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Please see foot & ankle anatomy for more information about the midfoot joint.
Arthritis is disease (damage) of cartilage. Cartilage lines the surface of the bones where two or more bones form a joint. Cartilage allows smooth and frictionless movements. Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. This in turn can cause inflammation, pain, and joint deformity.
Midfoot arthritis is when arthritis involves the midfoot joint.
Plain radiograph (x-ray) of both feet showing a normal right foot and and an arthritic left foot involving the left 2nd and 3rd TMT joints. Note the decreased joint space indicating loss of normal cartilage in the joint
Any condition that damages the cartilage (joint surface) will cause midfoot arthritis to develop.
The common conditions that cause midfoot arthritis are:
Typical symptoms of midfoot arthritis include:
Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.
Plain radiographs are a quick and effective way of confirming arthritis in a joint. In the early stages when there is inflammation with no damage to the joint they maybe normal. Most people however present when there is some structural damage.
The following are features of arthritis on a plain radiograph:
Plain radiograph (x-ray) of both feet which shows arthritis in the left big toe (1st MTP) joint and 2nd & 3rd TMT joints – note the complete loss of joint space in the 2nd & 3rd TMT joints
MRI provides excellent high definition static images. It is useful in pre operative planning and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.
MRI is particularly useful in assessing:
CT images give excellent information on bone structure and is superior to plain radiography in that respect.
CT is particularly useful in the following cases:
Bone scan is a non specific test. It utilises a radioactive dye, absorbed by the body and taken up by areas of high metabolic activity such as inflammation and infection. It will not tell you what the diagnosis is, but will usually tell you if an abnormality is present.
This test is done in special circumstances.
Picture of a bone scan showing increased uptake in the foot
The natural history of midfoot arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.
The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification. However some patients describe significant pain and functional limitation.
You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:
As the midfoot arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.
Grading a disease in medicine is used for the following reasons:
There are a number of grading systems used for arthritis. We use the following grading system based on radiographic (x-ray) features at The London Foot & Ankle Clinic:
Non-operative management for midfoot arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning and twisting.
Wearing above ankle boots that give more support to the midfoot joints. The use of a shoe with a rocker bottom sole can also help as it helps spread the load away from the midfoot.
Custom orthotics that stiffen the mid portion of the foot can ease symptoms.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with midfoot arthritis by reducing inflammation in the joint.
The use of paracetamol and other painkillers to help reduce pain levels.
Physiotherapy works by strengthening muscles around not only the midfoot joints but the whole kinetic chain. Calf stretches can also help reduce loads and forces going across the midfoot.
Results are variable with arthritis and depend really on the severity of the disease. In a very stiff and damaged joint, physiotherapy may make your symptoms worse. Your surgeon will guide you.
The use of a walking stick or cane to reduce the forces going across the damaged joints.
Can relieve the pressure on painful damaged joints.
These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.
Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.
Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.
There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.
Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.
At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.
There are a number of treatments that involve an injection or series of injections for the treatment of midfoot arthritis.
This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.
The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.
Steroids reduce inflammation and ease pain when injected directly into an arthritic joint. It is most likely to be effective in the early stages of arthritis.
We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.
The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.
Injections are not repeated less than 6 monthly intervals.
Please read here for more information regarding injections and possible complications.
Radiographic images of arthritis in the left midfoot TMT 1 – 5 joints, treated with an image guided injection under x-ray control – note the dye in the lower image indicating correct placement of needle
Normal joints have lubrication fluid called synovial fluid. A major constituent of synovial fluid is a substance called hyaluronic acid. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint.
It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal.
Viscosupplementation involves injecting hyaluronic acid into arthritic joints. The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
This operation has excellent outcomes in terms of pain relief and return to activities of daily living.
It involves removing all remnants of the diseased joint (cartilage) and fusing the the bones so that no joint exists. With no more joint there will be no more movement and therefore no more pain. The aim is to sacrifice painful movement for pain relief.
