Medial Naviculocuneiform Arthritis Associated With Central Tarsometatarsal Arthritis: Case Series of a Distinct Midfoot Arthritis Pattern

Abstract

Background:

Midfoot arthritis affects patient function and can cause notable pain. We describe a distinct pattern of midfoot arthritis in patients without known trauma or underlying medical diagnosis.

Methods:

Patients were identified from clinical practice as having radiographic arthritis involving the medial naviculocuneiform and central tarsometatarsal joints, without a history of trauma. Medical records were reviewed to examine demographic data, bilaterality, treatment, and surgical outcomes (if applicable).

Results:

Forty-one patients were identified as having this pattern of midfoot arthritis. Ninety-eight percentage of patients in this cohort were female. Bilaterality was observed in 63% of patients with bilateral radiographs available for comparison. Seventy-seven percentage of patients who underwent fluoroscopic injection into their medial navicular cuneiform joint and central tarsometatarsal joints experienced notable improvement in symptoms (and did not undergo surgical intervention during the study time frame). Among patients who underwent surgery (n = 10), the union rate was 78% (five/nine patients, one patient lost to follow-up). Surgical patients had an average of 2.2 (range of 0 to 5) fluoroscopically guided injections before surgery.

Conclusion:

This report educates practitioners on a distinct pattern of midfoot arthritis. This pattern of midfoot arthritis seems to respond favorably with fluoroscopically guided injections into the medial cuneiform joint and/or the central tarsometatarsal joints. Only a subset of patients required midfoot arthrodesis.

Fundamental to the optimization of patient treatment is an accurate descriptive diagnosis of the underlying problem. Midfoot arthritis affects patient function and can cause notable pain.¹ Various types of midfoot arthritis have been described.^2,3 Post-traumatic midfoot arthritis after injury is well documented in the literature.^4-6 Less is known about nontraumatic patterns of midfoot arthritis.⁷ The purpose of this article was to bring attention to a specific pattern of arthritis of the midfoot that primarily affects the medial naviculocuneiform and the central tarsometatarsal joints (and notably spares the first tarsometatarsal joint). A more specific understanding of the etiologies and types of midfoot arthritis presumably will yield better treatment options and insights into the effectiveness of various therapies. Without a clear understanding of the pattern of arthritis or the etiology of its cause, clinicians are hampered in their ability to give optimal advice to patients.

Methods

A cohort of patients was identified from clinical practice at our institution between 2012 and 2025. The case series reported here represents only a subset of patients treated at our facility with this arthritis pattern, and not the entire cohort, because it is difficult to accurately capture midfoot arthritis using clinic billing diagnosis codes. In total, 41 patients with this arthritis pattern were included. Medical records were reviewed to exclude those patients with a known history of diagnosed conditions such as inflammatory arthropathy, crystalline arthropathy, neuroarthropathy, and/or midfoot trauma. Bilaterality was reviewed from the clinical records. Weight-bearing radiographs taken at the time of clinical presentation were retrospectively reviewed and assessed to verify the presence of notable medial naviculocuneiform arthritis and central tarsometatarsal arthritis, without large periarticular cystic change or evidence of severe arthritis elsewhere in the foot or ankle (Figure 1).

Figure 1.

Radiographic image demonstrating midfoot arthritis involving the medial navicular cuneiform joint and central tarsometatarsal joints, with sparing of the first tarsometatarsal joint.

Treatment for this pattern of midfoot arthritis was identified from patient records, including use of anti-inflammatory medications, foot orthoses, fluoroscopically guided injections, and/or surgery. In general, at our institution, we have found that patients with this arthritis pattern who underwent fluoroscopically guided injections into the midfoot often achieved notable and sustained improvements in pain. Over the years, a subset of patients, however, have undergone arthrodesis of the affected joints (Figure 2). Representative surgical cases were identified.

Figure 2.

Radiographic image demonstrating surgical correction through arthrodesis of the medial navicular cuneiform joint and the central tarsometatarsal joints.

Results

Demographic information is summarized in Table 1. Nearly 98% of patients in this cohort were female. Bilaterality was observed in 63% of patients with bilateral radiographs available for comparison. Of patients (N = 35) who underwent fluoroscopically guided injections into their medial navicular cuneiform and/or central tarsometatarsal joints, 27 (77%) experienced improvement in symptoms and did not undergo surgical intervention during the study period. Of those who received injections (N = 35), 24 had injections in both naviculocuneiform (NC) and tarsometatarsal (TMT) joints, eight in the NC joint alone, and three in the TMT joints alone. For all injections, methylprednisolone acetate (40 to 80 mg) with either bupivacaine or ropivacaine was used.

Table 1.

Summary of Patient Characteristics

Characteristic	Levels	Summary (N = 41)
Age, yr	Mean (SD)	68 (8.09)
	Median (IQR)	67 (64-74)
	Range	(52-85)
Sex	Female	40 (97.6%)
	Male	1 (2.4%)
Laterality	Bilateral	26 (63.4%)
	Unilateral	15 (36.6%)
Initial treatment	Injections	20 (48.8%)
	Bracing treatment/orthotics	3 (7.3%)
	NSAIDs	2 (4.9%)
	Combination	16 (39.0%)
Underwent injectionsa	Yes	35 (87.5%)
	No	5 (12.5%)
Underwent surgerya	Yes	10 (25.0%)
	No	30 (75.0%)

^aOne patient was later treated at an outside institution.

In the surgical cohort (N = 10), 70% underwent fusion of the naviculocuneiform and second/third tarsometatarsal joints. Of the patients who underwent fusion surgery, the union rate based on radiographs was 78% (seven of nine patients). One patient was lost to follow-up; union status is unknown. The average time to fusion was 5 months based on surgeon interpretation of patient radiographs (range, 3 to 8 months). In the surgical cohort, two patients had plates implanted (with an average of 5.5 screws), one had four staples and one screw, and the remaining patients were treated with screws alone (average of 6.34 screws). Proximal tibial bone autograft was used in two patients, and allograft cancellous chips were used in four patients. Surgical patients underwent an average of 2.2 (range of 0 to 5) fluoroscopically guided injections before surgery. All patients were followed for an average of 34 months.

Discussion

This report describes a distinct pattern of midfoot arthritis whose etiology is unknown. Certain patterns of arthritis in the foot such as hallux rigidus may be associated with an underlying genetic predisposition.⁸ Given its apparent idiopathic nature with a larger female cohort, this pattern of midfoot arthritis may have developmental factors related to genetics, hormones, biomechanics, or footwear choice, but this is speculative at this point. It seems that fluoroscopically guided injections into the medial cuneiform joint and the central tarsometatarsal joints can be successful in managing symptoms.⁹ For patients who require arthrodesis, union is a challenge. In the literature, nonunion rates of the naviculocuneiform joint alone range from 20% to 30%, and this does not consider an extended midfoot fusion that involves both naviculocuneiform and tarsometatarsal joints.^10-12 The optimal surgical strategy for the pattern of midfoot arthritis described here is unknown but should likely include robust fixation to provide sufficient joint compression. We were unable to identify variables that distinguished why some patients continued to respond favorably to injections, whereas others required surgery for their symptoms.

There are clear limitations to this article that are recognized. This study is retrospective with a relatively small sample size. There is also a potential for selection bias and a lack of standardized outcomes. However, it is believed that these factors do not distract from the purpose of describing this novel arthritic pattern.

Overall, the aim of this article was to help improve recognition of this specific midfoot arthritis pattern among practicing foot and ankle surgeons, which can hopefully lead to increased interest in determining etiology, treatments, and patient outcomes.