Classification for adult acquired flat foot

NewsBot · Sep 6, 2012

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The RAM classification: a novel, systematic approach to the adult-acquired flatfoot.
Raikin SM, Winters BS, Daniel JN.
Foot Ankle Clin. 2012 Jun;17(2):169-81.

In summary, prior classifications have provided broad guidelines for treating the AAFF without accounting for case-specific variables in determining a treatment plan. The current system breaks down the deformity into three independent levels of involvement: the rearfoot, the ankle, and the midfoot. Via a simple, easy to remember, and reproducible schema based off the original Johnson and Strom classification, each level can be independently evaluated and a patient-specific surgical treatment plan can be formulated based on our most current understanding of the AAFF.
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Admin2 · Sep 6, 2012

Related Threads:
Other threads tagged with adult acquired flatfoot, posterior tibial tendon dysfunction and pttd

NewsBot · Jun 14, 2018

Adult Acquired Flat Foot: A New Biomechanical Classification for the
Deformity Based on two Point Failure of the Medial Column
Pasapula C et al
Pasapula et al., Clin Res Foot Ankle 2018, 6:2

Adult acquired flatfoot deformity (AAFD) is a common condition which is historically thought to be the result of
tibialis posterior tendon dysfunction. As a result, the classification of the disease and its management centres
around the state of the tibialis posterior tendon. This classification system has been accepted in the absence of
substantial evidence to support it. In this paper, we propose a new biomechanical classification of (AAFD) based on
available evidence that not only explains the progression of the disease but also aids clinicians to formulate a
management plan.
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NewsBot · Dec 2, 2021

Intra- and Interobserver Reliability of the New Classification System of Progressive Collapsing Foot Deformity
Hee Young Lee et al
Foot Ankle Int. 2021 Dec 1

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.
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NewsBot · Jan 26, 2022

A Comparison Between the Bluman et al. Classification and the Progressive Collapsing Foot Deformity Consensus for Flatfeet Assessment
Matthieu Lalevée, Hee Young Lee, Nacime S. Mansur, MD, ...
Foot & Ankle Orthopaedics January 21, 2022

Introduction/Purpose:
Bluman et al. flatfoot classification (2007) is based on the posterior tibial tendon (PTT) rupture leading to a chronological appearance of several foot deformities. Since then, several discordances have been noted in this concept. An expert consensus met recently to update it. Emphasis on posterior tibial tendon rupture was shifted to a non-chronological approach focusing on five different independent foot and ankle deformations and each deformation's flexibility or rigidity. This concept, named Progressive Collapsing Foot Deformity (PCFD), was approved with a strong consensus. The aim of this study was to compare Bluman et al. and PCFD classifications. We hypothesize that both classifications will be intra and interobserver reliable and that the PCFD classification will allow a better distribution of the different types of foot.

Methods:
We performed a retrospective IRB approved study including 92 flatfeet. Three fellowship trained foot and ankle surgeons studied clinical information and X-rays and classified them in Bluman and PCFD classifications. One performed a blinded second assessment. Bluman classification was analyzed one time as initially described and a second time after removing the Angle of Gissane sclerosis sign. Bluman stage I represents isolated PTT dysfunction, stage II and III Flexible and Rigid Hindfoot Valgus, and stage IV Tibio-Talar Valgus. These stages are progressive and don't allow any combinations. PCFD classifies Hindfoot valgus (A), Midfoot Abduction (B), Forefoot Varus (C), Peritalar Subluxation (D), and Tibiotalar Valgus (E). Combinations of these deformities is allowed. Each deformity can be Flexible (1) or Rigid (2). Interobserver and Intraobserver reliabilities were determined with respectively unweighted Fleiss' and Cohen's kappa values. Descriptive analysis was performed on the 276 readings to highlight discrepancies between classifications.

Results:
Inter and Intraobserver reliabilities were respectively moderate (K=0.55) and substantial (K=0.62) for Bluman and moderate (K=0.56) and very good (K=0.85) for PCFD. The 276 readings were spread into 10 subgroups in Bluman and 64 in PCFD. 2.9% of the flatfeet were classified Bluman stage I, 31.5% stage II, 43.8% stage III and 21.7% stage IV. Bluman stages II and III were mainly composed of PCFD 1ABC (respectively 40.2% and 28.1%). The most represented Bluman subgroup was IIIB (32.6%) whereas after removing the Angle of Gissane sclerosis sign from the classification it was the IIC subgroup (44.2%). PCFD A, B and C were mainly composed of Bluman subgroup IIIB (respectively 35.7%, 43.6% and 36.2%) and PCFD D and E of Bluman subgroup IVB (31.9% and 73.3%).

