The identification and appraisal of assessment tools used to evaluate metatarsus adductus: a systematic review of their measurement properties

The identification and appraisal of assessment tools used to evaluate metatarsus adductus: a... Background: Metatarsus adductus is the most common congenital foot deformity in newborns. It involves adduction of the metatarsals at the Lisfranc joint. A systematic literature review was conducted to investigate the following question: What tools are used to identify and quantify metatarsus adductus and how reliable, valid and responsive are they? Methods: The following electronic databases were searched for studies describing tools for the identification and quantification of metatarsus adductus in adults and children published from inception to June 2016: Ovid MEDLINE, Embase, CINAHL, Scopus, Web of Science and AMED. Two researchers initially searched all articles by screening titles and abstracts. If there was any doubt as to an article’s eligibility, the full text paper was retrieved. Reference lists and citations of all retained studies were examined in an attempt to locate further studies. Articles were excluded if they were not in English or described other congenital foot conditions that did not include metatarsus adductus. Studies included in the review reporting measurement properties of measurement tools were critically appraised using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) critical appraisal tool. Results: There were 282 articles screened by title and abstract and 28 articles screened from full text. Fifteen articles were included and nine had data that were extractable for appraisal using the COSMIN critical appraisal tool. Techniques to measure metatarsus adductus included the heel bisector method, photocopies, ultrasound, footprints, dynamic foot pressure and radiographs. There was a paucity of quality data reporting the reliability, validity or responsiveness for measuring metatarsus adductus. Several radiographic angles showed good reliability (intraclass correlation (ICC) – 0.84, 0.97) in adults during pre-operative planning. Conclusion: There have been multiple assessment techniques proposed for quantification of metatarsus adductus, but there is paucity of reliability, validity or responsiveness to measurement data about these techniques, especially in relation to the paediatric population. Further consideration of measurement testing is required to determine if the most common non-radiographic measures of metatarsus adductus are acceptable for clinical use. Keywords: Metatarsus adductus, Assessment, Paediatric, Child * Correspondence: Marnj008@mymail.unisa.edu.au University of South Australia, School of Health Science, Adelaide, SA 5000, Australia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 2 of 10 Background development and continues to be clinically utilised to Metatarsus adductus is the most common congenital reassure parents that their child’sfootpositionwill resolve foot deformity in newborns with a reported prevalence with time or to drive treatment initiation [4, 19, 20]. of one to two cases per 1000 births [1]. The deformity Other assessment methods described within the litera- appears as an adduction or medial deviation of the fore- ture to grade severity include a multitude of radio- foot at the tarsometatarsal joints (Lisfranc joint) with graphic angles [23–25], photocopies of the child’s foot associated soft tissue contractures that may lead to osse- [19] and the V-finger test [16, 17]. Radiographs may be ous changes over time [2–4]. The metatarsals are devi- considered time consuming and unnecessary given ated medially in the transverse plane resulting in a potential risk to the child. Photocopying the child’s foot convex lateral border of the foot and a prominent styloid poses potential risk due to glass breakage. Recent studies process [3, 5, 6]. Metatarsus adductus can be differenti- suggest the use of ultrasound as a measurement ated from other congenital foot conditions as it is purely technique as it allows for the imaging of cartilaginous a forefoot condition that does not involve the hindfoot structures [21]. unlike talipes equinovarus or skewfoot [3]. The exact As previously discussed, many treatment options are aetiology of metatarsus adductus is unknown, however, initiated based on the observed presence of deformity, to it has been suggested that increased intrauterine measure severity and flexibility of the condition. There- pressure, osseous abnormality and abnormal muscle at- fore if the tool used to measure these components was tachments may be potential causes [7–12]. Between 87 not adequate, this has implications for the initiation of and 90% of flexible metatarsus adductus cases resolve treatment where needed, or potentially unnecessary spontaneously without the need for further treatment treatment leading to a potential poor prognosis for that [10, 11, 13, 14]. child. [16]. The primary aim of this systematic review There is inconclusive evidence on the long term effect was to identify, and where possible, appraise the meas- of metatarsus adductus on the adult foot [15]. Some au- urement properties of all known methods for identifying thors propose that if metatarsus adductus persists into the severity and/or flexibility of metatarsus adductus. adulthood it can lead to the development of hallux val- gus, skewfoot or hammer toes, intoeing, increased med- Methods ial tibial torsion, fifth metatarsal stress fractures, Search strategy difficulty fitting into shoes and can contribute to in- The PRISMA guidelines for systematic reviews were creased falling or tripping later in life [7, 12, 16–18]. followed [26]. The question and search terms were de- Metatarsus adductus is commonly diagnosed accord- veloped using the broad concepts of the PICO (Popula- ing to the presence and severity of the deformity and the tion, Intervention Comparison and Outcomes) model degree of flexibility using the Bleck manual assessment [27]. The systematic review was registered with Prospero [3, 4, 19–21]. Clinically, assessments are used to deter- (CRD42016039622). The following electronic databases mine if treatment is required, the method of treatment, were searched for studies describing assessment tools for monitoring progress and to ensure the child’s foot has the identification and quantification of metatarsus returned to a normal foot alignment post intervention adductus in adults and children published from incep- [22]. Whilst there are numerous assessment techniques tion to June 2016: Ovid MEDLINE, CINAHL, Scopus, published to quantify the presence of metatarsus adduc- Web of Science and AMED. Broad MeSH terms and tus, there is little research assessing validity, reliability or keywords were used to identify the articles of interest responsiveness of these measures. This is potentially (e.g. Metatarsus adductus) and quantification termin- problematic for clinicians, as quantification of the condi- ology (e.g. measure, assess). Additional file 1 contains tion drives treatment and management decisions [15]. the full search terms and truncation used within each There have been several assessment techniques pro- database. Citation chaining was undertaken to identify posed in the literature for the assessment of the deform- any articles that may have been missed in the initial ity to quantify the severity. In 1983, Bleck created a search strategy. It involved employing a forward and visual assessment called the ‘heel bisector method’. It in- backward searching strategy using Google Scholar cita- volves firstly visually identifying the severity of the de- tions to identify relevant articles using a single paper as formity and categorising it as mild, moderate or severe a starting point which creates a ‘chain’ of references according to the heel bisector and secondly making a linked backward and forward from the original article. classification of flexibility as fully flexible, partially The inclusion and exclusion criteria used for search flexible or severe. This simple method requires minimal strategy is listed in Table 1. time for both the clinician and patient and as it was ob- Two researchers (NM & CMW) initially screened the servation based, and cost effective [3]. This measure has title and abstract of all articles. If there was any doubt as been modified and used in numerous studies since its to an article’s eligibility, the full text paper was retrieved. Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 3 of 10 Table 1 Inclusion and exclusion criteria for articles included in the systematic review Inclusion Criteria: Exclusion Criteria: � Studies describing a tool measuring metatarsus adductus. � Studies describing congenital foot deformities with no inclusion of metatarsus adductus These included but were not limited to: skewfoot, congenital talipes equinovarus, metatarsus primus varus, congenital metatarsus varus or serpentine foot. � Studies reporting any measurement properties of measurement tools � Non-English publications. for assessing metatarsus adductus as defined by the COSMIN tool. � Grey literature � All study designs � Studies based on both adults and children Articles were imported into Covidence for screening Data extraction [28]. The full text of included study abstracts were inde- Data were extracted by the first author and where there pendently screened against the inclusion criteria by two were queries, these were resolved with all authors. Data reviewers (NM & EW). Any disagreement was resolved extracted included the study design, population, by discussion or through consultation with the third assessment measure/description, sample size, reliability author. Figure 1 displays the search process. (inter/intra rater reliability), statistical quality, available Fig. 1 PRISMA flow of article inclusion Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 4 of 10 domains of the COSMIN and author derived measure- Reliability of measures employed to quantify metatarsus ment [29]. adductus There were three studies assessing the reliability of three different individual radiographic angles to assess meta- Critical appraisal of study methodology quality tarsus adductus [23, 32, 33]. These measures (Table 3) Where studies reported measurement properties, they included the traditional and modified metatarsus adduc- were critically appraised using the Consensus-based tus angle, the Engel and/or modified Engel angles and Standards for the selection of health Measurement the rearfoot-second metatarsal angle [32, 33]. Only Instruments (COSMIN) critical appraisal tool [29]. The radiological measures reported any intra-rater reliability COSMIN was developed in an international Delphi intra-class correlation coefficient (ICC). These ranged study to improve the selection of health measurement from 0.85–0.97 and the inter-rater reliability ICC ranged instruments [29]. This was found to have adequate from 0.84–0.972 [32, 33] (Table 4). content validity [30]. COSMIN assessed the internal The Berg’s classification system reported diagnostic consistency, reliability, measurement error, hypothesis agreement ranging from 66.7–81% for inter-rater testing, content and structural validity, responsiveness consistency and 61.9–66.7% for intra-rater consistency. and interpretability of a measurement [31]. Articles During reliability testing, authors removed five radio- chosen for inclusion in the synthesis were subject to graphs that produced high disagreement between re- appraisal by two independent reviewers. viewers from results, the administrations were not The COSMIN may be utilised as a modular tool and independent and there was no time interval between used to assess the quality of measurement based studies reviewing the images. including patient reported outcome measures, scales and simple measures such as those appraised in this present Methodology quality of the included studies study. Therefore only relevant parts of the checklist were The COSMIN criterion was applied to the nine studies used for quality evaluation of measurements [29] included: reporting measurement properties to determine their box B (reliability), D (content validity), H (criterion validity) methodological quality (Table 5). Three reported the and I (responsiveness). For example, if the study reported reliability of the measure and assessed as fair to good on the measurement properties involving reliability then methodological quality [23, 32, 33]. One included box Bwas theonlypartofthe COSMIN completed[29]. reported content validity which rated poorly for methodo- COSMIN also requires generalizability to be assigned for logical quality [34], one included criterion validity which each measure. The results of these modules were then also rated poorly for methodological quality [35]. There assessed using a 4 point scale to allow calculation of the were five of the nine included studies assessed for respon- overall methodological quality score for each study. This siveness. All five studies were rated poorly for methodo- methodological quality score per box was obtained by logical properties relating to responsiveness according to assigning the lowest rating of any item in a box (‘worse the COSMIN criterion [2, 4, 20, 25, 34]. There were no score counts’). studies reporting specific data on sensitivity or specificity in any included research. Results There were several other measurement techniques Included studies identified for assessing metatarsus adductus. These were There were 15 studies included in this review. Of these unable to be critically appraised using the COSMIN due 15 articles, nine reported on measurement properties to a lack of reported measurement properties. These that were able to be critically appraised for quality using measures included Bleck’s heel bisector method [3], the COSMIN and six reported methods of measurement photocopying the child’s foot [19], ultrasound [21], and that were unable to be appraised. Table 2 provides a dynamic foot pressure [13]. description of the 15 included studies. A meta-analysis was not performed as studies were heterogeneous. Each Discussion study varied in terms of participant age, country the Metatarsus adductus has been described as the most study was conducted, gender and measurement tool common congenital foot deformity presenting in new- used. Out of the 15 studies, two studies were conducted borns [1]. While this condition is self limiting in the vast on an adult population, eight studies had a paediatric majority of cases, there is time when treatment is war- population and five studies did not mention age. The ranted and guided by measurements assessed within this majority of studies were cohort study designs (Table 2). review. Several measurement techniques are reported for There were six methods of measurement described to assessment of this condition, but there was limited high assess the severity or flexibility of metatarsus adductus quality evidence supporting the measurement properties (Table 3). of many of these measurements. Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 5 of 10 Table 2 Studies included within review Primary Study Design Country Sample Size Gender Age Measure Inclusion Exclusion Data collection Tool developed Author Male/ Female (Age (SD), Range) Criteria Criteria method by author: Engel [35] Retrospective USA 571 radiographs Not stated Not stated 1. Traditional metatarsus Foot radiographs Not stated Weight-bearing Yes cohort adductus angle (intersection from Oxford hospital. foot radiographs of longitudinal axis of lesser tarsus with bisector of second metatarsal) 2. Simplified metatarsus angle (intersection of longitudinal bisector of 2nd metatarsal and medial cuneiform) Dawoodi [38] Literature United Not stated Not stated Not stated 1. Traditional metatarsus Not stated Not stated Not stated No review Kingdom adductus angle (intersection of longitudinal axis of lesser tarsus with bisector of second metatarsal) 2. Engel’s angle (bisection of middle cuneiform with longitudinal axis of second metatarsal) 3. Modified Engel’s angle using the base of the middle cuneiform as a reference line Dawoodi [32] Validation United 130 patients 119/14 50.6 (15.4) years, 1. Sgarlarto’s angle/traditional Symptomatic hallux Evidence of Dorsoplantar No study Kingdom (50 randomly 14–80 years metatarsus adductus angle abductovalgus, listed trauma, radiographic views. selected (angle between 2nd for corrective surgery Previous radiographs) metatarsal and longitudinal surgery axis of the lesser tarsus using 4th metatarso-cuboid joint as reference) 2. Rearfoot-2nd meta-tarsal angle 3. Engel’s angle (bisection of middle cuneiform with longitudinal axis of second metatarsal) 4. Modified Engel’s angle using the base of the middle cuneiform as a reference line French [34] Non-Controlled USA 42 (68 ft) 29/13 9.1 months 1. Lateral calcaneal 5th Clinical observation Not stated AP and lateral First metatarsal Trial 1–3 years Metatarsal angle (line of metatarsus adductus radiographs -5th metatarsal representing the lateral angle only aspect of calcaneus and the was author longitudinal bisector of the driven. fifth metatarsal) 2. Inter-metatarsal angle (angle formed by longitudinal bisectors of 1st and 2nd metatarsals) 3. Talus first metatarsal angle (longitudinal bisectors of talus and the first metatarsals) Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 6 of 10 Table 2 Studies included within review (Continued) Primary Study Design Country Sample Size Gender Age Measure Inclusion Exclusion Data collection Tool developed Author Male/ Female (Age (SD), Range) Criteria Criteria method by author: 4. Talocalcaneal angle (Kite’s angle) (longitudinal bisector of the talus and the calcaneus) 5. First metatarsal fifth metatarsal angle (angle formed by l ongitudinal bisection of 1st and 5th metatarsals) 6. Talocaneal angle lateral view (bisection of talus and a line representing inferior aspect of the calcaneus) Hutchinson Expert Opinion USA Not stated Not stated Not stated Describes Kite’s talocalcaneal Not applicable Not Radiographs No [39] angle and calcaneal metatarsal applicable angle without labeling of method Widhe [13] Prospective Sweden 2, 401 Not stated 0–16 years Dynamic foot pressure and Not specifically stated. Not stated EMED No cohort gait analysis dynamometric system Knörr [4] Prospective Spain 26 (34 ft) 16/10 5.7 years, 1. Heel bisector method Rigid Metatarsus Not stated Weight bearing No cohort 3–8.5 years (undescribed) adductus scheduled radiographs 2. First cuneiform metatarsal for surgery angle (medial angulation of first cuneometatarsal joint) 3. Metatarsal-metaphyseal angle (metatarsal metaphyseal incurvation) Miron [21] Expert Opinion Canada N/A Not stated Not stated Lateral displacement of the Not applicable Not Ultrasonography Yes medial (first) cuneiform over applicable the navicular as the single feature. Lepow [25] Retrospective USA 15 7/8 6 months, 1. Traditional metatarsus adductus Diagnosed with No WB AP No cohort (2–15 months) angle (intersection of longitudinal metatarsus adductus treatment radiographs axis of lesser tarsus with bisector No of second metatarsal). radiography Herzenberg Prospective USA 27 (43 ft) Not stated 3–9 months. 1. Footprints analysed using < 9 months, Failed Children Footprints Yes [20] cohort modification of Bleck’s heel program of parent older than bisector method. A transparent stretching 9 months template with longitudinal of age bisector was applied over footprint and graded 2. Talocalcaneal angle (Kite’s angle) (longitudinal bisector of the talus and the calcaneus) Smith [19] Expert Opinion USA Not applicable Not Not applicable Heel bisector drawn N/A N/A Photocopied Yes applicable onto photocopy of a footprint child’s footprint. A second copy in maximum correction Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 7 of 10 Table 2 Studies included within review (Continued) Primary Study Design Country Sample Size Gender Age Measure Inclusion Exclusion Data collection Tool developed Author Male/ Female (Age (SD), Range) Criteria Criteria method by author: for quantification of flexibility Dominguez Retrospective Spain 121 106/103 23.88 years (2.85), Metatarsus adductus > 20 years Disease or Dorsoplantar No [33] cohort (20 randomly 20–29 years angle - cuboid and No history of foot trauma radiographs selected the 4th metatarsal surgery or alteration causing foot weight bearing radiographs) and cuboid and the in plantar pressures pathology, 5th metatarsal distribution pain, toe deformities Cook [23] Retrospective USA 40 ft Not stated 9 weeks – Berg classification - Metatarsus adductus Poor quality Radiographs no cohort 9 months talus-first metatarsal diagnosis on clinical radiograph deviation, calcaneal examination line to cuboid, AP talocalcaneal line, lateral talocalcaneal angle Berg [2] Prospective USA 84 50/34 2.5 years Talocalcaneal angle Stretches failed to Neurological AP weight-bearing Yes cohort 2.2–3.8 (Kite’s angle) (longitudinal resolve metarasus conditions radiographs bisector of the talus adductus and the calcaneus) Bleck [3] Retrospective USA 160 93/67 5–36 months Heel bisector method: Metatarsus adductus Dynamic Observation and Yes cohort Severity measure: The diagnosis on clinical hallux varus, physical heel bisector centres examination metatarsus assessment of the hindfoot plantar primus varus surface. Line crosses or serpentine between the 2nd and foot. 3rd toes = normal, through the 3rd toe (mild deformity), between 3rd and 4th toes (moderate), between 4th and 5th toes (severe deformity). Flexibility measure: Abduction beyond the midline heel bisector (mild classification), only to the midline (partially flexible), no abduction possible (severe) *N/A Not applicable Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 8 of 10 Table 3 Identified measurement techniques for measuring not allow many of these angles to be easily calculated metatarsus adductus [21]. The radiographic angles with the highest reliability Type of measure: Frequency of measure [32, 33] identified in this review were calculated and reli- n =15 ant on osseous structures that appear after the age of Visual – heel bisector method [3, 4, 19–21, 38] 6 (40%) five [38]. Ultrasonography was utilised as a dynamic im- Radiographs [2, 4, 20, 23, 25, 32–35, 38, 39] 11 (73%) aging modality for quantification of metatarsus adductus in infants as it allows for the imaging of the cartilaginous Ultrasound [21] 1 (7%) structures. It also differentiates between metatarsus Photocopier [19] 1 (7%) adductus and skewfoot, as in metatarsus adductus the Footprints [20] 1 (7%) medial cuneiform will be displaced laterally over the Dynamic foot pressure and gait analysis [13] 1 (7%) navicular [21]. Whilst this is a new imaging modality, no studies have assessed the measurement properties of this Radiographic angles had high levels of reliability for method. This has the potential to be a costly measure- measuring metatarsus adductus in adults when taken ment technique requiring additional skills by clinicians during pre-operative planning. However, these studies for interpretation, however, would negate the radiation should be interpreted with caution as they were con- exposure that radiographs impose. ducted with adult participants with no history of The Bleck’s heel bisector method was the most fre- metatarsus adductus. Therefore, results may not be quently reported measurement for assessing metatarsus transferable to the paediatric population. Furthermore, adductus in the paediatric population. It is the measure radiographs measure and quantify the severity of that appears most frequently within studies relating to metatarsus adductus but do not take into account the metatarsus adductus [3, 4, 19–21, 38]. The Bleck meas- flexibility of the condition. There is little benefit for urement was also recently used to assess the treatment supporting using this measurement technique in outcome of stretching for metatarsus adductus versus no children unless surgical management is recommended treatment [22]. This simple measure requires a short [16, 36, 37]. One study assessed radiographic angles time for the clinician to assess both any flexibility and in children however, the author developed their own rat- severity of the adduction deformity. As this measure is a ing tool and it scored poorly for quality on the COSMIN manual assessment that requires no equipment, it is for both content validity and responsiveness [34]. considered simple and is less costly than radiological Metatarsus adductus is primarily identified and treated measurement. No studies have assessed the measure- conservatively in the paediatric population where the ment properties of this measurement. Due to the com- benefits and risks of measurement technique must be monality of this measure and clinical use to guide considered [15]. Radiographs and the associated angles treatment and success of treatment, further research measure the osseous deviation and change. In the youn- should be considered to determine the measurement ger population, the lack of tarsal bone ossification does properties of this assessment. Table 4 Intra and inter-rater reliability of radiographic angles used to assess metatarsus adductus Radiographic angles: Description of measurement: Study Intra-rater ICC: Inter-rater ICC: Traditional metatarsus Angle between the second metatarsal and longitudinal axis of [32] 0.92 0.87 adductus angle (5th) the lesser tarsus using the fifth metatarso-cuboid joint as a reference [33] 0.970 0.962 Modified metatarsus Angle between the second metatarsal and longitudinal axis of the [38] 0.91 0.93 adductus angle (4th) lesser tarsus using the forth metatarso-cuboid joint as a reference [33] 0.962 0.972 Rearfoot-2nd Angle between the longitudinal bisection of the second metatarsal [32] 0.85 0.87 metatarsal angle bone and the line parallel to the lateral border of the calcaneum Engel’s angle Angle between the longitudinal axis of the middle cuneiform and [32] 0.90 0.84 the longitudinal axis of the second metatarsal Modified Engel Angle between the longitudinal axis of the second metatarsal and [32] 0.92 0.91 a line perpendicular to the proximal articular surface of the middle cuneiform and the angle between the rearfoot reference line (line parallel to the lateral border of the calcaneum) and the longitudinal axis of the second metatarsal