Review of Current Concepts in Metatarsus Adductus.

Metatarsus adductus (MA), the most common congenital foot deformity, involves adduction of the forefoot at the tarsometatarsal joint, with normal hindfoot alignment. Early diagnosis is important because treatment is more successful if initiated before age 9 months. Treatment of MA depends on deformity severity, in which mild to moderate deformity can be treated conservatively. Current standard of care for severe or rigid deformity involves referral by primary care physicians to specialists for management by casting and splinting. Recently, several orthoses have demonstrated equal effectiveness to casting and may allow for primary care physicians to treat MA without the need for referral. In this review article, we provide an overview of MA and discuss diagnosis and treatment. We also discuss novel devices and suggest how they may affect the future management of severe and rigid MA. [Pediatr Ann. 2024;53(4):e152-e156.].

The Windswept Foot: Dealing with Metatarsus Adductus and Toe Valgus.

The windswept foot remains a reconstructive challenge. The hallux valgus associated with the medially displaced lesser metatarsal heads is hard to correct. Either the lesser metatarsal heads need to be displaced laterally or the deformity accepted. With the deformity, all the toes tend to be aligned into valgus with the position of the flexor and extensor tendons. Several treatment alternatives exist and may require a combination of open and percutaneous surgery. The authors think that, in severe metatarsus adductus, proximal correction of the first, second, and third metatarsals is required.

Treatment of Post-traumatic Pediatric Ankle Varus Deformity with Physeal Bar Resection and Hemi-Epiphysiodesis.

Children presenting with partial physeal arrest and significant remaining growth may benefit from physeal bar resection, although the operation is a technique demanding procedure. This study evaluates the treatment of post-traumatic pediatric ankle varus deformity using physeal bar resection and hemi-epiphysiodesis with the assistance of two operative methods. Forty-five patients presenting with a distal tibial medial physeal bridge as well as ankle varus deformity following traumatic ankle physeal injury between 2009 and 2017 were followed. These patients were treated with physeal bar resection and hemi-epiphysiodesis, with the assistance of either fluoroscopy (10 cases) or intraoperative three-dimensional navigation (35 cases). Of the 45 cases, the median age was 9.0 years (range: 3-14 years) with 28 male and 17 female patients. The median of pre-operation ankle varus angle was 20 degrees (IQR 15-25) and 5 degrees (IQR 0-20) at the time of final follow up, representing a statistically significant difference (P<0.05). No differences were observed with regards to age, gender, and surgical history between effective group and ineffective group (P>0.05). The median of pre-operative ankle varus angles of the navigation and fluoroscopy groups were both 20 degrees (P>0.05). The median correction angle of the navigation and fluoroscopy groups was 10 and 15 degrees, respectively (P>0.05). Our results indicate that physeal bar resection and hemiepiphysiodesis are effective treatments for correcting ankle varus deformity due to traumatic medial physeal arrest of the distal tibia. We observe no difference in outcome between fluoroscopy group and three-dimensional navigation group during the procedures.

Reverse-Shoe Wearing Method for Treating Toe-In Gait in Children Can Lead to Hallux Valgus.

BACKGROUND The aim of this study was to compare the effect of 2 methods for treating toe-in gait in children (reverse-shoe wearing and orthopedic insoles) and to determine whether reverse-shoe wearing results in hallux valgus. MATERIAL AND METHODS Between July 2012 and July 2014, 337 children diagnosed with toe-in gait over 2 years were recruited. For 139 children, parents selected use of reverse-shoe wearing treatment (RS group) and for 198 children, parents selected orthopedic insoles treatment (OI group). There were 98 children in the RS group and 167 in the OI group who completed the 12-month therapy and follow-up. We excluded 28 children who failed to complete the study, and 44 children who ceased treatment within the first month were selected as controls. Patients were assessed for up to 24 months after the cessation of treatment. Foot progression angle (FPA) and presence and degree of hallux valgus angle (HVA) were recorded. RESULTS FPA was significantly reduced after 6 months in both RS and OI groups (P<0.05). FPA returned to almost normal after 12 months of treatment, with no significant difference between the 2 groups. There were 29 cases (51 feet) of hallux valgus in the RS group after 12-month treatment; the HVA had significantly declined by 2 years after treatment with normal shoe wearing but did not return to normal. CONCLUSIONS Corrective treatment should be used with children diagnosed with toe-in gait over 2 years showing no remission. Both reverse-shoe wearing and orthopedic insoles show similar levels of treatment success, but reverse-shoe wearing has a significant adverse effect of hallux valgus.

Does the parental stretching programs improve metatarsus adductus in newborns?

