Multi-staged Versus Single-staged Reconstruction for Progressive Collapsing Foot Deformity (PCFD): A Retrospective Cohort Study of Complications and Cost

Abstract

Background

Surgical reconstruction of progressive collapsing foot deformity (PCFD) is generally performed using a single-staged (SS) approach. However, a multi-staged (MS) approach may be used and has not been previously described or evaluated. Questions: 1. Are there any differences in complication rates and subsequent operation rates between SS and MS PCFD reconstruction? 2. How do the costs of SS PCFD reconstruction compare to MS PCFD reconstruction?

Methods

A retrospective cohort study of SS and MS PCFD reconstruction was performed, with treatment allocation determined by the treating surgeon. Rates of major complications, subsequent operations, and costs of operating time and hospital admissions were compared.

Results

Seventy-four feet with SS and 63 feet with MS reconstruction were included. Higher major complication rates were noted in SS (16%) compared with MS reconstruction (2%) (P = .02), with no significant difference in subsequent operation rate (P = .05). Total operating room and hospital admission costs were higher in SS ($20 868) compared with MS ($14 900) (P = .01).

Conclusions

This study reports outcomes of MS approach for PCFD reconstruction. In this cohort, MS reconstruction was associated with lower wound complication risks and costs compared with a traditional SS approach. Future studies evaluating patient-reported outcomes are warranted to further optimize surgical management of PCFD.

Level of Evidence

Keywords

AAFD complications cost analysis flatfoot multi-staged PCFD planovalgus reconstruction single-staged

“The etiology of PCFD is complex; the deformity involves varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus.”

Introduction

Background

Progressive collapsing foot deformity (PCFD), previously known as adult acquired flatfoot deformity (AAFD), is common, with a prevalence of 3.3% in women over 40 years old.¹-³ PCFD is a painful, debilitating condition reflected by extremely poor preoperative patient-reported outcomes.^4,5 The etiology of PCFD is complex; the deformity involves varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus.³ Over the past century, numerous surgical procedures have been proposed for the treatment of PCFD, ranging from various osteotomies and hindfoot realignment procedures to tendon transfers, arthrodesis of one or more joints, and arthroereisis techniques.⁶ Nowadays, surgical treatment of PCFD is still heterogeneous,⁷-⁹ and surgical technique is commonly dictated by surgeon preference, with lack of overall consensus on optimal approach.¹⁰ Published complication rates reach up to 20%.¹¹ Progressive collapsing foot deformity reconstruction is commonly performed as a single-stage (SS), which amalgamates multiple separate procedures with their corresponding incisions to achieve deformity correction. The considerable complication rate may relate to the sheer number of surgical incisions traumatizing the extremely small surface area of the foot, all applied within one encounter. Given this extensile surgical trauma, PCFD reconstruction usually requires postoperative hospital admission for pain management.¹²

Rationale

With an aging population, the operative incidence and associated economic burden of PCFD correction has increased over the last 2 decades.¹³ A multi-staged (MS) approach may be an equivalent alternative for SS PCFD surgery with potential to minimize the burden of surgical trauma to the foot and associated costs of resultant complications. In MS reconstruction, patients undergo 2 operations, approximately 4 weeks apart, and typically do not require hospital admission. By staging surgery over multiple episodes of care, MS reconstruction reduces overall trauma to the foot at one encounter. This may limit wound complication risks, allowing incisions time to heal under lesser tension.¹⁴ This effect has been illustrated in foot and ankle trauma where staged fixation results in more favorable outcomes by minimizing soft tissue trauma.^15,16 In addition, staged procedures enable outpatient surgery which may reduce overall cost of treatment.

This study aims to evaluate the rate of major complications and subsequent intervention associated with SS and MS reconstruction. Second, we compare direct cost of SS and MS PCFD reconstruction, specifically those associated with operating room (OR) time and hospital admission. We hypothesize that MS reconstruction may be associated with lower complication rates and potentially lower health care costs compared with SS reconstruction.

Material and Methods

Study Design

In this retrospective cohort study, PCFD reconstructions performed by 2 fellowship-trained foot and ankle surgeons at a University-affiliated teaching hospital, between November 2011 and December 2019, were assessed. Both surgeons had similar treatment approaches and number of surgical procedures. One surgeon primarily performed SS reconstruction while the other did MS. Billing codes for lower extremity tendon transfer, calcaneal osteotomy, midtarsal osteotomy, and midtarsal joint arthrodesis were utilized to identify patients for inclusion.

Patients were included if they were 19 years or older, had PCFD reconstruction including bony and soft tissue procedures, and had minimum 1-year follow-up. Patients were excluded if they had concomitant ankle joint replacement or fusion, diabetic Charcot arthropathy, active infection, or revision reconstruction. Study size was determined by the number of treated patients meeting the inclusion criteria within the selected 8-year period. Primary outcomes included major complication and subsequent operation rates. Secondary outcomes included total OR and hospital admission cost.

