What Kind Of Surgeon Are You: Functional Or Structural?

Kathleen Satterfield DPM FACFAOM

This is an interesting question and a timely one. This is what separates orthopedic surgeons from many podiatric surgeons but it is a distinction that our profession is close to losing.

Recent changes to the CPME 320, the Council on Podiatric Medicine’s “rule book” that governs residency programs, reduced the emphasis on biomechanics and medicine in residency programs. Our new foot and ankle surgeons are becoming more structural and less functional.

Are you unfamiliar with the terms? Let me explain.

The functional surgeon is one who takes into account the biomechanics and function of the muscles and bones involved before doing a surgery. A structural surgeon is one who sees the foot and ankle as a static entity. That surgeon’s work will look impeccable on the X-ray and on the table, but the doctor will then wonder why his or her work does not look so wonderful six months later when the patient returns. A hallux or calcaneal varus appears. The flatfoot repair does not have such a nice arch. The tendon lengthening did not achieve the expected outcome.

But why did this happen? It looked so nice on the table.

The sutures were perfectly placed.

The X-ray looked like it had come out of a textbook.

The angles were classic.

What happened between then and now?

The patient dared to walk two months after surgery and expected the foot to look semi-normal. The patient was a human being and the podiatric surgeon failed to factor that into the equation. While taking biomechanics — or foot function as I prefer to call it — into consideration might make the outcome much better, as a profession, we have lost that part of what made us special to begin with and that is very sad.

I once attended an educational conference where I saw a hard-bitten surgeon almost reduced to speechlessness. This surgeon had treated a man who was well over six feet tall and weighed more than 350 pounds. He underwent a simple bunion surgery. Now the man was rendered almost unable to walk because he was in such pain.

The procedure had been so simple that a first-year resident could have done it (and probably had). A soft-spoken biomechanics professor from one of the colleges started questioning the surgeon about why he had not assessed the patient for the pathology at the hips that he had missed before he had performed the failed foot surgery. It was so obvious. The surgeon stared. Silently.

The eventual conclusion was that if he had truly assessed the man’s condition, a conservative treatment would have solved his problems and he would not have suffered needlessly. He thanked the professor quietly and returned to his seat without further words. The audience was silent.

If we stay silent as a profession and do not stand up, we are at risk for losing what made us unique in the beginning of our profession. What makes us unique is the ability to analyze and evaluate a surgery from a functional standpoint and not just a structural standpoint.

We are better than that. We must not lose that which makes us unique.


I commend Dr. Satterfield's well articulated comments and I agree entirely. We are given the opportunity to work on our patients and they have entrusted to us their care. I recall our professors' comments in podiatry school who always reminded us that "the foot is connected to the rest of the body." It is paramount that we stay forthright in our discussions with our patients and offering them the best solutions (surgical or non-surgical) for their feet.

Grace Torres-Hodges, DPM
Andrews Institute of Orthopedics & Sports Medicine
Pensacola/Gulf Breeze, Florida

Is it any wonder that pressure plate scanners for the prescribing of foot orthoses have proliferated? No longer is it necessary to even evaluate foot function. A computer can do it for you! I know of podiatrists who rarely even bother to assess subtalar joint motion but instead focus solely on "structural" problems and pathology.

ALL surgical procedures should be based on a detailed understanding of biomechanics with a thorough evaluation of foot mechanics as the foundation for ANY planned procedure.

Conway T. McLean, DPM
Director of Podiatry and Surgery
The Medical and Foot Care Group
Palos Heights, IL

I agree that biomechanics is important but there is a difference between biomechanics as a science and clinical biomechanics. As of now, there are many versions of clinical biomechanics, some more scientific than others. What version is Dr. Satterfield subscribing to?

There are great speakers who will explain with ease why a surgical complication has occurred. All they need are a few magic words such as pronation, compensation, equinus and planal dominance. They may " make sense" or give us a headache, but their theories reflect reality about 60 percent of the time.

Real research is a little more than smooth talk and is coming from 3D computerized gait analysis.

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