Postural deformations (metatarsus adductus, pes calcaneovalgus)
Objectives- Define malformation, deformation, dysplasia
- Discuss treatment principles for congenital deformations
- Describe the natural history for metatarsus adductus and pes calcaneovalgus
- Discuss treatment for metatarsus adductus and pes calcaneovalgus
Discussion
The concept of normal development and its variations is extremely helpful in evaluating and making treatment decisions about entities such as metatarsus adductus and calcaneovalgus foot posture in the newborn. Dunne and Clarren have outlined different ways in which morphogenesis can be altered. A malformation results from an interruption of normal organogenesis during the time of organ formation at 4-8 weeks postconception. Dysplasias result from abnormal organization of cells into tissues, leading to abnormal tissue differentiation, such as in connective tissue disorders. Deformations are abnormalities in shape, form, or position of structurally normal body parts from extrinsic pressure. The fetus is susceptible to deformation secondary to intrauterine molding and its rapid growth.
All that said, it is not easy to make complete sense of the literature on metatarsus adductus. Widhe concluded no treatment was necessary for adductus confined to the forefoot or for pes calcaneovalgus. Berg found that metatarsus adductus accompanied by radiographically demonstrable hindfoot valgus were more difficult to treat. Cook was unable to apply Berg's method due to inconsistent ossification patterns of the hindfoot. Bleck felt good results could be reliably obtained until 8 months of age, but then the deformity might be so rigid as to require surgery. Farseti, in a longterm follow-up found that all feet that were passively correctable did well with no treatment, and 9% of treated feet did well. No foot underwent surgery. Ghali found that 23 of 43 feet with metatarsus adductus treated in his series required surgery, but they did well regardless of time of surgery. Stark included patients with idiopathic metatarsus adductus in his series of tarsometatarsal cappsulotomies that did not do well. Katz treated 65 infants with short leg casts, and they all did well. Finally, Morcuende and Ponseti found the first metatarso cuneiform joint was tilted in embryos of 16 and 19 weeks, suggesting a "developmental abnormality." The reader is left to his/ her own conclusions. Clinical experience would indicate that most feet with metatarsus adductus at birth are passively correctable and need no treatment. Those that do not correct usually correct with casting. There does seem to be agreement that pes calcaneovalgus needs no treatment.
References
- Berg EE. A reappraisal of metatarsus adductus and skewfoot. Journal of Bone & Joint Surgery -American Volume 1986; 68( 8): 1185-96.
- Bleck EE. Metatarsus adductus: classification and relationship to outcomes of treatment. Journal of Pediatric Orthopedics 1983; 3( 1): 2-9.
- Cook DA, Breed AL, Cook T, DeSmet AD, Muehle CM. Observer variability in the radiographic measurement and classification of metatarsus adductus. Journal of Pediatric Orthopedics 1992; 12( 1): 86-9.
- Dunne KB, Clarren SK. The origin of prenatal and postnatal deformities. Pediatric Clinics of North America 1986; 33( 6): 1277-97.
- Farsetti P, Weinstein SL, Ponseti IV. The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus. Journal of Bone & Joint Surgery - American Volume 1994; 76( 2): 257-65.
- Ghali NN, Abberton MJ, Silk FF. The management of metatarsus adductus et supinatus. Journal of Bone & Joint Surgery -British Volume 1984; 66( 3): 376-80.
- Katz K, David R, Soudry M. Below-knee plaster cast for the treatment of metatarsus adductus. Journal of Pediatric Orthopedics 1999; 19( 1): 49-50.
- Morcuende JA, Ponseti IV. Congenital metatarsus adductus in early human fetal development: a histologic study. Clinical Orthopaedics & Related Research 1996( 333): 261-6.
- Stark JG, Johanson JE, Winter RB. The Heyman-Herndon tarsometatarsal capsulotomy for metatarsus adductus: results in 48 feet. Journal of Pediatric Orthopedics 1987; 7( 3): 305-10.
- Theodorou DJ, Theodorou SJ, Boutin RD, Chung C, Fliszar E, Kakitsubata Y, et al. Stress fractures of the lateral metatarsal bones in metatarsus adductus foot deformity: a previously unrecognized association. Skeletal Radiology 1999; 28( 12): 679-84.
- Widhe T, Aaro S, Elmstedt E. Foot deformities in the newborn--incidence and prognosis. Acta Orthopaedica Scandinavica 1988; 59( 2): 176-9.
May 16-19, 2012 in Denver, CO
