Years ago, when studying under Dr. ST Hansen in Seattle, I was introduced to the philosophy of Baruch Spinoza, a European philosopher from the 1600s. Spinoza’s warning against the “passive mind” reminded us to always question dogma. That is how the field is advanced. Nowhere is this more appropriate than with modern surgery for the acquired flatfoot.
Surgery for the collapsed arch really took off in the 1970s and 80s, and it focused on reconstructing the posterior tibial tendon, which is the muscle on the inner side of the ankle which gives support to the arch. Most people with a collapsed arch have both pain and swelling there.
Because that surgery was not successful in some patients, surgeons moved to realigning the bones of the arch, which was often done with fusions. Fusions limit motion, so we ended up with some stiffness. We were still less than perfect.
Then, in the 1990s, osteotomies (cutting and reshaping bones) took off. These surgeries can generally avoid fusion, so stiffness is less of a problem. Some osteotomies, such as the medial slide calcaneal osteotomy, don’t do much to correct alignment, which brings us back to square one. Other osteotomies, especially the lateral column lengthening, have a remarkable ability to realign the collapsed arch.
And so there we were around the turn of the millennium, very excited about the ability of the lateral column lengthening to be the panacea for the collapsed arch. But then something amazing happened – we got more follow-up!
Although the lateral column lengthening can be very successful in many patients, a significant minority end up with some pain or stiffness, making it less than perfect. In some ways, we have come full circle, as research in the Orthopaedic Research Lab at Columbia University goes back to soft tissues, not bone. The next big thing in surgery for the flat foot may be reconstructing the failed ligaments, especially the spring ligament. In modern practice, I use all of these different procedures, tailored to the individual foot on the individual patient, to get the best results. There is no “one surgery” for all flat feet. Each one requires a custom approach!
Greisberg J, Vosseller JT. Spring ligament reconstruction in a cadaver model, In preparation, 2020.
Greisberg J, Sangeorzan B. Hindfoot arthrodesis. J Am Acad Orthop Surg. 2007 Jan;15(1):65-71.
Greisberg J, Assal M, Hansen ST Jr, Sangeorzan BJ. Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res. 2005 Jun;(435):197-202.
Greisberg J, Hansen ST Jr, Sangeorzan B. Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int. 2003 Jul;24(7):530-4.