Multimodal Surgical Management of Stage 1a/1b PCFD (Stage II AAFD): Early Outcomes of a Standardized Four-in-One Procedure Protocol

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Abstract
Background/Objectives: Progressive collapsing foot deformity (PCFD) is driven by multiplanar peritalar instability. This study evaluated the clinical and radiographic outcomes of a standardized four-component reconstruction protocol designed to facilitate immediate postoperative weight-bearing in Stage 1a/1b PCFD. Methods: This single-center retrospective study included 20 patients treated between 2015 and 2023 with medializing calcaneal osteotomy, spring ligament repair, flexor digitorum longus (FDL) tendon transfer with internal brace augmentation, and subtalar arthroereisis. Clinical (VAS, AOFAS) and radiographic parameters (anteroposterior and lateral Meary angles, calcaneal pitch, and talonavicular coverage angle) were assessed longitudinally, with subgroup analysis comparing implant removal versus retention. Results: The protocol yielded significant overall improvements. Mean VAS decreased by 4.37 points (p < 0.001), and final AOFAS reached 84.7 ± 7.6 at the final follow-up. Although subtalar arthroereisis was removed in 45% of patients due to symptomatic irritation, subgroup analysis revealed no significant loss of radiographic correction (p > 0.05). Notably, a significant interaction effect was observed for VAS scores (p = 0.002) and AOFAS scores (p = 0.041), with the removal group demonstrating a pronounced functional recovery trajectory following explantation. No major complications occurred. Conclusions: A standardized four-in-one reconstruction provides reliable multiplanar correction in Stage 1a/1b PCFD. The maintenance of structural alignment despite a high implant removal rate supports the role of arthroereisis as a temporary but valuable adjunct for early mobilization. This strategy offers a reproducible framework for joint-preserving PCFD management.

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