Background:Modified oblique Keller capsular interposition arthroplasty (MOKCIA) is a treatment for hallux rigidus that has been shown to have similar long-term outcomes compared with metatarsophalangeal (MTP) arthrodesis. The purpose of this study was to evaluate differences in the level of sport and other activity following MOKCIA or first MTP arthrodesis. Methods:From 2005 to 2020, 58 MOKCIA and 112 arthrodesis patients were identified. Patients completed a sports-specific questionnaire (SSQ) along with the visual analog scale (VAS) pain/satisfaction, Foot and Ankle Ability Measure (FAAM), and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments, which yielded 14 MOKCIA and 15 arthrodesis subjects. Results:At an average 13 years' follow-up, the MOKCIA group participated in a mean of 3.4 ± 1.7 sport activities preoperatively and 3.4 ± 1.9 postoperatively, whereas arthrodesis patients participated in 3.5 ± 1.7 activities preoperatively and 2.9 ± 1.4 postoperatively (P = .22). Compared with preoperative, the MOKCIA group rated sporting activities as less difficult (10/12) and same difficulty (2/12). Hundred percent of patients in the MOKCIA group were satisfied with their overall level of activity following surgery, whereas 87% patients (13/15) in the arthrodesis group were satisfied. Patients in the MOKCIA group were able to participate in similar numbers of activities postoperatively, but arthrodesis patients had decreased activities. PROMIS, VAS pain/satisfaction, and FAAM Sports scores were similar between the groups. Conclusion:We found that MOKCIA compared similarly with MTP arthrodesis in sports physical function at long-term follow-up. These results must be interpreted in light of the very low follow-up and retrospective recall of preoperative activities. Level of Evidence:Level III, retrospective cohort study.

Background: Although metatarsophalangeal joint (MTPJ) arthrodesis is considered the “gold standard” for treatment of advanced MTPJ arthritis, a modified oblique Keller capsular interposition arthroplasty (MOKCIA) is an alternative treatment for hallux rigidus that retains MTPJ motion. We aim to retrospectively compare long-term patient-reported outcomes, radiographic alignment, MTPJ walking kinematics, and plantar pressure between the MOKCIA and MTPJ arthrodesis for advanced hallux rigidus. Methods: Thirty-five patients were recruited from a retrospective chart review (MOKCIA [n = 15, average 15 years from surgery] or an arthrodesis [n = 20, average 13 years from surgery]). We measured visual analog scale (VAS) pain and satisfaction, Foot and Ankle Ability Measure (FAAM), Patient-Reported Outcomes Measurement Information System (PROMIS) physical function scores, radiographs, walking MTPJ sagittal plane kinematics, forefoot, and first toe peak plantar pressure during walking, MTPJ goniometer range of motion, and need for additional surgery. Two-sample t tests or χ 2 were used to compare groups. A Spearman correlation was used to examine the relationships between measured variables. Results: Groups did not differ on demographic characteristics, FAAM activities of daily living scale (MOKCIA = 94 ± 8, arthrodesis = 94 ± 7, P = .93), PROMIS physical function T-score (MOKCIA = 50 ± 6, arthrodesis = 48 ± 6, P = .41), forefoot, and first-toe walking peak plantar pressure. The MOKCIA had small but significantly lower VAS pain (MOKCIA = 0.1 ± 0.3, arthrodesis = 1.0 ± 1.6, P = .02) and higher satisfaction scores (MOKCIA = 9.5 ± 0.9, arthrodesis = 8.4 ± 1.8, P = .03). MTPJ passive arc of excursion in the MOKCIA group was 44 ± 15 degrees, and greater goniometric measured flexion of the first MTPJ correlated with greater patient satisfaction in the MOKCIA group (ρ = 0.70, P < .01). No MOKCIA patient in our study group required additional surgery. Conclusion: Patients in both the MOKCIA and arthrodesis groups reported high function with little limitation due to their toe surgery. Patients in the MOKCIA group had similar pain and satisfaction compared with the arthrodesis group. These results suggest MOKCIA is a joint range of motion–preserving alternative to MTPJ arthrodesis for long-term treatment of hallux rigidus. Level of Evidence: Level III, retrospective, cohort study.

