Classification and Nomenclature: Progressive Collapsing Foot Deformity

Recommendation: The historical nomenclature for the adult acquired flatfoot deformity (AAFD) is confusing, at times called posterior tibial tendon dysfunction (PTTD), the adult flexible flatfoot deformity, posterior tibial tendon rupture, peritalar instability and peritalar subluxation (PTS), and progressive talipes equinovalgus. Many but not all of these deformities are associated with a rupture of the posterior tibial tendon (PTT), and some of these are associated with deformities either primarily or secondarily in the midfoot or ankle. There is similar inconsistency with the use of classification schemata for these deformities, and from the first introduced by Johnson and Strom (1989), and then modified by Myerson (1997), there have been many attempts to provide a more comprehensive classification system. However, although these newer more complete classification systems have addressed some of the anatomic variations of deformities encountered, none of the above have ever been validated. The proposed system better incorporates the most recent data and understanding of the condition and better allows for standardization of reporting. In light of this information, the consensus group proposes the adoption of the nomenclature “Progressive Collapsing Foot Deformity” (PCFD) and a new classification system aiming at summarizing recent data published on the subject and to standardize data reporting regarding this complex 3-dimensional deformity. Level of Evidence: Level V, consensus, expert opinion. Consensus Statements Voted: CONSENSUS STATEMENT ONE: We will rename the condition to Progressive Collapsing Foot Deformity (PCFD), a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT TWO: Our current classification systems are incomplete or outdated. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT THREE: MRI findings should be part of a new classification system. Delegate vote: agree, 33% (3/9); disagree, 67% (6/9); abstain, 0%. (Weak negative consensus) CONSENSUS STATEMENT FOUR: Weightbearing CT (WBCT) findings should be part of a new classification system. Delegate vote: agree, 56% (5/9); disagree, 44% (4/9); abstain, 0%. (Weak consensus) CONSENSUS STATEMENT FIVE: A new classification system is proposed and should be used to stage the deformity clinically and to define treatment. Delegate vote: agree, 89% (8/9); abstain, 11% (1/9). (Strong consensus)

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Intra- and Interobserver Reliability of the New Classification System of Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/10711007211058154 ◽

2021 ◽

pp. 107110072110581

Author(s):

Hee Young Lee ◽

Nacime Salomao Barbachan Mansur ◽

Matthieu Lalevee ◽

Kevin N. Dibbern ◽

Mark S. Myerson ◽

...

Keyword(s):

Classification System ◽

Interobserver Reliability ◽

Joint Involvement ◽

Posterior Tibial Tendon ◽

Diagnostic Study ◽

Foot Deformity ◽

New Classification ◽

Posterior Tibial Tendon Dysfunction ◽

Level Of Evidence ◽

Radiographic Findings

Background: Historical concept of flatfoot as posterior tibial tendon dysfunction (PTTD) has been questioned. Recently, the consensus group published a new classification system and recommended renaming PTTD to Progressive Collapsing Foot Deformity (PCFD). The new PCFD classification could be effective in providing comprehensive information on the deformity. To date, there has been no study reporting intra- and interobserver reliability and the frequency of each class in PCFD classification. Methods: This was a single-center, retrospective study conducted from prospectively collected registry data. A consecutive cohort of PCFD patients evaluated from February 2015 to October 2020 was included, consisting of 92 feet in 84 patients. Classification of each patient was made using characteristic clinical and radiographic findings by 3 independent observers. Frequencies of each class and subclass were assessed. Intraobserver and inteobserver reliabilities were analyzed with Cohen kappa and Fleiss kappa, respectively. Results: Mean sample age was 54.4, 38% was male and 62% were female. 1ABC (25.4%) was the most common subclass, followed by 1AC (8.7%) and 1ABCD (6.9%). Only a small percentage of patients had isolated deformity. Class A was the most frequent component (89.5%), followed by C in 86.2% of the cases. Moderate interobserver reliability (Fleiss kappa = 0.561, P < .001, 95% CI 0.528-0.594) was found for overall classification. Very good intraobserver reliability was found (Cohen kappa = 0.851, P < .001, 95% CI 0.777-0.926). Conclusion: Almost half (49.3%) of patients had a presentation dominantly involving the hindfoot (A) with various combinations of midfoot and/or forefoot deformity (B), (C) with or without subtalar joint involvement (D). The new system may cover all possible combinations of the PCFD, providing a comprehensive description and guiding treatment in a systematic and individualized manner, but this initial study suggests an opportunity to improve overall interobserver reliability. Level of Evidence: Level III, retrospective diagnostic study.

