmetric degeneration across midfoot
        • abduction of forefoot
  • Differential
    • PTTI 
    • post-traumatic Lis-Franc injury 
    • Lateral ankle instability
  • Treatment
    • Nonoperative
      • NSAIDS, activity modification, orthotic/bracing
        • indications
          • first line of treatment
        • modalities
          • steroid injections under radiographic guidance
            • can be diagnostic and therapeutic
          • orthotics
            • cushioned heel
            • longtidunal arch supports
            • stiff sole with a rocker bottom
    • Operative
      • midfoot arthrodesis, +/- TAL, +/- hindfoot realignment
        • indications
          • failure of non operative management
        • outcomes
          • midfoot joints are non-essential joints
          • arthrodesis results in close to normal foot function
          • use of autograft associated with decreased nonunion rates
      • Achilles tendon lengthening/hindfoot realignment
        • may need to be done concomitantly
  • Technique
    • Midfoot arthrodesis
      • approach
        • realignment arthrodesis
          • close to full physiologic foot function, especially during push-off, can be established
        • tarsometatarsal joints are 2-3 cm deep and warrant appropriate preparation prior to fusion
      • realignment arthrodesis
        • fusion of the first ray via the first tarso-metatarsal joint
        • fusion of the second/third rays via the naviculocuneiform/intercuneiform joints
        • do not fuse the 4th/5th tarsometatarsal joints
          • the lateral ray mobility facilitates foot accomodation during stance
        • interpositional arthroplasties of the 4th/5th tarsometatarsal joints
          • select cases
          • will maintain length of lateral column
          • can assist with gait accommodation
      • instrumentation
        • may use screws, staples, plates designed for midfoot fusions
      • concomitant procedures
        • Achilles tendon lengthening
        • hindfoot realignment
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