Conclusion:
Both classifications showed moderate reliabilities although the PCFD represented 6 times as many different choices by readers. Bluman stage I was rare, possibly because it is based on PTT dysfunction with little or no deformity. This entity is no longer considered in the PCFD. Bluman stage III, assumed to represent rigid hindfoot varus included numerous flexible PCFD. Main confusion could come from the Angle of Gissane sclerosis sign, which leads to Bluman stage III. This sign is however a sign of extraarticular sinus tarsi impingement which should not lead to a triple arthrodesis as recommended in the Bluman classification.
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NewsBot · Mar 25, 2022

Diagnostic Accuracy of the Progressive Collapsing Foot Deformity (PCFD) Classification
Shuyuan Li et al
Foot Ankle Int. 2022 Mar 18

Background: A consensus group recently proposed the term progressive collapsing foot deformity (PCFD) and a new classification with 2 stages plus 5 classes to describe the complex array of flatfoot deformities. This study aimed to validate different diagnostic accuracy rates of the PCFD classification.

Methods: This was a survey-based study distributed among 13 foot and ankle fellowship programs for 3 groups of participants with varied experience in practice (group 1: fellows in training, group 2: surgeons in practice for 1-4 years, and group 3: surgeons in practice for ≥5 years). Each participant was asked to assign 20 different cases of flatfoot deformity to the appropriate classes and stages using the PCFD classification. The overall diagnostic accuracy, class, and stage diagnostic accuracy rates for the 20 cases were calculated first for the entire cohort and then compared among the 3 groups. The misdiagnosis rate for each class of deformity (the sum of overdiagnosis and underdiagnosis rates) of the entire cohort was calculated and compared with the other classes. Mean and standard evidence were used to describe numerical data. One-way analysis of variance was used to compare values among the 3 groups and the 5 classes. P <.05 was considered statistically significant.

Results: For the whole cohort, the overall diagnostic accuracy, class diagnostic accuracy, and stage diagnostic accuracy rates were 71.0%, 78.3%, and 81.7%, respectively There was a statistically significant difference between group 1 and 2, and group 1 and 3, in overall diagnostic accuracy and class diagnostic accuracy, with no significant difference among the 3 groups regarding stage diagnostic accuracy. Class B had a significantly higher overdiagnosis rate than the rest of the classes, whereas class D was significantly underdiagnosed than others. The misdiagnosis rates for classes A to E were 3.3%, 17.5%, 11.1%, 26.0%, and 3.7%, respectively.

Conclusion: The PCFD classification showed overall fair diagnostic accuracy rates. The highest diagnostic accuracy was for "hindfoot valgus deformity" and "ankle instability." Further content validation of the PCFD classification is needed to examine the terminology and interpretation of those classes with low diagnostic accuracy including "midfoot/forefoot abduction deformity," "forefoot varus deformity/medial column instability," and "peritalar subluxation/dislocation."Level of Evidence: Level II, prospective comparative study.
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NewsBot · Jan 16, 2023

Influence of Weightbearing Computed Tomography in the Progressive Collapsing Foot Deformity Classification System
Nacime Salomão Barbachan Mansur et al
Foot Ankle Int. 2023 Jan 13

Background: The objective of this study was to compare progressive collapsing foot deformity (PCFD) classifications performed using clinical and conventional radiographs (CR) with classifications established using clinical and weightbearing computed tomography (WBCT).

Methods: This retrospective comparative study evaluated 89 consecutive PCFD feet (84 patients). Three readers performed chart reviews and CR evaluations, determining PCFD classifications that were previously published. After a washout period, the sequence was randomized, and a new classification was executed using clinical and WBCT assessment. One of the readers repeated the WBCT evaluation for intrarater reliability.

Results: Interrater reliability for the WBCT was found moderate (0.55) and intrarater excellent (0.98). Evaluation using WBCT produced 29.6% of 1ABC (CR: 25.4%, P = .270), 11.6% of 1ABCD (CR: 6.9%, P = .081), and 6.4% of BC (CR: 3.3%, P = .090) as most prevalent. Class A was presented in 83.9% (CR: 89.5%, P = .55), class B in 89.9% (CR: 76.4%, P < .001), class C in 93.6% (CR: 86.2%, P = .004), class D in 46.4% (CR: 34.8%, P = .006), and class E in 27.7% (CR: 22.5%, P = .158) of the classifications performed by WBCT.

