Hallux valgus

Last evidence check March 2010

Ludloff described a long oblique osteotomy of the first metatarsal shaft in 1918. Originally the osteotomy was not fixed, but Myerson described a method of screw fixation (see technique panel. The long osteotomy plane and additional fixation makes the Ludloff very stable to both bending and cyclical loading, and there is an increase in interest in it in the current literature. Although the osteotomy is made through the metatarsal shaft, rotation is carried out round a proximal screw in Myerson's modification, so the procedure is grouped with proximal osteotomies in the Hyperbook.

Basic science

A good deal of basic science investigation and three clinical studies make the Ludloff one of the better characterised procedures. It provides correction of the intermetatarsal angle comparable to proximal crescentic and wedge osteotomies with less shortening (Nyska et al 2002).Dropping the saw blade in a dorsomedial to plantarlateral direction 10 deg minimises metatarsal head elevation (Nyska 2003). It is stable enough to allow use of simple post-operative shoes without cast in good bone stock (Trnka et al 2000). Hofstaetter (2008) found that screw fixation of the Ludloff osteotomy was more stable to repeated stress than spacer plate fixation of an opening wedge osteotomy.

Clinical studies

Saxena (1997) reported 14 patients with a mean of 4 years follow-up. Mean HVA improved from 30 to 13 deg and IMA from 16 to 9.4 deg. Mean first MT shortening was 1mm and there were no transfer lesions. Mean AOFAS forefoot score was 93.

Chiodo et al (2004) reported 70 Ludloff osteotomies followed for 18-42 months. Mean AOFAS forefoot score improved from 54 to 91/100. Mean HVA improved from 31 to 11 deg and IMA from 16 to 7 deg. The first metatarsal head was, on average, plantarflexed 1 deg. There were no second ray trasfer lesions and other complications were within expected values.

Trnka et al (2008) reported 111 procedures in 99 patients followed for 18-56 months. Patients were reviewed by an independent observer. Mean AOFAS forefoot score improved from 53 to 88/100 (results were better in patients under 60 years), mean HVA from 35 to 9 deg and IMA from 17 to 8 deg. Mean first metatarsal shortening was 2mm and there were no dorsiflexion malunions. Transfer lesions resolved after surgery in 15/21 patients and new calluses developed in 4 patients. First MTP joint range of movement decreased by 10 deg on average and 22% of patients still had some forefoot pain.

Choi (2009) reported a comparative series of 46 PCOs and 52 Ludloff osteotomies; the PCOs were done first and then policy changed to the Ludloff. After a mean of 49 months' follow-up of the PCOs and 22 months of the Ludloffs, there was no difference in correction of IMA or HVA, or in AOFAS hallux scores. The Ludloff osteotomy gave better correction in patients with IMA >20deg at the cost of more 1st MT shortening.

Robinson (2009) reported a sequential comparative study of the scarf and Ludloff osteotomies. The scarf group were done first so had longer follow-up. The scarf group had more pain and more problems with swelling and shoe wear pre-operatively. Intra-operative correction was equivalent in both groups but better maintained after a scarf. 68% of pre-operative transfer lesions resolved after a scarf compared with 58% after a Ludloff, and there were no new transfer lesions. There were no non-unions or mal-unions in the scarf group compared with three in the Ludloff group. However, there were no significant differences in a number of functional assessments between the two groups.

Probably the Ludloff osteotomy is about as good as other options for the more severe group of patients.