review article management of tarsometatarsal joint injuriesmechanism of injury injuries to the tmt...

Review Article

Management of TarsometatarsalJoint Injuries

Abstract

Joint disruptions to the tarsometatarsal (TMT) joint complex, alsoknown as the Lisfranc joint, represent a broad spectrum of pathologyfrom subtle athletic sprains to severe crush injuries. Although injuriesto the TMT joint complex are uncommon, whenmissed, theymay leadto pain and dysfunction secondary to posttraumatic arthritis and archcollapse. An understanding of the appropriate anatomy, mechanism,physical examination, and imaging techniques is necessary todiagnose and treat injuries of the TMT joints. Nonsurgicalmanagement is indicated in select patients who maintain reduction ofthe TMT joints under physiologic stress. Successful surgicalmanagementof these injuries is predicatedonanatomic reductionandstable fixation. Open reduction and internal fixation remains thestandard treatment, although primary arthrodesis has emerged as aviable option for certain types of TMT joint injuries.

The tarsometatarsal (TMT), orLisfranc, joint complex is com-

posed of the TMT, intertarsal, andproximal intermetatarsal joints.1 Theunique osseous anatomy of themidfoot along with the stout liga-mentous support allows effectiveforce transfer from the hindfoot tothe forefoot during ambulation.Injuries to the TMT joint complex arerare, accounting for only 0.2% of allfractures, with a reported incidence of1 per 55,000 persons.2 When they dooccur, TMT injuries represent abroad spectrum of pathology rangingfrom low-energy, subtle ligamentousdisruptions to high-energy crushinjuries with associated soft-tissuecompromise.Given the uncommon occurrence

of TMT joint disruptions, as well asthe potential for subtle presentationand a lack of familiarity with theinjury among treating physicians, upto 20% of TMT injuries are missedinitially.3 A high index of suspicion isnecessary when evaluating suspectedmidfoot trauma. Left untreated,

these injuries often result in painfulposttraumatic arthritis and archcollapse. Early diagnosis and main-tenance of anatomic reduction of theTMT joints are necessary to maxi-mize patient function.Nevertheless, appropriate initial

treatment of TMT injuries is contro-versial. A variety of techniques havebeen described for the managementof TMT injuries, but rates of post-traumatic arthritis following surgicaltreatment still range from 27% to94%.4,5 Recently, primary arthrodesisof the TMT joints has shown favor-able results for certain injurypatterns.6,7 Despite these promisingresults, the role of arthrodesis in themanagement of TMT injuries has yetto be clearly defined.

Anatomy

The combined ligamentous andosseous anatomy of the TMT jointcomplex is essential for maintenanceof the transverse and longitudinalarches of the foot. The TMT joint

Brian M. Weatherford, MD

John G. Anderson, MD

Donald R. Bohay, MD, FACS

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Join Dr. Weatherford, Dr. Anderson,and Dr. Bohay for the interactiveJAAOS Plus Webinar discussing“Management of Tarsometatarsal JointInjuries,” on Tuesday, July 11, 2017, at8 pm Eastern Time. The moderator willbe Christopher P. Chiodo, MD, theJournal ’s Deputy Editor for Foot andAnkle topics. Sign up now athttp://www.aaos.org/jaaosplus.

From the Illinois Bone and JointInstitute, Glenview, IL(Dr. Weatherford) and OrthopaedicAssociates of Michigan, GrandRapids, MI (Dr. Anderson andDr. Bohay).

J Am Acad Orthop Surg 2017;25:469-479

DOI: 10.5435/JAAOS-D-15-00556

Copyright 2017 by the AmericanAcademy of Orthopaedic Surgeons.

