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CONSENSUS STATEMENT TWO: Our current classification systems are incomplete or outdated.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)
Recommendation:
There is evidence that the use of WEIGHTBEARING imaging aids in the assessment of progressive collapsing foot deformity (PCFD). The following WEIGHTBEARING conventional radiographs ...(CRs) are necessary in the assessment of PCFD patients: anteroposterior (AP) foot, AP or mortise ankle, and lateral foot. If available, a hindfoot alignment view is strongly recommended. If available, WEIGHTBEARING computed tomography (CT) is strongly recommended for surgical planning. When WEIGHTBEARING CT is obtained, important findings to be assessed are sinus tarsi impingement, subfibular impingement, increased valgus inclination of the posterior facet of the subtalar joint, and subluxation of the subtalar joint at the posterior and/or middle facet.
Level of Evidence:
Level V, consensus, expert opinion.
Background:
The purpose of this systematic review is to examine the literature on Achilles tendon (AT) injuries in professional athletes to determine their rate of return to play (RTP), performance, ...and career outcome after AT rupture.
Methods:
A literature search of MEDLINE, Google Scholar, CINAHL, and Cochrane Library databases was performed. Included studies reported outcomes related to RTP (time and rate), durability and player participation, and player performance following AT rupture in professional athletes of the National Football League (NFL), National Basketball Association (NBA), Major League Baseball (MLB), and professional soccer leagues.
Results:
Fifteen studies met inclusion criteria for analysis. Athletes were able to return to professional sport participation 76% of the time, with mean time to RTP of 11 months following AT injury. Athletes experienced a decline in player efficiency ratings, power ratings, and sport- and position-specific statistics in the NFL, NBA, and professional soccer leagues compared to noninjured controls. RTP rate was significantly lower following AT rupture in comparison to athletes sustaining other common orthopedic injuries such as anterior cruciate ligament injuries, meniscal tears, and ankle fractures in both NFL and NBA athletes.
Conclusion:
AT rupture prohibits nearly 25% of professional athletes from returning to their respective sport. Of those able to return to compete at a professional level, the mean time to RTP is 11 months—nearly double the estimated 6-month recovery for RTP in the general population. Furthermore, player performance and durability were curtailed following AT rupture. This review of the literature should be used to set evidence-based goals and establish realistic expectations for RTP for elite athletes following AT injuries.
Level of Evidence:
Level III, systematic review.
Recommendation:
There is evidence supporting medial soft tissue reconstruction, such as spring and deltoid ligament reconstructions, in the treatment of severe progressive collapsing foot deformity ...(PCFD). We recommend spring ligament reconstruction to be considered in addition to lateral column lengthening or subtalar fusion at the initial operation when those procedures have given at least 50% correction but inadequate correction of the severe flexible subluxation of the talonavicular and subtalar joints. We also recommend combined flatfoot reconstruction and deltoid reconstruction be considered as a joint sparing alternative in the presence of PCFD with valgus deformity of the ankle joint if there is 50% or more of the lateral joint space remaining.
Level of Evidence:
Level V, expert opinion.
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)
Recommendation:
In the treatment of progressive collapsing foot deformity (PCFD), the combination of bone shape, soft tissue failure, and host factors create a complex algorithm that may confound ...choices for operative treatment. Realignment and balancing are primary goals. There was consensus that preservation of joint motion is preferred when possible. This choice needs to be balanced with the need for performing joint-sacrificing procedures such as fusions to obtain and maintain correction. In addition, a patient’s age and health status such as body mass index is important to consider. Although preservation of motion is important, it is secondary to a stable and properly aligned foot.
Level of Evidence:
Level V, consensus, expert opinion.
PDF
