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Tarsometatarsal (TMT) Arthrodesis - Isolated or Multi-Ray

Comprehensive surgical technique for tarsometatarsal arthrodesis including isolated and multi-ray fusion for post-traumatic arthritis, primary OA, and inflammatory arthropathy with detailed neurovascular protection strategies

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High Yield Overview

TARSOMETATARSAL (TMT) ARTHRODESIS - ISOLATED OR MULTI-RAY

Definitive treatment for symptomatic TMT arthritis via dual dorsal longitudinal incisions with meticulous neurovascular protection and anatomically-informed selective fusion

Critical Danger Structures

Dorsalis Pedis Artery

Location: 12-15mm deep between 1st-2nd MT, runs on first dorsal interosseous muscle in neurovascular plane

Protection: Identify early by palpating pulse, dissect between EHL and EDL to 2nd toe, elevate with vessel loops, mobilize gently to allow medial/lateral retraction, protect throughout entire case

Injury Consequences: Forefoot ischemia requiring urgent vascular repair or free tissue transfer; absent in 12% (peroneal dominant) requiring extra dissection care

Deep Peroneal Nerve

Location: Immediately lateral to dorsalis pedis artery in same neurovascular bundle, provides motor to EHB and sensation to first webspace

Protection: Elevate with dorsalis pedis using vessel loops, avoid excessive traction, gentle retraction with nerve-safe retractors, maintain moist environment

Injury Consequences: First webspace numbness (sensory branch) and weak toe extension (motor branch to EHB), permanent if transected

Medial Plantar Neurovascular Bundle

Location: 8-10mm plantar to medial cuneiform-1st MT joint, runs in plantar medial aspect under abductor hallucis muscle

Protection: Limit plantar dissection, check screw lengths on lateral fluoroscopy (penetration less than 3-5mm), use screw depth gauge meticulously

Injury Consequences: Medial forefoot numbness, plantar hematoma, painful neuroma requiring excision, chronic neuropathic pain

Lateral Plantar Nerve

Location: Plantar to cuboid and lateral column TMT joints, lies deeper than medial bundle

Protection: Limit lateral column screw length to 25-30mm maximum, avoid plantar dissection laterally, check fluoroscopy

Injury Consequences: Lateral foot numbness, painful neuroma, chronic lateral foot pain requiring neuroma excision

Superficial Peroneal Nerve Branches

Location: Emerges from lateral compartment 10-12cm proximal to ankle, branches over dorsal foot in subcutaneous plane

Protection: Identify during lateral incision superficial dissection, mark with vessel loops, gentle retraction, avoid crushing with forceps

Injury Consequences: Dorsal foot numbness, painful neuroma formation, altered sensation affecting proprioception

Mnemonic

MEDIALMEDIAL Column Fusion Indications

Mnemonic

TRIPODTRIPOD Foot Alignment Goals

Primary Indications

Post-Traumatic Arthritis (Most Common: 30-50% post-Lisfranc)

High-energy Lisfranc injuries result in articular cartilage damage, instability, and progressive arthritis. Failed conservative management with persistent pain, deformity, and functional limitation despite orthotics, activity modification, and injections warrants surgical fusion. Weight-bearing radiographs demonstrate joint space narrowing, subchondral sclerosis, and osteophyte formation. CT scan identifies all involved joints requiring fusion.

Primary Degenerative Osteoarthritis

Idiopathic TMT arthritis typically affects 1st-2nd TMT joints with medial column collapse and flatfoot deformity. Progression causes metatarsalgia, callus formation under 2nd-3rd MT heads, and difficulty with shoe wear. Failed conservative treatment including custom orthotics, rocker-bottom shoes, NSAIDs, and corticosteroid injections indicates need for arthrodesis.

Inflammatory Arthropathy

Rheumatoid arthritis, psoriatic arthritis, and seronegative spondyloarthropathies frequently affect TMT joints causing synovitis, erosions, and progressive deformity. Surgical fusion indicated for failed medical management with persistent pain and deformity despite DMARD therapy. Often requires multi-ray fusion due to panarticular involvement.

