High-yield overview

Tarsometatarsal | Post-Traumatic Common | Midfoot Fusion

TMTTarsometatarsal joints

PrimaryMost common cause

OrthoticsFirst-line conservative

FusionDefinitive treatment

Affected Joints

Medial Column

Pattern1st TMT

TreatmentMost commonly symptomatic

Middle Column

Pattern2nd, 3rd TMT

TreatmentKeystone, stable

Lateral Column

Pattern4th, 5th TMT

TreatmentPreserve if possible

Critical Must-Knows

Tarsometatarsal (TMT) joints most commonly affected
Primary OA and post-traumatic (Lisfranc injury) are common causes
Medial column (1st TMT) is most commonly symptomatic
Stiff-soled shoe and orthotic are first-line treatment
Midfoot fusion is definitive for refractory cases

Clinical Pearls

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Lateral column motion more important - preserve if possible
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Dorsal osteophyte impingement is common pattern
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Weight-bearing X-ray essential
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Oblique view shows TMT joints well

Clinical Imaging

Imaging Gallery

Clinical picture of involved right foot on presentation (uninvolved left foot for comparison)Credit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))

AP and lateral radiograph of involved foot on presentationCredit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))

CT images of involved foot on presentationCredit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))

Clinical picture and X-ray on Ilizarov ring fixatorCredit: Open-i / NIH via Open-i (NIH) (Open Access (CC BY))

Critical Midfoot Arthritis Exam Points

Anatomy

Midfoot = Lisfranc (TMT) joint and naviculocuneiform joints. Medial column (1st ray) is most commonly symptomatic. Middle column (2nd, 3rd) is the keystone.

Causes

Primary OA: Idiopathic, most common. Post-traumatic: After Lisfranc injury (even subtle). Inflammatory: RA, gout. Neuropathic: Charcot (diabetic).

Clinical

Dorsal midfoot pain worse with activity. Pain with push-off. Palpable dorsal osteophytes. Difficulty with uneven ground or shoes.

Fusion Principles

Medial and middle columns tolerate fusion well (minimal motion normally). Preserve lateral column motion if possible - important for gait adaptation.

At a Glance

Midfoot arthritis primarily affects the tarsometatarsal (Lisfranc) joints and naviculocuneiform joints, most commonly caused by primary osteoarthritis or post-traumatic degeneration following Lisfranc injuries. The medial column (1st TMT) is most commonly symptomatic, presenting with dorsal midfoot pain worse with activity and palpable dorsal osteophytes. First-line treatment involves stiff-soled shoes and orthotics; definitive management for refractory cases is midfoot fusion. The lateral column (4th/5th TMT) motion should be preserved when possible as it is important for gait adaptation on uneven terrain.

Mnemonic

1-2-3-4-5Midfoot Columns

1	Medial column (1st TMT) Most symptomatic, fuses well
2-3	Middle column (2nd, 3rd TMT) Keystone, stable, fuses well
4-5	Lateral column (4th, 5th TMT) Mobile, preserve if possible

1	Medial column (1st TMT) Most symptomatic, fuses well
2-3	Middle column (2nd, 3rd TMT) Keystone, stable, fuses well
4-5	Lateral column (4th, 5th TMT) Mobile, preserve if possible

Hook:Medial (1) and Middle (2-3) = fuse OK. Lateral (4-5) = preserve motion!

Overview & Epidemiology

Midfoot arthritis affects the tarsometatarsal (Lisfranc) joints and/or naviculocuneiform joints and is an important cause of midfoot pain and disability.

Epidemiology: Symptomatic midfoot OA affects about 12% of adults over 50 (Thomas/Roddy 2015) and is mechanically driven (obesity, prior injury, female sex, age over 75). Post-traumatic disease dominates in younger active patients - radiographic OA develops in roughly 70% and symptomatic OA in about half after surgically treated Lisfranc injuries (Dubois-Ferriere 2016).

Pathophysiology & Anatomy

Anatomy

The midfoot is divided into three columns:

Medial column: 1st metatarsal, medial cuneiform
Middle column: 2nd and 3rd metatarsals, intermediate and lateral cuneiforms - this is the "keystone" providing stability
Lateral column: 4th and 5th metatarsals, cuboid

Pathophysiology

The medial and middle columns are intrinsically rigid (the 2nd TMT is recessed in a mortise between the cuneiforms - the "keystone"), with very little physiological motion; the lateral column is comparatively mobile to allow the foot to accommodate uneven ground. Cartilage loss and incongruity at these load-bearing joints generate dorsal shear and osteophyte (dorsal boss) formation, which impinges on shoe wear and at push-off. Because the medial/middle columns normally move little, fusing them sacrifices minimal function - the biomechanical rationale for arthrodesis being well tolerated there while lateral column motion is protected.

Etiology

Primary Osteoarthritis: Most common. Idiopathic degeneration.

Post-Traumatic: Following Lisfranc injury (even subtle ligamentous injury can lead to arthritis).

Inflammatory Arthritis: RA, psoriatic arthritis, gout (particularly 1st TMT).

Neuropathic (Charcot): Diabetic neuroarthropathy can affect midfoot.

Mnemonic

PAINCauses of Midfoot Arthritis

P	Post-traumatic After Lisfranc injury - commonest in younger active patients (Dubois-Ferriere 2016)
A	Aging / primary OA Idiopathic degeneration - 12% of over-50s symptomatic (Thomas/Roddy 2015)
I	Inflammatory RA, psoriatic arthritis, gout (1st TMT)
N	Neuropathic Charcot - diabetic; exclude before any fusion

P	Post-traumatic After Lisfranc injury - commonest in younger active patients (Dubois-Ferriere 2016)	I	Inflammatory RA, psoriatic arthritis, gout (1st TMT)
A	Aging / primary OA Idiopathic degeneration - 12% of over-50s symptomatic (Thomas/Roddy 2015)	N	Neuropathic Charcot - diabetic; exclude before any fusion

Hook:Midfoot arthritis is a PAIN: Post-traumatic, Aging, Inflammatory, Neuropathic.

Clinical Presentation

History

Dorsal midfoot pain worse with walking, running, or standing. Pain with push-off phase of gait. Difficulty wearing shoes (dorsal osteophytes rub). May report prominence on top of foot. Worse on uneven ground.

Examination

Inspection: Dorsal prominences (osteophytes) may be visible. Swelling over midfoot.

Palpation: Tenderness over affected TMT joints. Palpable dorsal spurs.

Range of Motion: Pain with midfoot pronation/supination. Reduced naviculocuneiform motion if involved.

Gait: May have antalgic gait or limited push-off.

Investigations

Weight-Bearing Radiographs: Essential for assessment.

AP Foot: Shows TMT joint space narrowing, osteophytes, any malalignment.

Lateral Foot: Shows dorsal osteophytes, any collapse.

Oblique View: Best visualization of TMT joints.

CT Scan: Details joint involvement for surgical planning. Shows extent of arthritis.

