Hans-Joerg Trnka and Stefan G. Hofstaetter
DEFINITION
Symptomatic hallux valgus associated with a first intermetatarsal angle greater than 15 degrees is typically corrected with a proximal first metatarsal osteotomy and distal soft tissue procedure when nonoperative treatment fails.
Multiple techniques for the hallux valgus deformity correction have been decribed.5
In 1918 Ludloff4 described an oblique osteotomy from the dorsal–proximal to distal–plantar aspects of the first metatarsal, and the procedure was performed without internal fixation.
The procedure recently gained renewed attention when Myerson1,6 recommended adding internal fixation and modified several parts of the technique.
The modified Ludloff osteotomy has been extensively studied with biomechanical and mathematical investigations.
ANATOMY
The special situation distinguishing the first metatarsophalangeal (MTP) joint from the lesser MTP joints is the sesamoid mechanism.
On the plantar surface of the metatarsal head are two longitudinal cartilage-covered grooves separated by a rounded ridge. The sesamoids run in these grooves.
The sesamoid bone is contained in each tendon of the flexor hallucis brevis; they are distally attached by the fibrous plantar plate to the base of the proximal phalanx.
The head of the first metatarsal is rounded and cartilagecovered and articulates with the smaller concave elliptical base of the proximal phalanx.
Fan-shaped ligamentous bands originate from the medial and lateral condyles of the metatarsal head and run to the base of the proximal phalanx and the margins of the sesamoids and the plantar plate.
Tendons and muscles that move the great toe are arranged in four groups:
Long and short extensor tendons
Long and short flexor tendons
Abductor hallucis
Adductor hallucis
Blood supply to the metatarsal head
First dorsal metatarsal artery
Branches from the first plantar metatarsal artery
PATHOGENESIS
Extrinsic causes
Hallux valgus occurs almost exclusively in shoe-wearing populations, but only occasionally in the unshod individual.
Although shoes are an essential factor in the cause of hallux valgus, not all individuals wearing fashionable shoes develop this deformity.
Intrinsic causes
Hardy and Clapham2 found, in a series of 91 patients, a positive family history in 63%.
Coughlin5 reported that a bunion was identified in 94% of 31 mothers whose children inherited a hallux valgus deformity.
The association of pes planus with the development of a hallux valgus deformity has been controversial.
Hohmann was the most definitive proponent that hallux valgus is always combined with pes planus.
Coughlin5 and Kilmartin noted no incidence of pes planus in the juvenile patient.
Pronation of the foot imposes a longitudinal rotation of the first ray that places the axis of the MTP joint in an oblique plane relative to the floor. In this position the foot appears to be less able to withstand the deformity pressures exerted on it by either shoes or weight bearing.11
The simultaneous occurrence of hallux valgus and metatarsus primus varus has been frequently described. The question of cause and effect continues to be debated.
PATIENT HISTORY AND PHYSICAL FINDINGS
Physical findings associated with hallux valgus deformity include the following:
Pain in narrow shoes
Symptomatic intractable keratoses beneath the second metatarsal head (in 40% of patients)
Lateral deviation of the great toe
Pronation of the great toe
Keratosis medial plantar underneath the interphalangeal joint
Bursitis over the medial aspect of the medial condyle of the first metatarsal head
Hypermobility of the first metatarsocuneiform joint
Physical examination for hallux valgus deformity should include the following:
Hallux valgus angle measurement: Normal is 15 degrees or less.
Intermetatarsal angle measurement: Normal is 9 degrees or less.
Sesamoid position measurements
Joint congruency
IMAGING AND OTHER DIAGNOSTIC STUDIES
Radiographs of the foot should always be obtained with the patient in the weight-bearing position, with AP, lateral, and oblique views. The following criteria are examined:
Hallux valgus angle
Intermetatarsal angle
Sesamoid position
Joint congruency
Distal metatarsal articular angle: the relationship between the articular surface of the first metatarsal head and a line bisecting the first metatarsal shaft (normal is 10 degrees or less)
Arthrosis of the first MTP joint
DIFFERENTIAL DIAGNOSIS
Ganglion
Hallux rigidus
NONOPERATIVE MANAGEMENT
Comfortable wider shoes
Orthotics?
Spiral dynamics physiotherapy in adolescents
SURGICAL MANAGEMENT
Indications
Symptomatic hallux valgus deformity with a first intermetatarsal angle of more than 15 degrees
Stable first metatarsal-cuneiform joint
Contraindications
Narrow metatarsal so that adequate rotation of the dorsal fragment is not possible
Severe osteoporosis
Skeletally immature patient
Severe osteoarthritic changes
Preoperative Planning
Standard weight-bearing AP and lateral radiographs are mandatory.
The hallux valgus and intermetatarsal angles and tibial sesamoid position are measured.
A preoperative drawing is helpful.
Clinical examination includes measurement of active and passive range of motion of the first MTP joint as well as inspection of the foot for plantar callus formation indicative of transfer metatarsalgia and stability of the first tarsometatarsal joint.
Positioning
The foot is prepared in the standard manner.
The patient is positioned supine.
An ankle tourniquet is optional.
