Midfoot arthritis- current concepts review

Journal of Clinical Orthopaedics and Trauma 11 (2020) 399e405 Contents lists available at ScienceDirect Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot Review article Midfoot arthritis- current concepts review Harish Kurup*, Nijil Vasukutty Pilgrim Hospital, Boston, PE21 9QS, United Kingdom a r t i c l e i n f o a b s t r a c t Article history: Received 20 January 2020 Received in revised form 25 February 2020 Accepted 3 March 2020 Available online 8 March 2020 Midfoot arthritis causes chronic foot pain and significant impairment of daily activities. Although post traumatic arthritis and primary osteoarthritis are the most common pathologies encountered, surgeons need to rule out inflammatory causes and neuropathic aetiology before starting treatment. Steroid Injections are invaluable in conservative management and have diagnostic value in guiding surgical treatment. For the definitive surgical option of fusion there are a variety of fixation devices available. A successful union is linked to a satisfactory outcome which most authors report to be in the range of 90% following the key principles of careful patient selection, pre-operative planning, adequate joint preparation and a stable fixation. Crown Copyright © 2020 All rights reserved. Keywords: Midfoot Arthritis Lisfranc Fusion Tarso-metatarsal joint 1. Introduction Midfoot arthritis is a challenging problem causing chronic foot pain and significant impairment of daily activity. There is little written about this subject in literature and is often not well known by orthopaedic surgeons in general. In this review we describe the anatomy of midfoot, pathology of midfoot arthritis, examination and diagnosis, investigations followed by treatment options. 2. Anatomy Midfoot includes Tarso-metatarsal (TMT) joints and naviculocuneiform joints (NCJ). Talo-navicular joint (TNJ) and calcaneocuboid joint (CCJ) are considered to be part of hindfoot along with sub-talar joint. Tarso-metatarsal joints are divided into three columns anatomically: the medial column (First Tarsometatarsal joint), the middle column (second and third TMT joints) and the lateral column (Fourth and Fifth TMT or Metatarsocuboid joints). TMT joints are collectively known as Lisfranc joints as well. The navicular has three facets distally each of which articulates with the three cuneiforms. Cuboideonavicular joint is a fibrous joint reinforced by ligaments but in some cases a true synovial joint may be present.1 In the coronal plane the TMT joints are arranged in the form of a roman arch (Fig. 1). The cuneiforms are wedge-shaped, * Corresponding author. E-mail address: [email protected] (H. Kurup). https://doi.org/10.1016/j.jcot.2020.03.002 0976-5662/Crown Copyright © 2020 All rights reserved. with their narrow portions being plantar, thus allowing for the arch configuration. Metatarsal bases also have a similar shape. The second metatarsal base assumes the position of keystone because of the unique slightly more proximal positioning of second TMT joint than the first and third TMT joints effectively wedging it between the five neighbouring bones. This geometry gives the midfoot it’s inherent stability. Metatarsal bases are connected together by strong interosseous ligaments except between the first and second. Instead, the Lisfranc ligament goes obliquely plantarwards from the medial cuneiform to the base of the second metatarsal. This is the strongest ligament of all in the Lisfranc joints. In addition to strong ligamentous support, the entire configuration also receives soft-tissue support from the peroneus longus tendon, the attachments to which allow it to function as a strong tie beam for this transverse metatarsal arch.2 3. Biomechanics The function of the midfoot is to connect the hindfoot to the forefoot and hence it is less mobile compared to the other joints. The midfoot functions as a beam, transforming the flexible foot at heel strike to a rigid lever arm at toe-off. At toe-off, the foot is supinated, locking the transverse tarsal joint. Locking of the transverse tarsal joint allows the midfoot to transfer the force generated during gait from the hindfoot to the forefoot for locomotion.3 The peak weight distribution in the standing barefoot adult is 60.5% at the heel, 7.8% at the midfoot, 28.1% at the forefoot, and 3.6% at the toes.4 The medial tarsometatarsal joints provide <7 of sagittal 400 H. Kurup, N. Vasukutty / Journal of Clinical Orthopaedics and Trauma 11 (2020) 