71 old Metatarsus Adductus-2022.pdf

TERMINOLOGY What is metatarsus adductus? Metatarsus varus Metatarsus adductovarus Pes adductus Metatarsus supinatus Forefoot adductus Hooked forefoot Skewfoot Which is correct? 3 ORIGIN Theories of etiology Abnormal in utero position oLeft foot oFirst pregnancy oMultiple births 4 ORIGIN Hereditary 1...

TERMINOLOGY What is metatarsus adductus? Metatarsus varus Metatarsus adductovarus Pes adductus Metatarsus supinatus Forefoot adductus Hooked forefoot Skewfoot Which is correct? 3 ORIGIN Theories of etiology Abnormal in utero position oLeft foot oFirst pregnancy oMultiple births 4 ORIGIN Hereditary 1.3:1 ratio male to female Muscle imbalance TA, PT versus peroneal Abnormal insertion of TA, PT, Abductor hallucis Osseous malformation Medial cuneiform 5 6 DISTINCT FORMS 1. Simple metatarsus adductus o Normal forefoot to rearfoot relationship o Metatarsals adducted on the transverse plane at the Lisfranc articulation o Pure adduction on plane parallel to the ground 6 6 DISTINCT FORMS 2. Metatarsus adductovarus Adductive metatarsals with frontal plane varus component 2 plane involvement: Frontal and transverse 3. Metatarsus primus adductus First ray adductus with IM angle of greater than 15° 7 6 DISTINCT FORMS 4. Complex metatarsus adductus Presents with valgus deformity of rear foot Serpentine foot/Z foot 3 different types Complex metatarsus adductus Adducted forefoot, lateral transition of midfoot, normal hindfoot Skew foot Adducted forefoot, normal midfoot and hindfoot valgus Complex skew foot Adducted forefoot, lateral translation of midfoot, hindfoot valgus 8 6 DISTINCT FORMS 5. Talipes equinovarus Classic clubfoot Equinus-key factor in differentiating versus metatarsus adductus and more difficult component to correct 6. Cavoadductovarus Metatarsals adducted, rearfoot varus position Condition seen more in early teens–suggestive of possible neurologic cause 9 CLINICAL PRESENTATION In toeing-biggest complaint Forefoot adduction-concave lateral border Medial soft tissue crease secondary to rigidity “ARM” method of PE- Ganley Attitude: of the foot in non-weightbearing position Relationship: Rearfoot to forefoot and 3 cardinal planes Movement: Forefoot relative to rearfoot 10 CLINICAL PRESENTATION Femoral anteversion Hip motion shows >70° internal rotation (normal is 30-60°) and decreased external rotation Patella internally rotated Tibial torsion observe foot-thigh angle in prone position > 10° of internal rotation is indicative of tibial torsion (normal is 0-20° of external rotation) 11 CLASSIFICATION Berg Classification Simple MTA o MTA Complex MTA o MTA, lateral shift of midfoot Skew foot o MTA, valgus hindfoot Complex skew foot (serpentine foot) o MTA, lateral shift, valgus hindfoot 12 CLASSIFICATION Bleck Classification Normal - heel bisector line through 2nd and 3rd toe webspace Mild - heel bisector line through 3rd toe Moderate - heel bisector through 3rd and 4th toe webspace Severe - heel bisector through 4th and 5th toe webspace Bleck EE: Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatr Orthop 3:2-9, 1983.13 IMAGING AP view Metatarsus Adductus Angle Reference points o Medial ▪ Proximal aspect of first metatarsal base ▪ Distal aspect of the talonavicular articulation o Lateral ▪ Proximal aspect of the fourth metatarsal base ▪ Distal aspect of CC joint Angled above 20° is consider adducted 14 IMAGING Kites angle 20-25° Calcaneal-second metatarsal angle Useful in determining forefoot adduction 15° (+/-3) 15 Treatment 16 Treatment Nonoperative Benign condition that resolves spontaneously in 90% of cases by age 4 Another 5% resolve in the early walking years (age 1-4 years) 17 Condition Non-Operative Treatment Flexible deformities that can be actively corrected at the midline No treatment required Flexible deformities that can be passively corrected at the midline Serial stretching by parents at home Serial casting Rigid deformity with with the goal of medial crease obtaining a straight lateral border of foot 18 CONSERVATIVE TREATMENT Casting birth to 9 months Ponseti method Plaster/fiberglass Splinting Ganley splint Permits position in all 3 planes Shoe therapy Often used in the past but difficult to control the rear foot 19 SURGICAL THERAPY Considered for failure of conservative treatment and children older than 2 years of age Various procedures Age Severity of deformity Presence of associated deformity 20 SURGICAL THERAPY Soft tissue procedures Birth to age 6 Adjunctive to other procedures o Abductor hallucis release 21 SURGICAL THERAPY Heyman, Herndon, and Strong TMT release 22 SURGICAL THERAPY Osseous procedures 6-8 years of age Bankart (1921)-excision of cuboid Peabody and Muro (1933) o Excision of bases of 3 central metatarsals o Osteotomy of fifth metatarsal o First metatarsocuneiform joint reduction o Correction of tibialis anterior tendon insertion o Hoke triple arthrodesis recommended for realignment of rear foot complex 23 SURGICAL THERAPY McCormack and Blount (1949) Arthrodesis of first metatarsocuneiform joint Osteotomies of 3 central metatarsals Possible wedge resection of cuboid Steytler and Van der Walt (1966) Oblique “V” osteotomies of the metatarsals angled toward the rear foot Still in use today 24 SURGICAL THERAPY Berman and Gartland (1970) Ages 4 years and older Steytler and Van der Walt variation Crescentic-based osteotomies of all the metatarsal bases o Pin fixation and 6 weeks casting 25 SURGICAL THERAPY Lepird Ages 4 years and older Crescentic-based osteotomies of the central metatarsals Oblique osteotomy of 1st and 5th 26 SURGICAL THERAPY McHale and Lenhart (1991) and Ganley (1992) Opening wedge osteotomy of the medial cuneiform Closing wedge osteotomy of the cuboid Fowler at al (1959) First suggestive for deformities of the tarsus as opposed to the metatarsals Lateral closing wedge osteotomy of the 27 28 QUESTIONS???? 29