Approach
The lateral soft tissue release is performed through a dorsal approach.
The Ludloff osteotomy is performed through a straight midline incision.
TECHNIQUES
LATERAL SOFT TISSUE RELEASE
The procedure is typically performed under the peripheral nerve.
Make a dorsal 3-cm longitudinal incision over the first web space (TECH FIG 1A,B).
Continue deep dissection bluntly.
Insert a lamina spreader and a Langenbeck retractor to expose the first web space.
Divide the lateral joint capsule (metatarsal-sesamoid ligament) immediately superior to the lateral sesamoid. Fenestrate the lateral capsule at the first MTP joint (TECH FIG 1C,D).
Apply a varus stress to the hallux to complete the lateral release (TECH FIG 1E).
Place one or two sutures between the lateral capsule of the first MTP joint and the periosteum of the second metatarsal.
TECH FIG 1 • A. A dorsal 3-cm longitudinal incision is made over the first web space. B. A lamina spreader and a Langenbeck retractor are inserted to expose the first web space. C, D. Release of the metatarsal-sesamoid ligament. (continued)
TECH FIG 1 • (continued) E. The great toe is brought into 20 degrees varus to demonstrate the release of the lateral structures.
LUDLOFF OSTEOTOMY
Incision and Exposure
Make a midaxial skin incision over the medial first MTP joint, extending to the first tarsometatarsal joint (TECH FIG 2A,B).
After careful subcutaneous dissection to avoid damage to the dorsomedial nerve bundle, expose the periosteum of the first metatarsal and insert dorsal–proximal and distal–plantar Hohmann retractors (TECH FIG 2C).
Perform an L-shaped medial capsulotomy and split the periosteum up to the first tarsometatarsal joint level. Minimize periosteal dissection (TECH FIG 2D,E).
Beginning the Osteotomy
Plan an oblique first metatarsal osteotomy from the dorsal–proximal first metatarsal (immediately distal to the first tarsometatarsal joint) to the plantar–distal first metatarsal (immediately proximal to the sesamoid complex). First mark the osteotomy with the electrocautery (TECH FIG 3A).
The osteotomy is inclined from medial to lateral plantar at an angle of 10 degrees (TECH FIG 3B).
Perform only the dorsal two thirds of the osteotomy initially to guarantee a stable situation (TECH FIG 3C,D).
TECH FIG 2 • A–C. Medial skin incision for the osteotomy. D, E. Exposure of the metatarsal.
TECH FIG 3 • A. The metatarsal is exposed. B. The osteotomy should be 10 degrees inclined from medial to lateral. C, D. The proximal two thirds of the osteotomy is performed first. E–G. The proximal 3.0 AO cannulated titanium screw is inserted but not tightened.
Insert a guidewire for a 3.0-mm or 4.0-mm cannulated screw (Synthes, Paoli, PA) or a Charlotte multiuse compression screw (Wright Medical Technology) in the proximal aspect of the dorsal fragment perpendicular to the osteotomy (TECH FIG 3E,F).
Insert the first screw without full compression and complete the osteotomy (TECH FIG 3G).
Osteotomy Completion and Internal Fixation
Complete the plantar third of the osteotomy (TECH FIG 4A,B).
Using a towel clip, gently pull the plantar fragment medially, and rotate the dorsal fragment laterally with gentle thumb pressure on the first metatarsal head’s medial aspect (TECH FIG 4C,D).
TECH FIG 4 • A, B. Osteotomy of the plantar third. C, D. With the use of a towel clip, the dorsal fragment is rotated laterally around the proximal screw. E. On the plantar side, a 3.0 Charlotte multiuse compression screw is inserted.
After confirming the desired correction fluoroscopically, tighten the first screw to secure the osteotomy.
Insert a second Charlotte multiuse compression screw from plantar to dorsal across the distal aspect of the osteotomy (TECH FIG 4E).
Completion and Closure
Resect the medial eminence (TECH FIG 5A). This is not done before the osteotomy because otherwise too much of the metatarsal head might be resected.
Shave the slight medial bone prominence at the osteotomy smooth with the edge of the saw blade (TECH FIG 5B).
TECH FIG 5 • A, B. The medial eminence is resected. (continued)
While an assistant holds the great toe in a slightly overcorrected position, repair the medial joint capsule with U-type sutures, and tighten the first web space sutures (TECH FIG 5C).
Wrap the foot in a traditional, mildly compressive wetand-dry bunion dressing.
TECH FIG 5 • (continued) C. Closing the medial capsule with
U-type sutures.
POSTOPERATIVE CARE
Starting immediately postoperatively, ice application to the foot is helpful to reduce swelling.
Provided that the bone quality was intraoperatively sufficient, patients are allowed to walk with a postsurgical cork-soled shoe (OFA Rathgeber Health Shoes) or an OrthoWedge-type shoe (Darco) on the same day.
If the bone quality was not sufficient, the patient is put in a walker boot or a short-leg cast.
Weekly changes of the tape dressing are necessary.
An alternative to weekly dressing changes is the postoperative hallux valgus compression stocking, which also reduces postoperative edema (FIG 1).