Study abroad programs represent an effective way to enhance student learning and development in business higher education, especially in international business, marketing, and trade. However, in the face of disruptors and barriers that affect a student's ability to travel internationally, virtual study abroad (VSA) programs can be a more accessible alternative to achieving comparable outcomes. This paper presents a purposeful design for VSA programs with comprehensive goals of students' personal, cultural, and professional development. Our study provides measurement and analysis of their effectiveness and demonstrates notable improvement across twelve essential facets of personal, cultural, and professional learning objectives among participants engaged in a virtual, project-based study abroad program. These findings underscore the significance of VSA programs and advocate for their continued inclusion in university curricula.

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures are among the most common injuries that Orthopaedic Surgeons treat; yet, little guidance exists in postoperative protocols for ankle fractures concerning time of immobilization and weightbearing. Results from previous studies have been mixed; demonstrating improved outcomes, no difference in outcome, or poorer outcomes including increased wound complications in patients who are mobilized early. Here, we aim to investigate the association between early immobilization and patient reported outcomes. Our null hypothesis was that no difference in PROMIS scores would be identified in patients when comparing the effect of time of immobilization and time of weightbearing. Methods: A chart review identified ankle fractures that underwent surgical fixation between 2015 and 2020 at a level 1 trauma center and its associated facilities. One-hundred nineteen patients from 8 providers met inclusion criteria for our final analysis. Fifty patients were immobilized for <6 weeks and 69 patients were immobilized for at least 6 weeks. Our primary outcome measures included the PROMIS questionnaire, time of immobilization, and time to full weightbearing. Our secondary outcome measures included time to return to work, wound complications (infection, delayed healing), and complications associated with fracture fixation (loss of reduction, delayed union, reoperation, hardware failure). Repeated-measures ANOVAs were used to predict each of the PROMIS outcomes of anxiety, depression, physical function, and pain interference. Each model included the predictors of age, sex, race, BMI, payor, provider, time to radiographic union, time to return to work, time to full weightbearing, and early vs late immobilized groups. Results: There were no differences in PROMIS scores between mobilization groups and time to full weightbearing (p>0.05). Furthermore, there were no differences in wound complications nor complications associated with fracture fixation (p>0.05). Across our cohort, physical function scores were negatively impacted by higher BMI, increasing age and longer time to return to work/play (p<0.05). Our analysis further showed that depression, anxiety, pain interference and physical function levels improve as a function of time (p<0.05). African Americans showed more pain interference than other groups of patients (p<0.05). No difference in PROMIS scores were identified between treating providers (p>0.05). Conclusion: In this study, the null hypothesis was accepted. Data from our analysis shows no significant differences between the early and late mobilization and weightbearing groups in terms of PROMIS outcomes nor with wound complications and complications associated with fracture fixation. Our study does suggest that early mobilization after operative treatment of ankle fractures is safe and results in similar patient reported outcomes with no increased risk of complication. We did find that African American patients experienced more pain that other groups and we aim to further explore this topic to find potential modalities to address this disparity.

Background: This study aimed to assess the preferred operative treatment for patients over the age of 60 with end-stage ankle arthritis and perspectives on total ankle replacement (TAR) among American Orthopaedic Foot & Ankle Society (AOFAS) members. Associated factors were analyzed for potential contraindications among members with different levels of experience. Method: A questionnaire containing 6 questions was designed and sent to 2056 members of the AOFAS. Responses were received from 467 orthopaedic surgeons practicing in the United States (76%), Canada (5%), and 26 other countries (20%). Participants were grouped for response comparisons according to country as well as experience level. Differences in contraindications were compared using χ2 tests or exact tests. Results: Respondents practicing in the United States and surgeons who perform 11 or more TARs per year tended to recommend operative treatments favoring TAR and displayed recognition of its increasing role (P < .05). Overall, respondents felt that 41% of typical patients over 60 years old with end-stage arthritis would be best treated with TAR. Talus avascular necrosis, morbid obesity (body mass index >40 kg/m2), and poorly controlled diabetes with neuropathy were most recognized as the absolute contraindications to TAR. Surgeon’s experience affected the consideration of these clinical factors as contraindications. Conclusions: Total ankle replacement has a substantial and increasing role in the treatment of end-stage ankle arthritis in patients over the age of 60. Absolute and potential contraindications of the procedures were indicated from a cross-sectional survey of AOFAS members. Surgeons more experienced with total ankle replacement felt more comfortable employing it in a wider range of clinical settings. Level of Evidence: Level III, therapeutic.

Background The management of symptomatic osteochondral lesions of the talus (OLTs) previously treated with arthroscopy is controversial. Minimal data exist on the role for repeat arthroscopy. Here, we describe our experience with repeat arthroscopy and microfracture for symptomatic OLTs. Methods Our database was queried over an 8-year period to identify patients undergoing repeat arthroscopy and microfracture as treatment for symptomatic OLTs. Phone surveys were conducted to assess residual pain, patient satisfaction, and need for subsequent surgery. We compared patient outcomes based on the size of their OLT (small lesions ≤150 mm2, large >150 mm2) and the presence or absence of subchondral cysts. Results We identified 14 patients who underwent repeat arthroscopy and microfracture for symptomatic OLTs. Patients reported reasonable satisfaction (7.6 ± 3.5 out of 10) but moderate residual pain (4.7 ± 3.4 out of 10) at midterm follow-up (5.1 ± 2.9 years). In total, 21% (3/14) of patients had undergone subsequent surgery. Patients with small (n = 5) and large OLTs (n = 9) had similar postoperative pain scores (4.2 ± 4.1 vs 4.9 ± 3.2) and postoperative satisfaction levels (6.4 ± 4.9 vs 8.3 ± 2.5). Conclusion At midterm follow-up, repeat arthroscopy for symptomatic OLTs demonstrated reasonable satisfaction but moderate residual pain. Lesion size or presence of subchondral cysts did not affect outcome, but our sample size was likely too small to detect statistically significant differences. These data show that repeat ankle arthroscopy can be performed safely with modest outcomes, and we hope that this report aids in managing patient expectations. Level of Evidence: Level IV Case Series

Foot drop is a common clinical condition which may substantially impact physical function and health-related quality of life. The etiologies of foot drop are diverse and a detailed history and physical examination are essential in understanding the underlying pathophysiology and capacity for spontaneous recovery. Patients presenting with acute foot drop or those without significant spontaneous recovery of motor deficits may be candidates for surgical intervention. The timing, mechanism, and severity of neural injury resulting in foot drop influence the selection of the most appropriate peripheral nerve surgery, which may include direct nerve repair, neurolysis, nerve grafting, or nerve transfer.

Background: Recently, the Canadian Orthopaedic Foot and Ankle Society (COFAS) proposed a classification system addressing adjunct procedures in the treatment for end-stage ankle arthritis. We reviewed Patient-Reported Outcome Measures Information System (PROMIS) data to determine if outcomes of total ankle arthroplasty (TAA) correlated with postoperative COFAS classification. We hypothesize that as COFAS classification increases, patients will demonstrate greater improvement in the change between pre- and postoperative PROMIS scores. Methods: From June 2015 to December 2018, a total of 127 patients underwent 132 TAA. Demographic factors and preoperative and most recent postoperative PROMIS scores were collected. Univariate, multivariate and post hoc analyses with a significance threshold of P <.05 were performed. Results: Eighty-seven patients with a mean follow-up of 13.6±7.3 months and complete PROMIS scores were classified into COFAS types 1-4. Significant differences were identified in the PROMIS Pain Interference domain comparing COFAS types 2 and 4 and COFAS types 3 and 4. These results demonstrate that more complex ankles with a higher COFAS score had worse interval improvement in PROMIS scores. Additionally, multivariate linear regression showed that age and BMI were associated with worse physical function and depression, whereas diabetes and a history of prior surgeries were associated with improved postoperative function. Conclusion: The COFAS postoperative classification system is useful for categorizing end-stage ankle arthritis. Further research into the ideal timing of surgery and higher-level studies to better determine TAA efficacy with different classification systems is warranted. This information can be helpful with preoperative counseling about treatment outcomes. Level of Evidence: Level IV, retrospective analysis of prospectively collected data.

Foot drop is a common condition that may impact physical function and health-related quality of life. A detailed clinical history and physical examination are critical components of the initial evaluation of patients presenting with foot drop. Patients with refractory foot drop without spontaneous recovery of motor deficits, delayed presentation greater than 12 months from injury, or neural lesions that are not amenable to or have failed nerve reconstruction may be candidates for tendon transfers to restore active ankle dorsiflexion. The modified Bridle procedure is a dynamic tendon transfer that has demonstrated excellent functional outcomes in patients with refractory foot drop.

