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.

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.

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.