Ethics approval was obtained prior to study conduction by the Institutional Research Ethics Board. This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Surgical Approaches SS Versus MS

Single-staged surgery included the following procedures: medializing calcaneal osteotomy or calcaneal lengthening (Evans) osteotomy, medial column stabilization with naviculocuneiform (NC) or first tarsometatarsal (TMT1) fusion, and soft tissue procedures including peroneus brevis to posterior tibial tendon transfer and gastrocnemius recession (Strayer procedure). Single-staged patients were kept non-weightbearing (NWB) for approximately 8 weeks in total (Figure 1).

Figure 1

Weightbearing protocols for SS and MS PCFD reconstruction. Patients were kept NWB for 8 weeks in SS group, 10 weeks in MS group.

Multi-staged surgery included medializing calcaneal osteotomy, medial column stabilization with plantarflexion osteotomy of the medial cuneiform (Cotton), NC fusion or TMT1 fusion in the first stage, and soft tissue procedures in the second stage (approximately 4 weeks after stage 1) including tendon transfers (flexor digitorum longus to navicular and/or peroneus brevis to peroneus longus), spring ligament reconstruction, and gastrocnemius recession. Multi-staged patients were kept NWB for approximately 10 weeks in total (Figure 1).

Both surgeons harvested iliac crest or proximal tibial bone graft as required. Surgical approach including number and length of incisions applied to the foot were similar in both groups upon completion of SS or MS. Patients were admitted postoperatively for pain and medical management if needed.

Data Collection

Patient demographics including age, sex, medical comorbidities (conditions requiring medical management such as hypertension, hyperthyroidism, etc), diabetes, smoking status, and prior ipsilateral surgery were recorded. Talonavicular coverage angle (TNCa) and Meary’s angle (MA) were measured on anterior-posterior and lateral preoperative weightbearing radiographs, respectively, to assess for degree of PCFD deformity. This was performed independently by 2 foot and ankle fellows who were not part of the treating physician team.

Charts were reviewed for minimum 1-year follow-up from index surgery, with events recorded within 3-year follow-up when available. Total OR time, length of hospital admission, subsequent operations performed, and major complications defined as wound dehiscence, or infection not resolved by oral antibiotics were recorded.

For cost analysis, local health authority non-resident rates in Canadian dollars were utilized as a proxy for direct health system costs. Total OR and hospital stay costs were calculated for each patient using OR rates per hour ($2650 for first 2 hours, $1320 for additional hours) and hospital stay per diem ($4030).

Statistical Analysis

All metric variables were reported as mean with standard deviation (SD). Student t test was used for normally distributed metric variables. For categorical variables, chi-square test was used. A multivariate logistic regression model was applied to determine associations between major complication and subsequent operation rates with SS and MS groups. For determining differences in mean cost between SS and MS groups, a multivariate linear regression model was used. Results from the regression analyses were reported as adjusted and unadjusted odds ratio and mean difference, respectively, with a 95% confidence interval. Confounding variables considered in the adjustments included age, presence of medical comorbidities, diabetes and smoking status, and prior ipsilateral surgery. Statistical significance was determined by P < .05. Analysis was completed using SAS software.

Results

Initial screening identified 284 feet from 273 patients. After applying inclusion and exclusion criteria, 74 feet from 66 patients and 63 feet from 60 patients were included in the SS and MS groups, respectively. Patient demographics are shown in Table 1. The MS group had a trend toward younger patients, with lower rates of medical comorbidities, diabetes, and smoking status than the SS group, though not statistically significant besides age. The degree of preoperative PCFD deformity, as determined by MA and TNCa, was not significantly different between the groups (Table 1). A higher rate of major complications occurred in SS (16%) patients compared with MS patients (2%) (P = .02) (Table 2). The dorsal incision to the medial column was most commonly affected in wound complications. The odds of having a subsequent operation to the ipsilateral foot or ankle during follow-up were similar between the MS and SS groups (Table 2). There was a trend toward a higher rate of PCFD-related revision procedures in the SS group (27.0% vs 12.7%), which include mal-union/non-union, infection/wound dehiscence, and residual/recurrent PCFD deformity, with borderline statistical significance (P = .0505) (Table 2). In contrast, overall subsequent operations during follow-up did not differ significantly between groups (43.2% vs 34.9%; P = .4379). Subsequent operations were performed in both groups for various indications (Table 3).

Table 1.

Patient Baseline Demographics and Preoperative PCFD Deformity.

