Updated: 1/7/2017

Midfoot Arthritis

Topic

Review Topic

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Questions

4 4

Evidence

3 3

Videos

1 1

Cases

1 1

Techniques

Topic

Introduction

Defined as arthritis of the midfoot which includes the following joints
- naviculocuneiform joint
- intercuneiform joint
- metatarsal cuneiform
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 push 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
- 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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Technique Guides (2)

Technique Guide

CPT Codes: 28725 Arthrodesis; subtalar

Subtalar Arthrodesis

Orthobullets Team

Foot & Ankle
- Midfoot Arthritis

Technique Guide

Tarsalmetatarsal Arthrodesis

Orthobullets Team

Foot & Ankle
- Midfoot Arthritis

Questions (4)

(SBQ12FA.15) An active 70-year-old female presents to your office with increasing foot pain over the last several years. She enjoys walking however is limited to 2 blocks due to pain. Her pain is greatest with "push off". She has attempted shoe wear modifications, orthotics, physical therapy and non steroidal anti-inflammatories with limited relief of her symptoms. Her current weight bearing radiographs are seen in Figures A, B and C. What is the most appropriate treatment at this time? Tested Concept

QID: 3822

FIGURES: