What does the field of podiatric surgery need to improve on in the future?

“Why did you choose podiatry?” This is a commonly asked question to podiatry students and practicing podiatrists, and our response has the opportunity to inspire or dissuade. Intuitively, our profession has trained us to produce responses that inspire and encourage opportunities in the field. These responses may include ideas of professional versatility, specialty, surgery, money, and a multi-faceted lifestyle. While all these ideas are true and attractive, our love of podiatric surgery matures from a critical analysis that elicits progress to advance our profession. At the conclusion of my own analysis, I argue that the field of podiatric surgery requires improvement in our application of lower extremity biomechanics in the decision-making process, through the development of newer techniques and the role of research in this process.

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Historically, the foot and ankle system has been theorized as a uni-segmental model, in which biomechanists studied motions of the body and inferred that the foot acted as a rigid segment around the ankle joint axis relative to the tibia. Fortunately, contemporary kinematics rightfully rejects this notion; we now know that the individual joints within the foot may function dependent or independent of one another. This birthed the development of a multi-segmental foot and ankle model. Admittedly, it seems that we are on the right path in search of the truth, but this comes with complications, and new discoveries may conflict with canonical theories.

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For example, cadaveric reports of isolated calcaneocuboid arthrodeses may significantly limit talonavicular motion by approximately 67%, while an isolated talonavicular arthrodesis produced negligible limitations at the calcaneocuboid and subtalar joints¹. Furthermore, different groups argue different arthrokinematic origins of the midtarsal joint; whether it has one, two, three, or infinite axes of motion²-⁴. Altogether. these examples question the validity of our classical theory of the midfoot and rearfoot relationship, and, more globally, our understanding of the biomechanics of the foot. Yet, it is irrefutable that this important information is pertinent in the appropriate prescription of corrective surgery. So, what is the true relationship between the midfoot and rearfoot? Moreover, how can we find the answers to this and other crucial questions when we prepare our patients for podiatric surgery?

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Our profession has progressed, adapted, and moved forward in recent years. The key to our progression is the persistence of research! Through research, we’ve adapted various benchmarks of surgical success, including alignment, patient comfort, and appropriate healing. However, there remains a lack of detailed biomechanical studies to aid in the understanding of the arthrokinematic effects of joint obliteration, modification, or reconstruction in vivo.

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Post-operative foot and ankle biomechanics research will reveal the short and longer term effects of our surgical interventions. Furthermore, by knocking in or out joints and observing their effects on the foot, it will provide more insight into “true” biomechanics. With this new information, we are able to pave the way for our future generations, as well as allow for cutting-edge developments that will ultimately benefit our patients.

By Timothy
Dr. William M. Scholl College of Podiatric Medicine
DPM-PhD, Class of 2022

References:

  1. Astion DJ, Dekand JT, Otis JC, Kenneally S. Motion of the hindfoot after simulated arthrodesis. Journal of Bone and Joint Surgery. 1997;79(2):241-246.
  2. Nester CG, Findlow A, Bowker P. “Scientific Approach to the Axis of Rotation of the Midtarsal Joint.” JAPMA. 2001;91(2):68-73.
  3. Okita N, Meyers SA, Challis JH, Sharkey NA. Midtarsal joint locking: new perspectives on an old paradigm. J Orthop Res. 2014;32(1):110-115.
  4. Tweed JL, Campbell JA, Thompson RJ, Curran MJ. The function of the midtarsal joint: a review of the literature. The Foot. 2008; 16(2):106-112.

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