Adult acquired flatfoot

and tibialis posterior tendonopathy

Medial column realignment and stabilisation

This page considers medial column surgery distal to the talonavicular joint. Talonavicular fusion is considered elsewhere. Medial column relaignment or stabilisation may be combined with tibialis posterior debridement, transfer of the FDL, FHL or split tibialis anterior, posterior calcaneal osteotomy or lateral column lengthening to correct other components of the flatfoot deformity.

Medial column surgery may be useful in:

• Instability of the first ray leading to a low arch, often with the apex at the first tarsometatarsal joint. The realtionship of this problem to hallux valgus has come into question in the last few years.
• Symptomatic degenerative disease of the medial column joints, sometimes with deformity. The relationship of this presentation to the rest of the adult acquired flatfoot spectrum is unclear.
• Adult acquired flatfoot with correctable hindfoot valgus but fixed mid/forefoot supination. This combination was denied by Johnson and Strom and does not appear in their classification. It is type 4 in the Truro classification. This deformity may be correctable with a talonavicular fusion, although it can be difficult. A medial column correction more distally allows the preservation of more movement.

Procedures on the medial column have been performed on children with severe flatfoot for many years. Miller described plication of an osteoperiosteal flap of the navicular, medial cuneiform and first metatarsal, with tibialis posterior advancement and naviculocuneiform fusion. Hoke modified this with a dorsal opening wedge osteotomy of the navicular to plantarflex the medial column.

The Seattle group have been the main proponents of medial column surgery in adults with flatfoot deformities. Sangeorzan published a series in 1999, including corrective fusions of the naviculocuneiform and tarsometatarsal joints. Most of these patients also had lateral column lengthening and were also published in a separate series arranged around the latter procedure. The same group also published a series of patients with isolated medial column procedures in 2003. They considered this was indicated where the arch was lowered but there was no hindfoot valgus (although they felt hindfoot deformities could be improved by medial column surgery).

Another series in 2005 described a dorsal opening wedge osteotomy of the medial cuneiform, mainly in congenital deformities although one patient had adult acquired flatfoot.

We have performed medial column surgery in a significant proportion of our patients, mainly fusion of the first tarsometatarsal joint. This has usually been precipitated by symptomatic OA as the dominant presenting problem. All of these patients have also required a posterior medial displacement calcaneal osteotomy.