69: Metatarsus Adductus - Feilmeier

Question 1

what do you see with metatarsus adductus?

Answer 1

Medial deviation of the forefoot on the rearfoot

• Concave medial border
• Convex lateral border
• Prominent styloid process

Question 2

what is metatarsus adductus associated with?

Answer 2

hip dyplasia

torticollis

Question 3

what is the level of deformity metatarsus adductus?

Answer 3

lisfranc’s tarso-metatarsal jt

Question 4

other causes of pigen/in-toeing besides metatarsus adductus

Answer 4

• Tibial/Malleolar torsion
• Femoral anteversion (inward twisting of the femur-medial torsion)
• Total ROM ~100 degrees. If >70 degress internal rotation may be present
• “Psuedo”- femur is normal, but soft tissue are allowing tighter internally, not allowing external
• also check for ortolani and barlow hip dysplasia

Question 5

v-finger test

Answer 5

• Infant’s heel in the examiners hand second webspace
• Medical foot rests against index finger
• Lateral foot rests against middle finger
• Foot observed from plantar aspect
• Observe for medial deviation of forefoot
• Forefoot deviates away from middle finger

Question 6

clinical “ARM” evaluation

Answer 6

• Attitude
  
  • Position that is visible
• Relationship
  
  • Forefoot to rearfoot
  • All three planes
• Movement
  
  • Flexible, Semi Flexible, Rigid

Question 7

Answer 7

heel bisector

should go through the second met area

Question 8

metatarsus adductus vs. adductovarus vs. skewfoot

Answer 8

• (A) Metatarsus Adductus
  
  • Transverse plane adduction
  • Most Common
• (B) Metatarsus adductovarus
  
  • Transverse plane adduction
  • Frontal plane inversion of forefoot(supinatus)
• (C) Skewfoot
  
  • Transverse plane adduction
  • Frontal plane inversion of forefoot (supinatus)
  • Rearfoot eversion

Question 9

berg classification

Answer 9

Question 10

bleck’s severity of deformity

Answer 10

based on bisection fo the heel relative

Question 11

metatarsus adductus angles

mild

moderate

severe

Answer 11

Metatarsus adductus angle =Relationship between the longitudinal axis of the lesser tarsus and the line bisecting the second metatarsal

• 15-20 degrees-mild
• 21-25 degrees-moderate
• > 25 degrees-severe

Question 12

soft tissue abnormalities assoc with met add

Answer 12

• Anterior Tibial Tendon: More plantar insertion on cuneiform
• Posterior Tibial Tendon contracture
• Abductor Hallucis-hyperactivity/abnormal insertion
• Peroneal tendons
• Ligaments
• Joint capsules

Question 13

bone abnormalities assoc with met add

Answer 13

• Arrest of normal ontologic rotation
• Medial cuneiform
  
  • Growth pattern disturbance
  • Trapezoidal shape
  • Absence-metatarsal varus?

Question 14

does severity correlate with outcomes?

Answer 14

nope

Question 15

non-op treatment

Answer 15

• Observation (mild)
• Stretching (mild)
• Splints
• Corrective shoes (reverse shoes)
• Serial casting (all)

Question 16

tx newborn to 2 years

Answer 16

serial casting

• Casting treatment past 8 months is controversial. Not all agree that casting after 1 year is effective
• Have to remember aggressive or excessive casting can damage immature osseous structures
• Classification DOES NOT correlate well with expected outcome

Question 17

casting technique

Answer 17

• Short Leg typically works but may need long leg
• Fast Drying Plaster (more accurate modeling) vs. fiberglass (faster)
• Minimal cast padding
• Ankle at 90°
• STJ Neutral
• Cup foot at 5th met base with thenar eminence with thumb on bottom and index finger on the top- parallel to each other.
  
  • Or, thumb at 5th met cuboid and index finger around posterior heel holding STJ neutral
• Thumb of other hand gently pushes 1st MPJ laterally (transverse plane) -abducting the forefoot

Question 18

stretching/casting position (picture)

Answer 18

Question 19

surgical tx 2-4 yo

Answer 19

• Soft tissue releases
  
  • Abductor Hallucis release
  • Release soft tissue 1st Met – Cuneiform jt
  • Release soft tissue naviculo-cuneiform jt
  • Release cuneiform insertion of Anterior Tibialis
  • Combination of the above

Question 20

tx 4 yo +

Answer 20

• Where is the deformity and how can you make the foot rectus?
• Soft Tissue Procedure
  
  • Tarsometatarsal capsulotomy (Heyman-Herndon-Strong Procedure)
• Osseous Procedures
  
  • Multiple Metatarsal Osteotomies (Berman and Gartland, Lepird)
  • Medial opening wedge osteotomies
  • Lateral closing wedge osteotomies
  • TMTJ Arthrodesis

Question 21

who can get soft tissue release?

Answer 21

2-6 yo

Question 22

criticism soft tissue release

Answer 22

stiff foot

Question 23

technique soft tissue release

Answer 23

• Transverse or longitudinal incision
• May need to osteotomize the 2nd met to allow mobility of the other metatarsals (keystone)
• Pin 6-8 weeks
• Cast 3-4 months
• Splinting after

Question 24

when do we do osteotomy?

Answer 24

greater than 6 yo

Question 25

name these osteotomies

Answer 25

(A) Peabody and Muro

(B) McCormick and Blount

(C) Steytler and Van DerWalt

(D) Berman and Gartland procedures

Question 26

fowler procedure

Answer 26

• Opening-wedge osteotomy of the first cuneiform.
• The defect is replaced by a triangle shaped bone graft.

Question 27

lepird procedure

Answer 27

•Oblique wedge osteotomy of the first and fifth metatarsals are performed with through and through rotational osteotomy of second, third and fourth metatarsals.