MRI: For soft tissue assessment or early disease. Shows bone marrow edema.

Findings

Classic features include joint space narrowing, subchondral sclerosis, dorsal osteophytes, and subchondral cysts. Dorsal osteophyte impingement is a common source of symptoms.

Differential Diagnosis

Dorsal midfoot pain is not specific. The key examiner skill is distinguishing localised TMT/NC arthritis from mimics that change management entirely (especially Charcot and stress fracture, where surgical fusion or weight-bearing through an arthritic joint can be catastrophic).

Midfoot Pain: Differential Diagnosis

Diagnosis	Distinguishing Features	Key Investigation	Why It Matters
Primary / post-traumatic TMT OA	Dorsal pain on push-off, palpable dorsal boss, prior Lisfranc injury	Weight-bearing AP/lateral/oblique radiographs	The diagnosis in question - fusion is definitive
Charcot (neuropathic) arthropathy	Diabetic/neuropathic, warm swollen foot, rocker-bottom deformity, often painless	Compare skin temperature, sensory exam, MRI/bone scan to exclude osteomyelitis	Acute Charcot needs offloading/total contact cast - operating into active disease risks disaster
Metatarsal / navicular stress fracture	Focal bony tenderness, recent change in load, athletes/runners	MRI (marrow oedema) - radiographs often normal early	Navicular stress fracture risks non-union; managed with offloading, not fusion
Inflammatory arthropathy (RA, psoriatic, gout)	Polyarticular, morning stiffness, synovitis, systemic features	Inflammatory markers, urate, autoantibodies, MRI synovitis	DMARD optimisation first; surgery and DMARD timing coordinated with rheumatology
Tarsal coalition (symptomatic adult)	Stiff hindfoot, recurrent ankle sprains, younger patient	CT (osseous) / MRI (fibrocartilaginous bar)	Different anatomical site and treatment pathway

Management

Footwear Modification: Stiff-soled shoe (rocker bottom) reduces motion through midfoot. Reduces pain.

Orthotic: Stiff carbon fiber insole or total contact orthotic. Reduces midfoot motion and load.

Activity Modification: Avoid high-impact activities.

Pharmacological: NSAIDs, topical agents.

Injection: Intra-articular corticosteroid to affected TMT joint. May provide temporary relief (diagnostic and therapeutic).

Conservative measures are first-line and may be adequate for mild to moderate symptoms.

Complications

Complications relate chiefly to arthrodesis; untreated arthritis itself causes progressive pain, deformity and disability.

Non-union: 5-10% for medial/middle column constructs, rising with the number of joints fused and in smokers, diabetics, inflammatory arthropathy and the lateral column (Dang et al 2020). Mann et al (1996) achieved 98% union in a largely medial/middle-column series.
Malunion / residual deformity: Loss of arch height or dorsal malposition of the first ray alters load and gait; slight plantarflexion of the first ray at fusion guards against this.
Adjacent / transfer overload: Stiffening the midfoot transfers stress to neighbouring joints; inappropriate lateral column fusion causes lateral foot pain and metatarsal stress fracture (3 cases in Mann et al 1996).
Wound and soft-tissue problems: Dorsal incisions risk skin slough and incisional neuroma (superficial peroneal/deep peroneal branches); higher risk in diabetics, smokers and inflammatory disease.
Hardware prominence / failure: Dorsal plates and screws may be palpable and require removal; hardware can fail before union.
Infection: Increased in diabetics, smokers and patients on biologics - a key reason for perioperative medication planning.

Mnemonic

SMOKEMidfoot Fusion Non-Union Risk Factors

S	Smoking Most modifiable - mandatory cessation before elective fusion
M	Multiple joints fused Non-union rises with number of joints spanned (Dang 2020)
O	Osteopenia / poor bone RA, steroids, inflammatory disease
K	Komorbidity (diabetes, immunosuppression) Biologics, methotrexate, poor glycaemic control
E	Extended / lateral column Lateral column and pan-midfoot constructs heal less reliably

S	Smoking Most modifiable - mandatory cessation before elective fusion	K	Komorbidity (diabetes, immunosuppression) Biologics, methotrexate, poor glycaemic control
M	Multiple joints fused Non-union rises with number of joints spanned (Dang 2020)	E	Extended / lateral column Lateral column and pan-midfoot constructs heal less reliably
O	Osteopenia / poor bone RA, steroids, inflammatory disease

Hook:SMOKE out the non-union risks before you fuse a midfoot.

Evidence Base

Mann, Prieskorn & Sobel

Key Findings:

Landmark long-term series: 40 patients (41 feet) undergoing mid-tarsal and/or TMT arthrodesis for primary degenerative or post-traumatic osteoarthrosis
37 of 40 patients (93%) satisfied at mean 6-year follow-up (range 2 to 17 years)
Union achieved in 176 of 179 attempted arthrodeses (98%); only 1 of 3 non-unions required operative repair
Complications included second metatarsal stress fracture (3 patients) and incisional neuroma (3 patients)

Clinical Implication: Establishes midfoot arthrodesis as a reliable, high-union, high-satisfaction procedure for symptomatic mid-tarsal/TMT osteoarthrosis - the historical benchmark series.

Source: J Bone Joint Surg Am 1996

Verify on PubMed (PMID 8816654)

Dang, Coughlin & Hirose et al

Key Findings:

62 patients (173 joints) undergoing midfoot arthrodesis with locked dorsal compression plates over 7 years
Overall joint fusion rate 81.5% (141 of 173 joints); 14 patients developed non-union
Significantly more joints were spanned in non-union (mean 3.6) than in union (mean 2.5) cases (p = 0.02)
Novel compression-plate technology did not improve fusion rates over prior fixation reports

Clinical Implication: Non-union risk rises with the number of joints fused - argues for fusing only symptomatic joints and counselling higher non-union risk in extensive (pan-midfoot) constructs.

Source: J Foot Ankle Surg 2020

Verify on PubMed (PMID 32863117)

Exam Viva Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

Scenario 1: Midfoot Arthritis

CLINICAL PROMPT

"A 55-year-old woman has dorsal midfoot pain and a palpable prominence. Weight-bearing X-ray shows 1st TMT joint arthritis with dorsal osteophytes. How do you manage her?"

PRACTICAL APPROACH

This is midfoot arthritis affecting the first tarsometatarsal (TMT) joint, which is part of the medial column. Primary osteoarthritis is the most common cause. The dorsal osteophytes she describes are a common finding and often impinge causing symptoms. For diagnostic assessment, I would obtain weight-bearing radiographs including AP, lateral, and oblique views. The oblique view shows TMT joints well. I would assess for involvement of other joints (middle and lateral columns). For management, I would start with conservative measures. First-line is footwear modification with a stiff-soled shoe, ideally with a rocker bottom, which reduces motion through the painful midfoot. A carbon fiber insole or custom orthotic can achieve similar effect. Activity modification to avoid impact loading. NSAIDs for pain. I would offer an intra-articular corticosteroid injection to the 1st TMT joint which is both diagnostic (confirms the pain source) and therapeutic (may provide months of relief). If conservative measures fail and she has significant ongoing symptoms, the definitive treatment is midfoot fusion. The 1st TMT joint (medial column) tolerates fusion very well as it has minimal normal motion. I would fuse only the symptomatic joints. Importantly, I would preserve lateral column motion (4th and 5th TMT) if uninvolved, as this is important for gait adaptation on uneven surfaces. Outcomes of midfoot fusion are good with high satisfaction rates.

