Sage Journals: Discover world-class research

Abstract

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.

Keywords

PCFD flatfoot AAFD deformity foot radiographs clinical consensus classification

Get full access to this article

View all access options for this article.

References

Abousayed

Tartaglione

Rosenbaum

Dipreta

JA.

Classifications in brief: Johnson and Strom classification of adult-acquired flatfoot deformity. Clin Orthop Relat Res. 2016;474(2):588-593. doi: 10.1007/s11999-015-4581-6.

Arunakul

Amendola

Gao

Goetz

Femino

Phisitkul

Tripod index: a new radiographic parameter assessing foot alignment. Foot Ankle Int. 2013;34(10):1411-1420. doi: 10.1177/1071100713488761.

Blackwood

Gossett

Hallux valgus/medial column instability and their relationship with posterior tibial tendon dysfunction. Foot Ankle Clin. 2018;23(2):297-313. doi: 10.1016/j.fcl.2018.02.003.

Bluman

Myerson

MS.

Stage IV posterior tibial tendon rupture. Foot Ankle Clin. 2007;12(2):341-362, viii. doi: 10.1016/j.fcl.2007.03.004.

Bluman

Title

Myerson

MS.

Posterior tibial tendon rupture: a refined classification system. Foot Ankle Clin. 2007;12(2):233-249, v. doi: 10.1016/j.fcl.2007.03.003.

Brodell

Jr MacDonald

Perkins

Deland

Deltoid-spring ligament reconstruction in adult acquired flatfoot deformity with medial peritalar instability. Foot Ankle Int. 2019;40(7):753-761. doi: 10.1177/1071100719839176.

Cheng

Matson

Morgenstern

Agel

Hoogervorst

Levels of urgency for orthopaedic procedures: reliability and adoption of a consensus-driven classification. J Am Acad Orthop Surg. 2021;29(21):e1078-e1086. doi: 10.5435/jaaos-d-20-00631.

Cho

Hwang

Seo

, et al. Reliability of the classification and treatment of dislocations of the acromioclavicular joint. J Shoulder Elbow Surg. 2014;23(5):665-670. doi: 10.1016/j.jse.2014.02.005.

Cohen

A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1):37-46.

10.

Conti

Chan

Ellis

Deland

JT.

Correlation of postoperative midfoot position with outcome following reconstruction of the stage II adult acquired flatfoot deformity. Foot Ankle Int 2015;36(3):239-247. doi: 10.1177/1071100714564217.

11.

Coughlin

Jones

CP.

Hallux valgus and first ray mobility. A prospective study. J Bone Joint Surg Am. 2007;89(9):1887-1898. doi: 10.2106/JBJS.F.01139.

12.

Coughlin

Kaz

Correlation of Harris mats, physical exam, pictures, and radiographic measurements in adult flatfoot deformity. Foot Ankle Int. 2009;30(7):604-612. doi: 10.3113/FAI.2009.0604.

13.

de Cesar Netto

Deland

Ellis

SJ.

Guest Editorial: Expert consensus on adult-acquired flatfoot deformity. Foot Ankle Int 2020;41(10):1269-1271. doi: 10.1177/1071100720950715.

14.

de Cesar Netto

Godoy-Santos

Saito

, et al. Subluxation of the middle facet of the subtalar joint as a marker of peritalar subluxation in adult acquired flatfoot deformity: a case-control study. J Bone Joint Surg Am. 2019;101(20):1838-1844.

15.

de Cesar Netto

Kunas

Soukup

Marinescu

Ellis

SJ.

Correlation of clinical evaluation and radiographic hindfoot alignment in stage II adult-acquired flatfoot deformity. Foot Ankle Int. 2018;39(7):771-779.

16.

de Cesar Netto

Myerson

Day

, et al. Consensus for the use of weightbearing CT in the assessment of progressive collapsing foot deformity. Foot Ankle Int. 2020;41(10):1277-1282. doi: 10.1177/1071100720950734.

17.

Deland

JT.

The adult acquired flatfoot and spring ligament complex. Pathology and implications for treatment. Foot Ankle Clin. 2001;6(1):129-135, vii. doi: 10.1016/s1083-7515(03)00086-x.

18.

Deland

de Asla

Sung

Ernberg

Potter

HG.

Posterior tibial tendon insufficiency: which ligaments are involved?

Foot Ankle Int. 2005;26(6):427-435.

19.

Deland

Ellis

Day

, et al. Indications for deltoid and spring ligament reconstruction in progressive collapsing foot deformity. Foot Ankle Int. 2020:1071100720950742. doi: 10.1177/1071100720950742.

20.

Eugenio

Glass

The kappa statistic: A second look. Computational linguistics 2004;30(1):95-101.

21.

Fleiss

JL.

Measuring nominal scale agreement among many raters. Psychological bulletin 1971;76(5):378.