Our understanding of the cause and principles of treatment of progressive collapsing foot deformity (PCFD) has significantly evolved in recent decades. The goals of treatment remain improvement in symptoms, correction of deformity, maintenance of joint motion, and return of function. Although notable advancements in understanding the deformity have been made, complications still occur and typically result from (1) poor decision making, (2) technical errors, and (3) patient-related conditions. In this article, we discuss common surgical modalities used in the treatment of PCFD and further highlight the common complications that occur and the techniques that can be used to prevent them.

Purpose The purpose of this study is to explore modifications to the supply chain strategies of international manufacturers resulting from recent momentous trade disruptions, including the US-China trade war, global tariff escalations, Brexit and heightened geopolitical tensions. Design/methodology/approach The research methodology consisted of a series of in-depth personal interviews with senior supply chain executives of six large US international manufacturers. Findings The study identified several short-term reactive strategies taken, including pulling purchase orders or production forward, building inventory and applying for exceptions from tariffs, along with longer-term proactive strategies such as shifting and expanding supplier and manufacturing locations. Research limitations/implications The study's limitations involve its small sample size and its findings being industry and company-specific to a limited number of firms. While the sample size was deemed sufficient for this exploratory study, larger sample sizes and subsequent industry-specific analyses are recommended. Practical implications The global supply chain modifications effectively used by the firms in the study can offer guidance for practitioners facing similar challenges following major trade disruptions. Originality/value Due to the very recent emergence of the trade disruptors examined in this study, extant literature is limited. Hence, the findings noted in the paper offer not only guidance for practitioners but also make a strong contribution to research and literature on global supply chain risk management and disruption risk mitigation.

Dislocation of the native knee represents a challenging injury, further complicated by the high rate of concurrent injury to the common peroneal nerve (CPN). Initial management of this injury requires a thorough neurovascular examination, given the prevalence of popliteal artery injury and limb-threatening ischemia. Further management of a knee dislocation with associated CPN palsy requires coordinated care involving the sports surgeon for ligamentous knee reconstruction and the peripheral nerve surgeon for staged or concurrent peroneal nerve decompression and/or reconstruction. Finally, the foot and ankle surgeon is often required to manage a foot drop with a distal tendon transfer to restore foot dorsiflexion. For instance, the Bridle Procedure—a modification of the anterior transfer of the posterior tibialis muscle, under the extensor retinaculum, with tri-tendon anastomosis to the anterior tibial and peroneus longus tendons at the anterior ankle—can successfully return patients to brace-free ambulation and athletic function following CPN palsy. Cross-discipline coordination and collaboration is essential to ensure appropriate timing of operative interventions and ensure maintenance of passive dorsiflexion prior to tendon transfer.

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: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: Decreased lean muscle mass in the lower extremity in diabetic peripheral neuropathy (DPN) is thought to contribute to altered joint loading, immobility, and disability. However, the mechanism behind this loss is unknown and could derive from a reduction in size of myofibers (atrophy), destruction of myofibers (degeneration), or both. Degenerative changes require participation of muscle stem (satellite) cells to regenerate lost myofibers and restore lean mass. Determining the degenerative state and residual regenerative capacity of DPN muscle will inform the utility of regeneration-targeted therapeutic strategies. Methods: Biopsies were acquired from 2 muscles in 12 individuals with and without diabetic neuropathy undergoing below-knee amputation surgery. Biopsies were subdivided for histological analysis, transcriptional profiling, and satellite cell isolation and culture. Results: Histological analysis revealed evidence of ongoing degeneration and regeneration in DPN muscles. Transcriptional profiling supports these findings, indicating significant upregulation of regeneration-related pathways. However, regeneration appeared to be limited in samples exhibiting the most severe structural pathology as only extremely small, immature regenerated myofibers were found. Immunostaining for satellite cells revealed a significant decrease in their relative frequency only in the subset with severe pathology. Similarly, a reduction in fusion in cultured satellite cells in this group suggests impairment in regenerative capacity in severe DPN pathology. Conclusion: DPN muscle exhibited features of degeneration with attempted regeneration. In the most severely pathological muscle samples, regeneration appeared to be stymied and our data suggest that this may be partly due to intrinsic dysfunction of the satellite cell pool in addition to extrinsic structural pathology (eg, nerve damage). Clinical Relevance: Restoration of DPN muscle function for improved mobility and physical activity is a goal of surgical and rehabilitation clinicians. Identifying myofiber degeneration and compromised regeneration as contributors to dysfunction suggests that adjuvant cell-based therapies may improve clinical outcomes.

