Ludloff Osteotomy

   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


   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.


May 27, 2017 | Posted by in ORTHOPEDIC | Comments Off on Ludloff Osteotomy

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