Management of Tarsometatarsal Joint Injuries

Abstract

Joint disruptions to the tarsometatarsal (TMT) joint complex, also known as the Lisfranc joint, represent a broad spectrum of pathology from subtle athletic sprains to severe crush injuries. Although injuries to the TMT joint complex are uncommon, when missed, they may lead to pain and dysfunction secondary to posttraumatic arthritis and arch collapse. An understanding of the appropriate anatomy, mechanism, physical examination, and imaging techniques is necessary to diagnose and treat injuries of the TMT joints. Nonsurgical management is indicated in select patients who maintain reduction of the TMT joints under physiologic stress. Successful surgical management of these injuries is predicated on anatomic reduction and stable fixation. Open reduction and internal fixation remains the standard treatment, although primary arthrodesis has emerged as a viable option for certain types of TMT joint injuries.

Dynamic Lisfranc Joint Repair Concept: Surgical Technique for a Synthetic Neoligamentplasty

“…They provide adequate stability but they compromise the TMT joint articular surface and make the joint rigid and less adaptable in a stand position. (4,17,18) The concept of midfoot ligament reconstruction and motion preservation breaks the common sense of immobilization to hope for ligament healing. The use of trans articular screws or a primary arthrodesis has never been considered in knee or shoulder ligament injuries, and, in that way, why should they be considered in a joint with movement and with an important biomechanical property in the foot?…”

Midfoot Degenerative Arthritis and Partial Fusion After Pediatric Lisfranc Fracture-Dislocation

“…There was also no fixation placed across the Lisfranc joint proper or intercuneiform joints, where any subtle instability could lead to the development of arthritis and deformity. 6 Loss of reduction or instability in our patient may also be attributed to early pin removal and initiation of full weight-bearing only at 4 weeks postoperatively. In one series, pediatric patients who received surgical treatment of bony Lisfranc injuries were kept non–weight-bearing for 11 to 14 weeks, whereas those treated nonsurgically for sprains were non–weight-bearing for 7 weeks.…”

“…In adults, degenerative arthritis is the most common complication, with radiographic changes in 72% to 94% of patients, >50% of whom are clinically symptomatic. 5 , 6 Unfavorable outcomes, including pain, arthritis, decreased functional activity, and orthotic requirements, have been associated with the poor quality of initial reduction or failure to maintain an anatomic reduction. 1 , 5 , 9 , 10 However, degenerative changes and disability have been seen to occur even with appropriate treatment.…”

“…Typically, rigid fixation is used for stabilization of the medial and middle columns in the form of screws or plates, with flexible fixation reserved for the mobile lateral column. 3 , 6 , 13 In this instance, flexible temporary K-wires were used as the sole mode of fixation. Smooth pins may have been used to protect the joint surfaces and open physes in a child, but this was potentially inadequate to hold the reduction.…”

“…Adult studies have reported incidences of radiographic arthritis in 72% to 94% of patients, with >50% of those being clinically symptomatic. 5 , 6 It is unknown whether children will go on to develop arthritis at a similar rate. We present a case of a 10-year-old girl with a Lisfranc fracture-dislocation treated surgically with open reduction and K-wire fixation who went on to develop symptomatic midfoot arthritis with partial fusion identified at 5-year follow-up and discuss several possible explanations for her outcome.…”