This paper refines the Johnson-Strom/Myerson PTTR classification into substages that each map to a distinct surgical construct. The goal is to move beyond a generic 'flexible flatfoot' label and instead identify the dominant deformity — hindfoot valgus, forefoot abduction, fixed forefoot varus, or medial column instability. The result is a treatment algorithm where operative planning is driven by specific anatomic pathology rather than broad stage alone.
The classic Johnson-Strom system put every flexible flatfoot into one bucket called 'Stage II' and every rigid flatfoot into 'Stage III.' That grouping left surgeons making ad hoc decisions about lateral column lengthening, Cotton osteotomies, and medial column fusions without a shared framework.
The Bluman refinement gives you a decision tree: when you see a Stage II patient, the first question is not 'flexible or rigid?' but 'what is the dominant deformity?' Forefoot abduction with talar uncovering above 40% means lateral column lengthening goes into the plan. Fixed forefoot varus means Cotton osteotomy. Medial column instability that persists even with ankle plantarflexion means consider first TMT fusion rather than osteotomy alone.
For Stage IV, reducibility is the fork in the road. A supple tibiotalar valgus without arthritis is a reconstruction problem (deltoid repair + hindfoot realignment). A rigid or arthritic ankle is a fusion problem — and undertreating a Stage III with residual hindfoot valgus is how you create a Stage IV in the first place.
The 7%-to-60% ankle arthritis progression after triple arthrodesis is worth knowing for boards and for counseling patients, even though it did not drive dissatisfaction in Pell's series.
This paper refines the Johnson-Strom/Myerson PTTR classification into substages that each map to a distinct surgical construct. The goal is to move beyond a generic 'flexible flatfoot' label and instead identify the dominant deformity — hindfoot valgus, forefoot abduction, fixed forefoot varus, or medial column instability. The result is a treatment algorithm where operative planning is driven by specific anatomic pathology rather than broad stage alone.
The classic Johnson-Strom system put every flexible flatfoot into one bucket called 'Stage II' and every rigid flatfoot into 'Stage III.' That grouping left surgeons making ad hoc decisions about lateral column lengthening, Cotton osteotomies, and medial column fusions without a shared framework.
The Bluman refinement gives you a decision tree: when you see a Stage II patient, the first question is not 'flexible or rigid?' but 'what is the dominant deformity?' Forefoot abduction with talar uncovering above 40% means lateral column lengthening goes into the plan. Fixed forefoot varus means Cotton osteotomy. Medial column instability that persists even with ankle plantarflexion means consider first TMT fusion rather than osteotomy alone.
For Stage IV, reducibility is the fork in the road. A supple tibiotalar valgus without arthritis is a reconstruction problem (deltoid repair + hindfoot realignment). A rigid or arthritic ankle is a fusion problem — and undertreating a Stage III with residual hindfoot valgus is how you create a Stage IV in the first place.
The 7%-to-60% ankle arthritis progression after triple arthrodesis is worth knowing for boards and for counseling patients, even though it did not drive dissatisfaction in Pell's series.