July 2017, Vol 25, No 7 469

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

http://dx.doi.org/10.5435/JAAOS-D-15-00556

complex is composed of the TMT,intertarsal, and proximal inter-metatarsal joints.8 The first, second,and third metatarsals articulate withthe medial, middle, and lateralcuneiforms, whereas the fourth andfifth metatarsals articulate with sep-arate facets of the cuboid.Several unique aspects of the osse-

ous anatomy contribute to the sta-bility of the midfoot. In the coronalplane, the three cuneiforms alongwith their corresponding metatarsalbases have a trapezoidal configura-tion, with the middle cuneiform andsecond metatarsal base serving as thekeystone of the transverse or Romanarch9 (Figure 1). The middle cunei-form is 8 mm proximal to the medialcuneiform and 4 mm proximalrelative to the lateral cuneiform, al-lowing the second metatarsal base tobe recessed.10 This mortise configu-ration confers additional stabilitybecause the second metatarsal hasfive separate articulations with theadjacent cuneiforms and metatar-sals. Anatomic variations of thesecond TMT joint may predisposecertain patients to Lisfranc injuries.Shorter length of the second meta-tarsal as well as decreased depth ofthe second TMT mortise have beenidentified as risk factors for Lisfrancinjury.11,12

The ligamentous structure of theTMT joint complex can be catego-rized according to orientation (ie,transverse, oblique, longitudinal) andanatomic location (ie, dorsal, inter-osseous, plantar).8 The transverseintermetatarsal ligaments secure thebases of the second through the fifthmetatarsals; however, no such liga-ment exists between the first and

second metatarsals. Instead, a seriesof dorsal, interosseous, and plantaroblique ligaments secure the medialcuneiform to the recessed secondmetatarsal to maintain the crucialmortise relationship.8 Of these, theinterosseous ligament is the strongestrestraint of the TMT joint complexand is commonly referred to as theLisfranc ligament13 (Figure 2). TheLisfranc ligament may have variableanatomy, with both single-bundleand double-bundle variationsdescribed.14

The plantar oblique ligament,another critical component of theTMT ligamentous complex, dividesinto deep and superficial bands thatinsert on the base of the second andthird metatarsals, respectively.10 Ingeneral, the plantar ligaments arestronger than the dorsal ligaments,which can have important clinicalimplications for the pattern ofinjury.13,15

The TMT joint complex is dynam-ically stabilized by the insertions ofthe tibialis anterior and peroneuslongus tendons. In certain injurypatterns, the tibialis anterior tendonbecomes entrapped between themedial and middle cuneiforms, pre-cluding reduction. The dorsalispedis artery and the accompanyingdeep peroneal nerve cross the TMTjoint complex and are consistentlylocated just lateral to the extensorhallucis brevis tendon. The deepperoneal artery dives between thefirst and second metatarsal bases toform the plantar arch. The arterymay be avulsed in more severe injurypatterns, leading to dorsal hema-toma formation or compartmentsyndrome.

The functional anatomy of theTMT joint complex is best under-stood by dividing the midfoot intomedial, middle, and lateral col-umns.1,16 The medial column iscomposed of the medial cuneiformand first metatarsal, whereas themiddle column consists of the middleand lateral cuneiform bones and thesecond and third metatarsals. Jointmotion for the middle column islimited, with a 0.6� arc of sagittalplane motion seen at the secondTMT joint.17 In contrast, the mobilelateral column, which is formed bythe fourth and fifth TMT joints,functions as a shock absorber whenthe foot encounters uneven surfaces.Every effort should be made to main-tain the mobility of the fourth and fifthTMT joints. Arthrodesis of the lateralcolumn substantially increases plantarforefoot and calcaneocuboid jointpressure and can compromise treat-ment outcomes after TMT injuries.5,18

Mechanism of Injury

Injuries to the TMT joint complexcan be broadly grouped as direct orindirect mechanisms. Direct injuriestypically involve high-energy blunttrauma, oftentimes a crush injuryto the dorsal aspect of the footwith substantial soft-tissue disruption.Crush mechanisms commonly involvecompartment syndrome and openinjuries.19

Indirect mechanisms account formost injuries to the TMT complexand are typically seen with an axialand/or rotational force applied to aplantarflexed and stationary foot.20

