A FOREFOOT ABDUCTION PROCEDURE FOR RESIDUAL METATARSUS ADDUCTUS DEFORMITY – THE ANATOMIC APPROACH

Abstract

Metatarsus adductus (MA) is associated with a medially facing distal facet of the medial cuneiform (with a normal first metatarsal) and varus/adducted deformities of the metaphysis of the lesser metatarsals. A number of patients with severe symptomatic metatarsus adductus do not improve with time. A number of surgical techniques have been described but the series are small and use radiological rather functional outcomes. It is clear however that the failure and complication rate with these procedures is high. A combined medial cuneiform and lesser metatarsal basal closing wedge osteotomy has potential advantages over more commonly used procedures (including the combined cuneiform-calcaneal) osteotomy, by correcting at the level of deformity.

We reviewed a consecutive series of 15 cases (11 severe idiopathic metatarsus adductus, 4 with history of clubfoot) (all Bleck’s grade severe) treated with combined cuneiform-metatarsal osteotomies. Patients were followed up for a mean of 30 months using child-, parent and clinician-based outcome measures as well as radiological assessment. Outcomes are also compared to currently used and historical procedures.

Bleck’s grade improved to 65% normal 35% mild post op; Radiographic improvements (all p< 0.001); 1stray angle 30°→62°, 1stMT-Talar angle 43°→9°, 2ndMT-Talar angle 41°→8°, 2ndMT-Calcaneal angle 48°→14°, 5thMT-Calcaneal angle improved from 13°→3°. Mean postop scores; Chesney - 14 (12–15); Utukari – 13 (10–18); Laaweg – 93 (81–100); Vitale – 13 (10–14). None of the radiographic scores correlated with the clinical scores. All children gained improved levels of activity.

Our findings indicate that this technique can be used effectively in children > 4 years and is a safe alternative to historical procedures, with excellent radiographic/ clinical outcomes, and a low complication rate.