KEY CLINICAL POINTS

1st TMT is medial column, most commonly symptomatic

Stiff-soled shoe reduces motion through midfoot

Fusion for refractory cases

Preserve lateral column motion if possible

COMMON PITFALLS

Fusing lateral column unnecessarily

Not knowing column anatomy

Not trying conservative measures first

FURTHER QUESTIONS

"Why preserve lateral column motion?"

"What about isolated cheilectomy?"

CLINICAL SCENARIOChallenging

Scenario 2: Post-Traumatic Midfoot Arthritis Following Lisfranc Injury - Conservative Trial and Extent of Fusion Decision

CLINICAL PROMPT

"You are seeing a 32-year-old male construction worker in your foot and ankle clinic who was referred by his GP for persistent right midfoot pain. He has a history of a Lisfranc injury sustained 4 years ago when he fell from scaffolding and twisted his foot. At that time, he was treated at another hospital with open reduction and internal fixation (ORIF) of a 1st and 2nd TMT joint dislocation using screws, which were removed 6 months post-operatively. He did well initially and returned to work after 9 months. However, over the past 12 months, he has developed progressive aching pain in the midfoot, particularly with prolonged standing at work, walking on uneven ground, and at the end of a long day. He describes the pain as a deep ache across the dorsum of the midfoot, worse with push-off. He has tried over-the-counter NSAIDs and supportive work boots with limited relief. He is very motivated to avoid surgery if possible as he cannot afford to take time off work (self-employed). On examination, he has a well-healed dorsal midfoot surgical scar. There is tenderness to palpation over the 1st, 2nd, and 3rd TMT joints. You can palpate small osteophytes dorsally. His foot alignment appears normal with a well-maintained medial longitudinal arch. There is no significant swelling. Passive range of motion through the midfoot is stiff and reproduces his pain. The lateral column (4th and 5th TMT) is non-tender with good mobility. Ankle and subtalar joint motion are normal and pain-free. You order weight-bearing radiographs (AP, lateral, oblique views) which show: 'Post-surgical changes with previous screw tracks visible in 1st and 2nd TMT joints. Moderate to severe osteoarthritis of 1st, 2nd, and 3rd TMT joints with joint space narrowing, subchondral sclerosis, and small dorsal osteophytes. The naviculocuneiform joints appear mildly arthritic. 4th and 5th TMT joints appear preserved. Alignment is maintained with no collapse of the medial longitudinal arch.' The patient asks: (1) Can I avoid surgery with the right footwear and supports? (2) If I need surgery, what exactly would you fuse? (3) Will fusing my foot affect my ability to work on scaffolding and uneven surfaces? (4) What are the risks that the fusion won't heal given I had hardware removed before?"

PRACTICAL APPROACH

This is a classic presentation of post-traumatic midfoot arthritis following a Lisfranc injury - this is the MOST COMMON cause of midfoot arthritis in younger active patients. The initial injury 4 years ago was a significant Lisfranc dislocation requiring ORIF, and despite anatomic reduction and return to function, he has now developed secondary osteoarthritis. This progression occurs even after anatomically reduced and surgically treated Lisfranc injuries - Dubois-Ferriere et al (JBJS Am 2016) found radiographic OA in 72% and symptomatic OA in 54% at a mean of 10.9 years, with non-anatomic reduction, Myerson type C pattern and smoking as the key risk factors. The pattern of arthritis here is important - he has symptomatic arthritis of the MEDIAL and MIDDLE columns (1st, 2nd, 3rd TMT joints) with some naviculocuneiform involvement, but critically his LATERAL column (4th-5th TMT) is PRESERVED both clinically and radiographically. This will influence surgical planning if required. For CONSERVATIVE MANAGEMENT (which he strongly prefers), I would implement a comprehensive trial before considering surgery. This includes: (1) FOOTWEAR MODIFICATION - This is first-line and most important. A STIFF-SOLED shoe or work boot with a ROCKER BOTTOM sole reduces motion through the arthritic midfoot joints. For a construction worker, I would recommend industrial-grade work boots with composite shanks (carbon fiber or steel) and rocker soles. (2) CUSTOM ORTHOTIC - A carbon fiber insole or custom orthotic that limits midfoot motion. A full-length carbon fiber plate insert can be very effective. (3) ACTIVITY MODIFICATION - Where possible, minimize prolonged weight-bearing on uneven surfaces, use proper scaffolding planks rather than ladders when feasible. (4) REGULAR NSAIDs - Scheduled rather than PRN dosing during work periods. (5) INTRA-ARTICULAR CORTICOSTEROID INJECTIONS - I would offer fluoroscopy-guided injections into the symptomatic 1st, 2nd, 3rd TMT joints. This is both diagnostic (confirms pain source) and therapeutic (may provide 3-6 months relief). Some patients get sufficient relief to continue working with repeated injections every 4-6 months. I would give this conservative protocol a THOROUGH trial of 3-6 months before considering surgery, particularly given his strong motivation to avoid operative intervention and work constraints. For SURGICAL PLANNING if conservative measures fail: The definitive treatment for symptomatic post-traumatic midfoot arthritis is ARTHRODESIS (fusion) of the affected joints. The key surgical decision here is the EXTENT OF FUSION - which joints to include. Based on his imaging: (1) DEFINITELY FUSE: 1st, 2nd, 3rd TMT joints (medial and middle columns) - these are clearly arthritic and symptomatic. (2) NAVICULOCUNEIFORM JOINTS - The imaging shows 'mild arthritis'. I would assess these INTRAOPERATIVELY. If there is significant cartilage loss or if stressed intraoperatively they appear unstable, I would include them in the fusion. If cartilage is reasonably preserved, I might initially leave them and only fuse if they become symptomatic later (staged approach). (3) CRITICALLY - PRESERVE the 4th and 5th TMT joints (LATERAL COLUMN) - these are clinically and radiographically normal. The lateral column provides essential flexibility for gait adaptation on uneven surfaces - CRITICAL for his occupation as a construction worker on scaffolding. Fusing the lateral column unnecessarily leads to transfer stress to adjacent joints, painful lateral foot, and difficulty with uneven ground. The surgical technique would be: Open approach, prepare joint surfaces (remove cartilage, subchondral drilling/fish-scaling), anatomic reduction with slight plantarflexion of 1st ray to maintain arch height, internal fixation with plates and/or screws to achieve rigid compression across the prepared joints. Bone grafting is NOT routinely needed for primary fusion unless there are large defects. For his question about NON-UNION RISK given previous hardware removal: Standard TMT fusion nonunion rates are 5-10% for medial/middle columns. His risk factors include: (1) Young active patient with high functional demands, (2) Previous surgery in the area (scarring, potential vascular compromise), (3) Smoking status (if he smokes - I would need to ask and counsel cessation), (4) Post-traumatic arthritis (slightly higher nonunion than primary OA), (5) Multiple joint fusion (higher nonunion with more joints fused). However, PREVIOUS HARDWARE REMOVAL is NOT itself a significant nonunion risk factor - the bone has healed after the Lisfranc ORIF. The screw tracks visible on X-ray are healed bone. To MINIMIZE nonunion risk: Meticulous surgical technique, adequate joint preparation, stable internal fixation with plates (not just screws), strict non-weight-bearing protocol (typically 6-8 weeks NWB then progressive weight-bearing in boot), smoking cessation if applicable, optimize nutrition and vitamin D. For his concern about WORKING ON SCAFFOLDING after fusion: I would be honest - medial/middle column fusion will result in a STIFFER midfoot which may affect proprioception and balance on uneven surfaces initially. However, most patients adapt well over 6-12 months. The PRESERVED lateral column will help with adaptation to uneven ground. Return to full construction work including scaffolding would typically be 4-6 months post-fusion once union is confirmed and he has regained confidence. Overall prognosis for midfoot fusion is GOOD - Mann, Prieskorn and Sobel (JBJS Am 1996) reported 93% patient satisfaction and 98% union in their long-term series of mid-tarsal/TMT arthrodesis, and selective fusion of only the symptomatic joints (preserving an uninvolved lateral column) gives better functional outcomes than pan-midfoot fusion.

