The management of metatarsus adductus et supinatus

Universal neonatal foot orthotics-a novel treatment of infantile metatarsus adductus

Approximately one in 100 babies has metatarsus adductus) MTA(. Although most deformities may resolve spontaneously, moderate and severe deformities might cause future discomfort and are therefore often treated. Common treatment alternatives include stretching, serial casting, and orthoses. Surgery is reserved for severe cases that are unresponsive to conservative management. The purpose of this study was to present our experience with a novel orthosis designed to correct and maintain correction of MTA in infants. Seventy-three children between the ages of 4 and 11.5 months with moderate to severe MTA were treated using the Universal Neonatal Foot Orthosis (UNFO). Treatment was started in cases of rigid deformity when the child was first seen in the clinic, or after the age of 5 months in children with moderate or severe but flexible deformity that failed to improve spontaneously. The orthosis was applied for 23 h daily. Weaning was started after a complete correction of the deformity was achieved. Follow-up was continued at least until walking age. Results were assessed utilizing the heel bisector line (HBL) as a measure of foot deformity before, during, and after treatment completion, and at the end of follow-up. Seventy-one patients (114 feet (were followed from the time of diagnosis to at least walking age. There were 102 severe (HBL at, or lateral to, the 4^TH toe) and 12 moderate MTA (HBL between 3^rd and 4^th toes). Average age at the beginning of treatment was 6.58 months (range 4-11.5). Of the study population, 56 patients (98 feet) improved significantly by the end of the follow-up. In 11 children (11 feet), no change was noted, and in 3 children (3 feet), worsening of the deformity was observed at the end of follow-up. In one child who discontinued treatment after 6 weeks, there was no change in one foot and worsening in the other. Minor side effects were observed in 11 patients, all resolved uneventfully.Conclusion: UNFO is an effective treatment for moderate and severe MTA in children younger than10 months, with only infrequent minor side effects. What is Known: • Debate exists as to which patient warrants treatment since spontaneous improvement is the rule. However, some deformities persist to adulthood and may be esthetically unpleasing. • Treatment modalities available vary from benign neglect, special shoe ware that are either static or need special tools, and knowledge to adjust or casting by an orthopedic surgeon What is New: • This is a description of the results of treatment with a new orthotics which may be applied by pediatricians to treat this very common neonatal deformity. The orthotics provides an excellent, short duration solution, easy for the baby and caregiver with results comparable to those of more elaborate orthotics and casting • The use of digital pictures to assess forefoot adduction deformity severity instead of radiographs is a reliable measurement method.

Corrective Bandage for Conservative Treatment of Metatarsus Adductus: Retrospective Study

BACKGROUND

Metatarsus adductus (MA) is the most common congenital foot deformity observed in children.

OBJECTIVES

The aims of this study were: (1) to analyze the evolution of a corrective bandage for semirigid MA in newborns and (2) to recommend the age interval at which to start treatment of MA with the corrective bandage alone, without the need of splints.

DESIGN

An observational clinical study was conducted.

METHODS

The study was conducted at Virgen Macarena University Hospital in Seville, Spain. Children born with semirigid MA at the hospital during the years 2010-2011 were included. Corrective bandaging was applied to all children until clinical correction of the deformity. Sex, laterality of the deformity, weight and length of the newborn, age at the start of treatment, antecedents related to the pregnancy and birth, type of treatment (bandaging, splints), and correction or no correction with bandaging alone were recorded. Age differences at the start of the bandaging treatment between children whose deformity was corrected with and without the need of splints were examined. The receiver operating characteristic curve method was applied to analyze the predictive ability of the age at the start of bandaging treatment relative to whether the deformity was corrected or not corrected with bandaging alone.

RESULTS

The bandage achieved complete correction in 68.1% of the children and corrected the deformity more frequently in girls compared with boys. Of the 56 children who began the treatment within the first month of life, 92.8% achieved correction of the foot deformity with the corrective bandaging alone.

LIMITATIONS

Patients' follow-up time was only 2 years, so it was only feasible to analyze the corrective bandaging method over the short term and medium term.

CONCLUSIONS

Corrective bandages showed high effectiveness, particularly in girls, and overall when started within the first month of life.

Resistant metatarsus adductus: prospective randomized trial of casting versus orthosis

BACKGROUND

Metatarsus adductus is a common pediatric foot deformity related to intrauterine molding. It is usually a mild deformity that responds well to simple observation or minimal treatment with a home program of stretching. Resistant cases may need a more aggressive approach such as serial casting or special bracing to avoid the need for surgical intervention. We compared clinical outcomes using serial casting with orthoses for resistant metatarsus adductus.

METHODS

We prospectively treated 27 infants (43 feet) between the ages 3 and 9 months who failed home stretching treatment. Patients were randomized to either serial plaster casting or Bebax orthoses. Footprints and simulated weight-bearing anteroposterior and lateral view radiographs were made at entry and follow-up.

