Dorsal Approach to Midfoot

What it exposes. The dorsal approach to the midfoot is a family of longitudinal incisions on the dorsum of the foot giving access to the tarsometatarsal (TMT) joints (the Lisfranc joint complex), the naviculocuneiform and intercuneiform joints, and the metatarsal bases. It is the workhorse exposure for Lisfranc injuries, primary TMT arthrodesis, displaced midfoot fractures (cuneiform, navicular, metatarsal base), and Charcot or deformity reconstruction. The anatomic principle that drives incision design. The dorsum of the foot is supplied by longitudinal angiosomes (vascular territories) with limited cross-communication. A single transverse incision across the dorsum therefore risks devascularising the intervening skin and creating ischaemic flaps, and parallel incisions placed too close together leave a narrow, poorly perfused bridge. Standard technique uses multiple longitudinal incisions (2-3) oriented parallel to the metatarsal shafts, separated by an adequate soft-tissue bridge (commonly cited as approximately 3cm or more), with full-thickness incisions straight down to bone and no undermining. Three-column concept. Incision planning follows the three midfoot columns:

• Medial column: 1st TMT joint (1st metatarsal to medial cuneiform) and the medial naviculocuneiform joint.
• Middle column: 2nd and 3rd TMT joints (2nd/3rd metatarsals to middle/lateral cuneiforms) - the keystone of the midfoot arch.
• Lateral column: 4th and 5th TMT joints (4th/5th metatarsals to cuboid), plus the calcaneocuboid joint; mobile, and generally pinned rather than fused. Most Lisfranc injuries involve the medial and middle columns (Myerson Types A-C) and are managed with the two-incision technique; a third lateral incision is added only when the lateral column is injured. Primary indications.
• Lisfranc injuries with displacement over 2mm - purely ligamentous (1st-2nd TMT diastasis) or fracture-dislocation. Myerson 1986 established that the quality of reduction is the chief determinant of outcome, and that displacement over 2mm or a talometatarsal angle over 15deg after closed reduction mandates open reduction. Modern comparative evidence (Ly & Coetzee 2006; O'Connor 2024) favours primary arthrodesis over ORIF for primarily ligamentous injuries.
• Primary TMT arthrodesis: post-traumatic arthritis, Charcot arthropathy, inflammatory arthritis, severe progressive flatfoot deformity.
• Displaced midfoot fractures requiring ORIF: navicular body fractures, cuneiform fractures, intra-articular metatarsal base fractures with over 2mm step-off.
• Relative indications: non-displaced Lisfranc injuries with instability on weight-bearing or stress views; revision surgery. Contraindications. Absolute: active infection (osteomyelitis, soft-tissue abscess) until eradicated; severe vascular insufficiency (ABI less than 0.5, absent pulses, tissue loss); an insensate foot in a patient who cannot comply with offloading. Relative: significant soft-tissue injury (crush, compartment syndrome sequelae) favouring delayed surgery or external fixation; non-displaced stable injuries suitable for non-operative care; severe osteoporosis (consider primary arthrodesis rather than ORIF). Position & landmarks. Supine with a bump under the ipsilateral hip to externally rotate the leg and present the dorsum; thigh tourniquet inflated to 300-350mmHg after exsanguination (haemostasis is critical for these small midfoot structures); C-arm brought in from the contralateral side. Palpate and mark the 1st metatarsal base, the recessed 2nd metatarsal base (the keystone, sitting between the cuneiforms), the navicular tuberosity, the cuboid, and the dorsalis pedis pulse in the 1st-2nd interval (which marks the deep peroneal nerve location).

The midfoot is exposed through two (occasionally three) longitudinal dorsal incisions. The medial incision opens the 1st TMT joint; the dorsal incision in the 2nd-3rd metatarsal interval - the safe zone between the deep and superficial peroneal nerves - opens the 2nd and 3rd TMT joints after the neurovascular bundle is identified and protected.

