Classifications of AAFD/PCFD have evolved with an increased understanding of the pathology involved. A review of classification systems helps identify deficiencies and respective contributions to the evolution in understanding the classification of AAFD. Using multiple electronic database searches (Medline, PubMed) and Google search, original papers classifying AAFD were identified. Nine original articles were identified that met the inclusion criteria. Johnson's original classification and multiple variants provided a significant leap in understanding and communicating the pathology but remained tibialis posterior tendon focussed. Drawbacks of these classifications include the implication of causality, linearity of progression through stages, an over-simplification of stage 2 deformity and a failure to understand multiple tendons react, not just tibialis posterior. Later classifications, such as the PCFD classification, are deformity-centric. Early instability in non-cavus feet and all stages of cavus feet can present pain and instability with minor/no deformity. These may not be captured in deformity-based classifications biased to planus feet.' The authors developed the 'Triple Classification' (TC) understanding that primary pathology is a progressive ligament failure/instability that presents as tendon reactivity, deformity, and painful impingement. There is a variable manifestation dependent on starting foot morphology. This review has identified deficiencies within classification systems used in AAFD/PCFD and, as a result, was used to help develop a more comprehensive 'Triple classification'. Advantages of the TC include representing foot types with no deformity, defining complex secondary instabilities, delinking of foot types, tendon reactivity/ligament instability and deformity to represent these independently in a more comprehensive classification system.

Introduction: Subtalar Arthroereisis (STA) is a surgical intervention for pediatric flexible flatfoot (PFF), primarily targeting hindfoot alignment by limiting excessive subtalar eversion. However, its effects on forefoot parameters remain underexplored. This study aims to investigate radiological changes following STA in pediatric patients. Materials and Methods: A retrospective analysis was conducted on consecutive patients treated with STA for PFF. First ray-related angles, including Hallux Valgus Angle (HVA) and Inter-Metatarsal Angle (IMA), alongside hindfoot radiological parameters such as Meary, Calcaneal Pitch, and Costa Bartani angles, were assessed. Subgroup analysis by gender was performed, and correlations between demographic and pre-operative radiological parameters were examined. Results: Forty-one patients (81 feet) with a mean age of 11.6 years were included, with a mean follow-up duration of 6.4 months. No significant differences were observed in first ray-related an-gles pre- and post-operatively, with mean IMA changing from 7.97° to 7.18° and mean HV angles from 9.51° to 8.66°. Noteworthy improvements were seen in flat foot angles, including Meary, Calcaneal Pitch, and Costa Bartani angles, postoperatively. Age subgroup analysis revealed similar trends in IMA and HVA changes between Group A (operated before peak growth) and Group B (operated later). Higher preoperative angles tended to improve, while lower preoperative IMA and HVA tended to worsen postoperatively, all remaining within normal ranges. Conclusion: STA showed positive radiological outcomes for PFF treatment, while negligible changes in first ray-related angles were observed. Age subgroup analysis indicated similar trends regardless of operation timing. Higher preoperative angles tended to improve, while lower preoperative angles tended to worsen postoperatively, despite all falling within non-pathological ranges. Further re-search is warranted to confirm this correlation.

We investigated the radioclinical outcomes of naviculectomy and limited/tailored soft-tissue releases in a short series of ambulatory children with complex/intractable congenital vertical talus subsets namely neglected, multiple operated and recurrent patients. We postulated that this technique will yield satisfactory radioclinical outcomes and minimal complications because it avoids extensive surgical release/trauma that is otherwise classically recommended for complex congenital vertical talus (CVT). The cohort consisted of five -four boys, one girl- complex CVT children with neglected, multiple operated and/or recurrent subsets. Patients were included if manipulative casting techniques were deemed unlikely to produce a plantigrade foot. Patients underwent naviculectomy with variable on-demand limited soft tissue releases. Two patients had bilateral affection and two had a non-idiopathic aetiology. The mean age was 5.2 years (4 to 6.25) and mean follow-up was 2.3 years (1 to 3). We reported satisfactory outcomes as per foot posture, function, overall parent satisfaction including pain and radiography per lateral views of talar-axis-first metatarsal base angle on the short/intermediate term. Whereas manipulative casting is unlikely to yield lasting outcomes in ambulatory children with complex subsets of CVT, extensive surgical soft-tissue releases have unfavourable long-term complications. As a substitute, naviculectomy as a form of resection arthroplasty created a practical and affordable third way between manipulative casting with minimally invasive surgery and the extensive surgical soft tissue releases on the short/intermediate term.