KEY CLINICAL POINTS

Post-traumatic midfoot arthritis is the MOST COMMON cause of midfoot arthritis in younger patients - typically follows Lisfranc injuries even after anatomic reduction and ORIF. Dubois-Ferriere et al (JBJS Am 2016) found radiographic OA in 72% and symptomatic OA in 54% at mean 10.9 years after surgery, with non-anatomic reduction, Myerson type C and smoking as key risk factors. For purely ligamentous Lisfranc injuries, Ly and Coetzee (JBJS Am 2006, RCT) showed primary arthrodesis outperforms ORIF (AOFAS 88 vs 68.6).

Conservative management protocol for post-traumatic midfoot arthritis - comprehensive trial before surgery: (1) STIFF-SOLED footwear or ROCKER BOTTOM shoes - reduces motion through arthritic joints (first-line, most effective conservative measure), (2) CARBON FIBER insole/orthotic - limits midfoot motion, (3) Activity modification where feasible, (4) Regular NSAIDs scheduled dosing, (5) Fluoroscopy-guided intra-articular corticosteroid injections - both diagnostic and therapeutic, may provide 3-6 months relief, some patients manage with repeated injections every 4-6 months. Give 3-6 months trial before considering surgery.

Extent of fusion decision in post-traumatic midfoot arthritis - based on clinical and radiographic assessment: (1) ALWAYS fuse clearly symptomatic and arthritic joints (in this case 1st, 2nd, 3rd TMT joints - medial and middle columns), (2) ASSESS INTRAOPERATIVELY naviculocuneiform joints if mildly arthritic - fuse if significant cartilage loss or instability, consider leaving if reasonably preserved (staged approach option), (3) CRITICALLY - PRESERVE lateral column (4th-5th TMT) if not arthritic. SELECTIVE fusion of only the symptomatic joints, preserving an uninvolved lateral column, gives better functional outcomes than pan-midfoot fusion - lateral column flexibility is ESSENTIAL for gait adaptation on uneven surfaces, and fewer joints fused means lower non-union risk (Dang et al, J Foot Ankle Surg 2020: non-union associated with more joints spanned, 3.6 vs 2.5, p=0.02).

Midfoot fusion surgical technique and outcomes: Open approach, meticulous joint preparation (remove all cartilage, subchondral drilling/fish-scaling to create bleeding bone bed), anatomic reduction with slight plantarflexion of 1st ray to maintain medial longitudinal arch, internal fixation with PLATES and/or SCREWS to achieve rigid compression (dorsal plating is widely used for TMT fusion), bone grafting NOT routinely needed for primary fusion. Standard nonunion rate 5-10% for medial/middle column, union rates greater than 90% with proper technique. Post-op: 6-8 weeks strict non-weight-bearing, then progressive weight-bearing in boot. Return to manual labor 4-6 months. Mann, Prieskorn and Sobel (JBJS Am 1996) reported 93% satisfaction and 98% union at mean 6-year follow-up across mid-tarsal/TMT arthrodesis for both primary and post-traumatic osteoarthrosis.

Risk factors for nonunion in midfoot fusion - counsel patients appropriately: (1) Smoking (MOST MODIFIABLE - absolute smoking cessation required), (2) Multiple joints fused (higher nonunion with more joints), (3) Lateral column fusion (higher nonunion than medial/middle column), (4) Inadequate fixation (plates superior to screws alone), (5) Medical comorbidities (diabetes, inflammatory arthritis, immunosuppression). Previous hardware removal from prior surgery is NOT a significant nonunion risk factor - bone has healed. Optimize modifiable factors: smoking cessation, nutrition, vitamin D levels, glycemic control if diabetic.

COMMON PITFALLS

Proceeding directly to surgery without a thorough trial of conservative management: This patient is HIGHLY MOTIVATED to avoid surgery due to work constraints. A comprehensive conservative trial (stiff-soled shoes, carbon fiber orthotic, injections) should ALWAYS be attempted first - some patients achieve sufficient symptom control to defer or avoid surgery. Midfoot fusion is a SALVAGE procedure for failed conservative treatment, not first-line.

Planning to fuse the lateral column (4th-5th TMT joints) despite them being clinically and radiographically NORMAL: This is a CRITICAL ERROR. The lateral column provides essential flexibility for gait adaptation on uneven surfaces - absolutely CRITICAL for a construction worker on scaffolding. Preserving an uninvolved lateral column and fusing only the symptomatic joints gives BETTER functional outcomes and lower non-union risk (fewer joints fused). Unnecessary lateral column fusion leads to transfer stress, painful lateral foot, and difficulty on uneven ground. Only fuse lateral column if SEVERELY arthritic and SYMPTOMATIC.

Underestimating the impact of smoking on fusion outcomes: If this patient smokes (need to specifically ask), this is the MOST IMPORTANT modifiable risk factor for nonunion. Smoking cessation is MANDATORY before elective midfoot fusion. Nicotine causes vasoconstriction and impairs bone healing - nonunion rates are 2-3 times higher in smokers. Must counsel comprehensive smoking cessation (minimum 6-8 weeks pre-op, ideally permanent cessation) and consider delaying surgery if patient unable/unwilling to quit.