The Berg Four radiographic measurements that categorises foot deformities [23] Average intra-rater Average inter-rater Classification system into; metatarsus adductus, complex metatarsus adductus, consistency: 74% consistency: 64% simple skewfoot and complex skewfoot (ranged from 66.7–81%). (ranged from 61.9–66.7%). This includes the following: talus-first metatarsal deviation, calcaneal line to cuboid, AP talocalcaneal line, lateral talocalcaneal angle Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 9 of 10 Table 5 COSMIN critical appraisal tool used for studies that could be analysed for their measurement properties Study: Measurement tool: Author driven: Reliability (B): Content Validity (D): Criterion Validity (H): Responsiveness (I): Berg et al. [2] Radiographs: Berg Yes n/a n/a n/a Poor classification system Cook et al. [23] Radiographs: Berg No Poor n/a n/a n/a classification system Dawoodi et al. [32] Radiographs: metatarsal No Good n/a n/a n/a angle (4th), modified metatarsal angle (5th), rearfoot – 2nd metatarsal angle, Engel’s Angle, modified Engel’s angle. Dominguez et al. [33] Radiographs: Traditional No Fair n/a n/a n/a metatarsus adductus angle (cuboid and the 4th metatarsal as reference), modified metatarsus adductus angle (cuboid and the 5th metatarsal). Engel, et al. [35] Radiographs: Traditional Modified metatarsus n/a n/a Fair n/a metatarsus adductus angle adductus angle only. and the modified metatarsus adductus angle French, et al. [34] Radiographs: Lateral First-metatarsal n/a Poor n/a Poor calcaneal 5th metatarsal fifth-metatarsal angle, inter-metatarsal angle, angle was author talus first metatarsal angle, driven. All other talocalcaneal angle (Kite’s angles were not. angle), first metatarsal fifth metatarsal angle, talocaneal angle (lateral view). Herzenberg et al. [20] Footprints analysed using a Yes n/a n/a n/a Poor modified version of Bleck’s measurement. Knörr et al. [4] Radiographs: First cuneiform No n/a n/a n/a Poor metatarsal angle, metatarsal- metaphyseal angle. Lepow et al. [25] Radiographs: Paediatric Yes n/a n/a n/a Poor metatarsus adductus angle There are a number of limitations within this no cost-benefit analysis of any of the measures found review that impact findings and recommendations. within the literature. English only articles were included and due to limited and varied data extracted, no meta-analysis was per- Conclusion formed. A broader search encompassing grey litera- There have been multiple assessment techniques proposed ture may have found additional papers reporting the for quantification of metatarsus adductus but there is a pau- quality of measures. They may have included hospital city of quality data on reliability, validity or responsiveness of or department protocols or guidelines. Future studies these techniques, especially in relation to the paediatric popu- should consider encompassing these within the lation. There have been several radiographic measures shown review. The generalisability of radiological reliability to have good reliability in adult participants and are used for findings to the paediatric population was not possible surgical guidance. Further research is required to determine due to osseous development and the methodology of if simple measures commonly guiding reassurance or imple- measure development did not always include the mentation of conservative treatment are a reliable way of paediatric population. measuring metatarsus adductus in the paediatric population. Sensitivity and specificity was not specifically men- tioned in any of the measurement tools analysed in this Additional file review which impacted on the responsiveness criterion of the COSMIN. This also limited the number of items Additional file 1: Search terms and truncation used within each that could be selected from the COSMIN appraisal tool database. (DOCX 89 kb) and used to analyse each study. Additionally, there was Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 10 of 10 Abbreviations 16. Connors J, Wernick E, Lowy L, Falcone J, Volpe R. Guidelines for evaluation COSMIN: Consensus-based Standards for the selection of health and management of five common podopediatric conditions. J Am Podiatr Measurement INstruments; ICC: Intraclass correlation coefficient; IRT: Item Med Assoc. 1998;88:206–22. response theory 17. Gore AI, Spencer JP. The newborn foot. Am Fam Physician. 2004;69:865–72. 18. Theodorou D, Theodorou S, Boutin R, Chung C, Fliszar E, Kakitsubata Y, Funding Resnick D. Stress fractures of the lateral metatarsal bones in metatarsus CMW is supported by a National Health and Medical Research early career adductus foot deformity: a previously unrecognized association. Skelet health professional research fellowship. Radiol. 1999;28:679–84. 19. Smith JT, Bleck EE, Gamble JG, Rinsky LA, Pena T. Simple method of Availability of data and materials documenting metatarsus adductus. J Pediatr Orthop. 1991;11:679–80. Data sharing not applicable to this article as no datasets were generated or 20. Herzenberg JE, Burghardt RD. Resistant metatarsus adductus: prospective analysed during the study. All relevant data has been included within the review. randomized trial of casting versus orthosis. J Orthop Sci. 2014;19:250–6. 21. Miron M, Grimard G. Ultrasound evaluation of foot deformities in infants. Authors’ contributions Pediatr Radiol. 2016;46:193–209. NM, EW and CMW conceived and designed this systematic review, NM and 22. Eamsobhana P, Rojjananukulpong K, Ariyawatkul T, Chotigavanichaya C, CMW contributed to the screening and processing of articles, EW and NM Kaewpornsawan K. Does the parental stretching programs improve critically appraised the data, NM drafted the manuscript, all authors reviewed metatarsus adductus in newborns? J Orthop Surg. 2017;25:1–5. critically the final manuscript and approved for submission. 23. 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Combined medial cuniform osteotomy and multiple metatarsal osteotomies for correction of persistent metatarsus adductus in children. J Pediatr Orthop. 2016;36:730–5. 15. Williams C, James A, Tran T. Metatarsus adductus: development of a non- surgical treatment pathway. J Paediatr Child Health. 2013;49:428–33. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Foot and Ankle Research Springer Journals

The identification and appraisal of assessment tools used to evaluate metatarsus adductus: a systematic review of their measurement properties

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Medicine & Public Health; Orthopedics; Rehabilitation
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Abstract

Background: Metatarsus adductus is the most common congenital foot deformity in newborns. It involves adduction of the metatarsals at the Lisfranc joint. A systematic literature review was conducted to investigate the following question: What tools are used to identify and quantify metatarsus adductus and how reliable, valid and responsive are they? Methods: The following electronic databases were searched for studies describing tools for the identification and quantification of metatarsus adductus in adults and children published from inception to June 2016: Ovid MEDLINE, Embase, CINAHL, Scopus, Web of Science and AMED. Two researchers initially searched all articles by screening titles and abstracts. If there was any doubt as to an article’s eligibility, the full text paper was retrieved. Reference lists and citations of all retained studies were examined in an attempt to locate further studies. Articles were excluded if they were not in English or described other congenital foot conditions that did not include metatarsus adductus. Studies included in the review reporting measurement properties of measurement tools were critically appraised using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) critical appraisal tool. Results: There were 282 articles screened by title and abstract and 28 articles screened from full text. Fifteen articles were included and nine had data that were extractable for appraisal using the COSMIN critical appraisal tool. Techniques to measure metatarsus adductus included the heel bisector method, photocopies, ultrasound, footprints, dynamic foot pressure and radiographs. There was a paucity of quality data reporting the reliability, validity or responsiveness for measuring metatarsus adductus. Several radiographic angles showed good reliability (intraclass correlation (ICC) – 0.84, 0.97) in adults during pre-operative planning. Conclusion: There have been multiple assessment techniques proposed for quantification of metatarsus adductus, but there is paucity of reliability, validity or responsiveness to measurement data about these techniques, especially in relation to the paediatric population. Further consideration of