Conclusion: WBCT showed a different rate of deformity recognition, which increased the incidence of all classes, especially B, C, and D. An excellent intrarater agreement was found, which infers assessment reliability combining clinical and WBCT evaluation. The obtained information could enhance disease understanding and supply patients with more precise care.
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NewsBot · Jan 24, 2023

Adult acquired flatfoot deformity: an update in classification
JamesLiChandr et al
Orthopaedics and Trauma; 7 January 2023

Adult acquired flatfoot deformity (AAFD) involves a complex spectrum of pathologies, arising primarily from failure of static restrains, leading to collapse of the medial longitudinal arch and further subsequent deformities in the foot. The landmark paper and classification by Johnson et al. proposed that pathology in the posterior tibial tendon (PTT) was key in the development of AAFD. Since then, the understanding of AAFD has evolved and advanced. Multiple structures aside from the PTT, such as the spring ligament, plantar fascia and deltoid ligament, have been identified to play a similarly key role in disease development and progression. Classification systems have also evolved to incorporate this new understanding. These include modifications to Johnson's classification (Myerson, Bluman) as well as new systems which aim to incorporate modern thinking, capture the wide spectrum of presentations or utilize modern advancements in imaging modalities. Current classification systems continue to aid understanding and management of AAFD, despite their increasing complexity. Future classifications should aim to provide a succinct way to describe and understand AAFD, as well as guiding prognosis and management.
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NewsBot · Jan 30, 2023

Foot Arch Classification via ML-based Image Classification
Wudhichart Sawangphol et al
Source

Foot pain have become one of the common health problem. One of the
commonly-used noninvasive method to relieve foot pain is to insert insoles in ones’ shoes.
However, choosing the right insoles strongly depends on foot arch types, i.e., high arch,
normal arch, and flat foot. Aside from manual classification, using foot images become an
alternative methods to classify the foot type. We propose to develop mathematical models
using machine learning techniques to improve the accuracy and reduce the time of the foot
arch classification from foot pressure scanning image. 200 foot images were used to develop
the models by applying decision tree, random forest, support vector machine, artificial neural
network, and XGBoost algorithm. We found that the decision tree classifier with the features
including different areas of part of foots, arch index, whole foot area, and side of foot has the
best performance than the other classifiers in terms of accuracy, precision, recall, F1 score,
and the number of features. The results also demonstrates that the obtained model can
classify foot arch types with high accuracy at 95% on the testing experiment.
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NewsBot · Jul 18, 2023

Review of classification systems
for AAFD/PCFD and the Triple
classification delinking
instability/deformity and foot type
Preprint

Background: Classifications of AAFD/PCFD have evolved with an increased understanding of the pathology involved. A
review of classification systems helps identify deficiencies and respective contributions to the evolution in understanding the classification
of AAFD.Methods: Using multiple electronic database searches (Medline, PubMed) and Google search, original papers classifying
AAFD were identified. Nine original papers were identified that met the inclusion criteria. Results: Johnson's original classification
and multiple variants provided a significant leap in understanding and communicating the pathology but remained tibialis
posterior tendon focussed. Drawbacks of these classifications include the implication of causality, linearity of progression through
stages, an over-simplification of stage 2 deformity and a failure to understand multiple tendons react, not just tibialis posterior. Later
classifications, such as the PCFD classification, are deformity-centric. Early instability in non-cavus feet and all stages of cavus feet
can present with pain and instability with minor/no deformity. These may not be captured in deformity-based classifications biased
to planus feet.' The authors developed the 'Triple Classification' (TC) understanding that primary pathology is a progressive ligament
failure/instability that presents as tendon reactivity, deformity, and painful impingement. There is a variable manifestation dependent
on starting foot morphology. Conclusions: This review has identified deficiencies within classification systems used in
AAFD/PCFD and, as a result, was used to help develop a more comprehensive 'Triple classification'. Advantages of the TC include
representing foot types with no deformity, defining complex secondary instabilities, delinking of foot types, tendon reactivity/ligament
instability and deformity to represent these independently in a more comprehensive classification system
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NewsBot · Oct 25, 2023

Flatfeet Severity-Level Detection Based on Alignment Measuring
Fatmah A Alsaidi, Kawthar M Moria et al
Sensors (Basel). 2023 Oct 2;23(19)

