Progressive collapsing foot deformity

Indication

Progressive collapsing foot deformity (PCFD), formerly adult-acquired flatfoot deformity, is a multiplanar, progressive condition typically driven by posterior tibial tendon insufficiency. The decision point for surgeons is selecting a joint-preserving reconstruction (arthroereisis, medialising calcaneal osteotomy with or without tendon transfer, lateral column lengthening) versus a definitive fusions (triple arthrodesis) based on deformity flexibility, stage, and patient factors.

The techniques

• Subtalar arthroereisis – implantation of a device (screw, plug, or stent) into the sinus tarsi to limit subtalar eversion; usually combined with soft-tissue procedures rather than performed in isolation.
• Medialising calcaneal osteotomy (MDCO) ± FDL transfer – a transverse osteotomy of the calcaneus shifted medially to restore the mechanical axis; often augmented with flexor digitorum longus transfer to substitute for the insufficient posterior tibial tendon.
• Cotton / Evans lateral column lengthening – an opening-wedge osteotomy of the anterior calcaneus (Evans) or distraction arthrodesis of the calcaneocuboid joint (Cotton) to lengthen the lateral column and correct forefoot abduction.
• Triple arthrodesis – fusion of the subtalar, talonavicular, and calcaneocuboid joints to achieve rigid correction of fixed, multiplanar deformity.

What the evidence says

A network meta-analysis of 21 studies (498 patients) found that no single procedure dominated across all radiographic and clinical endpoints: medial displacement calcaneal osteotomy (MDCO) had the highest probability of being best for lateral talocalcaneal angle and calcaneal pitch, lateral column lengthening (LCL) ranked best for AP talo-first metatarsal and lateral talo-first metatarsal angles, while triple arthrodesis ranked best for lateral talocalcaneal-arch height, AP talocalcaneal, lateral talocalcaneal-talocalcaneal, AP talonavicular coverage, talonavicular coverage, and AOFAS score [1]. A dedicated meta-analysis of 355 LCL cases (osteotomy or arthrodesis) reported similar union rates between techniques but fewer complications — including less lateral column pain — with calcaneocuboid arthrodesis versus opening-wedge osteotomy; autograft outperformed allograft, and keeping graft size ≤8 mm reduced complications [2]. Two systematic reviews on subtalar arthroereisis for stage‑II deformity reached slightly different conclusions: one (12 studies) noted high complication rates, chiefly sinus tarsi pain, and emphasised that arthroereisis is rarely used alone [3]; the other (9 studies, 190 procedures) reported improvement in clinical and radiological scores with a low complication rate and suggested benefit as an adjunct [4]. A 2024 systematic review of minimally invasive MDCO (501 cases) showed a 3 % infection rate, 1 % sural neuropathy, and 4 % screw removal for pain; comparative data indicated significantly lower infection rates versus open MDCO (1 % vs 14 %) [5]. Direct head‑to‑head trials between the four options are absent; the network meta-analysis relies on indirect comparisons, and the arthroereisis reviews are limited to stage‑II flexible deformity.

What members see

How often do you use arthroereisis as a standalone procedure versus an adjunct, and what is your reoperation rate for sinus tarsi pain? For those performing MDCO with FDL transfer, do you see a meaningful difference in functional scores compared with MDCO alone (the network meta-analysis did not evaluate the combination separately) [1]? When do you choose Cotton arthrodesis over Evans osteotomy for lateral column lengthening, and what graft size threshold do you observe in practice?

Cost and access

The supplied sources do not report cost data. Factors that drive cost differences include implant cost for arthroereisis devices, allograft versus autograft expense for lateral column lengthening, operative time (open vs minimally invasive MDCO), and the potential need for a second procedure for hardware removal (4 % screw removal in MIS‑MDCO series) [5]. Triple arthrodesis eliminates joint motion but avoids implant costs and may reduce revision surgery for progressive arthritis.

Open questions

• What is the comparative effectiveness of MDCO + FDL transfer versus MDCO alone in stage‑IIB/IIC deformity?
• Does minimally invasive MDCO maintain radiographic correction at long-term follow-up (>5 years) equivalent to open MDCO?
• At what degree of fixed hindfoot varus/valgus or midfoot arthritis does triple arthrodesis become clearly superior to joint-preserving options?
• What is the optimal graft material and size threshold for Evans osteotomy to minimise non-union and lateral column pain?
• Are there identifiable patient subgroups (age, BMI, activity level) in which arthroereisis as an adjunct provides durable benefit without high reoperation rates?

References

5 of 5 papers retrieved for this room are cited above. The search was limited to systematic reviews, meta-analyses and randomised trials in humans, English, 2016 onwards. Query and full result set: research/raw/pcfd.json.

1. 1Surgical procedures for treatment of adult acquired flatfoot deformity: a network meta-analysis. J Orthop Surg Res 2019 · PMID 30791933 Review
2. 2Lateral Column Lengthening For Flexible Adult Acquired Flatfoot: Systematic Review and Meta-Analysis. J Foot Ankle Surg 2021 · PMID 34253434 Meta-Analysis, Systematic Review
3. 3Is subtalar arthroereisis a good procedure in adult-acquired flatfoot? A systematic review of the literature. Orthop Traumatol Surg Res 2021 · PMID 34216843 Systematic Review
4. 4Outcomes Following the Use of Subtalar Arthroereisis in the Correction of Adult Acquired Flatfoot: A Systematic Review. Foot Ankle Spec 2022 · PMID 33511862 Systematic Review
5. 5Minimally invasive surgery in medial displacement calcaneal osteotomy for acquired flatfoot deformity: a systematic review of the literature. Arch Orthop Trauma Surg 2024 · PMID 38212588 Systematic Review

Back to the comparisons