measurement testing is required to determine if the most common non-radiographic measures of metatarsus adductus are acceptable for clinical use. Keywords: Metatarsus adductus, Assessment, Paediatric, Child * Correspondence: Marnj008@mymail.unisa.edu.au University of South Australia, School of Health Science, Adelaide, SA 5000, Australia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 2 of 10 Background development and continues to be clinically utilised to Metatarsus adductus is the most common congenital reassure parents that their child’sfootpositionwill resolve foot deformity in newborns with a reported prevalence with time or to drive treatment initiation [4, 19, 20]. of one to two cases per 1000 births [1]. The deformity Other assessment methods described within the litera- appears as an adduction or medial deviation of the fore- ture to grade severity include a multitude of radio- foot at the tarsometatarsal joints (Lisfranc joint) with graphic angles [23–25], photocopies of the child’s foot associated soft tissue contractures that may lead to osse- [19] and the V-finger test [16, 17]. Radiographs may be ous changes over time [2–4]. The metatarsals are devi- considered time consuming and unnecessary given ated medially in the transverse plane resulting in a potential risk to the child. Photocopying the child’s foot convex lateral border of the foot and a prominent styloid poses potential risk due to glass breakage. Recent studies process [3, 5, 6]. Metatarsus adductus can be differenti- suggest the use of ultrasound as a measurement ated from other congenital foot conditions as it is purely technique as it allows for the imaging of cartilaginous a forefoot condition that does not involve the hindfoot structures [21]. unlike talipes equinovarus or skewfoot [3]. The exact As previously discussed, many treatment options are aetiology of metatarsus adductus is unknown, however, initiated based on the observed presence of deformity, to it has been suggested that increased intrauterine measure severity and flexibility of the condition. There- pressure, osseous abnormality and abnormal muscle at- fore if the tool used to measure these components was tachments may be potential causes [7–12]. Between 87 not adequate, this has implications for the initiation of and 90% of flexible metatarsus adductus cases resolve treatment where needed, or potentially unnecessary spontaneously without the need for further treatment treatment leading to a potential poor prognosis for that [10, 11, 13, 14]. child. [16]. The primary aim of this systematic review There is inconclusive evidence on the long term effect was to identify, and where possible, appraise the meas- of metatarsus adductus on the adult foot [15]. Some au- urement properties of all known methods for identifying thors propose that if metatarsus adductus persists into the severity and/or flexibility of metatarsus adductus. adulthood it can lead to the development of hallux val- gus, skewfoot or hammer toes, intoeing, increased med- Methods ial tibial torsion, fifth metatarsal stress fractures, Search strategy difficulty fitting into shoes and can contribute to in- The PRISMA guidelines for systematic reviews were creased falling or tripping later in life [7, 12, 16–18]. followed [26]. The question and search terms were de- Metatarsus adductus is commonly diagnosed accord- veloped using the broad concepts of the PICO (Popula- ing to the presence and severity of the deformity and the tion, Intervention Comparison and Outcomes) model degree of flexibility using the Bleck manual assessment [27]. The systematic review was registered with Prospero [3, 4, 19–21]. Clinically, assessments are used to deter- (CRD42016039622). The following electronic databases mine if treatment is required, the method of treatment, were searched for studies describing assessment tools for monitoring progress and to ensure the child’s foot has the identification and quantification of metatarsus returned to a normal foot alignment post intervention adductus in adults and children published from incep- [22]. Whilst there are numerous assessment techniques tion to June 2016: Ovid MEDLINE, CINAHL, Scopus, published to quantify the presence of metatarsus adduc- Web of Science and AMED. Broad MeSH terms and tus, there is little research assessing validity, reliability or keywords were used to identify the articles of interest responsiveness of these measures. This is potentially (e.g. Metatarsus adductus) and quantification termin- problematic for clinicians, as quantification of the condi- ology (e.g. measure, assess). Additional file 1 contains tion drives treatment and management decisions [15]. the full search terms and truncation used within each There have been several assessment techniques pro- database. Citation chaining was undertaken to identify posed in the literature for the assessment of the deform- any articles that may have been missed in the initial ity to quantify the severity. In 1983, Bleck created a search strategy. It involved employing a forward and visual assessment called the ‘heel bisector method’. It in- backward searching strategy using Google Scholar cita- volves firstly visually identifying the severity of the de- tions to identify relevant articles using a single paper as formity and categorising it as mild, moderate or severe a starting point which creates a ‘chain’ of references according to the heel bisector and secondly making a linked backward and forward from the original article. classification of flexibility as fully flexible, partially The inclusion and exclusion criteria used for search flexible or severe. This simple method requires minimal strategy is listed in Table 1. time for both the clinician and patient and as it was ob- Two researchers (NM & CMW) initially screened the servation based, and cost effective [3]. This measure has title and abstract of all articles. If there was any doubt as been modified and used in numerous studies since its to an article’s eligibility, the full text paper was retrieved. Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 3 of 10 Table 1 Inclusion and exclusion criteria for articles included in the systematic review Inclusion Criteria: Exclusion Criteria: � Studies describing a tool measuring metatarsus adductus. � Studies describing congenital foot deformities with no inclusion of metatarsus adductus These included but were not limited to: skewfoot, congenital talipes equinovarus, metatarsus primus varus, congenital metatarsus varus or serpentine foot. � Studies reporting any measurement properties of measurement tools � Non-English publications. for assessing metatarsus adductus as defined by the COSMIN tool. � Grey literature � All study designs � Studies based on both adults and children Articles were imported into Covidence for screening Data extraction [28]. The full text of included study abstracts were inde- Data were extracted by the first author and where there pendently screened against the inclusion criteria by two were queries, these were resolved with all authors. Data reviewers (NM & EW). Any disagreement was resolved extracted included the study design, population, by discussion or through consultation with the third assessment measure/description, sample size, reliability author. Figure 1 displays the search process. (inter/intra rater reliability), statistical quality, available Fig. 1 PRISMA flow of article inclusion Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 4 of 10 domains of the COSMIN and author derived measure- Reliability of measures employed to quantify metatarsus ment [29]. adductus There were three studies assessing the reliability of three different individual radiographic angles to assess meta- Critical appraisal of study methodology quality tarsus adductus [23, 32, 33]. These measures (Table 3) Where studies reported measurement properties, they included the traditional and modified metatarsus adduc- were critically appraised using the Consensus-based tus angle, the Engel and/or modified Engel angles and Standards for the selection of health Measurement the rearfoot-second metatarsal angle [32, 33]. Only Instruments (COSMIN) critical appraisal tool [29]. The radiological measures reported any intra-rater reliability COSMIN was developed in an international Delphi intra-class correlation coefficient (ICC). These ranged study to improve the selection of health measurement from 0.85–0.97 and the inter-rater reliability ICC ranged instruments [29]. This was found to have adequate from 0.84–0.972 [32, 33] (Table 4). content validity [30]. COSMIN assessed the internal The Berg’s classification system reported diagnostic consistency, reliability, measurement error, hypothesis agreement ranging from 66.7–81% for inter-rater testing, content and structural