Midfoot Arthritis Lisfranc Fusion 2026 | Podiatrist

Midfoot arthritis (tarsometatarsal joint arthritis) is degeneration of the cartilage in the joints between the metatarsal bases and the cuneiform and cuboid bones of the midfoot -- most commonly post-traumatic following a Lisfranc injury, but also occurring as primary osteoarthritis in older adults; it produces a characteristic pattern of midfoot pain that worsens with prolonged walking and push-off activities. The midfoot joints affected: the tarsometatarsal (TMT) joints form the Lisfranc joint complex; the medial column (first, second, and third TMT joints) bears the highest forces during push-off and is most prone to arthritis; the lateral column (fourth and fifth TMT joints) is more mobile and more fibrocartilaginous, making it more resistant to degenerative arthritis; post-traumatic midfoot arthritis is the most common type: following a Lisfranc fracture-dislocation, the articular cartilage is damaged at the time of injury; even with perfect reduction, the cartilage damage initiates progressive degeneration; the arthritis develops over 1-5 years after the initial injury; primary midfoot osteoarthritis: occurs in the absence of prior injury; associated with generalized osteoarthritis, obesity, and occupations requiring prolonged standing; the naviculocuneiform and first TMT joints are most commonly involved; pes planus (flatfoot) and pes cavus both create abnormal TMT joint loading that accelerates arthritic degeneration; Symptoms: dorsal midfoot pain and swelling; pain that worsens through the day with prolonged standing; pain specifically with push-off during gait (the TMT joints are loaded in dorsiflexion at toe-off); painful dorsal bony prominences (osteophytes develop on the dorsal TMT joints and are easily palpable); relief with rest; morning stiffness; X-ray: joint space narrowing, subchondral sclerosis, and osteophyte formation at the affected TMT joints; the dorsal osteophytes are often visible on the lateral X-ray; CT scan: more detailed assessment of the extent of involvement and planning for fusion.

Midfoot arthritis treatment progresses from conservative offloading measures to tarsometatarsal arthrodesis (fusion) -- unlike ankle or hip arthritis, there is no joint replacement option for the midfoot; fusion is the definitive surgical procedure and produces reliable pain relief with minimal functional compromise given the normally limited motion of these joints. Conservative treatment: rocker-bottom shoes (the most effective single footwear intervention): a shoe with a curved, stiff sole eliminates the normal flexion of the midfoot during push-off; this dramatically reduces the stress across the arthritic TMT joints; commercially available rocker-bottom shoes (Dansko clogs, Skechers Shape-Ups, dedicated rocker shoes) provide substantial relief; custom rigid-soled shoes with a rocker modification are the most effective; custom orthotics with rigid midfoot support: a carbon fiber or rigid polypropylene insole custom molded to the foot eliminates midfoot motion during gait; a metatarsal bar proximal to the metatarsal heads further reduces forefoot loading; corticosteroid injections: fluoroscopic or ultrasound-guided injections into the arthritic TMT joints; provide 3-6 months of relief; confirm diagnosis when pain resolves with the injection (diagnostic value as well as therapeutic); viscosupplementation: limited evidence in the small joints of the midfoot; PRP: emerging evidence; walking boot: for acute flares; activity modification: reducing prolonged walking and high-impact activities; Surgical treatment -- TMT arthrodesis (midfoot fusion): the gold standard for failed conservative management; the arthritic joint surfaces are excised, the bones are aligned in the correct position, and rigid internal fixation (screws and plates) is applied to hold the bones in contact until fusion occurs; the medial column (first, second, and third TMT joints) is routinely fused; the lateral column (fourth and fifth TMT joints) is generally preserved because they have meaningful range of motion that contributes to gait; fixation: a combination of locking plates and crossing screws; non-weight-bearing for 6-8 weeks postoperatively; transition to regular shoes at 3-4 months; return to full activity: 4-6 months; outcomes: 85-90% of patients achieve significant pain relief; stiffness of the midfoot is permanent (the fused joints no longer move) but is generally well tolerated because the preoperative arthritis had already eliminated most motion.