399e405 Fig. 1. Roman arch structure of cuneiforms- Coronal CT. Fig. 3. AP Radiograph showing alignment of medial and middle columns. Fig. 2. Injection of midfoot joints under fluoroscopy with use of radiopaque dye. plane motion, the more mobile lateral fourth and fifth TMT joints provide balance and accommodation on uneven ground. These small constrained TMT joints also provide stability and translate the forward propulsion motion of the hindfoot and ankle joint to the forefoot metatarsophalangeal joints from heel rise to toe-off.5 Ouzounian and Shereff6 quantified midfoot motion in freshfrozen amputation specimens. Dorsiflexion/plantar flexion motion was greatest at the fourth/fifth TMT joints (means, 9.6 and 10.2 , respectively), followed by the navicular-middle cuneiform (mean, 5.2 ) and the navicular-medial cuneiform articulation (mean, 5.0 ). Supination & Pronation movements also followed a similar trend. The second TMT joint had the least motion in dorsiflexion/plantar flexion (mean, 0.6 ) and supination/pronation (mean, 1.2 ). The limited motion at the second TMT joint is again thought to be limited by the strong Lisfranc ligament and the geometry of the second metatarsal as the keystone in the transverse arch. A study7 of contact mechanics of the normal tarsometatarsal joints in cadaveric feet found that the second/third tarsometatarsal joints bore the majority of the force in all positions of the foot compared with the first and fourth/fifth tarsometatarsal joint articulations. The force transferred from the second/third tarsometatarsal joints to the first and fourth/fifth tarsometatarsal joints was greatest in plantar flexion. This appears to be the mechanism by which the midfoot limits pressure on the second/third tarsometatarsal joints and allows the midfoot to adapt to varying loads and repetitive stresses. This would explain why second and third TMT joints are the most common joints to develop arthritis in midfoot (even in the absence of any history of previous injury). 4. Pathology Mid foot arthritis is usually caused by one of the following aetiologies.      Degenerative Post traumatic Inflammatory Neuropathic Post hindfoot fusion Post-traumatic arthritis is common in midfoot following both fractures and the more subtle ligamentous Lisfranc injuries. Primary degenerative arthritis can appear spontaneously, but most patients may still describe an injury which has been overlooked. Inflammatory arthritis typically affects multiple joints and so does neuropathic Charcot. Ankle or Hindfoot fusion can transfer stresses to midfoot leading to secondary arthritis in later life. 5. Diagnosis The diagnosis of a Lisfranc pathology must be made on the basis of the history, physical examination, and radiographic evaluation of H. Kurup, N. Vasukutty / Journal of Clinical Orthopaedics and Trauma 11 (2020) 399e405 Fig. 4. Lateral Radiograph showing alignment of lateral column. Fig. 5. Sagittal T1 weighted MR image showing arthritis of second TMT joint. the foot. History helps to rule out diabetes and inflammatory arthritis. Most patients recall history of a past injury which they themselves may have overlooked. Pain typically gets worse when using stairs or on uneven grounds. Symptoms are due to lack of stability, altered mechanics and loading on the inflamed joint. Eventually midfoot collapse occurs leading to a rigid flatfoot deformity, forefoot abduction and varus, longitudinal arch collapse (midfoot break usually becomes more apparent on weight bearing), and osteophyte formation.8 Patients usually have shoe-wear difficulty secondary to residual deformity. 6. Clinical assessment Passive manipulation of the midfoot involves abduction of the forefoot and a pronation stress test to determine the location of maximal pain. Tenderness across the midfoot is made worse by this manoeuvre but it cannot stress the TMT joints individually.9 The piano key test described by Keiserman et al.10 offer better localization of symptomatic joints than manipulation of the whole midfoot. The midfoot and hindfoot are manually secured and a plantar force is applied to the individual metatarsal head (as if one were striking a piano key). An alternative method is to grasp the 401 Fig. 6. Axial T2 weighted MR image showing arthritis of second TMT joint. desired toe to apply the downward force to the corresponding metatarsal. The metatarsal acts as a lever arm transmitting the force and a positive test will produce localized pain at the corresponding TMT joint. The gap sign11 shows an obvious gap between the first and second toes of the affected foot, which occurred during weightbearing. It occurs as a result of widening of the intercuneiform joint with disruption of the Lisfranc ligament but without injury to the TMT joints. Injection of a local anaesthetic is an option to determine which joints are painful or symptomatic. However, some authors8 do not consider this to be sufficiently accurate, as these joints are small for selective anaesthesia and local anaesthetic can leak from one to another. If performed use of radiopaque dye is advisable to confirm and document exact location of the needle and injection (Fig. 2). 