	SS (N = 74)	MS (N = 63)	P value
Age at OR (years)^a	57.5 (14.4)	49.1 (14.9)	.0051
Sex (% male)	37.8%	31.7%	.4536
Medical comorbidities (% Yes)	71.6%	68.3%	.6742
Diabetes (% Yes)	5.4%	03.2%	.5310
Smoker (% Yes)	13.5%	6.3%	.1650
Prior ipsilateral surgery (% Yes)	24.3%	34.9%	.1737
Meary’s angle (°)^b	-12.7 (11.9)	-18.6 (13.3)	.0907
Talonavicular coverage angle (°)^c	24.3 (14.2)	26.2 (18.6)	.1292

Abbreviation: OR, operating room.

a,b,c

Values presented as mean (SD).

Table 2.

Rate of Subsequent Operations and Major Complications.

	SS (N = 74), %	MS (N = 63), %	Unadjusted odds ratio (95% CI)	P value	Adjusted odds ratio (95% CI)^a	P value
Major complications (% Yes)	16.2	1.6	0.08 (0.00, 0.44)	.0186	0.07 (0.00, 0.42)	.0163
Subsequent ipsilateral foot/ankle operations during follow-up^b (% Yes)	43.2	34.9	0.70 (0.35, 1.41)	.3212	0.75 (0.36, 1.56)	.4379
Subsequent revision surgeries related to PCFD reconstruction (% Yes)^c	27.0	12.7	0.39 (0.15, 0.94)	.0422	0.37 (0.13, 0.97)	.0505

Abbreviations: CI, confidence interval; PCFD, progressive collapsing foot deformity.

Adjusted odds ratio accounts for potential confounders: age, medical comorbidities, smoking and diabetes status, prior ipsilateral surgery.

Included procedures for the following: mal-union/non-union, infection/wound dehiscence, residual/recurrent PCFD deformity, hardware irritation, ankle synovitis, toe deformities, talar osteochondral lesion.

Included procedures for the following: mal-union/non-union, infection/wound dehiscence, residual/recurrent PCFD deformity.

Table 3.

Indications for Subsequent Operations.

	SS (N = 74)	MS (N = 63)
Mal-union/non-union	10	4
Infection/wound dehiscence	12	1
Residual/recurrent PCFD deformity	5	4
Hardware irritation	17	14
Ankle synovitis	0	4
Toe deformities	3	1
Talar OCL	0	2

Abbreviations: PCFD, progressive collapsing foot deformity; OCL, osteochondral lesion.

The total OR time in the MS group was significantly higher by 91 minutes (Table 4). This was associated with $3968 higher total OR costs in the MS group. The length of hospital stay was 2 days longer in the SS group. Twenty-two MS cases (34.9%) and all SS cases (100%) were admitted to hospital postoperatively (P < .001). This was associated with a mean of $9047 higher ward costs per case in the SS group (P < .001). When combining total OR and hospital stay costs, MS reconstruction was associated with lower cost of $5078.34 in the mean (P = .01). All reported costs are presented in Canadian dollars.

Table 4.

Cost Analysis of Single-Staged and Multi-Staged PCFD Reconstruction.

	SS (N = 74)^a	MS (N = 63)^b	Unadjusted mean difference (95% CI)	P value	Adjusted mean difference (95% CI)^c	P value
Total OR time (minutes)	172 (41)	262 (65)	90 (72, 108)	<.0001	91 (72, 110)	<.0001
Total hospital stay (days)	4 (3)	1 (2)	-2 (-3,-2)	<.0001	-2 (-3,1)	<.0001
Total OR costs ($)	6327 (938)	10 294 (1986)	3967 (3454, 4480)	<.0001	3968 (3434, 4503)	<.0001
Total ward costs ($)	14 541 (12 706)	4606 (7990)	-9935 (-135 396, -6274)	<.0001	-9047 (-12 803, -5290)	<.0001
Total OR + ward costs ($)	20 868 (12 831)	14 900 (8686)	-5968 (-9738, -2198)	.0021	-5078 (-8938,-1219)	.0103

Abbreviations: CI, confidence interval; OR, operating room.

a,b

Values presented as mean (SD).

Adjusted mean difference accounts for potential confounders: age, medical comorbidities, smoking and diabetes status, prior ipsilateral surgery.

Discussion

Wound healing disturbance and infection are feared complications in foot and ankle surgery. To our knowledge, no previous studies have evaluated a MS approach to PCFD reconstruction, nor compared complications and costs with SS reconstruction. In this retrospective cohort study, SS was observed to have a higher incidence of major complications, and postoperative admission, a trend toward higher rate of subsequent operations related to PCFD reconstruction, with no difference in subsequent operation rate to the ipsilateral foot or ankle between the groups.

