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 Chiodo et al1 and Myerson6 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 cartilage-covered 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.

 

Mann and Coughlin5 and Kilmartin3 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.8

 

 

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 anteroposterior (AP), lateral, and oblique views. The following criteria are examined:

 

 

 

 

Hallux valgus angle Intermetatarsal angle

 

 

 

Sesamoid position Joint congruency

 

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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.

   

   

   

  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)

   

   

  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.

   

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  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).

 

 

 

TECH FIG 2 • A-C. Medial skin incision for the osteotomy. D,E. Exposure of the metatarsal.

 

 

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).

 

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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-mm AO cannulated titanium screw is inserted but not tightened.

 

 

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).

 

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, Arlington, PA) 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).

 

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).

 

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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-mm Charlotte multiuse compression screw is inserted.

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 wet-and-dry bunion dressing.

 

 

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TECH FIG 5 • (continued) C. Closing the medial capsule with U-type sutures.

 

PEARLS AND PITFALLS

Avoid short osteotomy because it would create too small of a contact area.

There should be a long enough distance between the two screws; otherwise, the rotational control is not

 

guaranteed.

When the screws do not have enough bite, use a cast for postoperative treatment.

 

 

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 corksoled shoe (OFA Rathgeber Health Shoes, Ofa Bamberg GmbH, Bamberg, Germany) 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).

 

 

 

 

FIG 1 • Postoperative hallux valgus compression stocking, for use after suture removal.

 

 

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).

 

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 American Orthopaedic Foot and Ankle Society (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 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 McCammon7 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.

 

Weinfeld10 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 al9 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

 

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significantly from 46 ± 11 points before surgery to 88 ± 13 points at follow-up. Patients younger than 60 years of age had a significantly higher AOFAS score (90 ± 12 points) than patients older than 60 years of age (82 ± 17 points). 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.

 

FIG 2 • Fifty-year-old woman (A) before surgery and (B) 2 years after the Ludloff osteotomy and Weil osteotomy 2 to 4.

 

 

 

COMPLICATIONS

Potential complications are similar to other proximal osteotomies. Hallux varus in 8% and 6%

Delayed union Loss of fixation Iatrogenic fracture

 

 

REFERENCES

1. 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.

    

    

2. Hardy R, Clapham J. Observations on hallux valgus. J Bone Joint Surg Br 1951;33B:376-391.

    

    

3. Kilmartin TE, Wallace WA. The significance of pes planus in juvenile hallux valgus. Foot Ankle 1992;13(2):53-56.

    

    

4. Ludloff K. Die Beseitigung des Hallux valgus durch die schräge plantadorsale Osteotomie des Metatarsus

   I. Arch Klin Chir 1918;110:364-387.

    

    

5. Mann RA, Coughlin MJ. Adult hallux valgus. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. St. Louis: Mosby, 1999:150-269.

    

    

6. Myerson MS. Hallux valgus. In: Myerson MS, ed. Foot and Ankle Disorders. Philadelphia: WB Saunders, 2000:213-288.

    

    

7. Saxena A, McCammon D. The Ludloff osteotomy: a critical analysis. J Foot Ankle Surg 1997;36:100-105.

    

    

8. Trnka HJ, Hofstaetter SG. The Ludloff osteotomy. Techniques Foot Ankle Surg 2005;4:263-268.

    

    

9. 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.

    

    

10. 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.