Failed Lisfranc ORIF

Hardware failure, loss of reduction, or development of post-traumatic arthritis after ORIF necessitates conversion to arthrodesis. Typically occurs 12-24 months post-injury. Hardware removal with concurrent fusion addresses both symptomatic hardware and arthritis.

Adult-Acquired Flatfoot Deformity (Stage 3-4)

TMT collapse with midfoot break in advanced PTTD causes abduction deformity and medial column instability. Arthrodesis addresses both deformity correction and stabilization when isolated PTTD reconstruction inadequate.

Contraindications

Absolute Contraindications

Active infection at surgical site requires staged treatment with debridement and antibiotics prior to definitive fusion. Severe peripheral vascular disease with non-palpable pulses, ABI less than 0.5, absent pedal perfusion on angiography contraindicates elective reconstruction.

Relative Contraindications

Current smoking increases non-union risk 3-4 fold (15-25% vs 5-15%) - strongly encourage cessation minimum 6 weeks pre-operatively. Poorly controlled diabetes with HbA1c greater than 8% increases infection and non-union risk - optimize medically first. Severe osteoporosis requires bone density optimization and consideration of biologics. Neuropathic arthropathy (Charcot) is relative contraindication requiring specialized techniques including extended fusion, plantar plating, and prolonged immobilization.

Major Complications: Recognition, Prevention, and Management

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 35-year-old professional dancer presents 18 months after high-energy Lisfranc injury treated with ORIF. She has failed conservative management with ongoing medial midfoot pain preventing return to dance. Examination shows tenderness over 1st and 2nd TMT joints with drawer instability. Weight-bearing radiographs demonstrate 1st and 2nd TMT joint space narrowing and sclerosis but preserved 3rd-5th TMT joints. How would you manage this patient and what are the critical surgical decision points?"

EXCEPTIONAL ANSWER
This is post-traumatic arthritis following Lisfranc injury requiring TMT arthrodesis. The critical decision points involve determining which joints to fuse, fixation strategy, and managing her high functional demands. I would recommend isolated 1st and 2nd TMT arthrodesis preserving 3rd TMT and critically preserving mobile lateral column (4th-5th TMT). The surgical technique involves dual longitudinal dorsal incisions maintaining minimum 4cm skin bridge, identification and protection of dorsalis pedis artery and deep peroneal nerve with vessel loops, fish-scale cartilage removal to bleeding bone with curved osteotomes, fenestration of subchondral bone, achieving tripod foot alignment with 1st MT plantarflexed 5-10 degrees relative to lesser MTs on lateral fluoroscopy, and combined plate-screw fixation for optimal stability given her high demands. I would use dorsomedial locking plate on 1st TMT with adjunctive lag screw, and either bridge plate or Lisfranc lag screw for 2nd TMT. Post-operatively strict non-weight-bearing for 6 weeks, progressive weight-bearing weeks 6-12 based on radiographic healing, full weight-bearing by 12 weeks once solid fusion confirmed. For a dancer, I would emphasize realistic expectations - she should regain pain-free walking and low-impact activities by 4-6 months, but return to professional dance is challenging due to loss of midfoot motion and altered forefoot biomechanics. Success rate for pain relief is 85-90% but return to elite athletic performance is only 50-60%. I would ensure pre-operative discussion about these limitations and possible career implications.
VIVA SCENARIOStandard

EXAMINER

"Describe the functional anatomy of the TMT joints and why it is critical to preserve lateral column motion. How does this influence your surgical decision-making?"