Although several mechanisms have

Dr. Weatherford or an immediate family member serves as a paid consultant to Orthobullets and BESPA Consulting. Dr. Anderson or animmediate family member has received royalties from and is a member of a speakers’ bureau or has made paid presentations on behalf ofStryker; serves as a paid consultant to Zimmer Biomet and Stryker; has stock or stock options held in Pfizer; has received research orinstitutional support from Stryker; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Footand Ankle Society. Dr. Bohay or an immediate family member has received royalties from Stryker; is a member of a speakers’ bureau or hasmade paid presentations on behalf of BESPA Consulting, Zimmer Biomet, and OsteoMed; serves as a paid consultant to BESPAConsulting, Zimmer Biomet, OsteoMed, and Stryker; and has received research or institutional support from the Research and EducationInstitute at Orthopaedic Associates of Michigan.

Management of Tarsometatarsal Joint Injuries

470 Journal of the American Academy of Orthopaedic Surgeons


been proposed, these injuries varydepending on the position of the footand the direction of force applied.

The weaker dorsal ligaments typicallyfail under tension, leading to dorsaldisplacement of the metatarsals.

Abduction or torsional mechanismsmay lead to fracture of the secondmetatarsal base with subsequentlateral displacement of the lessermetatarsals.Two common mechanisms are

theorized to occur in the athleticpopulation.21 A direct axial force onthe hindfoot, with the foot plantar-flexed and the metatarsophalangealjoints in maximal dorsiflexion (ie, astypically observed in a falling player),leads to dorsal tension failure.Abduction injury may occur with thehindfoot fixed and sudden rotationabout the midfoot. This mechanismcan occur in persons who have thefoot anchored in a strap, such asequestrians or windsurfers, or withathletes who suddenly change direc-tion on a planted foot.

Diagnosis

Physical ExaminationSubtle disruptions of the TMT jointcomplex are challenging to diagnose.

Figure 1

A, Illustration of the Roman arch architecture of the metatarsal bases with thesecondmetatarsal as the keystone. The interosseous (C1-M2) and plantar obliqueligaments (pC1-M2M3) are shown. B, Coronal T2-weighted MRI sequencedemonstrating the Roman arch configuration of the metatarsal bases. C, Axiallong-axis CT cut. The arrow highlights the recessed position of the secondmetatarsal in the mortise. C1 =medial cuneiform, C3 = lateral cuneiform, M1 = firstmetatarsal, M2 = second metatarsal, M3 = third metatarsal, M4 = fourthmetatarsal, M5 = fifth metatarsal, Nav = navicular, pC1 = plantar medial cuneiform.(Panels B and C reproduced with permission from Siddiqui NA, Galizia MS,Almusa E, Omar IM: Evaluation of the tarsometatarsal joint using conventionalradiography, CT, and MR imaging. Radiographics 2014;34[2]:514-531.)

Figure 2

Photograph of a cadaver specimendemonstrating the orientation of theLisfranc (ie, interosseous) ligamentand the plantar oblique ligament.(Reproduced with permission fromPanchbhavi VK, Molina D IV, VillarealJ, Curry MC, Andersen CR: Three-dimensional, digital, and grossanatomy of the Lisfranc ligament.Foot Ankle Int 2013;34[6]:876-880.)

Brian M. Weatherford, MD, et al

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Patients typically have difficulty withweight bearing; in subtle injuries,however, patients may experiencepain only during strenuous activity.Swelling is typically located over thedorsomedial midfoot. When present,plantar arch ecchymosis is highlyassociated with Lisfranc injury22

(Figure 3). Pain may be reproducedwith direct palpation of theTMT joints as well as with passiveabduction stress of the midfoot whilethe transverse tarsal joint is stabi-lized. Dorsal and plantar translationof the midfoot may reveal sub-luxation at the level of the TMTjoint. In patients who are weight

bearing, symptoms can be elicitedduring attempts at a single-limbstance on the forefoot.Although the diagnosis may be

obvious in patients with high-energyinjuries, careful attention should bedirected to the soft-tissue envelope.Closed injuries with fracture blisterssignify a substantial soft-tissue insultthat may benefit from delayed man-agement or staged fixation.23 Tenseswelling and increasing pain shouldalert the clinician to the possibility ofcompartment syndrome.24