validity, responsiveness consistency and 61.9–66.7% for intra-rater consistency. and interpretability of a measurement [31]. Articles During reliability testing, authors removed five radio- chosen for inclusion in the synthesis were subject to graphs that produced high disagreement between re- appraisal by two independent reviewers. viewers from results, the administrations were not The COSMIN may be utilised as a modular tool and independent and there was no time interval between used to assess the quality of measurement based studies reviewing the images. including patient reported outcome measures, scales and simple measures such as those appraised in this present Methodology quality of the included studies study. Therefore only relevant parts of the checklist were The COSMIN criterion was applied to the nine studies used for quality evaluation of measurements [29] included: reporting measurement properties to determine their box B (reliability), D (content validity), H (criterion validity) methodological quality (Table 5). Three reported the and I (responsiveness). For example, if the study reported reliability of the measure and assessed as fair to good on the measurement properties involving reliability then methodological quality [23, 32, 33]. One included box Bwas theonlypartofthe COSMIN completed[29]. reported content validity which rated poorly for methodo- COSMIN also requires generalizability to be assigned for logical quality [34], one included criterion validity which each measure. The results of these modules were then also rated poorly for methodological quality [35]. There assessed using a 4 point scale to allow calculation of the were five of the nine included studies assessed for respon- overall methodological quality score for each study. This siveness. All five studies were rated poorly for methodo- methodological quality score per box was obtained by logical properties relating to responsiveness according to assigning the lowest rating of any item in a box (‘worse the COSMIN criterion [2, 4, 20, 25, 34]. There were no score counts’). studies reporting specific data on sensitivity or specificity in any included research. Results There were several other measurement techniques Included studies identified for assessing metatarsus adductus. These were There were 15 studies included in this review. Of these unable to be critically appraised using the COSMIN due 15 articles, nine reported on measurement properties to a lack of reported measurement properties. These that were able to be critically appraised for quality using measures included Bleck’s heel bisector method [3], the COSMIN and six reported methods of measurement photocopying the child’s foot [19], ultrasound [21], and that were unable to be appraised. Table 2 provides a dynamic foot pressure [13]. description of the 15 included studies. A meta-analysis was not performed as studies were heterogeneous. Each Discussion study varied in terms of participant age, country the Metatarsus adductus has been described as the most study was conducted, gender and measurement tool common congenital foot deformity presenting in new- used. Out of the 15 studies, two studies were conducted borns [1]. While this condition is self limiting in the vast on an adult population, eight studies had a paediatric majority of cases, there is time when treatment is war- population and five studies did not mention age. The ranted and guided by measurements assessed within this majority of studies were cohort study designs (Table 2). review. Several measurement techniques are reported for There were six methods of measurement described to assessment of this condition, but there was limited high assess the severity or flexibility of metatarsus adductus quality evidence supporting the measurement properties (Table 3). of many of these measurements. Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 5 of 10 Table 2 Studies included within review Primary Study Design Country Sample Size Gender Age Measure Inclusion Exclusion Data collection Tool developed Author Male/ Female (Age (SD), Range) Criteria Criteria method by author: Engel [35] Retrospective USA 571 radiographs Not stated Not stated 1. Traditional metatarsus Foot radiographs Not stated Weight-bearing Yes cohort adductus angle (intersection from Oxford hospital. foot radiographs of longitudinal axis of lesser tarsus with bisector of second metatarsal) 2. Simplified metatarsus angle (intersection of longitudinal bisector of 2nd metatarsal and medial cuneiform) Dawoodi [38] Literature United Not stated Not stated Not stated 1. Traditional metatarsus Not stated Not stated Not stated No review Kingdom adductus angle (intersection of longitudinal axis of lesser tarsus with bisector of second metatarsal) 2. Engel’s angle (bisection of middle cuneiform with longitudinal axis of second metatarsal) 3. Modified Engel’s angle using the base of the middle cuneiform as a reference line Dawoodi [32] Validation United 130 patients 119/14 50.6 (15.4) years, 1. Sgarlarto’s angle/traditional Symptomatic hallux Evidence of Dorsoplantar No study Kingdom (50 randomly 14–80 years metatarsus adductus angle abductovalgus, listed trauma, radiographic views. selected (angle between 2nd for corrective surgery Previous radiographs) metatarsal and longitudinal surgery axis of the lesser tarsus using 4th metatarso-cuboid joint as reference) 2. Rearfoot-2nd meta-tarsal angle 3. Engel’s angle (bisection of middle cuneiform with longitudinal axis of second metatarsal) 4. Modified Engel’s angle using the base of the middle cuneiform as a reference line French [34] Non-Controlled USA 42 (68 ft) 29/13 9.1 months 1. Lateral calcaneal 5th Clinical observation Not stated AP and lateral First metatarsal Trial 1–3 years Metatarsal angle (line of metatarsus adductus radiographs -5th metatarsal representing the lateral angle only aspect of calcaneus and the was author longitudinal bisector of the driven. fifth metatarsal) 2. Inter-metatarsal angle (angle formed by longitudinal bisectors of 1st and 2nd metatarsals) 3. Talus first metatarsal angle (longitudinal bisectors of talus and the first metatarsals) Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 6 of 10 Table 2 Studies included within review (Continued) Primary Study Design Country Sample Size Gender Age Measure Inclusion Exclusion Data collection Tool developed Author Male/ Female (Age (SD), Range) Criteria Criteria method by author: 4. Talocalcaneal angle (Kite’s angle) (longitudinal bisector of the talus and the calcaneus) 5. First metatarsal fifth metatarsal angle (angle formed by l ongitudinal bisection of 1st and 5th metatarsals) 6. Talocaneal angle lateral view (bisection of talus and a line representing inferior aspect of the calcaneus) Hutchinson Expert Opinion USA Not stated Not stated Not stated Describes Kite’s talocalcaneal Not applicable Not Radiographs No [39] angle and calcaneal metatarsal applicable angle without labeling of method Widhe [13] Prospective Sweden 2, 401 Not stated 0–16 years Dynamic foot pressure and Not specifically stated. Not stated EMED No cohort gait analysis dynamometric system Knörr [4] Prospective Spain 26 (34 ft) 16/10 5.7 years, 1. Heel bisector method Rigid Metatarsus Not stated Weight bearing No cohort 3–8.5 years (undescribed) adductus scheduled radiographs 2. First cuneiform metatarsal for surgery angle (medial angulation of first cuneometatarsal joint) 3. Metatarsal-metaphyseal angle (metatarsal metaphyseal incurvation) Miron [21] Expert Opinion Canada N/A Not stated Not stated Lateral displacement of the Not applicable Not Ultrasonography Yes medial (first) cuneiform over applicable the navicular as the single feature. Lepow [25] Retrospective USA 15 7/8 6 months, 1. Traditional metatarsus adductus Diagnosed with No WB AP No cohort (2–15 months) angle (intersection of longitudinal metatarsus adductus treatment radiographs axis of lesser tarsus with bisector No of second metatarsal). radiography Herzenberg Prospective USA 27 (43 ft) Not stated 3–9 months. 