Background: Lesser toe metatarsal head degeneration and collapse can cause significant pain and disability. In the setting of global metatarsal head collapse, there are limited operative options. The purpose of our study was to evaluate clinical and radiographic outcomes after lesser toe metatarsophalangeal (MTP) joint interpositional arthroplasty with a tendon allograft and to describe the operative technique. Methods: We retrospectively reviewed a consecutive series of patients treated by 3 fellowship-trained foot and ankle surgeons at one institution. We created a phone survey to evaluate satisfaction, pain, and likelihood to repeat the surgery. Foot and Ankle Ability Measure (FAAM) scores were reviewed before and after surgery. Preoperative and postoperative radiographs were evaluated for preservation of metatarsal length. The procedure was performed through a dorsal midline approach. The metatarsal head was reamed to a concave shape. A tendon allograft was fashioned into a ball and secured to the metatarsal with an anchor. Fifteen feet in 14 patients underwent lesser MTP joint interposition arthroplasty, with the average age of 49 years (range, 24-69), and an average follow-up of 4.2 years. Results: Eighty percent (12/15) reported they would have the procedure again. Visual analog scale pain scores showed a decrease in pain from 7 to 1. FAAM sports subscale improved from 56% to 85%. Radiographically, the ratio of the affected metatarsal length to the adjacent metatarsal remained constant before and after surgery, suggesting preservation of the metatarsal cascade. Conclusion: Interpositional arthroplasty of the lesser MTP joints with a rolled tendon allograft provided a unique solution, as it allows the surgeon to fill a large void without harvesting an autograft. This study showed improved patient-reported outcomes, high patient satisfaction, and good radiographic outcomes. Lesser metatarsophalangeal joint allograft interposition arthroplasty was a viable solution as a salvage procedure in the setting of global metatarsal head collapse. Level of Evidence: Level IV, retrospective case series.

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: There is evidence that the medial displacement calcaneal osteotomy (MDCO) can be effective in treating the progressive collapsing foot deformity (PCFD). This juxta-articular osteotomy of the tuberosity shifts the mechanical axis of the calcaneus from a more lateral position to a more medial position, which provides mechanical advantage in the reconstruction for this condition. This also shifts the action of the Achilles tendon medially, which minimizes the everting deforming effect and improves the inversion forces. When isolated hindfoot valgus exists with adequate talonavicular joint coverage (less than 35%-40% uncoverage) and a lack of significant forefoot supination, varus, or abduction, we recommend performing this osteotomy as an isolated bony procedure, with or without additional soft tissue procedures. The clinical goal of the hindfoot valgus correction is to achieve a clinically neutral heel, as defined by a vertical axis from the heel up the longitudinal axis of the Achilles tendon and distal aspect of the leg. The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction. Level of Evidence: Level V, consensus, expert opinion.

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:Forefoot varus is a physical and radiographic examination finding associated with the Progressive Collapsing Foot Deformity (PCFD). Varus position of the forefoot relative to the hindfoot is caused by medial midfoot collapse with apex plantar angulation of the medial column. Some surgeons use the term forefoot supination to describe this same deformity (see Introduction section with nomenclature). Correction of this deformity is important to restore the weightbearing tripod of the foot and help resist a recurrence of foot collapse. When the forefoot varus deformity is isolated to the medial metatarsal and medial cuneiform, correction is indicated with an opening wedge medial cuneiform (Cotton) osteotomy, typically with interposition of an allograft bone wedge from 5 to 11 mm in width at the base. When the forefoot varus is global, involving varus angulation of the entire forefoot and midfoot relative to the hindfoot, other procedures are needed to adequately correct the deformity.LEVEL OF EVIDENCE:Level V, consensus, expert opinion.