Surgery for the Rigid Flatfoot

  This episode is designed for anyone interested in foot and ankle health, including patients considering flatfoot surgery, athletes dealing with progressive deformity, medical students, residents, podiatrists, orthopedic surgeons, and anyone interested in understanding how complex reconstructive foot surgery actually works. The rigid flatfoot is not simply an arch that has fallen. It is a three-dimensional structural deformity involving the bones, joints, tendons, and ligaments of the entire foot and ankle. The goal of reconstruction isn't simply to make the arch look better. It is to create a plantigrade, stable, well-aligned, functional, and substantially less painful foot. Arthrodesis is a cornerstone of reconstructing the rigid or grossly unstable flatfoot. This involves fusion or permanent stiffening of one or more joints to achieve stability and reduce pain and dysfunction. In the case of severe adaptation or arthritis this approach has the highest likelihood of long term success.  Isolated talonavicular or subtalar joint fusion are often performed, in conjunction with gastrocnemius lengthening or corrective osteotomies. However this would be entertained in earlier presentations of a painful non-reducible flatfoot. In later stages, a double or triple arthrodesis is commonly chosen for its predictability in restoring all of the major deformity components and long term stability. Often, the surgeon is tasked with developing a treatment plan based on clinical and radiographic evidence. This approach - a single recipe for a set of circumstances - is in my opinion archaic. Modern reconstruction should not follow a recipe, rather careful assessment of the condition and patient expectations and choosing the least destructive procedures to get there. A well trained foot and ankle surgeon should be nimble enough to make decisions after careful inventory both pre- and intra-operatively. And if the deformity magnitude is extreme, staging may be appropriate. Oftentimes a single procedure can be effective. For example, with profound peri-talar subluxation without adjacent joint arthritis an isolated talonavicular joint arthrodesis may be all that is required. This procedure will realign the TN joint to restore stability, reduce forefoot abduction, and effectively stabilize the calcaneus underneath the leg by way of retrograde stiffening. I have performed calcaneocuboid distraction arthrodesis in isolation for the same purpose when this joint alone is degenerated. Swinging the forefoot around on the talar head and stabilizing the lateral column from further luxation can be achieved this way, while preserving subtalar motion required for traversing uneven terrains. I have also planned for isolated joint fusion and ended up fusing multiple joints and rerouting tendons and ligaments in the end. No two flatfeet are alike, so they cannot be approached that way.  The most important principle of all: Don't reconstruct the flatfoot from a recipe. Reconstruct the deformity.   The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.