7. Radiology Weight bearing Antero-posterior, lateral and oblique views are the first investigation of choice in midfoot arthritis. The addition of non-weight-bearing lateral radiographs can help identify the level of midfoot break, which may be at TMT, NCJ, TNJ or a combination of these. Radiologically medial border of first metatarsal is aligned with the medical border of the medial cuneiform. The middle column is aligned when the medial border of the second metatarsal is aligned with the medial border of intermediate cuneiform. On the lateral side the medial border of the fourth metatarsal is aligned with the medial border of the cuboid. On lateral radiographs restoration of arch height and first metatarsal declinational angle are imperative (Figs. 3 and 4). MRI (Magnetic Resonance Imaging) is useful in mapping the degree & extend of arthritis in midfoot. It is very useful to look for early signs of arthritis in adjacent joints before considering surgical interventions such as fusion. (Figs. 5 and 6). Technetium bone scan may be helpful but increased uptake is often noted in joints that are not painful particularly with respect to the lateral column. Spect-CT may be useful to find out which one of the arthritic joints is the worst but again has limited value. 402 H. Kurup, N. Vasukutty / Journal of Clinical Orthopaedics and Trauma 11 (2020) 399e405 8. Injection studies Selective Injection into the affected joints under radiological guidance is the most commonly used diagnostic test. This also helps in isolating symptoms and most surgeons prefer to do an injection before offering a fusion to predict success rate. Injection is preferably done with radiopaque dye to confirm position of the needle within the targeted joint; however it is common to see it leaking out to the adjacent joints as they are interconnected (Fig. 2). Some surgeons inject in clinic with blind palpation which may not always be accurate, but this can be improved with the use of ultrasound guidance.12 Drakonaki et al.13 reviewed a series 59 patients with midfoot joint degenerative changes who received USguided injection. The majority of patients had a positive response up to 3 months post-injection (78.4% still experiencing pain relief at 2 weeks, 57.5% at 3 months and fewer than 15% of patients further than 3 months post-injection). 9. Management additional diagnostic benefit in localising the source of symptoms and targeting any operative intervention effectively. Evidence on the effectiveness of local injection is sparse in literature with no level 1 studies. Grice and colleagues21 retrospectively reviewed 365 patients who had image guided foot injections. 86% reported a significant improvement in symptoms and 66% a complete resolution of pain. The mode time of recurrence of pain was 3 months and 29% were asymptomatic at the 2 year follow up. They had 24% of patients who had operative intervention within the follow up period. Although they have not restricted this large series to midfoot pathology it will serve as a guide to practice and help in patient education and in obtaining an informed consent. Obesity has been linked to all joint degenerative pathology and the foot is no different. Investigators from Swansea22 have noted a significant difference in response to corticosteroid injections for midfoot OA between obese and nonobese patients with their BMI cut-off being 30. They found a statistically significant improvement in post injection Selfreported Foot and Ankle Scores (SEFAS) at 4 and 12 months in a cohort of 37 patients who had 67 injections. 