Throughout antiquity, physicians and surgeons have concerned themselves with maladies of the foot and ankle. The literature is rife with articles describing management of clubfoot deformities and traumatic amputations of feet and legs. Authors have described tenotomies and manipulation for clubfeet as well as optimal techniques and levels for amputations to promote healing and functional outcomes. In progressive and aggressive surgical centers in Austria and Germany, techniques for correction of the deformities created by disease and trauma formed the basis for today’s reconstructive methodologies.
During my orthopedic residency in the 1960s, we managed pediatric versions of clubfoot, vertical talus, and neuromuscular conditions of the lower extremity (myelomeningocele, muscular dystrophy, cerebral palsy); adolescent bunions and pathologic flat feet; and, in adults, residual polio, arthritis, bunions, lesser toe deformities, ankle disorders, and trauma. Then along came the excitement of total joint arthroplasty, with its spectacular results, and the thrill in devoting careers to athletes and their myriad problems. Other interesting subspecialties emerged, and the orthopedic focus on a significant part of our heritage, the issues of foot and ankle, was lost for decades. Care for these problems was left to a small cadre of pediatric doctors, and soon-to-retire orthopedists who tended to view the field as
less demanding. Dynamic young practitioners showed little or no interest in caring for foot and ankle patients, and no progress was made in clinical care, research, and development of orthopedic technology and devices.
In the late 1960s, a small group of middle-aged and senior devotees of the specialty met in New York to form the American Orthopaedic Foot Society (AOFS), later to become the American Orthopaedic Foot and Ankle Society (AOFAS). The group’s goal was to renew interest in the foot and ankle specialty among orthopedic surgeons. As everyone knows, AOFAS has flourished and become one of the most progressive, innovative, and dynamic of all the orthopedic subspecialty
groups. In 1985, John Gartland, president of the American Academy of Orthopaedic Surgeons, called together the leaders in the foot and ankle field to formulate a long-range plan to reclaim foot and ankle from the morass of substandard care
and to advance the subspecialty in every quarter. As AOFS (and later AOFAS) president, I was part of Gartland’s team. I recall we aimed to convince orthopedic chairs, the Residency Review Committee for Orthopaedic Surgery, and the Board
of Orthopaedic Surgery to increase training requirements, to develop foot and ankle educators, and to promote the area in training programs. Orthopedic educators developed fellowships (essentially nonexistent up until then) and organized and taught beginner and advanced continuing education courses at annual meetings and throughout the year.
There were other needs to be addressed. One was to educate nonorthopedic doctors to appreciate that foot and ankle problems had good nonoperative and surgical solutions, that there was an orthopedic subspecialty for these conditions, and that foot and ankle patients should be referred to its practitioners. Second, these patients’ public advocacy groups needed to know what knowledgeable orthopedists could provide and needed to be encouraged to seek care from these physicians rather than from less qualified providers and nonspecialists.
To an extraordinary degree, the goal of educating orthopedists has been achieved, and the field is now populated with young, energetic leaders, teachers, and practitioners. We have been less successful in educating potential referring physicians, the public, public advocacy groups, and third-party payers, including the US government. Progress has been made with private insurers and, as advisors, with the Centers for Medicare and Medicaid Services and state government health committees.
Driven by emerging market opportunities, the orthopedic device industry has made unanticipated and enormous advances in the distal lower extremity realm. Small
companies have been founded, and larger companies have dedicated entire divisions to making fixation devices and prosthetic implants for every procedure involving the foot or the ankle. Biomedical engineers, metallurgists, orthopedic
consultant researchers, and well-funded projects have led the surge to develop the best foot and ankle technology. In addition, industry courses and scholarships for residents, fellows, teaching programs, and young physicians have been generating interest in these advances. Although it may be argued that entrepreneurship brings enormous bias, it must be conceded that interest in the foot and ankle field has increased tremendously. Outreach programs for foot and ankle care in the Third World have emerged as an additional humanitarian benefit of the expansion of the field.
From its strong start as a medical specialty to its fall into ignorance and neglect, the foot and ankle field, the unwanted stepchild of medicine and orthopedics, has made a dramatic recovery and has become a premier example of what medicine can achieve through focused effort. As leaders in orthopedic medicine in North America, we must also acknowledge the huge contributions made by a sterling array of international researchers, educators, and practitioners.