ImagingLisfranc injuries are commonlymissed when diagnosis is based onradiographic imaging. Initial imagingshould consist of AP, lateral, and 30�

oblique views of the foot. For visu-alization of the TMT joints on pro-file, the AP view should be takenwith the x-ray beam 15� off thevertical plane.Certain radiographic landmarks

should be scrutinized on each imageto rule out Lisfranc injury. On the APview, the medial border of the secondmetatarsal should align with themedial border of the middle cunei-form.On the oblique view, themedialborder of the fourth metatarsal andthe medial border of the cuboidshould be collinear. The lateral viewshould demonstrate alignment of thedorsal and plantar cortices of themetatarsals with the cuneiforms andthe cuboid. Contralateral imagesshould be obtained for comparisonwith the patient’s normal anatomy.

Figure 3

Clinical photograph demonstratingplantar arch ecchymosis suggestiveof Lisfranc injury.

Figure 4

AP bilateral weight-bearing radiograph of the feet demonstrating lateralsubluxation of the second metatarsal base and intercuneiform widening of theright foot.




Markers of instability include wid-ening of .2 mm between the firstmetatarsal-medial cuneiform and thesecond metatarsal compared withthe contralateral side, .2 mm ofjoint subluxation of the TMT joint,or any dorsal displacement of themetatarsal on the lateral view.3 Anavulsion fracture off the base of thesecond metatarsal or medial cunei-form, known as the fleck sign, sig-nifies disruption of the Lisfrancligament.20

Signs of instability may not be pre-sent on initial radiographs. Inpatients with suspected midfootinjury, weight-bearing radiographsshould be obtained to place physio-logic stresson theTMT joint complex.An AP weight-bearing radiograph ofboth feet on the same cassette isparticularly useful for evaluatingsubtle instability (Figure 4). Inpatients who are unable to bearweight, a pronation-abduction stressradiograph25 may be adequate todiagnose instability (Figure 5). In theoffice setting, stress radiographs maycause major patient discomfort. Inpatients with a mechanism of injury,examination results, and staticimages suspicious for TMT jointcomplex injury, stress views obtainedunder anesthesia allow appropriateevaluation of midfoot instability.Advanced imaging can also play a

role in the management of TMT jointinjuries. CT is useful for delineatingareas of articular comminution andnondisplaced fracture lines in high-energy injury patterns. Axial, thin-cut CT slices may also be reformattedinmultiple axes tomatch the coronal,sagittal, and transverse planes of theTMT joint complex.26 However, CTis not dynamic, and normal osseousrelationships may be present in thesetting of ligamentous instability.MRI may be particularly valuable indepicting subtle ligamentous injurieswith normal radiographic parame-ters. For example, Raikin et al27

demonstrated that disruption of the

plantar oblique ligament visible onMRI was highly predictive of intra-operative instability

ClassificationSeveral classification systems havebeen proposed for TMT jointinjuries. Myerson et al20 developedthe most commonly used system,which incorporates the prior work ofQuenu and Guss28 and Hardcastleet al29 (Figure 6). The classificationscheme divides injuries in terms ofjoint congruity, location of involve-ment, and direction of instability.Type A injuries have total jointincongruity. Type B injuries aresubdivided into injuries involving themedial column in isolation (ie, B1)and those involving the lateral rays(ie, B2). Type C injuries representdivergent patterns with either partial(ie, C1) or total (ie, C2) incongruity.

Although this classification systemdoes not predict outcome, it providesa framework for understandingpatterns of injury, including patternsof instability that may extend to theintercuneiform or naviculocunei-form joints. Importantly, it impliesthat the energy dissipates in differentdirections as it enters and exits themidfoot. This is analogous to thetension and compression sides offailure in fracture patterns and mayhave implications for selection ofexposure and type of implant.Nunley and Vertullo30 proposed a

classification system to guide treat-ment of low-energy, athletic injurypatterns. Injuries are differentiatedaccording to examination, radio-graphic, and bone scintigraphy find-ings. Stage I injuries have painisolated to the TMT joint complex,normal weight-bearing radiographs,and increased uptake on bone scan.

