SLR- MARCH 2014- Nicholas Schmerbach
Reference: Knorr J, Soldado F, Pham TT, Torres A, Cahuzac JP, Sales de Gauzy, J. Percutaneous Correction of Persistent Severe Metatarsus Adductus in Children. Journal of Pediatric Orthopaedics. 2013 Nov 21. [Epub ahead of print].
Scientific Literature Review
Reviewed by: Nicholas Schmerbach, DPM
Residency Program: Columbia – St. Mary’s Milwaukee, WI
Podiatric Relevance: This article demonstrates relevance to the practice of podiatric medicine and surgery on multiple fronts in that it addresses both metatarsus adductus (which we as foot and ankle surgeons continuously struggle with and is noted as the most common pediatric foot deformity) as well as percutaneous procedures in foot and ankle surgery (which are becoming increasingly popular through the field of foot and ankle surgery). The article also brings to light the idea that percutaneous procedures are many times used for adults, but have not been as well studied for use in children. The article presents a percutaneous approach for the correction of metatarsus adductus in the pediatric population and results of the described procedure.
Methods: This was a prospective level II study in which 26 pediatric patients (34 feet) with metatarsus adductus deformities underwent percutaneous correction of the deformity. The purpose of the study was to report the results of metatarsus adductus correction using the percutaneous Cahuzac procedure. In the study, all procedures were performed by a single surgeon from January 2006 to December 2010. The study's population included both males (16) and females (10), mean age at surgery of 5.7 years, and included both idiopathic (9) and secondary to clubfoot surgery (25) cases of the deformity. Patients were analyzed both pre- and post-operatively using a heel bisector method, bilateral weightbearing radiographs looking at the first metatarsal-cuneiform angle (CM1) as a measure of the first cuneometatarsal deviation, the metatarsal metaphyseal angle (M angle) as a measure of adduction of the central metatarsals, and functional assessment using AOFAS scores. The procedure was performed by percutaneous metaphyseal osteotomies of metatarsals 2-4 utilizing a 2.0mm Shannon burr through two incisions. Additionally, a 19-gauze needle was used to perform a first cuneometatarsal capsulotomy and to section the distal tibialis insertion. All procedures were performed with the assistance of intraoperative fluoroscopy. Following the osteotomies and release an abduction maneuver is utilized to obtain correction and a 2mm Kirschner wire was inserted obliquely from the first metatarsal to the tarsal bones for fixation. The patient was placed in a below knee cast following the procedure and immobilized for six weeks post-operatively with a thermoconformed splint recommended at night for two months following removal of cast.
Results: Each of the cases in this study was determined to be severe deformities based on the heel bisector method. The study states that they were able to successfully correct the metatarsus adductus deformity in all cases with the heel bisector passing medially to the third toe at final follow-up. In terms of radiographic analysis, the mean preoperative CM1 and M angles were 31.61 +/- 8.91 degrees and 6.42 +/- 9.12 degrees, respectively, and were corrected to 10.28 +/- 4.93 and 0.91 +/- 2.14 post-operatively. These results did show a statistically significant difference from pre- and post-operative values. The mean preoperative AOFAS score was noted to be 78 +/- 16 and the postoperative AOFAS score was noted to be 98.7 +/- 1.3, which shows a significant overall increase in function. The study also looks at overall mean surgical time (14 +/- 7 minutes) and mean hospital stay (6 +/- 2.3 hours), which were not compared to open procedures or a control of any type. Noted complications included lateral deviation of the metatarsal osteotomy (40/102) with complete remodeling and asymptomatic second and third intermetatarsal synostosis.
Conclusions: This study demonstrates results consistent with open techniques, but with a much shorter surgical time and hospital stay. The study also states that there were no cases of recurrence of the deformity at final follow up, which is noted to be one of the main complications of other options for correction. In conclusion, this particular study brings forth a viable alternative treatment option for severe metatarsus adductus in the pediatric population, but it should be known that there are potential drawbacks to percutaneous procedures and that a thorough understanding of anatomy and the procedure itself are needed prior to attempting this type of correction.