RESULTS

There was no statistical difference between casting and Bebax for the following parameters: age at study entry, length of treatment, number of clinic visits, follow-up, and follow-up maintenance treatments. Both groups showed improvement in footprint and radiographic measurements post-treatment, without worsening of heel valgus. The Bebax group had greater improvement in the footprint heel bisector measurement than the casting group. The Bebax treatment requires more active parental cooperation. A simulated cost analysis of materials and office visit charges, however, revealed that Bebax treatment was significantly less expensive, about half the cost of casting.

CONCLUSION

Because of the cost savings and virtually identical clinical results, we recommend the Bebax orthosis for resistant metatarsus in pre-walking infants with parents who are compliant. Other considerations include specific insurance plans, which may pay for casts but not orthoses.

Metatarsus adductus and skewfoot deformity

Metatarsus adductus deformity should be recognized and addressed appropriately and in a timely fashion so as to achieve an effective correction with low rates of recurrence. Early diagnosis and treatment are of paramount importance, because spontaneous resolution is rare. Although nonoperative treatment is desirable via manipulation and soft tissue stretching and serial cast immobilization, appropriate surgical intervention needs to be used on occasion to achieve correction of resistant cases. Depending on the severity and flexibility of the deformity and the age of the patient, various methods of surgical reconstruction are available. A long-standing untreated or undertreated adductus deformity can lead to the formation of a skewfoot deformity with more significant symptoms and deformity. Treatment of this deformity is rarely successful by nonoperative means, and appropriate surgical procedures addressing the metatarsal adductus component and the flatfoot component can be used for correction of the dysfunctional or symptomatic skewfoot.

Abductory midfoot osteotomy procedure for metatarsus adductus

The authors describe a new surgical technique for the correction of metatarsus adductus using an abductory osteotomy performed in the lesser tarsal region that enables transverse plane correction of an adducted forefoot. This procedure is based on the premise that matatarsus adductus deformity is actually a deformity of the midtarsus rather than the metatarsus segment of the foot. The osteotomy technique involves shortening of the lateral column using closing wedge technique and lengthening of the medial column using opening wedge technique. The correction is entirely in the transverse plane; however, modifications may be performed when other planal deformities are present. Historical review, principles, technique, and case studies are discussed.

The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus

Thirty-one patients (forty-five feet) who had metatarsus adductus were evaluated at our institution and were followed for an average of thirty-two years and six months. Of these thirty-one patients, twenty-one (thirty-one feet) were examined clinically and radiographically. Information on the remaining ten patients (fourteen feet) was obtained by letter or telephone, or both. Twelve patients (sixteen feet) who had a passively correctable deformity (mild or moderate) at the time of the initial presentation had no treatment. Twenty patients (twenty-nine feet) who had a partly flexible or rigid deformity (moderate or severe) at the time of the initial presentation were managed with serial manipulation and application of plaster holding casts. (One patient who had a bilateral deformity had no treatment on one side and conservative management on the other). The results were good in all sixteen of the untreated feet and in twenty-six (90 per cent) of the twenty-nine feet that had been conservatively treated. There were no poor results. The passively correctable deformities resolved spontaneously. Radiographs showed an obliquity of the medial cuneiform-metatarsal joint in twenty-one (68 per cent) of the thirty-one feet that were examined clinically and radiographically. Similar findings were observed in four of eleven contralateral, normal feet. Hallux valgus was not a common outcome. No patient had operative correction.

The treatment of rigid metatarsus adductovarus with the use of a new hinged adjustable shoe orthosis

A retrospective review of the early results of treatment of metatarsus adductovarus with a new hinged adjustable shoe orthosis, the Bebax shoe, is presented. The results in 120 cases (210 feet) are included in the study. Criteria for severity of the initial deformity were developed, and all cases of true clubfoot and those cases with prior treatment were excluded. The average age at institution of treatment was 4.5 months, and treatment time averaged 2.7 months (range 1-7 months). Overall, 96% of the cases were completely resolved with the use of the orthotic alone, 3% required additional casting, and 1% required a bar and shoes for complete correction of the deformity. No treatment complications were encountered except some minor problems with hinge loosening, particularly in the child of walking age. We believe that the Bebax shoe is a lightweight, convenient, safe, and both cost- and treatment-effective device in the management of metatarsus adductovarus.

Management of metatarsus adductovarus

A retrospective analysis of 795 patients treated for metatarsus adductovarus by a standardized outpatient approach by one of the authors (D.S.W.) from 1970 to 1983 was conducted to evaluate the efficacy of a straight metal bar and attached reverse last shoe protocol. Criteria for inclusion were developed excluding those milder cases in which spontaneous resolution was expected and indeed occurred. Nearly uniform excellent results were encountered, with a 99% likelihood of obtaining a fully corrected foot. Surgical intervention was deemed necessary in under 1% of cases seen. The authors also examined birth weights and rank in relation to metatarsus adductovarus. Those children with the deformity had a mean birth weight of 7.6 pounds, without statistical variance from normal average birth weights. We were unable to establish any statistical association with birth rank. In light of the results of this study, which compare favorably with serial casting, we recommend this approach as a more economical and less disruptive and cumbersome technique for parent, patient, and physician.