9.1. Non operative management 9.4. Operative management Initial management of midfoot degenerative arthritis should always be non-operative. These include use of analgesics, functional orthoses and local injections. Mild to moderate symptoms do get better with simple analgesics including non-steroidal anti-inflammatory tablets. A network meta-analysis of 74 randomised trials of 7 NSAIDs (Non-steroidal anti-inflammatory Drugs)and paracetamol in people with knee or hip arthritis has come to the conclusion that NSAIDs were more effective than placebo. Diclofenac at maximum daily dose of 150 mg/day was more effective than ibuprofen, naproxen and celecoxib.14 It is reasonable to extrapolate the results of this to the management of degenerative arthritis of the foot. Paracetamol was not found to be effective at any dose. Moreover, concern has been raised regarding the adverse cardiovascular effects of selective COX-2 inhibitors.15 In patients who cannot tolerate oral medication, topical analgesics is an alternative. However, there is no evidence on literature for the effectiveness of these in foot arthritis. There are studies showing some efficacy of topical application of Diclofenac, ketoprofen and capsaicin in knee and hand arthritis.16,17 9.2. Orthoses Footwear modification and functional orthoses play a key role in most foot pathology and midfoot arthritis is no exception. For foot arthritis two types of orthosis are mainly used: 1) shoe stiffening inserts made from flat thin semi rigid material extending the full length of the shoe and 2) contoured orthoses which contour the arch of the foot and extend just proximal to the metatarsal heads.18 Individuals with midfoot arthritis have pronated feet and generate higher loads under the midfoot. Therefore, the orthoses are designed to reduce hindfoot eversion and support the medial longitudinal arch. A recent randomised control trial showed improved pain control and function in midfoot arthritis with a semi rigid contoured orthosis compared to a sham insert over a 12-week period.19 Although both full length and three-quarter length inserts are popular among surgeons and orthotists, it has been shown that full length inserts reduce magnitude and duration of loading under the medial midfoot and thus better symptom control.20 The decision to operate is usually guided by the level of symptoms and functional restrictions. Where there are prominent osteophytes or bony prominences, excision of these is one conservative procedure that would help with pain and make shoe wear more comfortable however high failure rates have been reported some surgeons anecdotally. A more definitive treatment option would be arthrodesis of the arthritic joints or columns. The pain should be localized to the degenerate joint as seen on X-rays. Diagnostic steroid injections are invaluable in confirming this before going ahead with fusion.23,24 This is especially true in multi-joint disease. Midfoot arthrodesis can be challenging especially if multiple joints are involved and choosing suitable hardware is important. A variety of fixation methods have been used ranging from Kirschner wires, screws, staples and a selection of plates (Figs. 7e10). Filippi, Myerson and team25 have used a novel hybrid plating system which incorporated locking and non-locking screws and obtained bony union in 67 out of 72 patients. They conclude that hybrid plating system is a reliable alternative for fusion in multi joint disease. A study from 1996 looked at lag screws for arthrodesis in a series of 32 patients8 and reported improvement of AOFAS (American Orthopaedic Foot and Ankle Society) scores from 44 to 78. Nemec and coworkers26 report on a large series of 104 feet in 95 patients in whom 9.3. Injections Intra articular corticosteroids have been used joint degenerative pathology for their therapeutic effect. In the foot they have an Fig. 7. 65 year old with symptomatic arthritis of 2nd to 5th TMT joints e AP view (Previous 1st TMT Fusion). H. Kurup, N. Vasukutty / Journal of Clinical Orthopaedics and Trauma 11 (2020) 399e405 403 Fig. 8. 65 year old with symptomatic arthritis of 2nd to 5th TMT joints e Lateral view. Fig. 10. Post-operative Radiographs at 6 months Post Fusion 2nd to 5th TMT joints e Lateral view. Fig. 9. Post-operative Radiographs at 6 months Post Fusion 2nd to 5th TMT joints e AP view. they achieved a 92% union rate following midfoot arthrodesis of primary osteoarthritis. They combined this with deformity correction and soft tissue balancing where applicable. Complications included 8 non unions,3 deep infections and one case of chronic regional pain syndrome. There were 11 re-operations and 26 symptomatic hardware removals. AOFAS scores improved from 32 pre-operative to 79 post operatively. Staples are an effective alternative