Preoperative Planning
Our clinical examination includes measuring hallux metatarsophalangeal
joint range of motion, symptoms associated with hallux range of motion, first
tarsometatarsal joint stability, and lesser metatarsal head plantar
callosities (indicative of transfer metatarsalgia). We rountinely make
standard weight-bearing anteroposterior and lateral radiographs of both feet
to assess the hallux valgus deformity according to the guidelines of the
American Orthopaedic Foot and Ankle
Society10: (1)
hallux valgus and intermetatarsal angles, (2) sesamoid position relative to
the first metatarsal head, and (3) the lengths of the first and second
metatarsals.
Preparation
The procedure is performed with the patient under regional anesthesia
(ankle block with 1% Xylocaine [lidocaine] and 0.5% bupivacaine). The use of a
fluoroscope to monitor alignment and fixation is recommended. In general, we
perform the procedure without a tourniquet in order to reduce postoperative
edema.
Skin Incision/Approach (Fig.
1)
A dorsal incision is made over the first web space for the lateral
soft-tissue release, and a medial incision is made over the first
metatarsophalangeal joint from the middle of the shaft of the proximal phalanx
to the base of the first metatarsal.
Lateral Capsular Release
After blunt dissection through the dorsal incision, a lamina spreader and a
Langenbeck retractor are inserted to expose the first web space. The lateral
capsule (the metatarsosesamoid ligament) is incised longitudinally, dorsal to
the lateral sesamoid (Figs. 2-A and
2-B), and is then perforated at the first metatarsophalangeal
joint line. The great toe is forced manually into a 20° varus position
(Fig. 3). We do not routinely
release the adductor tendon or intermetatarsal ligament, except when these
structures are severely contracted, preventing the satisfactory correction of
the hallux valgus angle. One suture is placed through the lateral aspect of
the first metatarsal and the medial periosteum of the second metatarsal to be
tied after the osteotomy is completed.
Medial Approach
The leg is externally rotated. A second skin incision is made over the
medial aspect of the first metatarsophalangeal joint
(Fig. 4) and is extended
proximally to the first metatarsocuneiform joint. The incision is deepened
through the subcutaneous tissue to the capsule. During the dissection, care is
taken to identify and protect the medial dorsal cutaneous nerve. We perform
the medial metatarsophalangeal joint capsulotomy with an inverted L-type
incision (Fig. 5) and inspect
the articular surfaces for degenerative changes.
The metatarsal shaft is exposed with minimal periosteal stripping, and
Hohmann retractors are placed dorsal-proximally and plantar-distally
(Fig. 6). The plantar-distal
Hohmann retractor protects the plantar artery to the metatarsal head, and the
dorsal-proximal retractor protects the extensor hallucis longus tendon and the
interosseous branch of the dorsalis pedis artery.
An oblique osteotomy of the first metatarsal is then performed, starting
dorsally at the level of the metatarsocuneiform joint, aiming distally, and
ending just proximal to the sesamoid apparatus. The osteotomy is inclined
10° from medial to lateral (Fig.
7). The dorsal two-thirds of the osteotomy is carried out as a
first step, without completing the cut through the plantar cortex
(Fig. 8).
A guidewire for a 3.0-mm cannulated screw or a headless multiple-use
compression screw is inserted in the proximal aspect of the dorsal fragment,
perpendicular to the plane of the osteotomy. The screw is tightened to
demonstrate compression but is then released to allow reintroduction of the
saw blade to complete the osteotomy (Fig.
9). Irrespective of screw type, we recommend countersinking the
screw, not only to reduce the screw's prominence but also to minimize the risk
of dorsal metatarsal cortical fracture. The osteotomy is then completed
distally (Figs. 10-A and
10-B). The plantar fragment is pulled medially with use of a towel
clip (Fig. 10-C), and the
dorsal fragment is rotated laterally with a push of the thumb on the medial
metatarsal head. After the desired correction has been achieved, the proximal
screw is tightened and a second screw is inserted from plantar to dorsal
across the distal aspect of the osteotomy site
(Fig. 11). If instability is
noted, a third screw with bicortical purchase should be placed from dorsal to
plantar. The medial eminence of the metatarsal head is judiciously excised in
line with the metatarsal shaft. The medial prominence created with shift of
the osteotomy is also removed, but not excessively, in order to maintain
adequate cortical support for the plantar-to-dorsally directed second screw
(Fig. 12).