Interestingly, a study comparing inpatient and outpatient total ankle arthroplasty also found significantly higher wound complication rates for inpatients, with no difference in reoperation rate.¹⁷ Various studies have stated that outpatient orthopaedic procedures are safe compared with inpatient procedures, with no increased complication risk, given correct patient selection,¹⁸-²⁴ including cases of closed ankle fractures.²⁵ Compared with MS PCFD reconstruction, a greater number of incisions are made to the foot in one SS encounter, potentially leading to greater wound complication. It has been shown that minimizing soft tissue trauma, resultant swelling, and tension on surgical incisions maximizes wound healing. In trauma literature, staging foot and ankle fracture fixation also reduced postoperative complications related to wound breakdown.^15,16

With an aging population, further understanding of PCFD, and an overall increased economic burden of foot and ankle surgery, it is important for surgeons to find cost-effective treatment approaches.²⁶ In this study, we found lower direct costs associated with MS compared with SS reconstruction, for patients with similar degree of PCFD deformity. Although, as expected, the length of OR time and associated OR costs were higher for MS, we found overall higher costs for SS which is attributed to longer hospital stays. We speculate that this may be related to SS patients requiring in-hospital pain control more frequently after an extensive procedure and treatment of increased complications. While MS patients were younger, we note that after adjusting for age as a confounder, the difference in cost was still statistically significant.

Recently, there has been growing interest in performing outpatient orthopaedic procedures given the health care cost savings and potential improved patient satisfaction.¹⁸-^20,22,23,27 Cost savings in outpatient anterior cervical discectomy and fusion, open Bankart repair, and ACL reconstruction have been shown.^18,23,27 Outpatient or short-stay total knee, hip, and ankle arthroplasty have also resulted in less cost than inpatient arthroplasty.^19,20,22,28 In our study, MS PCFD reconstruction was found to have a 24.3% cost reduction compared with SS, as only 22 of 63 MS cases required inpatient hospital stay postoperatively. Therefore, MS reconstruction may be advantageous in countries with limited resources (eg, hospital beds), as outpatient operations can be performed with just blocks.

While this study aims to provide a comprehensive evaluation of SS versus MS PCFD reconstruction, there are some limitations. First, this retrospective single-center study is subject to inherent limitations including lack of randomization, blinding, and the constraints of chart review. Treatment allocation to SS or MS procedures was at the discretion of the primary surgeon. As each procedure type was performed by a different surgeon, exposure was fully confounded by surgeon, introducing potential performance and expertise bias as well as systematic differences in perioperative management. Second, baseline differences between groups were present, with MS patients being generally younger, which may have influenced complication risk, recovery trajectory, and suitability for outpatient care. Furthermore, SS procedures were more frequently performed in the inpatient setting, which may have increased the likelihood of complication detection. In addition, follow-up duration was not uniform despite a minimum of 1-year review, and long-term events may have been underreported in patients with shorter observation periods. In addition, feet were analyzed as independent observations without adjustment for within-patient clustering, potentially violating independence assumptions. Furthermore, in our cost analysis, we utilized non-resident rates for OR and hospital stay costs as a proxy for direct health care costs. This does not take into account the type of hardware utilized in the groups, though we estimate these costs to be similar given the types of procedures performed. We also note that procedures were performed in a teaching hospital where OR time and costs may be higher than in a non-teaching setting. It is possible that other methods of cost estimation may lead to slightly different results. In addition, follow-up appointments, outpatient rehab, and imaging costs were not included, though these are likely similar between the groups. We also acknowledge that patients required approximately 2 weeks of additional weightbearing restrictions on their midfoot in the MS group (heel-weightbearing rather than full-weightbearing) after the second stage. This could be associated with personal income loss which is not accounted for in this study. Therefore, to further characterize the impact of SS versus MS PCFD reconstruction, it would be important to assess pain, functional, and patient-reported outcomes in a prospective study.

Conclusions

This is the first study that reports MS PCFD reconstruction and compares complications and costs with SS PCFD reconstruction. In our cohort, MS reconstruction is associated with lower rates of wound complications and lower direct health care costs compared with a SS approach. Further prospective, randomized studies evaluating patient-reported outcomes and standardized cost-effectiveness are required to validate these findings and to optimize surgical management of PCFD.

Footnotes

Acknowledgements

We would like to thank Qian Zhang and Vuong Nguyen for providing statistical support.

Author Contributions

All authors participated in the design, performance, analysis, and drafting of this manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

Ethical approval was obtained from the ethics committee of the University of British Columbia (H19-03433).

Informed Consent

Informed consent was obtained from all patients included in this study.

Declaration Regarding AI Use

The authors used artificial intelligence–based language assistance tools to improve the clarity, grammar, and readability of the manuscript.

Location of Work

St. Paul’s Hospital, Vancouver, BC, Canada.

ORCID iDs

Alice (Wei Ting) Wang

Joachim Ortmayr

Oliver Gagne

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