22.

Gentchos

Anderson

Bohay

DR.

Management of the rigid arthritic flatfoot in the adults: alternatives to triple arthrodesis. Foot Ankle Clin 2012;17(2):323-35. doi: 10.1016/j.fcl.2012.03.009.

23.

Hintermann

Deland

de Cesar Netto

, et al. Consensus on Indications for Isolated Subtalar Joint Fusion and Naviculocuneiform Fusions for Progressive Collapsing Foot Deformity. Foot Ankle Int 2020;41(10):1302-1306. doi: 10.1177/1071100720950738.

24.

Johnson

Strom

DE.

Tibialis posterior tendon dysfunction. Clin Orthop Relat. Res. 1989;239:196-206.

25.

Kitaoka

Ahn

Luo

KN.

Stability of the arch of the foot. Foot Ankle Int 1997;18(10):644-648. doi: 10.1177/107110079701801008.

26.

Landis

Koch

GG.

The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174.

27.

Lintz

Beldame

Kerhousse

, et al. Intra- and inter-observer reliability of the AFCP classification for sagittal plane deformities of the second toe. Foot Ankle Surg. 2020;26(6):650-656. doi: 10.1016/j.fas.2019.08.011.

28.

Malicky

Crary

Houghton

Agel

Hansen

Jr Sangeorzan

BJ.

Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. J Bone Joint Surg Am. 2002;84(11):2005-2009.

29.

Mansur

NSB

de Souza Nery

CA.

Hypermobility in hallux valgus. Foot Ankle Clin. 2020;25(1):1-17. doi: 10.1016/j.fcl.2019.10.004.

30.

McCormick

Johnson

JE.

Medial column procedures in the correction of adult acquired flatfoot deformity. Foot Ankle Clin. 2012;17(2):283-298. doi: 10.1016/j.fcl.2012.03.003.

31.

Metzl

JA.

Naviculocuneiform sag in the acquired flatfoot: what to do. Foot Ankle Clin. 2017;22(3):529-544. doi: 10.1016/j.fcl.2017.04.007.

32.

Miniaci-Coxhead

Weisenthal

Ketz

Flemister

AS.

Incidence and radiographic predictors of valgus tibiotalar tilt after hindfoot fusion. Foot Ankle Int. 2017;38(5):519-525. doi: 10.1177/1071100717690439.

33.

Myerson

Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;46:393-405.

34.

Myerson

Thordarson

Johnson

, et al. Classification and nomenclature: progressive collapsing foot deformity. Foot Ankle Int. 2020;41(10):1271-1276. doi: 10.1177/1071100720950722.

35.

Parsons

Naim

Richards

McBride

Correction and prevention of deformity in type II tibialis posterior dysfunction. Clin Orthop Relat Res. 2010;468(4):1025-1032. doi: 10.1007/s11999-009-1122-1.

36.

Pasapula

Cutts

Modern theory of the development of adult acquired flat foot and an updated spring ligament classification system. Clin Res Foot Ankle. 2017;5(3):247.

37.

Raikin

Winters

Daniel

JN.

The RAM classification: a novel, systematic approach to the adult-acquired flatfoot. Foot Ankle Clin. 2012;17(2):169-181.

38.

Richter

Lintz

de Cesar Netto

Barg

Burssens

Ellis

. The hind- and midfoot alignment analyzed after a medializing calcaneal osteotomy using a 3D weight bearing CT. In: Weight Bearing Cone Beam Computed Tomography (WBCT) in the Foot and Ankle. Springer; 2020:121-133.

39.

Rosenbaum

DiPreta

JA.

Classifications in Brief: Eichenholtz Classification of Charcot Arthropathy. Springer; 2015.

40.

Saltzman

el-Khoury

GY.

The hindfoot alignment view. Foot Ankle Int. 1995;16(9):572-576. doi: 10.1177/107110079501600911.

41.

Sangeorzan

Subtalar joint biomechanics: from normal to pathologic. Foot Ankle Clin. 2018;23(3):341-352. doi: 10.1016/j.fcl.2018.04.002.

42.

Thordarson

Schon

de Cesar Netto

, et al. Consensus for the indication of lateral column lengthening in the treatment of progressive collapsing foot deformity. Foot Ankle Int. 2020;41(10):1286-1288. doi: 10.1177/1071100720950732.

43.

Vosoughi

Shayan

Salehi

Jaberi

Solooki

Kardeh

Agreement between Sanders classification of intraarticular calcaneal fractures and assessment during the surgery. Foot Ankle Surg. 2020;26(1):94-97. doi: 10.1016/j.fas.2018.12.001.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

1.35 MB

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

Abstract

Background:

Methods:

Results:

Conclusion:

Level of Evidence:

Keywords

Get full access to this article

References

Supplementary Material