Midfoot Arthrodesis Donald R. Bohay, MD, FACS Professor, Michigan State University College of Human Medicine Private Practice: Orthopaedic Associates of Michigan, PC Director, Grand Rapids Orthopaedic Foot and Ankle Fellowship Grand Rapids, MI Midfoot Arthrodesis Introduction  Common procedure among foot and ankle surgeons  Indications include :   Osteoarthritis   Post-traumatic arthritis   Rheumatoid arthritis  Conservative treatment  Activity modifications   NSAID  Lisfranc Injuries  Diagnosis  Tender, swollen midfoot  Pain with weight bearing Surgical Treatment Options  Fusion 1st tarsometatarsal (TMT) joint  Can be applied to:  Hallux valgus  Pes planus  Hypermobile first ray treatment  Instability of first TMT joint  Cause for symptoms  Fusion joint Difficulties of Midfoot Arthodesis  Technically challenging  Plagued with complications  Shortening first ray  MTP stiffness  Criticism  High non-union rate (10-12%)  First TMT joint

Psoriatic arthritis Deformity Medial column instability Longitudinal arch supports +/- injection

 Plantar ecchymosis

 Arthritis

 Modified Lapidus procedure  Correct deformity

 Dorsal malunion  Recurrence

Single Joint Midfoot Arthrodesis: Technique Tips  Be sure to denude the entire joint. Do not miss the plantar joint surface. 30 mm deep  Avoid shortening of the first metatarsal

Postoperative Course  Splint 2 weeks  NWB  Cast 4 weeks  Weight of leg  Fracture boot 4 weeks  Progressive weight bearing  Total 10 weeks immobilized  More complex foot reconstructions require 8 weeks NWB In the literature: FAI 2005 Sep:26(9):698-703, Thompson IM, Bohay DR, Anderson JG  Union rate 96%  Non-union 4%  50% previous surgery  Revision rate 2% 1st TMT Fusion: Important Points/Summary  Early weightbearing  Predispose to nonunion  Achilles contracture  ↑ stress midfoot  Surgical technique/Post op protocol  Safe  Effective

 Predictable & acceptable union rates  Few complications

 Previous bunion surgery  May increase risk for non-union? Medial Column Stabilization  Solution for midfoot sag  Hypermobility  Concurrent bunion deformity Medial Column Stabilization: Technique Notes  Tarsometatrsal/Naviculocuneiform joints  Screws and/or Plates  Stress relief bone graft  Pocket / Countersink “Manoli” Hole  Prevents dorsal cortical breakout as screw head engages  Os calcis osteotomy  Lateral column lengthening Neuropathic Midfoot Collapse  Complicated by other co -morbidities i.e obesity,diabetes,vascular insufficiency  Usually significant deformity refractory to conservative measure  Surgical indications include:  Non-healing ulcer  Unbraceable deformity  Pending ulcer  Pain  Instability

Neuropathic Midfoot Collapse: Patient Case  35 y/o female  2 month history foot pain and deformity  No known neuropathy  Surgical correction o TMTJ 1-3 , ICJ, NCJ fusions with LCL and gastrocnemius recession Research Report: Midfoot Reconstruction for Primary Atraumatic Arthritis: Analysis of Outcomes  Hypothesis:  Midfoot arthrodesis is an excellent procedure for primary midfoot arthritis and can achieve good results with acceptable rate of complications.  Retrospective Chart Review: Methods  95 patients (104 feet)  Mean age 61 (20 – 80)  Male/female (18/77)  297 total joints fused  77.9% gastroc recession  55.8% forefoot  Results  92.4% union rate  3.8% major complication  99% union rate after  25% hardware removal revision (7 patients)  Statistical Significance (p < 0.05): o VAS improvement : 6.9 pre-op  2.3 post-op o AOFAS improvement : 32 pre-op  79 post-op o Satisfaction: BMI ≥ 30 7/35 & BMI < 30 1/39  Conclusions  Limitations o Retrospective study o 28% loss to followup o Did not correlate outcome to correction achieved  Hypothesis is sound Lis Franc: Mechanism of Injury  Direct loading  Load parallel to joint surfaces  Significant soft tissue disruption  Indirect loading  Axial load along metatarsals  Variable bony fracture involved To fuse or not to fuse?  The “gold standard” of ORIF has been based on the assumption that the patients “all do well”  In reality a fair percentage develop a chronic disability despite anatomic reduction, early treatment and accurate diagnosis  Be careful in your decision making; significant instability, articular damage, higher energy, ligamentous lisfrancs and complex fracture dislocations may do better with ORIF with fusion

Research Report: Primary Open Reduction Internal Fixation vs. Primary Arthrodesis of Lisfranc Joint Injuries: A Prospective Randomized Trial  Introduction/Purpose  Lisfranc/TMT joint injuries are associated with long-term disability subsequent painful osteoarthritis and residual deformity, surgical management is Primary ORIF (PORIF)  The purpose of this study is to compare standard PORIF to salvage primary arthrodesis (PA)  Prospective Randomized Study: Methods  PA: 17% 3 HW removals  40 patients (32 complete)  PORIF: 114% req. addtl.  PORIF/PA (14/18) Surgery  Results  PORIF o No infections, loss of fixation, neural injury, or malalignment were noted  PA o 1 delayed union associated with a broken first TMT joint screw, healed at the six month mark o 1 non-union of a first TMT joint was treated non-operatively o No deep infections  Surgical Evaluation Category PORIF PA Anatomic Reduction 14/14 (110%) 17/18 (94%) Solid Fusion N/A 17/18 (94%) Addtl. Surgery 15 (114%)* 3 (17%)* Delayed/Non-Union 0 2 Hardware Failure 0 1 *p < 0.05  SF-36 & SMFA o No statistical difference between ORIF and PA at 3, 6, 12,or 24 months  Phone survey: 21/32 patients were very satisfied or satisfied  Results/Discussion  PA may lead to less revision surgery than PORIF  PA: viable treatment option, investigator’s next steps: o Possible longer follow-up analyses o Adjacent arthritis o Gait analysis Lisfranc Fractures: To fuse or not to fuse?  When treating a closed displaced and unstable fracture of the tarsometatarsal joints, management includes all but one of the following:

    

anatomic ORIF delayed surgical treatment secondary to soft tissue constraints preoperative evaluation including radiographs and CT scan consider EUA anatomic ORIF with fusion

Conclusion  Safe procedure with excellent union rate  High patient satisfaction and acceptable complication rate  Outcomes/ satisfaction reduced with complications  Elevated BMI may correlate with poor outcomes Final Tips/Notes  Recreate the “tripod”  Address bony deformity  Spare the essential joints

IF IT LOOKS LIKE A FOOT, IT WILL WORK LIKE A FOOT! 1.

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