Figure 5

A, AP non2weight-bearing radiograph of the foot in a patient with a mechanismand physical examination findings suspicious for Lisfranc injury. B, AP stressradiograph during pronation-abduction of the midfoot demonstrating instability,including lateral subluxation of the first and second tarsometatarsal joints.


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Stage II injuries demonstrate 1 to5 mm of widening between the firstand second metatarsals on weight-bearing views without evidence ofheight loss in the longitudinal arch.Stage III injuries have .5 mm ofwidening of the intermetatarsal spaceas well as longitudinal arch collapse.Although these classification sys-

tems provide a common descriptivelanguage, none has been usefulin predicting outcomes followingLisfranc injury.

Management

NonsurgicalNonsurgical management of TMTjoint complex trauma is reserved forpatients who have a stable injury pat-tern or are unable to tolerate surgicalintervention. The key to successfulnonsurgical management of Lisfrancinjuries is to rule out subtle instability.Midfoot injuries suspicious forinstability by history and physical

examination but showing normalresults onweight-bearing radiographsshould either be followed closely withserial examinations and imaging orbe further evaluated with advancedimaging. When a high index of suspi-cion remains with equivocal findingson advanced images, an examinationunder anesthesia should be per-formed. Patients should be counseledand should provide consent for surgi-cal fixation if the examination dem-onstrates instability.

Figure 6

Illustration demonstrating the classification of tarsometatarsal joint injuries. The shaded areas represent the injured ordisplaced portion of the foot. A, Type A represents total incongruity, which involves displacement of all five metatarsalswith or without fracture at the base of the second metatarsal. The usual displacement is lateral or dorsolateral. Theseinjuries are homolateral. B, In type B injuries, one or more articulations remain intact. Type B1 represents partialincongruity with medial dislocation. Type B2 represents partial incongruity with lateral dislocation; the firsttarsometatarsal 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 fromWatson TS, Shurnas PS, Denker J: Treatment of Lisfranc joint injury: Current concepts. J Am Acad Orthop Surg2010;18[12]:718-728.)




In patients with stable injury pat-terns, treatment consists of non–weight-bearing immobilization in aCAM boot or short leg cast for 4 to 6weeks. Once the immobilization hasbeen removed, patients can progressto weight bearing with a full-lengtharch support orthotic as tolerated. Acourse of physical therapy focusingon gait and balance can expediterecovery. Return to function andresolution of pain and swelling maytake 4 to 6 months.

Initial Surgical ManagementSurgical intervention is indicatedwhen there is evidence of instabilityof the TMT joint complex. Mostinjuries are initially managed withsplint immobilization until soft-tissueswelling resolves. Midfoot disloca-tions require a closed reductionto minimize soft-tissue compromise.When left unreduced, these injuriescan lead to continued soft-tissuedamage and even full-thickness skinnecrosis. Certain high-energy injurypatterns may require a stagedapproach.23 Provisional reductionusing Kirschner wires and/or anexternal fixator can maintain align-ment and facilitate soft-tissue man-agement until definitive fixation canbe achieved (Figure 7).

Definitive SurgicalManagementThe goal of surgical treatment is torestore the functional anatomy of thefoot. However, definitive manage-ment is delayed until the soft-tissueenvelope is appropriate for openapproaches and the pattern of insta-bility and involved joints is clearlyunderstood. Rigid fixation is used torecreate the stability of the medialandmiddle columns,whereas flexibletemporary fixation is used for themobile lateral column. If relativeankle equinus is not addressed, it canlead to increased loading of the mid-foot and theoretically to failure of

fixation. We routinely assess forequinus contracture while the patientis under anesthesia and perform agastrocnemius recession when amajor contracture is found.31