Attention is next directed toward the medial capsule, and a wedge of
approximately 5 mm is removed from the short arm of the L-type capsular
incision (Fig. 13). While an
assistant holds the great toe in a slightly overcorrected position, the medial
joint capsule is repaired with mattress sutures
(Figs. 14-A and 14-B). If
pronation was a component of the preoperative deformity, then the assistant
should also supinate the hallux during the medial capsulorrhaphy. The
previously placed first web space sutures are tightened. The wound is closed
in standard fashion.
Immediately following the operation, ice is applied to the foot to reduce
swelling. Provided that the bone quality and fixation were sufficient, the
patient is allowed to walk with a post-surgical forefoot offloading-type shoe,
starting on the day of surgery and continuing until six weeks after surgery.
We recommend weekly dressing changes/bunion strapping in the first five to six
weeks. If the fixation is questionable, the patient is managed with a fracture
boot or a short leg walking cast for six weeks. Radiographs are made
intraoperatively and at six weeks. After radiographic union is observed, we
permit the patient to graduate to stiff-soled dress shoes and to advance to
full weight-bearing. Generally, unrestricted weight-bearing is allowed at six
weeks after surgery, and sports activity is allowed at ten to twelve weeks
(Figs. 15-A and 15-B).
CRITICAL CONCEPTSINDICATIONS:Symptomatic hallux valgus deformity with an intermetatarsal angle of
=15°Painful bunion deformity failing treatment with appropriate shoewear
modificationsCONTRAINDICATIONS:A narrow metatarsal (fixation becomes difficult with adequate rotation)Substantial first tarsometatarsal joint instabilityAn asymptomatic patient who desires improved cosmesisPainful first metatarsophalangeal joint arthritisSevere osteopeniaInfectionNeurological diseasePeripheral vascular diseaseTobacco usePITFALLS:An increased distal metatarsal articular angle (the relationship of the
articular surface of the first metatarsal to the longitudinal axis of the
first metatarsal, with normal regarded as =6°). After the rotation of
the first metatarsal, either a preoperatively congruent metatarsophalangeal
joint will become incongruent or there will be a recurrence of the deformity.
In this situation, the Ludloff osteotomy must be combined with a distal medial
closing-wedge first metatarsal or proximal phalangeal osteotomy.Delayed bone healing. Satisfactory fixation and bone quality are crucial
for a successful outcome. If fixation is not optimal, we advise more rigorous
postoperative immobilization (casting) and delay of weight-bearing.Fracture of the dorsal fragment. This can occur when the dorsal fragment is
too thin and the proximal screw is inserted too close to the proximal end of
the dorsal fragment or is not countersunk to accommodate the screw's head.Hallux varus. Overcorrection can occur as a result of overplication of the
medial capsule, excessive resection of the medial eminence, or overcorrection
of the intermetatarsal angle.Transfer metatarsalgia. This can result from an elevation of the first
metatarsal due to improper angulation of the saw blade. The saw should be
angled 10° in a plantar lateral direction to avoid dorsiflexion of the
distal fragment when the osteotomy is shifted.AUTHOR UPDATE:The Ludloff osteotomy should heal by direct bone-healing. Osseous callus at
the osteotomy site noted on postoperative radiographs suggests motion and
inadequate fixation that may lead to loss of correction. While not all
patients more than sixty-five years of age are osteopenic, we observed in our
clinical study a significantly increased incidence of osseous callus at the
osteotomy site in patients more than sixty-five years of age when compared
with those patients less than sixty-five years of age.