Flat foot is a postural deformity in which the plantar part of the foot is either completely or partially contacted with the ground. In recent clinical practices, X-ray radiographs have been introduced to detect flat feet because they are more affordable to many clinics than using specialized devices. This research aims to develop an automated model that detects flat foot cases and their severity levels from lateral foot X-ray images by measuring three different foot angles: the Arch Angle, Meary's Angle, and the Calcaneal Inclination Angle. Since these angles are formed by connecting a set of points on the image, Template Matching is used to allocate a set of potential points for each angle, and then a classifier is used to select the points with the highest predicted likelihood to be the correct point. Inspired by literature, this research constructed and compared two models: a Convolutional Neural Network-based model and a Random Forest-based model. These models were trained on 8000 images and tested on 240 unseen cases. As a result, the highest overall accuracy rate was 93.13% achieved by the Random Forest model, with mean values for all foot types (normal foot, mild flat foot, and moderate flat foot) being: 93.38 precision, 92.56 recall, 96.46 specificity, 95.42 accuracy, and 92.90 F-Score. The main conclusions that were deduced from this research are: (1) Using transfer learning (VGG-16) as a feature-extractor-only, in addition to image augmentation, has greatly increased the overall accuracy rate. (2) Relying on three different foot angles shows more accurate estimations than measuring a single foot angle.
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NewsBot · Dec 28, 2023

Content validation of the progressive collapsing foot deformity classification
Mingjie Zhu et al
Vol. 17 No. 3 (2023): Journal of the Foot and Ankle

Objective: The aim of this study was to validate the content accuracy of the PCFD classification. Methods: A survey-based study distributed through international foot and ankle programs among surgeons with vast experience in practice to analyze the terminology and interpretations used in the PCFD classification. A returned survey with completion of all questions filled out was considered a valid record. Descriptive statistical analysis was applied using SAS version 9.4 for data processing, statistical analysis, and visualization. Results: Eighty-two valid returned surveys from surgeons in 22 countries with a mean of 16 years in clinical practice were included. Among them, 80.5% of the participants considered the PCFD classification helpful in guiding decision-making, 79.3% thought it helped facilitate diagnosis and documentation, 58.5% found it easy to use, 30.5% were unlikely to use the classification, and 29.3% noted that the interpretation of the classification was not clear. Regarding the accuracy, clarity, and clinical relevance of terminology, 42.7% had difficulty in using increased foot and ankle offset, 35.4% had difficulty in using increased hindfoot moment arm, 19.5% found peritalar subluxation not clear, 13.4% found the term sinus tarsi impingement an unclear description, and 8.5% found forefoot varus difficult to diagnose. Conclusions: This international survey-based study provides readers with insights into the content of the PCFD classification. The findings indicate that some terminologies used in the PCFD classification are not universally understood. The authors recommend that modifications may be beneficial to enhance the accuracy and user-friendliness of the PCFD classification
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NewsBot · Jan 15, 2024

Deformities Influencing Different Classes in Progressive Collapsing Foot
Aly Fayed et al
Iowa Orthop J. 2023 Dec;43(2):8-13.

Background: The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 possible classes. PCFD is understood to be a complex, three-dimensional deformity occurring in many regions along the foot and ankle. The question remains whether a deformity in one area impacts other areas. The objective of this study is to assess how each one of the classes is influenced by other classes by evaluating each associated angular measurement. We hypothesized that positive and linear correlations would occur for each class with at least one other class and that this influence would be high.

Methods: We retrospectively assessed weight bearing CT (WBCT) measurements of 32 feet with PCFD diagnosis. The classes and their associated radiographic measurements were defined as follows: class A (hindfoot valgus) measured by the hindfoot moment arm (HMA), class B (midfoot abduction) measured by the talonavicular coverage angle (TNCA), class C (medial column instability) measured by Meary's angle, class D (peritalar sub-luxation) measured by the medial facet uncoverage (MFU), and class E (ankle valgus) measured using the talar tilt angle (TTA). Multivariate analyses were completed comparing each class measurement to the other classes. A p-value <0.05 was considered significant.

Results: Class A showed substantial positive correlation with class C (ρ=0.71; R2=0.576; p=0.001). Class B was substantially correlated with class D (ρ=0.74; R2=0.613; p=0.001). Class C showed a substantial positive correlation with class A (ρ=0.71; R2=0.576; p=0.001) and class D (ρ=0.75; R2=0.559; p=0.001). Class D showed substantial positive correlation with class B and class C (ρ=0.74; R2=0.613; p=0.001), (ρ=0.75; R2=0.559; p=0.001) respectively. Class E did not show correlation with class B, C or D (ρ=0.24; R2=0.074; p=0.059), (ρ=0.17; R2=0.071; p=0.179), and (ρ=0.22; R2=0.022; p=0.082) respectively.