Radiographs are taken intraoperatively and at 6 weeks of follow-up.
After radiographic union is achieved, normal dress shoes with a more rigid sole are allowed.
After 6 weeks, physiotherapy to achieve normal forefoot function is recommended (FIG 2).
FIG 1 • Postoperative hallux valgus compression stocking, for use after suture removal.
FIG 2 • 50-year-old woman (A) before surgery and (B) 2 years after the Ludloff osteotomy and Weil osteotomy 2 to 4.
OUTCOMES
Chiodo et al1 presented their results on 82 consecutive Ludloff cases. Follow-up was possible in 70 cases (85%) at an average of 30 months (range 18 to 42 months). In their series, no symptomatic transfer lesions were found on the second metatarsal. The mean AOFAS forefoot score improved from 54 to 91 points. The mean hallux valgus and first intermetatarsal angles before surgery were 31 degrees and 16 degrees, respectively; postoperatively they averaged 11 degrees and 7 degrees. Complications included prominent hardware requiring removal (7%, 5/70), hallux varus deformity (6%, 4/70), delayed union (4%, 3/70), superficial infection (4%, 3/70), and neuralgia (4%, 3/70). The average patient age was not mentioned in the study.
Saxena and McCammon9 reported the results of 14 procedures in 12 patients with the original technique. The mean hallux valgus angle was corrected from 30.1 to 13.4 degrees and the intermetatarsal angle from 15.9 to 10.8 degrees.
Weinfeld14 reported in 2001 a series of 31 patients. The mean hallux valgus angle was corrected from 36.7 to 10.8 degrees and the mean first intermetatarsal angle from 14.8 to 3.9 degrees.
Trnka et al12 reviewed the results of 99 patients (111 feet), with an average age of 56 years (range 20 to 78 years), in a multicenter study. The average AOFAS score improved significantly from 46 ± 11 points before surgery to 88 ± 13 points at follow-up. Patients under 60 years of age had a significantly higher AOFAS score (90 ± 12 points) than patients over 60 years of age (82 ± 17). The average preoperative hallux valgus angle of 35 ± 7 degrees decreased significantly to 8 ± 9 degrees, and the average intermetatarsal angle decreased significantly from 17 ± 2 degrees to 8 ± 3 degrees. All osteotomies united without dorsiflexion malunion. In the early postoperative period, 17% (18/111) had bony callus formation at the osteotomy site.
COMPLICATIONS
Potential complications are similar to other proximal osteotomies.
Hallux varus in 8% and 6%
Delayed union
Loss of fixation
Iatrogenic fracture
REFERENCES
· Chiodo CP, Schon LC, Myerson, MS. Clinical results with the Ludloff osteotomy for correction of adult hallux valgus. Foot Ankle Int 2004;25:532–536.
· Hardy R, Clapham J. Observations on hallux valgus. J Bone Joint Surg Br 1951;33B:376–391.
· Hofstaetter SG, Gruber F, Ritschl P, et al. [The modified Ludloff osteotomy for correction of severe metatarsus primus varus with hallux valgus deformity.] Z Orthop Ihre Grenzgeb 2006;144:141–147.
· Ludloff K. Die Beseitigung des Hallux valgus durch die schräge planta-dorsale Osteotomie des Metatarsus I. Arch Klin Chir 1918; 110:364–387.
· Mann RA, Coughlin MJ. Adult hallux valgus. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. St. Louis, MO: Mosby, 1999:150–269.
· Myerson MS. Hallux valgus. In: Myerson MS, ed. Foot and Ankle Disorders. Philadelphia: WB Saunders, 2000:213–288.
· Nyska M, Trnka HJ, Parks BG, et al. Proximal metatarsal osteotomies: a comparative geometric analysis conducted on sawbone models. Foot Ankle Int 2002;23:938–945.
· Nyska M, Trnka HJ, Parks BG, et al. The Ludloff metatarsal osteotomy: guidelines for optimal correction based on a geometric analysis conducted on a sawbone model. Foot Ankle Int 2003; 24:34–39.
· Saxena A, McCammon D. The Ludloff osteotomy: a critical analysis. J Foot Ankle Surg 1997;36:100–105.
· Shereff MJ, Yang QM, Kummer FJ. Extraosseous and intraosseous arterial supply to the first metatarsal and metatarsophalangeal joint. Foot Ankle 1987;8:81–93.
· Trnka HJ, Hofstaetter SG. The Ludloff osteotomy. Techniques Foot Ankle Surg 2005;4:263–268.
· Trnka HJ, Hofstaetter SG, Hofstaetter JG, et al. Intermediate-term results of the Ludloff osteotomy in 111 feet. J Bone Joint Surg Am 2008;90A:531–539. Erratum in: J Bone Joint Surg Am 2008;90A:1337.
· Trnka HJ, Parks BG, Ivanic G, et al. Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons. Clin Orthop Relat Res 2000;381:256–265.
· Weinfeld SB. The Ludloff osteotomy for correction of hallux valgus: results of 31 cases by one surgeon. Presented at the 31st Annual Meeting of the American Orthopaedic Foot and Ankle Society, San Francisco, CA, March 3, 2001.