9 Ludloff Proximal First Metatarsal Osteotomy for Hallux Valgus Correction Abstract The Ludloff osteotomy was initially described in 1918 for correction of deformities of the first metatarsal. Ludloff performed this procedure without internal fixation. With the addition of rigid fixation, it has gained popularity for correction of hallux valgus deformities because of its inherent stability and reproducible results. It is combined with soft-tissue realignment to correct moderate and severe hallux valgus deformities. Keywords: Ludloff, proximal osteotomy, hallux valgus, rotational osteotomy • Pathology of hallux valgus includes lateral deviation of the great toe, an increased intermetatarsal angle (IMA) between the first and second metatarsals, contracture of the lateral soft tissues, and displacement of the sesamoid complex. Pronation of the hallux may also be present along with a prominent medial eminence.1 • A proximal osteotomy, combined with soft-tissue realignment, is indicated for moderate to severe deformities including a hallux valgus angle (HVA) > 35 degrees and an IMA > 14 degrees. • Patients should be assessed standing to evaluate true degree of deformity. • Clinical evaluation of range of motion and pain with motion at the metatarsophalangeal (MTP) joint is essential to rule out arthritis within the joint. • In most cases, there is no pain with motion at the MTP joint. Presence of pain may suggest arthritis or an osteochondral defect within the metatarsal head. • Careful evaluation for associated lesser toe deformities and MTP instability must be performed • Assess stability of first tarsometatarsal (TMT) joint for hypermobility or presence of arthritis. • Weight-bearing anteroposterior and lateral radiographs are used to assess the HVA and IMA along with any other associated pathology. • Carefully assess first TMT for evidence of arthritis or hypermobility. • Sesamoid view can be useful if sesamoid metatarsal arthritis is suspected. • Associated planovalgus should be evaluated clinically and radiographically. • Tertiary studies (computed tomography/magnetic resonance imaging [CT/MRI]) are not usually indicated, unless there is concern for intra-articular pathology not seen on plane radiographs. • Wide toe-box shoe. • Padding. • Orthotic inserts. • Bunion spacers. • This procedure should not be used in patients with significant degenerative changes of the first MTP joint. Consider first MTP arthrodesis in these patients. • Hypermobility of the first ray also is a relative contraindication for the Ludloff osteotomy. A Lapidus fusion may be better suited for this population to address the first ray hypermobility. • Severe osteopenia may prevent adequate fixation of the Ludloff osteotomy. • A very narrow first metatarsal shaft may also be a contraindication to this procedure. • Patients with an abnormal distal metatarsal articular angle may be better treated with a closing wedge chevron osteotomy. • Patients with a small IMA but a large HVA may be better treated with a distal metatarsal osteotomy with the addition of an Akin osteotomy of the proximal phalanx. • Mild deformities (IMA < 14 degrees or HVA < 35 degrees) may be better treated with a distal first metatarsal osteotomy. • The goals of the Ludloff osteotomy are to correct the IMA along with the hallux valgus deformity. This osteotomy is combined with a modified McBride soft-tissue realignment to achieve these goals. • The Ludloff osteotomy allows for excellent correction of the IMA while providing stable fixation, which permits the patient early weight-bearing.2 • The Ludloff osteotomy can be performed to plantarflex or dorsiflex the first ray if desired. Stable fixation and reliable healing prevent malunion and nonunion of this osteotomy. • Metaphyseal osteotomy allows excellent healing rates. • Rotational osteotomy allows for unlimited angular correction. • Initial rotational screw prevents any metatarsal shortening of the first ray, thereby avoiding stress transfer to the second metatarsal. • Second fixation screw prevents loss of correction and creates rigid fixation. • Due to the inherent stability of this procedure, patients can be weight-bearing as tolerated almost immediately. • Medial first metatarsal approach from the MTP to TMT joint level. • Always performed with associated distal soft-tissue release. • Osteotomy extends from dorsal proximal first metatarsal in 20-degree plantar oblique angle to exit the plantar aspect of the first metatarsal neck just proximal to the capsular insertion. • Do not complete the osteotomy cut plantarly until an initial rotational screw is inserted. • Once initial length fixation has been achieved (but not tightened), the plantar osteotomy is completed. • The metatarsal is rotated around the first screw until required IMA (< 9 degrees) is obtained. • A second parallel fixation screw is then placed perpendicular to the osteotomy to maintain correction, and both screws are tightened to rigidly fix the osteotomy. • The medial capsule is then repaired. The joint should be congruently aligned before repair so that the repair holds the joint in position and is not used to correct the joint alignment. • Patient placed supine on operating table. • Regional anesthesia (popliteal block or ankle block) with sedation. • I prefer to not use tourniquet. • Sterile prep and draping to midcalf level. • One medial incision from 2 cm distal to first MTP joint to first TMT joint proximally. • Identify and protect the medial hallucal nerve. • Inverted L-shaped capsulotomy to expose medial eminence. • Resect medial eminence with sagittal saw parallel to medial aspect of first metatarsal. • Make a 4to 5-cm incision in first web space for lateral release. • Perform release of intermetatarsal ligament, adductor hallucis tendon, lateral capsule, and sesamoid complex. • Expose medial aspect of first metatarsal proximally to level of first TMT joint. • Perform osteotomy from dorsal proximal aspect of first metatarsal to plantar distal aspect of metatarsal. • Begin osteotomy 2 to 3 mm distal to the first TMT joint and complete the osteotomy 2 cm proximal to the sesamoids (Fig. 9.1). • Osteotomy proceeds from proximal to distal at approximately 20-degree angle. • Prior to completion of the osteotomy distally, a 3.5or 2.7mm cortical screw is placed across the proximal portion of the osteotomy using lag technique to engage both fragments. The screw is tightened and then loosened slightly to allow rotation of the distal fragment upon completion of the osteotomy (Fig. 9.2). • The osteotomy is completed distally with the sagittal saw, and the distal aspect of the metatarsal is rotated laterally on the proximal screw to reduce the IMA (Fig. 9.3). • Once the proper position is obtained, the proximal screw is tightened, being careful not to crack the dorsal bone. Countersinking of the screws is helpful to avoid fracture. • A pointed bone reduction clamp is used to secure the distal part of the osteotomy. • A second 3.5or 2.7-mm cortical screw is then placed in the distal part of the osteotomy. This can be placed from either the dorsal-to-plantar or plantar-to-dorsal direction. • It is critical to place the second screw carefully as the medial bone shelf that was produced from rotation of the metatarsal will be removed following secure fixation. • Carefully remove medial bone shelf (Fig. 9.4) with sagittal saw, power burr, or rongeur. • Assess correction and screw placement with image intensifier. Obtaining lateral image is the best way to check the first ray is not plantar or dorsally displaced and that proximal screw does not violate first TMT joint.
9.1 Indications
9.1.1 Clinical Evaluation
9.1.2 Radiographic Evaluation
9.1.3 Nonoperative Options
9.1.4 Contraindications
9.2 Goals of Surgical Procedure
9.3 Advantages of Surgical Procedure
9.4 Key Principles
9.4.1 Operative Technique
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