Conclusion: This study was able to find relations between components of PCFD deformity with exception of ankle valgus (Class E). Measurements associated with each class were influenced by others, and in some instances with pronounced strength. The presented data may support the notion that PCFD is a three-dimensional complex deformity and suggests a possible relation among its ostensibly independent features.
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NewsBot · Jan 15, 2024

Interpretation of expert consensus for progressive collapsing foot deformity
J Z Zhang et al
Zhonghua Yi Xue Za Zhi. 2023 Oct 10;103(37):2907-2911

Adult flatfoot is a common foot deformity, mainly manifested as medial arch collapsing, hindfoot valgus and forefoot abduction. People have a more thorough understanding of the pathological changes and pathogenesis of flatfoot with further research. There is a new expert consensus for adult flatfoot published in Foot & Ankle Inter. in 2020. The expert panel reviewed the latest literature to develop consensus recommendations for flatfoot, including its nomenclature, diagnosis, classification and operative treatment. The consensus represents a new understanding of the disease and a new concept because of the authority of its authors and the comprehensiveness of its content, and it is also a phased summary of the theoretical and clinical progress of adult flatfoot. This article gives a detailed interpretation of the content in the consensus.
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NewsBot · Feb 16, 2024

Review of Classification Systems for Adult Acquired Flatfoot Deformity/Progressive Collapsing Foot Deformity and the Novel Development of the Triple Classification Delinking Instability/Deformity/Reactivity and Foot Type
Chandra Seker Pasapula et al
J. Clin. Med. 2024, 13(4), 942

Background: Classifications of AAFD/PCFD have evolved with an increased understanding of the pathology involved. A review of classification systems helps identify deficiencies and respective contributions to the evolution in understanding the classification of AAFD/PCFD. Methods: Using multiple electronic database searches (Medline, PubMed) and Google search, original papers classifying AAFD/PCFD were identified. Nine original papers were identified that met the inclusion criteria. Results: Johnson’s original classification and multiple variants provided a significant leap in understanding and communicating the pathology but remained tibialis posterior tendon-focused. Drawbacks of these classifications include the implication of causality, linearity of progression through stages, an oversimplification of stage 2 deformity, and a failure to understand that multiple tendons react, not just tibialis posterior. Later classifications, such as the PCFD classification, are deformity-centric. Early ligament laxity/instability in normal attitude feet and all stages of cavus feet can present with pain and instability with minor/no deformity. These may not be captured in deformity-based classifications. The authors developed the ‘Triple Classification’ (TC) understanding that primary pathology is a progressive ligament failure/laxity that presents as tendon reactivity, deformity, and painful impingement, variably manifested depending on starting foot morphology. In this classification, starting foot morphology is typed, ligament laxities are staged, and deformity is zoned. Conclusions: This review has used identified deficiencies within classification systems for AAFD/PCFD to delink ligament laxity, deformity, and foot type and develop the ‘Triple classification’. Advantages of the TC may include representing foot types with no deformity, defining complex secondary instabilities, delinking foot types, tendon reactivity/ligament instability, and deformity to represent these independently in a new classification system.
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NewsBot · Feb 26, 2024

Review of Classification Systems for Adult Acquired Flatfoot Deformity/Progressive Collapsing Foot Deformity and the Novel Development of the Triple Classification Delinking Instability/Deformity/Reactivity and Foot Type
Chandra Seker Pasapula et al
J Clin Med. 2024 Feb 6;13(4):942

Background: Classifications of AAFD/PCFD have evolved with an increased understanding of the pathology involved. A review of classification systems helps identify deficiencies and respective contributions to the evolution in understanding the classification of AAFD/PCFD. Methods: Using multiple electronic database searches (Medline, PubMed) and Google search, original papers classifying AAFD/PCFD were identified. Nine original papers were identified that met the inclusion criteria. Results: Johnson's original classification and multiple variants provided a significant leap in understanding and communicating the pathology but remained tibialis posterior tendon-focused. Drawbacks of these classifications include the implication of causality, linearity of progression through stages, an oversimplification of stage 2 deformity, and a failure to understand that multiple tendons react, not just tibialis posterior. Later classifications, such as the PCFD classification, are deformity-centric. Early ligament laxity/instability in normal attitude feet and all stages of cavus feet can present with pain and instability with minor/no deformity. These may not be captured in deformity-based classifications. The authors developed the 'Triple Classification' (TC) understanding that primary pathology is a progressive ligament failure/laxity that presents as tendon reactivity, deformity, and painful impingement, variably manifested depending on starting foot morphology. In this classification, starting foot morphology is typed, ligament laxities are staged, and deformity is zoned. Conclusions: This review has used identified deficiencies within classification systems for AAFD/PCFD to delink ligament laxity, deformity, and foot type and develop the 'Triple classification'. Advantages of the TC may include representing foot types with no deformity, defining complex secondary instabilities, delinking foot types, tendon reactivity/ligament instability, and deformity to represent these independently in a new classification system
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