Not counseling realistic return to work timeline and functional expectations: Midfoot fusion is a MAJOR procedure requiring 6-8 weeks strict non-weight-bearing, then progressive rehabilitation. Return to full manual labor including scaffolding work is typically 4-6 MONTHS, not weeks. Patient needs to plan financially for this time off. Also counsel that while outcomes are generally good, the fused midfoot will be STIFFER which may affect proprioception and balance on uneven surfaces initially - most adapt over 6-12 months but some permanent limitation is possible. Realistic expectations are critical for satisfaction.

FURTHER QUESTIONS

"What are the indications for including the naviculocuneiform joints in a midfoot fusion? How do you assess this intraoperatively?"

"Describe the surgical technique for TMT fusion - why are plates preferred over screws alone?"

"What would you do if this patient developed symptomatic arthritis in the 4th-5th TMT joints (lateral column) 5 years after medial/middle column fusion?"

"How would your management differ if this was neuropathic (Charcot) midfoot arthropathy rather than post-traumatic OA?"

CLINICAL SCENARIOCritical

Scenario 3: Pan-Midfoot Arthritis with Lateral Column Involvement - Complex Fusion Decision and Revision Surgery Considerations

CLINICAL PROMPT

"You are reviewing a 48-year-old female office administrator in your complex foot and ankle reconstruction clinic. She was referred by a colleague for a second opinion regarding management of severe pan-midfoot arthritis. She has a 15-year history of rheumatoid arthritis (RA) affecting multiple joints including her hands, feet, and knees. Her RA is currently reasonably controlled on methotrexate and adalimumab (Humira), but she has developed progressive destructive arthropathy in her right midfoot over the past 3-4 years. She describes constant aching pain across the entire dorsum and plantar aspect of her right midfoot, significantly worse with any weight-bearing activity. The pain is now affecting her ability to work (she sits most of the day but needs to walk between offices and to the parking lot). She has failed comprehensive conservative management including: custom orthotics with rigid carbon fiber plate, rocker-bottom shoes, regular NSAIDs, and three sets of corticosteroid injections over 18 months (into multiple TMT joints under fluoroscopy) which provided progressively less relief (initial injection helped for 4 months, subsequent injections only 4-6 weeks). She is very keen for definitive surgical treatment. On examination, she has swan-neck deformities in her fingers and bilateral hallux valgus deformities with claw toes. Her right midfoot is diffusely swollen and tender to palpation across all TMT joints and naviculocuneiform joints. There is palpable synovitis. Passive motion through the midfoot is globally stiff and painful. Her medial longitudinal arch is somewhat collapsed (mild planovalgus alignment). There is NO significant forefoot abduction or hindfoot valgus. Her ankle and subtalar joints have reasonable range of motion and are not significantly symptomatic. You review the weight-bearing radiographs she brought from the referring surgeon: 'Severe pan-midfoot arthritis involving ALL tarsometatarsal joints (1st through 5th TMT) and naviculocuneiform joints. Diffuse joint space loss, erosive changes, subchondral cysts, and sclerosis throughout the midfoot. There is some collapse of the medial longitudinal arch with mild dorsal subluxation at multiple TMT joints. The 4th and 5th TMT joints show advanced arthritis with near-complete joint space loss, similar severity to the medial/middle columns. Ankle and subtalar joints appear preserved.' You also review a recent MRI (ordered by the referring surgeon): 'Extensive synovitis throughout all midfoot joints with large joint effusions. Diffuse bone marrow edema in all cuneiforms, navicular, cuboid, and metatarsal bases. Advanced articular cartilage loss in all TMT and NC joints. No osteomyelitis. Findings consistent with severe inflammatory arthropathy (rheumatoid arthritis).' The referring surgeon has suggested pan-midfoot fusion (1st through 5th TMT joints plus naviculocuneiform joints) and wants your opinion. The patient has done her own research and has several questions: (1) Do you agree that I need all my midfoot joints fused, including the lateral ones? I read online that the lateral joints should be preserved if possible. (2) What are the risks of such a big fusion? (3) Will the fusion heal given I'm on methotrexate and Humira for my RA? (4) What happens if the fusion doesn't heal - would I need another operation? Your rheumatology colleague has sent a letter stating: 'Patient has active inflammatory arthropathy affecting midfoot. Would recommend continuing current DMARD therapy perioperatively. Suggest stopping methotrexate 2 weeks pre-op and restarting 2 weeks post-op. Continue adalimumab perioperatively as withholding biologics increases flare risk. Please liaise regarding timing.'"

