What is the next step when you see a patient with metatarsus adductus who is clearly not a candidate for casting or manipulation?
Is the patient not a candidate because of age or activity level? Certainly, it is very difficult to cast a 3- or 4-year-old who is running at full tilt all day and there is a high likelihood that he or she will not respond to casting. Is surgery indicated at this point?
As we all learn, there seems to be a “gray zone” where surgery is really not indicated. If you get patients who are young enough and they do not respond to casting, they may be candidates for soft tissue releases and subsequent casting to maintain the correction. If they are in this gray zone between 2 and 8 years of age, the parents need to learn that there is hope to correct their child’s deformity but it may need to wait until the child is older.
There are certainly many variations of surgical corrective procedures. The key is being able to identify the compensation that has occurred and what foot type you are dealing with before making an assertion as to what procedure to perform.
There is a key pitfall to consider. By correcting one aspect, it may actually appear to worsen the deformity. The prime example of this is the flatfoot compensation that occurs secondarily to the metatarsus adductus.
It is important to educate families that if you are considering a subtalar arthroereisis, there is a likelihood that the deformity will appear to worsen and that you will address this at a later time. If you do not explain that some of these procedures work best in stages, necessitating more than one trip to the OR, there is trouble ahead.
All in all, metatarsus adductus is a rather complex issue. In order to properly address the concerns of your patients and their families, it is necessary to not only have the required manual and surgical skills but people skills as well.