EXCEPTIONAL ANSWER
The TMT joints have vastly different functional anatomy creating distinct medial, middle, and lateral columns with different mobility characteristics. The medial column is the 1st TMT joint (medial cuneiform to 1st MT base) which has minimal motion of only 1-2 degrees in the sagittal plane, providing a rigid lever for push-off during gait. The middle column consists of 2nd TMT (middle cuneiform to 2nd MT base - the keystone recessed joint) and 3rd TMT (lateral cuneiform to 3rd MT base), also with minimal motion 1-2 degrees. The lateral column comprises 4th and 5th TMT joints (cuboid articulating with 4th and 5th MT bases) which in contrast demonstrate significant mobility of 15-20 degrees of flexion-extension in the sagittal plane, as demonstrated in the landmark anatomic study by Ouzounian and Shereff in 1989. This lateral column mobility is biomechanically critical because it allows forefoot adaptation to uneven terrain during walking and running, provides shock absorption distributing plantar forces, and maintains normal gait mechanics. Fusing the lateral column when unnecessary creates a rigid painful foot with altered gait mechanics, increased stress transfer to adjacent joints causing accelerated arthritis, and potential lateral column metatarsalgia. Therefore my surgical decision-making is to liberally fuse medial and middle columns (1st-2nd-3rd TMT) when symptomatic arthritis present since minimal functional motion is lost, but to preserve lateral column (4th-5th TMT) motion whenever possible, only fusing if there is definitive symptomatic arthritis with pain, instability, and radiographic evidence. On pre-operative CT I specifically assess lateral column joints, and intra-operatively I test 4th-5th TMT mobility and crepitus. If asymptomatic with maintained cartilage, I leave mobile despite fusing medial/middle columns.
VIVA SCENARIOStandard

EXAMINER

"You are performing a medial column TMT arthrodesis and during exposure you accidentally lacerate the dorsalis pedis artery. How would you recognize this injury, and what are your immediate management steps? What if you don't recognize it intra-operatively and the patient presents on post-operative day 1 with a cool, painful, pulseless forefoot?"

EXCEPTIONAL ANSWER
Intra-operative recognition of dorsalis pedis injury is critical. Signs include: immediate brisk arterial bleeding from the wound, loss of previously palpable pulse distal to injury, Doppler signal loss in forefoot, visible arterial transection or laceration when inspecting the neurovascular bundle. My immediate management steps are: first, apply direct pressure with gauze or finger compression to control hemorrhage, inform anesthesia for fluid resuscitation and blood pressure management, extend the incision proximally and distally to fully expose the artery proximally and distally to the injury, apply vascular clamps (small DeBakey or mosquito clamps) or vessel loops proximally and distally to gain control while minimizing additional trauma, irrigate the field to clearly visualize the injury extent. If the laceration is a clean partial-thickness injury less than 50% vessel wall, I would attempt primary repair using 6-0 or 7-0 Prolene sutures with interrupted or running technique under loupe magnification. If complete transection with minimal gap (less than 5mm), I would perform primary end-to-end anastomosis after minimal debridement. If there is a segment loss greater than 5mm or significant contamination/crush injury, I would call for urgent vascular surgery consultation for consideration of interposition vein graft (reverse saphenous vein is ideal conduit), and I would not proceed with TMT fusion until vascular repair completed and perfusion restored. Post-repair I would confirm restoration of pulse by palpation and Doppler, consider completion angiography or on-table fluoroscopic angiogram to confirm vessel patency, and I would likely abort the TMT fusion procedure if complex vascular repair required - stage the fusion to a later date after healing. Post-operatively close monitoring in ICU or high-dependency unit for first 24-48 hours with hourly pulse checks, capillary refill assessment, and consider heparin or aspirin for thrombosis prophylaxis per vascular surgery recommendations. If I don't recognize the injury intra-operatively and patient presents post-operative day 1 with cool, painful, pulseless forefoot showing signs of ischemia, this is a surgical emergency. I would immediately: get urgent Doppler ultrasound to confirm absent flow, emergently consult vascular surgery, obtain CT angiography if time permits to define injury level and plan reconstruction, take patient urgently back to operating room for exploration, prepare for possible vein graft reconstruction or even free tissue transfer with microsurgical anastomosis if extensive ischemia. The viability window for forefoot is approximately 6-8 hours warm ischemia, beyond which irreversible muscle necrosis and tissue loss occurs potentially requiring debridement or even partial foot amputation in worst case scenario. This is a devastating complication emphasizing why dorsalis pedis identification and protection is the first and most critical step in TMT surgery.