PRACTICAL APPROACH

This is an extremely complex case of severe pan-midfoot arthritis secondary to rheumatoid arthritis (RA) with several critical decision points. The KEY surgical question is whether to include the lateral column (4th-5th TMT joints) in the fusion construct given that they are SEVERELY arthritic, which contradicts the usual teaching to preserve lateral column motion. This requires careful analysis of the SPECIFIC indications for lateral column fusion and detailed counseling about the functional implications. For ASSESSMENT OF LATERAL COLUMN: The general principle in midfoot fusion is to PRESERVE lateral column motion when possible because the 4th-5th TMT joints provide essential flexibility for gait adaptation on uneven surfaces. However, this principle applies when the lateral column is NOT significantly arthritic. The INDICATIONS for INCLUDING lateral column in fusion are: (1) SEVERE symptomatic arthritis of 4th-5th TMT joints - which this patient clearly has ('advanced arthritis with near-complete joint space loss, similar severity to medial/middle columns'), (2) INFLAMMATORY arthropathy causing progressive destruction - RA continues to attack any remaining synovial joints, so leaving diseased lateral column joints unfused risks ongoing pain and progression, (3) FAILED conservative management including injections - she has had multiple injection series with diminishing returns, (4) Midfoot INSTABILITY or significant deformity - she has some arch collapse and dorsal subluxation suggesting instability. In this specific case, I would AGREE with the referring surgeon that pan-midfoot fusion including the lateral column is indicated because the lateral column is SEVERELY and SYMPTOMATICALLY arthritic. This is one of the few situations where lateral column fusion is appropriate. The alternative - preserving severely arthritic lateral column joints - would leave a persistent pain source and risk progressive deformity. However, I would clearly counsel the patient about the FUNCTIONAL IMPLICATIONS of lateral column fusion: The fused midfoot will be COMPLETELY RIGID with no adaptive motion. She will have difficulty on uneven ground, stairs, and slopes. Walking will require MORE ankle and hip motion to compensate. There is risk of TRANSFER STRESS to adjacent unfused joints (particularly navicular-cuneiform joints if any are preserved, and intercuneiform joints). Some patients find the rigid midfoot uncomfortable despite pain relief. For the EXTENT OF FUSION, I would plan: (1) All five TMT joints (1st through 5th) - clearly indicated given advanced arthritis across all TMT joints, (2) Naviculocuneiform joints - the imaging and MRI show these are also involved. I would plan to include these in the fusion. In inflammatory arthropathy, it's better to fuse all diseased joints in one procedure rather than stage (staged procedures risk incomplete pain relief and need for revision), (3) Intercuneiform joints - I would assess INTRAOPERATIVELY. If there is significant synovitis and cartilage destruction, I would fuse them as well to prevent a future pain source. Some surgeons routinely fuse all intercuneiform joints in RA midfoot fusion to prevent progression. (4) Cuboid-cuneiform joint and calcaneocuboid joint - typically PRESERVED unless severely involved. These are extra-articular to the main midfoot complex. This would be a MASSIVE midfoot arthrodesis. For NONUNION RISK in this patient - this is a CRITICAL concern: Baseline nonunion rate for medial/middle column TMT fusion is 5-10%. However, this patient has MULTIPLE risk factors for nonunion: (1) EXTENSIVE fusion (more joints = higher nonunion risk, pan-midfoot fusion has nonunion rates 15-25%), (2) LATERAL column inclusion (4th-5th TMT have HIGHER nonunion rates than medial column - up to 20-30% in some series), (3) RHEUMATOID ARTHRITIS (inflammatory arthropathy increases nonunion risk), (4) IMMUNOSUPPRESSION - methotrexate and adalimumab (biologics) - controversial but may impair bone healing, (5) Bone quality - RA causes osteopenia and erosive bone damage, (6) Smoking status (need to ask). Given these risks, I would quote her a nonunion risk of 20-30% for this extensive fusion. This is REALISTIC counseling - under-promising and over-delivering is better than the reverse. To MINIMIZE nonunion risk: (1) Meticulous surgical technique with thorough joint preparation and stable fixation (locking plates for better purchase in osteopenic bone), (2) Consider bone grafting - autograft from calcaneus or iliac crest, or allograft/bone graft substitute to augment healing, (3) PERIOPERATIVE DMARD MANAGEMENT - this is nuanced and best guided by the ACR/AAHKS guideline (Goodman et al, Arthritis Rheumatol 2017; recommendations for elective arthroplasty extrapolated to elective fusion): CONVENTIONAL DMARDs such as METHOTREXATE should be CONTINUED through surgery, BIOLOGICS (adalimumab) should be WITHHELD with surgery timed at the END of the dosing cycle and restarted once the wound shows healing with no infection (typically about 14 days). All recommendations are conditional and based on low-to-moderate quality evidence, so I would individualise in conjunction with rheumatology, (4) Post-operative protocol - STRICT non-weight-bearing for 8-12 weeks (longer than standard fusion given extensive nature and nonunion risk), then progressive weight-bearing in boot, (5) Bone stimulator - consider adjunctive bone stimulator (pulsed electromagnetic field or low-intensity pulsed ultrasound) though evidence is mixed, (6) Smoking cessation if applicable (absolute requirement), (7) Optimize nutrition, vitamin D, calcium. For REVISION SURGERY if nonunion occurs: If nonunion develops (typically evident at 4-6 months post-op if patient has persistent pain and mobility at fusion site), options include: (1) REVISION fusion - take down nonunion, repeat joint preparation, bone grafting, revision fixation with better/different hardware. May need to temporarily STOP immunosuppression if possible (coordinate with rheumatology - may not be feasible if RA very active), (2) If PERSISTENT nonunion despite revision - consider exision arthroplasty of nonunion site (essentially creating a pseudarthrosis - controversial and unpredictable), (3) If extensive hardware failure or infection - may need staged revision with temporary external fixation, (4) If MULTIPLE nonunions and patient has acceptable pain control - may elect to leave alone if fibrous union provides stability. Revision midfoot fusion surgery has LOWER success rates (union rates 60-75% vs greater than 90% for primary fusion) and higher complication rates. Finally, I would discuss the ALTERNATIVE of lesser surgery - could we do a MEDIAL COLUMN-only fusion initially and see if that provides sufficient pain relief, preserving lateral column despite its arthritis? This would be a COMPROMISE with potentially less functional impairment but risk of incomplete pain relief and need for later lateral column fusion (staged approach). Given her severe lateral column involvement and failed conservative measures, I would NOT recommend this - I think it would lead to persistent lateral foot pain and likely revision surgery. Better to do definitive pan-midfoot fusion as single procedure. OVERALL RECOMMENDATION: Proceed with pan-midfoot arthrodesis including lateral column given extensive disease, but counsel extensively about: (1) High nonunion risk (20-30%) requiring potential revision surgery, (2) Complete midfoot rigidity with functional limitations, (3) Long rehabilitation (6-12 months to full function), (4) Need to coordinate DMARD management with rheumatology, (5) Possibility of transfer stress to adjacent joints long-term. Despite these concerns, if conservative measures have genuinely failed and her pain is significantly impacting quality of life, fusion is the only definitive option. Patient needs to understand this is complex salvage surgery with significant risks, not a routine procedure.

KEY CLINICAL POINTS

Indications for INCLUDING lateral column (4th-5th TMT) in midfoot fusion - deviation from usual teaching to preserve lateral column: Standard teaching is to PRESERVE lateral column motion when possible as it provides flexibility for uneven ground. However, lateral column fusion IS indicated when: (1) SEVERE symptomatic arthritis of 4th-5th TMT joints (advanced joint space loss, failure of conservative measures including injections), (2) INFLAMMATORY arthropathy (RA, psoriatic arthritis) causing progressive destruction - leaving diseased joints unfused risks ongoing pain and deformity, (3) Midfoot INSTABILITY or significant deformity requiring correction, (4) Post-traumatic arthritis with lateral column involvement. In this case with advanced RA affecting ALL midfoot joints, including lateral column in fusion is APPROPRIATE despite the functional compromise.

Functional implications of lateral column fusion - must counsel patient: Pan-midfoot fusion including lateral column creates a COMPLETELY RIGID midfoot with NO adaptive motion. Functional consequences: (1) Difficulty on uneven ground, stairs, slopes (loss of flexibility), (2) Requires MORE ankle and hip motion to compensate (may cause secondary problems if these joints arthritic), (3) Altered gait mechanics - shorter stride, less push-off power, (4) Risk of TRANSFER STRESS to adjacent unfused joints (ankle, subtalar, NC joints if preserved). Despite these limitations, most patients accept the tradeoff for pain relief - but REALISTIC expectations are critical for satisfaction.

Nonunion risk factors in extensive midfoot fusion - risk stratification and counseling: Baseline nonunion rate medial/middle column TMT fusion is 5-10%, but MULTIPLE factors increase risk: (1) EXTENSIVE fusion (more joints = higher risk, pan-midfoot fusion 15-25% nonunion), (2) LATERAL column inclusion (20-30% nonunion rate for 4th-5th TMT - higher than medial column), (3) Inflammatory arthropathy (RA increases nonunion risk), (4) IMMUNOSUPPRESSION (methotrexate, biologics - controversial but may impair healing), (5) Osteopenia/poor bone quality in RA, (6) Smoking. In this case with multiple risk factors, realistic nonunion risk is 20-30% - must counsel appropriately. Under-promising better than over-promising.