Exposure, reduction, and fixationgenerally proceed from proximal todistal and from medial to lateral.Careful attention should be paid tothe intercuneiform joint for signs ofinstability. We directly visualize thedorsal ligaments of the intercunei-form joint for evidence of injury.When the evidence is unclear, weperform dorsal-plantar translationand axial loading across the first rayto identify occult intercuneiforminstability. For three-column injuries,a two-incision dorsal approach isnecessary to adequately visualize theinvolved joints. The dorsal-medialincision, centered between the firstand second rays, can help visualizethe first TMT joint and the medialaspect of the second TMT joint. Thisincision can be carried proximally as

needed to address instability orassociated fractures of the cunei-forms or navicular bone. Branches ofthe superficial peroneal nerve crossthe extensor hallucis longus in theproximal portion of this incisionand are easily injured if not pro-tected. The dorsalis pedis artery andvein and deep peroneal nerve aremobilized laterally and are pro-tected. The interval between theextensor hallucis longus and exten-sor hallucis brevis is commonly ex-ploited; however, several intervalscan be used to expose the affectedjoints.32 The dorsal-lateral incisionis centered over the fourth meta-tarsal and can help visualize thelateral aspect of the second TMTjoint, as well as the third and fourthTMT joints. The common extensortendons are mobilized medially,and the muscle belly of the extensordigitorum brevis is split in line withits fibers to gain exposure of theaffected joints.Once adequate exposure has been

obtained, anatomic reduction is

Figure 7

Clinical photograph of a patient witha high-energy fracture-dislocationfollowing biplanar external fixation.The reduction did not remain closed,and the soft tissues were notamenable to definitive fixation.(Courtesy of Robert Marsh, DO,Tulsa, OK.)

Figure 8

Illustration of lateral views of the firsttarsometatarsal joint demonstrating aburred trough in the dorsal cortex ofthe first metatarsal. This allowsretrograde screw placement acrossthe tarsometatarsal joint perpendicularto the joint, minimizes screw headprominence, and prevents breakagein the dorsal cortex.)


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achieved under direct visualizationand is provisionally heldwithmultipleKirschner wires. At this point, thesurgeon may proceed with eitherinternal fixation or primary arthro-desis on the basis of the injury patternand surgeon preference. Reductiontypically beginswith assessment of theintercuneiform joint. If left unad-dressed, intercuneiform instability canlead to continued pain and recurrenceof deformity. When occult instabilityis a concern, we recommend rigidfixation across the intercuneiformjoint. Reduction of the first TMT jointis then performed according to thealignment of the dorsal and plantarcortices with the correspondingmedial cuneiform. Reduction of thefirst metatarsal base allows appropri-ate placement of the second meta-tarsal base into the mortise.

A variety of implants are availablefor fixation; however, most ligamen-tous injuries can be adequately sta-bilized with solid or cannulated smallfragment cortical screws. When ret-rograde lag screws are placed acrossthe TMT joints, making a trough inthe dorsal cortex of the metatarsalcan be helpful (Figure 8). This allowsscrew placement perpendicular tothe TMT joint and prevents screwbreakage in the dorsal cortex. Injurypatterns with metatarsal base frac-tures may require adjunctive platefixation (Figure 9). When arthrode-sis is performed, autograft cancellousbone can be placed at the junction ofthe fusion sites. This forms a rapidspot weld that relieves shear strainacross the fixation.Certain injury patterns can cause

substantial impaction of the

cuboid.33 These injuries require res-toration of lateral column length.Contralateral foot radiographs aidthe orthopaedic surgeon in deter-mining the patient’s anatomic lateralcolumn length. Although simplefractures may be treated with openreduction and internal fixation(ORIF) of the cuboid in isolation,many of these injuries requireadjunctive bone grafting of thecuboid and spanning internal orexternal fixation (Figure 10). Span-ning fixation is typically removed at8 to 12 weeks to mobilize the fourthand fifth TMT joints.Patients should be counseled that

recovery can take up to 1 year aftersurgery. Postoperatively, the limb isimmobilized in a well-padded splint,which is then converted to a shortleg non–weight-bearing cast for 8

