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Skew Foot



- Discussion:
    - a type of flat foot described as a z foot or serpentine foot;
    - pathoanatomy:
           - forefoot:
                  - first metatarsal lies adducted and plantar flexed on the medial cuneiform, w/ resultant marked adductus deformity of the 
                          forefoot;
           - midfoot:
                  - lies in abduction w/ lateral displacement of the navicular on the head of the talus;
                  - navicular may also lie dorsally subluxed in relation to the talus;
           - hindfoot
                  - lies in valgus w/ pronation and inward rotation of the talus, w/ lateral subluxation of the navicular on the talar head;
                  - achilles tendon is contracted;
    - diff dx:
           - metatarsus adductus:
                  - in infants it may not always be possible to different these disorders;


- Radiographs:
    - dx is confirmed by AP & lateral standing roentgenograms of foot;
    - AP view:
         - combination of abduction at mid tarsal joints & adduction of metatarsals gives foot z configuration on AP view:
         - mid-talar axis will generally be medial to base of first metatarsal;
    - lateral view:
         - shows a reduction in calcaneal pitch & plantar flexion of talus;


- Non Operative Treatment:
    - generally ineffective in changing the shape of the foot, however, many patients will remain highly functional and relatively free of 
          symptoms;
    - if casts are applied to correct the forefoot adductus component, then consider varus hindfoot molding (to avoid valgus stress on the 
          hindfoot);


- Operative Treatment:
    - 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;
    - delayed until after age of six 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;
    - this is combined w/ opening wedge osteotomy of the first cuneiform to correct the forefoot adductus



Calcaneal Lengthening for Valgus Deformity of the Hindfoot.  Results in Children Who Had Severe, Symptomatic Flatfoot and Skewfoot.