Perioperative DMARD management in foot/ankle fusion surgery - coordinate with rheumatology: Best guided by the ACR/AAHKS guideline (Goodman et al, Arthritis Rheumatol 2017; written for elective hip/knee arthroplasty, principles extrapolated to elective fusion): (1) CONVENTIONAL DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) - CONTINUE through surgery, (2) BIOLOGICS (TNF inhibitors such as adalimumab) - WITHHOLD perioperatively and time surgery at the END of the dosing cycle; restart once the wound shows healing with no infection (about 14 days), (3) Corticosteroids - continue daily chronic dose rather than giving supraphysiologic stress dosing (current ACR guidance), and never abruptly stop chronic steroids. All recommendations are conditional/low-to-moderate quality, so individualise based on disease activity and surgical risk.

Strategies to minimize nonunion in high-risk midfoot fusion: (1) Meticulous surgical technique - thorough cartilage removal, subchondral drilling/fish-scaling for bleeding bone bed, anatomic reduction, STABLE fixation (locking plates for osteopenic bone, consider supplemental screws), (2) BONE GRAFTING - autograft (calcaneus, iliac crest) or allograft/bone graft substitute to augment healing (consider in all high-risk cases), (3) Extended non-weight-bearing protocol (8-12 weeks strict NWB rather than standard 6-8 weeks), (4) Optimize modifiable factors (smoking cessation MANDATORY, optimize nutrition/vitamin D/calcium, glycemic control if diabetic), (5) Consider adjunctive bone stimulator (pulsed electromagnetic field or LIPUS - mixed evidence but low risk), (6) Coordinate immunosuppression management with rheumatology (may need to modify DMARD timing if feasible without causing flare).

COMMON PITFALLS

Preserving the lateral column despite severe arthritis based on the general teaching to 'always preserve lateral column motion': This is misapplication of the principle. The teaching to preserve lateral column applies when it is NOT significantly arthritic. In this case, the lateral column has ADVANCED arthritis ('near-complete joint space loss') and is clearly symptomatic (diffuse pain across entire midfoot, failed multiple injections). Leaving severely arthritic lateral column joints unfused would result in: (1) Persistent pain from unfused diseased joints (incomplete symptom relief), (2) Progressive deformity (RA continues to destroy unfused joints), (3) High likelihood of requiring revision surgery for lateral column fusion later (better to do comprehensive fusion as single procedure). In inflammatory arthropathy with pan-midfoot involvement, including lateral column in fusion is APPROPRIATE.

Underestimating and under-communicating the nonunion risk in this extensive fusion with multiple risk factors: This patient has MULTIPLE nonunion risk factors (extensive fusion, lateral column, RA, immunosuppression, osteopenia). Quoting her a 'standard' 5-10% nonunion risk would be MISLEADING. Realistic nonunion risk is 20-30% - must counsel this clearly pre-operatively. Patients need to understand this is HIGH-RISK surgery with significant chance of complications and possible need for revision. Under-promising and over-delivering leads to better satisfaction than the reverse. Document detailed informed consent discussion in notes.

Stopping ALL DMARDs perioperatively without rheumatology input: This is DANGEROUS and can precipitate severe RA flare requiring hospitalization. DMARDs should be managed in close coordination with rheumatology. The ACR/AAHKS guideline (Goodman et al, Arthritis Rheumatol 2017) recommends CONTINUING conventional DMARDs such as methotrexate through surgery while WITHHOLDING biologics and timing surgery at the end of the dosing cycle - stopping all immunosuppression increases flare risk. The old practice of stopping ALL immunosuppression for 6-8 weeks perioperatively is OUTDATED and potentially harmful. Work with rheumatology to develop individualized plan balancing infection/healing risk vs flare risk.

Not counseling realistic functional expectations and rehabilitation timeline for pan-midfoot fusion: This is a MASSIVE procedure requiring 8-12 weeks strict non-weight-bearing, then progressive rehabilitation over many months. Return to normal function (walking, stairs, normal shoes) is typically 6-9 MONTHS, not weeks. The fused midfoot will be PERMANENTLY rigid with limitations on uneven ground and may require ankle/hip compensation causing secondary problems. Some patients (10-15%) are dissatisfied despite pain relief due to functional limitations. Must set realistic expectations pre-operatively - if patient expects to be 'back to normal' at 3 months, she will be very disappointed.

FURTHER QUESTIONS

"What are the alternatives to pan-midfoot fusion in this case? Could you do a more limited medial column fusion initially?"

"Describe your surgical technique for pan-midfoot arthrodesis - how do you approach this, what fixation do you use?"

"If this patient develops a nonunion at 6 months post-op, how would you manage it? Describe your approach to revision midfoot fusion."

"What would be your long-term follow-up plan for this patient given her RA and risk of progression to other joints (ankle, subtalar)?"

MCQ Practice Points

Clinical Pearl

Q: What is the most common cause of midfoot arthritis?

A: Post-traumatic arthritis following Lisfranc injuries - even subtle injuries can lead to progressive arthritis. Other causes: Primary osteoarthritis, inflammatory arthritis (RA, gout), neuropathic (Charcot). Tarsometatarsal (TMT) joints and naviculocuneiform (NC) joints most commonly affected. Medial column arthritis more symptomatic than lateral.

Clinical Pearl

Q: What is the recommended surgical treatment for isolated medial column midfoot arthritis?

A: First TMT and NC fusion (medial column arthrodesis). The medial column is essential for weightbearing - tolerates fusion well. Typically fuse 1st TMT and NC joints together. Position: Slight plantarflexion of first ray to maintain arch. Union rates greater than 90%. Lateral column fusions have higher nonunion and stiffness.

Clinical Pearl

Q: Why should the 4th and 5th TMT joints be preserved if possible?

A: The lateral column (4th-5th TMT) provides essential flexibility for adaptation to uneven ground. Fusion leads to transfer stress to adjacent joints and painful lateral foot. Only fuse lateral column if severely arthritic and symptomatic. Medial and middle columns tolerate fusion better due to inherent stability.

Clinical Pearl

Q: What are the key radiographic findings in midfoot arthritis?

A: Joint space narrowing, osteophyte formation (dorsal most common - causes "dorsal boss"), subchondral sclerosis, malalignment (loss of normal first-second TMT alignment, loss of arch height). Weight-bearing radiographs essential - non-weightbearing underestimates severity. CT for surgical planning and identifying all involved joints.

Clinical Pearl

Q: What non-operative treatments should be tried before midfoot fusion?