Figure 9

A, Preoperative AP radiograph of a foot demonstrating a Lisfranc injury with major impaction of the articular surface of thefourth metatarsal base. B, Postoperative AP radiograph of the same foot. Dorsal plating was used for the comminuted thirdand fourth metatarsal base fractures. Arthrodesis was performed for the first, second, and third tarsometatarsal joints. C, APweight-bearing radiograph of the same foot obtained after the patient had the fourth tarsometatarsal bridge plate removed at3 months postoperatively.




weeks. The patient is transitioned toa walking boot at 8 weeks withprogressive weight bearing to toler-ance. Most patients return to sup-portive shoe wear with use of an archsupport by 3 months after surgery.Once the patient is weight bearing,physical therapy focusing on gaitand edema control is initiated.

Controversies and FutureDirection

Joint-sparing FixationTransarticular screws are routinelyused for fixation of the TMT jointcomplex; however, there is concernthat drilling and placement of screwsacross the articular surface increasesrates of posttraumatic arthritis seenwith these injuries. Joint-sparing fix-ation techniques, including suturebutton constructs and dorsal span-ning plates, have been explored asalternatives to transarticular screwfixation.Flexible fixation is an intriguing

alternative to standard screw fixationbecause it allows some physiologicmotion but does not violate thearticular surface or require a secondsurgery for implant removal. Recentbiomechanical studies in a cadaverinjury model demonstrated equiva-lent stability with suture buttondevices compared with screw fixa-tion.34-36 However, suture buttonconstructs may not adequately con-trol multiplanar instability patterns;in these situations, standard tech-niques or hybrid constructs withboth flexible and rigid fixation areadvisable.Spanning plate fixation of the

TMT joints provides rigidity whilepreserving the articular surface(Figure 11). In a cadaver model of aligamentous Lisfranc injury, dorsalplate fixation was biomechanicallyequivalent to transarticular screwfixation.37 Direct clinical compari-son of dorsal plate fixation with

transarticular screw fixation islacking; however, comparable ratesof complications and functionaloutcomes have been demonstrated ina small study.38

Open Reduction and InternalFixation Versus ArthrodesisPerhaps the most relevant contro-versy in the management of TMTjoint complex injuries is whether toproceed with ORIF or with primaryarthrodesis. The broad spectrum ofLisfranc injury patterns and thevariety of treatments available fur-ther complicate decision making.Modern series examining the out-

comes of ORIF for TMT injuriesfound overall favorable results;however, a relatively high rate ofposttraumatic arthritis occurreddespite appropriate reduction. Kuoet al39 examined the outcomes of 48patients following ORIF of TMTinjuries at a mean follow-up of 52months. The overall rate of post-traumatic arthritis was 25%, withboth arthritis and American Ortho-paedic Foot & Ankle Society mid-foot scores significantly correlatedwith the quality of the reduction, P =0.004 and P = 0.05, respectively. Theauthors also found a trend towardincreased arthritis in patients withpurely ligamentous injuries (40%)despite anatomic reduction andsuggested that this population maybenefit from primary arthrodesis. Incontrast, Abbasian et al40 found nosubstantial difference in functionaloutcome, pain, return to activity, orrates of posttraumatic arthritis fol-lowing ORIF in matched cohorts of29 patients each with ligamentousinjuries or osseous injury patterns.Radiographic arthritis was seen in27% of ligamentous injuries com-pared with 31% of osseous injuries;however, only one patient in eachtreatment group (3%) requiredconversion to arthrodesis duringthe study period. The authors theo-

rized that the postoperative protocolof prolonged non–weight-bearingimmobilization (ie, for 3 months)and use of an arch support followinginitiation of weight bearing contrib-uted to improvements in the liga-mentous cohort.Two randomized studies directly

compared the results of primaryarthrodesis with those of ORIF forTMT joint complex injuries. Ly andCoetzee6 randomly assigned 41patients to either open reduction orprimary arthrodesis for ligamentousinjury patterns. The arthrodesisgroup had substantially improvedfunctional outcomes, higher returnsto preinjury activity levels, lowerrates of revision surgery, and lesspain at final follow-up. In the group

Figure 10

Oblique radiograph demonstratingopen reduction and internal fixationof the cuboid with the use of a bridgeplate from the calcaneus to the fourthmetatarsal to maintain lateral columnlength. (Courtesy of Jason Nascone,MD, Baltimore, MD.)