1. Footprints analysed using < 9 months, Failed Children Footprints Yes [20] cohort modification of Bleck’s heel program of parent older than bisector method. A transparent stretching 9 months template with longitudinal of age bisector was applied over footprint and graded 2. Talocalcaneal angle (Kite’s angle) (longitudinal bisector of the talus and the calcaneus) Smith [19] Expert Opinion USA Not applicable Not Not applicable Heel bisector drawn N/A N/A Photocopied Yes applicable onto photocopy of a footprint child’s footprint. A second copy in maximum correction Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 7 of 10 Table 2 Studies included within review (Continued) Primary Study Design Country Sample Size Gender Age Measure Inclusion Exclusion Data collection Tool developed Author Male/ Female (Age (SD), Range) Criteria Criteria method by author: for quantification of flexibility Dominguez Retrospective Spain 121 106/103 23.88 years (2.85), Metatarsus adductus > 20 years Disease or Dorsoplantar No [33] cohort (20 randomly 20–29 years angle - cuboid and No history of foot trauma radiographs selected the 4th metatarsal surgery or alteration causing foot weight bearing radiographs) and cuboid and the in plantar pressures pathology, 5th metatarsal distribution pain, toe deformities Cook [23] Retrospective USA 40 ft Not stated 9 weeks – Berg classification - Metatarsus adductus Poor quality Radiographs no cohort 9 months talus-first metatarsal diagnosis on clinical radiograph deviation, calcaneal examination line to cuboid, AP talocalcaneal line, lateral talocalcaneal angle Berg [2] Prospective USA 84 50/34 2.5 years Talocalcaneal angle Stretches failed to Neurological AP weight-bearing Yes cohort 2.2–3.8 (Kite’s angle) (longitudinal resolve metarasus conditions radiographs bisector of the talus adductus and the calcaneus) Bleck [3] Retrospective USA 160 93/67 5–36 months Heel bisector method: Metatarsus adductus Dynamic Observation and Yes cohort Severity measure: The diagnosis on clinical hallux varus, physical heel bisector centres examination metatarsus assessment of the hindfoot plantar primus varus surface. Line crosses or serpentine between the 2nd and foot. 3rd toes = normal, through the 3rd toe (mild deformity), between 3rd and 4th toes (moderate), between 4th and 5th toes (severe deformity). Flexibility measure: Abduction beyond the midline heel bisector (mild classification), only to the midline (partially flexible), no abduction possible (severe) *N/A Not applicable Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 8 of 10 Table 3 Identified measurement techniques for measuring not allow many of these angles to be easily calculated metatarsus adductus [21]. The radiographic angles with the highest reliability Type of measure: Frequency of measure [32, 33] identified in this review were calculated and reli- n =15 ant on osseous structures that appear after the age of Visual – heel bisector method [3, 4, 19–21, 38] 6 (40%) five [38]. Ultrasonography was utilised as a dynamic im- Radiographs [2, 4, 20, 23, 25, 32–35, 38, 39] 11 (73%) aging modality for quantification of metatarsus adductus in infants as it allows for the imaging of the cartilaginous Ultrasound [21] 1 (7%) structures. It also differentiates between metatarsus Photocopier [19] 1 (7%) adductus and skewfoot, as in metatarsus adductus the Footprints [20] 1 (7%) medial cuneiform will be displaced laterally over the Dynamic foot pressure and gait analysis [13] 1 (7%) navicular [21]. Whilst this is a new imaging modality, no studies have assessed the measurement properties of this Radiographic angles had high levels of reliability for method. This has the potential to be a costly measure- measuring metatarsus adductus in adults when taken ment technique requiring additional skills by clinicians during pre-operative planning. However, these studies for interpretation, however, would negate the radiation should be interpreted with caution as they were con- exposure that radiographs impose. ducted with adult participants with no history of The Bleck’s heel bisector method was the most fre- metatarsus adductus. Therefore, results may not be quently reported measurement for assessing metatarsus transferable to the paediatric population. Furthermore, adductus in the paediatric population. It is the measure radiographs measure and quantify the severity of that appears most frequently within studies relating to metatarsus adductus but do not take into account the metatarsus adductus [3, 4, 19–21, 38]. The Bleck meas- flexibility of the condition. There is little benefit for urement was also recently used to assess the treatment supporting using this measurement technique in outcome of stretching for metatarsus adductus versus no children unless surgical management is recommended treatment [22]. This simple measure requires a short [16, 36, 37]. One study assessed radiographic angles time for the clinician to assess both any flexibility and in children however, the author developed their own rat- severity of the adduction deformity. As this measure is a ing tool and it scored poorly for quality on the COSMIN manual assessment that requires no equipment, it is for both content validity and responsiveness [34]. considered simple and is less costly than radiological Metatarsus adductus is primarily identified and treated measurement. No studies have assessed the measure- conservatively in the paediatric population where the ment properties of this measurement. Due to the com- benefits and risks of measurement technique must be monality of this measure and clinical use to guide considered [15]. Radiographs and the associated angles treatment and success of treatment, further research measure the osseous deviation and change. In the youn- should be considered to determine the measurement ger population, the lack of tarsal bone ossification does properties of this assessment. Table 4 Intra and inter-rater reliability of radiographic angles used to assess metatarsus adductus Radiographic angles: Description of measurement: Study Intra-rater ICC: Inter-rater ICC: Traditional metatarsus Angle between the second metatarsal and longitudinal axis of [32] 0.92 0.87 adductus angle (5th) the lesser tarsus using the fifth metatarso-cuboid joint as a reference [33] 0.970 0.962 Modified metatarsus Angle between the second metatarsal and longitudinal axis of the [38] 0.91 0.93 adductus angle (4th) lesser tarsus using the forth metatarso-cuboid joint as a reference [33] 0.962 0.972 Rearfoot-2nd Angle between the longitudinal bisection of the second metatarsal [32] 0.85 0.87 metatarsal angle bone and the line parallel to the lateral border of the calcaneum Engel’s angle Angle between the longitudinal axis of the middle cuneiform and [32] 0.90 0.84 the longitudinal axis of the second metatarsal Modified Engel Angle between the longitudinal axis of the second metatarsal and [32] 0.92 0.91 a line perpendicular to the proximal articular surface of the middle cuneiform and the angle between the rearfoot reference line (line parallel to the lateral border of the calcaneum) and the longitudinal axis of the second metatarsal The Berg Four radiographic measurements that categorises foot deformities [23] Average intra-rater Average inter-rater Classification system into; metatarsus adductus, complex metatarsus adductus, consistency: 74% consistency: 64% simple skewfoot and complex skewfoot (ranged from 66.7–81%). (ranged from 61.9–66.7%). This includes the following: talus-first metatarsal deviation, calcaneal line to cuboid, AP talocalcaneal line, lateral talocalcaneal angle Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 9 of 10 Table 5 COSMIN critical appraisal tool used for studies that could be analysed for their measurement properties Study: Measurement tool: Author driven: Reliability (B): Content Validity (D): Criterion Validity (H): Responsiveness (I): Berg et al. [2] Radiographs: Berg Yes n/a n/a n/a Poor classification system Cook et al. [23] Radiographs: Berg No Poor n/a n/a n/a classification system Dawoodi et al. [32] Radiographs: metatarsal No Good n/a n/a n/a angle (4th), modified metatarsal angle (5th), rearfoot – 2nd metatarsal angle, Engel’s Angle, modified Engel’s angle. Dominguez et al. [33] Radiographs: Traditional No Fair n/a n/a n/a metatarsus adductus angle (cuboid and the 4th metatarsal as reference), modified metatarsus adductus angle (cuboid and the 5th metatarsal). Engel, et al. [35] Radiographs: Traditional Modified metatarsus n/a n/a Fair n/a metatarsus adductus angle adductus angle only. and the modified metatarsus adductus angle French, et al. [34] Radiographs: Lateral First-metatarsal n/a Poor n/a Poor calcaneal 5th metatarsal fifth-metatarsal angle, inter-metatarsal angle, angle was author talus first metatarsal angle, driven. All other talocalcaneal angle (Kite’s angles were not. angle), first metatarsal fifth metatarsal angle, talocaneal angle (lateral view). Herzenberg et al. [20] Footprints analysed using a Yes n/a n/a n/a Poor modified version of Bleck’s measurement. Knörr et al. [4] Radiographs: First cuneiform No n/a n/a n/a Poor metatarsal angle, metatarsal- metaphyseal angle. Lepow et al. [25] Radiographs: Paediatric Yes n/a n/a n/a Poor metatarsus adductus angle There are a number of limitations within this no cost-benefit analysis of any of the measures found review that impact findings and recommendations. within the literature. English only articles were included and due to limited and varied data extracted, no meta-analysis was per- Conclusion formed. A broader