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Structures at risk, by layer

Neurovascular anatomy. The deep peroneal nerve supplies the short toe extensors (EHB, EDB) through its terminal lateral branch and the first-webspace skin through its medial branch; the long extensors and tibialis anterior are supplied in the anterior compartment of the leg and are NOT at risk at the foot. An injury at the foot therefore gives only mild EDB/EHB weakness (NOT a foot drop) and first-webspace numbness - usually a traction neurapraxia recovering over weeks to months, with less reliable recovery after sharp transection. The dorsalis pedis artery is the continuation of the anterior tibial artery; if injured it can usually be ligated because the plantar collateral circulation is adequate, but a cold, pale foot post-operatively needs urgent vascular review. The superficial peroneal branches (medial and intermediate dorsal cutaneous nerves) frequently cross the incisions and cause dorsal numbness or a tender neuroma if injured. Extensile options. Each longitudinal incision can be extended proximally to the naviculocuneiform or calcaneocuboid joint, or distally along the metatarsal shafts. If more exposure is needed, extend an existing incision or add a SEPARATE longitudinal incision (with an adequate bridge) - never convert two parallel incisions into a single transverse incision. Closure. Irrigate, reapproximate capsules where possible, close the subcutaneous tissue and skin, and apply a bulky dressing with a posterior splint holding the foot neutral. Hardware prominence is common on the subcutaneous dorsum, so use low-profile implants and warn the patient that elective removal may be needed.

• ORIF of Lisfranc injury / TMT fracture-dislocation - the principal indication for the trauma exposure.
• TMT arthrodesis (isolated or multi-ray) and Lapidus / 1st TMT arthrodesis for hallux valgus - primary fusion for ligamentous injury, post-traumatic arthritis, Charcot collapse and inflammatory arthritis.
• ORIF of displaced midfoot fractures (navicular body, cuneiform, intra-articular metatarsal base) and Charcot midfoot reconstruction. Reduction sequence (medial to lateral). Reduce the 1st TMT first (the medial column is foundational): plantar pressure on the 1st metatarsal head with a medial and plantar pull on the base restores the articulation with the medial cuneiform, held on two 2.0mm K-wires. Reduce the 2nd TMT next (the keystone): elevate and disimpact the recessed 2nd metatarsal base until its medial border is flush with the middle cuneiform on the AP view, then pin it. The 3rd TMT usually follows the 2nd indirectly. Reduce the lateral column (4th-5th TMT) last and pin it. Confirm on multiple fluoroscopic views that the 1st-2nd diastasis is less than 2mm before definitive fixation; if it persists, add an intercuneiform screw. Fixation options

• Bridge / dorsal plating: a low-profile 2.7mm or 3.5mm plate along the metatarsal bases avoids transarticular cartilage violation and suits comminuted or osteoporotic bone - an AO-Foundation-favoured alternative.
• Primary arthrodesis: remove cartilage to bleeding subchondral bone, compress with screws and/or dorsal plates, and bone-graft large defects; union is high (around 95%, Komenda & Myerson 1996; Ly & Coetzee 2006). For ligamentous injuries the RCT reported AOFAS 88 after arthrodesis versus 68.6 after ORIF (p less than 0.005). Global practice. The indication for surgery (over 2mm diastasis, or a talometatarsal angle over 15deg after closed reduction) is universal across AAOS, BOA/BOAST and AO Foundation teaching. The genuine divergence is the threshold for primary arthrodesis: Level I evidence and pooled meta-analyses increasingly favour primary fusion of the medial 2-3 rays for primarily ligamentous injuries, while ORIF remains standard for bony fracture-dislocations and in younger patients prioritising motion. Implant choice varies by resource setting (cannulated screws are universal; dedicated low-profile Lisfranc plates and suture-button devices are used where available). No country-specific billing or coding applies. Post-operative protocol. Non-weight-bearing for 0-6 weeks with suture removal at 2-3 weeks; partial weight-bearing in a boot from 6-12 weeks as radiographic healing permits; full weight-bearing and boot weaning around 12 weeks. Remove lateral-column K-wires at 6-8 weeks; remove temporary transarticular screws around 12 weeks if planned.