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Metatarsus Adductus

- Discussion:
    - a condition in which the there is medial displacement of the metatarsals on the cuneiform;
    - forefoot is adducted at the tarsal metarsal joint;
    - usually seen in the first year;
    - is bilateral in 50% of patients may be associated with hip displasia (10-15%);
    - most common congenital foot deformity is metatarsus adductus;
    - is caused by intrauterine position, is flexible & resolves spontaneously in more than 90 % of children.
    - diff dx of metatarsus adductus:
           - skew foot: in infants it may not always be possible to different these disorders;
           - metatarsus varus: is rigid, causes plantar crease, deforms medial cuneiform, and often persists so that it requires treatment;
    - diff dx of intoeing:
           - metatarsus adductus
           - skew foot
           - tibial torsion
           - femoral anteversion
           - club foot deformity

- Exam:
    - in a true metatarsus adductus, the hindfoot will be completely normal;
    - determine whether the forefoot deformity is passively correctable past neutral;

- Radiographs:
    - radiographs are usually not necessary, if the forefoot is passively correctable and if the hindfoot is normal;
    - w/ metatarsus adductus, the mid-tarsal axis will hit the base of the first metatarsal or be lateral to it;
    - note that an easy technique to document the deformity is to place the childs feet on a photocopier;

- Non Operative Treatment:
    - approximately 85% will resolve spontaneously w/o treatment;
    - no specific treatment is necessary if the foot can be passively corrected past neutral;
    - some patients may benefit from passive stretching;
    - Denis Browne bar has been used liberally in the past;
    - casting:
          - indicated for rigid or persistent deformity;
          - most effective if started before child reaches one year of age, but casting can be effective in children upto age of 4-5 years;
          - persistent or rigid forefoot adductus can be readily corrected w/ cast;
          - cast should extend above knee w/ knee flexed 20 - 25 deg (allows child to walk);
          - casts are changed biweekly, and correction is usually achieved after two to three changes;
          - note that because it can be difficult to differentiate between severe metatarsus adductus skew foot in young toddlers, casts should be applied
                   with varus hindfoot molding in order to avoid valgus stress on the hindfoot;

- Operative Treatment:
    - rarely require tarsal metatarsal release or metatarsal osteotomies;
    - tarsometatarsal capsulotomies 
          - indicated in patients less than 5 years of age:
          - release of the abductor hallucis, capsulotomy, & metatarsal osteotomy are surgical options;
          - consider tarsal-metatarsal capsulotomies followed by casting;
    - patients older than 5 years of age:
          - consider proximal osteotomies of the lesser metatarsals

The Long-Term Functional and Radiographic Outcomes of Untreated and Non-Operatively Treated Metatarsus Adductus.

Shoe Corrections and Orthopaedic Foot Supports.    

Combined Midfoot Osteotomy for Severe Forefoot Adductus.

Opening Wedge Osteotomy of the Medial Cuneiform Before Age 4 Years in the Treatment of Forefoot Adduction.

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