Updated: 1/7/2017

Midfoot Arthritis

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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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