What Is the Best Treatment for Injury to the Tarsometatarsal Joint Complex?

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Chapter 77 What Is the Best Treatment for Injury to the Tarsometatarsal Joint Complex?

DOMINIC. CARREIRA, MD, MARK S. MYERSON, MD

The tarsometatarsal joints, commonly but incorrectly called the tarsometatarsal joint, divides the midfoot from the forefoot, and injuries to this joint complex continue to be both a diagnostic and a treatment challenge. The term tarsometatarsal joint complex was introduced by Myerson and colleagues ¹ to highlight the more extensive nature of this injury to include not only the joints between the metatarsals and cuneiforms or cuboid, but also the intercuneiform and the naviculocuneiform joints. The presentation of this injury is quite varied and may take the form of a joint subluxation, dislocation with or without fracture. Although the reported occurrence is 1 per 55,000 fractures per year,² these injuries seem to be increasing in frequency since the late 1990s, particularly in certain sports.

Diagnosis is made based on a high index of suspicion with tenderness about the midfoot. Radiographs must be taken while bearing weight, and if equivocal, a fluoroscopic stress test with forefoot abduction and pronation is performed. Various treatment modalities have been utilized, including closed treatment with immobilization, closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF), and primary arthrodesis. The best approach to achieve and maintain an anatomic reduction must be balanced with the risks for operative intervention and the possible development of arthritis and the need for future surgery.

Treatment of these injuries does not have uniformly excellent outcomes, even with anatomic reduction and stable internal fixation. Arthritis and hence disability may result even with surgical treatment,³ and the reported prevalence of painful arthrosis with these injuries has ranged from 0 of 9 patients⁴ to 15 (58%) of 26 patients.⁵ In a series of 69 patients, degenerative joint disease developed in 21 (30%).⁶ Regardless of the incidence of post-traumatic arthritis, it is now well accepted that an anatomic reduction is critical to a successful outcome. One such study by Arntz and Hansen⁷ demonstrated an overall good or excellent functional result in 95% of patients in whom an anatomic reduction was obtained. In contrast, a satisfactory result was obtained in only one of five patients in whom congruity of the joint was not accurately restored.

Multiple confounding factors make it difficult to make treatment recommendations, few Level I studies exist to support any single approach, and the best treatment approach is unclear if not controversial. This chapter initially reviews treatment recommendations based on levels of evidence followed by specific issues associated with this topic.

LEVEL I STUDY

Only a single Level I study has been published on clinical outcomes of surgical treatment of the tarsometatarsal joint. Ly and Coetzee ⁸ compared ORIF versus primary arthrodesis in a study of 41 patients with isolated acute and subacute primarily ligamentous injuries. The average follow-up was 42 months with a minimum of 2 years after treatment. The primary arthrodesis group included a fusion of the first two or three rays, but never included the lateral rays. The mean American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score was 68.6 for the open reduction group and was 88 in the arthrodesis group. In the open reduction group, five patients who had persistent midfoot pain with or without the development of deformity eventually underwent arthrodesis. Patients treated with a primary arthrodesis estimated achievement of postoperative level of activity was 92% of their preinjury level, whereas the open reduction group estimated that the postoperative level was only 65% of their preoperative level (P, 0.005). Multiple criticisms have been made for this Level I study. The medium- to long-term results of primary arthrodesis and the risk for arthritis in adjacent joints over the long term remain unknown. Furthermore, significant bony injuries were not addressed in this study because this treatment was based on ligamentous injuries (subluxation and dislocation). Lastly, the inclusion and exclusion criteria are not clear, given that no high-performance athlete was treated in this manner, and no massive and complete high-energy dislocations were treated.

LEVEL II STUDY

Only a single Level II study has been published on tarsometatarsal injuries. In a surgeon randomized study, Mulier and colleagues ⁹ analyzed patients with severe tarsometatarsal injuries who were treated by surgical intervention, with one surgeon always performing an arthrodesis and the other surgeon always performing ORIF. ORIF (16 patients) and partial arthrodesis (6 patients) was recommended over complete arthrodesis of all 5 tarsometatarsal joints (6 patients). The subgroups were identical in age, follow-up, type of fracture, type of injury, and time to intervention. Anatomic reduction was achieved in 8 of the 12 patients in the arthrodesis group and in 12 of the 16 patients in the ORIF group. The Baltimore painful foot score was greater in the ORIF group than in the complete arthrodesis group, meaning the ORIF group had less pain. Stiffness of the forefoot, loss of the metatarsal arch, and sympathetic dystrophy occurred more frequently in the complete arthrodesis group. However, it is noted that 94% of the open-reduction group had signs of radiographic degeneration at the average final follow-up of 30 months.

LEVEL III AND IV STUDIES

Several Level III and IV studies also have been published that provide guidance in decision making. Closed treatment with plaster immobilization has resulted in poor results.¹⁰^–¹² Wilson¹³ reports that only 1 of 14 patients undergoing closed reduction and cast immobilization had an anatomic reduction, and 7 of the 14 patients were noted to have residual displacement of 5 mm or more. These studies consist of limited small numbers, and their poor results are of historic interest only. The demographics of tarsometatarsal injury have changed markedly, and with closer attention to diagnosis, subtle injuries have been diagnosed with increased frequency. Although closed reduction or closed reduction and percutaneous screw fixation does not allow for assessment under direct visualization of the reduction or for removal of osteocartilaginous debris, percutaneous screw fixation has gained popularity.

Based on these reports, and because the potential for long-term morbidity after tarsometatarsal injuries, any patient with a displaced fracture-dislocation or with any degree of instability of the tarsometatarsal joint should be treated with surgery. The question remains, however, as to what is the ideal method of surgical treatment (Level IV).