The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. However contrary to what most people think, after a fusion you will be less likely to limp and be a lot more active. Please read this blog for more details.
The operation is usually carried out through one or more incisions on the top (dorsum) of the foot.
Right Midfoot Arthritis treated with 2nd & 3rd TMT joint fusion, wound appearance at 3 months post surgery
The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.
The main complication is non union (the bones not fusing together). This is reported in numerous studies to be around 5%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.
Currently midfoot fusion remains the treatment of choice for end stage midfoot arthritis. There is no midfoot joint replacement.
Radiograph of the foot A – before and B – after 2nd & 3rd TMT joint fusion (blue arrows indicate the arthritic joints)
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
You will have a backslab applied post operatively for two weeks. You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning.
A picture of a backslab
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
You will be non weight bearing for approximately 6 to 8 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A picture demonstrating high elevation
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling.
You will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.
Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster.
If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
Check radiographs should show signs of bone healing. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
A midfoot fusion takes up to 90 minutes to complete.
Depends on the side operated on and whether you drive an automatic car. If the car is manual then regardless of the side operated on it will be roughly 3 months post surgery. If you drive an automatic and the left foot has been operated on then it will be roughly 4 weeks before you can drive short distances.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and return to full activities of daily living.
To enable me to walk pain free.
I was concerned the operation may not work.
My right foot, the first to be operated on, took me far longer to recover from than the left. I had an overnight stay and took pain relief for longer the first time round and I felt generally very tired for a few weeks. The second time (several months later), the left foot, I came home the same day and was able to manage without the pain relief after the first week. I also had much more energy.
The most challenging part of the recovery was the time of non weight bearing, adjusting to a wheel chair, walking frame and relying on others help.
I was wrongly diagnosed about 12 years ago and told to ‘ walk through the pain ‘ the doctors could find nothing wrong with my foot ! I therefore did as I was told and suffered the pain for all these years especially when out walking and exercising. It was when the pain started in my other foot that I decided to try just once more to see if anything could be done. Fortunately I was recommended to see Mr Ahmad Malik. he knew immediately the cause of my pain – I was in shock ! There was a reason and it could be repaired. The decision to have the operation was an easy one and the sooner the better before the condition worsened.
My main concern before the operation was not the actual procedure but the long recovery time ie being non weight bearing on one foot and not driving for 3 months.
The operation went well and I felt no pain as I was given painkillers. After an over night stay in hospital I was given a lesson in hopping with crutches – I quickly discovered that it had to be a zimmer frame ! the first 2 weeks in bed went quite quickly as i had organised a trolley by my bed with books, ipad, and knitting etc to keep me occupied. A partner or good friend is needed to provide food and drinks as there is little you can do on one foot. We hired a folding wheel chair to put in the car which was great once you can venture outside. Once you are in the plastic boot it is easy to walk on crutches. However getting dressed takes practice as the boot is cumbersome. When the boot comes off you have to learn to walk again ! Hydro therapy and physiotherapy are essential to build up your muscles and have the confidence to walk on two feet again.
The most challenging part of having the operation for me was not the boredom ( I watched Sky box sets ) it was sheer frustration and lack of independence. Not being able to carry a drink or move something to another location without having to rely on someone else is very difficult. I also worried a great deal when I was learning to walk again that I might damage the bone fusion. I know that was silly my brain had learnt to protect my operated foot.
The best advice I can give future patients is PREPARATION both mentally and practically. Accept that the recovery period is a long one but you will be pain free in the end. Make sure you have hobbies, books or tv by your bed especially for the first 2 weeks and ask your partner or friend to take you out on trips – even to the local supermarket (Waitrose have the best wheelchairs you can borrow) I enjoyed the sheer freedom of just going round the aisles on my own. Accept help from people and find a good physiotherapist to get you back on your feet again.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
Mon - Fri (8am-8pm) Sat (9am - 5pm)
info@lfaclinic.co.uk