CRITICAL CONCEPTS
INDICATIONS:
Symptomatic hallux valgus deformity with an intermetatarsal angle of
=15°Painful bunion deformity failing treatment with appropriate shoewear
modifications
Symptomatic hallux valgus deformity with an intermetatarsal angle of
=15°
Painful bunion deformity failing treatment with appropriate shoewear
modifications
CONTRAINDICATIONS:
A narrow metatarsal (fixation becomes difficult with adequate rotation)Substantial first tarsometatarsal joint instabilityAn asymptomatic patient who desires improved cosmesisPainful first metatarsophalangeal joint arthritisSevere osteopeniaInfectionNeurological diseasePeripheral vascular diseaseTobacco use
A narrow metatarsal (fixation becomes difficult with adequate rotation)
Substantial first tarsometatarsal joint instability
An asymptomatic patient who desires improved cosmesis
Painful first metatarsophalangeal joint arthritis
Severe osteopenia
Infection
Neurological disease
Peripheral vascular disease
Tobacco use
PITFALLS:
An increased distal metatarsal articular angle (the relationship of the
articular surface of the first metatarsal to the longitudinal axis of the
first metatarsal, with normal regarded as =6°). After the rotation of
the first metatarsal, either a preoperatively congruent metatarsophalangeal
joint will become incongruent or there will be a recurrence of the deformity.
In this situation, the Ludloff osteotomy must be combined with a distal medial
closing-wedge first metatarsal or proximal phalangeal osteotomy.Delayed bone healing. Satisfactory fixation and bone quality are crucial
for a successful outcome. If fixation is not optimal, we advise more rigorous
postoperative immobilization (casting) and delay of weight-bearing.Fracture of the dorsal fragment. This can occur when the dorsal fragment is
too thin and the proximal screw is inserted too close to the proximal end of
the dorsal fragment or is not countersunk to accommodate the screw's head.Hallux varus. Overcorrection can occur as a result of overplication of the
medial capsule, excessive resection of the medial eminence, or overcorrection
of the intermetatarsal angle.Transfer metatarsalgia. This can result from an elevation of the first
metatarsal due to improper angulation of the saw blade. The saw should be
angled 10° in a plantar lateral direction to avoid dorsiflexion of the
distal fragment when the osteotomy is shifted.
An increased distal metatarsal articular angle (the relationship of the
articular surface of the first metatarsal to the longitudinal axis of the
first metatarsal, with normal regarded as =6°). After the rotation of
the first metatarsal, either a preoperatively congruent metatarsophalangeal
joint will become incongruent or there will be a recurrence of the deformity.
In this situation, the Ludloff osteotomy must be combined with a distal medial
closing-wedge first metatarsal or proximal phalangeal osteotomy.
Delayed bone healing. Satisfactory fixation and bone quality are crucial
for a successful outcome. If fixation is not optimal, we advise more rigorous
postoperative immobilization (casting) and delay of weight-bearing.
Fracture of the dorsal fragment. This can occur when the dorsal fragment is
too thin and the proximal screw is inserted too close to the proximal end of
the dorsal fragment or is not countersunk to accommodate the screw's head.
Hallux varus. Overcorrection can occur as a result of overplication of the
medial capsule, excessive resection of the medial eminence, or overcorrection
of the intermetatarsal angle.
Transfer metatarsalgia. This can result from an elevation of the first
metatarsal due to improper angulation of the saw blade. The saw should be
angled 10° in a plantar lateral direction to avoid dorsiflexion of the
distal fragment when the osteotomy is shifted.
AUTHOR UPDATE:
The Ludloff osteotomy should heal by direct bone-healing. Osseous callus at
the osteotomy site noted on postoperative radiographs suggests motion and
inadequate fixation that may lead to loss of correction. While not all
patients more than sixty-five years of age are osteopenic, we observed in our
clinical study a significantly increased incidence of osseous callus at the
osteotomy site in patients more than sixty-five years of age when compared
with those patients less than sixty-five years of age.