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At the 2024 AOFAS Annual Meeting, experts convened to discuss “Flatfoot, PCFD ... or Whatever We Call It These Days,” moderated by Scott J. Ellis, MD, and Simon R. Platt, MBChB, FRCS. Among the highlights of this track were insights from the panel on the progressive collapsing foot deformity (PCFD) classification’s pearls and pitfalls.

Cesar de Cesar Netto, MD, PhD, kicked off his part of the session by sharing some history on the PCFD Consensus from November 2019. He shared that he believed it would change surgeons’ view on the pathology and its treatment. Beginning with a literature review, he explained that the panel was invited to an in-person meeting. Preliminary questions were sent beforehand for the panel’s consideration. They reviewed the literature orally, discussed the proposal for the classification, sent follow-up questions, and then formulated the classification.

Publication began in 2020¹, and Dr. de Cesar Netto characterized the classification as a reorganization and reimagining of existing knowledge, with the addition of the focus on peritalar subluxation. He then moved on to answering a few key questions about this system.

Is this classification decisive? Dr. de Cesar Netto said “yes.” He pointed out that it allows surgeons to describe what they see, taking into account that deformity patterns can happen nonsequentially and concomitantly. In general, he contended that it can help in thinking what to do surgically to correct each of these deformity patterns.

Is it a cookbook? He said “no.” Surgeons approach deformities differently, he added, and PCFD is a complex deformity. This complexity and the nature of surgeon preferences cannot fit into a cookbook approach.

He commented that we live in a 2-dimensional world, but we forget sometimes that the foot is a 3-dimensional structure. “Moving the tripod, it all changes,” he said.

Dr. de Cesar Netto then went on to present a case example and how one could implement the PCFD classification. 

What Flaws Exist With This System?

Eric M. Bluman, MD, PhD, then took the podium to provide constructive criticism of this system. He said from his point of view, almost all of this classification is Level 5 evidence, although the workgroup is highly respectable. He acknowledged that the refined PCFD classification system is functional, but that there are significant areas that need improvement, in his observation.

What the Classification Got Right. Dr. Bluman shared that the system was indeed collaborative. Different thought leaders gathered to form a best practices consensus on description of this disorder. He added that the name of the system is good. This is not to be confused with the associated nomenclature, he said. The name of previous classifications were problematic and had inaccuracies, whereas he said he feels this one works. Lastly, he agreed that was indeed built on previous knowledge, highlighting and expanding upon concepts from the earlier systems. In particular, he said the PCFD classification system does more robustly address the pathology of this 3-dimensional deformity.

What Needs Improvement? He explained that he feels the system is not very intuitive. It starts with hindfoot valgus (A), then moves to midfoot/forefoot (B), forefoot varus/instability (C), and then loops back to hindfoot (D) and ankle (E).¹ He commented that this can be circuitous, and could lead to concerns regarding conceptualization and communication.

As an example, he shared several classification designations using the PCFD system and then asked the audience to envision the corresponding deformity. Overall, the PCFD classification has 242 different permutations, which he feels is too much to keep track of.

Dr. Bluman also shared his observation that the group methodology was not totally transparent. He also contended that this classification lacks a linkage to possible or recommended treatment options. He acknowledged that this is not a requirement, per se, but that it would be a useful feature.

He concluded by suggesting that the system should keep its current name, but that the nomenclature itself should be more intuitive and easily applicable. Linking treatment pathways would also be helpful. And lastly, broader input could possibly work towards achieving the most implementable and helpful system possible.

Other thought leaders discussed soft tissue and bony considerations, along with the role of arthroereisis.

Reference
1.        de Cesar Netto C, Deland JT, Ellis SJ. Guest Editorial: Expert Consensus on Adult-Acquired Flatfoot Deformity. Foot Ankle Int. 2020;41(10):1269-1271. doi: 10.1177/1071100720950715. Epub 2020 Sep 1. PMID: 32870716.