The injuries to the fourth and fifth tarsometatarsal joints: A review of the surgical management by internal fixation, arthrodesis and arthroplasty

Abstract

The surgical management to the injuries of the fourth and fifth tarsometatarsal (TMT) joints is controversial. We briefly review the anatomical characteristics to the injuries, the diagnosis, as well as the individualized treatment of the injuries of the fourth and fifth TMT joints by open reduction and internal fixation, TMT arthrodesis and arthroplasty. We conclude that open reduction and internal fixation is the recommended option for acute injuries, while arthrodesis can be used in cases of malunion of the fourth and fifth TMT joints with gross pain or arthritic changes and obvious structural deformity. Arthroplasty is an effective salvage operation mainly used in high-demand patients with severe TMT arthritis. Finally, we propose a recommended treatment algorithm (based on the literature and our experience), taking into account the specific indications for internal fixation, TMT arthrodesis and arthroplasty to optimize the individualized treatment. Data sources/Study selection Data from survey reports, descriptive, cross-sectional and longitudinal studies published from 2002 to 2012 on the topic of the injuries to the fourth and fifth tarsometatarsal joint on human and radiography studies were included. Data Extraction The data was extracted from online resources of American Orthopaedic Foot & Ankle Society, American Academy of Orthopaedic Surgeons, US National Library of Medicine, The MEDLINE. Conclusion It is important to comprehend the specific anatomical characteristics and grasp the strict indications, advantages and disadvantages of the ORIF, TMT arthrodesis and arthroplasty to optimize the individualized treatment of the fourth and fifth TMT joints injuries in a maximum extent.

Keywords: Arthrodesis; Arthroplasty; Open reduction and internal fixation; Tarsometatarsal joint.

Fig.1

Patterns of injuries to the fourth and fifth TMT joints. A, B: In Myerson type A, all the TMT joints dislocated medially or laterally. C: In type B2, one or more of the lateral four TMT joints dislocated laterally. D: In type C2, the first TMT joint and the lateral four TMT joints dislocated in a divergent way.

Fig.2

The use of K-wire to treat the injuries to the fourth and fifth TMT joints. A: Preoperative radiograph indicated Myerson type A injury with all the TMT joints dislocated laterally. B: Postoperative radiograph indicated the anatomic reduction with the fourth and fifth TMT joints being fixated with K-wires

Fig.3

The interpositional arthroplasty with the Orthosphere® spherical ceramic implant. A: A dorsolateral approach over the lateral cuboid. B: Exposure of the lateral two TMT joints. C: Creation of a central hole in the opposing articular surfaces of each joint. D: Creation of semispherical recesses. E: The use of the sizing guides. F: Insertion of the spherical ceramic implant.

Fig.4

The surgical treatment algorithm for the injuries to the fourth and fifth TMT joints