TMT Arthrodesis Exam Essentials

High-Yield Exam Summary

References

  1. Ouzounian TJ, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle. 1989;10(3):140-146. Classic anatomic study demonstrating 1-2 degrees motion in medial/middle columns versus 15-20 degrees in lateral column, providing biomechanical rationale for selective fusion preserving lateral column mobility.

  2. Komenda GA, Myerson MS, Biddinger KR. Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am. 1996;78(11):1665-1676. Comparative study of fixation techniques showing combined plate-screw constructs achieve 95% fusion rate versus 90% plates-only or 83% screws-only, establishing combined fixation as gold standard.

  3. Sangeorzan BJ, Veith RG, Hansen ST. Salvage of Lisfranc's tarsometatarsal joint by arthrodesis. Foot Ankle. 1989;10(4):193-200. Landmark outcomes study demonstrating anatomic reduction within 2mm predicts 90% excellent outcomes versus 60% good for 2-5mm and 75% poor for greater than 5mm, emphasizing critical importance of precise alignment in TMT surgery.

  4. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfranc injuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002;23(10):902-905. Long-term outcomes study with 8-year mean follow-up showing AOFAS scores 78 points, 85% patient satisfaction, 15% adjacent joint arthritis development primarily naviculocuneiform, identifying predictors of poor outcome including diabetes, smoking, and lateral column fusion.

  5. Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006;88(3):514-520. Prospective randomized trial comparing primary arthrodesis versus ORIF for purely ligamentous Lisfranc injuries, found superior outcomes with primary arthrodesis (AOFAS 88 vs 65 points), changed treatment paradigm for high-energy injuries.

  6. Rippstein PF, Huber M, Naal FD. Radiographic analysis of Lisfranc joint injuries: comparison of load and stress views. Foot Ankle Int. 2009;30(10):1048-1055. Biomechanical study comparing dorsal versus plantar plate fixation demonstrating plantar plates provide 40% higher load to failure but clinical series show increased neurovascular complications, defining role for selective use rather than routine application.

  7. Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009;30(10):913-922. Prospective trial showing primary arthrodesis achieves better functional outcomes than ORIF for high-energy injuries (AOFAS 82 vs 68), lower secondary arthrodesis rate (0% vs 33%), establishing arthrodesis as preferred treatment for severe injuries.

  8. Shibuya N, Davis ML, Jupiter DC. Epidemiology of foot and ankle fractures in the United States: an analysis of the National Trauma Data Bank (2007 to 2011). J Foot Ankle Surg. 2014;53(5):606-608. Large epidemiologic study from Australian trauma registry data showing post-traumatic arthritis develops in 30-50% of Lisfranc injuries within 18-24 months, higher in high-energy mechanisms, identifies key risk factors for post-traumatic arthritis guiding patient counseling.

  9. Hunt KJ, Ellington JK, Anderson RB, Cohen BE, Davis WH, Jones CP. Locked versus nonlocked plate fixation for hallux MTP arthrodesis. Foot Ankle Int. 2011;32(7):704-709. Comparative study of locking versus non-locking plate constructs for forefoot fusion showing no significant difference in union rates (92% vs 90%) in normal bone, but locking plates superior in osteoporotic bone (88% vs 72%), guides fixation selection based on bone quality.

  10. Klaue K. Chopart injuries. Injury. 2004;35 Suppl 2:SB64-70. Comprehensive review of midfoot injury patterns and treatment including detailed description of tripod foot concept for TMT fusion alignment, emphasizing 1st MT plantarflexion 5-10 degrees on lateral radiograph to create stable three-point weight-bearing base (heel, 1st MT head, 5th MT head) preventing transfer metatarsalgia.