Tarsometatarsal (TMT) Arthritis

Tarsometatarsal (TMT) arthritis affects the joints between the metatarsal bases and the three cuneiforms (medial, intermediate, lateral) and cuboid. This complex of five joints forms the anatomic and functional transition between the midfoot and forefoot.

Anatomic Subdivisions

Post-Traumatic Arthritis (80% of cases)

The most common pathway to TMT arthritis follows inadequately treated Lisfranc injuries:

Primary Osteoarthritis (20% of cases)

Primary TMT arthritis typically affects the first TMT joint in isolation, likely due to mechanical factors:

• Hypermobility: First ray instability from ligamentous laxity
• Hallux valgus association: Lateral thrust force from great toe deformity
• Inflammatory arthritis: Rheumatoid, psoriatic arthritis can involve TMT joints

Arthritis Severity (Descriptive)

No universally accepted classification system exists for TMT arthritis severity. Typically described by radiographic changes:

Key Clinical Signs

Differential Diagnosis

Radiographic Features

Conservative Management

Conservative management is first-line for mild to moderate TMT arthritis without significant deformity.

Injection Therapy

Surgical Management

Indications for Surgery

Surgical Options

TMT ArthrodesisExtended ArthrodesisAlternative Procedures

TMT Arthrodesis (Gold Standard)

Principle

Fusion of affected TMT joints to eliminate painful motion while preserving adjacent joint function.

Selective fusion strategy

• Fuse TMT 1-3 (medial column): Minimal functional loss due to low native motion
• Preserve TMT 4-5 (lateral column): Maintains forefoot flexibility for ground adaptation
• Extend proximally if needed: Include NC or IC joints if arthritic on pre-op imaging

Algorithm

View larger

Operative Steps

Step 1Approach

Dual dorsal longitudinal incisions over TMT 1-2 and TMT 2-3 intervals. Protect superficial peroneal nerve branches. Expose joints, perform joint debridement to bleeding bone.

Step 2Preparation

Remove all cartilage with osteotomes and curettes. Fashion flat apposing surfaces. Avoid excessive bone resection (causes shortening, transfer metatarsalgia). Preserve metatarsal length.

Step 3Reduction

Correct deformity. Restore longitudinal arch height. Ensure metatarsal alignment in coronal plane (no forefoot abduction). Check with intraoperative fluoroscopy in multiple planes.

Step 4Fixation

Compression screws: 4.0mm cannulated screws across each TMT joint. Direct compression essential. Or dorsal plates: Low-profile 2.7-3.5mm plates if poor bone quality. Avoid crossing TMT 4-5.

Step 5Closure

Layered closure. Consider drain if significant oozing. Bulky compressive dressing. Below-knee non-weight-bearing cast applied.

Fixation options

• Compression screws: Preferred for good bone quality, maximal compression
• Dorsal plates: Better for osteoporotic bone, deformity correction
• Combination: Plates + screws for severe deformity or revision

Outcomes

• Fusion rate: 85-95%
• Good-excellent results: 80-90%
• Return to walking: 3-4 months
• Full recovery: 6-12 months

Selective fusion TMT 1-3 preserves lateral column motion and provides good functional outcomes.

Extended Arthrodesis

Indications

• Arthritis involving naviculocuneiform (NC) joints
• Intercuneiform (IC) joint arthritis
• Previous failed TMT arthrodesis with adjacent joint degeneration

Additional fusion sites

• Naviculocuneiform joints: If joint space loss on CT and intra-operative inspection confirms arthritis
• Intercuneiform joints: Fuse if involved (often accompanies NC arthritis)

Technical considerations

• Requires additional medial incision for NC joint access
• More bone surface area requires meticulous preparation
• May require structural bone graft if significant deformity correction
• Consider iliac crest autograft or allograft for larger defects

Outcomes

• Similar fusion rates (85-90%) but longer time to fusion
• More postoperative stiffness (expected)
• Functional outcomes remain good if lateral column preserved

The key principle remains selective fusion of medial column while preserving lateral column motion.

Alternative Procedures (Rarely Indicated)

TMT joint replacement (arthroplasty)

• Investigational only
• No long-term data
• Not recommended currently

Joint debridement/cheilectomy

• Very limited role
• May temporarily relieve dorsal impingement from osteophytes
• Does not address arthritis - symptoms recur
• Consider only if patient refuses fusion and has isolated dorsal osteophytes

TMT 4-5 fusion

• Avoid if possible - significant functional loss
• Only indicated if severe arthritis and no other option
• Consider alternative diagnoses before fusing lateral column

Arthrodesis remains the gold standard and most reliable procedure for symptomatic TMT arthritis.

Technical Pearls

TMT arthrodesis provides reliable pain relief and functional improvement for appropriately selected patients.

Prognostic Factors

The topic states that primary (atraumatic) OA "typically affects the first TMT joint in isolation", names "first-ray instability from ligamentous laxity" and the "hallux valgus association", but never develops this distinct first-ray entity - which behaves and is treated differently from the post-traumatic TMT 1-3 pattern.