search encompassing grey litera- There have been multiple assessment techniques proposed ture may have found additional papers reporting the for quantification of metatarsus adductus but there is a pau- quality of measures. They may have included hospital city of quality data on reliability, validity or responsiveness of or department protocols or guidelines. Future studies these techniques, especially in relation to the paediatric popu- should consider encompassing these within the lation. There have been several radiographic measures shown review. The generalisability of radiological reliability to have good reliability in adult participants and are used for findings to the paediatric population was not possible surgical guidance. Further research is required to determine due to osseous development and the methodology of if simple measures commonly guiding reassurance or imple- measure development did not always include the mentation of conservative treatment are a reliable way of paediatric population. measuring metatarsus adductus in the paediatric population. Sensitivity and specificity was not specifically men- tioned in any of the measurement tools analysed in this Additional file review which impacted on the responsiveness criterion of the COSMIN. This also limited the number of items Additional file 1: Search terms and truncation used within each that could be selected from the COSMIN appraisal tool database. (DOCX 89 kb) and used to analyse each study. Additionally, there was Marshall et al. Journal of Foot and Ankle Research (2018) 11:25 Page 10 of 10 Abbreviations 16. Connors J, Wernick E, Lowy L, Falcone J, Volpe R. Guidelines for evaluation COSMIN: Consensus-based Standards for the selection of health and management of five common podopediatric conditions. J Am Podiatr Measurement INstruments; ICC: Intraclass correlation coefficient; IRT: Item Med Assoc. 1998;88:206–22. response theory 17. Gore AI, Spencer JP. The newborn foot. Am Fam Physician. 2004;69:865–72. 18. Theodorou D, Theodorou S, Boutin R, Chung C, Fliszar E, Kakitsubata Y, Funding Resnick D. Stress fractures of the lateral metatarsal bones in metatarsus CMW is supported by a National Health and Medical Research early career adductus foot deformity: a previously unrecognized association. Skelet health professional research fellowship. Radiol. 1999;28:679–84. 19. Smith JT, Bleck EE, Gamble JG, Rinsky LA, Pena T. Simple method of Availability of data and materials documenting metatarsus adductus. J Pediatr Orthop. 1991;11:679–80. Data sharing not applicable to this article as no datasets were generated or 20. Herzenberg JE, Burghardt RD. Resistant metatarsus adductus: prospective analysed during the study. All relevant data has been included within the review. randomized trial of casting versus orthosis. J Orthop Sci. 2014;19:250–6. 21. Miron M, Grimard G. Ultrasound evaluation of foot deformities in infants. Authors’ contributions Pediatr Radiol. 2016;46:193–209. NM, EW and CMW conceived and designed this systematic review, NM and 22. Eamsobhana P, Rojjananukulpong K, Ariyawatkul T, Chotigavanichaya C, CMW contributed to the screening and processing of articles, EW and NM Kaewpornsawan K. Does the parental stretching programs improve critically appraised the data, NM drafted the manuscript, all authors reviewed metatarsus adductus in newborns? J Orthop Surg. 2017;25:1–5. critically the final manuscript and approved for submission. 23. Cook DA, Breed AL, Cook T, Desmet AD, Muehle CM. Observer variability in the radiographic measurement and classification of metatarsus adductus. J Ethics approval and consent to participate Pediatr Orthop. 1992;12:86–9. Not applicable. 24. Farsetti P, Weinstein SL, Ponseti IV. The long-term functional and radiographic outcomes of untreated and non-operatively treated Competing interests metatarsus adductus. J Bone Joint Surg (Am Vol). 1994;76A:257–65. The authors declare that they have no competing interests. 25. Lepow GM, Lepow RS, Lepow RM, Hillman L, Neville R. Pediatric metatarsus adductus angle. J Am Podiatr Med Assoc. 1987;77:529–32. 26. Moher D, Liberati A, Tetzlaff J, Altman D, Group TP. Preferred reporting Publisher’sNote items for systematic reviews and meta-analyses: the PRISMA statement. Int J Springer Nature remains neutral with regard to jurisdictional claims in Surg. 2010;8:336–41. published maps and institutional affiliations. 27. Huang X, Lin J, Demner-Fushman D. Evaluation of PICO as a knowledge representation for clinical questions. AMIA Annu Symp Proc Arch. 2016;2006: Author details 359–63. University of South Australia, School of Health Science, Adelaide, SA 5000, 28. Veritas Health Innovation. Covidence systematic review software. Australia. Department of Physiotherapy, Monash University, Frankston, VIC Melbourne: Veritas Health Innovation; 2017. 3199, Australia. Peninsula Health, Allied Health, Frankston, VIC 3199, 29. Mokkink L, Terwee C, Patrick D, Alonso J, Stratford P, Knol D, Bouter L, De Australia. Vet H, COSMIN checklist manual, http://www.cosmin.nl/images/upload/files/ COSMIN%20checklist%20manual%20v9.pdf, Accessed 28th June, 2017 Received: 13 October 2017 Accepted: 22 May 2018 30. Mokkink L, Terwee C, Gibbons E, Stratford P, Alonso J, Patrick D, Knol D, Bouter L, De Vet H. Inter-rater reliability of the COSMIN (COnsensus-based standards for the selection of health status measurement instruments) References checklist. BMC Med Res Methodol. 2010;10:25. 1. Dietz F: Intoeing - fact, fiction and opinion. Am Fam Physician 1994, 50: 31. Mokkink L, Terwee C, Patrick D, Alonso J, Stratford P, Knol D, Bouter L, De 1249–1259. Vet H. International consensus on taxonomy, terminology and definitions of 2. Berg EE. A reappraisal of metatarsus adductus and skewfoot. J Bone Joint measurement properties: results of the COSMIN study. J Clin Epidemiol. Surg – Ser A. 1986;68:1185–96. 2010;63:737–45. 3. Bleck EE. METATARSUS ADDUCTUS - CLASSIFICATION AND RELATIONSHIP 32. Dawoodi A, Perera A. Reliability of metatarsus adductus angle and TO OUTCOMES OF TREATMENT. J Pediatr Orthop. 1983;3:2–9. correlation with hallux valgus. Foot Ankle Surg. 2012;18:180–6. 4. Knörr J, Soldado F, Pham TT, Torres A, Cahuzac JP, De Gauzy JS. 33. Dominguez G, Munuera PV. Metatarsus adductus angle in male and female Percutaneous correction of persistent severe metatarsus adductus in feet - normal values with two measurement techniques. J Am Podiatr Med children. J Pediatr Orthop. 2014;34:447–50. Assoc. 2008;98:364–9. 5. Ponseti IB,J. Congenital metatarsus adductus: the results of treatment. J 34. French S, Niespodziany J, Wysong D, Zahari D. A radiographic study of Bone Joint Surg – Am Vol. 1966;48:702–11. infant metatarsus adductus treatment by serial casting. J Foot Surg. 1985;24: 6. Galluzzo AJ, Hugar DW. Congenital metatarsus adductus: clinical evaluation 222–9. and treatment. J Foot Surg. 1979;18:16–22. 35. Engel E, Nelson E, Krems I. A simplified metatarsus adductus angle. J Am 7. Sass P, Hassan G. Lower extremity abnormalities in children. Am Fam Podiatry Assoc. 1983;73:620–8. Physician. 2003;68:461–8. 36. Applegate K, Cost N. Image gently: a campaign to reduce Children’s 8. Morcuende JAPI. Congenital metatarsus adductus in early human fetal Adolescents’ risk for Cancer during adulthood. J Adolesc Health. 2013;52:93–7. development: a histologic study. Clin Orthop Relat Res. 1996;333:261–266. 37. Australian Government. Medicare Benefits Schedule. Canberra: Department 9. Robb J. Intoeing and out-toeing gait. In: Paediatric orthopaedic diagnosis: of Health; 2017. asking the right questions. India: Springer; 2015. p. 207–20. 38. Dawoodi A, Perera A. Radiological assessment of metatarsus adductus. Foot 10. Geddis C, Jones S. Foot disorders in childhood. Surgery. 2011;29:187–90. Ankle Surg. 2012;18:1–8. 11. Hart ES, Grottkau BE, Rebello GN, Albright MB. The newborn foot: diagnosis 39. Hutchinson B. Pediatric metatarsus adductus and skewfoot deformity. Clin and management of common conditions. Orthop Nurs. 2005;24:313–21. Podiatr Med Surg. 2010;27:93–104. quiz 322-313 12. Wan SC. Metatarsus adductus and skewfoot deformity. Clin Podiatr Med Surg. 2006;23:23–40. 13. Widhe T. Foot deformities at birth: a longitudinal prospective study over a 16- year period. J Pediatr Orthop. 1997;17:20–4. 14. Feng L, Sussman M. Combined medial cuniform osteotomy and multiple metatarsal osteotomies for correction of persistent metatarsus adductus in children. J Pediatr Orthop. 2016;36:730–5. 15. Williams C, James A, Tran T. Metatarsus adductus: development of a non- surgical treatment pathway. J Paediatr Child Health. 2013;49:428–33.

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Journal of Foot and Ankle ResearchSpringer Journals

Published: Jun 1, 2018

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