Management of metatarsus adductus, bean-shaped foot, residual clubfoot adduction and Z-shaped foot in children, with conservative treatment and double column osteotomy of the first cuneiform and the cuboid

Abstract

Metatarsus adductus (bean-shaped foot) is a deformity located at Lisfranc’s joint in a pure transverse plane. The deformity is spontaneously corrected in few months for the majority of newborns. In rare cases it demonstrates a clinical stiffness and it results in Z-shaped or skewfoot in toddler, where valgus of the heel creates equilibration of resistant metatarsus adductus. Although, recurrent metatarsus adductus varus is observed in treated idiopathic clubfeet, usually in children over three years of age, but valgus of the heel when exists is related to the surgical overcorrection of the heel’s varus.

Conservative treatment is advocated in flexible metatarsus adductus, considering manipulations, cast and adequate shoes. The surgery is performed when conservative treatment failed, and in walking patient. The procedures described in the literature considering soft tissue releases, osteotomies of metatarsals and medial epiphysiodesis of the metatarsal base gave good results in short term, but they could not avoid the recurrence of the deformity and growth disturbance of the foot. Therefore, permanent correction has been obtained with the osteotomy carried out proximal to the Lisfranc's joint. Surgical procedures going from opening wedge osteotomy of medial cuneiform, calcaneo-cuboid fusion and resection of anterior end of the calcaneus, all act only on one of the sides of deformity. The theory of elongated lateral column associated with a shortened medial column is crucial in dealing with this deformity. Therefore, combining opening wedge osteotomy of cuneiform with closing wedge osteotomy of cuboid described by Jawish et al after 4 years old allows in all causes of metatarsus adductus stiffness a lateral shifting of forefoot. Concerning the associated heel’s valgus, it is thoroughly corrected in Z-shaped foot after the double osteotomy cuneiform/cuboid. However, in clubfoot a particular treatment for the posterior tarsal is necessary, because valgus is considered a non-functional deformity related to imbalance at the rearfoot.