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Consensus on Indications for Isolated Subtalar Joint Fusion and Naviculocuneiform Fusions for Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950738 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1295-1298

Author(s):

Beat Hintermann ◽

Jonathan T. Deland ◽

Cesar de Cesar Netto ◽

Scott J. Ellis ◽

Jeffrey E. Johnson ◽

...

Keyword(s):

Sagittal Plane ◽

External Rotation ◽

Plantar Flexion ◽

Posterior Tibial Tendon ◽

Foot Deformity ◽

Level Of Evidence ◽

Lateral Column ◽

3 Dimensional ◽

Joint Fusion ◽

First Ray

Recommendation: Peritalar subluxation represents an important hindfoot component of progressive collapsing foot deformity, which can be associated with a breakdown of the medial longitudinal arch. It results in a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and pronation. Loss of peritalar stability allows the talus to rotate and translate on the calcaneal and navicular bone surfaces, typically moving medially and anteriorly, which may result in sinus tarsi and subfibular impingement. The onset of degenerative disease can manifest with stiffening of the subtalar (ST) joint and subsequent fixed and possibly arthritic deformity. While ST joint fusion may permit repositioning and stabilization of the talus on top of the calcaneus, it may not fully correct forefoot abduction and it does not correct forefoot varus. Such varus may be addressed by a talonavicular (TN) fusion or a plantar flexion osteotomy of the first ray, but, if too pronounced, it may be more effectively corrected with a naviculocuneiform (NC) fusion. The NC joint has a curvature in the sagittal plane. Thus, preserving the shape of the joint is the key to permitting plantarflexion correction by rotating the midfoot along the debrided surfaces and to fix it. Intraoperatively, care must be also taken to not overcorrect the talocalcaneal angle in the horizontal plane during the ST fusion (eg, to exceed the external rotation of the talus and inadvertently put the midfoot in a supinated position). Such overcorrection can lead to lateral column overload with persistent lateral midfoot pain and discomfort. A contraindication for an isolated ST fusion may be a rupture of posterior tibial tendon because of the resultant loss of the internal rotation force at the TN joint. In these cases, a flexor digitorum longus tendon transfer is added to the procedure. Level of Evidence: Level V, consensus, expert opinion.

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Posterior Tibial Tendon Transfer and Tendo-Achilles Lengthening for Equinovarus Foot Deformity Due to Severe Crush Injury

Foot & Ankle International ◽

10.1177/107110070202301204 ◽

2002 ◽

Vol 23 (12) ◽

pp. 1103-1106 ◽

Cited By ~ 2

Author(s):

Ali Sabri Atesalp ◽

Cemil Yıldız ◽

Mahmut Kömürcü ◽

Mustafa Basbozkurt ◽

Ethem Gür

Keyword(s):

Tendon Transfer ◽

Operative Procedure ◽

Varus Deformity ◽

Crush Injury ◽

Posterior Tibial Tendon ◽

Foot Deformity ◽

Posterior Tibial ◽

Tendon Lengthening ◽

Achilles Tendon Lengthening

Surgical correction was performed on nine patients who had equinovarus deformity caused by severe crush injury of the leg sustained in an earthquake. The operative procedure used involved the transfer of the posterior tibial tendon to the dorsum of the foot by passing it through the interosseous membrane using a modified procedure as published in 1978. 5 This procedure was combined with percutaneous Achilles tendon lengthening and tenotomy of toe flexors when needed. The average follow-up time after the operation was 21 months. The treatment improved the heel-toe steppage gait in all patients and all were able to walk in standard shoes. There were no complications in the postoperative period. Recurrence of varus deformity was not seen in any of the patients. They had active dorsiflexion of the foot, with a median active dorsiflexion of 5° (0 to 10°) and median active plantarflexion of 16.1° (10 to 25°) compared to the median active dorsiflexion and plantarflexion on the uninvolved side. The total range-of-motion was 21.1° (10 to 35°).