when the surgeon is concerned about soft tissue quality and in situations where scarring from previous procedures preclude extensive dissection. There have been several reports27,28 of the use of staples although none of these looks exclusive at their use in midfoot joints. Fixation devices which use principles of both staples and plate screw construct are also popular, but no clinical studies have looked at their use exclusively in midfoot (Figs. 11 and 12). Pre-operative planning should consider whether an in-situ arthrodesis or a corrective fusion is in the patient’s best interest. Fig. 11. Post traumatic arthritis of 2nd TMT joint- Fusion with a Polyaxial Dynamic plating system with locking screws and compression by spreader e AP & Oblique views. Evidence is conflicting in this regard and there have been reports of this in the setting of post traumatic arthritis. Johnson and Johnson29 report on a series of 15 patients who had an in-situ dowel graft 404 H. Kurup, N. Vasukutty / Journal of Clinical Orthopaedics and Trauma 11 (2020) 399e405 Fig. 14. Medial column fusion (Navicular to 1st metatarsal) with locking plate- Lateral view. Fig. 12. Post traumatic arthritis of 2nd TMT joint- Fusion with a Polyaxial Dynamic plating system with locking screws and compression by spreader e Lateral view. arthrodesis. At a mean follow up of 37 months 11 out of 13 patients available for follow up, had subjective satisfactory pain relief. Good to excellent relief was reported in 9 out of the 13 and union was achieved in 10. On the other hand, Sangeorzan and colleagues30 report results of fusion for failed initial treatment of Lisfranc injuries and state that reduction is key to a good result. They had 69% good to excellent results. These researchers tried to determine if fusion of lateral rays was required and have reported that this is not a factor in determining outcome. We feel that in situ arthrodesis is acceptable for patients with normal radiographic alignment. In patients with adult flat foot or cavovarus foot, a deformity correction is required with or without osteotomies. These would make shoe fitting easier and reduce the risk of the transferring load to adjacent joints. Medial column fusions are used to correct severe midfoot break or arch collapse that accompany diffuse midfoot arthritis. These are usually done with anatomically contoured plates with the option of locking and locking screws and typically span the whole medial column from talus or navicular to first metatarsal depending on the joints involved Figs. 13 and 14. Regardless of aetiology the treatment of the symptomatic lateral TMT joint arthritis is challenging. These joints are mobile and fusion could lead to non-union, chronic pain and stress fractures. There have been several reports31,32 of motion sparing procedures like soft tissue interposition and ceramic interposition arthroplasty. These report varying outcomes and currently long-term studies are lacking. This is one area where authors would recommend persisting with non-operative treatment as long as the symptoms are bearable. Complications following midfoot surgery include wound healing problems, infection (3%), peripheral nerve injury (9%), nonunion (3e8%), painful neuroma formation (7%) and screw irritation or breakage (9%).33 Arthritis in adjacent joints (4.5%) is a longterm problem that patients should be made aware of. Stress fractures and CRPS have been reported although less common.20,26 Midfoot arthritis can be debilitating, and a successful union is linked to a satisfactory outcome which most authors report to be on the range of 90%. The hardware appropriate for each case should be carefully chosen but the surgeon should not deviate from the key principles of careful patient selection, pre-operative planning, adequate joint preparation and a stable fixation. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References Fig. 13. Medial column fusion (Navicular to 1st metatarsal) with locking plate- AP view. 1. Jaffe WL, Gannon PJ, Laitman JT. Paleontology, embryology, and anatomy of the foot. In: Jahss MH, ed. Disorders of the Foot and Ankle: Medical and Surgical H. Kurup, N. Vasukutty / Journal of Clinical Orthopaedics and Trauma 11 (2020) 399e405 Management. Philadelphia, PA: Saunders; 1991:3e34. 2. Jahss MH. Disorders of the anterior tarsus, midtarsus, and Lisfranc’s joint: the anterior tarsus, midtarsus, and Lisfranc’s joint. In: Jahss MH, ed. Disorders of the Foot and Ankle: Medical and Surgical Management. Philadelphia, PA: Saunders; 1991:1284e1332. 