For many years, I have employed a modification of the traditional Hoke procedure in the management of flatfoot deformity. Surgeons generally employ medial column stabilization in flatfoot deformity to augment other pronation limiting surgical interventions such as arthroereisis, tendo-Achilles lengthening (TAL), calcaneal osteotomy, etc.

The technique I have utilized is a wedge resection of the anterior navicular together with osteotomy/resection of the posterior articular surfaces of the medial and middle cuneiforms, and osteotomy of the lateral cuneiform. The procedure is simple to perform and it is powerful in the correction of abduction and dorsiflexion deformity. One can also correct some frontal plane rotational deformity.

Surgeons can perform the resection with a long oscillating or sagittal saw blade. Initially, you would perform conservative resection and expand the resection for further correction if necessary.

One may expand the procedure to include a Lapidus type resection when indicated, particularly when it comes to stabilizing deformities secondary to Charcot’s joint disease.

The standard incision is a universal medial longitudinal incision (Figure 1). No undermining of the skin or “anatomical dissection” is necessary. Perform subperiosteal/capsular dissection to expose the navicular-cuneiform joint or the first metatarsocuneiform joint when necessary (Figure 2). Proceed to perform a wedge resection of the anterior navicular and posterior cuneiforms, extending into the lateral cuneiform (Figure 3).

The wedge is wider medially (Figure 4) and plantarly (Figure 5,6) so when the deformity is reduced, adduction and plantarflexion correction occurs (Figure 7). It is prudent to be conservative with initial resection. You can obtain greater correction as needed. One may accomplish fixation by a variety of means, utilizing standard bone staples (Figure 8), Wright compression staples (Figure 9), OSStaples (Figure 10) or screws (Figure 11). Deformity correction in Charcot’s joint disease may necessitate orthobiologic enhancement (Figure 15), non-locking or locking plates (Figures 16,17) or supplementary external fixation, particularly when you perform an additional metatarsocuneiform arthrodesis (Figures 18-19).

Typically, four to six weeks of immobilization is required.

In my opinion, the key to success is extension of the osteotomy/arthrodesis into the lateral cuneiform. One should initially ensure satisfactory resection of the surfaces to be resected. Then proceed to carefully remove greater amounts of bone for additional correction as required. In a pinch, for example, when you encounter poor quality bone, you may employ crossed Steinmann pins or a small external fixator.