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. The existence of this combination was denied by Johnson and Strom and does not appear in their classification. It is type 2c 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. Kidner (1929) described advanciement of the tibialis posterior insertion with excision of an accessory navicular. Giorgini (2010) described a combination of the Kidner and Cobb procedures in 21 patients with stage 2 adult acquired flatfoot, as well as 19 children with hypermobile flatfeet. An unspecified number of additional procedures were also performed. 19/21 had no pain, problems with shoe wear or activity limitations at a mean follow-up of 4.6y.
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 (Greisberg 2005). 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 - we have also found this to be the case). 19 patients had corrective fusions of the naviculocuneiform and/or 1st TMT joints, and most also had debridement of tibialis posterior and FDL transfer. Radiographic correction was into the normal range, but no clinical results were reported.
Hirose (2004) described a dorsal opening wedge osteotomy of the medial cuneiform, mainly in congenital deformities although one patient had adult acquired flatfoot. Lutz (2011), however, described 81 opening wedge cuneiform osteotomies for flatfoot, though only 20 had "tibialis posterior tendon dysfunction". 64 also had lateral column lengthening procedures, as well as other additional procedures. Iliac crest allograft was used as the wedge and no internal fixation was used. There were no non-unions, most patients got a significant improvement in alignment (although it is impossible to attribute this solely to the cuneiform osteotomy) and this was maintained at 2 years in 24 patients. However, 20 patients got a variety of adverse events, usually biomechanical problems, and overall clinical results were not reported in this paper.
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.