The Role of the Transverse Arch in Progressive Collapsing Foot Deformity (PCFD): A Retrospective Case Control Study
Authors: Schmidt Eli , Kim Ki Chun , Carvalho Kepler , Dibbern Kevin N. , Cychosz Chris , Mansur Nacime SB , Braza Samuel , Lalevée Matthieu , Netto Cesar de Cesar 
Published: November 2022

Category: Midfoot/Forefoot; Basic Sciences/Biologics; Hindfoot Introduction/Purpose: A recent study published in Nature (Venkadesan et al.) demonstrated that coupling the transverse arch (TA) with the medial longitudinal arch (MLA) significantly increased midfoot intrinsic stiffness. The contribution of the TA is substantial, suggested as the evolutionary advancement providing the foot stiffness required for human bipedalism. Progressive collapsing foot deformity (PCFD) is a complex deformity ultimately resulting in loss of stiffness and collapse of the MLA. The novel understanding of the TA may play a key role in the pathogenesis of this deformity. The objectives of this study were to assess and compare the TA curvature in PCFD and controls and to evaluate its relationship with accepted PCFD measures. We hypothesized that the curvature of the TA will be decreased in PCFD. Methods: A retrospective review was conducted for 32 PCFD and 32 controls. Measurements were performed using weight- bearing CT (WBCT). A novel measurement, the transverse arch plantar (TAP) angle, was designed to directly measure the TA in both PCFD (Figure 1a) and controls (Figure 1b). TA curvature was calculated using the equation described by Venkadesan et al. (Figure 6) utilizing width, length (Figure 3a), 3rd metatarsal thickness (Figure 3b), and 4th metatarsal torsion (Figure 4a, 4b). Finally, uni- and multivariate analyses were performed to analyze the relationship between the TAP angle, Foot and Ankle Offset (FAO), peritalar subluxation, and measurements associated with PCFD classes: hindfoot moment arm (class A), talonavicular coverage angle (class B), Meary angle (class C), medial facet uncoverage angle (class D), and talar tilt (class E). Normality of different variables was assessed using the Shapiro-Wilk test. Two groups were compared using t-test for normal, and Mann-Whitney for non-normal variables. Results: Measurements of the TAP angle were found to be significantly higher in the PCFD group than the control group with a mean angle of 115.24° (SD 10.68) and 100.76° (SD 7.92) respectively (p<0.001) (Figure 2).No significant difference was found in the calculated TA curvature between PCFD and controls with mean values of 17.84 (SD 4.41) and 18.18 (SD 3.68) respectively (p=0.741) (Figure 5).The univariate analysis performed showed a moderate positive correlation between the TAP angle and the FAO (ρ=0.58;r2=0.34;p <0.001).The multivariate analyses showed, among the different PCFD class measurements and the TAP angle, only the middle facet uncoverage (β=0.08,p<0.001) and hindfoot moment arm (β=0.32, p<0.001) were associated with higher values of FAO, while only the Meary (β=0.49,p=0.004) and the talonavicular coverage angles were associated with higher values of peritalar subluxation (β=0.75,p<0.001). Whereas, Meary's angle was the only predictive factor of higher TA collapse (β=0.55,p<0.001). Conclusion: Our direct measurement showed a collapsed of the TA in PCFD. However, this did not appear to be a consequence of insufficient bone torsion, but rather some other etiology, possibly a soft tissue failure. Considering the implication of the TA among the different PCFD classes, it did not appear to play a significant role on the overall PCFD deformity. TA collapse seemed mainly influenced by Meary's angle, which assess the MLA. This further supports the idea behind TA and MLA coupling suggesting that when the TA is collapsed, the foot does not possess the required stiffness to maintain the MLA.