Management of Tarsometatarsal Joint Injuries

Brian M. Weatherford, MD; John G. Anderson, MD; Donald R. Bohay, MD, FACS

Disclosures

J Am Acad Orthop Surg. 2017;25(7):469-479. 

In This Article

Abstract and Introduction

Abstract

Joint disruptions to the tarsometatarsal (TMT) joint complex, also known as the Lisfranc joint, represent a broad spectrum of pathology from subtle athletic sprains to severe crush injuries. Although injuries to the TMT joint complex are uncommon, when missed, they may lead to pain and dysfunction secondary to posttraumatic arthritis and arch collapse. An understanding of the appropriate anatomy, mechanism, physical examination, and imaging techniques is necessary to diagnose and treat injuries of the TMT joints. Nonsurgical management is indicated in select patients who maintain reduction of the TMT joints under physiologic stress. Successful surgical management of these injuries is predicated on anatomic reduction and stable fixation. Open reduction and internal fixation remains the standard treatment, although primary arthrodesis has emerged as a viable option for certain types of TMT joint injuries.

Introduction

The tarsometatarsal (TMT), or Lisfranc, joint complex is composed of the TMT, intertarsal, and proximal intermetatarsal joints.[1] The unique osseous anatomy of the midfoot along with the stout ligamentous support allows effective force transfer from the hindfoot to the forefoot during ambulation. Injuries to the TMT joint complex are rare, accounting for only 0.2% of all fractures, with a reported incidence of 1 per 55,000 persons.[2] When they do occur, TMT injuries represent a broad spectrum of pathology ranging from low-energy, subtle ligamentous disruptions to high-energy crush injuries with associated soft-tissue compromise.

Given the uncommon occurrence of TMT joint disruptions, as well as the potential for subtle presentation and a lack of familiarity with the injury among treating physicians, up to 20% of TMT injuries are missed initially.[3] A high index of suspicion is necessary when evaluating suspected midfoot trauma. Left untreated, these injuries often result in painful posttraumatic arthritis and arch collapse. Early diagnosis and maintenance of anatomic reduction of the TMT joints are necessary to maximize patient function.

Nevertheless, appropriate initial treatment of TMT injuries is controversial. A variety of techniques have been described for the management of TMT injuries, but rates of posttraumatic arthritis following surgical treatment still range from 27% to 94%.[4,5] Recently, primary arthrodesis of the TMT joints has shown favorable results for certain injury patterns.[6,7] Despite these promising results, the role of arthrodesis in the management of TMT injuries has yet to be clearly defined.

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