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that underwent open reduction,25% of patients required conversionto arthrodesis for symptomaticposttraumatic arthritis. Routineremoval of transarticular screws wasnot performed in the ORIF group;however, 16 of 21 patients had screwremoval during the study period at anaverage of 6.75 months post-operatively. Results in the ORIF groupmay have been compromised becausepermanent or prolonged transarticularfixation can lead to painful arthro-fibrosis of the affected joints.Henning et al41 found no sub-

stantial difference in either the ShortMusculoskeletal Function Assess-ment or Medical Outcomes 36-ItemShort Form scores at 2-year follow-up in patients undergoing arthrode-sis versus ORIF for both ligamentousand combined injury patterns. Therewas a substantially higher rate ofsecondary surgery in the ORIF group;however, most revision surgerieswere for elective implant removal aspart of the study protocol.Although both studies reported

slight advantages for arthrodesis interms of functional outcome and

revision surgery, neither review wasable to definitively demonstrate thesuperiority of one technique over theother. More recent systematic reviewshave highlighted the need for furtherhigh-quality randomized studiescomparing the two techniques.4,42

Summary

TMT joint complex injuries areuncommon and are frequentlymissed. A high index of suspicion isnecessary when evaluating suspectedmidfoot trauma because missedinjuries may result in a painful, dys-functional foot. Nonsurgical man-agement is successful in select stableinjuries. When surgery is indicated,anatomic reduction and stable fixa-tion are necessary to restore thefunctional anatomy of the foot andmaximize patient outcomes.ORIF remains the standard treat-

ment of unstable or displaced injuriesto the TMT joint complex. However,posttraumatic arthritis can occurdespite appropriate reduction andfixation. Although ligamentousinjuries have benefited from partial

arthrodesis, the role of this techniquein managing all TMT joint complexinjuries has not been determined.Further studies are needed to clarifywhich injury patterns will benefitfrom primary arthrodesis.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, references 6and 41 are level I studies. References4, 19, 27, and 42 are level II studies.References 5, 7, 11, 12, and 40 arelevel III studies. References 2, 20, 22,23, 29-33, 36, 38, and 39 are level IVstudies. Reference 28 is level Vexpert opinion.

References printed in bold type arethose published within the past 5years.

1. Benirschke SK, Meinberg E, Anderson SA,Jones CB, Cole PA: Fractures anddislocations of the midfoot: Lisfranc andChopart injuries. J Bone Joint Surg Am2012;94(14):1325-1337.

2. Cassebaum WH: Lisfranc fracture-dislocations. Clin Orthop Relat Res 1963;30(30):116-129.

Figure 11

A, AP stress fluoroscopic image demonstrating instability across the first tarsometatarsal joint and second and thirdmetatarsal base fractures. AP (B) and lateral (C) fluoroscopic images of the foot after a joint-sparing technique wasperformed with dorsal bridge plating of the first, second, and third tarsometatarsal joints.




3. Aronow MS: Treatment of the missedLisfranc injury. Foot Ankle Clin 2006;11(1):127-142, ix.

4. Sheibani-Rad S, Coetzee JC, Giveans MR,DiGiovanni C: Arthrodesis versus ORIF forLisfranc fractures. Orthopedics 2012;35(6):e868-e873.

5. Mulier T, Reynders P, Dereymaeker G,Broos P: Severe Lisfrancs injuries: Primaryarthrodesis or ORIF? Foot Ankle Int 2002;23(10):902-905.

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