BACKGROUND: Metatarsus adductus (MA) is a common pediatric foot deformity. Current recommendations suggest observation until 4-6 months, then casting if the deformity persists. Based on our review of the literatures, no randomized controlled trial has been conducted to study the effectiveness of parental stretching in the correction of MA in newborn. MATERIAL AND METHODS: Ninety-four newborn feet that were diagnosed as MA by clinical examination were enrolled. Feet were randomized into two groups: observation group and stretching group. Outcome measurements were performed to compare success rate between groups. RESULTS: According to Pearson's χ2 test, there were no statistically significant differences between groups with regard to the overall success of the parental stretching program ( p = 0.191). There was also no significant difference between groups for mild degree or moderate-to-severe degree ( p = 0.134, p = 0.274, respectively). A more rapid success rate was observed in the stretching group at the first month follow-up, but rate of improvement then decreased. The stretching group tended to have a lower success rate compared to the observation group in moderate-to-severe feet, but the difference was not statistically significant. CONCLUSIONS: Parental stretching program found no benefit over observation group in this study. Parental stretching program should not be applied for newborn babies with moderate-to-severe MA as the result from the study appeared to have lower success rate compared to observation group. Observe until 4-6 months, then corrective casting for the persisting deformity is recommended.

The efficiency of gait plate insole for children with in-toeing gait due to femoral antetorsion.

BACKGROUND: One of the most common gait disorders in children is in-toeing. Few studies have examined the efficacy gait plate insole in in-toeing. we used more precise apparatus than previous studies. OBJECTIVES: The aim of this study was to investigate the immediate effect of gait plate insole on the angle of gait and center of pressure displacement in children with in-toeing gait. STUDY DESIGN: Quasi-experimental before -after study. METHODS: The angle of gait and center of pressure displacement were measured in 17 children aged 4-10 years with in-toeing gait. The RS scan pressure platform was employed to perform walking tests in three conditions including barefoot, with shoes only, and gait plate insole with shoes. RESULTS: The gait plate insole with shoes as well as shoes alone produced a significant 11.1° and 3.85° increase in the angle of gait in in-toeing children respectively ( p < 0.05). The medial-lateral displacement of center of pressure showed a significant difference (3 mm) in shoes only condition when compared with barefoot condition. The shoes only and gait plate insole compared with barefoot condition increased the anterior-posterior displacement by 28 and 30 mm respectively. CONCLUSION: The gait plate insole with ordinary shoes and shoes only were able to increase angle of gait and the center of pressure displacement in the anterior-posterior direction in children with in-toeing gait due to excessive femoral anteversion. Clinical relevance The use of a gait plate insole inserted in ordinary shoes can improve gait appearance in children with in-toeing gait caused by Excessive femoral anteversion.

In-Toeing Is Often a Primary Care Orthopedic Condition.

OBJECTIVE: To evaluate in-toeing consults to a pediatric orthopedic clinic to determine the proportion that could be managed by a primary care physician. STUDY DESIGN: A prospective registry was created for 143 consecutive children referred to a pediatric orthopedic clinic for "in-toeing." Each patient underwent a careful history and physical examination, which included a rotational profile. We recorded the final diagnosis, treatment offered, follow-up visit results, and the source of the referral. RESULTS: After pediatric orthopedic evaluation, 85% of patients had a confirmed diagnosis of in-toeing, and 15% had a different final diagnosis. Seventy-four percent of patients had 1 consultation visit, 18% had 2, and 8% had >2 visits. None of the referred patients was a candidate for treatment by casting or surgery. CONCLUSION: In most cases, in-toeing is a normal variation of development that can be managed by counseling and observation by the primary care physician alone. Rare cases of severe in-toeing >2 standard deviations from the mean should likely still prompt referral to a pediatric orthopedic surgeon for potential intervention.

FOREFOOT ADDUCTION IN CHILDREN. Management and Treatment.

Forefoot adduction is a common condition between metatarsus adductus, Z-shaped foot and residual clubfoot. This deformity is located in a pure transverse plane at Lisfranc's joint. Isolated metatarsus adductus is corrected spontaneously for the majority of newborns. In rare uncorrected cases, it could result in Z-shaped foot with a functional hindfoot valgus to equilibrate the resistant metatarsus adductus. As well, in residual clubfoot, recurrent metatarsus adductus varus is observed, usually in children over three years. In flexible metatarsus adductus the treatment is conservative. The surgery is proposed in toddlers and after failure of conservative treatment. Procedures carried out on metatarsals gave good results on short term, but showed a high rate of recurrence and growth disturbance. Osteotomies proximal to the Lisfranc's joint: calcaneo-cuboid fusion, anterior resection of calcaneus, and opening wedge osteotomy of medial cuneiform, gave permanent correction but they act only on one of the sides of deformity. Therefore, the theory of elongated lateral column associated with a shortened medial column is crucial in dealing with this deformity: combining opening wedge osteotomy of cuneiform with closing wedge osteotomy of cuboid described by Jawish et al. in children over 4 years allows ­ in all causes of metatarsus adductus stiffness ­ a lateral shifting of forefoot. Concerning the associated heel's valgus, it is corrected in Z-shaped foot after the associated heel's valgus, it is corrected in Z-shaped foot after the double osteotomy cuneiform/cuboid. However, in complicated treated clubfoot a particular treatment for the posterior tarsal is necessary.