Tarsometatarsal | Post-Traumatic Common | Midfoot Fusion
Affected Joints
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
- "Lateral column motion more important - preserve if possible
- "Dorsal osteophyte impingement is common pattern
- "Weight-bearing X-ray essential
- "Oblique view shows TMT joints well
Clinical Imaging
Imaging Gallery




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.
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.
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.
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
- 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)
- 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
Exam Viva Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Midfoot Arthritis
"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?"
Scenario 2: Post-Traumatic Midfoot Arthritis Following Lisfranc Injury - Conservative Trial and Extent of Fusion Decision
"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?"
Scenario 3: Pan-Midfoot Arthritis with Lateral Column Involvement - Complex Fusion Decision and Revision Surgery Considerations
"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.'"
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