- What is the tarsometatarsal complex?
- What are the symptoms?
- What investigations are required?
- What is the rationale for treatment?
- What is the non surgical treatment?
- What does the rehabilitation involve?
- How long will I be off work?
- When can I drive?
- What are the risks of the procedure?
- What are the long term results?
Injuries to the tarsometatarsal joints occur due to trauma. This may be a crush injury or a direct blow. It can occur after non contact trauma or after a simple fall. Injuries can range from simple to complex an may involve multiple joints. Both fractures of the bones or tearing of ligaments can occur.
What is the tarsometatarsal complex?
The tarsometatarsal joint comprises of the joints between the metatarsals, cuneiforms and cuboid bone.
The joints are very stable and held together by strong ligaments. They form the arch of the foot and provide stability during walking. The most important ligament is the Lis Franc ligament, which lies between the medial cuneiform and the 2nd metatarsal.
What are the symptoms?
Patients report pain and swelling in the middle of the foot. This is associated with bruising, often on the sole of the foot. Patients are often unable to weight bear due to pain.
What investigations are required?
The investigations required are dependent on the degree of injury
- Weightbearing plain xrays both feet
- CT scan
If the injury is subtle or requires further conformation additional investigation may include:
- Weightbearing CT scan
- MRI scan
What is the rationale for treatment?
If the joints are disrupted and unstable either by fracture or ligament tear surgical treatment is recommended to allow the joints to heal up in the correct position to minimise the incidence of on going pain, foot deformity, functional impairment and subsequent arthritis.
What is the non surgical treatment?
In undisplaced fractures and ligament tears that do not cause joint instability non operative treatment can be undertaken. This involves:
- 6 weeks in a boot non weightbearing
- 6 weeks in a boot with progressively weight bearing
- The use of an arch support for 6 months
What is the surgical treatment?
Surgery is reserved for displaced fractures and when the joints are unstable.
The surgery is dependent on the extent and type of the injury and is performed when the swelling has reduced, usually 2 weeks.
This is performed through an incision on the top of the foot and involves either:
- Joint stabilisation (most common) with plates and screws that require removal at 6 months.
- Joint fusion and bone grafting in specific circumstances.
What does the rehabilitation involve?
- 2 nights in hospital
- 2 weeks rest and elevation of the foot in a cast non weightbearing
- 4 weeks in a boot non weightbearing
- 6 weeks in a boot progressively weightbearing
- Physiotherapy from 6 weeks
- At 3 months managing most daily activities in a shoe with an arch support
- By 6 months back to recreational activities
- When swelling resolves at 6-9 months a permanent custom orthotic is required
- Final result at 1 year
How long will I be off work?
- Seated job 3-4 weeks
- Standing job 10-12weeks
- Heavy lifting job 5-6 months
When can I drive?
- Manual car – 12 weeks
- Automatic car – Left foot – 2 weeks
- Automatic car – Right foot – 12 weeks
What are the risks of the procedure?
General risks of surgery
- Wound healing problems
- Nerve injury – there is routinely numbness between the 1st and 2nd toes
- Blood clots to the leg
- Anaesthetic problems
- On going pain as a result of the injury
Specific risks for joint stabilisation
- Need for removal of metal at 6 months
- Loss of joint stability after metalware removal resulting in a progressive flat foot and pain
- Midfoot arthritis
Specific risks for joint fusion
- Non union of the fusion (bones not joining). This may require repeat surgery.
- Development of arthritis in adjacent joints. The movement that has been lost is transferred to adjacent joints.
- Metalware irritation requiring removal.
What are the long term results?
This is a significant injury and despite appropriate treatment some patients may experience ongoing pain and have functional impairment that prevents the return to their pre injury activity level. There is also a risk of development of arthritis in the future.