DefinitionA deformity that consists of an adducted forefoot and hindfoot valgus with plantar flexion of the talus.
PatoanatomyForefoot: The first metatarsal bone is adducted and plantar flexed on the medial cuneiform, which leads to marked adductus deformity of the forefoot.
- The midfoot lies in abduction with lateral displacement of the navicular on the head of the talus.
- The navicular may also lie dorsally subluxed in relation to the talus.
- Hindfoot lies in valgus with pronation and inward rotation of the talus, w/ lateral subluxation of the navicular on the talar head.
- The achilles tendon is contracted.
Berg classificationDivides the condition into four subtypes:
- Simple MTA: MTA.
- Complex MTA: MTA, lateral shift of midfoot.
- Skew foot: MTA, valgus hindfoot.
- Complex skew foot (serpentine foot): MTA, lateral shift, valgus hindfoot.
Napiontek classificationNapiontek proposed a classification scheme to distinguish four clinical types of the deformity:
- Congenital idiopathic skewfoot.
- Congenital skewfoot associated with syndromes or systemic disorders.
- Neurogenic skewfoot.
- Iatrogenic skewfoot.
Differential DiagnosisMetatarsus adductus: It is not always be possible to different these disorders in infants. Assessment of hindfoot valgus may be difficult due to the fat pad in children under 1 year of age.
SymptomsNo specific symptoms.
SignsPatients may become symptomatic at the talar head or the base of the fifth metatarsal.
Conventional RadiographyProjections: Weight-bearing frontal (AP) and lateral radiographs of the foot.
- AP view: A combination of abduction at mid tarsal joints and adduction of metatarsals gives foot z configuration. The mid-talar axis will generally be medial to base of first metatarsal.
- Lateral view: Shows a reduction in calcaneal pitch and plantar flexion of talus.
OverviewGenerally observed and in severe cases treated with surgery.
- Nonoperative treatment is generally ineffective in changing the shape of the foot.
- Consider varus hindfoot molding (to avoid valgus stress on the hindfoot) if casts are applied to correct the forefoot adductus component.
Operative TreatmentIndication: Persistent pain.
- Surgery should generally be avoided if possible, since there is deformity in the forefoot, midfoot, and hindfoot which essentially means that the
entire foot has to be reconstructed inorder to re-establish a functional relationaships;
- Surgery should be delayed until after age of 6 years.
- Opening wedge osteotomy of the calcaneus is done to correct mid-tarsal abduction deformity and to position the sustentaculum to elevate neck of the talus.
- Opening wedge osteotomy of the medial cuneiform is done to correct the forefoot adductus.00
Operation MethodsOpening wedge and closing wedge osteotomies:
- Indications: Symptomatic deformity that significantly limits function. Operative treatment is difficult and the deformity is often accepted and observed.
- Calcaneal osteotomy for hindfoot valgus.
- Possible midfoot osteotomies to correct midfoot and forefoot deformities.
- Multiple metatarsal osteotomies with forefoot pinning and tarsometatarsal capsular release (Hamen procedure).