3. Sayeed SA, Khan FA, Turner 3rd NS, Kitaoka HB. Midfoot arthritis. Am J Orthop (Belle Mead NJ). 2008 May;37(5):251e256. 4. Cavanagh PR, Rodgers MM, Iiboshi A. Pressure distribution under symptomfree feet during barefoot standing. Foot Ankle. 1987;7(3):262e276. 5. Patel Amar, Rao Smita PT, Nawoczenski Deborah PT, Flemister Adolf S, DiGiovanni Benedict, Baumhauer Judith F. Midfoot Arthritis. J. Am. Acad. Orthop. Surg. 2010;18(7):417e425. July. 6. Ouzounian TJ, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle. 1989;10(3):140e146. 7. Lakin RC, DeGnore LT, Pienkowski D. Contact mechanics of normal tarsometatarsal joints. J Bone Joint Surg Am. 2001;83(4):520e528. 8. Komenda GA, Myerson MS, Biddinger KR. Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg. 1996;78-A: 1665e1676. 9. Myerson MS. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin N Am. 1989;20:655e664. 10. Keiserman LS, Cassandra J, Amis JA. The piano key test: a clinical sign for the identification of subtle tarsometatarsal pathology. Foot Ankle Int. 2003 May;24(5):437e438. 11. Davies MS, Saxby TS. Intercuneiform instability and the “Gap” sign. Foot Ankle Int. 1999;20:606e609. 12. Khosla S, Thiele R, Baumhauer JF. Ultrasound guidance for intra-articular injections of the foot and ankle. Foot Ankle Int. 2009 Sep;30(9):886e890. 13. Drakonaki EE, Kho JS, Sharp RJ, Ostlere SJ. Efficacy of ultrasound-guided steroid injections for pain management of midfoot joint degenerative disease. Skeletal Radiol. 2011 Aug;40(8):1001e1006. 14. Da Costa BR, Reischenbach S, Keller N, et al. Effectiveness of non-steroidal antiinflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet. 2017;387:2093e2105. 15. Mukherjee D, Nissen SE, Topol EJ. Risk of cardiovascular events associated with selective COX-2 inhibitors. J Am Med Assoc. 2001;286(8):954e959. 16. Derry S, Conaghan P, Da Silva JA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016;4. CD007400. 17. Laslett LL, Jones G. Capsaicin for osteoarthritis pain. Prog Drug Res. 2014;68: 405 277e291. 18. Roddy E, Menz HB. Foot osteoarthritis: latest evidence and developments. Ther Adv Musculoskelet Dis. 2018 Apr;10(4):91e103. 19. Halstead J, Chapman GJ, Gray JC, et al. Foot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study. Clin Rheumatol. 2016;35:987e996. 20. Rao S, Baumhauer JF, Becica L, Nawoczenski DA. Shoe inserts after plantar loading and function in patients with midfoot arthritis. J Orthop Sports Phys Ther. 2009;39(7):522e531. 21. Grice J, Marsland D, Smith G, Calder J. Efficacy of foot and ankle corticosteroid injections. Foot Ankle Int. 2017;38:8e13. 22. Protheroe D, Gadgil A. Guided intra articular Corticosteroid injection in the Midfoot. Foot Ankle Int. 2018 Aug;39(8):1001e1004. 23. Khoury NJ, El-Khoury GY, Saltzman CL, Brandser EA. Intra articular foot and ankle injections to identify source of pain before arthrodesis. AJR Am J Roentgenol. 1996;167(3):669e673. 24. Lucas PE, Hurwitz SR, Kaplan PA, et al. Fluoroscopically guided injections into the foot and ankle: localisation of the source of pain as a guide to treatment e prospective study. Radiology. 1997;204(2):411e415. 25. Filippi J, Myerson MS, Scioli MW, et al. Midfoot arthrodesis following multi joint stabilisation with a novel hybrid plating system. Foot Ankle Int. 2012;33(3):220e225. 26. Nemec SA, Habbu RA Anderson JG, Bohay GR, Outcomes following midfoot arthrodesis for primary arthritis. Foot Ankle Int32(4):355-361. 27. Schipper ON, Ford SE, Moody PW, Van Doren B, Ellington JK. Radiographic results of nitinol compression staples for hindfoot and midfoot arthrodeses. Foot Ankle Int. 2018 Feb;39(2):172e179. 28. Malal JJ, Hegde G, Ferdinand RD. Tarsal joint fusion using memory compression staples–a study of 10 cases. J Foot Ankle Surg. 2006 Mar-Apr;45(2):113e117. 29. Johnson JE, Johnson KA. Dowel arthrodesis for degenerative arthritis of the tarso metatarsal joints. Foot Ankle. 1986;6(5):243e253. 30. Sangeorzan BJ, Veith RG, Hansen Jr ST. Salvage of Lisfranc’s tarsometatarsal joint by arthrodesis. Foot Ankle. 1990 Feb;10(4):193e200. 31. Raikin SM, Schon LC. Arthrodesis of the fourth and fifth tarsometatarsal joints of the midfoot. Foot Ankle Int. 2003;24(8):584e590. 32. Berlet GC, Hodges Davis W, Anderson RB. Tendon Arthroplasty for basal fourth and fifth metatarsal arthritis. Foot Ankle Int. 2002;23(5):440e446. 33. Bibbo C, Anderson RB, Davis WH. Complications of midfoot and hindfoot arthrodesis. Clin Orthop Relat Res. 2001;391:45e58.