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Consensus for the Indication of Lateral Column Lengthening in the Treatment of Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950732 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1286-1288

Author(s):

David B. Thordarson ◽

Lew C. Schon ◽

Cesar de Cesar Netto ◽

Jonathan T. Deland ◽

Scott J. Ellis ◽

...

Keyword(s):

Subtalar Joint ◽

Consensus Statement ◽

Talonavicular Joint ◽

Foot Deformity ◽

Foot Care ◽

Level Of Evidence ◽

Lateral Column ◽

Fluoroscopic Imaging ◽

Lateral Column Lengthening ◽

Important Sign

Recommendation: Progressive collapsing foot deformity (PCFD) is a complex 3D deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot supination. Although a medial displacement calcaneal osteotomy can correct heel valgus, it has far less ability to correct forefoot abduction. More severe forefoot abduction, most frequently measured preoperatively by assessing talonavicular coverage on an anteroposterior (AP) weightbearing conventional radiographic view of the foot, can be more effectively corrected with a lateral column lengthening procedure than by other osteotomies in the foot. Care must be taken intraoperatively to not overcorrect the deformity by restricting passive eversion of the subtalar joint or causing adduction at the talonavicular joint on simulated AP weightbearing fluoroscopic imaging. Overcorrection can lead to lateral column overload with persistent lateral midfoot pain. The typical amount of lengthening of the lateral column is between 5 and 10 mm. Level of Evidence: Level V, consensus, expert opinion. CONSENSUS STATEMENT ONE: Lateral column lengthening (LCL) procedure is recommended when the amount of talonavicular joint uncoverage is above 40%. The amount of lengthening needed in the lateral column should be judged intraoperatively by the amount of correction of the uncoverage and by adequate residual passive eversion range of motion of the subtalar joint. Delegate vote: agree, 78% (7/9); disagree, 11% (1/9); abstain, 11% (1/9). (Strong consensus) CONSENSUS STATEMENT TWO: When titrating the amount of correction of abduction deformity intraoperatively, the presence of adduction at the talonavicular joint on simulated weightbearing fluoroscopic imaging is an important sign of hypercorrection and higher risk for lateral column overload. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT THREE: The typical range for performing a lateral column lengthening is between 5 and 10 mm to achieve an adequate amount of talonavicular coverage. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus)

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The Surgical Treatment of Adult Acquired Buried Penis Syndrome: A New Classification System

Aesthetic Surgery Journal ◽

10.1093/asj/sjy325 ◽

2018 ◽

Vol 39 (9) ◽

pp. 979-988 ◽

Cited By ~ 4

Author(s):

Madison A Hesse ◽

Jacqueline S Israel ◽

Nikita O Shulzhenko ◽

Ruston J Sanchez ◽

Catharine B Garland ◽

...

Keyword(s):

Surgical Treatment ◽

Classification System ◽

Recurrent Infection ◽

Well Being ◽

Classification Systems ◽

Penile Skin ◽

Level Of Evidence ◽

Excess Skin ◽

Wound Breakdown ◽

Buried Penis

Abstract Background Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality. Objectives The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment. Methods The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning. Results Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively. Conclusions Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being. Level of Evidence: 4

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Shifting syndromes: Sex chromosome variations and intersex classifications

Social Studies of Science ◽

10.1177/0306312718757081 ◽

2018 ◽

Vol 48 (1) ◽

pp. 125-148 ◽

Cited By ~ 13

Author(s):

David Andrew Griffiths

Keyword(s):