A: Activity modification, weight loss, stiff-soled shoes or rocker-bottom soles (reduce motion through midfoot), custom orthoses with medial arch support, NSAIDs, corticosteroid injections (diagnostic and therapeutic). Surgery indicated when conservative management fails after 3-6 months trial. Injection response predicts surgical outcome.

Controversies & Areas of Uncertainty

Midfoot arthritis surgery is governed more by principle than by high-level evidence; several areas remain genuinely debated and are favourite examiner territory.

Primary arthrodesis versus ORIF for ligamentous Lisfranc injuries. Ly & Coetzee's RCT (JBJS Am 2006) favours primary fusion for purely ligamentous patterns, but the trial is small (n=41), single-centre, and does not settle the question for bony or combined injuries, where ORIF (or flexible/suture-button fixation) remains common. The relevance to established arthritis is indirect.
How many joints to fuse. Fusing only symptomatic joints preserves function and lowers non-union risk (Dang et al 2020), but under-fusion risks persistent pain from joints that later decompensate. There is no validated threshold for including the naviculocuneiform or intercuneiform joints, and the decision is often made intraoperatively.
Lateral column - fuse or preserve. The lateral (4th-5th TMT) column should usually be preserved for gait adaptation, yet in inflammatory or severely arthritic disease it may need fusion. Some advocate interposition arthroplasty/resection rather than rigid fusion of the lateral column to retain some motion - evidence is limited.
Role of cheilectomy / dorsal exostectomy alone. Isolated removal of a dorsal boss can relieve shoe-related impingement but does not address the underlying arthritis; durability is uncertain and many regard it as temporising.
Fixation technology. Dorsal locked compression plates have not improved fusion rates over conventional screws/plates (Dang et al 2020); the optimal construct (screws vs plate vs combined, lag vs neutralisation) is unsettled.
Perioperative biologic management. The ACR/AAHKS guidance (Goodman et al 2017) is extrapolated from arthroplasty, conditional, and based on low-to-moderate quality evidence; the ideal timing of TNF-inhibitor withdrawal around foot/ankle fusion is not directly studied.

Guidelines, Registries & Global Practice

Global Epidemiology

Symptomatic midfoot OA affects about 12% of community-dwelling adults aged 50 and over (UK Clinical Assessment Study of the Foot; Thomas, Roddy et al 2015), making it more common than often assumed. It is more frequent in women, those over 75, and people with obesity, prior foot/ankle injury or pain in other weight-bearing joints - a mechanically driven pattern. Post-traumatic disease is the dominant cause in younger active patients: radiographic OA develops in roughly 70% and symptomatic OA in about half after surgically treated Lisfranc injuries at long-term follow-up (Dubois-Ferriere et al 2016).

Guideline Comparison

There is no single dedicated international midfoot-arthritis surgical guideline; practice is principle-based and draws on adjacent society guidance.

Body	Relevant guidance
AAOS (US)	OA care pathways emphasise stepwise non-operative management (footwear, orthoses, NSAIDs, injection) before arthrodesis; supports shared decision-making
NICE / BOA-BOFAS (UK)	NICE OA guidance prioritises core non-pharmacological care, weight management and topical/oral NSAIDs; BOFAS supports arthrodesis as the definitive procedure for refractory disease
AO Foundation	Provides operative principles for TMT arthrodesis - rigid compression fixation, anatomic alignment with slight plantarflexion of the first ray to preserve arch height
ACR/EULAR (rheumatology)	Govern DMARD/biologic optimisation in inflammatory arthropathy and, with AAHKS, perioperative medication timing (Goodman et al 2017)

The consistent global thread: exhaust conservative care first; fuse only the symptomatic joints; preserve an uninvolved lateral column.

Registry Notes

Unlike arthroplasty, midfoot arthrodesis is not systematically captured by national joint registries (NJR, AJRR, AOANJRR, SHAR all focus on implant replacement), so robust population-level outcome data are lacking. Evidence rests on institutional case series, which is itself a driver of the uncertainties above.

High- versus Limited-Resource Practice

In well-resourced settings, custom carbon-fibre orthoses, image-guided injections, CT planning and locking-plate fixation are routine. In limited-resource settings, stiff-soled footwear, generic rigid insoles and screw-only fixation remain effective and cost-conscious alternatives, and weight-bearing radiographs (rather than CT) carry most diagnostic decisions. The core principles of selective fusion and lateral column preservation apply universally.

MIDFOOT ARTHRITIS

Clinical summary

Columns

•Medial (1st): Most symptomatic
•Middle (2nd, 3rd): Keystone
•Lateral (4th, 5th): Preserve motion

Causes

•Primary OA (most common)
•Post-traumatic (Lisfranc)
•Inflammatory (RA, gout)
•Neuropathic (Charcot)

Conservative

•Stiff-soled shoe (rocker bottom)
•Carbon fiber insole
•NSAIDs
•Injection (diagnostic and therapeutic)

Surgical

•Midfoot fusion is definitive
•Fuse symptomatic joints only
•Medial/middle column fuse well
•Preserve lateral column motion

Diagnosis

Distinguishing Features

Key Investigation

Why It Matters

Primary / post-traumatic TMT OA

Dorsal pain on push-off, palpable dorsal boss, prior Lisfranc injury

Weight-bearing AP/lateral/oblique radiographs

The diagnosis in question - fusion is definitive

Charcot (neuropathic) arthropathy

Diabetic/neuropathic, warm swollen foot, rocker-bottom deformity, often painless

Compare skin temperature, sensory exam, MRI/bone scan to exclude osteomyelitis

Acute Charcot needs offloading/total contact cast - operating into active disease risks disaster

Metatarsal / navicular stress fracture

Focal bony tenderness, recent change in load, athletes/runners

MRI (marrow oedema) - radiographs often normal early

Navicular stress fracture risks non-union; managed with offloading, not fusion

Inflammatory arthropathy (RA, psoriatic, gout)

Polyarticular, morning stiffness, synovitis, systemic features

Inflammatory markers, urate, autoantibodies, MRI synovitis

DMARD optimisation first; surgery and DMARD timing coordinated with rheumatology

Tarsal coalition (symptomatic adult)

Stiff hindfoot, recurrent ankle sprains, younger patient

CT (osseous) / MRI (fibrocartilaginous bar)

Different anatomical site and treatment pathway

Body

Relevant guidance

AAOS (US)

OA care pathways emphasise stepwise non-operative management (footwear, orthoses, NSAIDs, injection) before arthrodesis; supports shared decision-making

NICE / BOA-BOFAS (UK)

NICE OA guidance prioritises core non-pharmacological care, weight management and topical/oral NSAIDs; BOFAS supports arthrodesis as the definitive procedure for refractory disease

AO Foundation

Provides operative principles for TMT arthrodesis - rigid compression fixation, anatomic alignment with slight plantarflexion of the first ray to preserve arch height

ACR/EULAR (rheumatology)

Govern DMARD/biologic optimisation in inflammatory arthropathy and, with AAHKS, perioperative medication timing (Goodman et al 2017)