• A different disease from post-traumatic TMT arthritis. Isolated first-tarsometatarsal (medial-cuneiform-MT1) OA is the commonest primary midfoot arthritis, with a female predominance in the fifth-to-seventh decades. It presents as dorso-medial pain over the first TMT joint and a dorsal osteophyte/bump (which can cause dorsal-cutaneous-nerve irritation and shoe conflict), rather than the diffuse dorsal-midfoot pain of the TMT 1-3 post-traumatic pattern.
• First-ray hypermobility is the mechanical driver - and the link to hallux valgus. Excess sagittal (and rotational) motion at the first TMT joint (first-ray hypermobility) overloads the joint and is strongly associated with hallux valgus: the unstable, dorsiflexed, everted first ray both fails to bear its share of load (transfer to the lesser rays / metatarsalgia) and lets the first metatarsal drift into varus, driving the bunion. So first-TMT arthritis, first-ray hypermobility and hallux valgus form an interlinked triad.
• The Lapidus procedure treats both. A first-TMT arthrodesis (the Lapidus procedure) simultaneously (a) fuses the painful arthritic first TMT joint and (b) corrects the deforming force by stabilising the hypermobile first ray and correcting first-metatarsal varus - which is why it is a workhorse for hallux valgus with demonstrable first-ray hypermobility or coexisting first-TMT arthritis, and the definitive treatment for symptomatic isolated first-TMT OA. Technical caveats mirror the medial-column fusion above: preserve/set correct first-metatarsal length and plantarflexion (avoid dorsal malunion → transfer metatarsalgia), rigid compression fixation, and the usual non-union caution.

The topic's own account of "collapse deformity", the "midfoot break sign", forefoot abduction and progressive midfoot deformity describes exactly the picture that a Charcot neuroarthropathy produces at this joint - yet Charcot is never mentioned, and it is the single most important thing to exclude before calling a collapsing midfoot "arthritis", because the management is completely different.

• Why it matters at the TMT joint specifically. The tarsometatarsal (Lisfranc) joint is the classic site of midfoot Charcot (Eichenholtz/Brodsky pattern I), typically in a diabetic with peripheral neuropathy. Untreated, it collapses into the pathognomonic rocker-bottom (plantar-convex) foot with a plantar-medial bony prominence that ulcerates - a limb-threatening problem, not just a painful joint.
• How to tell them apart. Charcot classically presents as a warm, swollen, erythematous, often relatively PAINLESS foot in a neuropathic patient (pain out of proportion-ly low for the destruction), whereas degenerative TMT arthritis is painful in a sensate foot without the florid inflammatory signs. The acute Charcot foot mimics infection/cellulitis; the dependent-rundown test (elevation settles the erythema of Charcot but not of infection) and the neuropathy help. Radiographs in Charcot show fragmentation, debris, dislocation and disorganisation far exceeding the patient's pain.
• Why you must not treat them the same. In active (acute) Charcot the cornerstone is offloading and immobilisation in a total-contact cast until the process consolidates - operating on, or simply fusing, an actively inflamed Charcot joint as if it were degenerative arthritis courts hardware failure, non-union and catastrophic wound problems. Surgical reconstruction (with far more robust "superconstruct" fixation than a standard TMT fusion) is reserved for unstable deformity, recurrent ulceration or instability once the Charcot has consolidated - and the general Charcot work-up/management belongs to the dedicated neuroarthropathy topic.

Global Epidemiology

• Midfoot (Lisfranc) injuries account for roughly 0.2% of all fractures, with an incidence around 1 per 55,000 person-years; up to 20-40% of low-energy injuries are missed at first presentation.
• Post-traumatic arthritis is the dominant pathway to symptomatic TMT arthritis worldwide; the strongest modifiable predictor is the quality of initial reduction.
• Primary (atraumatic) TMT osteoarthritis is less common, has a female predominance, and most often isolates to the first TMT joint, frequently in association with hallux valgus or first-ray hypermobility.

Side-by-Side Society Guidance

Registry and Outcome Notes

• TMT arthritis and Lisfranc injuries are not implant-registry tracked the way hip/knee arthroplasty is (no NJR/AJRR/AOANJRR equivalent), so the evidence base rests on RCTs and case series rather than national registries.
• Across published series, medial-column arthrodesis achieves union in roughly 85-95% with good-to-excellent results in 80-90%; non-union (5-15%) is driven mainly by smoking, diabetes, and inadequate fixation.

High- vs Limited-Resource Practice

• Well-resourced settings: weight-bearing CT for planning, low-profile locking plates and lag screws, fluoroscopy, and protected non-weight-bearing with formal physiotherapy.
• Limited-resource settings: weight-bearing plain radiographs and clinical examination guide treatment; transarticular screws or K-wires substitute for plates; emphasis on accurate primary reduction is even greater because salvage surgery and imaging are less available.
• Universal principle regardless of resources: anatomic reduction of the medial-column keystone and early definitive management are the single most important determinants of avoiding post-traumatic arthritis.