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Surgical Management Of Adult Flatfoot With Arthrodesis Of Medial Column Structures

Summary: While virtually all surgical procedures for the treatment of flatfoot deformity include soft tissue balancing (tendon transfer or lengthening, ligament imbrication or release), this article addresses the circumstances in which the primary bony procedure involves the isolated or combined arthrodesis of the naviculocuneiform or cuneiform metatarsal joints. These small joint arthrodeses are collectively known as medial column stabilization. This approach is indicated for patients with symptomatic flatfoot, tight heel cord, and midfoot instability who have limited transverse plane deformity. It is not indicated (as an isolated procedure) for patients with advanced complex multiplane deformity, such as subtalar subluxation, severe hindfoot valgus, or marked abduction of the forefoot. The weight‐bearing lateral radiograph should show a sag in the talonavicular, naviculo cuneiform, or cuneiform metatarsal joint and a normal or mildly diminished calcaneal pitch angle. The subtalar joint should be clearly visible on the lateral radiograph. The inability to visualize the talocalcaneal joint on the lateral radiograph may indicate severe hindfoot valgus and possibly subluxation. The anteroposterior view should demonstrate only mild abduction (talonavicular coverage angle) through the midfoot and mild hindfoot deformity (talocalcaneal angle and calcaneocuboid subluxation). The primary advantage of medial column arthrodesis is that it corrects the deformity while sparing important motion of the hindfoot. The technique involves lengthening the heel cord, correcting muscle imbalance, identifying the joints whose laxity contributes to the deformity, and stabilizing them by arthrodesis. Complications include infection, nonunion (particularly the naviculocuneiform joint), and undercorrection.