Surgical Overview
The midfoot refers to the bones and joints that make up the arch (middle of the foot) and connect the forefoot (bones of the toes) to the hindfoot (bones of the ankle and hindfoot). The main purpose of the midfoot is to provide stability to the foot and to move through the gait sequence of heel strike to push-off through the forefoot. The bones comprising the midfoot are the: navicular, cuboid, medial cuneiform, intermediate cuneiform and lateral cuneiform.
Osteoarthritis is a degenerative joint disease in which the articular cartilage (tough but flexible tissue covering the articulating surfaces of the bones) gradually wears away and thins. In most cases, midfoot arthritis is related to a previous injury such as a fracture and is termed, post-traumatic arthritis. X-rays help determine the severity of the midfoot damage. In a normal XR the articular cartilage creates the appearance of a symmetric joint space between the two bones. As the articular cartilage wears away the joint space decreases progressing to bone on bone contact (foot on the left).
Other imaging studies such as a CT scan or MRI also assist the surgeon in determining the amount of joint space narrowing, joint surface positioning and the overall degree of arthritic change to surrounding/adjacent joints.
The main symptom usually associated with osteoarthritis in the midfoot is pain. In the early stages of disease, pain is present with movement or activity (walking, stairs, prolonged standing). As osteoarthritis progresses, the pain can be present even at rest. Other common symptoms of midfoot OA include: joint stiffness, swelling, and difficulty walking (or walking with a limp).
Treatment for midfoot OA is focused on controlling pain, limiting motion that causes pain, and assisting in increasing walking tolerance. Non-surgical treatment approaches are usually tried first. Non-surgical treatment options include: medications (nonsteroidal anti-inflammatory medications), custom foot orthotics, carbon fiber foot plate, addition of a steel shank and rocker sole to your shoe, physical therapy, dietary supplements (glucosamine and chondroitin) and steroid/PRP injections (performed under x-ray or ultrasound guidance) into the joint.
Once conservative treatment options have been exhausted or the degree of OA is very severe, surgical intervention is usually necessary. The surgical option to treat midfoot OA is a midfoot arthrodesis (fusion). A midfoot fusion (picture below) is the gold standard treatment for pain relief due to midfoot OA.
Midfoot Arthrodesis
Midfoot arthrodesis (fusion) is a surgical procedure for the treatment of disabling midfoot arthritis when conservative measures have failed to relieve pain. With this surgery, the joint is permanently stiffened by removing the degenerated cartilage and welding the bones together.
Most patients will walk better after the fusion as the midfoot joints are more for stability of the foot versus actual mobility. The normal up/down motion of the ankle and the in/out motion of the hindfoot are not affected.
Yes, you will notice that you will retain your ankle, hindfoot and toe motion.
Generally no, but many patients walk better with orthotics (custom shoe inserts). High heels can usually still be worn.
With a successful fusion, most patients can return to most activities they enjoy. Running and more impact activities can still occur but cross training is recommended.
You will not be able to perform rigorous agility sports such as soccer or basketball. This varies on the extent of the midfoot fusion and can be discussed on an individual basis.
Obviously, the fusion does not restore you to normal.
Alternatives to fusion include non-surgical treatments such as brace/orthotic wear, activity modification, nonsteroidal anti-inflammatories (NSAIDs: Advil, Aleve, Motrin, etc.), and cortisone/PRP injections.
Typically screws, plates and/or staples are used to hold the bones in position until the fusion is solid. Occasionally, bone graft is necessary if bony defects are present. Your own bone (autograft) or cadaver bone (allograft) may be used.
Your surgery generally takes place at the New England Baptist Hospital outpatient surgery center and is an outpatient procedure meaning you go home the same day as surgery.
The procedure generally takes about one to two hours.
Usually you will have general anesthesia, but occasionally spinal anesthesia will be recommended by the anesthesia team. Most patients will have a preoperative anesthetic popliteal block performed to the back of the knee immediately before the surgery. This will decrease your requirements for intra-operative anesthesia as well as post-operative pain medication. It is very effective in greatly reducing pain.
You will get a dose of antibiotics before surgery. Also, due to a length of time being immobilized, patients are started on one 325 mg aspirin once a day for 4 weeks.
No. Bleeding is minimal with use of a tourniquet during surgery.
Read carefully through your passport folder information.
After your surgery you will be placed in a bulky cotton and plaster splint. You will recover in the Post Anesthesia Care Unit or PACU, and then go home. The physical therapist will assist you in the use of crutches, a walker, or a medical scooter.
For the first two weeks you must rest, get sleep, eat well, and drink plenty of water. Your body will have greater metabolic demands on it to heal. If you are a poor eater, I strongly recommend drinking one or two medical protein shakes per day for the week before surgery and for two weeks after. Keep your surgical foot elevated at the level of your heart when you are not getting up to eat or use the bathroom. You should take the pain medication as directed as necessary. If prescribed, you should take the medication for reducing the chance of blood clots. Keep your splint dry.
Discuss this with your rheumatologist, but it is generally recommended that you stop immune suppressive modulators (eg. Methotrexate, Enbrel, Humira) for two weeks before and two weeks after surgery.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
This is an important question because it impacts home and work situations. Typically, it takes about 2-3 months to heal the fusion. This will require a period of non-weight-bearing with crutches, walker or medical scooter, followed by a walking boot for an additional 4-6 weeks, depending on each individual patient’s ability to heal. After the walker boot is applied, a compression sock obtained from your pharmacy will help with swelling. You will be able to remove the boot for sleep, showers, and physical therapy. After 2-3 months, most patients are transitioned into supportive roomy shoes and undergo physical therapy for strengthening and gait training. Expect a limp and some swelling for several months. It may take a full year to recover.
If your LEFT foot is fused, many patients drive by two weeks when they are off pain medication. If your RIGHT foot is fused, you may drive after eight weeks. You may also want to apply for a handicap placard. This should be filled out prior to surgery so that it is ready for the post-operative time period.
That depends on what you do. Sedentary desk workers may return as soon as two weeks. On the other end of the spectrum, construction laborers are typically out of work for 3-4 months. You will be provided out of work notes, or restricted duty notes, as necessary during your recovery. Family leave paperwork can also be submitted.
About ten percent of patients will have a delayed union or non-union. This can be even greater in patients who have additional medical problems, such as diabetes, have poor bone healing factors, or are smokers. To enhance your chances of healing, you should not smoke. For a delayed union you may be prescribed bone healing adjuvants, such as a bone stimulator, and prolonged immobilization. For an established non-union, you may require revision surgery and bone-grafting to try to get the fusion to heal.
Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, tendon injury, delayed union, non-union, or chronic pain and swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome.
Get ready for it! Optimize your physical and mental state and make sure you have allowed yourself the time necessary for recovery. Certainly, call us if you have any questions. More information can be obtained from the American Orthopedic Foot and Ankle Society website.
Download the Midfoot Arthrodesis Post-Operative Guidelines for full details.
