4th and 5th Tarsometatarsal Joint Arthritis

 

Introduction

  • 4th and 5th TMT joints form part of the lateral column
  • Their mobility is fundamental for mobile adaptation, shock absorption
  • Rigid lever for push off

 

Biomechanics

  • Heel strikes the floor in slight inversion
  • 5th MT head contacts floor next, becoming fully loaded in mid-third of stance with cuboid
  • Cuboid transmits the body weight forward along lateral column
  • 4/5 TMTJ motion: 10° plantar / dorsiflexion, supination / pronation
  • CCJ motion: 2° plantar / dorsiflexion, 7° supination / pronation

 

Causes of arthritis:

  • traumatic
  • degenerative
  • Charcot neuroarthropathy
  • functional breakdown

 

Symptoms

  • lateral border pain
  • difficulty weightbearing
  • abnormal gait pattern

 

Treatment

Conservative

Mainstay of treatment

  • NSAIDS
  • Orthotics:
    • insoles
    • modified shoe wear (stiff, rocker-soles)
  • Injections (diagnostic and therapeutic)

 

Surgical

Challenging

  • Arthrodesis:
    • raises concerns re lateral column overload, pain, non-union, stress fractures, adjacent joint disease
    • the calcaneo-cuboid joint, if left mobile, preserves some lateral column function
    • some encouraging results (Raikin)
  • Interposition arthroplasty with tendon graft (Berle)
  • Ceramic implant arthroplasty - good results (Carpenter)

 

References​

  • Miller S. Fusion of the fourth and fifth metatarsocuboid joints. The Podiatry Institute, Update 2004, Chapter 44
  • Raikin SM, Schon LC. Arthrodesis of the fourth and fifth tarsometatarsal joints of the midfoot. Foot Ankle Int 2003;24:584-90
  • Ouzounian TJ, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle 1989;10:140-6
  • Hicks JH. The mechanics of the foot: I. The joints. J Anat 7953;87:345-57
  • Berlet GC, Anderson RB, Davis MH: Tendon arthroplasty for basal 4th and 5th metatarsal arthritis. Presented at the 15th Annual Summer meeting of the American Orthropaedic Foot and Ankle Society, Fajardo (PR), July 10, 1999
  • Carpenter B, Motley T, Pourciau K, Orthosphere® Zirconia Ceramic Implant for Arthroplasty in Fifth Tarso-Metatarsal Joint Arthritis of the Foot: A Case Presentation, The Foot & Ankle Journal, 2008, 1941-6806/08/0102-0001
  • Russell DF, Ferdinand RD. Review of the evidence: surgical management of 4th and 5th tarsometatarsal joint osteoarthritis. Foot and Ankle Surgery, 2013 Dec;19(4):207-11