Lived Experience ◽

Classification System ◽

Consensus Statement ◽

Sex Chromosome ◽

Disorders Of Sex Development ◽

Current Drive ◽

Medical Community ◽

New Classification ◽

Sex Development

The 2006 ‘Consensus statement on management of intersex disorders’ recommended moving to a new classification of intersex variations, framed in terms of ‘disorders of sex development’ or DSD. Part of the rationale for this change was to move away from associations with gender, and to increase clarity by grounding the classification system in genetics. While the medical community has largely accepted the move, some individuals from intersex activist communities have condemned it. In addition, people both inside and outside the medical community have disagreed about what should be covered by the classification system, in particular whether sex chromosome variations and the related diagnoses of Turner and Klinefelter’s syndromes should be included. This article explores initial descriptions of Turner and Klinefelter’s syndromes and their subsequent inclusion in intersex classifications, which were increasingly grounded in scientific understandings of sex chromosomes that emerged in the 1950s. The article questions the current drive to stabilize and ‘sort out’ intersex classifications through a grounding in genetics. Alternative social and historical definitions of intersex – such as those proposed by the intersex activists – have the potential to do more justice to the lived experience of those affected by such classifications and their consequences.

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Acute Posterior Tibial Tendon Tear in an Ice-Hockey Player: A Case Report

Foot & Ankle International ◽

10.3113/fai.2008.1045 ◽

2008 ◽

Vol 29 (10) ◽

pp. 1045-1048 ◽

Cited By ~ 9

Author(s):

Sidney M. Jacoby ◽

James R. Slauterbeck ◽

Steven M. Raikin

Keyword(s):

Case Report ◽

Ice Hockey ◽

Posterior Tibial Tendon ◽

Tendon Tear ◽

Level Of Evidence ◽

Posterior Tibial ◽

Hockey Player

Level of Evidence: V, Case Report

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Surgical Treatment of Stage I Posterior Tibial Tendon Dysfunction

Foot & Ankle International ◽

10.1177/107110079401501203 ◽

1994 ◽

Vol 15 (12) ◽

pp. 646-648 ◽

Cited By ~ 77

Author(s):

Robert D. Teasdall ◽

Kenneth A. Johnson

Keyword(s):

Severe Pain ◽

Stage I ◽

Complete Relief ◽

Posterior Tibial Tendon ◽

Moderate Pain ◽

Foot Deformity ◽

Medial Aspect ◽

Posterior Tibial Tendon Dysfunction ◽

Posterior Tibial ◽

Surgical Release

Nineteen patients underwent surgical synovectomy and debridement for the clinical diagnosis of stage I posterior tibial tendon (PTT) dysfunction. Stage I PTT dysfunction is characterized by pain and swelling along the medial aspect of the ankle. Fourteen patients (74%) reported complete relief of pain, 3 patients (16%) reported minor pain, and 1 patient (5%) had moderate pain, and 1 (5%) had continued severe pain. Sixteen (84%) of the patients subjectively reported being “much better” and had a return of function of the PTT, as evidenced by their ability to perform a single limb-heel-rise test. Two patients (10%) underwent subtalar arthrodesis for progressive foot deformity and continued pain. Based on these results, surgical release, tenosynovectomy, and debridement are recommended for the treatment of stage I PTT dysfunction.

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Split Posterior Tibial Tendon Transfer for Spastic Equinovarus Foot Deformity

Foot & Ankle ◽

10.1177/107110078901000204 ◽

1989 ◽

Vol 10 (2) ◽

pp. 65-67 ◽

Cited By ~ 12

Author(s):

Phillip A. Medina ◽

Robert R. Karpman ◽

Anthony T. Yeung

Keyword(s):

Tendon Transfer ◽

Excellent Result ◽

Foot Deformities ◽

Posterior Tibial Tendon ◽

Foot Deformity ◽

Fair Result ◽

Posterior Tibial ◽

The Mean ◽

Peroneus Brevis ◽

Rehabilitative Services

This paper describes a simplified technique for split posterior tibial tendon transfer in the treatment of spastic equinovarus deformity of the foot. Thirteen children with spastic equinovarus foot deformities were treated at Children's Rehabilitative Services in Phoenix, Arizona, from 1983 to 1986. The technique was modified in 10 of the 13 patients by attaching the split posterior tibial tendon more proximally to the peroneus brevis, compared to a more distal attachment as described by other authors. The mean length of followup was 21 months. Eleven patients obtained a good or excellent result. Two patients were considered to have a fair result. No poor results or complications were noted in any of the patients. It was felt that the split posterior tibial tendon transfer was an effective procedure for correction of spastic equinovarus as reported by other authors. Modification of the technique significantly simplifies the operation by requiring less dissection while still producing favorable results.

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